Patients with inflammatory bowel disease (IBD) are often treated with immunosuppressive therapies that increase the risk of vaccine-preventable infections. Notwithstanding the publications of guidelines recommending immunizations for those with IBD and those receiving immunosuppressive therapies, vaccine uptake in IBD populations is poor. Two articles in this month's Inflammatory Bowel Diseases report on apparent knowledge deficiencies among gastroenterologists regarding immunization guidelines. Further efforts are needed for physician and patient education, as well as for implementation of immunization practices. In particular, physicians who accept responsibility for prescribing immunosuppressive therapies that increase infectious risk should be familiar with guidelines and educate patients appropriately.
For the past 50 years or more the mainstay of therapy for patients with IBD has involved immunosuppression with corticosteroids, immunomodulators, and more recently biologic therapy. Infections are known to be associated with all of these therapies, including serious infections that are responsible for missed days of school and work, hospitalization, and even death. Common infections including H1N1 and seasonal influenza can lead to significant morbidity and mortality, and patients with compromised immunity remain particularly vulnerable to these illnesses. The medical establishment that endorses and prescribes these medications implicitly accepts that the anticipated benefits of immunosuppressive therapies outweigh the rare risks of serious infectious complications when used appropriately. It appears, however, that as a gastroenterology community we fall short in recognizing our role in reducing these risks through appropriate recommendations for immunization against vaccine-preventable illnesses.
Guidelines for vaccination of adult patients receiving immunosuppression were initially published by the Centers for Disease Control nearly 20 years ago,1 and IBD-specific guidelines and recommendations have been promoted for over 5 years.2 However, the uptake of recommended vaccinations in patients with IBD is historically inadequate.3 Adults with IBD not receiving annual influenza vaccination despite exposure to immunosuppression cited “lack of awareness that it was indicated” as the primary reason, suggesting a breakdown between guideline recommendations and practitioner implementation of those guidelines.
In this issue of the IBD, two studies independently suggest that gastroenterologists have knowledge deficits with regard to appropriate immunization of their immunosuppressed patients with IBD.4 Yeung et al5 assessed 43 gastroenterologists and 167 patients in Alberta, Canada for immunization attitudes, knowledge, and practice. Only 14% of gastroenterologists reported taking an immunization history from “most or all” of their patients with IBD, and many (23%) did not know that live vaccines should be avoided in patients receiving immunosuppressive therapy. An important finding from the patient surveys is that patients felt most confident in the immunization information provided by gastroenterologists relative to other sources of information (family physicians, public health department, nurse, etc.), but that only a minority (25%) actually received this information from their gastroenterologist. Furthermore, the majority of patients surveyed felt they did not have enough information about immunizations.
In a similar study, Wasan et al report on 108 responses from an electronic survey sent to 1000 randomly selected members of the American College of Gastroenterology. Just over half of the respondents reported asking their patients with IBD about immunization history “most or all of the time,” and nearly one-third of the respondents would have (inappropriately) recommended live vaccines to immunosuppressed patients with IBD. The majority (64%) felt that the primary care provider should be advising patients on immunizations.
Both of these studies are limited by their design as self-administered surveys, with inherent selection and responder biases and a need for additional questionnaire content validation. However, these limitations should not detract from the message that apparently there are knowledge deficits regarding preventive immunizations among gastroenterologists who treat patients with IBD. Improving provider behavior, such as increasing compliance with existing clinical guidelines, is a challenging enterprise.5 The mere existence of guidelines is insufficient for quality improvement; guidelines must be effectively conveyed and followed in order to effect change in the process of care.6 While educating physicians and patients would seem a logical remedy to knowledge deficiencies, efforts at patient and provider education are inconsistently effective.
A meta-analysis of studies assessing various structure- and process-based intervention strategies for improving compliance with influenza and pneumonia vaccines in the elderly found that the most effective interventions involved organizational changes, such as the use of separate clinics devoted to prevention, and use of a planned care visit for prevention.7 Another effective strategy is the designation of nonphysician staff to perform specific prevention activities, such as a nurse or clerk identifying at-risk patients and arranging for a physician interaction on that basis.8 Many of these strategies can be applied in gastroenterology settings as well. White et al9 demonstrated increased vaccination rates from 54% to 81% at an IBD referral clinic by having patients fill out a short survey prior to seeing the doctor; they refined their quality improvement efforts through plan-do-study-act (PDSA) cycles that identified and addressed barriers to the implementation of immunization efforts. Electronic reminders incorporated into electronic health records have been successful in improving vaccination rates in a rheumatology clinic.10 Both small and large practices may benefit from utilizing office staff, checklists, or patient handouts to provide additional education. Further creative efforts are needed, with the recognition that individual practice settings may require different approaches to identify and target at-risk patients.
Taking care of patients with a chronic illness can be challenging and time-consuming. Shared decision-making efforts coupled with expanded treatment options require time for discussion that may relegate general healthcare maintenance to a lower priority when time is limited. Healthcare maintenance is often considered within the purview of primary care providers, who may not be familiar with the risks of IBD-specific therapy. Gastroenterology specialty practice settings may or may not be conducive to actually administering vaccinations, but we can do a better job of educating ourselves, our primary care colleagues, and our patients. If we are to assume the responsibility of prescribing medications that increase infectious risks, we must similarly accept responsibility for educating ourselves and our patients that some of these risks are preventable.