Updates in vaccination: Recommendations for adult inflammatory bowel disease patients

Table 1 Definition of the immune compromised inflammatory bowel disease patient[1]

Treatment with glucocorticoids: > prednisone 20 mg/d equivalent for 2 wk or more

Ongoing treatment with effective doses of 6-mercaptopurine, AZT, Methotrexate and anti tumor necrosis factor therapy

Within 3 mo of stopping the above listed immunosuppressive therapies

Significant protein-calorie malnutrition

Table 2 Risk factors for pneumococcal disease

All adults 65 and older

Symptomatic or asymptomatic human immunodeficiency virus

Chronic lung disease (COPD, emphysema, and asthma)

Chronic cardiovascular diseases

Diabetes mellitus

Chronic renal failure

Nephrotic syndrome

Chronic liver disease (including cirrhosis)

Alcoholism

Cochlear implants

Cerebrospinal fluid leaks

Immunocompromising conditions

Functional or anatomic asplenia

Residents of nursing homes or long-term care facilities

Smokers

COPD: Chronic obstructive pulmonary diseases.

Table 3 Risk factors for meningococcal disease

College freshman living in dormitories

Microbiologists routinely exposed to Neisseria meningitidis

Military recruits

Persons who travel to or reside in countries where Neisseria meningitidis is hyper-endemic or epidemic particularly if contact with the local population will be prolonged

Persons with persistent complement component deficiency

Persons with anatomic or functional asplenia

Persons with human immunodeficiency virus infection

Table 4 Risk factors for hepatitis

Risk factors for hepatitis A	Risk factors for hepatitis B
18 yr and older who care for an international adopted child	Polygamous relationship (e.g., persons with more than one sex partner during the previous 6 mo)
IV and non IV illicit drug users	Persons seeking evaluation or treatment for a sexually transmitted disease
Homosexual males	Current or recent injection-drug users
Chronic liver disease patient	Homosexual male
Patients awaiting transplant	Health-care personnel and public-safety workers who are potentially exposed to blood or other infectious body fluids
Occupational exposure to Hep A	All diabetics younger than age 60 yr
Persons who receive clotting factor concentrates	Diabetics 60 yr or older at the discretion of the treating clinician
Travel to endemic areas	ESRD, HD
	Human immunodeficiency virus chronic liver disease
	Household contacts and sex partners of hepatitis B surface antigen positive persons;
	clients and staff members of institutions for persons with developmental disabilities
	International travelers to countries with high or intermediate prevalence of chronic HBV infection

ESRD: End-stage renal disease.

Table 5 Evidence of immunity to varicella in adults includes any of the following

Documentation of 2 doses of varicella vaccine at least 4 wk apart

United States-born before 1980 except health-care personnel and pregnant women

History of varicella based on diagnosis or verification of varicella disease by a health-care provider

History of herpes zoster based on diagnosis or verification of herpes zoster disease by a health-care provider

Laboratory evidence of immunity or laboratory confirmation of disease

Table 6 Live attenuated vaccines with recommended times of administration[2]

Vaccine	Before initiation of immunosuppressive therapy	Already on immunosuppressive therapy
MMR	Contraindicated if plans to start therapy in 6 wk	Contraindicated
Zoster	Contraindicated if plans to start therapy in 1-3 mo	Contraindicated-could consider if:
		On short-term corticosteroids (< 14 d)
		On Methotrexate (< 0.4 mg/kg per week)
		On Azathioprine (< 3.0 mg/kg per day)
		On 6-mercaptopurine (< 1.5 mg/kg per day)
Varicella	Contraindicated if plans to start therapy in 1-3 mo	Contraindicated

MMR: Measles, mumps, rubella.

Table 7 Inflammatory bowel disease traveler

Vaccine	Type	Travel related indication
Yellow fever	Live	Parts of South America and Sub-Saharan Africa
Typhoid	Live and inactivated	Asia, Africa, Latin America, The Caribbean, and Oceania
polio
influenza
BCG vaccine	Live	Highly endemic area > 1 yr
Hepatitis A	inactivated	Central or South America, Mexico, Asia (except Japan), Africa, and Eastern Europe
Meningococcal vaccine	Inactivated	Africa
Japanese encephalitis virus	Inactivated	Rural Japan

BCG: Bacillus Calmette-Gue’rin.

Table 8 Vaccination in pregnancy

Category B	Category C	Category X
Influenza (LAIV)	PPSV23	Varicella; non-immune
	Adacel( Tdap)	1st dose. Upon completion or termination of pregnancy and before discharge from the health care facility
Influenza (IIV)	1 dose of Tdap vaccine during each pregnancy regardless of immunization status	2nd dose. 4-8 wk later
	Zoster
Boostrix (Tdap)	Meningococcus
1 dose of Tdap vaccine during each pregnancy regardless of immunization status	Hep A and B
	MMR. Non-immune
HPV 4, HPV 2	1st dose. Upon completion or termination of pregnancy and before discharge from the health care facility
PCV 13	2nd dose. 4-8 wk later

Newborns of immunosuppressed mothers must not receive any live vaccination up to first 6 mo. Tdap: Tetanus, diphtheria, acellular, pertussis; HPV: Human papillomavirus vaccine.

Table 9 Vaccinations in inflammatory bowel disease summary (quick reference)

Vaccine	How often	Live vaccine	Patients on immunosuppressive therapy
Influenza (Flu Vaccine)	1 dose every year	Nasal spray	Use flu shot only
Varicella (Chicken Pox)	If no documented immunity: 2 doses 4-8 wk apart	Yes	Contraindicated
Measles, mumps, rubella	If no documented immunity: 2 doses, 4 wk apart	Yes	Contraindicated
Zoster (Shingles)	1 dose starting at age 60 yr or older	Yes	Contraindicated
Tetanus, Diphtheria, Acellular Pertussis (Td/Tdap) Human papilloma virus	If no prior vaccination: 3 doses (0, 1, 6-12). Then 1 dose of Tdap followed by a booster of Td every 10 yr	No No	Follow recommended regimen Follow recommended regimen
	Female: 3 doses through age 26 (0, 2 and 6 mo)
Pneumococcal (pneumonia vaccine) for subset of patients	Male: 3 doses through age 21 (0, 2 and 6 mo)	No	Follow recommended regimen
	If no prior vaccination: (0, 2 then 5 yr) 1 dose at 65
	If had prior vaccination: 1 dose 5 yr after the last dose and 1 dose at age 65
Meningococcal (meningitis vaccine) for subset of patients	2 doses, 2 mo apart	No	Follow recommended regimen
Hepatitis A	2 doses, 6 mo apart	No	Follow recommended regimen
Hepatitis B	3 doses (0, 1 and 6 mo)	No	Follow recommended regimen

Centers for Disease Control and Prevention recommended vaccines for adults 2014, modified for inflammatory bowel disease patients.