Guidelines for immunizations in patients with inflammatory bowel disease

Common Mistakes in Managing Patients with Inflammatory Bowel Disease

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

Health Care Maintenance in Pediatric Inflammatory Bowel Disease

Patients with pediatric inflammatory bowel disease (pIBD) are at an increased risk for complications and comorbidities including infection, nutritional deficiencies, growth delay, bone disease, eye disease, malignancy, and psychologic disorders. Preventative health maintenance and monitoring is an important part to caring for patients with pIBD. Although practice is variable and published study within pIBD is limited, this article summarizes the important field of health-care maintenance in pIBD. A multidisciplinary approach, including the gastroenterologist provider, primary care provider, social worker, psychologist, as well as other subspecialists is necessary.

Is Vaccination Against COVID-19 Associated With Inflammatory Bowel Disease Flare? Self-Controlled Case Series Analysis Using the UK CPRD

INTRODUCTION

To investigate the association between vaccination against coronavirus disease 2019 (COVID-19) and inflammatory bowel disease (IBD) flare.

METHODS

Patients with IBD vaccinated against COVID-19 who consulted for disease flare between December 1, 2020, and December 31, 2021, were ascertained from the Clinical Practice Research Datalink. IBD flares were identified using consultation and corticosteroid prescription records. Vaccinations were identified using product codes and vaccination dates. The study period was partitioned into vaccine-exposed (vaccination date and 21 days immediately after), prevaccination (7 days immediately before vaccination), and the remaining vaccine-unexposed periods. Participants contributed data with multiple vaccinations and IBD flares. Season-adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) were calculated using self-controlled case series analysis.

RESULTS

Data for 1911 cases with IBD were included; 52% of them were female, and their mean age was 49 years. Approximately 63% of participants had ulcerative colitis (UC). COVID-19 vaccination was not associated with increased IBD flares in the vaccine-exposed period when all vaccinations were considered (aIRR [95% CI] 0.89 [0.77-1.02], 0.79 [0.66-0.95], and 1.00 [0.79-1.27] in IBD overall, UC, and Crohn's disease, respectively). Analyses stratified to include only first, second, or third COVID-19 vaccinations found no significant association between vaccination and IBD flares in the vaccine-exposed period (aIRR [95% CI] 0.87 [0.71-1.06], 0.93 [0.75-1.15], and 0.86 [0.63-1.17], respectively). Similarly, stratification by COVID-19 before vaccination and by vaccination with vectored DNA or messenger RNA vaccine did not reveal an increased risk of flare in any of these subgroups.

DISCUSSION

Vaccination against COVID-19 was not associated with IBD flares regardless of prior COVID-19 infection and whether messenger RNA or DNA vaccines were used.

Efficacy, immunogenicity, and safety of available vaccines in children on biologics: A systematic review and meta-analysis

Vaccinations are essential for preventing infectious diseases in children with chronic diseases as they have increased risk of infection from frequent use of biologics. Response to immunizations in this group is not well known.

OBJECTIVE

A systematic review was performed to evaluate three primary outcomes: efficacy; immunogenicity; and safety of vaccines in children with chronic conditions treated with biologics.

METHODS

The protocol for our systematic review and meta-analysis was registered and published with PROSPERO. We searched electronic bibliographic databases for studies published from 2009 to 2019, focusing on vaccinations in children with chronic conditions treated with biologics.

RESULTS

We retrieved 532 records. Thirty-one full-text articles were selected, and 14 were included in the meta-analysis. No significant publication bias was found.

EFFICACY

limited data are available regarding the efficacy of vaccination, as most studies have focused on immunogenicity as surrogate outcome for efficacy. Immunogenicity: patients receiving anti-TNF-alpha therapy had a statistically significant risk of poor seroconversion (p = 0.028) and seroprotection by the serotype B influenza vaccine [inflammatory bowel disease (IBD) p = 0.013; juvenile idiopathic arthritis (JIA) p = 0.004]. We found adequate responses with H1N1 and H3N2 serotypes. Few studies existed for pneumococcal, hepatitis A virus, hepatitis B virus, varicella-zoster virus, Measles Mumps Rubella virus, and multiple vaccine administration.

SAFETY

vaccine administration was not associated with serious side effects, but JIA patients on anti-TNF alpha therapy had a statistically significant risk of presenting with myalgia or arthralgia postinfluenza vaccine (p = 0.014).

CONCLUSIONS

More evidence concerning efficacy, immunogenicity, and safety of vaccinations is needed to guide physicians in the vaccine decision process for this pediatric population.

Seroprevalence of viral infectious diseases and associated factors in Korean patients with inflammatory bowel diseases

BACKGROUND/AIMS

Data on the immunoprotective status against measles, mumps, rubella, varicella zoster virus (VZV), hepatitis A virus (HAV), and Epstein-Barr virus (EBV) infection in patients with inflammatory bowel disease (IBD) are still lacking. Therefore, we investigated the seropositivity rates for viral infectious diseases and the associated factors in Korean patients with IBD.

METHODS

In this retrospective cohort study, serum immunoglobulin G antibody positivity rates against measles virus, mumps virus, rubella virus, VZV, HAV, and EBV viral capsid antigen (VCA) were measured in patients with Crohn's disease or ulcerative colitis (UC) who first visited the IBD clinic. Seropositivity rates and their associated factors were analyzed.

RESULTS

Between January 2016 and December 2018, 263 patients were enrolled (male, 167 [67.3%]; UC, 134 [50.9%]). The median age at serological test was 30 years (interquartile range, 22 to 46). The seropositivity rates were 84.0%, 85.2%, 66.5%, 87.4%, 50.0%, and 93.7% for measles, mumps, rubella, VZV, HAV, and EBV, respectively. Younger age at serological test was associated with seronegative status for measles (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.88 to 0.96), VZV (aOR, 0.83; 95% CI, 0.74 to 0.93), and HAV (aOR, 0.93; 95% CI, 0.91 to 0.95). Furthermore, IBD type-UC was associated with seronegative status against VZV (aOR, 0.33; 95% CI, 0.11 to 0.99).

CONCLUSION

Seropositivity rates for common viral infectious diseases in Korean patients with IBD were similar to those of the general population. In the younger age group, protective immunity against measles, VZV, and HAV is required, with proper vaccination, as necessary.

Insufficient vaccination and inadequate immunization rates among Korean patients with inflammatory bowel diseases

ABSTRACT

This study aimed to evaluate self-reported vaccination rates, immunity, knowledge of and attitudes toward vaccination among Korean patients with inflammatory bowel disease (IBD) as well as to identify factors associated with proper vaccination.Between November 2013 and February 2015, consecutive patients with IBD were invited to complete a standardized questionnaire on vaccination. Moreover, immune status for common vaccine-preventable diseases was evaluated via serologic tests.A total of 310 patients with IBD were invited to the questionnaire survey and 287 patients (92.6%) who completed the questionnaires were finally enrolled (men, 188 [65.5%], median age at survey, 29.9 years [interquartile range, 22.3-39.2], ulcerative colitis: Crohn disease = 165:122]. Self-reported vaccine uptake rates were as follows: hepatitis A virus (HAV; 13.2%), hepatitis B virus (HBV; 35.2%), seasonal influenza (43.2%), pneumococcus (4.9%). Most of the patients (87.1%) did not know that proper vaccination has been recommended for patients with IBD. Up to 64.8% and 32.8% of patients were negative for IgG anti-HAV antibody and IgG HBV surface antibody, respectively. In a multivariable analysis, newspaper subscription (aOR [adjusted odds ratio] 2.185, 95% confidence interval [CI] 1.136-4.203, P = .019), ever recommendation of vaccination by a physician (aOR 2.456, 95% CI 1.240-4.862, P = .010), and use of anti-tumor necrosis factor agents (aOR 4.966, 95% CI 1.098-22.464, P = .037) showed a significant association with uptake of adult vaccines recommended for patients with IBD.Vaccine uptake rates, positivity of antibody to HAV and HBV, and knowledge of patients with IBD regarding vaccination were not sufficient. Proper educational information and recommendation from physicians could enhance awareness among patients with IBD about the need for vaccination and thereby improve vaccination rates.Trial registration number: NCT01984879.

Risk of Vaccine-Preventable Infections in Swiss Adults with Inflammatory Bowel Disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of infection and are frequently not up to date with their immunizations.

OBJECTIVES

This study aims to review vaccination status and evaluate whether age, disease type, or treatment regimen could predict the absence of seroprotection against selected vaccine-preventable infection in adults with IBD.

METHODS

Cross-sectional study using questionnaire, immunization records review, and assessment of tetanus-specific, varicella-specific, and measles-specific immunoglobulin G concentrations. ClinicalTrials.gov: NCT01908283.

RESULTS

Among the 306 adults assessed (median age 42.7 years old, 70% with Crohn's disease, 78% receiving immunosuppressive treatment), only 33% had an immunization record available. Absence of seroprotection against tetanus (6%) was associated with increasing age and absence of booster dose; absence of seroprotection against varicella (1%) or measles (3%) was exclusively observed in younger patients with Crohn's disease. There was no statistically significant difference in immunoglobulin concentrations among treatment groups. Although vaccinations are strongly recommended in IBD patients, the frequencies of participants with at least 1 dose of vaccine recorded were low for nearly all antigens: tetanus 94%, diphtheria 87%, pertussis 54%, poliovirus 22%, measles-mumps-rubella 47%, varicella-zoster 0%, Streptococcus pneumoniae 5%, Neisseria meningitidis 12%, hepatitis A 41%, hepatitis B 48%, human papillomavirus 5%, and tick-borne encephalitis 6%.

CONCLUSIONS

Although many guidelines recommend the vaccination of IBD patients, disease prevention through immunization is still often overlooked, including in Switzerland, increasing their risk of vaccine-preventable diseases. Serological testing should be standardized to monitor patients' protection during follow-up as immunity may wane faster in this population.

A Review of Vaccinations in Adult Patients with Secondary Immunodeficiency

Vaccine-preventable diseases and their related complications are associated with increased morbidity and mortality in patients with altered immunocompetence. Optimised immunisation in this patient population is challenging because of limited data from vaccine trials, suboptimal vaccine efficacy and safety concerns. Reliable efficacy data are lacking among patients with altered immunocompetence, and existing recommendations are mainly based on expert consensus and may vary geographically. Inactivated vaccines can be generally used without risks in this group, but their efficacy may be reduced, and immunisation schedules vary according to local guidelines, age, and type and stage of the underlying disease. Live vaccines, if indicated, should be administered with care because of the risk of vaccine-associated disease. We have reviewed the current evidence on vaccination principles and recommendations in adult patients with secondary immunodeficiencies, including asplenia, HIV infection, stem cell and solid organ transplant, haematological malignancies, inflammatory bowel disease and other chronic disorders.

Are patients with inflammatory bowel disease receiving adequate immunisation?

INTRODUCTION

Inflammatory Bowel Disease (IBD) treatment may increase the risk of infections. Vaccines are part of the comprehensive IBD patient care. The aim of this study was to describe indications and adherence of immunizations in IBD and identify possible associated factors.

METHODS

A cross-sectional, analytic study was conducted in patients from an IBD Program of a tertiary center in Chile, between April - June 2019. Patients were asked to answer a vaccine survey and information also was obtained from the National Immunization Registry. Descriptive and association statistic were used (χ²; p<0.05).

RESULTS

A total of 243 patients were included (148 ulcerative colitis (UC), 86 Crohn's disease (CD) and 9 non-classifiable IBD). Only six patients (2%) of IBD patients received a complete immunization schedule. The highest vaccine rates were against influenza (67%), hepatitis B virus (40%), 13-valent pneumococcal (34%) and 23-polysaccharide pneumococcal (16%). The influenza vaccine rate has significantly increased, reaching 67% in 2019. The survey showed that 23% of patients have not been immunized with any vaccine, mainly due to lack of time, lack of medical prescription and high cost.

CONCLUSIONS

In this cohort, although vaccination rates are higher than previously reported, adherence to IBD immunization program would be improved, being considered since diagnosis by the multidisciplinary team.

Epstein-Barr virus infection in ulcerative colitis: a clinicopathologic study from a Chinese area

BACKGROUND

Opportunistic Epstein-Barr virus (EBV) infection in patients with ulcerative colitis (UC) has attracted increasing attention. This study aimed to evaluate the clinicopathological characteristics and clinical outcomes of UC with intestinal EBV infection and to explore the predictive value of blood EBV DNA for the presence of EBV in the intestine.

METHODS

Both peripheral blood and intestinal biopsies from 92 consecutive UC inpatients were included in this study. Normal colonic mucosal tissues from 20 colon cancer patients were used as controls. EBV testing and assessment were performed by EBV-DNA polymerase chain reaction (PCR), EBV-encoded small RNA in situ hybridization (EBER-ISH) and immunohistochemistry.

RESULTS

A total of 36 patients (39.1%) had UC with superimposed EBV colitis [EBER greater than 2/high-power field (HPF)]. EBER counts and disease activity were significantly correlated (p < 0.05). The major endoscopic findings revealed more irregular and longitudinal ulcers in patients with superimposed EBV colitis (p = 0.016, p = 0.021, respectively). Age, steroid dependence, and irregular ulcerations were identified as possible risk factors. The best EBER cut-off point for outcome prediction was 2.5/HPF. At a cut-off value of 2035 copies/ml, the sensitivity and specificity of the blood EBV-DNA PCR analysis for predicting EBV presence in the intestine were 76.5% and 68.5%, respectively. EBV-infected cells in UC with high EBV concentrations mainly included B lymphocytes by clinicopathology, and the infection might have progressed from the latent to the lytic phase of the EBV life cycle.

CONCLUSION

The EBER count is positively correlated with disease activity. The best cut-off point for outcome prediction is 2.5/HPF. A high EBV viremia load may effectively predict EBV presence in the colonic mucosa.

A comprehensive review of vaccination in patients with inflammatory bowel diseases: An Indian perspective

The disease burden of inflammatory bowel diseases (IBD) in India is estimated to be one of the highest in the world in the near future. Patients with IBD, particularly those on immunosuppressive therapy, are at increased risk for developing vaccine-preventable illnesses. Adult vaccination policy and vaccination in patients with IBD are presently being at a very low level in India. This review discusses in detail the need for vaccination, levels of immunosuppression, a brief account of live and inactivated vaccines, available vaccines, and their utility in patients with IBD, with a special focus on recent recommendations.

SEROCONVERSION ANALYSIS AFTER HABITUAL HEPATITIS B VACCINATION SCHEME IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

BACKGROUND

Patients with inflammatory bowel disease (IBD) vaccinated for hepatitis B have a low success rate in achieving protective antibody levels. The main factors suggested for this are IBD itself and the use of immunosuppressive drugs.

OBJECTIVE

To evaluate the concentration of anti-HBs antibodies and to verify factors associated with the effectiveness of hepatitis B vaccination in patients with IBD.

METHODS

This is a prospective, consecutive, observational, descriptive and analytical, non-randomized, qualitative study that evaluated the levels of anti-HBs antibodies in IBD patients at the Interdisciplinary Inflammatory Bowel Disease Clinic of the Family and Community Health Unit of UNIVALI - Itajaí, Santa Catarina.

RESULTS

Thirty-six patients were vaccinated against hepatitis B virus (HBV), of which 29 were female. The average age was 46.2 years. Regarding the type of IBD, twenty-four patients had Crohn's disease and the duration of inflammatory bowel disease was 74 months. Fifteen patients were on concomitant immunosuppressive therapy. The effective response rate to HBV vaccine was 72.2%, verified by anti-HBs titration ≥10 UI/L. Statistical analysis revealed a negative response to vaccination in patients with Crohn's disease and immunosuppressive drugs.

CONCLUSION

The success rate of HBV immunization in IBD patients is low compared to the general population. Type of disease and use of immunosuppressive drugs appear to influence the vaccine response.

The pharmacotherapeutic management of pediatric Crohn's disease

Introduction: Crohn's disease (CD) is a chronic inflammatory condition that can occur throughout the gastrointestinal tract. The aims of treatment of children with CD are to induce and maintain clinical remission of disease, optimize nutrition and growth, minimize adverse effects of therapies, and if possible, achieve mucosal healing.Areas covered: This review summarizes evidence for the various therapeutic options in the treatment of children with CD. Exclusive enteral nutrition, corticosteroids, and biologics may be used for induction of remission. Immunomodulators (thiopurines, methotrexate) and biologics (infliximab, adalimumab) may be employed for maintenance of remission to prevent flares of disease and avoid chronic steroid use. In cases of fibrotic disease, intestinal perforations, or medically refractory, surgery may be the best therapeutic option.Expert opinion: Exclusive enteral nutrition, corticosteroids, and biologics (including anti-TNF inhibitors) may be used for induction of remission in patients with active flare of their disease. Immunomodulators and TNF inhibitors may be used for maintenance of remission. Early use of anti-TNF inhibitors in patients with moderate to severe CD may improve efficacy and prevent penetrating complications of disease. While pediatric data is limited, newer biologics, such as vedolizumab and ustekinumab, are used off-label in anti-TNF refractory disease.

Health Maintenance and Vaccination of Patients With Inflammatory Bowel Disease: Practice and Perception of Responsibility of Gastroenterologists vs Primary Care Providers

Background: Although it is well established that patients with inflammatory bowel disease (IBD) are at increased risk of complicating diseases and vaccination-preventable infections, whether gastroenterologists (GIs) or primary care providers (PCPs) assume responsibility for these patients' health maintenance is not clear. Methods: We anonymously surveyed a convenience sample of 94 PCPs and 61 GIs at Saint Louis University School of Medicine in St. Louis, MO, about their practice and perception of the health maintenance and vaccination of patients with IBD. Results: Response rates were 82% and 93% for GIs and PCPs, respectively. GIs were as likely as PCPs to screen for smoking (88% vs 89%) and were significantly less likely to screen for depression/anxiety (24% vs 54%) or to provide pertussis (14% vs 44%) or diphtheria (20% vs 48%) vaccines. GIs were significantly more likely than PCPs to assess for colonoscopy need (94% vs 80%); to screen for nonmelanoma skin cancer (62% vs 14%), melanoma (56% vs 7%), osteoporosis (72% vs 51%), or tuberculosis (94% vs 44%); to prescribe calcium/vitamin D (74% vs 53%); to perform nutritional assessment (78% vs 33%); or to provide hepatitis A (60% vs 39%) or hepatitis B (86% vs 56%) vaccines. GIs were as likely as PCPs (64% vs 75%) to perceive that PCPs should order vaccinations and significantly more likely to perceive that GIs should track vaccinations (58% vs 16%) and other health maintenance issues (90% vs 49%). We found positive associations between performing the various health maintenance and vaccination tasks and the perception of responsibility. Conclusion: Several health maintenance aspects are inadequately addressed by GIs and PCPs, in part because of conflicting perceptions of responsibility. Clear guidelines and better GI/PCP communication are required to ensure effective health maintenance for patients with IBD.

IMMUNIZATION STATUS OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE

BACKGROUND

Treatment for inflammatory bowel disease (IBD) includes a variety of immunosuppressants and biological agents, which increase the risk of infections due to altered cellular and humoral immunity. Prevention of these infections can be done through vaccination, however, patients with IBD are usually under-immunized.

OBJECTIVE

Analyze the immunization status of patients with IBD and confront it with the current recommendations to verify if the immunization guidelines are being followed correctly.

METHODS

Analytical cross-sectional study including 239 IBD patients being regularly followed in the Gastroenterology Service from Hospital de Clínicas da Universidade Federal do Paraná, which were subjected to a survey about their relevant demographic data and immunization status.

RESULTS

The amount of patients that declared being unaware of their immunization status is high - between 34.3% (Tdap) and 52% (meningococcal) - excepting IIV, hepatitis B and HPV. The vaccines with the largest rates of patients declaring to have taken it are inactivated influenza vaccine (72.4%), BCG (55.3%), hepatitis B (48.3%), measles, mumps and rubella vaccine (43.8%) and DTaP (43%). The vaccines with the lowest rates of patients declaring to have taken it are Haemophilus influenza type b (0.8%), herpes zoster (2.1%) and HPV (3.4%). Patients that are being treated or have been treated with biological therapy have the largest immunization coverage for inactivated influenza vaccine (81%) and PPSV23 (25.9%), also they have the largest awareness rates for those vaccines.

CONCLUSION

Although being a specialized service linked to a university hospital, vaccination coverage and patients' awareness rates proved to be below the desirable level. Vaccination and recovery of the immunization history is recommended immediately after the diagnosis of IBD, regardless of the use of biological agents. Those findings support the need of implementing hospital guidelines and constantly verifying its application by the multidisciplinary team in specialized services in IBD.

Immunization Coverage in Children with Inflammatory Bowel Disease

Patients suffering from inflammatory bowel diseases (IBD) are at increased risk of infections, mainly due to immunosuppressive treatment. Moreover, infections may cause flares of IBD. Vaccination is the most effective way of preventing many infections. The aim of this study was to evaluate the vaccination status of Polish children with IBD. Individual immunization cards of children with IBD and healthy controls were reviewed. Demographic data such as age, sex, and IBD history, including therapy type, were collected. We enrolled 267 children into the study, including 214 children with IBD and 53 controls. None of the children had completed the full up-to-date routine childhood immunization schedule recommended in Poland. Controls were more than 4 times more likely to be vaccinated than the IBD patients, with the vaccines that enjoy the insurance reimbursed (OR 4.1, 95% CI 2.2-7.9). In conclusion, the study demonstrates a poor vaccination status in children suffering from IBD.

Improved Antibody Response to Three Additional Hepatitis B Vaccine Doses Following Primary Vaccination Failure in Patients with Inflammatory Bowel Disease

BACKGROUND

Studies have shown the efficacy of hepatitis B (HBV) vaccination in patients with inflammatory bowel disease (IBD) is impaired, but few data exist regarding the effectiveness of revaccination strategies following primary vaccination failure. Our aim was to analyze the association between administration of additional vaccine doses and hepatitis B surface antibody (HBsAb) seroconversion.

METHODS

This is a retrospective cohort study. Inclusion criteria are as follows: age ≥ 18, diagnosis of Crohn's disease (CD) or ulcerative colitis (UC), inadequate HBsAb < 10 IU/L following initial HBV vaccination series, subsequent administration of 1-3 additional doses of HBV vaccine with follow-up serum HBsAb measurements. Patients were stratified into groups of ≤ 2 or 3 doses received. Primary outcome was achieving HBsAb > 10 IU/L. Outcomes were stratified by age ≥ or < 40 years. We performed logistic and linear multivariable regression analyses for categorical and continuous data.

RESULTS

The study cohort consists of (n = 149) 54.4% women; 77.9% white; 72.6% with CD, with mean age: 46.2. Patients of all ages and age ≥ 40 years, who received 3 additional doses of vaccine, were more likely to achieve seroprotective HBsAb levels than patients who received 1 or 2 doses (OR 1.77, P = 0.01; OR 1.9, P = 0.03, respectively, after adjusting for age, sex, race, immunosuppressive medication exposure, time between vaccine/titer).

CONCLUSIONS

Following initial HBV vaccination failure, patients with IBD of all ages are more likely to develop seroprotective levels of HBsAb following 3 additional vaccine doses, rather than 1 or 2 alone. In patients who fail primary HBV vaccination, providers should consider a more aggressive revaccination strategy with an additional 3-dose series.

High Immunogenicity of the Pneumococcal Conjugated Vaccine in Immunocompromised Adults With Inflammatory Bowel Disease

INTRODUCTION

Patients with inflammatory bowel disease (IBD) are predisposed to pneumococcal infections due to their underlying disease and iatrogenic immunosuppression. Vaccination with the 13-valent pneumococcal conjugated vaccine (PCV13) is recommended, but with poor take-up and few data available. We performed an open-label, phase IV, multicenter study to evaluate the safety and immunogenicity of PCV13 in adults with IBD and to analyze the influence of immunomodulating treatments on anti-pneumococcal seroresponses.

METHODS

We enrolled 306 patients with IBD from March 2014 through February 2016, with the following exclusion criteria: current IBD flare, pregnancy, pneumococcal immunization in the previous 5 years, and influenza immunization in the previous 4 weeks. PCV13 was administered intramuscularly. Serotype-specific vaccine responses were evaluated using an opsonophagocytic assay. Adverse events were monitored by diary cards and standardized phone interviews.

RESULTS

The median seroprotection rate increased significantly from 43.9% (95% confidence interval [CI], 42.3-45.5) at inclusion to 90.4% (95% CI, 89.5-91.3%; P < 0.001) after vaccination. Patients receiving anti-tumor necrosis factor agents achieved a slightly lower seroprotection rate (from 44.5% [95% CI, 42.3%-46.8%] to 86.6% [95% CI, 84.9%-88.1%]) than patients treated with other types of immunosuppressive regimens (thiopurine, methotrexate, oral corticosteroids; from 44.7% [95% CI, 41.7%-47.7%] to 93.8% [95% CI, 92.1%-95.2%]) or nonimmunosuppressive treatment (5-aminosalicylate, topical corticosteroids, vedolizumab; from 41.3% [95% CI, 37.9%-44.8%] to 95.2% [95% CI, 93.4%-96.6%]). There were no safety issues.

DISCUSSION

Overall, the administration of PCV13 was highly immunogenic and well tolerated, irrespective of the baseline treatment, and should be encouraged in all adults with IBD.

Serologic Status of Routine Childhood Vaccines, Cytomegalovirus, and Epstein-Barr Virus in Children With Inflammatory Bowel Disease

BACKGROUND

Data on the serologic status of childhood vaccines, cytomegalovirus (CMV) and Epstein-Barr virus (EBV), are limited in inflammatory bowel disease (IBD). Therefore, we evaluated vaccine coverage and seroprotection, along with CMV and EBV seropositivity, in pediatric IBD.

METHODS

In a cross-sectional study, demographic data, IBD history, vaccine records, and serum for antibodies against measles, mumps, rubella, diphtheria, tetanus, varicella, hepatitis B (HBV), CMV, and EBV were collected from children with IBD. We evaluated potential factors associated with serologic status.

RESULTS

Of 156 subjects, vaccine coverage was up to date for age in 93.5% for measles, mumps, rubella, 95.6% for diphtheria, tetanus, pertussis, polio, hemophilus influenza B, 75.8% for HBV, and 93.5% for varicella, including past infection and vaccination. Seroprotection was present in 65.8% for measles, 60.5% for mumps, 79.1% for rubella, 79.5% for diphtheria, 80.8% for tetanus, 70.5% for varicella, and 62.8% for HBV of subjects. Older age at diagnosis was associated with seroprotection among subjects with complete HBV (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.03-1.39) and rubella series (OR, 1.18; 95% CI, 1.02-1.37). Older age at serum collection was associated with seroprotection among subjects with prior varicella vaccination or infection (OR, 1.69; 95% CI, 1.33-2.15). Only 25.2% and 37.8% demonstrated seropositivity to CMV and EBV, respectively. Among subjects on immunosuppressive medications, 75.3% and 62.4% were seronegative for CMV and EBV, respectively.

CONCLUSIONS

Children with IBD have low serologic protection to childhood vaccines in spite of high vaccine coverage and universal vaccinations. Children with IBD, including a large proportion on immunosuppressive medications, have low seropositivity to CMV and EBV.

Improving immunization strategies in patients with inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) are susceptible to varieties of opportunistic infections due to immunological changes in the setting of their disease and drug-induced immunosuppression. Even though numerous infections can be prevented by vaccine, vaccination in IBD patients is inadequate. Data showed only 9% were vaccinated against pneumococcal infection and 28% described commonly receiving influenza vaccine. This review article discusses the recent immunizations against influenza virus; pneumococcal infection; human papilloma virus; tetanus, diphtheria and pertussis; measles, mumps and rubella; varicella zoster; and herpes zoster for individuals diagnosed with IBD and those patients with drug-related immunosuppression. In addition, this review discusses concerns about IBD patients planning to travel abroad. Immunization status and screening for opportunistic infection need to be addressed in IBD patients at the time of diagnosis and they should be vaccinated accordingly. Generally, standard vaccination strategies should be pursued in IBD patients, although live vaccines should be avoided while they are not immunocompetent.

A Practical Guide to the Safety and Monitoring of New IBD Therapies

The therapeutic armamentarium of inflammatory bowel disease is rapidly evolving with the development of novel treatment options including targeted monoclonal antibodies and small molecules. With these new therapies come additional safety and side effect concerns. Infections, malignancies, immunogenicity, and metabolic issues exist for each treatment. Management of these agents in the face of such complications is a challenge clinicians will encounter. In this article, we review the existing safety data behind the monoclonal antibodies and small molecules, suggest appropriate risk stratification and assessment considerations before and during therapy, and make expert recommendations on the management of potential complications or clinical scenarios.

Updates on vaccinating the inflammatory bowel disease patient

Many of the therapeutic options for patients with inflammatory bowel disease (IBD) suppress the immune system, which increases the risk of certain infections in these patients. Effective vaccines exist and offer protection against a number of infectious diseases. However, data has shown that IBD patients are inadequately vaccinated and, as a result, are at risk of developing certain preventable infections. Furthermore, gastroenterologists' knowledge regarding the appropriate immunizations to administer to their IBD patients is suboptimal. Areas covered: Over the past several years, there has been a considerable amount of research contributing to our knowledge regarding vaccination of patients with IBD. Expert opinion: This updated 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 health maintenance of their IBD patients.

Immunogenicity of pneumococcal vaccines in comorbid autoimmune and chronic respiratory diseases

Streptococcus pneumoniae causes pneumonia, meningitis, otitis media, and bacteremia. The mortality and morbidity of invasive pneumococcal disease are high among adults aged >65 years or those with underlying chronic or immunosuppressive conditions. A recent systematic review showed that patients treated with immunosuppressive agents have impaired immune responses to pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine compared with healthy subjects. A more favorable response is observed in patients treated with tumor necrosis factor-alpha-blocking agents compared with those treated with other immunosuppressive agents. Low systemic corticosteroid doses do not affect the responses to pneumococcal vaccines. Patients with human immunodeficiency virus and idiopathic pulmonary fibrosis receiving immunosuppressive therapy exhibit decreased immunogenicity to pneumococcal vaccines. The effects of T-cell-dependent PCV possibly depend on host memory B cells in some disease conditions. Several immunosuppressive therapy types and disease conditions may affect the responses to pneumococcal vaccines. Immunization should be administered before immunosuppressive medication initiation whenever possible.

Update on Vaccinating the Patient With Inflammatory Bowel Disease

PURPOSE OF REVIEW

Patients with inflammatory bowel disease (IBD) are at increased risk of infectious diseases independent of their immunosuppression status, and yet, studies suggest that this population is not receiving standard vaccinations at the same rate as the general population. This review seeks to understand why IBD patients may not be receiving recommended immunizations and to provide guidelines on vaccinating this vulnerable population.

RECENT FINDINGS

Inactive vaccines are recommended for patients with IBD regardless of immunosuppression status due to the increased risk for many vaccine-preventable illnesses. Certain live vaccines can be administered to the immunocompromised patient with IBD. Additionally, many patients with IBD will be immunosuppressed some time in their disease course, further increasing their risk for infection. Despite this understanding, patients with IBD have poor vaccination rates. Inadequate knowledge, limited time with patients, and lack of consensus as to who is responsible for identifying and administering vaccinations are some of the most important barriers to vaccinating the patient with IBD. In this review, we discuss guidelines for vaccinating both the immunocompetent and immunosuppressed patient with IBD as well as provide vaccine-specific recommendations. The evidence suggests that patients with IBD are not receiving recommended vaccinations because of misconceptions on the part of patients as well as a paucity of knowledge by their health care team. Educational programs can be successfully implemented to increase knowledge about appropriate vaccinations and can ultimately increase vaccine uptake among patients with IBD. In the end, gastroenterologists and primary care physicians must work together with their patients with IBD to ensure that recommended vaccinations are administered.

Harmful Effects and Potential Benefits of Anti-Tumor Necrosis Factor (TNF)-α on the Liver

Anti-tumor necrosis factor (TNF)-α agents represent an effective treatment for chronic inflammatory diseases. However, some concerns about their potentially undesirable effects on liver function have been reported. On the other hand, evidence of their therapeutic effects on certain liver diseases is accumulating. Many data showed the safety of anti-TNF-α in patients with chronic hepatitis B and C and in liver transplanted patients even if a strict follow-up and prophylaxis are recommended in well-defined subgroups. On the other side, anti-TNF-α-induced liver injury is not a rare event. However, it is often reversible after anti-TNF-α withdrawal. Anti-TNF-α agents have been tested in advanced stages of severe alcoholic hepatitis and non-alcoholic fatty liver disease. Limited data on the efficacy of anti-TNF-α in patients with autoimmune hepatitis and primary biliary cholangitis are also available. In this review, we explored the hepatic safety concerns in patients receiving anti-TNF-α agents with and without pre-existent hepatic diseases. In addition, the available evidence on their potential benefits in the treatment of specific hepatic diseases is discussed.

Evidence-based consensus on opportunistic infections in inflammatory bowel disease (republication)

Inflammatory bowel disease (IBD) patients are a high-risk population for opportunistic infections. The IBD group of the Chinese Society of Gastroenterology of the Chinese Medical Association organized an expert group to discuss and develop this consensus opinion. This consensus opinion referenced clinical study results from China and other countries to provide guidance for clinical practices. Eight major topics, including cytomegalovirus infection, Epstein-Barr virus infection, viral hepatitis, bacterial infection, Mycobacterium tuberculosis infection, fungal infection, parasitic infection, and vaccines were introduced in this article.

Health Maintenance in Inflammatory Bowel Disease

PURPOSE OF REVIEW

Patients with inflammatory bowel disease (IBD) are not receiving preventative care services at the same rate as the general population. IBD patients are at increased risk for infections, osteoporosis, and certain malignancies secondary to their disease and as they are on immunosuppressive therapy. They are a younger population and often times consider their gastroenterologist as their primary care physician. In this review, we discuss up-to-date evidence pertaining to vaccine-preventable illnesses in the immunosuppressed IBD patient, screening for bone health, cervical cancer, skin malignancies, psychological wellbeing, and smoking cessation.

RECENT FINDINGS

Vaccinations are recommended in the IBD population as they are immunosuppressed and at increased risk for acquiring influenza and pneumonia. Not only are they at greater risk to acquire it but they also have a much severe complicated course. Ideally, IBD patients should be vaccinated prior to initiating immunosuppression and most inactive vaccines can be administered to them while they are on therapy. All IBD patients should be encouraged to stop smoking and have adequate vitamin D intake along with appropriate applicable cancer screenings. Gastroenterologists must work in collaboration with primary care providers along with other specialists to help provide our patients well-rounded care for their IBD.

Antibody Response to Hepatitis B Virus Vaccine is Impaired in Patients With Inflammatory Bowel Disease on Infliximab Therapy

BACKGROUND

Studies have demonstrated an association between anti-TNF/immunomodulator agents used in inflammatory bowel disease (IBD) and impaired hepatitis B virus (HBV) vaccine immunogenicity, but little data exist on whether specific medication types affect protective HBsAb titers. Our aim was to analyze this association.

METHODS

This is a retrospective cohort study. Inclusion criteria: age ≥18, diagnosis of Crohn's disease (CD) or ulcerative colitis (UC), previous HBV vaccination series and/or ≥1 positive HBsAb, and record of IBD therapy in 6 months before titer level. Patients were stratified based upon medication exposures: anti-TNF, immunomodulator, combination anti-TNF and immunomodulatory, and a reference arm. Titer levels following vaccination and specific medication types given in the 6 months before titer were recorded. Seroprotection was defined as HBsAb ≥10 IU/l and ≥100 IU/l.

RESULTS

The study cohort (N = 391) was 70.8% white, 51.4% female and 64.2% had CD and 35.8% had UC. The mean age was 45.8 years. A significantly lower percentage of patients exposed to anti-TNF, immunomodulator or dual therapy had titers ≥10 (P < 0.01). Regarding specific medications, only patients exposed to infliximab (P < 0.01) were less likely to have titer levels ≥10, after controlling for other medication exposures, age at titer level, and interval time between vaccination/titer level. This was not found for patients exposed to adalimumab, methotrexate, 6-mercaptopurine, or azathioprine.

CONCLUSIONS

Patients exposed to infliximab were significantly less likely to have protective HBsAb titer levels following vaccination, a trend not seen in patients on adalimumab. Efforts to vaccinate IBD patients against HBV before use of immunomodulators and anti-TNFs, infliximab specifically, and screen periodically thereafter must be reinforced.

Rates and Predictors of Vaccinations Among Inflammatory Bowel Disease Patients Receiving Anti-Tumor Necrosis Factor Agents

BACKGROUND

As an important quality measure, the rates of recommended immunizations among immunocompromised inflammatory bowel disease (IBD) patients in community practice have not been well studied.

AIMS

This study sought to investigate the rates and predictors of recommended immunizations and screening tests among IBD patients receiving anti-tumor necrosis factor (TNF) therapy in a large integrated healthcare organization.

METHODS

We conducted a retrospective cohort study of 1401 IBD patients on anti-TNF therapy between 2010 and 2013 within the Kaiser Permanente Northern California healthcare system. The rates of vaccinations and screening tests were quantified, and the associated predictors were investigated.

RESULTS

Vaccination rates for influenza and pneumococcus were 43.5 and 24.1%, respectively. The majority of patients (73.7%) received hepatitis B screening and/or vaccine. Patients receiving infliximab had higher rates of pneumococcal vaccine (P = 0.002), hepatitis B screening (P < 0.001), and tuberculin skin test (P < 0.001) compared with patients receiving adalimumab. Older patient age (≥50 years) was associated with higher likelihood of having HBsAg test (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-2.0, P = 0.002), influenza vaccine (OR 2.6 [2.1-3.4], P < 0.001), and pneumococcal vaccine (OR 4.0 [3.0-5.3], P < 0.001). In contrast, older providers (≥50 years) were associated with significantly lower likelihood of their patients' having hepatitis A and B screening tests, and pneumococcal vaccination.

CONCLUSIONS

The rates of immunizations for IBD patients receiving anti-TNF treatment were lower than recommended. Structured reminders for vaccinations and education for both patients and providers (older physicians in particular) may prove beneficial in improving immunization rates among immunocompromised IBD patients.

Screening, prophylaxis and counselling before the start of biological therapies: A practical approach focused on IBD patients

The standard of care in the management of immune-mediated inflammatory conditions relies on immunomodulators, glucocorticoids, and biologicals (including anti-tumour necrosis factor -α and other monoclonal antibodies). These agents have an overall favourable benefit/risk ratio; however, they modulate the immune response as part of their mechanisms of action, and therefore they may increase the risk of developing infections, particularly in older patients or in patients with concomitant corticosteroids. Some of these infections may be preventable by immunization, chemoprophylaxis or counselling.

AIM

screening for and monitoring infections throughout these therapies is so mandatory to ensure patients' safety. Still, standardized guidelines focused on these procedures have yet to be established. This review aims to fill such a gap. The authors searched for articles published in English from 2009 until 2017 using PUBMED, with the terms "immunomodulators", "biological drugs", "anti-TNF α", "inflammatory bowel diseases", "immunomediated inflammatory diseases", "risk of infection", "infection prevention", "screening", "immunization", "tuberculosis", "latent tuberculosis", "listeriosis", "endemic mycosis", "Pneumocystis jiroveci pneumonia", "granulomatous infection", "varicella", "herpes virus", "hepatitis B", "hepatitis A", "hepatitis C" and identified the journal articles. Based on the literature and in their own experience the authors established recommendations and a practical guide for infections' screening, monitoring and prevention before and during immunomodulatory and biological therapies.

The Proteome of Ulcerative Colitis in Colon Biopsies from Adults - Optimized Sample Preparation and Comparison with Healthy Controls

PURPOSE

The purpose of the study was to optimize the sample preparation and to further use an improved sample preparation to identify proteome differences between inflamed ulcerative colitis tissue from untreated adults and healthy controls.

EXPERIMENTAL DESIGN

To optimize the sample preparation, we studied the effect of adding different detergents to a urea containing lysis buffer for a Lys-C/trypsin tandem digestion. With the optimized method, we prepared clinical samples from six ulcerative colitis patients and six healthy controls and analysed them by LC-MS/MS. We examined the acquired data to identify differences between the states.

RESULTS

We improved the protein extraction and protein identification number by utilizing a urea and sodium deoxycholate containing buffer. Comparing ulcerative colitis and healthy tissue, we found 168 of 2366 identified proteins differently abundant. Inflammatory proteins are higher abundant in ulcerative colitis, proteins related to anion-transport and mucus production are lower abundant. A high proportion of S100 proteins is differently abundant, notably with both up-regulated and down-regulated proteins.

CONCLUSION AND CLINICAL RELEVANCE

The optimized sample preparation method will improve future proteomic studies on colon mucosa. The observed protein abundance changes and their enrichment in various groups improve our understanding of ulcerative colitis on protein level.

Systematic review: the safety of vedolizumab for the treatment of inflammatory bowel disease

BACKGROUND

Vedolizumab specifically recognises the α4β7 integrin and selectively blocks gut lymphocyte trafficking: potentially, it offers gut-specific immunosuppression.

AIM

To review the safety of vedolizumab and summarise post-marketing data to assess if any safety concerns that differ from registration trials have emerged.

METHOD

A systematic bibliographic search identified six registration trials and nine cohort studies.

RESULTS

Integrated data from registration trials included 2830 vedolizumab-exposed patients (4811 person-years exposure [PYs]) and 513 placebo patients. This reported lower exposure-adjusted incidence rates of infection (63.5/100 PYs; 95% CI: 59.6-67.3) and serious adverse events (20.0/100 PYs; 95% CI: 18.5-21.5) compared to placebo (82.9/100 PYs; 95% CI: 68.3-97.5) and (28.3/100 PYs 95% CI: 20.6-35.9) respectively. Higher, but statistically insignificant rates of enteric infections occurred in vedolizumab-exposed patients (7.4/100 PYs; 95% CI: 6.6-8.3) compared to placebo (6.7 PYs; 95% CI: 3.2-10.1). Six post-marketing cohort studies (1049 patients, 403 PYs) demonstrated rates of infection of 8% (82/1049); enteric infection of 2% (21/1049) and adverse events of 16% (166/1049). Multivariate analysis in one cohort study suggested increased risk of surgical site infection with perioperative VDZ. Human experience in pregnancy is limited.

CONCLUSIONS

Post-marketing data confirm the excellent safety of vedolizumab observed in registration trials. The signal of post-operative complications should be interpreted with caution, but warrants further study. Although comparative studies are needed, Vedolizumab may be a safe alternative in patients who best avoid systematic immunosuppression, including those pre-disposed to infection, malignancy or the elderly.

Healthcare maintenance in elderly patients with inflammatory bowel disease

The increasing number of older patients (age ≥60 years) with inflammatory bowel disease (IBD) highlights the importance of healthcare maintenance in this vulnerable population. Older IBD patients are more susceptible and have higher rates of many disease- and treatment-related adverse effects. Compared to younger IBD patients, older patients are at increased risk for infection, malignancy, bone disease, eye disease, malnutrition and thrombotic complications. Preventive strategies in the elderly differ from those in younger adults and are imperative. Changes to the immune system with aging can decrease the efficacy of vaccinations. Cancer screening guidelines in older IBD patients have to account for unique considerations, such as life expectancy, functional performance status, multimorbidity, financial status, and patient desires. Additionally, providers need to be vigilant in screening for osteoporosis, ocular disease, depression, and adverse events arising from polypharmacy.

Understanding the complications of anti-tumor necrosis factor therapy in East Asian patients with inflammatory bowel disease

Remarkable advances have been made in the treatment of inflammatory bowel disease since the introduction of anti-tumor necrosis factor-α agents, especially for patients who are refractory to or cannot tolerate conventional therapies. Currently, infliximab, adalimumab, and golimumab are available in the East Asian medical market, and these agents have been shown to be effective for inducing and maintaining long-term remission of inflammatory bowel disease. Despite their clinical benefits, anti-tumor necrosis factor therapy can also lead to increased vulnerability to infections, development of autoimmune diseases and malignancy, and decreased immunogenicity of vaccinations. Because infectious diseases, such as tuberculosis, hepatitis, and influenza, remain major health problems in East Asia, more cautious use of biologics is needed. To further improve treatment efficacy and safety, close monitoring of inflammation, regular surveillance for malignancy, and regularly scheduled vaccinations are needed. Treatment strategies for biologics should be customized to meet the needs of different patients.

Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part)

This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.

Diagnostic and vaccine strategies to prevent infections in patients with inflammatory bowel disease

OBJECTIVES

The treatment of inflammatory bowel disease (IBD) has been revolutionized by the use of immunomodulatory agents. Although these potent drugs are effective in controlling disease activity, they also cause an increased risk of new infections or reactivation of latent infections. On these premises, we aimed to provide guidance on the definitions of immunocompromised patients, opportunistic infections and the risk factors associated with their occurrence in an IBD context, and to suggest the proper screening tests for infectious diseases and the vaccination schedules to perform before and/or during therapy with immunomodulators.

METHODS

All the most recent evidences - filtered by the combined work of gastroenterologists and infectious disease experts - were summarized with the aim to provide a practical standpoint for the physician.

RESULTS

A systematic screening of all infections which may arise during therapy with immunomodulator drugs is necessary in all patients with IBD.

CONCLUSIONS

The ideal timing to perform screening tests and vaccinations is at the diagnosis of the disease, regardless of its severity at onset, because the course of IBD and its treatment may vary over time, and an immunocompromised status may hamper efficacy and/or possibility to perform all necessary vaccines.

ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease

Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.

[Ideal vaccination strategy in inflammatory bowel disease]

Inflammatory bowel disease (IBD) is a long-standing disease that often requires long-term use of immunosuppressive agents including immunomodulators (such as azathioprine, 6-mercaptopurine and methotrexate) and tumor necrosis factor-α inhibitors (such as infliximab and adalimumab). Introduction of immunosuppressive therapies, however, involves the risk of host susceptibility to opportunistic infections in this patient population. Therefore, adequate immunization for vaccine-preventable infectious diseases is currently recommended for all patients with IBD and is emerging as an important target for quality improvements in IBD care. However, ongoing issues regarding underuse of immunization, safety and efficacy of vaccines in patients with IBD remain. For quality improvements in IBD care, all physicians should follow the recent immunization guidelines proposed by professional IBD societies. Additionally, there are ongoing needs for intensive educational programs regarding a role of immunization in long-term care of IBD and up-to-date immunization guidelines. Immunization status should be checked at the time of diagnosis of IBD and timely vaccination before initiation of immunosuppressive therapies can be a practical solution for maximizing the efficacy of vaccination at this point. Inactivated vaccines can be used safely irrespective of immunization status of patients, while attenuated vaccines are contraindicated in patients on immunosuppressive therapies. This article reviews an ideal strategy for vaccinating patients with IBD based on the currently recommended immunization guidelines.

Experts Opinion on the Practical Use of Azathioprine and 6-Mercaptopurine in Inflammatory Bowel Disease

The relevance of azathioprine and 6-mercaptopurine therapy in inflammatory bowel disease, Crohn's disease, and ulcerative colitis, has been challenged in recent publications. In this article, a panel of experts gives advice, based on the relevant literature, on indications and practical use of azathioprine/6-mercaptopurine, prevention, and management of drug adverse reactions and special situations such as vaccination, pregnancy, and lactation.

Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA

BACKGROUND

Increasing prevalence of inflammatory bowel disease (IBD) poses significant challenges to medical community. Preventive medicine, including vaccination against opportunistic infections, is important in decreasing morbidity and mortality in patients with IBD. We conduct first study to evaluate general awareness and adherence to immunisation guidelines by primary care physicians in the USA.

METHODS

We administered an electronic questionnaire to the research panel of the American College of Physicians (ACP) assessing current vaccination practices, barriers to vaccination and provider responsibility for administering vaccinations and compared responses with the European Crohn's and Colitis Organization consensus guidelines and expert opinion from the USA.

RESULTS

All of surveyed physicians (276) had experience with patients with IBD and spent majority of their time in direct patient care. 49% of physicians took immunisation history frequently or always, and 76% reported never or rarely checking immunisation antibody titres with only 2% doing so routinely. 65% of physicians believed that primary care providers (PCPs) were responsible for determining patient's immunisation. Vaccine administration was felt to be the duty of primary care doctor 80% of the time. 2.5% of physicians correctly recommended vaccinations all the time. Physicians were more likely to recommend vaccination to immunocompetent than immunocompromised patients. Up to 23% of physicians would incorrectly recommend live vaccine to immunocompromised patients with IBD.

CONCLUSIONS

Current knowledge and degree of comfort among PCPs in the USA in preventing opportunistic infections in IBD population remain low. Management of patients with IBD requires structured approach to their healthcare maintenance in everyday practice, including enhanced educational policy aimed at primary care physicians.

Many Inflammatory Bowel Disease Patients Are Not Immune to Measles or Pertussis

BACKGROUND

Current guidelines emphasize vaccination for influenza and pneumococcus for IBD patients and the avoidance of live virus vaccines for those who are on immunosuppressive (ISS) therapy. Given the recent resurgence of measles and pertussis infections, we assessed the immune status of our IBD population in order to advise about these risks.

METHODS

We prospectively collected measles and pertussis titers in our IBD patients from February 1-May 1, 2015. Immune status based on standard threshold values was determined: measles antibodies ≤0.8 antibody index (AI) = negative immunity, 0.9-1.1 AI = equivocal immunity and titers ≥1.2 AI = positive immunity. For pertussis immunity, anti-pertussis antibodies ≤5 IU/mL were considered negative immunity. Univariate analysis was performed to examine predictive factors including age, disease duration, and current medical therapies.

RESULTS

A total of 122 patients' titers were assessed (77 Crohn's disease, 1 indeterminate colitis, and 45 ulcerative colitis). Sixteen (13.1 %) patients lacked detectable immunity to measles, and four (3 %) had equivocal immunity. Twelve (75 %) of the measles non-immune patients were on ISS therapy versus 65 (64 %) of 102 immune patients (OR 1.7, 95 % CI 0.5-5.9, p = 0.34). Out of 96 patients, 58 (60 %) were not immune to pertussis. Disease duration ≥10 years and age ≥50 were associated with significant lower measles titers.

CONCLUSIONS

A significant number of our IBD patients lack immunity to measles, and a majority of our IBD patients do not have detectable immunity to pertussis. Importantly, the majority of the measles non-immune patients are on ISS therapy and therefore unable to receive a booster.

Health Care Maintenance for the Pediatric Patient With Inflammatory Bowel Disease

Nearly one-quarter of patients with inflammatory bowel disease (IBD) are younger than 20 years of age at diagnosis. Furthermore, the incidence of IBD in children continues to increase. Nevertheless, variation in management exists within the care of patients with IBD with regards to disease screening and preventive care. A multidisciplinary approach that involves the general practitioner and pediatric gastroenterologist is needed to routinely monitor growth, bone health, vitamin and mineral deficiencies, vaccination status, and endoscopic surveillance. It is also important to monitor for extraintestinal manifestations of IBD that may affect the liver, joints, skin, and eyes. The purpose of this article is to provide an updated overview of comprehensive care for pediatric patients with IBD.

Infection-related hospitalizations in the first year after inflammatory bowel disease diagnosis

OBJECTIVE

With the rapid increase in the incidence of inflammatory bowel disease (IBD) in Asia, the natural course of the early phase of disease in these patients remains poorly defined. This study aimed to determined the incidence and characteristics of infection-related hospitalization in the first year in patients newly diagnosed with IBD in Hong Kong SAR, China.

METHODS

Patients newly diagnosed with IBD and enrolled in the territory-wide Hong Kong IBD Registry were identified. Details of their hospitalization within the first 12 months after diagnosis were retrieved and analyzed.

RESULTS

Altogether 433 newly diagnosed IBD patients were enrolled, including 188 with Crohn's disease (CD), 230 with ulcerative colitis (UC) and 15 with IBD-unclassified (IBD-U). Among them, 110 (25.4%) had at least one unscheduled hospitalization in the first year and 34 (7.9%) had infection-related hospitalization, leading to 43 (23.4%) of total hospitalizations. Gastrointestinal tract (30.2%), respiratory tract (34.9%) and skin and soft tissues (11.6%) were the most common sites of infection. Bacterial and viral infections accounted for 46.7% and 20.8% of hospitalizations for infection, respectively. Common identified pathogens included Clostridium difficile (16.3%) and Cytomegalovirus (11.6%). Multivariate analysis found that patient's age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.06) and the presence of comorbidity (OR 2.32, 95% CI 1.05-5.13) were significantly associated with hospitalization from infection in IBD patients.

CONCLUSIONS

Infection-related hospitalizations were found in 7.9% of newly diagnosed IBD patients within the first year after diagnosis in Hong Kong, which accounted for about one-quarter of all unscheduled hospitalizations. Elder patients with concurrent illnesses were at higher risk.

What is the best way to manage screening for infections and vaccination of inflammatory bowel disease patients?

The use of biological agents and immunomodulators for inflammatory bowel disease (IBD) is associated with an increased risk of opportunistic infections, in particular of viral or bacterial etiology. Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination in those patients with IBD, which are candidate for biologic therapy. Available strategies to screen, diagnose and prevent bacterial and viral infections in patients with IBD prior to start biological therapy are discussed in this review.