Vaccination in IBD Part 2: in particular

My dear patients !

Meanwhile you can tell that I am a great advocate of vaccines.

Especiall for my patients with inflammatory bowel disease, Crohn`s disease or ulcerative colitis.

Of course I know all the discussion around the issue and I know, that some people are completely and totally against vaccines for reasons, they consider important and even more important than other reasons that are evident.

This article is about certain vaccinations, in particular about influenca, pneumococci, HPV, Hepatitis B, VZV.

And  it turned out longer than I wanted it to be. Yet it is releveant, so make yourself comfortable…

The most important vaccination right now in the beginning (middle…)  of October is – and I bet you all know it already: influenza vaccination. For everybody and even more for patients who receive immunosuppressants (medication that suppress the bodies immune system, I wrote about that in the last article*). And – just that we are clear on that and are all tallking about the same thing – when I write influenza I mean influenza. Sometimes things get a little mixed up here, people say flue or imfluenza and mean “cold” (dripping nose and a little cough).

Influenca causes illness with the need to stay in bed for a couple of days, already when you are healthy in the sense of not having chronic disease. It can lead to high fewer and a situation where you have to be carefull not to “forget” to eat and to drink while beeing  all worn out and sleeping all day. And there is always the risk of additional bacterial infection. 

Because during influenza – even without immunosuppression – the immune system is weak and bacteria can easily overcome the immune defence. Actually influenca virus itself can cause pneumonia, it can cause myositis and myocarditis (very serious) and even encephalitis.

And you may guess who is at special risk for all that  – exactly : patients with immunosuppression. The problem is that there is “almost”(*) no therapy for virus infections. Antibiotica do not help against virus infections and (*) there is some discussion wether neuraminidase inhibitors (… what ??? … the special medication for virus infection) can be considered an effective therapy for influenza.

... year after year. Or every couple of years.

For influenza there is a new vaccine every year, since the virus is changing a bit every year and that`s why you have to get new vaccine every year.

The other important vaccine is – during fall and winter but actually over the whole year – pneumococci vaccine.

Pneumococci are bacteria, which can cause pneumonia over the whole year. And again: people who don`t have chronic disease like inflammatory bowel disease can catch it in a “weak” moment with the need to be  admitted to hospital. With everything that comes with it: oxygen therapy, intravenous antibiotics, respiratory exercise, inhalation, after all quite some reconvalescence time until you have completely recovered … what comes with it.

And I have seen healthy male adults (and writing this I actually recognize that I really remember males as healthy persons having to deal with severe pneumonia) , who were admitted to ICU with a pneumonia “out of nothing”.

That is to say: you have to take pneumococci seriously.

And I don`t always want to go like: YOU !!! You immunosuppressed people !!!!

But then again I have to, because it all comes down to immunosprression making things kind of dangerous. In case of immunosppuression you can get really seriously sick very quickly and get heavy pneumonia with need for respiratory therapy. If right and effective antibiotic therapy doesn`t start right away, infection might spread over the whole body, which we are talking about as sepsis. It can take a complicated course for example through meningitis and other complications. And I don´t like to write it, but in case of immunosuppression out of pneumococci pneumonia a very dangerous and serious situation can result up to the stage that comes after not successfully treated severe illness…

I don`t have the intention to cause fear or panic, that`s not the point and I think most of you know that. But you should know what we are talking about. In case of immunosupression, the body has almost nothing to show up against bacterial or viral infection.

There are different vaccines for pnemococci. (I don`t want to write down the names of the drugs here but just the medical substance): PPSV23 is a vaccine which needs to be vaccined every 5-6 years since over the time. The other vaccine is PCV13. So the recommendation for immunosuppressed patients is (to my english readers : please note that I am referring to a german recommendation (by the STIKO (ständige Impfkommission) which is a commitee that gives out the recommendations for vaccination in germany) to start with vaccine PCV 13 in the beginning, have another vaccine with PPSV 23 after 6-12 months and then repeat PSV 23 every 5-6 years.

That is the recommendation for people with immunosuppression.

Do you remember...?

Writing this (above) is again not to annoy you with complex letter and numer combinations, …but … so you have heard it. That you recognize by now : 1 time pneumococci vaccine isn`t enough. If your doctor has given you vaccine without mentioning: we need to repeat this in …whatever (dependig on the scheme he or her choose), ask about it.

So also pneumococci vaccine I really do recommend at that point in year.

What else ?

Some of you might remember the beginning of biological therapy (or antibody therapy), either Infiximab, Adalimumab or Vedolizumab, Ustekinumab …)

Do you remember all the bloodsamples that were taken in the beginning ? Remember having to wait for these results ? Well one of them was about Hepatitis B.

(And I hope you all know what values where checked on and why. I hope in case noone told you, you did ask. You are allowed and supposed to know what is going on in diagnostics and treatment of this life long disease…)

So another important vaccination is Hepatitis B. Hepatitis B is still present and it is transmitted mostly through sexual contacts in the first place, also through needles, blood transfusion. I know some patients who got infected by their mother during birth since nobody knew that the mother had Hepatitis B.

All in all Hepatitis B belongs to that kind of disease from which quite a few people think: Hepatitis ? Me ? … no way ! Not because they are vaccined but because they just think they are not at risk. But sometimes … suddenly Hepatitis B is just there. In the middle of a neat life without drugs, without injections, blood transfusion and I won`t go any further here. But I remember these male adults (sorry, no offence, but in the situations that come to my mind they were all male) in suites and ties sitting there: silence in the woods.

So what I want to emphazize: it does happen ! …. And Hepatitis B might – in case of a proper immune system – occur without you even recognising it, without symptoms like icterus or pain in the abdomen as one might imagine. You might feel a little tired for one or two days that`s about it.

And yes there is treatement for Hepatitis B but beeing  protected is far better than having to react. That is again valid for everybody, but again – especially for you with inflammatory bowel disease  with upcommimg need for immunosuppression or already existing  immunosuppression.

The situation is the following: Hepatitis B can very well be healed or kept under control from a body with a normal immune system. When everything is ok, when it has all the resources and a good body defence system.

That won`t work with immunosuppression. So even if your body is or was able keep Hepatitis B under control in times you were not chronically ill and had a normal immune response, when immunosupressive therapy is necessary, your body can not keep Hepatitis B under control anymore and a disease or a virus, that you had contact with years ago can be activated and cause problems in terms of active infectious disease.

Nowadays already the small babies get vaccine for Hepatitis B, it is recommended for youths who havn`t been vaccinated as a baby.

...noch 2:

Can we manage two more ? (vaccines)

1. HPV stands for human papilloma virus. Which is very widespread not to say almost everybody is confronted and by that infected with HPV sooner or later. It is also transmitted by sexual contact. By the age of 25 almost everybody has been confronted with it.  HPV also  won`t make you sick or ill right away and here as well a healthy body can denfend itself against the virus successfully.

The dangerous thing is that HPV might cause malignoma in the genital region. And again (and I think by now everybody has understand this basic principle): the weaker the immune sysetm and the bodies defense, the higher the risk for this consequence.

HPV should be vaccined exactly for that reason.  And it is recommendet for a few years for all young girls/women and also for young boys / men.

For immunosppressed people it is especially recommendet.


2. So last not leas t… I was about to write chickenpox. Which isn`t wrong. Most of us have been through chickenpox, not all though. To vaccine chickenpox – in case you didn`t have it – is not an option when you already have immunosuppressant therapy. Because it is a life vaccine.

BUT: it is wise to vaccine shingles. Because shingles are caused by the chickenpox virus – which is the varizella zoster virus, VZV –  after having been through chickenpox. The virus remains in the body and as long as the immunesystem is in good shape – no problem. As soon as it is not in good shape anymore  – here it goes again.

(… does this immunosuppression-thing actually get boring ?)

And when the virus gets activated for the 2nd, 3rd or 4th time it turns out to cause shingles. Shingles are these small bubbles, which form in a certain area of the skin (called dermatome, which means a segment according to an area which is innervated by a certain nerve) small little weeping blatters that turn into an exathem which is very painfull. Shingles occur more frequent in case of imunosuppression especially with double immunosuppresion. You can vaccine shingles with a dead vaccine, it is strongly recommended for immunosuppressed people.

... the most important ones so far

Enough for today, right ?

Did we cover it all ?  –  Of course not !

But listed above are the most important vaccines wich I would really like you to take to heart. In case you should think now: ” I havn`t been vaccined for years  !  Actually I was never asked about it !” – talk to your gastroenterologist or your general practitioner about it, 

In case you have an vaccination pass – excellent. You actually should have one, take care of it, it is important. In case you havn`t : go get a new one. Go to your general parctitioner and tell him: I lost my vaccination pass, I need a new one. And your doctor should be able to find in his records when you got vaccined the last tiome and in case not: maybe a good reason to take care about the issue of vaccination again. It is important !

And with this take care once again !

Best regards, yours

Dr. med. Susanne Weyrauch


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