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Immunization is underused in IBD care despite high infection risks from immunosuppressants—early, proactive vaccination is essential for prevention.
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As the burden of inflammatory bowel disease (IBD) grows, driven by lifestyle changes, dietary habits, and diagnostic capabilities, clinicians are increasingly challenged to manage not just the disease’s inflammatory component but also its broader systemic implications. Among these, the heightened risk of vaccine-preventable infections (VPIs) due to immunosuppressive therapy stands out as a major concern.
Despite well-established global guidelines, vaccination remains underutilized in developing and underdeveloped countries in adult IBD care. In this article, we explore the scientific rationale, timing, and strategy behind vaccinations for IBD, with the focus on the Indian clinical context.
IBD treatment often involves a continuum of immunosuppressive agents, such as corticosteroids, thiopurines, methotrexate, biologics, and Janus kinase (JAK) inhibitors. These agents are crucial for disease control but elevate the risk of both common and opportunistic infections. For instance, reactivation of hepatitis B virus (HBV) is a documented risk in patients receiving anti-TNF therapy, while herpes zoster reactivation is more common with tofacitinib, a JAK inhibitor.
This risk is compounded when multiple immunosuppressants are used in combination. A meta-analysis led by Murat Toruner, MD, reported that combination therapy was associated with a significantly higher incidence of serious infections compared to monotherapy.1 Therefore, pre-emptive vaccination emerges as a cornerstone in the preventive management of patients with IBD, particularly those on long-term or high-level immunosuppression.
Vaccines in IBD are broadly classified into 2 types: live-attenuated and inactivated. The former — including vaccines like MMR (measles, mumps, rubella), varicella, and live herpes zoster (Zostavax) — pose a risk of causing disease in immunocompromised hosts and are therefore contraindicated during high-level immunosuppressive therapy. In contrast, inactivated vaccines, such as those for influenza, pneumococcus, HBV, and the recombinant herpes zoster vaccine (Shingrix), are considered safe across all levels of immunosuppression, albeit with potentially reduced immunogenicity.
The ideal window for vaccination is either at the time of IBD diagnosis or prior to the initiation of immunosuppressive therapy.2 When necessary, live vaccines should be administered at least 4 weeks before immunosuppression begins or delayed until 1 to 3 months after therapy has ceased. This timeline allows sufficient time for the host immune system to mount an adequate response while minimizing adverse events.
The influenza vaccine should be administered annually via intramuscular injection. The live intranasal formulation is contraindicated in immunosuppressed patients. Studies suggest[ that high-dose influenza vaccines offer improved seroprotection in patients receiving biologics, underscoring the importance of optimizing formulation choice based on therapy status.3
Pneumococcal vaccination involves a 2-step regimen: PCV13 followed by PPSV23 at least 8 weeks later, with a PPSV23 booster at 5 years and again after age 65. Notably, combination immunosuppressive therapy has been shown to reduce vaccine efficacy, further emphasizing the need for early administration.
Hepatitis A and B vaccines are critically important in regions like India, where intermediate endemicity persists. For HBV, serological screening for HBsAg, anti-HBc, and anti-HBs is essential before vaccination. Immunosuppressed patients may require double-dose or accelerated regimens, and post-vaccination titers should be rechecked within 1 - 2 months to confirm seroconversion.
Human papillomavirus (HPV) vaccination is recommended for all individuals up to age 26 and optionally until age 45.4 The quadrivalent vaccine, covering HPV types 6, 11, 16, and 18, has shown to be both safe and effective in immunosuppressed individuals. Cervical cancer screening remains essential for women with IBD, irrespective of vaccination status.
Other vaccines, such as Tdap (tetanus, diphtheria, pertussis), meningococcal, and Shingrix (recombinant herpes zoster), are also indicated based on individual risk profiles. Notably, the availability of Shingrix in India remains limited, though it offers > 90% efficacy in preventing herpes zoster even in immunocompromised populations.5
Children with IBD should be vaccinated in accordance with pediatric guidelines, with additional caution around timing relative to immunosuppressive therapies. Pregnant women can safely receive inactivated vaccines such as influenza, Tdap, and HBV, but all live vaccines should be strictly avoided. Household contacts of IBD patients on immunosuppressants may receive all standard vaccines, including live ones, provided they do not develop vaccine-derived infections, such as a post-varicella rash.
Adult vaccination is largely neglected in developing countries, with national efforts primarily focused on pediatric immunization. Barriers include lack of patient awareness, vaccine cost, limited policy support, and insufficient physician initiative.
Gastroenterologists must lead the effort to integrate vaccination into routine IBD care. This includes reviewing immunization history during baseline evaluation, maintaining vaccine records, and using electronic health records (EHRs) to prompt timely vaccinations. Coordination with primary care and infectious disease specialists can further streamline implementation.
Vaccination represents one of the most effective, yet underutilized, interventions in IBD management. By assessing immunization history early, prioritizing inactivated vaccines, and timing live vaccines judiciously, clinicians can significantly reduce infection-related morbidity and mortality.
In countries where adult vaccination remains under-emphasized, a shift toward proactive immunization protocols is not just good practice—it is a clinical imperative.
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