Vaccination and Inflammatory Bowel Disease -Resources Targeted for Adult Patients

From a recent Gastroenterology & Hepatology –Full Link:

Gastroenterology & Hepatology  July 2017 – Volume 13, Issue 7; Vaccination of Patients With Inflammatory Bowel Disease.  Francis A. Farraye, MD, MSc

Thanks to John Pohl’s twitter feed for this link that provides recommendations for Adults with IBD.

An excerpt:

G&H  What specific resources for vaccinations are available to help gastroenterologists?

FF  It is helpful for providers to keep a copy of the Crohn’s and Colitis Foundation’s health maintenance recommendations posted in their office. This 1-page checklist (available at includes all recommended vaccines and also comments on other important health maintenance items, such as screening for cervical and skin cancer, depression, and osteoporosis. In addition, Cornerstones Health has a vaccination checklist (available at that can be downloaded, printed, and placed in each examination room to reinforce the importance of vaccination. Primary care providers as well as gastroenterologists can use these checklists as reminders in their busy practices.

Related blog post:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

More Measles Cases -Here’s the Data

This past month a recent perspective article (NEJM 2014; 371: 1661-3) provides an update on measles and the problems with vaccination rates.

Key points:

  • More measles cases in 2014 (592 thru Aug 29) than in any year in the past 20.  Already, the number of cases this year is >3-fold the number in 2013 and ~10-fold more than in 2012
  • Most cases are due to infections acquired during travel or due to cases being brought into U.S. by foreign travelers
  • Problem has expanded due to increasing number of unvaccinated children.  Vaccines “that remain in the vial are completely ineffective.”
  • Measles remains one of the most contagious illnesses and typically one person can infect up to 18 susceptible persons.  Due to its contagiousness, a high level of herd immunity (>92-94% immune) is needed to prevent sustained spread of virus.
  • Measles can be deadly with case fatality rate of 0.2% to 0.3% in the developed world and much higher in the developing world (2-15%).
  • Even a few cases are very expensive to control. A 2004 Iowa outbreak of only three patients cost more than $140,000 to contain/investigate.  An outbreak in Arizona with only 7 patients cost more than $800,000.

Related blog posts:

Measles, Seizures and Sometimes Death due to Vaccine Delays and Avoidance

Three recent news items provide more up-to-date reasons for childhood vaccines.

1. Delaying vaccines may increase seizures –here’s the link and an excerpt (from NY Times):

Some parents postpone their children’s vaccinations because they believe the delay decreases the risk. But a new study finds the opposite may be true.

The analysis, published online in Pediatrics, involved 5,496 children born from 2004 to 2008 who had seizures in the first two years of life.

For children who received any of their shots as recommended before age 1, there was no difference in the incidence of seizure in the 10 days after vaccination compared with the period before vaccination. But compared with giving it in the first year, giving the measles-mumps-rubella vaccine at 16 months doubled the incidence of seizure, and giving the measles-mumps-rubella-varicella vaccine at that age increased it almost six times.”


2. Rate of measles infections at 20 year high –here’s the link and an excerpt: (from USA Today)

The USA has the most measles cases in 20 years…The confirmed case count for 2014, as of May 23, was 288 and growing, the CDC says. That number includes 138 cases from Ohio, where the biggest outbreak is ongoing – and where the actual count is 166 as of Thursday, according to the state Health Department.

The nationwide total is the highest for late May since 1994, when 764 cases were reported, the CDC says. It surpasses the 220 cases reported in all of 2011, which was the most in the post-2000 era.

“This is not the kind of record we want to break, but should be a wake-up call for travelers and for parents to make sure vaccination records are up to date,” said Anne Schuchat, director of the CDC’s National Center for Immunizations and Respiratory Diseases. Schuchat…Before the measles vaccine became available in 1963, the virus infected about 500,000 Americans a year, causing 500 deaths and 48,000 hospitalizations.

Cases this year have been reported in 18 states and New York City. Ninety percent have been among people who have not been vaccinated or have unknown vaccination status, according to the CDC. Most of the patients report religious, philosophical or personal reasons for avoiding vaccines.”


3. When parents withhold vaccines, vulnerable children get sick and sometimes die  –here’s the link (reference noted from Eric Benchimol’s twitter feed) and an excerpt:

Jason Lawson recalled a terrifying 10 days in B.C. Children’s Hospital when his son Beckett was six, after Beckett became severely ill from chicken pox.

At the time, Beckett was still receiving a maintenance dose of chemotherapy to kill potential cancer cells. That treatment also suppressed Beckett’s immune system.

When an unvaccinated child at the school passed on chicken pox, the consequences were dire — at one point the virus got into Beckett’s liver and started to do damage, which in some cases can be irreversible….

Lawson said he’s speaking out to remind families that protecting their friends and neighbours is another good reason to make the effort.

Take home message:  With every medical intervention, there are risks and benefits.  Those who forego vaccines increase the risk for themselves, their families and friends.

Related blog posts:



Parental Immunity (to Education) and Vaccine Decision-Making

A recent NY Times editorial by the lead author of a provocative study in Pediatrics (Published online March 3, 2014  (doi: 10.1542/peds.2013-2365) argues that educational efforts to inform parents may not improve vaccination rates in children.

Here’s a link:  and here’s an excerpt:

“we found that parents with mixed or negative feelings toward vaccines actually became less likely to say they would vaccinate a future child after receiving information debunking the myth that vaccines cause autism.

Surprising as this may seem, our finding is consistent with a great deal of research on how people react to their beliefs being challenged. People frequently resist information that contradicts their views, such as corrective information— for example, by bringing to mind reasons to maintain their belief — and in some cases actually end up believing it more strongly as a result….

A more promising approach would require parents to consult with their health care provider, as the Oregon law also allows them to do. Parents name their children’s doctor as their most trusted source of vaccine information. That trust might allow doctors to do what evidence alone cannot: persuade parents to protect their children as well as yours and mine.

Related blog posts:

Life and Limb: The Price of Not Vaccinating Children

A recent article in USA Today focused some light on the issue of vaccine avoidance and its consequences. Two specific examples in the article included the death of an infant to pertusis and healthy boy who lost his arms and legs as a consequence of the measles. In my opinion, the authors and editors of this publication make a mistake by offering up too much credence to the vaccine naysayers presumably to provide a “balanced report.”  Their arguments should have been subjected to further scrutiny.  Here’s the link, decide for yourself:


Recent measles outbreaks in New York, California and Texas are examples of what could happen on a larger scale if vaccination rates dropped, says Anne Schuchat, the CDC’s director of immunizations and respiratory diseases. Officials declared measles, which causes itchy rashes and fevers, eradicated in the United States in 2000. Yet this year, the disease is on track to infect three times as many people as in 2009. That’s because in most cases people who have not been vaccinated are getting infected by others traveling into the United States. Then, Schuchat says, the infected spread it in their communities.

The 189 cases of measles in the U.S. last year is small compared with the 530,000 cases the country used to see on average each year in the 20th century. But, the disease — which started to wane when a vaccine was introduced in 1967 — is one of the most contagious in the world and could quickly go from sporadic nuisance to widespread killer.

Measles kills about once in every 1,000 cases. As cases mount, so does the risk. “We really don’t want a child to die from measles, but it’s almost inevitable,” says Schuchat. “Major resurgences of diseases can sneak up on us.”…

Even so, in some states the anti-vaccine movement, aided by religious and philosophical state exemptions, is growing, says Paul Offit, chief of infectious diseases at Children’s Hospital of Philadelphia. He points to states like Idaho, Illinois, Michigan, Oregon and Vermont — where more than 4.5% of kindergartners last year were unvaccinated for non-medical reasons — as examples of potential hot spots. Such states’ rates are four times the national average and illustrate a trend among select groups.

“People assume this will never happen to them until it happens to them,” Offit says. “It’s a shame that’s the way we have to learn the lesson. There’s a human price for that lesson.”

The most vulnerable are infants who may be too young to be vaccinated, children with compromised immune systems and others who may be unable to be vaccinated for medical reasons, scientists say.

Related blog posts:

“Too many vaccines and autism” is debunked

Based on false science, many parents think that refusing or delaying vaccinations will be safer for their children and decrease the risk of autism.  While the scientific underpinnings for such a concept have no basis (Pediatrics 2004; 114: 793-804, and Institute of Medicine. Immunization safety review: vaccines and autism. Washington, DC: National Academies Press; 2004), lingering concerns persist.  Into this background, another rigorous study (J Pediatr 2013; 163: 561-7) has concluded that there is “no association between exposure to antigens from vaccines during infancy and the development of autism spectrum disorder (ASD),” autism, or ASD with regression.

So how did the authors reach this conclusion?

Using a case-control study from three managed care organizations (MCOs) of 256 children with ASD and 752 control children, the authors examined exposure to total antibody stimulating proteins and polysaccharides from vaccines.  They utilized vaccine registries and medical records.  The children in this study were born between 1994-1999 and were aged 6-13 years at the time of data collection.

The results showed that with each 25-unit increase in total antigen exposure, the adjusted odds ratio (aOR) for ASD was 0.999 for cumulative exposure to age 3 months. The aOR stayed the same at 7 months and 2 years.  When autism or autism with regression were examined, similarly there was no increased risk.

One of the strengths of this study was that members of these MCOs have routine immunizations as a covered benefit; this helps minimize socioeconomic factors which could influence results.  A small number of ASD cases (5%) and controls (2%) had an older sibling with autism; results were unchanged when these children were excluded.

In many ways, this finding is completely anticipated and in agreement with the Institute of Medicines most recent 2013 report on immunizations (The Childhood Immunization Schedule and SafetyStakeholder ).  As the authors note in their discussion, “beginning at birth, an infant is exposed to hundreds of viruses and other antigens, and it has been estimated that an infant theoretically could respond to thousands of vaccines at once.”

Bottom-line: Vaccines prevent disease without causing autism.  Vaccine refusal increases the risk of disease for those who refuse and creates collateral damage as well.

Related blog entries:


Update on pertusis epidemic

Two previous blog entries have discussed the issue of pertusis resurgence:

More details on this epidemic have been published (J Pediatr 2012; 161: 1091-6, editorial 980).  There have been more Pertusis cases than in any period in the past 50 years.  Part of the problem is due to pertusis’ high reproduction number, 92-95% of the population must be protected against pertusis to halt transmission.

Specific issues highlighted in the report include the highest risk of severe disease occurring in the first 6 months of life, increased risk of disease in Hispanic infants despite similar immunization rates, and waning immunity in preadolescence.

Protecting the most vulnerable

Although pediatric gastroenterologists are not on the front lines of the vaccine controversies, we should add our voices to support immunizations.  Some of our immunocompromised patients are among the most vulnerable and rely on herd immunity to lessen their chances of serious infection.  When healthy children and adults do not receive their immunizations, this does not only increase their risk of infections but the risk to others.

A perfect example of this is highlighted in NEJM 2012; 366: 391-92.  In 2010, California reported over 9000 cases of pertusis; of these cases, 89% occurred in infants less than 6 months.  This population is too young to be adequately immunized.  Ten of these infants died.

The author recommends trying to persuade those who are hesitant to proceed with immunizations.  Parents who are opposed based on personal beliefs will not be persuaded.

  • Remove socioeconomic barriers to vaccination
  • Enforce school entry requirements; it should not be easier to opt out of immunizations than to receive them
  • Aggressively address misinformation
  • Learn to use persuasion effectively:

Additional references:

  • -NEJM 2011; 365: 1108. RV vaccine resulted in 64,000 less hospitalizations in US between 2007-2009.
  • -NEJM 2010; 362: 289, 299, & 358. Rotavirus vaccines lowering death rate in Africa & Mexico.
  • -NEJM 2011; 364: 2283. Rotavirus vaccine: risk of intussception ~1:50,000-1:70,000; thus could cause ~96 cases per year. Vaccine at same time prevented 80,000 hospitalizations & 1300 deaths in Brazil & Mexico.
  • -Gastroenterology 2007; 132: 1287. Two decades of HBV vaccination in Taiwan
  • -NEJM 2007; 16: 1275, 1278, 1281.  Medical evidence refuting Thimersol toxicity; yet many vaccine cases in litigation
  • -Liver Transplant 2008; 14: 1389.  Vaccine policies:  MMR/Varicella can be given as early as 6 months of age. Must give 3-4weeks before Tx. Can give inactivated ~6-12 mo p-OLT. Except for oral polio, good idea for contacts to get all their immunizations.
  • -Inflamm Bowel Dis 2009;15:1410–1416.  Vaccination Strategies for Patients with Inflammatory Bowel Disease on immunomodulators and biologics

Live Virus Vaccines, Generally Contraindicated in Patients Receiving Immune-Suppressive Therapy:

Anthrax vaccine
Intranasal influenza
Measles-mumps-rubella (MMR)
Polio live oral vaccine (OPV)
Smallpox vaccine
Tuberculosis BCG vaccine
Typhoid live oral vaccine
Yellow fever