Issue 01

Mentoring in IBD is an innovative and successful educational program for Canadian gastroenterologists that includes an annual national meeting, regional satellites in both official languages, www.mentoringinibd.com, an educational newsletter series, and regular electronic communications answering key clinical questions with new research. This issue is based on the presentation made by Dr. Jennifer Jones, at the 22nd annual national meeting, Mentoring in IBD XXII: The Master Class, held virtually, November 5, 2021.

Introduction

Patients with IBD may be at increased risk of some vaccine preventable illnesses (VPIs). Furthermore, vaccine safety, efficacy, and appropriateness may be altered by IBD and its therapies.(1,2) Despite this, studies have suggested that IBD patients have lower rates of vaccination uptake compared with the general population. For example, a study using self-administered questionnaires by IBD patients at a tertiary care center in the US found that 28% reported regularly receiving flu shots, 9% received pneumococcal vaccine, and 28% of those at risk for hepatitis B were vaccinated.(2) Lower vaccination rates may in part be based on uncertainty about which healthcare professional provides vaccines, a lack of knowledge, beliefs in vaccine inefficacy, and vaccine hesitancy.

Thus, the purpose of this presentation was to understand the care gap in the management of VPI in IBD and review the highlights from the recent Canadian Association of Gastroenterology (CAG) Clinical Practice guidelines (CPG) on VPI in IBD. In addition, there was brief discussion around the current recommendations for COVID-19 vaccines in patients with IBD.

Canadian Association of Gastroenterology: Clinical Practice Guidelines for Immunizations in Patients with IBD

CPG for immunizations in patients with IBD have recently been published by CAG in two parts: Part 1: Live vaccines, and Part 2: Inactivated vaccines.(3,4) The comprehensive systematic review and assessment of the certainty of evidence (CoE) of the benefits and harms of immunizations in patients with IBD that informed these guidelines considered all available evidence in the general population and other immune-mediated inflammatory diseases. Based on the information gathered from 1989–2019, evidence-based recommendations were developed for the administration of vaccines in adult and pediatric patients with IBD.

Existing systematic reviews, evidence, and guidelines (e.g., Centers for Disease Control and Prevention [CDC], National Advisory Committee on Immunization [NACI]) were used as an evidence base, where appropriate, and assessed in conjunction with available data in the IBD population. Data were included on topics of efficacy, effectiveness, and safety of vaccines in IBD, and other immune-mediated diseases. Per vaccine, the population was divided into adult and pediatric subgroups a priori. The CoE was rated according to the GRADE approach.

Key questions were developed through an iterative process and voted on by multidisciplinary panel. Voting was done anonymously with consensus defined ≧75% agreement. Strong recommendations were developed when it was determined that most patients should receive the recommended course of action vs. conditional recommendations when different choices may be appropriate for different patients.

In addition, the guidelines panel generated three overarching good clinical practice statements that are important, but in the judgment of the GRADE working group, are not appropriate for formal ratings of quality of evidence.

Part 1: Live Vaccines(1)

Overall, the recommendation is for live vaccines (e.g., measles-mumps-rubella [MMR], varicella) to be given to individuals (adult and pediatric) with IBD unless they are on immunosuppressive medications. The CoE varied for different vaccines and patient subgroups. Additionally, for infants born to mothers using biologic therapies, there is the additional concern related to vaccine safety in the potentially immunosuppressed newborn. The consensus group could not make a recommendation for or against giving live vaccines in the first 6 months of life due to a paucity of evidence.

Part 2: Inactivated Vaccines(2)

For inactivated vaccines (e.g., herpes zoster, hepatitis B, pneumococcal, etc.), most recommendations were congruent with current CDC and NACI recommendations with the following exceptions:

• In unimmunized pediatric patients with IBD, older than 5 years of age, suggest Haemophilus influenzae type b (Hib) vaccine be given. GRADE: Conditional recommendation, low CoE.
• In unimmunized adult patients with IBD, suggest Haemophilus influenzae type b (Hib) vaccine be given. Conditional recommendation, very low CoE.
• In unimmunized adult patients with IBD without a risk factor for hepatitis B infection, suggest hepatitis B vaccine be given. GRADE: Conditional recommendation, low CoE.
• In adult patients with IBD on immunosuppressive therapy, suggest pneumococcal vaccines be given. GRADE: Conditional recommendation, low CoE.
• In male patients with IBD age 9 to 26, suggest HPV vaccine be given. GRADE: Conditional recommendation, very low CoE.

In addition, consensus was not reached, and recommendations were not made, for the following 5 statements due to lack of evidence; need for double dose hepatitis B vaccine, timing of influenza immunization in patients on biologics, administration of pneumococcal and meningococcal vaccines in adults without risk factors, and administration of HPV vaccines in patients aged 27–45 years of age.

For herpes zoster vaccine (HZV), studies have shown an increased risk of shingles in IBD patients that increases with age and immunosuppressive medications (e.g., anti-TNFs, tofacitinib). Thus, the recombinant HZV is recommended in patients(3) 50 years of age (moderate CoE) and suggested in those <50 years of age (low CoE).

For the influenza vaccine, as studies have shown an increased likelihood of influenza and higher rates of hospitalization in individuals with IBD, the influenza vaccine is recommended for both pediatric and adult patients.  

COVID-19 Vaccination

The presentation then shifted to evolving evidence on COVID-19 vaccination in individuals with IBD. Knowledge has been generated, synthesized, and disseminated at an unprecedented pace during this pandemic, and in such an environment, the scientific community has played a key role in synthesizing, interpreting and making recommendations based on available data.

The CLARITY IBD study is one of the only published data relating directly to the IBD population. It was a comparative, observational cohort study from the United Kingdom involving 2,052 patients receiving infliximab and 925 patients receiving vedolizumab. Results showed that patients receiving infliximab produced fewer antibodies after two doses of Pfizer-BioNTech or AstraZeneca at four months than patients receiving vedolizumab, a gut-selective biologic known to have limited impact of vaccine seroconversion. Importantly, the study did not identify any difference in SARS-CoV-2 infection or COVID-19 between these groups, but these data have influenced the discussion around the need for booster doses.(5)

Other databases on COVID-19 in IBD are in development (e.g., PREVENT-COVID Study from BC and ICARUS study from the US), and will be of interest once published.

Furthermore, to support IBD patients, clinicians and scientists have had to fill advocacy and knowledge translational roles to support decision making and to influence health policy. An example of this, is the Crohn’s Colitis Canada (CCC) COVID-19 & IBD Task Force that was developed under the leadership of Drs. Eric Benchimol and Gil Kaplan. Since its inception in spring of 2020, this multidisciplinary panel of clinicians, researchers, scientists, and patients has generated accessible information for patients that is informed by the best available and rapidly emerging evidence on various topics related to COVID-19 (e.g., vaccines, navigating clinic visits, etc.), as well as the creation of the Impact of COVID-19 and IBD in Canada Report.

Conclusions

In conclusion, the management of VPIs has high clinical relevance in clinical practices and for persons living with IBD. Further research relating to best strategies for implementation of evidence-based guidelines relating to management of VPI is needed. As further evidence emerges, recommendations and health policy will continue to evolve in relation to management of VPI in IBD.

References

1. Melmed GY. Vaccination strategies for patients with inflammatory bowel disease on immunomodulators and biologics. IBD. 2009;15(9):1410–16.

2. Melmed GY, Ippoliti AF, Papdakis KA, et al. Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses. Am J Gastro. 2006;101(8):1834–40.

3. Benchimol EI, Tse F, Carroll MW, et al. Canadian Association of Gastroenterology Clinical Practice Guideline for immunizations in patients with inflammatory bowel disease (IBD)—Part 1: Live vaccines. JCAG. 2021;4(4):e59–71.

4. Jones JL, Tse F, Carroll MW, et al. Canadian Association of Gastroenterology Clinical Practice Guideline for immunizations in patients with inflammatory bowel disease (IBD)— Part 2: Inactivated vaccines. JCAG. 2021;4(4):e72–91.

5. Lin S, Kennedy NA, Saifuddin A, et al. Covid-19 vaccine-induced antibodies are attenuated and decay rapidly in infliximab treated patients. 2021 Preprint Research Square; DOI: https://doi.org/10.21203/rs.3.rs-755879/v1.

6. CCC Task Force & COVID-19. Available at: https://crohnsandcolitis.ca/About-Crohn-s-Colitis/COVID-19-and-IBD/Vaccines.

Editor-in-Chief

John K. Marshall, MD MSc FRCPC AGAF, Director, Division of Gastroenterology, Professor, Department of Medicine, McMaster University, Hamilton, ON

Contributing Author

Jennifer Jones, MD MSc FRCPC, Associate Professor, Departments of Medicine & Clinical Health and Epidemiology; Team Lead, Multidisciplinary IBD Clinical & Research Program, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS

Mentoring in IBD Curriculum Steering Committee

Alain Bitton, MD FRCPC, McGill University, Montreal, QC

Anne M. Griffiths, MC FRCPC, University of Toronto, Toronto, ON

Karen I. Kroeker, MD MSc FRCPC, University of Alberta, Edmonton, AB

Cynthia Seow, MBBS (Hons) MSc FRACP, University of Calgary, Calgary, AB

Jennifer Stretton, ACNP MN BScN, St. Joseph’s Healthcare, Hamilton, ON

IBD Dialogue 2022·Volume 18 is made possible by unrestricted educational grants from…

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