Immune response to influenza vaccine in pediatric patients with inflammatory bowel disease

The Effect of Maternal Peripartum Anti-TNFα Use on Infant Immune Response

BACKGROUND

Infliximab (IFX) and adalimumab (ADA) cross the placenta in the third trimester and can be detectable in infants for up to 12 months.

AIM

The aim of this study was to determine whether in utero IFX or ADA exposure results in an impaired immune response in infants, as measured by immunoglobulin levels and antibody responses to routine primary immunizations.

METHODS

Infants who were exposed to in utero anti-TNFα agents were prospectively evaluated. Immunoglobulin levels (IgG, IgM, IgA) and antibodies to standard vaccinations, including tetanus toxoid (tetanus) and Haemophilus influenza type b (Hib), were measured in infants of at least 6 months of age.

RESULTS

Twelve infants were prospectively studied: 10 exposed to in utero IFX and 2 exposed to ADA with at least one dose administered in the third trimester. Immunoglobulin levels were available on 10/12 patients, with all showing adequate immunoglobulin levels, except for low IgM levels in 5 (50 %) infants. Adequate responses to both the tetanus and Hib vaccines were seen in 11 of 12 (92 %) infants.

CONCLUSIONS

Infants exposed to anti-TNFα agents in utero demonstrate appropriate response to two commonly administered neonatal vaccines and show adequate immunoglobulin levels, except for IgM. Newborns with a history of exposure to anti-TNFα agents should follow a standard vaccination schedule for inactive vaccines.

Hospitalization for Varicella and Zoster in Children with Inflammatory Bowel Disease

OBJECTIVE

To evaluate the association between inflammatory bowel disease (IBD) and varicella- and herpes zoster-related pediatric hospitalizations.

STUDY DESIGN

We performed a cross-sectional inpatient study using the triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for years 1997-2012 to evaluate the association between a secondary diagnosis of IBD and a primary diagnosis of varicella or herpes zoster for hospitalized children ages 5-20 years. Billing codes were used to identify varicella, herpes zoster, ulcerative colitis, Crohn's disease, and other immunocompromising conditions. A logistic regression model was fitted to quantify the odds of varicella or zoster between these categories.

RESULTS

There were 8 828 712 weighted admissions meeting the study criteria, 4434 with varicella and 4488 with herpes zoster. There was an association of IBD and immunocompromising conditions with hospitalization for varicella and herpes zoster. This association was stronger among children with Crohn's disease (varicella OR, 12.75; 95% CI, 8.30-19.59; zoster OR, 7.91; 95% CI, 5.60-11.18) compared with children with ulcerative colitis (varicella OR 4.25; 95% CI 1.98-9.12, zoster OR 3.90; 95% CI 1.98-7.67).

CONCLUSIONS

IBD in children is associated with hospitalizations for varicella and herpes zoster. These results highlight the importance of efforts to vaccinate patients with IBD without varicella immunity, ideally before the initiation of immunosuppressive therapy. Furthermore, research is needed on the safety and efficacy of the varicella vaccine in children with IBD on immunomodulators or biologic therapy.

Immunogenicity of Influenza Vaccine for Patients with Inflammatory Bowel Disease on Maintenance Infliximab Therapy: A Randomized Trial

BACKGROUND

In patients with inflammatory bowel disease (IBD) on infliximab, data are limited on immune response to influenza vaccine and the impact of vaccine timing. The study aims were to evaluate immune responses to the influenza vaccine in IBD patients on infliximab and the impact of vaccine timing on immune responses.

METHODS

In this randomized study, 137 subjects with IBD on maintenance infliximab therapy were allocated to receive the 2012/2013 inactivated influenza vaccine at the time of infliximab infusion (n = 69) or midway between infusions (n = 68). Serum was collected before and after vaccination for hemagglutination inhibition titers. Serologic protection was defined by postvaccine titer of ≥1:40.

RESULTS

Comparing subjects vaccinated at the time of infliximab with those vaccinated midway, serologic protection was achieved in 67% versus 66% to H1N1 (P = 0.8), in 43% versus 49% to H3N2 (P = 0.5), and in 69% versus 79% to influenza B (P = 0.2). Although solicited adverse events were common (60%), no subject experienced a serious adverse event requiring additional medical attention. Only 6% of subjects had a clinically significant increase in disease activity score, not impacted by vaccine timing.

CONCLUSIONS

Serologic protection to influenza vaccine is achieved in only approximately 45% to 80% of IBD patients on maintenance infliximab therapy varying by antigen. Yet, importantly, vaccine timing relative to infliximab infusion does not affect the achievement of serologic protection, and the influenza vaccine is well tolerated. Therefore, influenza vaccination at any point during infliximab scheduling is recommended for patients with IBD and opportunities to broaden the availability and convenience of influenza vaccine to optimize coverage should be explored.

Features and perspectives of MR enterography for pediatric Crohn disease assessment

The aim of this paper is to provide indications for performing magnetic resonance enterography (MRE) in Crohn's disease (CD), the essential technical elements of MRE techniques and typical findings in patients with CD. Patients suffering from CD frequently require cross-sectional imaging. By performing MRE, it is possible to obtain results comparable to those obtained with endoscopy in terms of identifying and assessing disease activity and better than other cross-sectional imaging techniques, such as CT, in the evaluation of the fibrosis and complications of disease. The MR imaging of diffusion MR is a technique which enables medical staff to add important additional information and which may replace the use of intravenous contrast agents in the near future. Magnetic resonance enterography is an accurate tool for assessing bowel disease and the various complications associated with CD. The lack of exposure to non-ionizing radiation is an important advantage of this imaging technique, especially in the case of pediatric patients. Familiarity with common and pathognomonic imaging features of CD is essential for every clinician involved in the treatment of inflammatory bowel disease and the care of patients.

Vaccinations in paediatric rheumatology: an update on current developments

In 2011, the European League Against Rheumatism (EULAR) published recommendations regarding the vaccination of children with rheumatic diseases. These recommendations were based on a systematic literature review published in that same year. Since then, the evidence body on this topic has grown substantially. This review provides an update of the systematic literature study of 2011, summarizing all the available evidence on the safety and immunogenicity of vaccination in paediatric patients with rheumatic diseases. The current search yielded 21 articles, in addition to the 27 articles described in the 2011 review. In general, vaccines are immunogenic and safe in this patient population. The effect of immunosuppressive drugs on the immunogenicity of vaccines was not detrimental for glucocorticosteroids and methotrexate. Biologicals could accelerate a waning of antibody levels over time, although most patients were initially protected adequately. Overall, persistence of immunological memory may be reduced in children with rheumatic diseases, which shows the need for (booster) vaccination. This update of the 2011 systematic literature review strengthens the evidence base for the EULAR recommendations, and it must be concluded that vaccinations in patients with rheumatic diseases should be advocated.

Immunogenicity and Safety of Influenza Vaccine in Inflammatory Bowel Disease Patients Treated or not with Immunomodulators and/or Biologics: A Two-year Prospective Study

BACKGROUND AND AIMS

Data on the efficacy and safety of seasonal influenza vaccines in patients with inflammatory bowel disease (IBD) remain scarce. The aim of the study was to evaluate the impact of immunosuppressive (IS) therapeutics on serological response to 2-year influenza vaccination in IBD adults.

METHODS

A multicentre prospective study performed in 255 IBD adults (18-64 years) receiving the trivalent influenza vaccine in the years 2009-2010 and 2010-2011. Haemagglutination inhibition (HI) titres were assessed before and 3 weeks and 6 months after vaccination.

RESULTS

At inclusion, 31 patients were receiving no IS treatment (Group A), 77 were receiving IS treatment without anti-TNF (Group B) and 117 were receiving anti-tumour necrosis factor (TNF) treatment with or without IS treatment (Group C). Three weeks after the first vaccination, rates of seroprotection were 77, 75 and 66% for strain A/H1N12007 (p = 0.35), 77, 68 and 52% for strain A/H3N2 (p = 0.014) and 97, 96 and 95% for strain B (p = 0.99) in Groups A, B and C, respectively. Seroconversion rates for A/H1N12007 (67, 64 and 54%; p = 0.28), A/H3N2 (63, 50 and 41%; p = 0.074) and strain B (63, 76 and 60%; p = 0.078) were not significantly different among treatment groups. At 6 months after vaccination, seroprotection rates were lower in Group C compared with Groups A and B. Comparable results were observed for the second year of vaccination. No impact on Harvey-Bradshaw and Mayo scores was detected.

CONCLUSIONS

Influenza vaccine yielded high seroprotection rates in IBD patients. Persistence of seroprotection was lower in patients with anti-TNF treatment. ClinicalTrials.gov, number NCT01022749.

Treatment with infliximab or azathioprine negatively impact the efficacy of hepatitis B vaccine in inflammatory bowel disease patients

BACKGROUND AND AIM

Immunization against hepatitis B virus (HBV) infection is recommended in patients with inflammatory bowel disease (IBD), particularly in those under immunosuppressive therapy. Limited data are available about IBD patient's response to HBV vaccination. We assessed the response rate to HBV vaccination in IBD patients and evaluated the impact of different factors on the efficacy of HBV vaccination.

METHODS

Anti-HBs titers were measured in a cohort of IBD patients under treatment with infliximab and/or azathioprine. Vaccination was considered efficient when anti-HBs titers were higher than 10 IU/L.

RESULTS

We have identified 217 patients with IBD under infliximab who were vaccinated for hepatitis B, 172 (79%) with Crohn's Disease and the remaining with ulcerative colitis; 114 patients (53%) were male and mean age was 33 ± 11 years. Overall, HBV vaccine was successful in 164 (76%) patients. Only 14 patients were vaccinated after infliximab was initiated, and only two of them had antibody levels above 10 IU/L. Among the patients that received vaccination before the beginning of infliximab, 88% of those who were vaccinated before starting azathioprine developed antibodies in contrast to 55% who already were under azathioprine. In multivariable analysis, treatment with infliximab (adjusted OR [95% CI]: 17.642 [8.514-33.937]) and with azathioprine (adjusted OR [95% CI]: 3.344 [1.653-9.145]) were the only factors associated with weaker response to HBV vaccination.

CONCLUSION

The response rate to the standard HBV vaccination in IBD patients is low mainly in those treated with infliximab and/or azathioprine.

Immunogenicity and mechanisms impairing the response to vaccines in inflammatory bowel disease

Inflammatory bowel disease (IBD) is an immunological disorder that is usually treated with immunosuppressive therapy, potentially leading to increases in vulnerability to infections. Although many infections can be prevented by vaccination, vaccination coverage in these patients in clinical practice is insufficient. Therefore, the seroprotection condition should be verified, even for routine vaccines, such as hepatitis B or pneumococcus. Response to vaccines in IBD patients is thought to be impaired due to the immunological alterations generated by the disease and to the immunomodulatory treatments. The immunogenicity of hepatitis B, influenza, and pneumococcal vaccines is impaired in IBD patients, whereas the response to papillomavirus vaccine seems similar to that observed in the healthy population. On the other hand, data on the immunogenicity of tetanus vaccine in IBD patients are conflicting. Studies assessing the response to measles-mumps-rubella, varicella, and herpes zoster vaccines in IBD patients are scarce. The cellular and molecular mechanisms responsible for the impairment of the response to vaccination in IBD patients are poorly understood. Studies aiming to assess the response to vaccines in IBD patients and to identify the mechanisms involved in their immunogenicity are warranted. A better understanding of the immune response, specifically to vaccines, in patients with immune-mediated diseases (such as IBD), is crucial when developing vaccines that trigger more potent immunologic responses.

Management of IBD Patients with Current Immunosuppressive Therapy and Concurrent Infections

In an era of increasing use of immunomodulator therapy and biologics, opportunistic infections (OI) have emerged as a pivotal safety issue in patients with inflammatory bowel disease (IBD). Clinical studies, registries and case reports warn about the increased risk for infections, particularly OIs. Today, the challenge for a physician is not only to manage IBD, but also to recognize, prevent and treat common and uncommon infections. The 2014 European Crohn's and Colitis Organisation (ECCO) guidelines on the management and prevention of OIs in patients with IBD provide clinicians with guidance on the prevention, detection and management of OIs. Proposals may appear radical, potentially changing the current practice, but we believe that the recommendations will help optimize patient outcomes by reducing the morbidity and mortality related to OIs. In this ongoing process, prevention is by far the first and most important step. Prevention of OIs relies on recognition of risk factors for infection, the use of primary or secondary chemoprophylaxis, careful monitoring (clinical and laboratory work-up) before and during the use of immunomodulators, vaccination and education of the patient. Special recommendations should also be given to patients before and after travel.

Strategies to Improve Influenza Vaccination in Pediatric Inflammatory Bowel Disease Through Education and Access

BACKGROUND

Influenza vaccine uptake remains low in patients with inflammatory bowel disease despite an increased risk of complications from infection. We studied barriers to vaccination and evaluated the impact of an educational intervention and vaccine provision in pediatric patients with inflammatory bowel disease.

METHODS

A prospective cohort study was completed over 2 successive influenza seasons. In year 1, we surveyed parents and patients aged 14 years or older regarding influenza vaccination. In year 2, before the influenza season, patients were provided with an educational module. After influenza vaccine availability, patients were offered both education and vaccine in clinic. Chi-squared analysis was used to identify significant differences in vaccination rates in each intervention group. Demographic factors were associated with vaccination status.

RESULTS

In year 1, 180 parents and 183 adolescents completed the survey. In year 1, 47% of patients obtained the influenza vaccine and 34% of patients reported obtaining the vaccine annually. Top reasons for nonvaccination were perceived lack of benefit (28%) and concerns about adverse events (19%). In year 2 (n = 228), the vaccination rate in patients who received the education alone was 75.0%, compared with 89.5% of patients who received both education and vaccine access in clinic (P = 0.0043). Among the patients who took part in both study years (n = 129), influenza vaccination rates increased from 45% in year 1 to 82% in year 2 (P < 0.0001).

CONCLUSIONS

The educational intervention was associated with improved influenza vaccination rates. Additional vaccine uptake was achieved with provision of influenza vaccination during clinic visits.

Combined Immunosuppression Impairs Immunogenicity to Tetanus and Pertussis Vaccination Among Patients with Inflammatory Bowel Disease

BACKGROUND

Pertussis epidemics have recently emerged across the United States, prompting broad public health recommendations for adult Tdap vaccination (tetanus, diphtheria, acellular pertussis). The impact of immunosuppressive regimens for inflammatory bowel disease (IBD) on vaccine responses to the Tdap vaccine is not known.

METHODS

We performed a prospective controlled trial between April 2011 and March 2012. Adults with IBD were consecutively stratified based on therapeutic regimen into one of 5 groups: A: no IBD therapy or 5-aminosalicylates alone; B: maintenance biologic monotherapy; C: maintenance immunomodulator monotherapy; D: combined biologic and immunomodulator therapy; and E: healthy age-matched controls. Subjects received Tdap, and serum antibody levels against tetanus toxoid, pertussis toxoid, and filamentous hemagglutinin (FHA) were drawn just before and approximately 4 weeks after vaccination. The primary outcome was the booster response rate to each antigen. Secondary outcomes included the differences in pregeometric and postgeometric mean titers.

RESULTS

A total of 98 subjects enrolled, and 84 completed the study. Tetanus response rates were 55%, 56%, 40%, 27%, and 63% across groups A to E, respectively. Group D rates were lower than those of group B (P = 0.02). Postvaccination pertussis toxoid responses were 59%, 72%, 47%, 45%, and 75%, while FHA responses were 86%, 72%, 80%, 64%, and 75% across groups A to E, respectively. Prevaccination and postvaccination geometric mean titer differences for FHA were lower in group D than those in group A (P = 0.05).

CONCLUSIONS

Antibody responses to tetanus and pertussis vaccination may be affected by therapeutic drug regimen. Patients with IBD should optimally receive Tdap before starting immunomodulators, particularly when used in combination with anti-tumor necrosis factor alpha agents.

Immunizations in Pediatric and Adult Patients with Inflammatory Bowel Disease: A Practical Case-based Approach

As the treatment of inflammatory bowel disease (IBD) becomes more complex and increasingly relies on combinations of immunosuppression in patients with moderate to severe ulcerative colitis or Crohn's disease, the provider must be aware of recommendations for the appropriate use of vaccines-both inactivated and live. The timing and type of vaccination required may be altered based on the underlying medical treatment for the IBD. In some instances, titers may be required to assess for vaccine response. Vaccination recommendations have changed dramatically over the past 5 years with direct implications for the protection of the patients with IBD. There are several newly licensed vaccines and new recommendations by the U.S. Advisory Committee on Immunization Practices and Infectious Diseases Society of America defining degrees of immunosuppression and the use of certain live vaccines based on these levels. This review provides a case-based approach to vaccinating the pediatric and adult patients with IBD, with an emphasis on practicality. Case scenarios include children and adults with newly diagnosed and chronic IBD. Recommendations for vaccine management in these scenarios are provided, including special circumstances such as pregnancy and infant vaccinations when the mother is receiving immunosuppressive medication.

Survey of Immunization Practices in Patients With Inflammatory Bowel Disease Among Pediatric Gastroenterologists

OBJECTIVES

We aimed to determine vaccination practices of pediatric gastroenterologists, as well as barriers to following immunization guidelines in patients with inflammatory bowel disease.

METHODS

Institutions listed in the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition clinical research registry and/or ImproveCareNow were contacted. A total of 657 physicians from 129 institutions were asked to complete a 16-question electronic survey.

RESULTS

A total of 178 physicians (27.1%) responded, of whom 55% were male and 83.1% practiced in an academic setting. A total of 11 physicians (6.2%) do not routinely assess vaccination status, whereas 63.5% assess at the time of diagnosis, 29.8% at "well" visits, and 44.4% before initiating immunosuppression. At diagnosis, 51.1% verbally inquire about immunization status, 30.9% obtain records, and 9.0% obtain serology.The influenza (78%), hepatitis B (84%), and varicella (82%) vaccines were most frequently assessed. Fewer than 55.5% of physicians reviewed other vaccines. Physicians using a reminder mechanism were more likely to review immunizations at established visits (41.1% vs 20.8%), and before transfer to an adult gastroenterologist (14.4% vs 2.6%). Lack of coordination of care with primary care practitioners (41%), poor access to immunization records (36%), and inability to offer vaccinations in their immediate area (55%) are barriers to vaccination. Only 28% believed that primary care practitioners were solely responsible for immunizations.

CONCLUSIONS

There is practice variation among pediatric gastroenterologists in assessment of immunizations in patients with inflammatory bowel disease, including the specific vaccines assessed, and timing and method of assessment. Inability to coordinate care, access immunization records, and offer vaccines through their medical practice are barriers to adhering to immunization guidelines.

Immunogenicity of 13-Valent Pneumococcal Conjugate Vaccine in Pediatric Patients with Inflammatory Bowel Disease

BACKGROUND

There are only a few studies on immune response to pneumococcal vaccines in patients with inflammatory bowel disease (IBD); all of them assessed polysaccharide vaccines only. The aim of the study was to evaluate the immunogenicity and safety of 13-valent pneumococcal conjugate vaccine (PCV13) in IBD pediatric patients compared with healthy controls.

METHODS

This was a multicenter, prospective, and controlled study on children and adolescents aged 5 to 18 years with IBD with no history of pneumococcal immunization. The subjects for the study belonged to one of the following groups: patients with IBD on no immunosuppressive therapy (group A), those on tumor necrosis factor agents or immunomodulators (group B), and healthy controls (group C). The study population received 1 intramuscular injection of PCV13. The primary outcome measure was adequate vaccine response defined as postvaccination titer ≥0.35 μg/mL to all 13 serotypes. Geometric mean titers and geometric mean titer rises were measured for all serotypes. The evidence of local and systemic adverse effects for 5 days after the vaccine was registered.

RESULTS

A total of 178 subjects (122 patients and 56 controls) completed the study course. There was no significant difference in the rate of adequate vaccine response between patients with IBD and controls measured 4 to 8 weeks after vaccination (90.4% versus 96.5%, P = 0.5281). Children in group A had higher geometric mean titer rises than children in group B (P = 0.0369). There were no serious adverse events related to PCV13 during the study.

CONCLUSIONS

PCV13 is both immunogenic and safe in pediatric patients with IBD.

Effects of immunosuppressants on immune response to vaccine in inflammatory bowel disease

OBJECTIVE

To evaluate the response rate to vaccination in different treatment groups (nonimmunosuppressants and immunosuppressants).

DATA SOURCES

We completed an online systematic search using PubMed to identify all articles published in English between January 1990 and December 2013 assessing the effect of the response rate to vaccination in different treatment groups (with and without immunomodulators). The following terms were used: "inflammatory bowel disease (IBD)" OR "Crohn's disease" OR "ulcerative colitis" AND ("vaccination" OR "vaccine") AND ("corticosteroids" OR "mercaptopurine" OR "azathioprine" OR "methotrexate [MTX]") AND "immunomodulators."

STUDY SELECTION

The inclusion criteria of articles were that the studies: (1) Randomized controlled trials which included patients with a diagnosis of IBD (established by standard clinical, radiographic, endoscopic, and histologic criteria); (2) exposed patients received immunomodulators for maintenance (weight-appropriate doses of 6-mercaptopurine/azathioprine or within 3 months of stopping, 15 mg or more MTX per week or within 3 months of stopping; (3) exposed patients received nonimmunomodulators (no therapy, antibiotics only, mesalazine only, biological agent only such as infliximab, adalimumab, certolizumab or natalizumab or within 3 months of stopping one of these agents). The exclusion criteria of articles were that the studies: (1) History of hepatitis B virus (HBV), influenza or streptococcus pneumoniae infection; (2) patients who had previously been vaccinated against HBV, influenza or streptococcus pneumoniae; (3) any medical condition known to cause immunosuppression (e.g. chronic renal failure and human immunodeficiency virus infection); (4) individuals with positive hepatitis markers or liver cirrhosis; (5) patients with a known allergy to eggs or other components of the vaccines and (6) pregnancy.

RESULTS

Patients treated with immunomodulators were associated with lower response rates to vaccination.

CONCLUSIONS

Immunomodulators may impair the immune response to vaccination in patients with IBD. Vaccination should be made at the time of diagnosis or before starting immunosuppressed therapy.

Immunisation in children and adolescents with inflammatory bowel disease

Inflammatory bowel disease (IBD) patients may be at a higher risk for developing infections due to underlying disease, malnutrition, surgery, or immunosuppressive therapy. Therefore, protecting this group against infections is of particular importance. Immunisation against vaccine-preventable diseases is strongly recommended. This article for the first time summarises data on immunogenicity and safety of vaccines in IBD children and provides an update on some important issues regarding immunisation in these group of children.

Antibody and cell-mediated immune response to whole virion and split virion influenza vaccine in patients with inflammatory bowel disease on maintenance immunosuppressive and biological therapy

OBJECTIVE

Influenza vaccination is recommended for inflammatory bowel disease (IBD) patients on immunosuppressive therapy. The objective was to evaluate the antibody and cell-mediated immune response to the split and whole virion influenza vaccine in patients with IBD treated with anti-TNF-α and immunosuppressive therapy.

PATIENTS AND METHODS

One hundred and fifty-six immunocompromised IBD patients were vaccinated. Fifty-three patients (control group) refused vaccination. Split virion vaccine and whole virion vaccine were used. Serum samples were obtained for pre- and postimmunization antibody titers to influenza vaccine (A/California/7/2009 [H1N1], A/Victoria/361/2011 [H3N2], B/Wisconsin/1/2010-like B/Hubei-Wujiagang/158/2009). Cell-mediated response was evaluated using an interferon (INF)-γ, interleukine (IL)-2 and tumor necrosis factor (TNF)-α ELISA.

RESULTS

Postimmunization titers of both influenza subtypes increased significantly after the administration of split virion vaccines compared to the controls and to those who received whole virion vaccine. The antibody titers of Influenza B also increased significantly in patients immunized with split vaccine and treated with anti-TNF-α therapy. After influenza vaccination, the level of serum IL-2 significantly decreased. No serious side effects developed occurred after influenza vaccination, and the influenza-like symptoms did not differ significantly between vaccinated versus control patients. The relapse of the disease was observed in only 10% of the patients and was more common in vaccinated than in control subjects.

CONCLUSION

Split virion vaccines seem to be more effective than whole virion vaccines. Measuring the antibody responses is worthwhile in patients treated with immunosuppressants to determine the efficacy of influenza vaccination.

Vaccinating the inflammatory bowel disease patient

Current therapeutic options for patients with inflammatory bowel disease (IBD) include several agents that can alter their immune response to infections. Effective vaccines exist and offer protection against a number of infectious diseases. However, recent data has shown that IBD patients are inadequately vaccinated and, as a result, at risk to develop certain preventable infections. Furthermore, gastroenterologists' knowledge regarding the appropriate immunizations to administer to their IBD patients is suboptimal. This review article focuses on the current immunization schedule for the IBD patient and stresses the important role of the gastroenterologist as an active participant in the management of vaccination in their IBD patients.

Insufficient knowledge of korean gastroenterologists regarding the vaccination of patients with inflammatory bowel disease

Background/Aims

There is an increased risk for inflammatory bowel disease (IBD) patients to develop infections due to the use of immunomodulators and biologics. Several infections are preventable by immunizations. This study investigated the knowledge and awareness of Korean gastroenterologists regarding the vaccination of patients with IBD.

Methods

A self-reported questionnaire was sent by e-mail to the faculty members of tertiary hospitals. Gastroenterologists were asked ten questions regarding the immunization of patients with IBD. A total of 56 gastroenterologists completed the questionnaire.

Results

A majority of gastroenterologists (>60%) had rarely or never recorded an immunization history from their patients with IBD. Moreover, 50% to 70% of the gastroenterologists did not know that live vaccines should be avoided in immunosuppressed patients. The most commonly mentioned resistance to vaccinations was "the lack of concern and knowledge regarding vaccination." Gastroenterologists more frequently asked about the immunization history of influenza, pneumococcal, hepatitis A, and hepatitis B vaccines and recommended these vaccines more often than others.

Conclusions

Korean gastroenterologists' awareness and knowledge regarding the vaccination of patients with IBD were very poor. Intensive educational programs on immunization guidelines directed toward gastroenterologists who care for patients with IBD are required to ensure that these patients receive the necessary vaccinations.

Incidence, outcomes, and health services burden of very early onset inflammatory bowel disease

BACKGROUND & AIMS

The Paris pediatric modification of the Montreal classification defines very early onset inflammatory bowel disease (VEO-IBD) as a form of IBD distinct from that of older children. We compared the incidence and outcomes of VEO-IBD with those of IBD in older children.

METHODS

We performed a population-based retrospective cohort study of all children diagnosed with IBD in Ontario, Canada, from 1994 through 2009. Trends in standardized incidence were calculated using Poisson regression. We compared outpatient and emergency department visits, hospitalizations, and surgeries among children diagnosed with IBD when they were younger than age 6, ages 6-9.9, and older than age 10 years. Multivariable models were adjusted for income and stratified by sex.

RESULTS

The incidence of IBD increased from 9.4 per 100,000 children (95% confidence interval [CI], 8.2-10.8/100,000 children) in 1994 to 13.2 per 100,000 children (95% CI, 11.9-14.6/100,000 children) in 2009 (P < .0001). The incidence increased by 7.4% per year among children younger than 6 years old and 6-9.9 years old, and by 2.2% per year among children ≥10 years old. IBD-related outpatient visits were less frequent among children <6 years old than ≥10 years old (odds ratio for female patients, 0.67; 95% CI, 0.58-0.78; odds ratio for male patients, 0.86; 95% CI, 0.75-0.98). Hazard ratios [HRs] for hospitalization were lower for children <6 years old (female HR, 0.70; 95% CI, 0.56-0.87; male HR, 1.12; 95% CI, 0.94-1.33) than for older children. HRs for surgery among children <6 years old with Crohn's disease were 0.35 for female patients (95% CI, 0.16-0.78) and 0.59 for male patients (95% CI, 0.34-0.99). HRs for children <6 years old with ulcerative colitis were 0.88 for female patients (95% CI, 0.47-1.63) and 0.42 for male patients (95% CI, 0.21-0.85). There was no difference in hospitalization or surgery rates among children 6-9.9 years old vs those ≥10 years old.

CONCLUSIONS

Based on a retrospective cohort study, the incidence of VEO-IBD increased from 1994 through 2009. Children diagnosed with IBD before they were 6 years old used fewer health services and had lower rates of surgery than children diagnosed when they were 10 years or older.

Long-term safety of immunomodulators in pediatric inflammatory diseases

The medical management of chronic inflammatory disorders in children, including mainly inflammatory bowel diseases and rheumatic diseases, has evolved dramatically over recent years with the advent of disease-modifying drugs such as immunomodulators and biological agents capable of interrupting the inflammatory cascade underlying these disorders. These agents are generally administered in patients who are refractory to conventional therapies. However, there is growing support that their use in the initial phases of these disorders, especially in pediatric patients, could interrupt and cease the inflammatory process. Thus, the aims of therapy have transitioned from symptomatic control to the achievement of deeper remission, including the healing of the inflammatory lesions combined with symptomatic remission. Therefore, more patients are currently receiving immunomodulators or biologics, frequently in addition to corticosteroids. Immunosuppression due to these therapies increases safety concerns, particularly regarding the risk of infections and malignancies. The available literature highlights how the combination of more than one of these therapies, especially if the combination includes corticosteroids, amplifies the risk of severe opportunistic infections. Otherwise, the infections described are mainly mild. Regarding malignancies, the overall risk associated with treatment appears non-significant in pediatric populations, but an appropriate benefit/risk assessment is recommended prior to the introduction of aggressive treatments such as immunomodulants and biologics. The background cancer risk related to the disease itself remains an issue. Protracted follow-up programs are needed, and the results from international multicenter registries are awaited to better understand the true risk related to therapy of these pediatric populations.

Uptake of influenza vaccine in ulcerative colitis

BACKGROUND

The incidence of vaccine-preventable-disease is increasing. Current practice guidelines recommend annual influenza vaccination for all inflammatory bowel disease (IBD) patients.

STUDY

Using the Business Objects database of Clalit Health Services in the Tel Aviv district we identified all patients over 18 years-old with a diagnosis of ulcerative colitis (UC) on 31.12.05. This cohort was followed until 31.12.12. Subjects over age 50 without IBD who are also targeted for influenza vaccination served as controls. The uptake of annual influenza vaccination was recorded.

RESULTS

470 UC patients were included (241 (51.3%) males, age 50.4 ± 18.4 years, disease duration 158.9 ± 86.5 months), and 2960 controls. During the years 2006, 2007, 2008, 2009, 2010, 2011 and 2012 the uptake of influenza vaccination was 101 (21.5%), 122 (26.0%), 147 (31.3%), 181 (38.5%), 177 (37.7%), 170 (36.2%) and 178 (37.9%) amongst UC patients, and 993 (33.5%), 1360 (45.9%), 1524 (51.5%), 1611 (54.4%), 1446 (48.9%), 1576 (53.2%) and 1557 (52.6%) amongst controls (p<0.0001 for every year). Independent predictors of vaccination included age (OR, 1.05; 95% CI, 1.03-1.06; p<0.001) and cardiovascular risk (OR, 1.81; 95% CI, 1.31-2.49; p<0.01).

CONCLUSIONS

Although uptake influenza vaccination is consistently lower in UC compared to controls, an upward trend was observed over the study period. Public health initiatives should target this high-risk population to promote immunization.

Immunisations in Crohn's disease: who? why? what? when?

Immunosuppression induced by drugs increase the risk of infections in Crohn's disease (CD) patients. The vaccination rate in CD patients is usually low due to inaccurate information concerning the safety and efficacy of vaccines. Vaccines and immunoglobulins, are artificial ways of protection from common infectious diseases and they have had a major effect on mortality. Herein we detail the need of protection induced by vaccines of measles, varicella, Zoster, papillomavirus, shingles, pneumococcal invasive disease, influenza, hepatitis A and B in CD at diagnosis and during the course of the disease even during immunosuppression periods but with different singularities. Vaccination in CD travellers and the matters related to immunization of household healthy members of immunosuppressed patients are also discussed.

Defining quality indicators for best-practice management of inflammatory bowel disease in Canada

BACKGROUND

There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management.

METHODS

The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members.

RESULTS

Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy.

CONCLUSIONS

These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.

Infliximab and/or immunomodulators inhibit immune responses to trivalent influenza vaccination in adults with inflammatory bowel disease

BACKGROUND AND AIMS

Appropriate influenza vaccination is important for patients with inflammatory bowel disease under immunosuppressive therapy. The purpose of this study was to evaluate the influence of immunosuppressive therapy on the immune response to the trivalent influenza vaccine in adult patients with inflammatory bowel disease.

METHODS

In this cohort study, 91 participants received a single dose of influenza vaccine for the 2010/2011 season. Serum samples were collected at 3 different times (pre-vaccination, 3 weeks post-vaccination, and after flu season) to measure hemagglutination inhibition antibody titers. Immune responses were compared based on immunosuppressive therapy.

RESULTS

Among the 88 subjects who completed the study, the influenza vaccine induced a more than 4-fold increase in the mean antibody level for all flu strains. The overall seroprotection proportion (post-vaccination titer ≥ 1:40) was 81% for H1N1, 61% for H3N2, and 86% for B. Treatment with an immunomodulator reduced the immune response to the H1N1 strain (OR=0.20, p=0.01), and treatment with infliximab reduced the immune response to the other strains (H3N2 strain: OR=0.37, p=0.02; B strain: OR=0.18, p=0.03). Combination therapy with azathioprine/6-mercaptopurine and infliximab significantly inhibited the immune response to H1N1 (OR=0.056, p=0.02).

CONCLUSIONS

Infliximab and/or immunomodulators inhibit immune responses to some strains of trivalent influenza vaccination in adults with inflammatory bowel disease. For optimization of the trivalent influenza vaccination for patients with adult inflammatory bowel disease treated with immunosuppressive agents, establishing an effective vaccination method is crucial.

The pandemic influenza A (H1N1) 2009 vaccine does not increase the mortality rate of idiopathic interstitial pneumonia: a matched case-control study

Background

Evidence regarding the mortality rate after administration of the pandemic influenza A (H1N1) 2009 vaccine on patients with underlying diseases is currently scarce. We conducted a case-control study in Japan to compare the mortality rates of patients with idiopathic interstitial pneumonia after the vaccines were administered and were not administered.

Methods

Between October 2009 and March 2010, we collected clinical records in Japan and conducted a 1∶1 matched case-control study. Patients with idiopathic interstitial pneumonia who died during this period were considered case patients, and those who survived were considered control patients. We determined and compared the proportion of each group that received the pandemic influenza A (H1N1) 2009 vaccine and estimated the odds ratio. Finally, we conducted simulations that compensated for the shortcomings of the study associated with adjusted severity of idiopathic interstitial pneumonia.

Results

The case and control groups each comprised of 75 patients with idiopathic interstitial pneumonia. The proportion of patients who received the pandemic influenza A (H1N1) 2009 vaccine was 30.7% and 38.7% for the case and control groups, respectively. During that winter, the crude conditional odds ratio of mortality was 0.63 (95% confidence interval, 0.25–1.47) and the adjusted conditional odds ratio was 1.18 (95% confidence interval, 0.33–4.49); neither was significant. The simulation study showed more accurate conditional odds ratios of 0.63–0.71.

Conclusions

In our study, we detected no evidence that the influenza A (H1N1) 2009 vaccine increased the mortality rate of patients with idiopathic interstitial pneumonia. The results, however, are limited by the small sample size and low statistical power. A larger-scale study is required.

Influenza vaccination coverage in children with inflammatory bowel disease

The aim of this study was to evaluate the influenza vaccination status among paediatric patients with inflammatory bowel disease (IBD) in Poland. This was a questionnaire-based study. 242 patients with IBD and 142 controls were enrolled in the study. Of patients with IBD, 7·8% received an influenza vaccine, compared to 18·3% of controls (P = 0·0013). There were no statistically significant differences in time from IBD diagnosis, disease activity and in drugs, between vaccinated and non-vaccinated IBD children. In conclusion, the data of our study demonstrate an alarmingly poor influenza vaccination status in the majority of children with IBD. Therefore, there is an unmet need to implement better influenza vaccination strategies for this group of patients.

Utilization of influenza immunization in adults with Crohn's disease-a longitudinal, population-based study

BACKGROUND

The incidence of vaccine-preventable disease is increasing. Several guidelines recommend annual influenza vaccination for patients with inflammatory bowel disease.

METHODS

Using the Business Objects database of Clalit Health Services in the Tel Aviv district we identified all patients older than 18 years with a diagnosis of Crohn's disease (CD) on December 31, 2005. This cohort was followed until December 31, 2012. Subjects without inflammatory bowel disease older than 50 years served as controls. The uptake of annual influenza vaccination was recorded.

RESULTS

The study included 515 patients with CD (267 [51.8%] men, age 48.9 ± 17.5 years, disease duration 142.7 ± 56.9 months) and 2960 controls (1262 [42.6%] men, P < 0.01, age 68.9 ± 11.1 years, P < 0.01). The mean number of influenza vaccines received from 2006 to 2012 was 2.08 ± 2.46 and 3.40 ± 2.71 in CD and controls, respectively (P < 0.01). Uptake was higher in patients with CD aged 50 to 59 years and 60 to 69 years, compared with controls (0.45 ± 0.04 versus 0.24 ± 0.01, P < 0.01 and 0.64 ± 0.06 versus 0.50 ± 0.01, P = 0.04, respectively). Vaccination uptake increased significantly over time in both groups (P < 0.01). Predictors of vaccination in CD included age, female sex, immunosuppression, and cardiovascular disease.

CONCLUSIONS

Uptake of influenza vaccination in CD has increased over the past 7 years, and among subjects older than 50 years, uptake remains higher in age-matched controls. Nevertheless, overall uptake remains low, particularly in young males.

Efficacy of hepatitis A vaccination and factors impacting on seroconversion in patients with inflammatory bowel disease

BACKGROUND

Little is known about the immune response to hepatitis A virus (HAV) vaccinations in patients with inflammatory bowel disease (IBD). We therefore assessed the immunogenicity of HAV vaccine in patients with IBD and evaluated the impact on vaccination efficacy of immunosuppressants, including corticosteroids, thiopurines, and anti-tumor necrosis factor (anti-TNF) agents.

METHODS

This open prospective study evaluated the efficacy of HAV vaccination in 419 anti-HAV-negative adult patients with IBD. Patients were vaccinated against HAV at 0 and 6 to 12 months, with seroconversion (anti-HAV immunoglobulin G) measured 1 to 3 months after the second dose.

RESULTS

Of the 419 vaccinated patients who finished the study protocol (mean age, 26.9 yr), 355 (84.7%) had Crohn's disease and 64 (15.3%) had ulcerative colitis. The overall seroconversion rate was 97.6% (409/419) but was significantly lower in patients treated with the anti-TNF monoclonal antibody infliximab or adalimumab than in those not treated (92.4% [85/92] versus 99.1% [324/327], P = 0.001). In addition, the seroconversion rate was significantly lower in patients treated with ≥2 than with <2 immunosuppressants (92.6% [50/54] versus 98.4% [359/365], P = 0.03). When comparing anti-TNF alone with anti-TNF and other immunosuppressants, there was no significant difference in seroconversion rates (odds ratio, 1.2; 95% confidence interval, 0.2-5.6; P = 0.83). The sample/cutoff ratio was significantly lower in patients who did receive anti-TNF therapy than in those who did not (5.5 versus 9.6; P < 0.001).

CONCLUSIONS

Although HAV vaccination is generally effective in patients with IBD, the seroconversion rate is lower in patients receiving anti-TNF agents (ClinicalTrials.gov registration number NCT01341808).

2013 IDSA clinical practice guideline for vaccination of the immunocompromised host

An international panel of experts prepared an evidenced-based guideline for vaccination of immunocompromised adults and children. These guidelines are intended for use by primary care and subspecialty providers who care for immunocompromised patients. Evidence was often limited. Areas that warrant future investigation are highlighted.

Factors associated with vaccination among inflammatory bowel disease patients in Korea

BACKGROUND/AIMS

Vaccinations are generally recommended in patients with inflammatory bowel disease (IBD). However, several studies showed low rates of vaccinations in IBD patients. Furthermore, vaccination rate among IBD patients in Korea has never been investigated. We investigated the vaccination rate among IBD patients in Korea and evaluated some factors that might affect the vaccination rate.

METHODS

From November 2011 to February 2012, a total of 192 patients with IBD who visited Samsung Medical Center (Seoul, Korea) answered the IRB-approved questionnaire. The questionnaire included their sex, age, residence, past medical history, type of IBD, duration of illness, medications, history of vaccination about measles-mumps-rubella (MMR), varicella, tetanus-diphtheria (Td), influenza, hepatitis A and B, pneumococcus and human papilloma virus (HPV).

RESULTS

One hundred twenty one (63.0%) male and 71 (37.0%) female answered the questionnaire. The mean age of the enrolled patients was 39.7 (18-76) years. Eighty four patients (43.8%) had ulcerative colitis and 108 patients (56.3%) had Crohn's disease (CD). The percentage of the patients who had got vaccination was 42.2% for MMR, 34.9% for varicella, 15.6% for Td, 37.5% for influenza, 15.6% for hepatitis A, 52.6% for hepatitis B, 6.3% for pneumococcus and 11.3% for HPV respectively. Not knowing the necessity or the existence were the common reasons for non-vaccination. Age less than 40 years, CD patients and duration of illness less than 10 years were associated with a higher vaccination rate (p=0.002, 0.015 and 0.020, respectively).

CONCLUSIONS

Immunization rates for recommended vaccinations were very low in patients with IBD. Efforts to improve vaccination rate are needed.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

Evaluation of antibody response to polysaccharide vaccine and switched memory B cells in pediatric patients with inflammatory bowel disease

Background/Aims

Inflammatory bowel disease (IBD) is a chronic disease of the gastrointestinal tract, whose etiologies are still unknown. This study was performed to evaluate the humoral immune response in terms of B cell functions in selected IBD patients.

Methods

Eighteen pediatric patients with IBD, including 12 cases of ulcerative colitis (UC) and six with Crohn disease (CD), were enrolled in this study. The pneumococcal vaccine was injected in all patients, and the IgG antibody level to the polysaccharide antigen was measured before and 4 weeks after injection. The B cell switch-recombination process was evaluated.

Results

Five patients with IBD (three CD and two UC) had defects in B cell switching, which was significantly higher than in controls (p=0.05). Ten patients had a specific antibody deficiency and exhibited a higher frequency of bacterial infection than the healthy group. The mean increased level of IgG after vaccination was lower in IBD patients (82.9±32.5 µg/mL vs 219.8±59.0 µg/mL; p=0.001). Among the patients who had an insufficient response, no significant difference in the number of switched memory B-cell was observed.

Conclusions

A defect in B lymphocyte switching was observed in pediatric IBD patients, and especially in those patients with CD. Owing to an increased risk of bacterial infections in those patients with antibody production defects, pneumococcal vaccination could be recommended. However, not all patients can benefit from the vaccination, and several may require other prophylactic methods.

Immunization history of children with inflammatory bowel disease

BACKGROUND

Protection against vaccine-preventable diseases is important in children with inflammatory bowel disease (IBD) due to frequent immunosuppressive therapy use. The chronic relapsing nature and treatment regimen of IBD may necessitate modified timing of immunizations.

OBJECTIVE

To evaluate the completeness of immunizations in children with IBD.

METHODS

Immunization records of all children with IBD followed at the Alberta Children's Hospital (Calgary, Alberta) were reviewed. For children with incomplete immunization according to the province of Alberta schedule, the reasons for such were clarified. Demographic data and age at diagnosis were also collected.

RESULTS

Immunization records were obtained from 145 (79%) children with IBD. Fifteen children had incomplete routine childhood immunizations, including two with no previous immunizations. The most common incomplete immunizations included hepatitis B (n=9), diphtheria, tetanus, acellular pertussis at 14 to 16 years of age (n=7), and diphtheria, tetanus, acellular pertussis, inactivated polio at four to six years of age (n=6). The reasons for incomplete immunization included use of immunosuppressive therapy at time of scheduled immunization; IBD-related symptoms at time of scheduled immunization; parental refusal; recent move from elsewhere with different immunization schedule; unawareness of routine immunization; and needle phobia.

CONCLUSIONS

Although the majority of children with IBD had complete childhood immunizations, suboptimal immunizations were present in 10%. With increasing use of immunosuppressive therapy in IBD, physicians caring for children with IBD must periodically evaluate immunization status and ensure the completeness of childhood immunizations.

Safety and utilization of influenza immunization in children with inflammatory bowel disease

OBJECTIVE

Influenza immunization is recommended for children with IBD, however safety concerns may limit uptake. This study assessed whether immunization was associated with adverse events in IBD patients using a population-based database of children with IBD.

METHODS

All children <19 years diagnosed with IBD in Ontario, Canada between 1999-2009 were identified using health administrative data, and matched to non-IBD controls. Self-controlled case series (SCCS) analyses determined health services event rates (outpatient visits, hospitalizations and emergency visits) in any 2-week risk period to 180 days post-immunization compared to a no-risk control period. Relative incidence (RI) was calculated for overall and IBD-related events and rates were compared between IBD cases and controls using relative incidence ratios (RIR).

RESULTS

A total of 4916 IBD patients were matched to 21 686 controls. IBD patients were more likely to have received immunization than controls (25.3% vs 13.2%, P < .001). No increased event rates existed in IBD cases during risk periods (pooled RI 0.95, 95% CI 0.84-1.07), including hospitalizations and emergency visits. There was a slightly higher event rate in IBD cases versus controls for days 3-14 (RIR 1.60, 95% CI 1.05-2.44, P = .03). IBD-related visit rates were lower in risk periods compared to control period (pooled RI 0.81, 95% CI 0.68-0.96).

CONCLUSIONS

There was no increase in health services use in the post-vaccine risk period in IBD patients, and there was evidence for a protective effect of influenza immunization against IBD-related health services use. Influenza immunization is safe in children with IBD and should be encouraged to improve poor coverage rates.

Immunogenicity and tolerability to human papillomavirus-like particle vaccine in girls and young women with inflammatory bowel disease

BACKGROUND

Female patients receiving immunosuppressive therapy may be at increased risk for human papillomavirus (HPV) infection and cervical neoplasia.

METHODS

We administered the 3-dose HPV vaccine Gardasil to 37 females aged 9 to 26 years with inflammatory bowel disease (IBD) prescribed immunosuppressive therapy (prospective cohort). Geometric mean titers (GMT) in milli-Merck (mMu/mL) units were determined before dose 1 and 1 month after dose 3 by competitive Luminex immunoassay (cLIA) and qualitatively compared with healthy females of similar age from Merck's database. Side effects and adverse events were evaluated. Concurrently, in 15 similar patients with inflammatory bowel disease previously vaccinated by their primary care provider, we assessed antibody titers by competitive Luminex immunoassay and total immunoglobulin G LIA after dose 3 of vaccine (range, 0.5-27 months).

RESULTS

Mean age of prospective patients was 15 years with 51% on anti-tumor necrosis factor therapy and 49% on immunomodulators: 33 of 37 completed all 3 doses. Seropositivity after dose 3 was 100% for types 6, 11 and 16 and 96% for type 18. Geometric mean titers for HPV-6, HPV-11, HPV-16 and HPV-18 was 1080, 1682, 3975 and 858, respectively and did not qualitatively differ from healthy females. No serious adverse events were attributable to the vaccine. In the previously vaccinated cohort, seropositivity was 100% for types 6, 11, and 16, and 40% for type 18 by competitive Luminex immunoassay (93% for HPV-18 by immunoglobulin G LIA). Titers decreased with time since dose 3.

CONCLUSIONS

In this small study of patients with inflammatory bowel disease prescribed immunosuppressive therapy, Gardasil was immunogenic and there were no clinically significant vaccine-associated adverse events.

Vaccination strategies in patients with IBD

Patients with IBD are at increased risk of infection, in part owing to the disease itself, but mostly because of treatment with immunosuppressive drugs. Although many of these infections are vaccine-preventable, vaccination coverage in patients with IBD is extremely low. The vaccine strategies examined in this Review are based on data that enable us to provide practical advice for clinicians. Clinical evidence indicates that vaccines do not increase the risk of relapse in patients with IBD. Live vaccines are contraindicated in immunocompromised individuals, but inactivated vaccines can be safely administered. Most patients receiving immunosuppressive therapy develop an immune response after vaccination, but response rates might differ from those of nonimmunosuppressed individuals. Therefore, vaccination status should be checked and updated upon diagnosis of IBD.

Immune response to influenza A/H1N1 vaccine in inflammatory bowel disease patients treated with anti TNF-α agents: effects of combined therapy with immunosuppressants

BACKGROUND AND AIMS

Our first objective was to evaluate the immune response to the adjuvanted 2009 A/H1N1 pandemic (pH1N1) vaccine in inflammatory bowel disease (IBD) patients treated with anti-TNF-α alone or combined with immunosuppressants (IS). Second and third aims were the safety of pH1N1 vaccine and the effects on IBD clinical activity.

METHODS

36 patients with Crohn's disease (CD) and 26 with ulcerative colitis (UC) and thirty-one healthy control (HC) subjects were enrolled. 47 patients were on anti TNF-α maintenance monotherapy and 15 on anti TNF-α combined with IS. Sera were collected at baseline (T0) and 4 weeks after the vaccination (T1) for antibody determination by hemagglutination inhibition (HAI). Disease activity was monitored at T0 and T1.

RESULTS

Seroprotective titers (≥1:40) in patients were comparable to HC. Seroconvertion rate (≥4 fold increase in HAI titer) was lower than HC in IBD patients (p=0.009), either on anti TNF-α monotherapy (p=0.034) or combined with IS (p=0.011). Geometric mean titer (GMT) of antibodies at T1 was significantly lower in patients on combined therapy versus those on monotherapy (p=0.0017) and versus HC (p=0.011). The factor increase of GMT at T1 versus T0 was significantly lower in IBD patients versus HC (p=0.042), and in those on combined immunosuppression, both versus monotherapy (p=0.0048) and HC (p=0.0015). None of the patients experienced a disease flare.

CONCLUSION

Our study has shown a suboptimal response to pH1N1 vaccine in IBD patients on therapy with anti TNF-α and IS compared to those on anti-TNF-α monotherapy and HC.

Vaccines and recommendations for their use in inflammatory bowel disease

The patient with inflammatory bowel disease will be predisposed to numerous infections due their immune status. It is therefore important to understand the immune and serologic status at diagnosis and to put the patient into an adapted vaccination program. This program would be applied differently according to two patient groups: the immunocompromised and the non-immunocompromised. In general, the first group would avoid the use of live-virus vaccines, and in all cases, inflammatory bowel disease treatment would take precedence over vaccine risk. It is important to individualize vaccination schedules according to the type of patient, the treatment used and the disease pattern.In addition, patient with inflammatory bowel disease should be considered for the following vaccines: varicella vaccine, human papilloma virus, influenza, pneumococcal polysaccharide vaccine and hepatitis B vaccine.

Efficacy of the vaccination in inflammatory bowel disease

Inflammatory bowel disease (IBD) is associated with conditions that may predispose to infections, such as the lack of an appropriate innate immune response to infectious agents, malnutrition, surgery, and immunosuppressive and biological drugs. Some of these infections may be preventable by vaccination. Therefore, for this particular patient population, the benefits of implementing a well-established immunization protocol in daily clinical practice are potentially even greater than for the general population. In recent years international consensus guidelines have been published, but in spite of theses recommendations, studies have shown that a significant number of patients with IBD remain inadequately immunized. Another important issue regarding immunization in this population is that vaccine efficacy among patients receiving immunosuppressive therapies has been variable. In a healthy population, a humoral immune response to hepatitis B vaccination (HBV) is expected in > 90%, whereas a much lower rate is achieved in the IBD patients. Immunosuppressive, anti-tumor necrosis factor therapy and disease activity have been implicated in the impaired efficacy of the vaccination. The serological response to HBV should be confirmed and patients with an inadequate response should receive a second full series of vaccine. Modified dosing regimens, including doubling the standard antigen dose, might increase the effectiveness. Response to influenza, pneumococcal and tetanus immunization is still not clear, as there are studies that show a normal response to the vaccination while others demonstrate a lack of efficacy. We pose a series of questions on the efficacy of the different vaccinations recommended for IBD patients and attempt to answer them using scientific evidence.

An audit of influenza vaccination status in adults with inflammatory bowel disease

BACKGROUND

Several guidelines recommend influenza vaccination for high-risk patients, including those on immune-suppressing medications (IS).

OBJECTIVE

To assess the vaccination status and immunization history of an outpatient inflammatory bowel disease (IBD) population for H1N1 and seasonal influenza.

RESULTS

Among 250 patients, 104 (41.6%) had been immunized against H1N1 and 62 (24.8%) against seasonal influenza, and 158 (63.2%) were taking IS (azathioprine, 6-mercaptopurine, infliximab, adalimumab, methotrexate, cyclosporine or prednisone). Among subjects on IS, the presence of comorbidities warranting vaccination was associated with higher likelihood of H1N1 immunization (62.5% versus 35.8%; P=0.022) but not of seasonal influenza vaccination (25.0% versus 17.2%; P=0.392). Among patients without comorbidities warranting vaccination, IS was associated with a decreased likelihood of vaccination against seasonal influenza (17.2% versus 30.7%; P=0.036) but not H1N1 (35.8% versus 41.3%; P=0.46). The frequency of H1N1 vaccination was significantly higher among patients who visited a general practitioner at least once yearly (45.7% versus 20%; P=0.0027), with a similar trend for seasonal influenza vaccination (27.1% versus 12.5%; P=0.073). Among 91 patients on IS who declined vaccination, 39.6% reported fear of immediate side effects, 29.7% reported concerns about developing serious medical complications, 15.4% reported concerns about activating IBD and 15.4% were not aware that vaccination was indicated.

CONCLUSIONS

Current strategies for vaccinating IBD patients on IS are inadequate. Primary care provider education, incentive programs and regular primary care contact may improve immunization uptake.

Immunogenicity and acceptance of influenza A (H1N1) vaccine in a cohort of chronic hepatitis C patients receiving pegylated-interferon treatment

Background & Aims

Individuals at risk of (H1N1) influenza A infection are recommended to receive vaccination. Chronic hepatitis C (CHC) patients receiving treatment might be at a higher risk of respiratory bacterial infections after influenza infection. However, there are no observational studies evaluating the immunogenicity, tolerance and acceptance of 2009 influenza A vaccine in CHC patients.

Methods

We evaluated the immunogenicity of influenza A vaccine (Pandemrix®) by using the hemagglutination inhibition (HI) titers method in a well defined cohort of CHC patients receiving or not receiving pegylated-interferon and ribavirin, and compared it with healthy subjects (controls). A group of patients with inflammatory bowel disease (IBD) under immunosuppression, thought to have a lower immune response to seasonal influenza vaccine, were also included as a negative control group. In addition, tolerance to injection site reactions and acceptance was assessed by a validated questionnaire (Vaccinees' perception of injection-VAPI-questionnaire).

Results

Of 114 subjects invited to participate, 68% accepted and, after exclusions, 72 were included. Post-vaccination geometric mean titers and seroprotection/seroconversion rates were optimal in CHC patients with ongoing treatment (n = 15; 232, CI95% 46–1166; 93%; 93%), without treatment (n = 10; 226, CI95% 69–743: 100%; 100%) and controls (n = 15;168, CI95% 42–680; 93%; 86%) with no differences between groups (P = 0.8). In contrast, IBD patients had a significantly lower immunogenic response (n = 27; 60, CI95% 42–680;66%;66%; P = 0.006). All the groups showed a satisfactory tolerance although CHC patients with ongoing treatment showed more local discomfort after vaccine injection.

Conclusion

There appeared to be no differences between CHC patients and healthy controls in serological response and acceptance of (H1N1) influenza vaccination.

The efficiency of influenza vaccines in patients with inflammatory bowel disease on immunosuppressive therapy

Introduction: Inactivated influenza vaccination is recommended yearly for patients with inflammatory bowel disease on immunosuppressive therapy. Aim: The aim of our study was to evaluate the immune response to seasonal influenza vaccination in patients with inflammatory bowel disease treated with immunosuppressants. Patients and methods: Thirty patients were enrolled in this prospective study. Each patient was diagnosed with inflammatory bowel disease and treated with immunosuppressants. Blood samples were obtained from patients before and one month after influenza vaccination (A/California/7/2009(H1N1), A/Perth/16/2009(H3N2) B/Brisbane/60/2008) to assess the pre-and postimmunization antibody titers. Virus-specific antibodies were measured by ELISA. Results: The vaccine acceptance rate was 53.3%. Local adverse effect occurred in 5 patients. Seven patients developed systemic adverse events. Influenza-like symptoms occurred in 2 patients, although their antibody titers failed to increase significantly. Antibodies to influenza viruses were detected in each patient before the vaccination. Conclusion: The results confirmed that each patient had appropriate antibody titer as correlation of protection even before the immunisation. Seroprotection rates were not influenced by the vaccination. The vaccine seemed to be safe. Orv. Hetil., 2012, 153, 1870–1874.

Efficacy of hepatitis B vaccination and revaccination and factors impacting on response in patients with inflammatory bowel disease

OBJECTIVES

We assessed the effectiveness of hepatitis B virus (HBV) vaccine in inflammatory bowel disease (IBD) patients, evaluated the impact of immunosuppressors and anti-tumor necrosis factor (anti-TNF) agents, and assessed the effectiveness of revaccination.

METHODS

IBD patients were vaccinated against HBV with a quick (0, 1, and 2 months) and double-dose schedule (Engerix B). A second vaccination was administered to nonresponders.

RESULTS

Of 241 vaccinated patients, anti-HBs was >10 IU/l in 59% and >100 IU/l in 39%. The response rate (anti-HBs >10 IU/l) was lower among patients under anti-TNF therapy: 46% vs. 62%. In the multivariate analysis, a lower response rate was demonstrated in older patients and those receiving anti-TNFs. The response rate (anti-HBs >100 IU/l) after revaccination was 42%.

CONCLUSIONS

The response rate to the HBV vaccination--even with a double-dose schedule--is very low in IBD patients, mainly in those receiving anti-TNFs. However, treatment with immunosuppressors did not affect the efficacy of the vaccine. A considerable--albeit insufficient--success rate may be obtained when two consecutive vaccination courses, each with a three-dose vaccine series, are administered.

Risk of infection and prevention in pediatric patients with IBD: ESPGHAN IBD Porto Group commentary

Combined immunosuppression by immunomodulators and biological therapy has become standard in the medical management of moderate-to-severe inflammatory bowel disease (IBD) because of clearly demonstrated efficacy. Clinical studies, registries, and case reports warn of the increased risk of infections, particularly opportunistic infections; however, already in the steroid monotherapy era, patients are at risk because it is accepted that a patient should be considered immunosuppressed when receiving a daily dose of 20 mg of prednisone for 2 weeks. Prescriptions increasingly involve azathioprine, methotrexate, and various biological agents. The TREAT registry evaluated safety in >6000 adult patients, half of them treated with infliximab (IFX) for about 1.9 years. IFX-treated patients had an increased risk of infections and this was associated with disease severity and concomitant prednisone use. The REACH study, evaluating the efficacy of IFX in children with moderate-to-severe Crohn disease, refractory to immunomodulatory treatment, reports serious infections as the major adverse events and their frequency is higher with shorter treatment intervals. The combination of immunosuppressive medications is a risk factor for opportunistic infections. Exhaustive guidelines on prophylaxis, diagnosis, and management of opportunistic infections in adult patients with IBD have been published by a European Crohn's and Colitis Organization working group, including clear evidence-based statements. We have reviewed the literature on infections in pediatric IBD as well as the European Crohn's and Colitis Organization guidelines to present a commentary on infection prophylaxis for the pediatric age group.

Health maintenance in the inflammatory bowel disease patient

Gastroenterologists are in a unique position to make very positive differences in the lives of their IBD patients. We understand that IBD patients do not receive preventive services at the same rate as general medical patients. Because these individuals are at increased risk for complications from preventable diseases, we have a valuable opportunity to protect this population (Table 1). Establishing a close working relationship with PCPs can facilitate delivering quality care, but it is important to note that some of these patients rely solely on their GI clinician for the majority of their care. In such a vulnerable population, it is important to be aggressive with vaccine recommendations, monitoring for depression, tobacco cessation, and in performing the appropriate cancer screening examinations. As professional societies and health care system increase their focus on quality measures, incorporating these important issues into routine practice will ultimately result in addressing quality standards; perhaps more important, it should provide our patients with the best individual care possible.