Implementation and Widespread of Inflammatory Bowel Disease Vaccination and Immunization Guidelines: Not an Easy Task

Reply to the Letter to the Editor of Dr Szántó et al.

To the Editors:

We thank Dr. Szanto and colleagues for their comments¹ on our paper “Vaccinations and Immunization Status in Pediatric Inflammatory Bowel Disease: A Multicenter Study From the Pediatric IBD Porto Group of the ESPGHAN”.² The authors report their positive experience at a tertiary adult IBD center in Hungary in screening patients with IBD before starting biologics after the introduction of a national mandatory vaccination program.¹ We certainly agree that mandatory vaccination programs will help reducing the burden of vaccine-preventable diseases in at-risk populations, such as patients with IBD. However, we once more underline the need to improve our efforts, as IBD practitioners, to apply and make the current recommendations widespread. As an example, we would like to emphasize with some concerns the diagnostic strategy for latent tuberculosis infection (LTBI) described by the authors.¹ Indeed, Szanto et al report that they exclude LTBI on the basis of chest x-ray, and only in high-risk patients do they routinely perform gold-standard quantiferon TB test.¹ We found this alarming strategy also in many centers participating in our study, with up to 30% of the total children starting biologics before June 2012 and up to 15% of cases after June 2012.² Also outlined in our manuscript, a chest x-ray alone lacks of the proper sensitivity to exclude LTBI.² On the basis of the ECCO guidelines, LTBI should be diagnosed by a combination of patient history, chest x-ray, tuberculin skin test (TST), and interferon-gamma release assays (IGRAs) according to local prevalence and national recommendations.³ The most recent guidelines on the diagnosis of Tuberculosis in Adults and Children from the American Thoracic Society/Infectious Diseases Society of America and Centers for Disease Control and Prevention are even more detailed.⁴ Indeed, in a child younger than 5 years old or in an adult for whom it is warranted to exclude LTBI, IGRAs are recommended as a first diagnostic tool.⁴ Tuberculin skin test should be preferred in children younger than 5 years old, and it can be used when IGRAs are not available.⁴ A chest x-ray does not represent a useful screening test, but it should be used in case of positivity of IGRA or TST to distinguish active from latent TB.⁴

Therefore, we confirm a poor awareness of the current recommendations even among tertiary centers. Specific campaigns through the use of apps, online podcasts, and/or e-learning programs should be urgently developed.

Conflicts of interest: EM received grant or research support from Nestle Italy and Nutricia Italy, served as a member of advisory board for Abbvie, and received payment/honorarium from Ferring.

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