When it comes to protecting children with rheumatic diseases from preventable infections, there's perhaps no intervention more powerful—or more underutilized—than the simple act of a healthcare provider making a clear, confident recommendation for the flu vaccine. New research is demonstrating just how transformative this guidance can be, while also revealing the persistent barriers that still keep some of our most vulnerable young patients unprotected.

The Remarkable Impact of Provider Recommendations

A recent comprehensive study examining flu vaccination patterns in pediatric rheumatology clinics has delivered compelling evidence about the power of healthcare provider guidance. Of the 226 completed surveys, 145 (64.2%) were completed by parents and 81 (35.8%) by patients. The majority (85%) reported the influenza vaccine was recommended by their rheumatologist—and remarkably, when this recommendation was made, 82.7% followed through with vaccination.

This finding underscores a fundamental truth in pediatric healthcare: families of children with chronic conditions like juvenile idiopathic arthritis actively seek and follow guidance from their specialized healthcare providers. Most patients with a pediatric rheumatic disease are at increased risk of influenza due to immunosuppressive medication use, making provider recommendations not just helpful, but potentially life-saving.

Breaking Down the Barriers

Despite the high follow-through rate when recommendations are made, significant barriers still prevent many children from receiving this crucial protection. The study revealed several key concerns that healthcare teams must address:

Primary Concerns Among Families:

The most common reasons for not receiving the influenza vaccine included: worry about disease flare (25.6%), concern the vaccine will cause influenza (25.6%), and lack of vaccine effectiveness (20.5%). Notably, parents (40.9%) were more worried about disease flare compared to patients (17%; p = 0.024).

Knowledge Gaps About Flu Symptoms:

One of the most striking findings was the prevalence of misconceptions about influenza symptoms. However, gastrointestinal symptoms (vomiting and/or diarrhea) were picked by 25.2% of respondents despite these symptoms occurring in 10% or less of children with influenza. Around 10% of our respondents listed joint swelling as one of the two most common symptoms of influenza despite joint swelling not being a common sign at time of influenza diagnosis in children.

These misconceptions highlight a critical education opportunity. When families don't understand what flu symptoms actually look like, they may not fully appreciate the importance of prevention or may attribute other health issues to influenza.

The Quality Improvement Success Story

Perhaps the most encouraging aspect of this research is the demonstration that targeted interventions can dramatically improve vaccination rates. Through a separate quality improvement initiative involving physician and nurse education, patient education handouts, posting signs in clinic, and more, we saw an improvement in our vaccination rate of patients on immunosuppression from 63.8% to 72% from 2015 to 2019.

The results were even more impressive when combined with the survey-based intervention: We saw additional improvement in our vaccination rate in tandem with this survey using quality improvement methodology to 85.5%. This represents a remarkable 21.7 percentage point increase from the baseline rate—proof that systematic, evidence-based approaches to vaccination promotion work.

Understanding the Unique Vulnerabilities

Children with rheumatic diseases face a perfect storm of infection risk factors that make flu vaccination particularly crucial:

Immunosuppressive Medications

Most respondents (95.1%) were aware that immunosuppressive medication increases risk of infection. This awareness is encouraging, but it must be coupled with understanding that vaccination is one of the most effective ways to mitigate this increased risk.

Disease-Related Factors

Children with pediatric rheumatic diseases are at increased risk of infections, which can contribute to morbidity and mortality, and can also trigger a flare-up of JIA symptoms. Several factors contribute to the increased risk of infection in JIA patients, including immunological disorders associated with the disease itself and its treatment.

The Vulnerability Paradox

Children who are on immunosuppressant drugs need additional protection precisely because their treatments make them more susceptible to infections. Yet these same medications can reduce vaccine effectiveness, creating a complex medical landscape that requires expert guidance.

The Science Behind Safety and Effectiveness

Decades of research have consistently demonstrated the safety and importance of flu vaccination in children with rheumatic diseases:

Safety Profile

The present study demonstrates adequate seroprotection rates against influenza A in immunosuppressed children with JIA. The trivalent vaccine had good immunogenicity and was safe to use in both JIA treatment groups. No long-term adverse events were reported after influenza vaccination in JIA and control group.

Effectiveness Despite Immunosuppression

While children on immunosuppressive medications may not mount as robust an immune response to vaccines as healthy children, studies consistently show meaningful protection. Annual flu vaccination is recommended for children with rheumatic diseases by major medical organizations including the American College of Rheumatology and the European League Against Rheumatism.

Addressing Flare Concerns

One study found that thirty-five percent of children with JIA experienced flare of the disease after vaccination, but protective antibodies against at least 2 vaccine viruses 6 months after vaccination were detected in all patients. Importantly, this rate of flare is within the expected range for these conditions and doesn't necessarily indicate a causal relationship with vaccination.

Professional Guidelines and Recommendations

The medical community has reached clear consensus on flu vaccination for children with rheumatic diseases:

American College of Rheumatology Guidelines

The 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases strongly recommends annual influenza vaccination for children with these conditions. The guidelines emphasize that the benefits far outweigh any potential risks.

Timing and Scheduling

Vaccine effectiveness relies on the recipient having a healthy immune system. Many of the drugs used to treat juvenile arthritis (JA) — biologics, corticosteroids and disease-modifying anti-rheumatic drugs — relieve symptoms by suppressing the immune system so it can't attack the joints. However, this doesn't contraindicate vaccination—rather, it makes it more important.

Practical Strategies for Healthcare Teams

The research provides clear direction for healthcare providers seeking to improve vaccination rates:

Clear, Confident Recommendations

The 85% recommendation rate and high follow-through demonstrate that when providers make clear recommendations, families respond positively. Every encounter should include discussion of vaccination status and clear guidance.

Education Focus Areas

Healthcare teams should specifically address:

• Actual flu symptoms (fever, cough, congestion) versus misconceptions about GI symptoms or joint swelling

• Disease flare risks and the distinction between coincidental timing and causation

• Vaccine safety in the context of immunosuppressive medications

• Effectiveness even with reduced immune response

Systems-Level Interventions

The quality improvement approach that increased vaccination rates from 63.8% to 85.5% included:

• Provider and staff education

• Patient education materials

• Visual reminders in clinical spaces

• Systematic tracking and feedback

Addressing Vaccine Hesitancy with Empathy

Healthcare providers must approach vaccine hesitancy with understanding and evidence-based responses:

For Flare Concerns

Acknowledge that disease flares are a genuine concern, but explain that influenza infection itself is more likely to trigger flares than vaccination. The temporary immune stimulation from vaccination is far preferable to the prolonged inflammation that can result from actual influenza infection.

For Safety Worries

Emphasize the extensive safety data available for flu vaccination in immunocompromised children. Rarely will any child — even one with arthritis — need to avoid all vaccinations. The risks of preventable diseases far outweigh vaccine risks.

For Effectiveness Doubts

Explain that while vaccine effectiveness may be reduced in immunocompromised individuals, any protection is better than none. Even partial protection can mean the difference between mild illness and hospitalization.

The Broader Community Impact

Vaccination of children with rheumatic diseases extends beyond individual protection:

Herd Immunity Benefits

Children with compromised immune systems rely on high vaccination rates in their communities for protection. When healthy children are vaccinated, it creates a protective barrier around more vulnerable individuals.

Healthcare System Impact

Probably the most important thing that both children with JIA and family members can do is get their yearly flu shots! While for most people influenza is relatively mild, children with chronic health problems like JIA represent a large number of the patients who are hospitalized every year with influenza.

Looking Forward: Building on Success

The research demonstrates that significant improvements in vaccination rates are possible when healthcare systems commit to evidence-based approaches. Key elements for continued success include:

Sustained Quality Improvement

The dramatic improvement from 63.8% to 85.5% didn't happen overnight—it required sustained effort and systematic approaches to change.

Provider Education

Healthcare teams must stay current on vaccination recommendations and be prepared to address common concerns with confidence and empathy.

Family Partnership

Most parents are very supportive of vaccination in their children with JIA when they understand the risks and benefits. The key is providing clear, accurate information and addressing concerns directly.

A Call to Action

This research provides a clear roadmap for protecting our most vulnerable young patients. When healthcare providers make confident, clear recommendations for flu vaccination, the vast majority of families follow through. When systems implement comprehensive quality improvement approaches, vaccination rates can increase dramatically.

For families navigating rheumatic diseases in children, the message is equally clear: flu vaccination is one of the most important steps you can take to protect your child's health. The concerns about flares, side effects, and effectiveness are understandable, but the evidence overwhelmingly supports vaccination as a safe and beneficial intervention.

As we move forward, the goal should be to build on these successes—ensuring that every child with a rheumatic disease receives not just excellent treatment for their underlying condition, but also the preventive care that can keep them healthier throughout the year. The power of provider recommendations, combined with systematic quality improvement approaches, gives us the tools to achieve this goal.

At the American Arthritis Foundation, we're committed to ensuring that children with juvenile arthritis and other rheumatic diseases receive comprehensive, evidence-based care. This research reinforces the importance of preventive measures like flu vaccination as part of a holistic approach to managing these complex conditions. We encourage all families to work closely with their healthcare teams to ensure their children receive recommended vaccinations and stay as healthy as possible.