• Welcome to Crohn's Forum, a support group for people with all forms of IBD. While this community is not a substitute for doctor's advice and we cannot treat or diagnose, we find being able to communicate with others who have IBD is invaluable as we navigate our struggles and celebrate our successes. We invite you to join us.

Immunizing Patients With Gastrointestinal Diseases

Transcript of a brief video presentation on the subject:

"Hello. I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

I wanted to chat with you today about vaccination strategies because I don't care whether you're a primary care physician or a gastroenterologist; somehow we're just not doing this well enough. The data are very striking. Who is responsible, and who understands the current standards for vaccinations in patients with gastrointestinal diseases?

Who Is Responsible?

A recent survey conducted at Boston University, Boston, Massachusetts, showed a striking disconnect between gastroenterologists and primary care physicians with respect to whose responsibility it was to make sure that patients received appropriate vaccinations.[1]

According to this survey, 65% of the patients in an inflammatory bowel disease clinic had received their vaccinations and were deemed to be adequately immunized.[1] When asked whose responsibility it was to make sure that these patients were adequately immunized, 83% of gastroenterologists believed that it was the domain of primary care physicians.[1] That's a pretty poor outcome when only about half of these patients are receiving adequate immunizations.

If you take it a step further, they looked at patients who had received the influenza vaccine in the inflammatory bowel clinic, and the rate was approximately 28%.[1] Just 9% had received the pneumococcal vaccine.[1]

It may be that primary care physicians don't understand that these patients can be given vaccines, and gastroenterologists are not counseling people very well as to who really needs vaccines. In that same survey, the gastroenterologic evaluations were abysmally poor as far as gastroenterologists' understanding of the current recommendations for immunization.[1]

slides 1 2.JPG

Vaccines and Immunosuppression

So how do we fix this?

Let's start by understanding what vaccines mean, who can receive certain types of vaccines, and to whom we should be careful about giving vaccines.

Vaccines are either live or attenuated or inactivated, with some element of the infectious agent. Pneumovax® is a good example, but we'll come back to that in a second.

Live vaccines are of concern if you have patients who are immunosuppressed, that is, patients who are receiving steroids or receiving biologic agents such as infliximab (Remicade®), adalimumab (Humira®), certolizumab, or natalizumab. Because it relates to the biologic anti-TNF [antinuclear tumor necrosis factor] agents or drugs such as azathioprine or 6-mercaptopurine, the immunomodulators, or the classic immunosuppressant steroids people are nervous when they have to give live vaccines to those patients -- and they should be.

You shouldn't be giving live vaccines to patients on those medications, and if you anticipate that a patient may be going on that type of immunosuppressant or biologic agent the recommendation is to withhold the immunosuppressant or biologic agent for at least 4-12 weeks after immunizing that patient.

slides 3.JPG

Live Vaccine Administration

The 3 most commonly delivered live vaccines in this country are the measles, mumps, and rubella vaccine; the varicella vaccine; and the herpes zoster vaccine.

Immunosuppressants or biologic agents should be withheld, if possible, for a minimum of 4-12 weeks after giving any of these vaccines. If you think that the patient is going to be in imminent need of immunosuppressants or biologic agents, then withhold the immunization and treat expectantly if they were exposed to any of those agents (ie, immunosuppressants or biologic agents).

A number of other live vaccines might be necessary if a patient is traveling to an endemic area. Typhoid and yellow fever vaccines can potentially pose a live vaccine risk for patients. The intranasal influenza vaccine carries a very significant live vaccine risk and should not be given to patients who are taking immunosuppressants or biologic agents.

In those patients I would consult with an infectious disease/travel medicine specialist and see whether something can be given as an alternative, or perhaps those patients shouldn't take those trips and put themselves at risk.

Attenuated Vaccine Administration

The attenuated vaccines can be given at any time. There is no significant risk for those patients in receiving these vaccines. The attenuated vaccines include tetanus, diphtheria, and pertussis: the immunizations that are given routinely. Patients who are at risk for hepatitis A or B (and we recommend this now for all inflammatory bowel patients), including patients with chronic liver disease, should receive hepatitis A and B vaccines. The pneumococcal vaccine is made from an oligosaccharide of the capsule of the virus, so it has no infectious risk or dissemination and can be given at any time. The influenza vaccine is similar.

These attenuated vaccines can be given to the immunosuppressed patient. The immunosuppressed patient may not register as good a biologic response to that vaccine: something that we see with the hepatitis A and B vaccines. Hepatitis B vaccine is occasionally a problem in patients who are immunosuppressed. If you give the hepatitis B vaccine with the hepatitis A vaccine, there may be an immunologic adjuvant booster effect, and so in patients who are suppressed for whatever reason, if you give them just the hepatitis B vaccine, I would recommend that you check their viral titers looking for surface antibody conversion. Recognize that core antibody means that they've actually had a previous infection, but surface antibody can be reflective of just the vaccine. If they don't register a serum antibody response, they could be double-dosed or they could be given a combination hepatitis A and B vaccine to provide the biologic booster effect.
 
Last edited:
slides 4.JPG

slides 5.JPG

slides 6.JPG

slides 7.JPG


Conclusion: We Can Do Better

In summary, who should receive live vaccines?

Basically we can give live vaccines only to patients who are not immunocompromised. There are recent recommendations from a national consensus on vaccinations.[2] If the patient is on low-dose immunosuppressants -- and by that I mean for our world in gastroenterology < 1.5 mg/kg 6-mercaptopurine, < 3 mg/kg azathioprine, < 0.4 mg/kg methotrexate, or on corticosteroids for < 14 days -- the patient can be given the standard vaccinations.

Patients are just not receiving the vaccination schedules that they should be receiving, and we need to be recording this in the medical record and asking them regularly whether they have had their vaccinations. This applies not only to patients with chronic liver disease and inflammatory bowel disease but our entire population of patients with gastrointestinal disease.

The job is just not getting done. The best way to treat these infections, as you know, is to prevent them. We can do a better job. Hopefully these discussions will lead to that."
 
Interesting info once again David. The one question no one seems to answer is:If you take Methotrexate to kill the antibodies your body builds against Remicade, won't the Methotrexate also kill the antibodies you build to any vaccine?

My Rheumatologist warns me to stay away from children being vaccinated with live vaccines (like the ones mentioned above) because the Methotrexate has destroyed the antibodies I've made from my childhood vaccines. Then she turns around and wants to give me the flu shot even though the only time I've had the flu is when I've taken the flu shot. (I know I know, it doesn't cause you to get the flu, but it is a pretty good conincidence that it's happened three times.)

Thoughts?
 

DustyKat

Super Moderator
Hey David,

Excellent article, thanks so much for posting.

Would you mind reposting this in the parent's forum? Maybe it could have a sticky attached to it.

Thanks, Dusty. :)
 
Top