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Vol. 66, No. 4 2015
Northeast Florida Medicine
DCMS online
. org
Inflammatory Bowel Disease
have recently discontinued within three months; patients
on biologic agents; or patients with severe protein-calorie
malnutrition.
6
Vaccination schedule:
The timing of vaccination is also quite essential. Live-at-
tenuated vaccines cannot be given to immunosuppressed
patients. This means it is imperative that physicians
anticipate and vaccinate the patients before they become
immunocompromised. Live-attenuated vaccines include
MMR (measles, mumps, rubella), varicella, herpes zoster,
rotavirus, yellow fever, oral typhoid and polio, and intranasal
influenza.
7,8
MMR is routinely given to all children starting
at age one in two doses. In adults with unknown status,
titers can be checked and the vaccine can be given if there
is no plan for immunosuppression within six weeks.
2,5,7,8
Varicella is recommended for all immunocompetent chil-
dren and adults if there is no known history of exposure.
Disseminated varicella occurs in 20/100,000 adults and
has a mortality rate of about 30 percent.
4
It is typically
recommended by experts to avoid immunosuppression
for one to three months after vaccination. Zoster vaccine
has the same strain as varicella, except it is 14 times more
potent.
9
It is recommended for persons who are 60 years
or older and patients should avoid immunosuppression for
four weeks after immunization.
2
Rotavirus is administered
at age 2 and 4 months and the maximum age for the first
dose in the series is 14 weeks. However, infants born to
mothers on infliximab, which can cross placenta, can be
immunosuppressed for up to six months. Rotavirus vaccine
is typically avoided in these cases.
7,8
Inactivated vaccines should be given to all IBD patients,
regardless of immunosuppressed state. These include influ-
enza, tetanus,HPV, pneumococcal,meningococcal, hepatitis
A and hepatitis B. For influenza vaccine, the intramuscular
form should be given annually and the intranasal form
should be avoided.
2,7,8
Tetanus should be given to all patients
in a 3-dose series, followed by a booster every 10 years.
2
The HPV vaccine is a quadrivalent vaccine that targets the
four HPV serotypes (6, 11, 16 and 18). It is indicated for
women and men age 11 to 26.
2,7,8
It has been shown that
patients with IBD have higher incidence of abnormal Pap
smears (47 percent vs. control) and are more likely to have
higher-grade lesions.
10
Pneumococcal vaccine is a 23-valent
pneumococcal polysaccharide vaccine that is recommend for
all IBD patients, regardless of age or immunosuppressive
status. A one-time dose revaccination is recommended after
five years in patients older than 65 or who are immunosup-
pressed.
2,7,8
Meningococcal vaccine is recommended to all
at-risk patients who have not been vaccinated. This includes
patients who are asplenic, patients with complement defi-
ciencies, college students who live in dormitories, or military
recruits.
7,8
For hepatitis B, it is routinely recommended to
check for serology before initiating biologic agents. If the
patient is not immune, the vaccine series should start at
month 0, 2 and 6.
4
Adequacy of immunogenicity:
One important question to ask is the adequacy of im-
munogenicity of patients with IBD and the effectiveness
of vaccination. In patients with IBD, the levels of serum
immunoglobulins are normal and also slightly higher than
normal circulating antibodies. These patients also have en-
hanced T-cell responses to luminal antigens. These factors
suggest an IBD patient should have an appropriate response
to vaccination.
6
However, in clinical practice there is limited
data in patients with IBD. It was shown that when patients
were onmonotherapywith either azathioprine or 6-MP, their
responses were comparable to control subjects when given
influenza vaccine after at least 24 weeks of therapy.
11
How-
ever, it was also shown that there was inadequate response
to influenza vaccine in patients who were on infliximab
and azathioprine.
12
Therefore, larger studies are needed to
evaluate for sustainability of immune response and timing
for booster dose.
Conclusion:
It is important for clinicians to vaccinate patients with
IBD early if anticipating escalation of immunosuppressive
therapy. Vaccination is safe, and potentially lifesaving, if done
appropriately. It is recommended to check titers for hepatitis
A and B, varicella and MMR during the initial visit prior to
vaccination. All patients should receive inactive vaccine for
Tdap, HPV, influenza, pneumococcus, meningococcus and
hepatitis A and B, regardless of immunosuppressive status.
The live-attenuated vaccines such as MMR, varicella and
zoster should only be administered if there is no plan for
immunosuppression in the next 4-12 weeks.
6
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