Inflammatory bowel disease (IBD) is a term that primarily refers to two diseases of the intestine: Crohn’s disease and ulcerative colitis. Both of these diseases involve inflammation in the digestive tract, but they differ in where the inflammation is located. In Crohn’s disease, inflammation can affect any part of the digestive tract and any depth of the bowel wall. In ulcerative colitis, inflammation is limited to the inner mucosa of the large intestine. IBD causes many persistent symptoms, including diarrhea, abdominal pain, fever, rectal bleeding, weight loss, and anemia, as well as other manifestations of inflammation outside of the digestive tract. To treat this condition, physicians prescribe a variety of strong medications.

Vaccines are a vital part of healthcare. We’ve managed to greatly limit or eradicate dangerous diseases through the use of these preventative measures, and it is important for everyone to stick to the vaccine schedules that healthcare professionals outline. However, some individuals with IBD are unable to safely take all vaccines, and they might not react to vaccines to the same degree as individuals without IBD.

This is because many people with IBD have an impaired immune system (immunocompromised). Usually, this results from the type of medications they are prescribed that are powerful enough to help them enter remission, including corticosteroids (Cortiment®, Entocort®, Betnesol®, Cortenema®, Cortifoam®, Proctofoam®), immunosupressives (Imuran®, Purinethol®, Xeljanz®, methotrexate), and biologics (Remicade®, Humira®, Simponi®, Entyvio®, Stelara®, Inflectra®, Renflexis®). These medications are very effective because they modulate the way that the immune system works and, while this reduces inflammation and symptoms, it can make people more susceptible to illnesses. Malnutrition that results from either poor absorption due to inflammation or inadequate dietary intake can also cause individuals to become immunocompromised, as the body doesn’t have the nutrients it needs to effectively fight disease.

Individuals who are immunocompromised need to follow different vaccination protocols than the general population. Read on to learn about some of these differences, and view this detailed chart from the Canadian IBD Nurses to learn more about specific vaccines.

 

Inactivated Vaccines

While it is generally safe for most people to get inactivated vaccines, such as hepatitis A and hepatitis B, immunocompromised individuals often have a suboptimal response. In these cases, the person might require an extra dose of the vaccine at a later time.

  • Inactivated vaccines are safe in immunosuppressed patients, but patients on immunosuppressive therapy may have a suboptimal response to vaccination
  • Optimize vaccination status prior to initiating immunosuppression whenever possible
  • Antibody and T-cell response to vaccine requires 2-4 weeks
  • Suggested time intervals to allow for best response to vaccine:
    • Between vaccine and initiation of immunosuppression: at least 2 weeks, and preferably 3-4 weeks
    • Between discontinuing immunosuppression and vaccine: ≥ 3 months (this interval may vary with the type and intensity of treatment, underlying disease, or urgency of vaccination if vaccines are needed for post-exposure or outbreak management)
  • If vaccines are administered during immunosuppression, attempt to give them when the next 2 weeks represent the least immunosuppression
  • Additional doses of inactivated vaccines may cause an increase in sore arm, but are not associated with adverse effects. In patients whose immunosuppression may be temporary, it is acceptable to give a vaccine which is due during immunosuppression in order to provide some immediate protection, and then give another dose when the patient is no longer immunocompromised and may respond more effectively.
Vaccine Check Titer Before Vaccination? Recommendations / Comments
Tetanus diphtheria/ Tetanus diphtheria acellular pertussis/ Tetanus diphtheria acellular pertussis and inactivated polio (Td/Tdap/DTaP/DTaP-IPV-Hib)

 

No Give according to routine schedule.

Td booster every 10 years; with Tdap used at 14-16 years of age.

Pregnant women should be offered Tdap vaccine to be given at 27-32 weeks gestation during every pregnancy, irrespective of previous immunization history.

Haemophilus influenza type B (Hib) No Give according to routine schedule.
Human papillomavirus (HPV) No Intended for males and females, ages 9-26 years old.

2 doses (0, then 6-12 months after i)

Highly recommended for MSM**.

Influenza

(inactivated / injectable form)

No Annual vaccine.  Timing of administration should balance nadir of immunosuppression and the need to deliver vaccine prior to the onset of influenza season (usually mid-December).
Pneumococcal

(conjugate) [Pneu-C-13]

No Give according to routine scheduleii.

In adults, if no prior pneumococcal vaccine, give 1 dose Prevnar 13, wait 8 weeks minimum, and then give 1 dose Pneumovax 23.

Pneumococcal

(polysaccharide) [Pneu-P-23]

No As above, with one time booster after 5 years (if first vaccine was given at > 10 years of age) or 3 years (if first vaccine given at ≤10 years) and immunosuppressed.
Meningococcal

(conjugate) [Men-C-ACYW]

No Give according to routine schedule.

Vaccinate at-risk patients if none previously.

Hepatitis A Vaccination

(HAV)

No 2 doses required: Give at 0, 6-12 months; or 0, 6-18 monthsiii.

If vaccinated during an immunosuppressed period and patient is in an at risk group, consider booster when no longer immunosuppressed.

Recommended for at risk groups (e.g. Liver disease such as *PSC, travelers, **MSM).

Hepatitis B Vaccination

(HBV)

Yes Give according to routine schedule.

Dosing schedule depends on particular vaccine.iii; check post vaccine titers at 1 month after finishing last dose. Refer to Canadian immunization guide for non-responders.

Twinrix

(Combination Hepatitis A/B)

Yes May be given instead of HAV and HBV individually.
Herpes zoster vaccine, inactivated No, but wait one year after episode of shingles Two doses, given 2-6 months apart.  Recommendations may change as further information becomes available.

*PSC – primary sclerosing cholangitis **MSM – males who have sex with males

 

Live Vaccines

Immunocompromised people generally cannot take live vaccines, such as measles, mumps, and rubella, because they aren’t able to respond to the live virus properly and might instead become ill with the disease that the vaccine contains.

When a person cannot take certain vaccines, they rely on ‘herd immunity’ to stay safe. Herd immunity occurs when there aren’t enough unvaccinated people to spread the disease to those who are unable to take the vaccine. If you are able to take live vaccines, make sure you do so, as immunocompromised people are relying on you for protection.

However, there are some cases where individuals who have close contact with someone who is immunocompromised, such as family, close friends, and roommates, should avoid certain live vaccines as well. They might become contagious to a degree that while safe for most people, could pose a danger to individuals with a weak immune system.

  • Contraindicated in patients who are immunosuppressed due to the concern that vaccination may result in disease (EXCEPTION: Live shingles vaccine)
  • Patients considered to be immunosuppressed include, but are not limited to:
    • Immunomodulators: Azathioprine, 6-Mercaptopurine, Methotrexateiv
    • Steroids: Patients on ≥2 mg/kg/day (patients < 10 kg) or ≥ 20 mg/day (patients ≥ 10 kg) for at least 2 weeksv
    • Biologics such as TNF antagonist (Infliximab, Adalimumab, Golimumab)vi, IL 12/23 antagonist (Ustekinumab). (EXCEPTION: Integrin receptor antagonist Vedolizumab)
    • Significant Protein-Calorie Malnutrition
  • Suggested time intervals to allow for immune system recovery:
    • Between last dose of vaccine and initiation of immune suppression: 4 – 6 weeks
    • From discontinuation of immunosuppression and vaccination: 3 months (1 month for high dose steroids)
  • Family members should be vaccinated to prevent transmission from family members to patients
Vaccine When Should Titres be Checked? Before Initiation of Anti Tnf or Immunomodulator? What to do if Already Immunosuppressed?

(On Anti Tnf or Immunomodulator?)

Measles, mumps, rubella (MMR) Considered immune if 2 documented doses of vaccine or positive serology Contraindicated if plan to start therapy in < 4 weeks. Contraindicated in pregnancy.

 

Contraindicated
Varicella Considered immune if good history of natural infection, or two doses of vaccine, or born before 1970.  Check serology prior to vaccination if >25 years of age, or one dose of vaccine or child with history of chickenpox in the immediate family but not individual.

 

Contraindicated if plan to start therapy in < 4 weeks. Contraindicated
Herpes Zoster (for >50 years old) Persons who have had shingles in the last year are considered immune. Not recommended. Use inactivated vaccine.

 

Not recommended. Use inactivated vaccine.
Live Attenuated Influenza

(Flu Mist intranasal form)

Not applicable Contraindicated (use inactivated vaccine) Contraindicated
Rotavirus Not applicable Contraindicated Contraindicated

Conclusion

Individuals who are immunocompromised have different needs than the general population when it comes to vaccines. They might need to avoid some or get an extra dose of others. For more information on this topic, Canadian IBD Nurses have produced a full chart on which vaccines are safe and under what circumstances. It also includes more details on vaccines for travel and for family members of immunocompromised individuals. View the full chart here.


First published in the Inside Tract® newsletter issue 211 – 2019
i CDC now recommends 2 doses of HPV vaccine for people starting the vaccination series before the 15th birthday. Three doses of HPV vaccine are recommended for people starting the vaccination series on or after the 15th birthday and for people with certain immunocompromising conditions (CDC October 2016)
ii In patients ≥ 5 years where pneumococcal polysaccharide vaccine is indicated, some experts recommend the use of conjugate vaccine prior to administration of polysaccharide vaccine in immunosuppressed patients (regardless of age) to enhance immune response. In these cases, the polysaccharide vaccine should be given at least 8 weeks after the conjugate, wait 5 years then one time revaccination with Pneumovax 23 booster dose (NACI 2012). Prevnar 13 is currently not licensed in patients ≥ 5 years of age, although its use is still recommended in high-risk patients. NACI. Update on the Use of Conjugate Pneumococcal Vaccines in Childhood.; 2010. NACI. Statement on the Use of Conjugate Pneumococcal Vaccine – 13 Valent in Adults (Pneu-C-13), 2013.
iii The dosage schedule for Hepatitis A and Hepatitis B vaccines depend on the vaccine used. See vaccine product monograph for instructions. Accelerated schedules are available for some vaccines.
iv As per NACI, ≤ 0.4 mg/kg/week methotrexate; ≤ 3.0 mg/kg/day azathioprine; ≤ 1.5 mg/kg/day 6-mercaptopurine.
For patients on high dose steroids (≥ 2 mg/kg/day or ≥ 20 mg/day) for less than 2 weeks, some experts would consider having a two week interval between discontinuing steroids and vaccination.
vi  Immunodeficiency that follows the use of recombinant human proteins, including tumor necrosis factor alpha antagonists (i.e. adalimumab, infliximab and etanercept) or anti-B cell monoclonal antibodies (i.e. rituximab) may be prolonged. The interval until immune reconstitution varies with the specific treatment regimen and other factors. Recommendations may change as further data become available
This guide was developed through CANIBD and the collaborative efforts of Frost, K.1, Watson, M2, Science, M1 and McGeer, A3, and sponsored by an educational grant to CANIBD from AbbVie.
1SickKids Hospital, Toronto, Ontario; 2London Health Sciences Centre, London, Ontario; 3Mt. Sinai Hospital, Toronto, Ontario
Charts reprinted by permission from CANIBD.