Study finds Many Gastroenterologists Unaware of Appropriate Immunizations for IBD Patients

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According to Boston University School of Medicine (BUSM) researchers and Boston Medical Center (BMC) clinicians, gastroenterologists are often unaware of the appropriate immunizations inflammatory bowel disease (IBD) patients need to help prevent illness.

Immunosuppressive agents are commonly used commonly to treat IBD. Immunosuppression, whether in IBD patients or transplant patients, is associated with an increased risk of infections. These infections include many preventable by immunization, such as influenza.

Sharmeel Wasan, MD, MSc, an assistant professor of medicine at BUSM and a gastroenterologist at BMC, and colleagues designed their study to examine physician and patient values and knowledge regarding immunization and immunization histories. Their findings have been published in the June issue of the journal Inflammatory Bowel Diseases.

Wasan and colleagues asked one thousand gastroenterologists, randomly selected from the membership of the American College of Gastroenterology, to complete a 19 question electronic survey regarding the suitable vaccines for the immunocompetent and immunosuppressed IBD patient, the barriers to recommending the vaccines, and the perceived role of the gastroenterologist versus the primary care physician (PCP).

The response rate was just over 10% with 108 gastroenterologist responding. The majority believed that the PCP should determine which vaccinations to give (64%) and to administer the vaccines (83%).

Just over half of the 108 responding gastroenterologists (n = 56, 52%) took an immunization history most or all of the time. The researchers noted no significant difference between gastroenterologists with smaller practices (less than 40 IBD patients) compared with those with larger practices (greater than 40 IBD patients) in how often they asked their patients about immunization history.

In contrast, more academic physicians (67.5%) asked their patients about immunization history most or all of the time compared to 42.4% of private physicians.

Sixteen of the 108 surveyed gastroenterologists did not regularly recommend immunization against influenza. The most common reasons included "too busy/forgot," "no specific reason," and "did not know my patient needed it".

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Overall, 66%–88% of gastroenterologists correctly recommended the inactivated vaccines for their IBD patients not on immunosuppressive therapies while 20%–30% incorrectly recommended administering the live, attenuated vaccines (MMR, herpes zoster, varicella) to their immunosuppressed patients.

Of the inactivated vaccines, knowledge regarding the HPV vaccine was particularly poor, with only 71 (66%) recommending the vaccine to their immune-competent patients and only 51 (47%) recommending the vaccine to their immune-suppressed patients).

In general, gastroenterologists were more likely to make the correct vaccine recommendations for their immunocompetent IBD patients. "Gastroenterologist knowledge of the appropriate immunizations to recommend to the IBD patient is limited and may be the primary reason why the majority of gastroenterologists believe that the PCP should be responsible for vaccinations," said primary author Sharmeel Wasan, MD, MSc, an assistant professor of medicine at BUSM and a gastroenterologist at BMC.

Over the last five years, the problem of vaccine preventable illnesses in patients with IBD have been described, including case reports of fulminant hepatitis and fatal varicella. "Despite an increased risk for infections on these agents, many IBD patients are not being appropriately vaccinated. Barriers to vaccination described by patients include a lack of awareness and concern for side effects, suggesting that providers are not adequately educating and recommending vaccinations to their immunosuppressed patients," said Francis Farraye, MD, MSc, a professor of medicine at BUSM and a gastroenterologist at BMC.

The authors recommend educational programs on vaccinations directed to gastroenterologists who prescribe immunosuppressive agents. A good place to begin is the 2004 article in the same journal which gives the following general recommendations for immunization of IBD patients:

  1. Standard recommended immunization schedules for children and adults should be generally adhered to.
  2. At diagnosis, children and adults should have complete review of immunization history for completeness. All patients with incomplete series should commence catch-up vaccination.
  3. Adults who cannot provide a clear history of chickenpox should have serologic testing for varicella. Nonimmune individuals should receive varicella vaccine. Children who are not immune by vaccination or acquired immunity through infection should receive varicella vaccine.
  4. Live bacterial or viral vaccines should be avoided in immune compromised children and adults with IBD.
  5. Whenever possible, adequate immune response (as reflected by serologic response) should be ascertained for individuals who have required immunization while immune-suppressed. Repeat dosing may be considered when immune response to immunization is insufficient.

Sources
Vaccinating the inflammatory bowel disease patient: Deficiencies in gastroenterologists knowledge; Sharmeel K. Wasan, Jennifer A. Coukos and Francis A. Farraye; Inflammatory Bowel Diseases Volume 17, Issue 6, June 2011; Article first published online : 28 APR 2011, DOI: 10.1002/ibd.21667

Inadequate knowledge of immunization guidelines: A missed opportunity for preventing infection in immunocompromised IBD patients; James H. Yeung, Karen J. Goodman and Richard N. Fedorak; Inflammatory Bowel Diseases Volume 17, Issue 6, June 2011; Article first published online : 18 FEB 2011, DOI: 10.1002/ibd.21668

Guidelines for immunizations in patients with inflammatory bowel disease; Bruce E. Sands, Carmen Cuffari, Jeffry Katz, Subra Kugathasan, Jane Onken, Charles Vitek and Walter Orenstein; Inflammatory Bowel Diseases Volume 10, Issue 5, September 2004, Pages: 677–692; Article first published online : 14 DEC 2006, DOI: 10.1097/00054725-200409000-00028

Boston University School of Medicine; May 16, 2011 press release

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