Well, I think we should start, just because you're here on time. And a bunch of the slides early on are just kind of background slides. And again, you'll have access to these. So my name's Frank Ferre. I'm a professor of medicine and director of the IBD Center at Mayo Clinic in Florida. I usually tell my patients that I'm meeting there that you're probably going to pick up my Brooklyn slash Boston accent, because I spent most of my career up north before seeing the light and saying enough of the cold winters and time to move south. I have a number of disclosures, none of which really apply to this talk. And so these are our goals. To identify gaps in achieving appropriate health maintenance among patients with IBD. Appreciate the increased risk of infections in patients with IBD. Let me turn this on. Review the recommended vaccinations. And we're going to spend a lot of time just talking about the new recommendations for pneumococcal vaccine, herpes zoster, and RSV. And I think RSV is one that needs to be on your radar screen. We'll definitely talk a bit about recommended cancer screenings, as well as other health maintenance issues. But this is mostly a vaccination talk. And although I'm talking about inflammatory bowel disease, many of these basic principles can apply to your liver transplant patients or anyone that you're seeing who's immunocompromised. So again, I kind of stumbled into this area. You can see this is our first paper published in 2010. A Practical Guide to Vaccinating a Patient with Inflammatory Bowel Disease. And this followed in 2017 with the ACG clinical guideline. And this has been a labor of love. We submitted this for publication to the American Journal, the update, about six months ago. And in my entire career, I've never had an article come back with 160 recommendations. So at least they read it. And this has been accepted and will be published, the new version, in the June or July 2025 American Journal. I've also been involved in some ECHO guidelines. This was published in 2021. And this is also being updated for 2025, the ECHO Guidelines on Prevention, Diagnosis, and Management of Infections in Patients with IBD. One of the people I work with, actually several of the people I work with here, or everyone I work with here. But Freddy Caldera has been my colleague and co-investigator on many of these things. And this was published in January, looking at the HEA clinical practice update. And this is just on vaccines. Doesn't really talk about non-colorectal cancer screening. So this comes out every February, March, or April. And I'm not going to make any comment about the present politics. But for some reason, the updated 2025 guidelines have not been published yet in the Annals of Internal Medicine. You can find some of the stuff on the website. But we'll be using this, as well as the Crohn's and Colitis Foundation recommendations, as we walk through our talk. So if you were to do a deep dive into these recommendations, what you could see is it's basically, this is the original paper. Then it's broken down by ages. And then it also is then broken down by various conditions. And the one we're interested in right here is the immunocompromised patient, excluding HIV. And if you look at the bottom, you can see there are some vaccines, basically the live vaccines, which are in red, which means those are the vaccines you really cannot administer. And so this is just a deeper dive, looking at the live flu vaccine, the MMR, and varicella vaccine. There are a number of other vaccines that are alive, mostly involved in individuals who are going to overseas to areas of the world where there are, for example, yellow fever. And in my practice, I send those patients to travelers clinic for them to decide what needs to be done. There are a number of other things. These are the checklists from Cornerstones that look at various things. And this is a relatively updated one. And then finally, we're going to spend all our time using this checklist from the Crohn's and Colitis Foundation to walk through the various vaccines. So what are the components of health care maintenance in patients with inflammatory bowel disease? Well, vaccinations, we're spending most of the time cancer screening and surveillance, anxiety and depression check, screening for osteoporosis, smoking cessation in all patients, regardless of ulcerative colitis or Crohn's disease, nutritional status assessment, pre-advanced therapy check. Those are all the blood tests you need to do before starting someone on advanced therapy. And then lab monitoring. This was always a big issue in patients on methotrexate and thiopurines. In my 35 years of practice, and I've taken care of patients for close to 35 years, I don't care how much they're my friend. I don't care how compliant they've always been. They get three months of methotrexate, three months of thiopurines to make sure that they come in for their monitoring. I think we need to do better for monitoring for some of our advanced therapies as well. So why are the initial visits with a patient with IBD so important? And again, there are a number of different things you may think about. But in 2025, as many as 70% of patients with IBD will require immunosuppressive therapy at some time in their course. So given the fact that we're seeing an 18-year-old, a 25-year-old with newly diagnosed inflammatory bowel disease, and the question is going to be, will they be immunosuppressed at some time? And let's use this opportunity to bring them up to date. So a little bit of history. I'm not much of a history buff, but I came across this and I thought it was interesting. So the first vaccination was given in 1796 by Dr. Edward Jenner. Now, if you take yourself back to that era, smallpox was rampant. And if you develop smallpox, 10% to 20% of those individuals who developed smallpox died. And of those people who survived, one in three became blind. So clearly a devastating disease. Jenner, who was like a family practice doctor, basically made this observation. Milkmaids who dealt with animals developed a disease called cowpox, and that's a mild disease. And his hypothesis was that inpatients, or milkmaids who had cowpox, and they developed or exposed to smallpox, they never really got smallpox. So his experiment, which was pretty audacious, and certainly could have been designed, the study could have been designed in a better way, and would have been designed in a better way these days, was that he basically took scrapings from a milkmaid with cowpox and scraped them onto this little boy, this eight-year-old. Now, the correct way to do this study would be to scrape it into a bunch of kids and then have a control group and see who developed smallpox or not. But he basically then injected smallpox into the eight-year-old, and the eight-year-old did not develop smallpox. And so he basically coined the word vaccine from the Latin word vacca, or cow. So I thought that was kind of an interesting story about vaccination. So vaccines are important and can prevent or reduce the risk of several infectious illnesses. Our advanced therapies, not all of them are as dangerous as others, but advanced therapies put our patients at risk for infection. And the goal in the practice would be to vaccinate all patients with IBD whenever possible prior to initiation of immunosuppressive medications for the optimal response. That doesn't mean you can't vaccinate them when they're on infliximab, eustakinumab, but those early visits would be the best time to vaccinate them. So over that first few visits with the patient would be the time to give the vaccine. Now, in 2025, you're probably gonna come across a scenario of someone who needs new therapy for their IBD, and so lo and behold, they've never received the measles vaccine. What are you gonna do in a situation like that? Well, in a situation like that, priority comes to just taking care of their IBD. So do not delay treatment for their IBD to administer vaccines. There's this concept of the cocoon strategy where family members of immunosuppressed patients with IBD should be up to date with their vaccines. So I am a new grandparent, just as of a week ago, my first grandchild, and it was very clear that I was not going to see my grandson in any time in the near future unless I was up to date on my pertussis vaccine. And so the bottom line is by taking those individuals who surround an immunocompromised patient, all those individuals should be up to date with their vaccines so that they will not bring to that immunocompromised child or adult an infection. Now, one of the issues that come up is, Dr. Frey, you told me that I have an abnormal immune response, and that's the reason why I have inflammatory bowel disease. Isn't giving a vaccine stimulating the immune response? Well, that's been studied. We've studied it, and the bottom line is that there's no evidence that vaccination exacerbates underlying IBD. So you can reassure your patient that this stimulation of the immune system is beneficial, will prevent or decrease the likelihood of serious infections down the line, and is not associated with the worsening of their IBD. I mentioned earlier there are a number of live and inactive, live vaccines and inactive vaccines. So these are all the non-live vaccines, and we're going to spend most of our time looking at influenza, pneumococcal vaccines, Zoster, COVID, hepatitis B, and RSV. There are a number of other ones. We won't talk about HPV. Now, in terms of the live vaccines, these are for the most part contraindicated immunocompromised patients. There are some fine lines where you could potentially give a live vaccine to a mildly immunosuppressed patient, but for the most part, the answer on the boards would be live vaccines are not given to immunocompromised patients. But of the individuals that we'll be talking about, the live vaccines that really we deal with in the United States are measles, mumps, rubella, chicken pox, and the intranasal influenza vaccine. The old shingles vaccine, Zostervax, was a live vaccine that's no longer available in the United States. So let's start walking through the checklist. So the first thing we'll talk about is influenza. So we know that patients with inflammatory bowel disease have an increased risk of developing influenza. Immunosuppressive therapies further increase the risk of developing complicated influenza, meaning they then develop a post-influenza infection, a bacterial infection, so they have higher rates of hospitalization and superimposed pneumonia. So the bottom line is the ACIP recommends that everyone six months and older receive an annual influenza vaccine, and that would be regardless of their immunocompromised state. And similarly, an issue that came up during COVID, and I think we've answered this very successfully, is do you need to time vaccinations relative to, for example, your infliximab infusion, your antivio infusion? And the answer is no. If you have a captive audience, someone coming in to the clinic, to your infusion center, and it's October 1st, and they want to get the flu shot, or they want to go to CVS to get the flu shot, they should go and get their flu shot. You should not delay or try to time it. And again, we do know that highly immunocompromised patients will have a blunted response, but some response is better than none. Again, there are a number of different vaccines for influenza. There's the standard dose influenza vaccine and the high-dose influenza vaccine. The high-dose inactivated influenza vaccine is administered in 2025 to all individuals who are 65 and older, and at least a higher antibody titers, and that's been studied. It's also been looked at in anti-TNF patients, and patients on anti-TNFs, the high-dose influenza vaccine generates a higher immune response. It's not in the label. I do try to give the high-dose influenza vaccine to patients on anti-TNFs and JAKs. And then the live attenuated influenza vaccine is contraindicated. That's the intranasal vaccine. Not every year is it recommended by the ACIP, but it was recommended this past year. And then again, we went over this concept of conclude strategy. You would not wanna give the intranasal live vaccine to someone who's gonna visit their son or daughter who's immunocompromised with inflammatory bowel disease. So this is typically a question for fellows or residents, and we kind of ask what's the most common infection that people get if they have IBD? And often people will talk about tuberculosis, things of that nature, but in reality, the most common infection is pneumococcal pneumonia, okay? This was a study that was done by Millie Long in 2013 using an Optum database, and the bottom line is if you kind of look at the annual influenza incidents, and across the board, you're gonna see higher rates of these infections in patients with Crohn's disease versus ulcerative colitis, but the bottom line is the rates are higher across the board of developing pneumonia in patients with ulcerative colitis and Crohn's disease higher with Crohn's disease. So let's walk through the checklist. So as you know, it used to be complicated. We had PCV13 and PPSV23. The CDC and the ACIP has made it a lot simpler for us. Several years ago, the PCV20 vaccine was approved, and that's a one and done. And then more recently, the PCV21 vaccine was approved. The reason why this was developed is that many of the cases seen in adults were caused by subtypes not covered by the other FDA-approved vaccines, and for example, if we look at the bottom line here, PCV20 covers up to 58% of the invasive pneumococcal strains while PCV21 covers up to 84% of the serotypes. So whether you give PCV20 or PCV21, the bottom line is you can give pneumococcal vaccine and get your patients protected. Now, this is kind of not cut off the presses, but this basically was approved or recommended in October 2024, and what they're basically saying is that the age for giving, it used to be everyone 65 and older got the pneumococcal vaccine, and then individuals 60 and older who had an immunocompromising condition were eligible. The new recommendations are that everyone 50 and older, so anyone, your parents, anyone who's 51 years old now is eligible to receive the pneumococcal vaccine, and that would be a single dose of PCV20 or PCV21, and then a second dose when they're above the age of 65. In the immunocompromised individuals, and so when we see your patient who's 21, they're at increased risk, those individuals can now also receive PCV20 or PCV21. So the bottom line is immunocompromised patients 19 to 49 are eligible to receive the single dose, and those individuals, anyone above the age of 50 are eligible, and remember, that risk of infection is independent of immunocompromising medications. Patients with ulcerative colitis and Crohn's disease have an increased risk of pneumococcal pneumonia. I'll show you some slides, an increased risk of zoster, and that's irregardless of the medicines they're on. So the innate immune problem that they have places them at risk. So again, these are the recommendations we're now doing. This comes from the paper that was published by Dr. Caldera in clinical gastroenterology and hepatology, and we'll have an updated figure in the ACG guidelines that are coming out in July, but it's a good way to kind of look at if they've been on previous pneumococcal vaccines, what other ones do they need to get? But again, if they've never been on any one single dose of PCV20 or PCV21. So let's now go and look at zoster. So this also from Milley Long, published 12 years ago, showing an increased risk of zoster in patients with inflammatory bowel disease. This study is kind of old, and so you can see, no, can't see my arrow, but anti-TNF and thiopurine therapy, that combination, which was the standard of care in 2013, gave you an increased risk of developing zoster 3.29. Now, once you look at the tofacidinib and the hepacidinib data, you know that in a non-vaccinated individual who's had chicken pox as a child, their risk approaches 4-5% of developing shingles within the first year of therapy. So clearly a very, very high rate of infection. This is a paper that we published in Clinical Gastroenterology and Hepatology where we looked at patients who developed zoster and compared IBD patients to non-IBD patients and the bottom line is rates of complications were much higher. So again, patients with IBD who develop zoster have higher rates of any number of complications. So the vaccine that we have is Shingrix. It's given as two doses at zero and two to six months and for your immune, so if you're starting a patient on TOFA or OOPA and they've never received the shingles vaccine, you could actually accelerate that dosing. Remember that risk is very high in the first year, so you really don't want to wait for zero and then six months to give the vaccine. You can give it at zero and one month. Now the recommendations used to be everyone over the age of 50 and that remains. Any adult individual over the age of 50 regardless, by the way, anyone over the age of 50 now has a 99% chance of having chicken pox in the past, so that's why everyone over the age of 50 is eligible to receive the shingles vaccine. In 2021, the new recommendations came which were very, very helpful and this basically is the FDA approved Shingrix for anyone above the age of 19. So the bottom line is our patients who are 25, 30 are now eligible to receive the shingles vaccine and we do administer it. I did mention the zero and one month as opposed to zero and two to six months and we actually, I'll show you some data. This is a study that we did comparing the risk of herpes zoster between a cohort that was vaccinated and a cohort of IBD patients who were not and you can see across the board the vaccinated patients had a lower risk of zoster, both IBD and Crohn's, above the age of 50, below the age of 50, patients on immunosuppressive therapy. So this is pretty obvious, you really need to give this vaccine. About one in five people will feel lousy after the vaccine. Being loud, feeling lousy after the first dose doesn't mean you'll feel lousy after the second dose, but at least in Florida I tell people don't take it if you plan to go golfing the next day. Just do it on a Friday afternoon when you're home on Saturday and nothing to worry about. We actually tried to help you all by doing this cost effective analysis and this was published in APT showing that it's actually cost effective or cost savings to give the shingles vaccine to patients with IBD because you're preventing shingles and then postherpetic neuralgia and all the other issues that go with it. Okay, so let's now move on to hepatitis. So four in five individuals born before 1991 do not have vaccine induced immunity. So the standard vaccine used to be NGERX, which was zero, one, and six months. And in 2021 there was, actually in 2021 the ACIP recommended universal screening for everyone. So the primary care doctors should be doing universal screening for all individuals 19 to 59. That avoids a kind of a difficult decision, a discussion of do you use intravenous drugs, how many sexual partners have you had, all that kind of stuff. So just test everybody just like you test for hepatitis C. But in November 2017 the FDA approved a new vaccine called Heplisav-B and what's really cool about this vaccine, two doses, zero in one month as opposed to zero, one, and six months. And in the clinical trials that did not include IBD patients, you can see the seroconversion was 95% for the Heplisav patients and 81% for the NGERX patients. So clearly higher. We've done a study showing higher rates of seroconversion as well. There's another vaccine that we haven't studied that was approved in 2021 called Pre-Heb-Re-Brio. And again, it's an adjuvanted vaccine. The thing about it is the adjuvanted vaccines do tend to cause more injection site reaction, mild systemic symptoms, but well worth the protection. We haven't studied this in IBD. All right. So probably something you've not really thought about was RSV until recently. So RSV is a common viral infection affecting the respiratory tract. It causes significant mortality and morbidity, especially in older individuals. And in the past, we wouldn't really know about it, right? You'd go to your primary care doctor, go to the emergency room, and you'd be tested for influenza A and B. So then COVID came around and then you were tested for influenza A and B and for COVID. And now more recently, certainly in our emergency room, if you get a respiratory panel kind of swab, you're tested for A, B, influenza, COVID, as well as RSV. So with this testing, we're learning more that more and more patients actually have it. So it's nice to know what they have. I guess there is a treatment for influenza. But in 2023, the FDA licensed two vaccines, one from GSK, one from Pfizer. And then in 2024, and that's the standard kind of vaccine, like the hepatitis B vaccine. It's a part of the virus with an adjuvant that stimulates the immune system. And then in 2024, the FDA approved the Moderna, an mRNA vaccine. And so we've actually decided to study it. And so this is the data from our work. And so this basically is looking at patients here on the right who did not receive the RSV vaccine. Actually, this is for individuals just looking at patients with IBD, comparing non-IBD patients. And just like with herpes zoster, just like with pneumococcal disease, you can see across the board that there's an increased risk of developing RSV infection and being hospitalized. So the bottom line is these patients are at increased risk. And these are the newest recommendations that came out for RSV. So at the meeting last month by the ACIP, it used to be you give RSV vaccine to everyone above the age of 75, regardless. And this is IBD, non-IBD. And then it was you give it to those individuals 60 to 74 who had a comorbid condition that would put them at risk for an adverse event. So they have diabetes. They have hypertension. They have chronic renal failure. So what the ACIP now did is extend that recommendation that anyone 50 and older who has a risk factor, 50 and 74, who has a risk factor for an adverse event. And that would be patients with IBD who are on immunocompromising medications are eligible to receive it. Now, the best time to give the vaccine is between August and October. But in reality, you can give it any time because right now there's only a recommendation for a single dose. There's no recommendation to repeat RSV vaccine. You can give it with other vaccines. For those women who are pregnant coming into RSV season, it is recommended that they receive a single dose, only a single dose of the RSV vaccine at week 32 to 36. That allows the woman to develop antibodies that are then transmitted placentally to the child to give that child the risk of protection during RSV season. And there are also some monoclonal antibodies that can be given in immunocompromised infants to protect them during RSV season. So let's kind of walk on to COVID. The several COVID vaccines, as you know, the Pfizer, the Moderna, and the GSK one, there is a non-mRNA vaccine by Novavax. So for those individuals that have really concerns about all of mRNA technology, then the Novavax vaccine is just like the hepatitis B vaccine. It's an adjuvant and the spike protein. So people who say, I don't want to take that new vaccine, you can also recommend the Novavax non-mRNA vaccine. The recommendations are that all patients with IBD should be vaccinated. Now I see patients all the time, Dr. Ferre, I had the vaccine back in 21, 2022. Well that strain of COVID is not the strain that's circulating right now. So we do recommend that they receive a strain in the fall. And so all those individuals who were previously vaccinated can still receive the new vaccine, which is a modification that covers the new strains. And I mentioned already, do not hold treatment to give the COVID vaccine. Now if you have a highly immunocompromised patient, a 65-year-old on a JAK inhibitor, and they're up to date, meaning they did receive a fall COVID vaccine, then they are potentially eligible to receive a second booster six months later. I can tell you that that's a hard sell in general, but I do try to sell it for my patients who have comorbid conditions, COPD, chronic renal failure, on a drug that's highly immunosuppressive to do that. So again, if you can get your patients to get a single updated vaccine, that would make sense. We're waiting for this to be published somewhere, but this was presented at DDW last year. This was a pretty group, a consortium of individuals, including gynecologists, maternal fetal medicine patients, pediatricians, IBD doctors, looking at which vaccines should be given to infants of women born to their moms who had IBD. So it's not surprising inactive vaccines can be given on schedule to all babies. Individuals, so if you did have a mother who was on a JAK or an S1P, not many women are on that, but if they were, they can receive a live vaccine one month after life. There's no live vaccine that you receive one month after life. Live vaccines can be given to infants of mothers with IBD who are breastfeeding while on biologics, so biologics don't cross into the breast milk and large enough thing to cause an issue. The live rotavirus, that was the old big thing. You give the live rotavirus vaccine at week 12 or 16 to babies whose moms were on anti-TNFs, and it was always a big controversy, but now they're coming out basically saying that the live rotavirus vaccine can be given to children whose mothers were on an anti-TNF. We recommend... So BCG is not really an issue here in the United States, and so I won't really talk about it, but obviously if you're in a part of the world where tuberculosis is endemic, the concern about giving BCG vaccine to an infant whose mother was on an anti-TNF, for example, is that BCG is a live vaccine and you can get disseminated BCG. Really not an issue here in the United States. Part of the reason that they changed the recommendation is based on a study like this. This was a study looking at 52 mothers with 57 babies, and what they did was all these children, all these infants received rotavirus vaccine, and there were no adverse events at seven days, one month, and nine months. And then when they actually did immune function testing, none of these infants had an alteration in their immune function, so clearly safe to give this vaccine. We summarized all the vaccines, and this table always continues to be modified. So for example, if you look at the section on RSV, actually I do have it updated where I went to age 50, so we're good there. So let's move on to cancer screening. We have colorectal cancer screening, cervical and skin cancer, colorectal cancer screening. This is a great article published in Gastroenterology. It's still the one that we use. Patients don't need yearly colonoscopy. We all see these folks where they've had multiple colonoscopies. They're in endoscopic and histologic remission, but they've had ulcerative colitis for 25 years, documented ulcerative colitis. Those patients do not need to come for yearly exams, and those patients, for the most part I do three years. There are a few patients with proctitis, for example, or proctosigmoiditis that I will take out to five years, but the bottom line is we don't need to overuse colonoscopy in low-risk individuals. What about cervical and skin cancer? These are the newest recommendations that are published in our guideline and are published and recommended by the gynecologic associations. So it used to be women on immunosuppressive therapy needed yearly Pap test, but now women with IBD on immunosuppressive therapy, and again, it's mostly, remember, thiopurines and JAKs are the ones that are associated with viral infections, should undergo cervical cancer by cytology annually if you do cytology alone, but more and more women are getting the dual therapy, so every three years if HPV negative. So the bottom line is every year is no longer necessary. And then recommendations for skin cancer screening. We know that patients with Crohn's disease have an increased risk of melanoma. Many of our medications, the thiopurines, the JAKs, increase the risk of non-melanoma skin cancer. I send patients to see the dermatologist. I let the dermatologist then have a discussion with the patient as to how often they need to come for repeat skin exams. So let's move on to other areas. So osteoporosis, I probably order more DEXA scans than many internists just because I see individuals that have been on more than three months of steroids, and more than three months of steroids is a risk factor. Osteoporosis and osteopenia are more common in patients with Crohn's disease versus UC. Every single patient who's on steroids should get vitamin D and calcium, and in addition to ordering lots of DEXA scans, I do order lots of vitamin D level and try to get patients at that level of 40 to 60 is my goal. In terms of mental health, this is one area where I think we could do better, our institution. We have access to psychologists. We have access to psychiatrists, but they're not embedded in our clinic. We do know that up to 25% of patients with IBD have underlying anxiety or depression. Screening is extremely important to ensure appropriate referral and treatment, and you can do any number of screening tests. You can have patients in the waiting room fill out screening tests. What I typically do is on my first intake with a new patient, I kind of go through their history. I ask, are they married? Are they single? Do they have any children? And then I ask what they do for a living and what they do for fun. If someone says they like to play golf and they're coming for their six-month follow-up, I ask them when's the last time they were out playing golf. If they say, Doc, you know, I'm just not up to going. I'm just tired all the time. I'm worried about having an accident. I just can't get up in the morning, then I kind of don't have to use a PHQ or any other type of screening. I know that they're struggling. In a situation like that, I'm not comfortable beginning therapy for depression or anxiety. I will refer them back to their primary care doctor. I can also refer them to our psychologist. Many of these patients do better with cognitive behavioral therapy and there are many apps that you can use to do that. And again, we do know the effect of smoking on ulcerative colitis makes it better, makes Crohn's disease worse, but the bottom line is there are negative factors across the board and we recommend all our patients with inflammatory bowel disease to quit. Miscellaneous recommendations, malnutrition screen for those at risk, so every time in my epic I get their last three weights and their last three blood pressures, so I kind of have an idea of whether they're losing weight. We went over the periodic testing, patients on thiopurines, patients on methotrexate need blood tests every three months. It is recommended patients starting IL-23 agents because there's a rare risk of developing abnormal liver function tests. They get best baseline and then they get a set of liver function tests at three months and six months. You also need to check the lipid level in patients starting JAX and then I check it just once. Cholesterol can go up, HDL cholesterol goes up at the same time, but I do refer those patients to their primary care provider. Hepatitis screen we went over, TB screen prior to starting certain agents and periodically thereafter in patients with risk factors. I don't do yearly quantifier on testing, but I just do ask if there have been any reason why they could have been exposed. I came across a patient in Boston who came from the most affluent suburb in the whole state of Massachusetts and lo and behold, I think at that point insurance was requiring that we check a yearly quantifier on and he was positive. He was negative before but he had done missionary work in Haiti. So the bottom line is just ask about risk factors and then you can check a quantifier on but again I don't do it every year. This also comes from that paper. This is where I made the change. This comes from the paper from Caldera, Dr. Ashash, Susie Kane, Millie Long. Again a nice little checklist of all the things that need to be done. If you look at the RSV, that's where it said greater than 60 and that's where I changed it now, greater than 50. So in terms of take home points and I was told to kind of wrap this up in 45 minutes so we have time to do questions. Subsets of patients with IBD have low immunization rates so ask about vaccination status. I got to tell you that in my referral practice 15 years ago this was rarely asked but it's very unusual that I don't see a patient in 2025 where somewhere in the medical record the GI doctor, the nurse practitioner have mentioned vaccination. Now the patient may not want to do vaccination but I think in general this is now on the radar screen of patients and physicians. I don't want to say anything bad about rheumatologists or anything like that but I'm often referred patients with joint issues, rule out IBD and they're on various advanced therapies that we use and there's been no comment about vaccination. So I think we as a field are doing much better. When possible vaccinate prior to initiation of immunosuppressive therapy but again even if you can't and you're seeing them and they're on hepatitis B negative and they're single, they're at risk for hepatitis B and they're on an advanced therapy you can still vaccinate them. Patients with IBD can mount a response to vaccine but again I mentioned the immunogenicity is reduced if they're on highly immunosuppressive therapy. Again this is a key point. You can reassure your patient that IBD disease activity will not be affected by vaccination. Do not hold treatment for inflammatory bowel disease to administer any inactive vaccines and I used to tell the patient to go to their primary care doctor and discuss vaccination and so at this point I think it's very clear that we as the prescribers for these medicines should take ownership of recommending vaccines. You don't have to administer vaccines. Now I have the luxury of having the patient go from the 6th floor to the 4th floor and they can be vaccinated but if you don't have that luxury you can just have them go to their CVS or whatever pharmacy they use and get their vaccine. Now you might have to write a prescription because when someone shows up who's 40 and you're recommending the shingles vaccine the pharmacist will often say well this is not a covered benefit but if you write a prescription often that will get the person covered. Now these are not inexpensive vaccines so patients have to ultimately decide if they want to pay out of pocket but I've given up on trying to send them back to their primary care doctor just because they're busier than we are and I think it's our responsibility to administer the vaccine, to recommend the vaccine. So refer patients for colon and skin cancer screening. Again pap testing, I send them to their gynecologist. I really am very aggressive about women on thiopurines and JAKs and then after their pap test whether it's cytology or the DNA testing I let the GYN doctor, the primary care doctor decide about the interval. We need to screen for anxiety and depression and have a plan to send those patients for counseling if they indeed are positive. Individuals who have been on steroids, ileopouch patients is another subgroup, high rates of osteoporosis and osteopenia so we'll test those patients with a DEXA scan. Counsel all your patients to stop smoking. Address nutritional status periodically and again I gave you a couple of different checklists. I gave you the cornerstone checklist that Crohn's and Colitis Foundation, you can go to their website. Again I've given you the website. You can download the checklist. That checklist is going to be a live document. As new recommendations come they'll be updated. This is my newest book. If anyone's interested for patients, Mayo Clinic on Crohn's Disease and Osteocolitis. This button always generates a little bit of interest but I've got my button that says Vaccines Save Lives. Again it's a bit of a dangerous button to wear in Florida and some parts of the country but it does at least let my patients know where I stand on the importance of vaccines for managing their inflammatory bowel disease. So with that I'm going to leave some time and answer any questions that you guys have. Going back to shingles and vaccination, I have quite a few patients who are younger so maybe between 18-25 who should likely have a varicella vaccine and up until now I have still been saying that no vaccine is 100% you really should still consider your shingles vaccine. Would you do the same thing? So the risk, so having varicella vaccine dramatically reduces your risk of getting shingles. But there are people who get, who have the varicella vaccine that still get shingles and especially for those individuals that are highly immunocompromised. So based on the new recommendation, anyone 19 and older I do recommend the shingles vaccine. Now to be honest with you, you know, you have to choose your battles. I think I would probably push harder for the pneumococcal vaccine than the shingles vaccine. But, you know, if they're there, everyone knows someone, not everyone, most people know someone who got shingles and ended up with postherpetic neuralgia or some complication. And so I don't try to scare my patients but I do basically say that the vaccines are highly effective in preventing shingles and in so doing your risk of developing, and even if you get shingles, your risk of developing postherpetic neuralgia are reduced. And by the way, anyone who's had Zostravax, it's still recommended they get shingles, shingrix. And anyone who had an episode of shingles, it's still recommended to get the two-dose vaccine. So if you have to choose your battles, I would probably for that 21-year-old, I would push for the pneumococcal vaccine first and then the next time around and just let them know that yes, you're at lower risk, but you're on medicine that puts you at an increased risk. Yes? Unless you know, can you say a 51-year-old is in a hospital with UC, atherosclerosis, tromboembolic sclerosis, and is having a lot of lactation. Has he received any vaccination in all his life? Is there any way that you would try to promote him to get, say, six vaccinations? Is there a timeline that you would propose to advance compliance and prevent possible side effects from vaccination? So a 51-year-old, newly diagnosed ulcerative colitis, discharged from the hospital on steroids, getting ready to start another therapy, and he says, I don't do vaccine stuff. Well, what I would do is say, God gave you two arms, and I would give the shingles vaccine in one arm and the pneumococcal vaccine in the other arm. That would be my highest priority. If it was flu season, if it was October, November, then a week later I would bring them back. You can even give three vaccines at the same time. I wouldn't give more than three. So you can give flu, pneumococcal vaccine, and shingles all at the same time. So I would concentrate on pneumococcal vaccine and shingles because those are the ones that I'm most concerned about high doses of steroids causing a problem. And then a couple weeks later, if it's flu season, do flu. If it's RSV season, do RSV. You'll test them for hepatitis A and B. Again, if they're 51, there's an absolute chance they didn't get childhood vaccination for hepatitis B. Then you look for their risk factors, and that's kind of a lower priority. They're monogamous relationship for whatever number of years. Their hepatitis B surface antibody is low titer. That's when you could wait and not have to worry too much about giving that vaccine at that time. You can do that at a later time. Yes? It's immunize.org. I can come up and I'll take a picture of it and you can get it. So there will be a paper published in CGH where what every gastroenterologist needs to know about measles during the, what every IBD doctor taking care of, I think every IBD doctor needs to know about measles in 2025. So the bottom line is if there were, initially there was a single measles vaccine, and then we now know there are two doses. So the bottom line is if you have a 20 year old and said, I had all my childhood vaccines, then you're good. And the reason why you don't want to check titers is that the sensitivity of the titers is relatively low. In other words, a positive titer is helpful telling you that that person has been exposed to measles or took the vaccine, but a negative titer could be a false negative. So what the CDC says is that if you have a history of receiving vaccination, then you're good. Now, if you ultimately do test them and they say, I've never had measles and their antibody is negative and they're now immunocompromised, you're in a quandary. You're really stuck because let's think about infliximab. You'd have to be off infliximab for almost three months before you give the vaccine. So in a situation like that, you just have to do your best to tell that patient to hopefully not be in an area where measles is going crazy, which is now Texas and Arkansas and a whole bunch of other places. But that's the quandary we're in. And that's what we could avoid by vaccinating in childhood. It's a big issue. And I think it's going to shed light on the importance. I think we are going to fall out of being a country without measles this year because we're going to go over this thousand cases. That's the indication that we're no longer measles free in the country. Most of the cases of measles in the past used to be imported. And it's really interesting when we looked at the rate of COVID infecting other individuals. For measles, one person with measles can infect up to 20 individuals in that area. And that measles vaccine stays around for a long, long time and everything. So the bottom line is hopefully there'll be... Well, I'm not optimistic there's going to be a change in certain populations. But all we can do is advocate for the greater good of the community. But it's a major problem. Yes? I was just recently made aware of general populations of women for cervical cancer screening in a patient who has always had MEGA-HPV. It's now 5HPV. So I have a couple of the patients, young women, who maybe are only on a tibia, and they come back to me like, oh, my doctor said I'm good for five years. And if you push back and say I'm good for three years, then... No, I wouldn't. I think ultimately I would defer to GYN. And first of all, Vita Legion Mab, I'm not overly concerned about immunosuppression. In fact, if you read the product label for Vita Legion Mab, it basically says that live vaccines can... So live vaccines can be given to someone on Vita Legion Mab because really it's an extraordinarily safe vaccine. And I would not. I think someone in a monogamous relationship, HPV negative by cytology and DNA, whatever testing they do, then that's someone I would be comfortable deferring to the gynecologist. Yes? How do you manage a patient who insists on dying? Yeah. I punt that one to the traveler's clinic, but that's the big issue because many of the countries require a letter that says that they've been vaccinated, but some countries will accept an exception letter. And so that patient, though, has to go into that country understanding that if they're exposed and they get sick, there's no treatment for yellow fever, as best as I know. I don't know if anyone knows if that's the case or not. But a situation like that, the patient has to make a decision how important it is to go to that part of the world. Now, the other scenario is, again, if they're on a JAK inhibitor, well, that's a little bit easier because the half-life is so short. You could potentially hold the JAK inhibitor for two weeks, give the yellow fever vaccine, wait four weeks, and then restart the JAK inhibitor because, again, those don't generate antibodies. And so the bottom line is there are some drugs you can work around for someone who wants to go to that country and doesn't want an exemption letter that basically puts them at risk. So it's a very complicated situation in general. Infectious disease will typically say, would recommend that person not go to the country. But it comes back to you. You may have no choice. Of course, if they tell you four weeks before they're going, then you have no time to do anything anyway. But if they came to see you six months before they're going, you can potentially, with a JAK or S1P, stop those therapies, vaccinate, wait a couple more weeks. But for the drugs with long half-lives, infliximab, these other drugs, ustekinumab, you're kind of in a quandary because ultimately your patient will be off therapy for four months and then run the risk of relapse. You do it any differently? Difficult. A great difficult situation. Yes? What do you recommend to help care workers who need IUDs? So that's a situation, again, part of it depends on how, so if, it depends on how long, the issue typically comes up is that I have an immunocompromised emergency room doctor. You know, what do they do when they're in the emergency room? Well, for that situation, they wear gloves and wear a mask all the time. But when you have someone who, let's say, needs the measles vaccine, what do you do? I think that individual, through good safety, through good hygiene, wearing a mask and things like that would be okay. The big one would be intranasal influenza vaccine, but you could avoid that one, right, because very few people get that. So it's really measles, mumps, rubella. Varicella, the big issue with varicella is if they develop an injection site blistering, well that would be something you don't want to get exposed to patients. But in general, I'm not dogmatic, and I just, I mean, the reality is those patients, those physicians, those providers have to take care of patients, so it's not like I'm going to write them a note and say you can stay home for four weeks. Anything that you do in particular? No, no, it is an issue, it is an issue. Other questions? Well, all the slides are there. My email is there. Feel free to do that. And then let me just quickly go to the last slide. I think it's 35. And so if you want to, oops, 45. I'll just come up and I'll have you take a picture of my lapel button so you can figure out where to get that vaccine. Thank you guys, appreciate it.

Inflammatory Bowel Disease

vaccination

health maintenance

immunocompromised patients

infection risks

cancer screenings

immunosuppressive therapy

nutritional assessments

proactive health strategies