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Opportunistic infections and vaccinations in IBD patients
Journal of Crohn's and Colitis (2011) 5, 263 available at www.sciencedirect.com
LETTER TO THE EDITOR Opportunistic infections and vaccinations in IBD patients KEYWORDS:
Opportunistic infection; Vaccination; Inflammatory bowel disease (IBD); Crohn's, ulcerative colitis (UC)
Dear Sir, Opportunistic infections are emerging as a major safety issue for patients with Inflammatory Bowel Disease (IBD) as immunomodulators and biologic agents are being used more often, and earlier1 in a patient disease course. The European Consensus guidelines on the prevention, diagnosis and management of opportunistic infections detail a vaccination and systemic work-up to consider before introducing immunomodulator therapy. 2 This checklist includes an interview, physical examination, laboratory tests and vaccine schedule, including VZV varicella and annual trivalent inactivated influenza vaccines. We believe further emphasis should be placed on the vaccination of close household contacts with both VZV varicella and influenza vaccines. Many clinicians have seen immunosuppressed IBD patients develop severe or disseminated varicella acquired from close household contacts, often their children. This may be a particular problem in countries such as the UK which do not include VZV vaccination as part of a national programme. Vaccination of household contacts, recommended by the UK Department of Health, provides protection for immunocompromised persons by decreasing the likelihood of wild-type virus introduction into the household. This is particularly important because: • Most patients diagnosed before the publication of these guidelines will not have been vaccinated and many will be unable to temporarily withhold immunosuppressive treatment to allow live vaccine administration. • IBD patients have decreased rates of immunisation uptake. 3 • The efficacy of influenza vaccination, even in healthy controls is no more than 73%. Therefore even with immunisation, IBD patients will remain at risk. • Immunocompromised patients receiving immunomodulators and/or anti-TNF agents have decreased rates of seroconversion in response to vaccinations. 4 • Breakthrough infections (i.e. varicella occurring in vaccinated persons following exposure to wild-type virus), although unusual, are recognised.
There is a theoretical risk of transmission of live VZV vaccine virus from immunised household contacts to immunocompromised individuals. This risk appears low and such infections are typically milder than the wild-type disease, with no requirement for acyclovir or VZIG administration. A 10 year post marketing safety review of the live VZV vaccine identified only 3 cases of secondary transmission. Importantly in all 3 of these cases the vaccine recipient had a post vaccination rash5 suggesting that contacts who develop a vaccine-related rash should avoid contact with immunocompromised IBD patients. In our opinion, immunosuppressed IBD patients should not only be offered a comprehensive vaccination schedule for protection against opportunistic infections according to the European evidence based consensus guidelines, but greater emphasis should be placed on vaccinating their close contacts. In particular close contacts of immunosuppressed patients should be offered annual influenza vaccination and VZV varicella vaccination when the immunosuppressed IBD patient lacks varicella immunity.
References 1. Viget N, Vernier-Massouille G, Salmon-Ceron D, Yazdanpanah Y, Colombel JF. Opportunistic infections in patients with inflammatory bowel disease: prevention and diagnosis. Gut 2008;57(4):549–58. 2. Rahier JF, et al. European evidence based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2009 June;3(2):47–91. 3. Melmed GY, Ippoliti AF, Papadakis KA, Tran TT, Birt JL, Lee SK, et al. Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses. Am J Gastroenterol 2006;101(8): 1834–40. 4. Elkayam O, Yaron M, Caspi D. Safety and efficacy of vaccination against hepatitis B in patients with rheumatoid arthritis. Ann Rheum Dis 2002;61(7):623–5. 5. Galea SA, Sweet A, Beninger P, Steinberg SP, Larussa PS, Gershon AA, et al. The safety profile of varicella vaccine: a 10-year review. J Infect Dis 2008;197(Suppl 2):S165–9.
Oliver Waters⁎ Tariq Ahmad Royal Devon and Exeter Hospital Trust, Devon EX2 5DW, United Kingdom ⁎Corresponding author. Tel.: + 44 1392402840 Fax: + 44 1392402810. E-mail address: [email protected]. 6 February 2011
1873-9946/$ - see front matter © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.crohns.2011.02.006
LETTER TO THE EDITOR Opportunistic infections and vaccinations in IBD patients KEYWORDS:
Opportunistic infection; Vaccination; Inflammatory bowel disease (IBD); Crohn's, ulcerative colitis (UC)
Dear Sir, Opportunistic infections are emerging as a major safety issue for patients with Inflammatory Bowel Disease (IBD) as immunomodulators and biologic agents are being used more often, and earlier1 in a patient disease course. The European Consensus guidelines on the prevention, diagnosis and management of opportunistic infections detail a vaccination and systemic work-up to consider before introducing immunomodulator therapy. 2 This checklist includes an interview, physical examination, laboratory tests and vaccine schedule, including VZV varicella and annual trivalent inactivated influenza vaccines. We believe further emphasis should be placed on the vaccination of close household contacts with both VZV varicella and influenza vaccines. Many clinicians have seen immunosuppressed IBD patients develop severe or disseminated varicella acquired from close household contacts, often their children. This may be a particular problem in countries such as the UK which do not include VZV vaccination as part of a national programme. Vaccination of household contacts, recommended by the UK Department of Health, provides protection for immunocompromised persons by decreasing the likelihood of wild-type virus introduction into the household. This is particularly important because: • Most patients diagnosed before the publication of these guidelines will not have been vaccinated and many will be unable to temporarily withhold immunosuppressive treatment to allow live vaccine administration. • IBD patients have decreased rates of immunisation uptake. 3 • The efficacy of influenza vaccination, even in healthy controls is no more than 73%. Therefore even with immunisation, IBD patients will remain at risk. • Immunocompromised patients receiving immunomodulators and/or anti-TNF agents have decreased rates of seroconversion in response to vaccinations. 4 • Breakthrough infections (i.e. varicella occurring in vaccinated persons following exposure to wild-type virus), although unusual, are recognised.
There is a theoretical risk of transmission of live VZV vaccine virus from immunised household contacts to immunocompromised individuals. This risk appears low and such infections are typically milder than the wild-type disease, with no requirement for acyclovir or VZIG administration. A 10 year post marketing safety review of the live VZV vaccine identified only 3 cases of secondary transmission. Importantly in all 3 of these cases the vaccine recipient had a post vaccination rash5 suggesting that contacts who develop a vaccine-related rash should avoid contact with immunocompromised IBD patients. In our opinion, immunosuppressed IBD patients should not only be offered a comprehensive vaccination schedule for protection against opportunistic infections according to the European evidence based consensus guidelines, but greater emphasis should be placed on vaccinating their close contacts. In particular close contacts of immunosuppressed patients should be offered annual influenza vaccination and VZV varicella vaccination when the immunosuppressed IBD patient lacks varicella immunity.
References 1. Viget N, Vernier-Massouille G, Salmon-Ceron D, Yazdanpanah Y, Colombel JF. Opportunistic infections in patients with inflammatory bowel disease: prevention and diagnosis. Gut 2008;57(4):549–58. 2. Rahier JF, et al. European evidence based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2009 June;3(2):47–91. 3. Melmed GY, Ippoliti AF, Papadakis KA, Tran TT, Birt JL, Lee SK, et al. Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses. Am J Gastroenterol 2006;101(8): 1834–40. 4. Elkayam O, Yaron M, Caspi D. Safety and efficacy of vaccination against hepatitis B in patients with rheumatoid arthritis. Ann Rheum Dis 2002;61(7):623–5. 5. Galea SA, Sweet A, Beninger P, Steinberg SP, Larussa PS, Gershon AA, et al. The safety profile of varicella vaccine: a 10-year review. J Infect Dis 2008;197(Suppl 2):S165–9.
Oliver Waters⁎ Tariq Ahmad Royal Devon and Exeter Hospital Trust, Devon EX2 5DW, United Kingdom ⁎Corresponding author. Tel.: + 44 1392402840 Fax: + 44 1392402810. E-mail address: [email protected]. 6 February 2011
1873-9946/$ - see front matter © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.crohns.2011.02.006