AIBD 2010: Only a Minority of At-risk IBD Patients Are Immunized

Only a minority of “at risk” inflammatory bowel disease (IBD) patients appear to be immunized; however, over 80% of these patients have visited their primary care physician in the last 12 months, according to research presented at the 2010 Advances in Inflammatory Bowel Diseases, the Crohn's & Colitis Foundation's Clinical & Research Conference, being held December 9-12 in Hollywood, FL.

During a session focusing on improving the quality of the care of IBD patients, Gil Y. Melmed, MD, MS, of Cedars Sinai Medical Center, Los Angeles, CA, discussed the prevention of infections and vaccination strategies among IBD patients. Melmed said infections are the most common significant adverse event among immunosuppressed patients with IBD, and that the risk of serious infection increases with the number of immunosuppressive therapies. However, he said that many infections are preventable with routine immunizations

According to current IBD-specific vaccination guidelines, IBD itself should not impact vaccine response. IBD is rare among children less than five years, so most IBD patients should have already received routine vaccinations. Physicians should check about varicella exposure and avoid vaccination with live viruses. In addition, immunization for influenza, pneumococcal, and human papillomavirus (HPV) should be considered in appropriate patients. According to current CDC recommendations, anyone age six months and older should get vaccinated against influenza. In addition, women with IBD have an increased risk for abnormal Pap smear, with HPV linked with cervical and anal cancer. While no specific guidelines are in place for women with IBD, the HPV vaccine is available and safe.

Overall, live virus vaccines including varicella, yellow fever, anthrax, BCG, MMR, small pox, adenovirus, live cholera, intranasal influenza vaccine, VZV, and shingles vaccine are generally contraindicated in immunosuppressed patients. According to Melmed, these vaccinations should only be considered in immunosuppressed patients if the risk of natural infection is greater than the risk of immunization.

However, the question remains whether vaccination is effective in immunosuppressed patients. In one study evaluating 146 children with IBD, no difference was seen between immunosuppressed and non-immunosuppressed patients. A sub-analysis showed that patients who were not seroprotected at baseline were less likely to respond to one of three antigens. Other data revealed that combined immunosuppression impaired response to pneumovax, with the combination of immunomodulator plus anti-TNF agents resulting in significantly lower antibody responses. Since immunosuppression varied among IBD patients, vaccination is still recommended for all patients.

While most vaccines are generally safe for administration among IBD patients, live virus vaccines, herpes zoster, yellow fever, and varicella vaccines should not be administered to immunosuppressed patients. The yellow fever vaccine may actually lead to death in immunosuppressed patients. In these cases, treatment should be discontinued before vaccine administration or vaccination should be performed prior to the start of treatment.

Overall, Melmed concluded that:

• People with IBD have unpredictable likelihood for immune suppression
• Vaccination against influenza and pneumonia should be considered in all those with IBD
• Vaccines may not work well if immunosuppressed, so consider early in disease in course

In addition, gastroenterologists and practicing clinicians should make sure they are immunized appropriately and specifically address varicella, patient travel plans that may require vaccination, as well as household contacts.