People with inflammatory bowel disease (IBD) appear to have an increased risk of herpes zoster infection (shingles), and Canadian researchers warn that low vaccination rates have been insufficient to reduce infection among IBD patients, a problem that continues to rise.
They recommend that vaccination against the virus should be considered early by clinicians and promoted by public health programs, especially in patients older than 50 and in those receiving biologic therapies.
Their study, “Herpes Zoster Infection and Herpes Zoster Vaccination in a Population-Based Sample of Persons With IBD: Is There Still an Unmet Need?” was published in the journal Inflammatory Bowel Diseases.
Herpes zoster infection, commonly known as shingles, is caused by the varicella-zoster virus, the same virus that causes chickenpox.
After someone has chickenpox, the virus usually remains “silent” in the body, but often reappears years or decades later as shingles, marked by an outbreak of rash or blisters on the skin.
The virus generally wakes when the immune system is suppressed or weakens with aging. The infection negatively impacts a person’s quality of life and can be associated with complications and even death in those with an impaired immune system.
So far, there has been little information about the incidence of the virus and vaccination rates — which can reduce the incidence of infection by 50-70% — especially in IBD patients.
Due to their chronic inflammatory condition or because they are taking immunomodulatory medications, IBD patients may be at a higher risk of developing shingles.
Researchers at the University of Manitoba in Canada conducted a population-based study which compared herpes zoster infection-related data of IBD patients with healthy people (matched controls).
The participants’ data was collected from the University of Manitoba IBD Epidemiology Database, which includes people living in the Manitoba province from 1984 to 2016.
A total of 4,998 people with IBD and 34,186 healthy controls were included in the study. Among IBD patients, 45% had Crohn’s disease and 55% had ulcerative colitis.
Patients with IBD were associated with significantly higher rates of herpes zoster infection per year. Infection incidence in people with IBD was 9.2 people per 1,000 person-years, while in controls it was 7.2 people per 1,000 person-years.
Patients were at higher risk of infection both before (42% higher risk) and after their diagnosis of IBD (52% higher risk).
But the infection rate continued to rise after 2009, when a vaccine against the virus was approved and began to be recommended by Health Canada for those older than 60.
Excluding those who received the vaccine, the annual percent change in the infection rate was 0.54 per 1,000 person-years in infection rates.
Even though after 2009 more people with IBD received the vaccine compared to controls — 15.5 vs. 12.8 per 1,000 person-years — the vaccination rate “was unacceptably low among persons with IBD,” the researchers wrote.
Nearly all those who got the vaccine were older than 50. However, only 412 patients with IBD (8% of all patients) were vaccinated at age 50 or older.
Despite that, annual rates of vaccination increased through the study (2009-2015), with slightly higher rates among IBD patients.
Those with fewer comorbidities, a recent IBD diagnosis, more frequent visits to gastroenterologists, and those not using immunosuppressants were more likely to have received the vaccine.
In addition, the incidence of herpes zoster infection and vaccination rates were significantly higher in women compared to men, both in patients and in controls.
While herpes zoster infections continued to rise in the province of Manitoba even after a vaccine become available in 2009, this is probably due to the increased use of immunomodulatory medications, including biologics, and because this vaccine is not covered by the provincial health plan.
Based on the study results, researchers have a number of recommendations.
Considering that corticosteroids, immunosuppressants and, in particular, biologics, are associated with a higher risk of herpes zoster infection, “a more proactive policy of vaccinating persons who may soon start biologicals, perhaps even starting at age 40 years, should be considered,” they wrote.
“Clinicians managing persons with IBD must be more vigilant and consider early administration of HZVac [herpes zoster vaccine], especially if patients are not yet on immunomodulating drugs and are older than age 50.”
Even those receiving biologics or immunosuppressants should be seriously considered, and more so because there is a now a nonlive vaccine available that’s unlikely to cause virus flares in these patients.
Also, researchers stress that making sure the vaccine “is covered by all health insurance plans, including government-supported provincial health plans,” will strongly promote vaccination and reduce infection.