Timing Is Everything: Pneumococcal Immunization in Inflammatory Bowel Disease.
Timing Is Everything: Pneumococcal Immunization in Inflammatory Bowel Disease.
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时机就是一切：炎症性肠病的肺炎球菌免疫。
DOI：
10.1093/cid/ciz231
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发表时间：
2020
期刊：
影响因子：
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通讯作者：
deStMaurice,Annabelle
中科院分区：
文献类型：
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作者：
Grijalva,CarlosG;deStMaurice,Annabelle
在美国，炎症性肠病（IBD）影响约1.3%（约300万）的成年人。IBD主要包括克罗恩病和溃疡性结肠炎，以肠层慢性炎症为特征。由于先天免疫反应的改变和免疫抑制药物的治疗，IBD患者感染的风险增加，包括侵袭性肺炎球菌疾病[2-4]。目前，免疫实践咨询委员会（ACIP）在其关于肺炎球菌免疫的建议中没有直接涉及IBD。然而，ACIP确实建议医源性免疫抑制（即需要免疫抑制药物治疗）的患者应接种13价肺炎球菌结合疫苗（PCV13），然后接种23价肺炎球菌多糖疫苗，5年后视情况再接种一次加强剂。然而，很少有研究评估IBD患者对acip推荐的序贯疫苗接种方案的免疫反应，探索免疫抑制药物对疫苗反应的作用的研究更少[7,8]。提供者和IBD患者将受益于了解顺序肺炎球菌疫苗接种是否有效预防肺炎球菌疾病。在频繁使用免疫抑制药物的背景下，了解如何优化对易感IBD患者的保护也将是有价值的。在这一期的《临床感染性疾病》中，van Aalst等人研究了成年IBD患者对acip推荐的顺序肺炎球菌疫苗的免疫反应，并研究了免疫抑制药物对疫苗反应的作用。从141名成年IBD患者的观察性队列中，研究人员收集了顺序接种疫苗前后的样本，并比较了未接受免疫抑制方案的IBD患者和接受免疫抑制药物（包括常规免疫调节剂、肿瘤坏死因子α (TNF-α)抑制剂或联合治疗）的IBD患者之间的血清转化。根据美国过敏、哮喘和免疫学学会对原发性免疫缺陷bbb患者接种疫苗应答的考虑，研究者严格地将血清转化的主要结局定义为70%的血清型的刺激后免疫球蛋白抗体浓度≥1.3 μg/mL。值得注意的是，这是一个比世界卫生组织（WHO）汇总的人群水平参考估计值（≥0.35 μg/mL）更保守的阈值，该阈值先前用于IBD患者疫苗应答的研究。与先前的报告一致，研究人员表明，IBD患者在接种疫苗前存在重要水平的肺炎球菌抗体。研究人员还指出，使用世卫组织汇总的人口参考估计值作为定义这些患者的疫苗反应的阈值将具有挑战性。尽管针对特定血清型的个体保护抗体的精确水平仍不清楚，但有证据表明，需要比世卫组织汇总人群参考水平更高的水平才能有效地为个体提供针对肺炎球菌疾病的保护[b]。研究人员发现，ACIP顺序肺炎球菌疫苗接种策略对IBD患者具有免疫原性，但使用免疫抑制药物的患者在顺序肺炎球菌接种后没有同样的血清转化
Inflammatory bowel disease (IBD) affects about 1.3%(~ 3 million) of adults in the United States [1]. IBD is mainly comprised of Crohn disease and ulcerative colitis [1], which is characterized by chronic inflammation of intestinal layers. Due to alterations in their innate immune response and treatment with immunosuppressive medications, patients with IBD are at increased risk of infections, including invasive pneumococcal disease [2–4]. Currently, the Advisory Committee on Immunization Practices (ACIP) does not directly address IBD in their recommendations for pneumococcal immunization [5]. However, ACIP does recommend that patients with iatrogenic immunosuppression (ie, requiring treatment with immunosuppressive drugs) should receive sequential vaccination with 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine, with a subsequent booster dose 5 years later, as appropriate [6]. Nevertheless, few studies have evaluated the immunological response to the ACIP-recommended sequential vaccination regimen among patients with IBD, and even fewer studies have explored the role of immunosuppressive medications on the vaccine response [7, 8]. Providers and patients with IBD would benefit from knowing if sequential pneumococcal vaccination is effective in preventing pneumococcal diseases. And in the context of frequent use of immunosuppressive medications, it would be also valuable to know how to optimize the protection of vulnerable patients with IBD. In this issue of Clinical Infectious Diseases, van Aalst et al studied immune responses to the ACIP-recommended sequential pneumococcal vaccination among adult patients with IBD, and examined the role of immunosuppressive medications on vaccine responses. From an observational cohort of 141 adult patients with IBD, the investigators collected samples before and after the sequential vaccination and compared seroconversion between patients with IBD not exposed to immunosuppressive regimens and patients exposed to immunosuppressive medications (including conventional immunomodulators, tumor necrosis factor alpha [TNF-α] inhibitors, or combination therapy). Investigators rigorously defined their primary outcome of seroconversion as a postimmunization immunoglobulinG antibody concentration of≥ 1.3 μg/mL for 70% of the measured serotypes based on the American Academy of Allergy, Asthma, and Immunology considerations for vaccination responses in patients with primary immunodeficiencies [9]. Of note, this is a more conservative threshold than the World Health Organization (WHO) pooled population-level reference estimate (≥ 0.35 μg/mL) that was used previously in studies on vaccine responses in patients with IBD [10]. Consistent with previous reports, investigators showed that there were important levels of pneumococcal antibodies prior to vaccination among patients with IBD [11]. The investigators also noted that using the WHO pooled population reference estimate as a threshold to define vaccine response in these patients would be challenging. Although the precise level of antibodies for individual protection against specific serotypes remains unclear, evidence indicates that higher levels than the WHO pooled population reference are needed to confer effective individual protection against pneumococcal diseases [12]. The investigators found that the ACIP sequential pneumococcal vaccination strategy was immunogenic in patients with IBD, but patients on immunosuppressive medications did not seroconvert as well after sequential pneumococcal