April 12, 2011

Health Prevention in IBD: Vaccinations

Health Prevention in Inflammatory Bowel Disease: Vaccinations
Nichole McCollum, B.S.1 , Sateesh R. Prakash, M.D.2,3

Mercer University School of Medicine1, SGS Research and Educational Institute2, and Medical College of Georiga3

Vaccinations play an important role in preventing illnesses. Inflammatory bowel disease (IBD) patients, including patients with Crohn’s Disease and Ulcerative Colitis, may be at increased risk for infection when compared to the general population. Reasons for the increased risk include underlying disease, malnutrition, surgery or immunosuppressive therapy. 1

In recent years many patients have benefitted from treatment with immunomodulators (Azothiopurine or 6-Murcaptopurine) and biologic therapy (anti-TNF therapy including Humira, Remicade, and Cimzia). While these newer therapies have improved disease activity, decreased frequency of hospitalizations and improved quality of life for IBD patients, they are associated with increased susceptibility to acquiring and fighting off various illnesses. 2 The degree of susceptibility is related to the degree of immunosuppression accompanied with the IBD patient’s treatment regime. 1 As more physicians and patients become aware of the increased risk of infection associated with IBD therapies, increased efforts and resources are utilized to vaccinate IBD patients for preventable illnesses. 2 Unfortunately, many worry that an IBD patient’s immune response will not be adequate because of immunosuppressive therapy.3 It is imperative that IBD patients stay up to date on immunizations to avoid common and preventable illnesses.

Recommended Vaccines for IBD Patient

In general, IBD patients should follow the recommended vaccine schedule for adults with the exception of patients on anti-TNF or biologic therapy. These patients should not receive any live virus vaccines which include Influenza inhaled (LAIV), Mumps-Measles-Rubella (MMR), Varicella, and Zoster vaccines. Other live virus vaccines less commonly administered in the United States include Typhoid (oral) and Yellow Fever vaccines. A live virus vaccine contains “living” virus that is used to produce immunity, usually without causing illness.

Patients on anti-TNF therapy should avoid live virus vaccines due to the increased risk of causing illness.3 In addition to the regular vaccine schedule for adults in the United States, it is recommended that IBD patients receive a few extra vaccines3. Studies have shown that women with IBD have a higher incidence of abnormal PAP smears than the general population. The increased risk for HPV infection and abnormal PAP smears may be greater in women on immunosuppressive therapy4. Thus, in addition to all females age 9-26 years old receiving the HPV vaccine, females with IBD older than 26 years of age who are negative for HPV should be considered as well. Furthermore there is an increased incidence in anal cancer with perianal Crohn’s disease and males should be considered for vaccination against HPV5. However, individuals with IBD should discuss these vaccinations with his or her health care provider. Pneumococcal infections and influenza are two common adult vaccine preventable diseases. All IBD patients should be up to date on their pneumococcal and influenza vaccinations.3 Pneumococcal vaccines are given earlier in IBD patients compared to the general population5. Vaccination with pneumococcal polysaccharide vaccine and inactivated influenza vaccine is safe and well tolerated by all patients. These vaccines may be administered simultaneously. 2 Adults with IBD who are not on anti-TNF therapy and have no reliable history of varicella illness or vaccination should be vaccinated for varicella.3 Physicians and patients should recognize the importance of live virus vaccinations PRIOR to beginning anti-TNF or biologic therapy. Mortality rates are typically much higher in adults who experience varicella compared to children with the same disease. For this reason alone, effort should be made to ensure every adult IBD patient is immune to varicella.2

The recommended vaccines for adults in the United States are listed below

-Tetanus, diphtheria, pertussis (Td/Tdap): Adults receive a one-time Tdap booster, then Td booster every 10 years thereafter

-Human Pailloma virus (HPV): 3 doses administered to females ages 9-26 years old

-Influenza: one dose annually

-Pneumococcal: 1 dose between ages 19-26 years old then booster after 5 years

-Hepatitis A: 2 doses administered to at risk populations

-Hepatitis B: 3 doses administered to at risk populations

-Meningococcal : administered to 1st year college students, military recruits and persons traveling to endemic areas

-MMR (*live vaccine):2 doses between 19-49 years old for adults born after 1957 or if serology does not show immunity, female

-Varicella(*live vaccine): all adults without evidence of immunity or prior vaccination

-Zoster/Shingles(*live vaccine): all adults age 60 or older; not recommended for those who received varicella vaccine

*all live vaccines are contraindicated for patients on biologic therapy

Travel Vaccinations

All persons traveling to areas where Typhoid and Yellow Fever are endemic are recommended to be vaccinated prior to travel. IBD patients on biologic therapy should only receive the intramuscular Typhoid vaccine as the oral Typhoid vaccine is a live virus vaccine. IBD patients on biologic therapy should not be vaccinated for yellow fever as it is a live virus vaccine3. IBD Patients’ Immune Response to Vaccines. Studies have shown IBD patients develop an adequate immune response to vaccine, though sometimes at lower levels than the general population. Thus, it is recommended that IBD patients be vaccinated with all vaccines not contraindicated due to therapy. Some immunosuppressive medications may lessen the immune response to vaccines, specifically IBD patients receiving combination immunosuppressive therapy. This population of IBD patients may benefit from vaccine boosters1. Vaccines have not been proven to worsen clinical activity of IBD. Vaccines are typically tolerated well by the general population and the same holds true for IBD patients3. For more information about vaccinations, please consult your physician. Vaccinations should be individualized and the decision to be vaccinated should be done for the appropriate vaccine after discussion and consultation with your gastroenterologist or primary care physician.

1. Lu Y JD, Bousvaros A. Immunizations in Patients with Inflammatory Bowel Disease. Inflammatory Bowel Disease 2009;15:1417-23.

2. GY M. Vaccination Strategies for Patients with Inflammatory Bowel Disease on Immunomodulators and Biologics. Inflammatory Bowel Disease 2009;15:1410-6.

3. Sands BE. CC, Katz J, Kugathasan S, Onken J, Vitek C, Orenstein W. Guidelines for Immunizations in Patients With Inflammatory Bowel Disease. Inflammatory Bowel Disease 2004;10:677-92.

4. Kane S KB, Reddy D. Higher Incidence of Abnormal Pap Smears in Women with Inflammatory Bowel Disease. American Journal of Gastroenterology 2008;103:631-6.

5. Moscandrew M MU, Kane S. General Health Mainenance in IBD. Inflammatory Bowel Disease 2009;15:1399-408.

6. Practices ACoI. Recommended Adult Immunization Schedule: United States, 2009. Annals of Internal Medicine 2009;150:40-4.


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