Patients With IBD Are at Risk for Vaccine-Preventable Illnesses
Background: Patients with chronic, immune-mediated conditions such as inflammatory bowel disease (IBD) are often treated with long-term immunosuppressive therapies, potentially increasing their risk of developing an infection. Empiric data suggest that vaccines are underutilized in immunocompromised patients, despite published guidelines recommending their use. We aimed to assess exposure risk and immunization status among patients receiving care in an IBD specialty clinic.
Methods: Patients completed a self-administered, pretested, structured questionnaire during a routine visit for the management of IBD. Survey questions related to medical and immunization histories, and exposures to known risk factors for influenza, pneumococcus, viral hepatitis, and varicella. Additionally, in a subgroup of patients who agreed to donate a sample of blood, immune status to hepatitis A (HAV), hepatitis B (HBV), and varicella was determined.
Results: Two hundred four patients were asked to participate in the study; 169 completed surveys and comprised the study population. Mean age was 35 yr (range 13–75 yr). One hundred forty-six respondents (86%) reported current or prior use of immunosuppressive medications. Only 45% of respondents recalled tetanus immunization within the past 10 yr, 41 (28%) reported regularly receiving flu shots, and 13 (9%) reported having received pneumococcal vaccine. The most common reasons for nonimmunization with influenza included lack of awareness (49%) and concern for side effects (18%). Responses indicated that 75 (44%) patients were at risk for HBV but only 47 (28%) had been vaccinated against the infection; of patients with previous HBV vaccination, only three of nine (33%) had measurable antibodies against hepatitis B surface antigen.
Conclusions: Immunization against selected vaccine-preventable illnesses was uncommon in patients with IBD, despite the presence of significant risk factors. Efforts to improve immunization status among patients with IBD and other chronic, immune-mediated conditions are needed.
The benefits of long-term immunosuppressive therapy have been widely recognized for a variety of chronic, immune-mediated conditions. Inflammatory bowel diseases (IBD), traditionally dichotomized into Crohn's disease and ulcerative colitis, are chronic conditions thought to result from an abnormal immunologic response to normal bowel flora. Treatment of IBD often involves the use of immune-suppressive medications including steroids, antimetabolites (such as 6-mercaptopurine [6-MP], methotrexate, or azathioprine), and more recently biologic therapy (such as infliximab). Although beneficial for controlling the primary disease, such treatments may place patients at increased risk for acquiring various infections, many of which are potentially preventable using available vaccines. For example, cases of fulminant or fatal infections with pneumococcus, varicella, and hepatitis B in immunosuppressed patients with rheumatoid arthritis, Still's disease, and IBD have been reported.
Guidelines have been established that pertain generally to adult immunosuppressed patients, and an expert consensus report on issues specifically relevant to patients with IBD was recently published. It is recommended that adult immunosuppressed patients be assessed for preventable illnesses including influenza, pneumococcal disease, varicella, hepatitis B (HBV), and tetanus. Adults on immunosuppressive medications should receive influenza and pneumococcal immunization, and a second pneumococcal vaccination after 5 yr. Additionally, consideration should be given to administering varicella vaccine to patients without a history of the infection who are likely to receive immunosuppressive agents. Patients with a history of potential hepatitis B exposure should be serologically tested prior to initiation of immunosuppressive therapy, which may cause reactivation and flare of viral hepatitis. All adults should also undergo immunization with tetanus toxoid (Td) every 10 yr.
Despite these recommendations, vaccination rates in high-risk adult populations are woefully inadequate. While it would be expected that similar findings would be present in patients with IBD, no published data are available. Therefore, we sought to determine the rate of immunization among patients with IBD, reasons for nonimmunization, and the frequency of exposure to selected factors known to increase the risk of acquiring an infection.
Abstract and Introduction
Abstract
Background: Patients with chronic, immune-mediated conditions such as inflammatory bowel disease (IBD) are often treated with long-term immunosuppressive therapies, potentially increasing their risk of developing an infection. Empiric data suggest that vaccines are underutilized in immunocompromised patients, despite published guidelines recommending their use. We aimed to assess exposure risk and immunization status among patients receiving care in an IBD specialty clinic.
Methods: Patients completed a self-administered, pretested, structured questionnaire during a routine visit for the management of IBD. Survey questions related to medical and immunization histories, and exposures to known risk factors for influenza, pneumococcus, viral hepatitis, and varicella. Additionally, in a subgroup of patients who agreed to donate a sample of blood, immune status to hepatitis A (HAV), hepatitis B (HBV), and varicella was determined.
Results: Two hundred four patients were asked to participate in the study; 169 completed surveys and comprised the study population. Mean age was 35 yr (range 13–75 yr). One hundred forty-six respondents (86%) reported current or prior use of immunosuppressive medications. Only 45% of respondents recalled tetanus immunization within the past 10 yr, 41 (28%) reported regularly receiving flu shots, and 13 (9%) reported having received pneumococcal vaccine. The most common reasons for nonimmunization with influenza included lack of awareness (49%) and concern for side effects (18%). Responses indicated that 75 (44%) patients were at risk for HBV but only 47 (28%) had been vaccinated against the infection; of patients with previous HBV vaccination, only three of nine (33%) had measurable antibodies against hepatitis B surface antigen.
Conclusions: Immunization against selected vaccine-preventable illnesses was uncommon in patients with IBD, despite the presence of significant risk factors. Efforts to improve immunization status among patients with IBD and other chronic, immune-mediated conditions are needed.
Introduction
The benefits of long-term immunosuppressive therapy have been widely recognized for a variety of chronic, immune-mediated conditions. Inflammatory bowel diseases (IBD), traditionally dichotomized into Crohn's disease and ulcerative colitis, are chronic conditions thought to result from an abnormal immunologic response to normal bowel flora. Treatment of IBD often involves the use of immune-suppressive medications including steroids, antimetabolites (such as 6-mercaptopurine [6-MP], methotrexate, or azathioprine), and more recently biologic therapy (such as infliximab). Although beneficial for controlling the primary disease, such treatments may place patients at increased risk for acquiring various infections, many of which are potentially preventable using available vaccines. For example, cases of fulminant or fatal infections with pneumococcus, varicella, and hepatitis B in immunosuppressed patients with rheumatoid arthritis, Still's disease, and IBD have been reported.
Guidelines have been established that pertain generally to adult immunosuppressed patients, and an expert consensus report on issues specifically relevant to patients with IBD was recently published. It is recommended that adult immunosuppressed patients be assessed for preventable illnesses including influenza, pneumococcal disease, varicella, hepatitis B (HBV), and tetanus. Adults on immunosuppressive medications should receive influenza and pneumococcal immunization, and a second pneumococcal vaccination after 5 yr. Additionally, consideration should be given to administering varicella vaccine to patients without a history of the infection who are likely to receive immunosuppressive agents. Patients with a history of potential hepatitis B exposure should be serologically tested prior to initiation of immunosuppressive therapy, which may cause reactivation and flare of viral hepatitis. All adults should also undergo immunization with tetanus toxoid (Td) every 10 yr.
Despite these recommendations, vaccination rates in high-risk adult populations are woefully inadequate. While it would be expected that similar findings would be present in patients with IBD, no published data are available. Therefore, we sought to determine the rate of immunization among patients with IBD, reasons for nonimmunization, and the frequency of exposure to selected factors known to increase the risk of acquiring an infection.
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