By SRINIVAS SEELA, MD; DR. AMISH PATEL; RITHVIK SEELA

Patients with inflammatory bowel disease (IBD) are at an increased risk for developing vaccine-preventable illnesses such as influenza, pneumococcal pneumonia, and hepatitis B virus. This risk is further exacerbated by immunosuppressant medications used to treat IBD. Patients with IBD are not vaccinated at the same rate as general medical patients. It has been shown that IBD patients are less likely to receive adequate preventive care when it comes to vaccinations and screenings. This is largely due to the fact that preventive health measures change based on a patient’s specific medical regimen and the communication between primary care providers and gastroenterologists may not be as clear. This is especially important when taking into consideration a large proportion of IBD patients are on immunosuppressive therapies such as corticosteroids, immunomodulators, and biologics. Not only does an impaired immune system significantly increase the risk of acquiring a preventable infection, it has also been shown that the IBD alone can increase the risk for certain pneumonias. Gastroenterologists should familiarize themselves with health maintenance measures pertaining to patients with IBD. Prevention of many of these infections can be achieved by the timely and judicious use of vaccinations.

Many things can be done to improve vaccination rates for IBD patients, starting with patient and physician education. A study performed by the Crohn’s and Colitis Foundation determined that a physician recommending a particular vaccine was highly predictive of an IBD patient receiving that certain vaccine. Information regarding recommendations for vaccinations in IBD patients is available on various gastroenterology society websites and if an office does not carry, or is unable to receive certain vaccines, they should be referred back to their primary care or local pharmacy with explicit recommendations or prescriptions.

It is imperative to note that data has shown no relationship between receiving vaccinations and current IBD activity rendering them completely safe. All patients with IBD should receive appropriate vaccinations, ideally before immunosuppressive therapy is initiated. Live-attenuated vaccinations should be avoided up to 6 weeks prior to starting and three months after discontinuing immunosuppressive therapy.

It is very important for patients with IBD planning to travel to visit the gastroenterologist. Vaccinating the traveling patient with IBD is a clinical situation with which gastroenterologists should be familiar. Prior to travel, it is recommended that patients schedule a visit with an infectious disease clinician or a university traveler’s clinic to discuss where they will be traveling and for how long. Both the patient and the practitioner can review travelers’ health information from the CDC and World Health Organization to assess what infections may be endemic to the region that the patient will be visiting.

One infection of particular concern for traveling patients is yellow fever, a flavivirus transmitted by the Aedesmosquito.  The virus is highly endemic in Sub-Saharan Africa and South America. The yellow fever vaccine is a live vaccine and, thus, is contraindicated in patients receiving immunosuppressive therapy. The vaccine is recommended for patients traveling to areas with a high prevalence of the disease, as some countries require proof of vaccination upon entering. 

Patients should stop immunosuppressive therapy for at least 4 months prior to vaccination. If patients cannot stop their immunosuppressive therapy, they should be strongly advised against traveling to regions where yellow fever is endemic.

Other live vaccines that must be considered for traveling IBD patients include MMR, typhoid fever, and poliomyelitis. Hepatitis B immune status should be checked in patients prior to travel in regions where hepatitis B virus is endemic (e.g., Southeast Asia, China, Africa).

If patients are immunosuppressed and their titers are below 10 mIU/mL, a hepatitis B booster should be administered. 

Inactivated vaccines include, but are not limited to, Japanese encephalitis virus, rabies, typhoid fever, poliomyelitis, and hepatitis A virus.  

There is no contraindication to using live vaccines in household members of immunosuppressed IBD patients. To improve the vaccination rates, the ideal time to assess a patient’s health maintenance needs and administer appropriate vaccinations is during the patient’s initial visit to a gastroenterologist. During this initial visit, timing of vaccinations should be considered if there are plans to start immunosuppressive therapy in the near future. If vaccination services are not available in the office, the primary care provider should be sent concise recommendations for vaccines to administer. 

The majority of practices and hospital systems currently use electronic-based health records (EHRs). EHRs can facilitate documentation of vaccinations and can also serve as a tool for providing physicians with alerts and reminders regarding vaccine administration. 

Taking care of patients with IBD often involves making complex medical decisions. Gastroenterologists are typically the primary provider for patients with IBD; therefore, it is essential to have a broad understanding of the issues surrounding administering vaccinations to patients with IBD.

Clinicians should recognize the increased risk of vaccine-preventable illnesses that IBD patients face and understand which vaccines can and cannot be administered to IBD patients on immunosuppressive therapy. Providers should take an active role in evaluating their office practice for assessing a patient’s vaccination history and administering appropriate vaccinations.

Srinivas Seela, MD, co-founder of Digestive and Liver Center of Florida, finished his fellowship in Gastroenterology at Yale University School of Medicine. He is an Assistant Professor at the University of Central Florida School of Medicine, and a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs.

Dr. Amish Patel is a medical student at Kansas City University School of Medicine and Biosciences.

Rithvik Seela is a sophomore at Stanford University. 

Visit www.dlcfl.com for more.