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Herpes Zoster and Vaccination Strategies in Inflammatory Bowel Diseases: A Practical Guide. Clin Gastroenterol Hepatol 2022; 20:481-490. [PMID: 33080353 DOI: 10.1016/j.cgh.2020.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023]
Abstract
Herpes zoster is a painful dermatomal cutaneous eruption resulting from reactivation of the latent varicella-zoster virus. Patients with inflammatory bowel diseases have an increased risk of shingles compared with the general population and this risk can be increased with the use of immunosuppressive therapy. Live zoster vaccine and recombinant zoster vaccine have shown efficacy for the prevention of herpes zoster. The recombinant zoster vaccine seems to offer greater efficacy and long-term protection profile compared with the life zoster vaccine. However, their use in clinical practice still is unclear and updated vaccination recommendations are lacking. This review discusses the risk for shingles in patients with inflammatory bowel diseases, available vaccines, and their efficacy and safety profiles. We also provide guidance on who, when, and how to vaccinate for herpes zoster in routine clinical practice among patients with inflammatory bowel diseases.
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Chan W, Salazar E, Lim TG, Ong WC, Shim HH. Vaccinations and inflammatory bowel disease - a systematic review. Dig Liver Dis 2021; 53:1079-1088. [PMID: 33994128 DOI: 10.1016/j.dld.2021.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with inflammatory bowel disease(IBD) are at risk of infections, many of which are preventable with vaccinations. We performed a systematic review on various aspects of vaccination in IBD. METHODS We searched PubMed, and EMBASE databases, through 31 January 2021. Primary outcomes included vaccination rates, predictors of vaccination, reasons of vaccination hesitancy and acceptance, and outcomes of intervention. Findings were presented with medians, ranges, and narrative synthesis. RESULTS We included 33 observational studies comprising 146,918 patients and 681 physicians. The median vaccination rates of influenza, pneumococcal pneumonia, and hepatitis B vaccines were 42%(IQR, 28%-61.5%), 20%(IQR, 9%-38.5%), and 48%(IQR, 29%-53%), respectively. Uses of immunosuppressant, older age and physician recommendations have positive influence on vaccination rate. Lack of vaccine-related knowledge and awareness of need for vaccination are main reasons of vaccine hesitancy among patients and physicians. There was disagreement between gastroenterologists and primary-care physicians on whose responsibility to offer vaccination. Education was the sole intervention identified, with variable success. CONCLUSION This systematic review demonstrates that the vaccination rates of IBD patients, similar to other chronic diseases, are suboptimal. Lack of vaccine-related knowledge and awareness of the need for vaccination are main reasons of vaccine hesitancy amongst patients and physicians. Education, though effective, was the only available intervention identified. Gastroenterologist could take the lead in educating, and initiating vaccination among IBD patients.
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Affiliation(s)
- Webber Chan
- Department of Gastroenterology and Hepatology, Singapore General Hospital Singapore.
| | - Ennaliza Salazar
- Department of Gastroenterology and Hepatology, Singapore General Hospital Singapore.
| | - Teong Guan Lim
- Department of Pharmacy, Singapore General Hospital, Singapore.
| | - Wan Chee Ong
- Department of Pharmacy, Singapore General Hospital, Singapore.
| | - Hang Hock Shim
- Parkway East Medical Center, 319 Joo Chiat Place, Singapore 427989.
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3
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Lai SW, Liao KF, Lin CL, Kuo YH, Liu CS, Hwang BF. The incidence rate of herpes zoster in inflammatory bowel disease: A meta-analysis of cohort studies. Medicine (Baltimore) 2021; 100:e26863. [PMID: 34414937 PMCID: PMC8376306 DOI: 10.1097/md.0000000000026863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Inflammatory bowel disease is associated with an increased risk of opportunistic infections. This study aimed to investigate the incidence rate of herpes zoster in patients with inflammatory bowel disease.A meta-analysis was conducted by searching PubMed literature published from January 2000 to July 2019. The main outcome was the incidence rate of a new diagnosis of herpes zoster in patients previously diagnosed with inflammatory bowel disease. The incidence rate ratio (IRR) and 95% confidence interval (95% CI) for herpes zoster associated with inflammatory bowel disease was measured.A total of 6 eligible cohort studies matching the entry criteria were included in the meta-analysis, providing 216,552 participants with inflammatory bowel disease and 790 events of herpes zoster among these participants with inflammatory bowel disease. The pooled incidence rate of developing herpes zoster was 10.41 per 1000 person-years in the inflammatory bowel disease group and 6.10 per 1000 person-years in the non-inflammatory bowel disease group, respectively. The meta-analysis demonstrated that patients with inflammatory bowel disease were associated with 1.68-fold increased risk of developing herpes zoster when compared to those without inflammatory bowel disease (IRR = 1.68, 95% CI = 1.53-1.84). Crohn disease and ulcerative colitis were associated with an increased risk of developing herpes zoster (IRR = 1.67, 95% CI = 1.40-1.98 for Crohn disease and IRR = 1.49, 95% CI = 1.34-1.65 for ulcerative colitis, respectively).Patients with inflammatory bowel disease are at increased risk of developing herpes zoster. We suggest that the vaccination should be considered at the time of inflammatory bowel disease being diagnosed.
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Affiliation(s)
- Shih-Wei Lai
- Department of Public Health, College of Public Health, and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Hepatogastroenterology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Hung Kuo
- Department of Research, Taichung Tzu Chi Hospital, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Bing-Fang Hwang
- Department of Occupational Safety and Health, College of Public Health, China Medical University, Taichung, Taiwan
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Kucharzik T, Ellul P, Greuter T, Rahier JF, Verstockt B, Abreu C, Albuquerque A, Allocca M, Esteve M, Farraye FA, Gordon H, Karmiris K, Kopylov U, Kirchgesner J, MacMahon E, Magro F, Maaser C, de Ridder L, Taxonera C, Toruner M, Tremblay L, Scharl M, Viget N, Zabana Y, Vavricka S. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:879-913. [PMID: 33730753 DOI: 10.1093/ecco-jcc/jjab052] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- T Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - P Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - T Greuter
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland, and Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois CHUV, University Hospital Lausanne, Lausanne, Switzerland
| | - J F Rahier
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Yvoir, Belgium
| | - B Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and Department of Chronic Diseases, Metabolism and Ageing, TARGID-IBD, KU Leuven, Leuven, Belgium
| | - C Abreu
- Infectious Diseases Service, Centro Hospitalar Universitário São João, Porto, Portugal.,Instituto de Inovação e Investigação em Saúde [I3s], Faculty of Medicine, Department of Medicine, University of Porto, Portugal
| | - A Albuquerque
- Gastroenterology Department, St James University Hospital, Leeds, UK
| | - M Allocca
- Humanitas Clinical and Research Center - IRCCS -, Rozzano [Mi], Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - M Esteve
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - F A Farraye
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - H Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - K Karmiris
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Greece
| | - U Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - J Kirchgesner
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Department of Gastroenterology, Paris, France
| | - E MacMahon
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - F Magro
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal.,Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal
| | - C Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Lüneburg, Germany
| | - L de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Taxonera
- IBD Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos [IdISSC], Madrid, Spain
| | - M Toruner
- Ankara University School of Medicine, Department of Gastroenterology, Ankara, Turkey
| | - L Tremblay
- Centre Hospitalier de l'Université de Montréal [CHUM] Pharmacy Department and Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - M Scharl
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
| | - N Viget
- Department of Infectious Diseases, Tourcoing Hospital, Tourcoing, France
| | - Y Zabana
- Hospital Universitari Mútua Terrassa, Digestive Diseases Department, Terrassa, Catalonia, and Centro de Investigación Biomédica en red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - S Vavricka
- University Hospital Zürich, Department of Gastroenterology and Hepatology, Zürich, Switzerland
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5
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Righi E, Gallo T, Azzini AM, Mazzaferri F, Cordioli M, Merighi M, Tacconelli E. A Review of Vaccinations in Adult Patients with Secondary Immunodeficiency. Infect Dis Ther 2021; 10:637-661. [PMID: 33687662 PMCID: PMC7941364 DOI: 10.1007/s40121-021-00404-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 01/20/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Elda Righi
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
- Infectious Diseases, Verona University Hospital, Verona, Italy.
| | - Tolinda Gallo
- Public Health Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Anna Maria Azzini
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Verona University Hospital, Verona, Italy
| | | | - Maddalena Cordioli
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Verona University Hospital, Verona, Italy
| | - Mara Merighi
- Infectious Diseases, Verona University Hospital, Verona, Italy
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Verona University Hospital, Verona, Italy
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6
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D'Arienzo D, Rumjahn Gryte K, Noya F, Morinville VD. Disseminated and Central Nervous System Vaccine-Strain Herpes Zoster Infection in a Teenager With Crohn's Disease on Maintenance Adalimumab Therapy. JPGN REPORTS 2021; 2:e072. [PMID: 37207068 PMCID: PMC10191570 DOI: 10.1097/pg9.0000000000000072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/14/2021] [Indexed: 05/21/2023]
Abstract
Patients on immunosuppression, including inflammatory bowel disease patients on anti-tumor necrosis factor therapies, are at increased risk of severe varicella and herpes zoster infections. Although varicella vaccine-related herpes zoster reactivation is a rare complication, physicians must remain vigilant about this diagnosis, particularly in those on immunosuppressive medications. Here, we report a case of a patient with Crohn disease, on only adalimumab immunosuppression, who developed varicella vaccine-related disseminated herpes zoster with meningitis, over 15 years after immunization.
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Affiliation(s)
- David D'Arienzo
- From the Department of Pediatrics, Montreal Children's Hospital, McGill University
| | | | - Francisco Noya
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital
| | - Veronique D Morinville
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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7
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Infectious Risks Associated with Biologics Targeting Janus Kinase-Signal Transducer and Activator of Transcription Signaling and Complement Pathway for Inflammatory Diseases. Infect Dis Clin North Am 2021; 34:271-310. [PMID: 32444011 DOI: 10.1016/j.idc.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The recognition of the role of complement and Janus kinase (JAK)-dependent cytokines in the pathogenesis of inflammatory and immune-mediated disorders has revolutionized the treatment of a myriad of rheumatological and inflammatory diseases. C5 inhibitors and Janus kinase inhibitors have emerged as attractive therapeutic options. Because of the blockage of immune pathways, these targeted therapies carry an increased risk of infection. This article reviews the mechanism of action and the approved and off-label indications of the agents with most clinical experience within this drug classes. It discusses the associated risks of infection, proposing screening, prevention, and risk mitigation strategies.
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8
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Schreiner P, Mueller NJ, Fehr J, Maillard MH, Brand S, Michetti P, Schoepfer A, Restellini S, Vulliemoz M, Vavricka SR, Juillerat P, Rogler G, Biedermann L. Varicella zoster virus in inflammatory bowel disease patients: what every gastroenterologist should know. J Crohns Colitis 2020; 15:jjaa132. [PMID: 32592587 DOI: 10.1093/ecco-jcc/jjaa132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Indexed: 12/17/2022]
Abstract
Primary Varicella Zoster virus (VZV) infection results in varicella (chickenpox) while its reactivation results in herpes zoster (HZ; shingles). Patients with Inflammatory Bowel Disease (IBD) are susceptible to complications of primary VZV infection and have an increased risk of HZ. Concerns of VZV and HZ infection in the IBD population has been highlighted by the emergence of JAK-inhibitors and their safety profile in this patient population such as tofacitinib for the treatment of ulcerative colitis (UC). The current pipeline of emerging therapies include novel molecules targeting multiple pathways including JAK/signal transducer and cytokine signalling pathways such as JAK/STAT. Hence VZV and HZ will be increasingly relevant for gastroenterologists treating IBD patients in light of these emerging therapies.
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Affiliation(s)
- Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich
| | - Nicolas J Mueller
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, Switzerland
| | - Jan Fehr
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Zurich, Switzerland
- Department of Public & Global Health, University of Zurich, Zurich, Switzerland
| | - Michel H Maillard
- Crohn and Colitis Center, Gastroentérologie Beaulieu SA, Lausanne, Switzerland
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Stephan Brand
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kantonsspital Sankt Gallen, St. Gallen, Switzerland
| | - Pierre Michetti
- Crohn and Colitis Center, Gastroentérologie Beaulieu SA, Lausanne, Switzerland
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Sophie Restellini
- Department of Gastroenterology and Hepatology, Geneva University Hospitals and University of Geneva, Switzerland
| | - Marianne Vulliemoz
- Crohn and Colitis Center, Gastroentérologie Beaulieu SA, Lausanne, Switzerland
| | - Stephan R Vavricka
- Department of Gastroenterology & Hepatology, University Hospital Zurich
- Center of Gastroenterology and Hepatology, CH, Zurich, Switzerland
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology & Hepatology, University Hospital Zurich
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Harris RE, Curtis L, Hegde V, Garrick V, Gervais L, Armstrong L, Delahunty C, Eccleston A, Al-Hourani G, Flynn DM, Merrick V, Barclay AR, Tayler R, Hansen R, Russell RK. A Decade of Varicella Screening Within a Paediatric Inflammatory Bowel Disease Population. J Crohns Colitis 2020; 14:608-616. [PMID: 31889176 DOI: 10.1093/ecco-jcc/jjz207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Increased risk of opportunistic infection-e.g., varicella zoster infection-secondary to therapies is a cause of morbidity in inflammatory bowel disease [IBD] patients. The UK vaccination schedule does not include varicella immunisation. We aimed to evaluate the varicella screening and immunisation programme in a paediatric IBD population. METHODS Data regarding IBD diagnosis, varicella status, and consequent immunisations/treatment interventions were collected retrospectively from the records of patients diagnosed with IBD over a 10-year period [2009-2018]. RESULTS In all, 520 IBD patients were diagnosed; 505/520 [97%] had varicella testing; 46/505 [9%] were naïve. Of 501 patients, 391[78%] were tested before or within 7 days of diagnosis; this increased in the second 5-year period compared with the first (229/268 [85%] versus 162/233 [70%]; p <0.00001). Median diagnosis age of naïve patients was lower [8.3 years versus 12.8 years; p <0.00001]. Where vaccination was feasible, 21/31 [68%] had two and 7/31 [23%] one immunisation. Prednisolone induction led to lower rates of vaccination (5/13 [39%] versus 23/33 [70%] for other induction therapies; p =0.02). Of 28 vaccinated patients, 5 [18%] had suspected breakthrough varicella; and 6/18 [33%] unimmunised patients required post-exposure prophylaxis or treatment for varicella. Immunisation was associated with a decrease in patients requiring post-exposure prophylaxis (0/28 [0%] versus 5/18 [28%]; p =0.0006) and varicella-related hospital admission (1/28 [4%] versus 4/18 [22%]; p =0.01). CONCLUSIONS High rates of varicella screening and immunisation within a PIBD population are possible, resulting in a reduction in hospital admissions for varicella treatment. Varicella immunisation may be of increasing importance within the PIBD population with the emergence of novel therapeutic strategies.
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Affiliation(s)
- Rachel E Harris
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lee Curtis
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Vikas Hegde
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Vikki Garrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lisa Gervais
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lawrence Armstrong
- Department of Paediatrics, University Hospital Crosshouse, Crosshouse, UK
| | | | - Andrew Eccleston
- Department of Paediatrics, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | - Diana M Flynn
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Victoria Merrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Andrew R Barclay
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Rachel Tayler
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
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Ning L, Liu R, Li S, Shan G, Du H, Zhang J, Chen W, Zhang F, Yu J, Xu G. Increased risk of herpes zoster infection in patients with inflammatory bowel disease: a meta-analysis of cohort studies. Eur J Clin Microbiol Infect Dis 2019; 39:219-227. [DOI: 10.1007/s10096-019-03706-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/05/2019] [Indexed: 12/22/2022]
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11
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Khan N, Trivedi C, Kavani H, Medvedeva E, Lewis J, Yang YX. Efficacy of Live Attenuated Herpes Zoster Vaccine in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2019; 17:1341-1347. [PMID: 30326303 DOI: 10.1016/j.cgh.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The risk of herpes zoster virus infection is increased among patients with inflammatory bowel diseases (IBD). The herpes zoster vaccine (HZV) is therefore recommended for these patients, but little is known about its effectiveness, resulting in low use. METHODS We conducted a retrospective cohort study using data from the national veterans Affairs Healthcare System (VAHS) from January 1, 2000 through June 30, 2016. We collected data from 39,983 veterans with IBD who had not received the HZV by an age of 60 years. The follow-up period started at age 60 or the date of first IBD medication prescription (whichever was later) and ended with the earliest diagnosis of herpes zoster infection, the end of the study period, or date of death. We identified veterans who received the HZV during the follow-up period and compared the incidence of herpes zoster between vaccinated vs unvaccinated patients. We performed multivariable Cox regression with time-dependent analysis to determine the risk of herpes zoster associated with vaccination status in the entire cohort and stratified by IBD medication. RESULTS We identified 7170 patients who received the HZV during the follow-up period (17.9% of total cohort; 96.6% male and 94.2% Caucasian). The crude incidence rate of herpes zoster infection during the follow-up period for unvaccinated patients was 6.97/1000 person-years and for vaccinated patients was 4.09/1000 person-years. Vaccination was associated with significantly lower risk of herpes zoster infection, compared to lack of vaccination (adjusted hazard ratio, 0.54; 95% CI, 0.44 - 0.68). CONCLUSION Vaccination was associated with a significantly reduced risk of herpes zoster infection among veterans with IBD. This vaccine is therefore effective in patients with IBD, but underused.
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Affiliation(s)
- Nabeel Khan
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
| | - Chinmay Trivedi
- Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Himanshu Kavani
- Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Elina Medvedeva
- Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - James Lewis
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Yu-Xiao Yang
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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12
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Farshidpour M, Charabaty A, Mattar MC. Improving immunization strategies in patients with inflammatory bowel disease. Ann Gastroenterol 2019; 32:247-256. [PMID: 31040621 PMCID: PMC6479655 DOI: 10.20524/aog.2019.0351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/11/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Maham Farshidpour
- Department of Inpatient Medicine, Banner University Medical Center, University of Arizona, Tucson (Maham Farshidpour), USA
| | - Aline Charabaty
- Division of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA (Aline Charabaty, Mark C. Mattar), USA
| | - Mark C Mattar
- Division of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA (Aline Charabaty, Mark C. Mattar), USA
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13
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Abstract
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.
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Affiliation(s)
- Samantha Zullow
- a Department of Medicine, Division of Gastroenterology and Hepatology , New York University School of Medicine , New York , NY , USA
| | - Francis A Farraye
- b Department of Medicine, Section of Gastroenterology , Boston University School of Medicine , Boston , MA , USA
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14
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Nugent Z, Singh H, Targownik LE, Bernstein CN. Herpes Zoster Infection and Herpes Zoster Vaccination in a Population-Based Sample of Persons With IBD: Is There Still an Unmet Need? Inflamm Bowel Dis 2019; 25:532-540. [PMID: 30085137 DOI: 10.1093/ibd/izy249] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND We aimed to report the rates of herpes zoster infection (HZI) before and after the introduction of herpes zoster vaccine (HZVac) and to determine the rates of HZVac after it became available in Manitoba in 2009. METHODS We used the population-based University of Manitoba IBD Epidemiology Database to identify cases of inflammatory bowel disease (IBD) and controls (1984-2016) who were diagnosed with HZI before and after 2009 and to determine the rate of HZVac in those older than age 50 years. Further, we explored predictors of receipt of HZVac among persons with IBD. RESULTS Persons with IBD vs matched controls have higher rates of HZI before diagnosis and postdiagnosis. HZI rates before 2009 per 1000 person-years were increased in persons with IBD (9.2) vs controls (7.2, P < 0.0001). Persons with IBD compared with controls were more likely to get HZVac (15.5 vs 12 per 1000 person-years). Persons newly diagnosed with IBD after 2009 and of higher socioeconomic status were more likely to get HZVac. Despite the introduction of HZVac, there was a steady rise in HZI throughout the study period (annual percent change in infection rates of +0.54, P < 0.0001). CONCLUSIONS The increased risk of HZI in IBD may reflect an inherent risk associated with the disease or, in those already diagnosed, an increased risk secondary to the use of immunomodulating drugs. HZVac rates are very low, which may reflect physician and patient knowledge of the vaccine's availability and utility and the fact that it is not covered by the provincially provided health care plan.
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Affiliation(s)
- Zoann Nugent
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Manitoba, Canada.,Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Manitoba, Canada.,Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Laura E Targownik
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Manitoba, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Manitoba, Canada
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15
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Fernández-Ruiz M, Aguado JM. Risk of infection associated with anti-TNF-α therapy. Expert Rev Anti Infect Ther 2018; 16:939-956. [PMID: 30388900 DOI: 10.1080/14787210.2018.1544490] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The advent, more than two decades ago, of monoclonal antibodies and soluble receptors targeting tumor necrosis factor (TNF)-α has revolutionized the therapeutic approach to otherwise difficult-to-treat autoimmune and inflammatory diseases. However, due to the pleiotropic functions played by this pro-inflammatory cytokine (with particular relevance in granuloma maintenance), TNF-α blockade may increase the incidence of serious infections. Areas covered: The present review summarizes the biological rationale supporting the impact of anti-TNF-α therapy on the host's susceptibility to infection. The structure, mode of action, and indications of available agents are reviewed, as well as the clinical evidence coming from clinical trials and observational registries. We discuss the impact of patient- and disease-related factors influencing the occurrence of infection. Finally, strategies for risk minimization are also covered, with particular attention to recommendations for screening of latent tuberculosis infection and management of chronic hepatitis B infection. Expert commentary: Methodological limitations (confounding by indication bias, patient dropout, or switching therapies) should be considered when interpreting observational data. Clinicians must individualize the infection risk assessment not only on the basis of the specific anti-TNF-α agent used or the expected duration of therapy, but also by taking into account the baseline susceptibility of a given patient.
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Affiliation(s)
- Mario Fernández-Ruiz
- a Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine , Universidad Complutense , Madrid , Spain.,b Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002) , Instituto de Salud Carlos III , Madrid , Spain
| | - José María Aguado
- a Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine , Universidad Complutense , Madrid , Spain.,b Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002) , Instituto de Salud Carlos III , Madrid , Spain
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16
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Borman ZA, Côté-Daigneault J, Colombel JF. The risk for opportunistic infections in inflammatory bowel disease with biologics: an update. Expert Rev Gastroenterol Hepatol 2018; 12:1101-1108. [PMID: 30277409 DOI: 10.1080/17474124.2018.1530983] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Crohn's disease and Ulcerative Colitis are forms of inflammatory bowel disease (IBD), chronic diseases treated with medical and surgical therapy. Patients with IBD are treated with potent immunomodulatory agents, leading to immunosuppression, and the potential for opportunistic infections. In 2014, the ECCO guidelines were released to guide the prevention, diagnosis and treatment of a variety of these opportunistic infections. Since 2014, there have been a number of new agents released as well as a significant expansion in our knowledge of the safety profile of IBD medications. In this article, we review the literature after 2014 regarding opportunistic infections and updates on safety data. Areas covered: We review updates in immunomodulatory therapies for IBD and opportunistic infections since the 2014 ECCO guidelines were published. Expert commentary: The prevention, diagnosis, and treatment of opportunistic infections continue to evolve, as new drugs are approved, and the use of a combination of biologic agents are considered for therapy in clinical trials. What causes some patients to fail to respond to vaccination, or for others to develop severe infections, remains unclear. Improved risk stratification for opportunistic infections in IBD patients and updated ECCO 2014 guidelines would be of significant benefit.
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Affiliation(s)
- Zachary A Borman
- a The Henry D. Janowitz Division of Gastroenterology , One Gustave L. Levy Place , New York , NY , USA
| | - Justin Côté-Daigneault
- b Gastroenterology Service , Centre Hospitalier de l'Université de Montréal (CHUM) , Montreal , Quebec , Canada
| | - Jean-Frédéric Colombel
- a The Henry D. Janowitz Division of Gastroenterology , One Gustave L. Levy Place , New York , NY , USA
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17
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Kochar B, Herfarth HH. Vaccinations in Adult Patients with Inflammatory Bowel Diseases in the West. Inflamm Intest Dis 2018; 3:11-15. [PMID: 30505837 PMCID: PMC6266030 DOI: 10.1159/000491752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/02/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with moderate-severe inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis are commonly treated with long-term immunosuppressive therapies involving immunomodulators such as thiopurines, biologics (anti-TNF and anti-adhesion molecules), or novel small molecules such as Janus kinase inhibitors. SUMMARY Some infections seen with immunosuppressive therapy in IBD are preventable with vaccines. IBD-specific immunosuppressive therapy is generally initiated by gastroenterologists. Therefore, gastroenterologists should comprehend the appropriate application of vaccines such as hepatitis B, pneumonia, and herpes zoster vaccinations. This review summarizes the current guidance for vaccinations of IBD patients in the United States. KEY MESSAGE Gastroenterologists treating IBD patients must be aware of necessary vaccination schedules in the setting of immunosuppressive therapies.
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Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Hans H. Herfarth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
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18
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Colombel JF. Herpes Zoster in Patients Receiving JAK Inhibitors For Ulcerative Colitis: Mechanism, Epidemiology, Management, and Prevention. Inflamm Bowel Dis 2018; 24:2173-2182. [PMID: 29788127 PMCID: PMC6140435 DOI: 10.1093/ibd/izy150] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Indexed: 02/06/2023]
Abstract
Increased risk of herpes zoster (HZ) has been observed in patients with immune-mediated diseases, including rheumatoid arthritis (RA), psoriasis (PsO), and inflammatory bowel disease; this risk can be further increased by the use of immunosuppressive therapy. One advancing modality of therapy for these diseases is Janus kinase (JAK) inhibition. Tofacitinib is an oral JAK inhibitor for the treatment of RA and psoriatic arthritis, which is currently under investigation for the treatment of ulcerative colitis (UC) and was previously investigated for psoriasis. JAK inhibitors have been associated with HZ events in patients across a number of indications. The pathogenesis underlying this risk of HZ is currently unknown. An increased risk of HZ has been noted in patients receiving immunosuppressive therapies for UC, including tofacitinib. In clinical trials, there was a dose-dependent risk of HZ (higher dose linked with increased risk). However, the majority of HZ cases are nonserious and noncomplicated, mild to moderate in severity, and manageable without permanent discontinuation of treatment. This review will discuss HZ risk in patients receiving JAK inhibitors, focusing on tofacitinib with respect to the potential mechanisms and epidemiology of HZ. Current guidelines for the prevention of HZ will be highlighted, and proposed management reviewed.
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Affiliation(s)
- Jean-Frédéric Colombel
- Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York,Address correspondence to: Jean-Frédéric Colombel, MD, The Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, 5th Floor, New York, NY 10029 ()
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19
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Sagami S, Kobayashi T, Hibi T. Prevention of Infectious Diseases due to Immunosuppression and Vaccinations in Asian Patients with Inflammatory Bowel Disease. Inflamm Intest Dis 2018; 3:1-10. [PMID: 30505836 DOI: 10.1159/000489643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/17/2018] [Indexed: 12/20/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) patients with immunocompromise have a high risk of developing complications related to viral infections. Western countries were the first to formulate vaccine guideline. Asian countries developed their national and international vaccine guidelines a little later in order to reduce the risk of mortality from viral infections. However, no studies to date have examined the differences in vaccinations that prevail among Asian countries. Summary This review summarizes the vaccination status and schedules in various Asian countries for immunocompromised IBD patients. Vaccination rates, regardless of the specific vaccine, were high in Japan, South Korea, and China and low in India and the Philippines. Vaccine schedules differed by country, and outbreaks of measles and rubella were seen due to low vaccination rates in Southeast Asia and South Asia. Live vaccines cannot be administered during immunosuppressive treatment. Infection with measles, mumps, and varicella during immunosuppressive therapy carries a high risk of mortality, and thus confirmation of immunization status is recommended as soon as IBD is diagnosed and, when possible, live vaccines should be administered before the initiation of immunosuppressive treatment. In patients seronegative for hepatitis B, administration of the hepatitis B vaccine is also recommended. Key Messages Physicians, while considering severity of outbreaks, should understand the differences in vaccination status that exist among the various Asian countries and regions.
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Affiliation(s)
- Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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20
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Rosenberg Danziger C, Anis E, Gordon ES, Grotto I, Danon YL. Reintroducing OPV in Israel on the journey to global polio eradication - Estimation at a low rate of contraindicated population. Vaccine 2018; 36:3717-3720. [PMID: 29776752 DOI: 10.1016/j.vaccine.2018.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/04/2018] [Accepted: 05/07/2018] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The 2013 reemergence of wild poliovirus in Israel led to the reinstatement of a routine OPV vaccination. Fearing VAPP in immunocompromised, the MOH regulated contraindications for vaccination candidates and household contacts. In this study we estimate the size of the contraindicated population to OPV vaccination. METHOD We studied vaccination candidates aged 2-9 and 14-23 months and probable household contacts. Using the rate of contraindications extracted for each study group from a medical records database, a statistical model was built to estimate the probability of contraindications in candidates. RESULTS 3.9% of the 2-9-month-old study group and 4% of the 14-23-month-old group had contraindications by either self or household contacts. CONCLUSION A statistical model can provide an estimation of the contraindicated population and can be used in the future when devising vaccination campaigns. In contrast to concerns raised by the MOH, our findings show a smaller than anticipated contraindicated population.
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Affiliation(s)
| | - Emilia Anis
- Public Health Services, Ministry of Health, Jerusalem 9101002, Israel; Braun School of Public Health, Hebrew University Hadassah Medical School, Jerusalem 9112102, Israel
| | | | - Itamar Grotto
- Public Health Services, Ministry of Health, Jerusalem 9101002, Israel; Epidemiology Department, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Yehuda L Danon
- Ariel University, Ariel 4070000, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel.
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21
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Côté-Daigneault J, Luong ML, Colombel JF, Peerani F. Letter: the safety of herpes zoster vaccination for patients with inflammatory bowel disease being treated with anti-TNF medications. Aliment Pharmacol Ther 2018; 47:446-447. [PMID: 29314127 DOI: 10.1111/apt.14435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- J Côté-Daigneault
- Division of Gastroenterology, CHUM/CRCHUM, University of Montreal, Quebec, Canada
| | - M L Luong
- Division of Microbiology and Infectious Diseases, CHUM, University of Montreal, Quebec, Canada
| | - J-F Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, New York, NY, USA
| | - F Peerani
- Division of Gastroenterology, University of Alberta, Alberta, Canada
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22
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Khan N, Lewis JD. Letter: the safety of herpes zoster vaccination for patients with inflammatory bowel disease being treated with anti-TNF medications-authors' reply. Aliment Pharmacol Ther 2018; 47:448. [PMID: 29314125 DOI: 10.1111/apt.14460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- N Khan
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - J D Lewis
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, PA, USA
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