Freddy Caldera, DO, on the Importance of Vaccines for Patients With IBD
Confusion about which health care provider is responsible for ensuring patients with inflammatory bowel disease (IBD) receive the vaccines they need is just one of several factors that contribute to the low rates of immunization among these patients. Freddy Caldera, DO, associate professor of Medicine at the University of Wisconsin School of Medicine & Public Health, answered some key questions about how gastroenterologists can better protect their patients with IBD from influenza, pneumonia, shingles, and more.
GASTROENTEROLOGY LEARNING NETWORK: Patients with inflammatory bowel disease (IBD) have historically shown lower rates of immunization against vaccine-preventable diseases than the population as a whole. Why is this the case? What are the barriers to ensuring patients with IBD are appropriately immunized?
FREDDY CALDERA, DO: In the past, immunization rates have been low for patients with IBD, but these rates can be improved. At University of Wisconsin, we have been able to achieve high immunization rates for influenza and pneumococcal vaccines by sharing responsibility with primary care providers for recommending and administering the vaccine.
One major barrier is attitudes regarding whether the gastroenterologist or primary care provider (PCP) is responsible for recommending and administering vaccines. Prior studies have found discordance between provider perceptions, with specialists often relying on PCPs to recommend and order vaccines, while PCPs may be uncertain of which vaccines are required and the safety of administering vaccines to immunosuppressed patients. Overcoming this barrier is essential, since a provider’s recommendation for vaccination has been shown to overcome vaccine hesitance and improve vaccine uptake. Thus, in order to improve immunization rates, gastroenterologists should play an active role in not only recommending vaccines but also in sharing equal responsibility with the PCP for ensuring that patients are vaccinated.
GLN: Patients with IBD are at higher risk for certain vaccine-preventable diseases or complications from these infections, such as influenza, streptococcal pneumonia, and herpes zoster, than the general population, due to taking immune-suppressing medications. How can providers reduce this increased risk, and how significant is the heightened risk for patients with IBD?
FC: Infections are one of the most common complications for patients with IBD. A recent study reported the annual incidence of these infections as 2.2% (1 in 45) for those on combination therapy (anti-tumor necrosis factor therapy and an immunomodulator), with the risk amplified to 5.1% (1 in 20) among those older than age 65 years. Additionally, these infections lead to significant morbidity and have a mortality rate at 3 months of 3.9%.
Not all immunosuppressive medications confer an increased risk for infection; for example, vedolizumab, which is a gut selective immunosuppressant, has an excellent safety profile. To decrease the risk of infections, providers should take an active role in assuring patients are immunized against these vaccine-preventable diseases.
GLN: You point out in one of your research papers that some IBD therapies—those that are immunosuppressive— can lower the immunogenicity of vaccines. What is the best way to ensure patients with IBD are receiving adequate protection from vaccine-preventable diseases?
FC: The optimal time to obtain an immunization history to provide appropriate booster or catch-up vaccines is at the time of initial diagnosis of IBD or during transfer of care. That way vaccines can be provided prior to initiation of immunosuppressive medications, as responses to certain vaccines may be blunted if administered after with certain immunosuppressive agents.
GLN: Is it possible for vaccines to cause an IBD flare?
FC: Multiple studies evaluating different vaccines have shown that they are safe for patients with IBD. No vaccine has been associated with a flare of IBD. Similar to data in the general population, vaccines are safe and effective and should be provided to immunosuppressed patients. To assure high vaccine uptake among patients with IBD, gastroenterologists need to help dispel vaccine hesitancy by educating patients that vaccines are safe for patients with IBD.
GLN: How can gastroenterologists contend with the challenge of a patient with IBD who is vaccine-resistant, or who has family members who refuse vaccines? What’s the best approach to take?
FC: A provider’s recommendation for vaccination has been shown to overcome vaccine hesitance and improve vaccine uptake. Patients who are hesitant to accept one vaccine, such as the influenza vaccine, maybe not be hesitant to all other vaccines, such as pneumococcal vaccine. Additionally, just because someone chooses not to receive the vaccine during their first visit doesn’t mean they won’t accept at a later time. At University of Wisconsin, we have implemented simple interventions, such as using a medical assistant to review the immunization history and administer influenza and pneumococcal vaccines under delegation protocols. This allows providers to focus on patients who are vaccine-hesitant, to review the benefits and dispel misconceptions about vaccines. Furthermore, certain vaccines (influenza, pneumococcal, and hepatitis B) are stocked in our offices and administered during office visits to increase vaccine uptake.
GLN: There are fast-track projects in the works to create a vaccine for COVID-19, but until it is available, does the pandemic create an even greater urgency for patients with IBD to be fully immunized against other communicable diseases?
FC: Yes, providers need to be proactive because telehealth has transformed the way health care is delivered. This platform will likely continue post-pandemic. Therefore, vaccination history and needs should be assessed at each visit irrespective of whether the visit occurs in the office or via telemedicine. Once it has been determined which vaccines are needed, they should be administered during in-person visits or arrangements made to have those patients seen via telehealth to have the vaccines administered, and also to make arrangements for patients who are seen in locations that don’t have the needed vaccine in their practice. To optimize capture of patients coming into a gastroenterology practice or medical system for ancillary services (e.g., laboratory, infusion center, nursing education) these appointments should be combined with a nursing or medical assistant appointment so the required vaccines can be administered.
Caldera F, Hayney MS, Farraye F. Vaccination in patients with inflammatory bowel disease. Am J Gastroenterol. 2020; 115(9 ):1356-1361