Audit of Pneumococcal Vaccination in Coeliac Disease Patients in a London Teaching Hospital Database

Simon F Bellringer1, Alan Steel2, Julian RF Walters2 1Imperial College London School Of Medicine, 2 Gastroenterology Unit, Hammersmith and Charing Cross Campuses,

Faculty of Medicine, Imperial College London.

Introduction Coeliac Disease affects 1-3%1,2,3 of the UK population. Established complications of coeliac disease include orthopaedic fracture and lymphoma. Until recently the risk of pneumococcal infection has been described only in case reports4,5 and suggested because studies have demonstrated that around 25% of coeliac patients have a degree of hyposplenism6, which itself is known to cause increased risk of pneumococcal infection.

New evidence from case control cohort studies confirms an increased risk of pneumococcal infection in coeliac patients7,8 and it is thought that hyposplenism is the most likely mechanism for this. An editorial in Gut from 20089 suggests that the overall risk of pneumococcal infection in coeliac patients exceeds that of the more established complications such as orthopaedic fracture and lymphoma (Fig 1).

The British Society of Gastroenterology (BSG) guidelines10 from 2002 recognise that “patients with CD invariably have a degree of hyposplensim for which immunisation with pneumococcal vaccine may be undertaken” .

Aims This study aimed to investigate the uptake of pneumococcal vaccination in a group of coeliac patients and to investigate whether current national guidelines are being adhered to.

Methods Coeliac disease patients were identified from a London teaching hospital clinical database. A web based survey (www.imperial.ac.uk/medicine/Giresearch) was set on the Imperial College website up to allow reporting of vaccination status by local General Practitioners (GPs).

All patients’ GPs were sent a letter inviting response by an anonymous on line reporting system. The letter invited GPs to indicate whether their patient with coeliac disease had received Pneumococcal vaccination.

Descriptive statistics were used to analyse the results.

An editorial by Walters and colleagues9 outlines the relative risk, expected number (from a reference population), actual number, as well as the absolute risk increase, of several complications of CD for comparison.

Discussion A previous report of pneumococcal vaccine uptake11 suggests that coeliac disease patients represent one of the lowest levels of vaccine uptake for a group at risk of pneumococcal infection. In this study, the uptake was particularly poor in patients between the ages of 5 and 65 years, where no age group exceeded 20% uptake.

As a point for comparison, this study finds a 22.2% overall uptake of vaccination for patients between the ages of 5 and 65, much higher uptake than that previously described (See Fig 2). However, this still represents a poor level of vaccine uptake.

Figure 2

The proportion of persons with celiac disease vaccinated in the past 5 years (in 2005) found in a national audit of pneumococcal vaccination uptake by Pebody et al, illustrates that no age groups between 5 and 65 years have a vaccination uptake exceeding 20% (20% uptake shown on the graph as a blue line).

Conclusions This study suggests that pneumococcal vaccination for at risk coeliac disease patients is not being well applied within the community, despite national guidance.

Low vaccination is perhaps unsurprising considering the vague nature in which the BSG guidelines have been written. This vagueness is most likely attributable the evidence base on which they were written in 2002.

With new and better evidence of pneumococcal infection risk in coeliac disease patients and considering its potential impact, it seems that national guidelines need to be reassessed.

After the guidelines have been rewritten, re-audit of uptake would be appropriate. At this time assessment of the efficacy of pneumococcal vaccination with the current Pneumovax II in coeliac patients also seems appropriate. Considering the mechanism of action of the Pneumovax II via T cell independent antibody production, which is reliant upon splenic function known to be decreased in coeliac patients, a clinical trial comparing current Pneumovax II with the alternative polyconjugate vaccine, currently licensed for use in children only but un-reliant upon splenic function, may also prove useful at this time.

References 1 - H Hin, G Bird, P Fisher et al. Coeliac disease in primary care: case finding study. BMJ 1999. 318;164.

2 - DS Sanders, D Patel, TJ Stephenson et al. A primary care cross-sectional study of undiagnosed adult coeliac disease. Eur J Gastroenterol Hepatol 2003. 15;407-13.

3 - J West , RF Logan, PG Hill et al. Seroprevalence, correlates, and characteristics of undetected coeliac disease in England. Gut 2003. 52;960-5.

4 - DJ O’Donoghue. Fatal pneumococcal septicaemia in coeliac disease. Postgraduate Medical Journal 1986. 62; 229-230.

5 - SD Johnson, J Robinson. Fatal pneumococcal septicaemia in a celiac patient. European Journal of Gastroenterology and Hepatology 1998. 10;353-4.

6 - The management of adults with coeliac disease in primary care. Primary Care Society for Gastroenterology (May 2006)

7 - JF Ludvigsson, O Olen, M Bell et al. Coeliac disease and risk of sepsis. Gut 2008. 57;1074-1080.

8 - HJ Thomas, CJ Wotton, D Yeates et al. Pneumococcal infection in patients with celiac disease. European Journal of Gastroenterology and Hepatology 2008. 20;624-628.

9 - JRF Walters, KB Bamford, S Ghosh. Coeliac disease and the risk of infections. Gut 2008. 57;1034-1035.

10 - Guidelines for the Management of patients with Coeliac Disease. British Society of Gastroenterology. 2002.

11 - RG Pebody, J Hippisley-Cox, S Harcourt et al. Uptake of Pneumococcal Polysaccharide Vaccine in at-risk populations in England and Wales 1999-2005. Epidemiol Infect 2008. 136;360-369.

Figure 1

Results 170 coeliac patients were identified from the clinical database and all GPs were sent a letter inviting participation in a study.

42 (24.7%) complete responses were submitted through the Imperial College web site.

22 (52.3%) of these responding GPs reported past pneumococcal vaccination of the coeliac disease patient under their care.