Poor Adherence to Immunization, Screening Guidelines for Pediatric IBD

By Marilynn Larkin

November 22, 2019

NEW YORK (Reuters Health) - Contrary to current guidelines, children with inflammatory bowel disease (IBD) often don't receive required vaccines and are not properly screened before initiation of biologics, a multicenter study from Europe reveals.

"Our data highlight that children with IBD show insufficient immunization coverage at diagnosis and that vaccination catch-up is not adequately performed," Drs. Massimo Martinelli and Erasmo Miele of the University of Naples told Reuters Health by email.

"We also demonstrated an unsatisfactory awareness of two hot topics of IBD preventive care: Epstein-Barr virus (EBV) status at the start of azathioprine therapy and screening for latent tuberculosis before anti-tumor necrosis factor (anti-TNF) agents," they said.

The purpose of the study was to evaluate vaccinations, immunization status, and consequent therapeutic management in children with IBD diagnosed before and after June 2012, when the European Society of Pediatric Gastroenterology, Hepatology and Nutrition published a commentary on risk and prevention of infections in children with IBD and adapted the 2009 European Crohn's and Colitis Organization adult guidelines for children.

Overall, the researchers studied 430 children at 13 European centers. About half were diagnosed before June 2012 and about half, after. For both groups, the median age at diagnosis was about 12, and about half were male.

As reported online November 5 in Inflammatory Bowel Diseases, vaccination rates at diagnosis were unsatisfactory for measles, mumps, and rubella (89.3%), Hemophilus influenzae (81.9%), meningococcus C (23.5%), chickenpox (18.4%), pneumococcus (18.6%), papillomavirus (5.9%), and rotavirus (1.9%).

Only 8.8% of children had complete immunizations. Among the children with incomplete immunization, specific vaccinations were recommended for 79 (20.1%), with no between-group differences (22.7% for the before-2012 group vs. 17.3% for the later group).

Vaccines that were caught up included: pneumococcus (98.7%), meningococcus C (72.1%), chickenpox (69.6%), hepatitis B (50.6%), MMR (36.7%), papillomavirus (25.3%), rotavirus (6.3%), DTP (1.2%), and poliomyelitis (1.2%).

Only 28.6% of children received yearly influenza vaccinations.

Reasons for not being vaccinated included: need for immediate immunosuppressive therapies (27.8%), parental refusal (7.7%), vaccination costs (1.6%), and unknown (49.2%).

At the start of immunosuppressive therapy, 22% of children were tested for EBV status, whereas 96.2% of EBV-naïve patients started azathioprine, with no between-group differences.

Screening for latent TB before the start of biologics was performed in 92.1%; however, there were nine different screening strategies and numerous inconsistencies.

Drs. Martinelli and Miele said, "On the basis of the study results, the overall impact of the current guidelines on vaccination and immunization status in children with IBD appears unsatisfactory, highlighting an urgent need for further educational efforts in order to widespread the available recommendations and to promote their correct application."

"Specific tools, such as apps, online podcasts and/or e-learning programs should be urgently developed," they said. "The use of such inexpensive training modalities for GI, general pediatricians and primary care (will) increase adherence to the current guidelines and improve the overall vaccination rate in this subset of medical fragile populations."

Dr. Joseph Picoraro, assistant professor of pediatrics at Columbia University Irving Medical Center and Director of Pediatric GI Inpatient Services at NewYork-Presbyterian Morgan Stanley Children's Hospital in New York City, commented in an email to Reuters Health, "With rates of decline in immunization among certain populations over past decade, this topic is becomingly ever more relevant to children who are at risk due to their disease or due to immune-modifying therapy."

"Rates of immunization among US children are overall higher, according to the Centers for Disease Control and Prevention records available during the time point studied," he noted. "For specific vaccinations series, such as varicella, the rates are dramatically higher than the study population in Europe."

"In my experience, public health efforts such as mandatory immunization for public schools, have been the most influential to ensure immunization in children," he said. "These policies may factor into the difference in the U.S."

"Several health insurance companies in the U.S. will not authorize payment for expensive biologic medications until (TB) screening is done, which may be unique to the U.S.," he said. "Hospital and facility policies for infusion therapies also tend to have hard stops - such as demonstration of TB risk screening - prior to the initial administration of the biologic."

That said, he added, "These policies for TB risk assessment sometimes lead to (treatment) delays, in that steps need to be taken sequentially rather than concurrently."

SOURCE: http://bit.ly/2Xw4gL0

Inflamm Bowel Dis 2019.