Nysaeter et al.indd ORIGINAL RESEARCH Correspondence: Dr. Gunnar Nysæter, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway. Tel: +47 55976739; Fax: +47 55974973; Email: gunnar.nysaeter@helse-bergen.no Copyright in this article, its metadata, and any supplementary data is held by its author or authors. It is published under the Creative Commons Attribution By licence. For further information go to: http://creativecommons.org/licenses/by/3.0/. Live Typhoid Vaccine for IBD-Patients—Well Tolerated and with Possible Therapeutic Effect Gunnar Nysæter1 and Arnold Berstad2 1Department of Medicine, Section for Gastroenterology, Haukeland University Hospital, Bergen, Norway. 2Institute of Medicine, University of Bergen, Norway. Abstract Background: Our incidental observation of a remarkable improvement of disease activity following vaccination against typhoid in a patient with infl ammatory bowel disease (IBD) was the incentive of this pilot study. Methods: Ten IBD-patients (7 with ulcerative colitis and 3 with Crohn’s disease) with disease activity grade 2–10 on simple colitis index were included in the study. The use of 5-ASA and prednisolone �12.5 mg/day, but no other immunosuppressive drugs, were allowed during the trial. Live typhoid vaccine containing Salmonella serovar Ty21a (Vivotif ®, Berna) was given in standard doses on day 1, 3 and 5. Symptoms and endoscopic fi ndings were followed up for a 3-months-period. Results: Improvement of abdominal symptoms was recorded in 8 patients after 90 days, one patient was unchanged and one slightly worse. Endoscopic fi ndings improved in 4 patients and were unchanged in 5 patients after 90 days. No side effects were observed. Conclusion: Our results indicate that a live typhoid vaccine is well tolerated by patients with IBD of moderate activity. The symptomatic and endoscopic improvements were not dramatic, but encouraging enough to warrant further studies on the potential therapeutic effect of live typhoid vaccine on patients with IBD. Keywords: salmonella Ty21a, colitis, infl ammatory bowel disease Introduction Vaccination has been one of the most rewarding efforts in modern medicine, reducing or even abolish- ing the threat of several serious infectious diseases. A limited number of vaccines are necessary when living in the western world. But with increasing international travel, the need for a wider spectrum of vaccines is rising. Current vaccination guidelines for chronic infl ammatory bowel disease (IBD) patients allow exten- sive use of vaccines, even live vaccines when the patient is not immunosuppressed (1). Still IBD-patients tend to underutilize immunisation against vaccine-preventable diseases (2). Vaccines like live typhoid vaccine or cholera vaccine may temporally cause slight abdominal symptoms. Information about this may deter some IBD-patients from taking the vaccine and thus increase their risk for attracting danger- ous infections. Some animal studies show a protective or therapeutic effect of vaccines on experimental colitis (3–5). But whether human IBD is infl uenced by vaccines seems to be unknown. The experience of one of our ulcerative colitis patients evoked our interest on this question. She is a 46 years old female, with a 20 years’ history of left-sided ulcerative colitis documented by colonoscopy and biopsies. For the fi rst 10 years she had almost continuous symptoms, had three colonocopies, and was treated with oral 5-ASA and intermittent cures with oral prednisone and steroid enemas. Then she prepared for travel to India and therefore had an oral vaccination with a live typhoid vaccine (Vivotif®, Berna). The fi rst two weeks thereafter she had slight worsening of the diarrhea, but then followed a 3 months’ period with practi- cally no symptoms. She thought this must be an effect of the vaccination as she found no better explanation. So when the colitis symptoms started to recur, she repeated the vaccination with the same Drug Target Insights 2008:3 119–123 119 http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0/ Nysæter and Berstad Drug Target Insights 2008:3 vaccine. Again improvement ensued, and she stayed symptom free for 9 months. After this she has continued to take oral typhoid vaccine about once a year for the last 9 years, being convinced of the vaccine’s positive effect on her ulcerative colitis. But she also continued to take oral 5-ASA during these years. A recent sigmoideoscopy showed a slight proctitis. With this story in mind we discovered two other ulcerative colitis patients who could report something similar after oral vaccination, though their improvement was less convincing. These observations inspired us to perform a pilot study in order to disclose any modifying effects, positive or negative of live typhoid vaccine on the course of IBD. Material and Methods Since few data exist on the effect of live oral typhoid vaccine’s effect on IBD, we did an open pilot study, well aware of its limitations when the numbers are so small. Ten IBD-patients were included, 7 with ulcer- ative colitis or proctitis, 3 with Crohn’s disease. Median age was 43 years, range 21–52 years. Male/female ratio 4/6. Duration of disease: median 7,5 years, range 2 months–23 years. Inclusion criteria: 1. Patients with verifi ed IBD by endoscopy, pathologic anatomic diagnosis of chronic inflammation or IBD, negative stool examinations for enteropathogenic microbes and Giardia lamblia. 2. Good general condition, and IBD activity index �10 for the last two weeks. 3. Age between 18 and 70 years. Exclusion criteria: 1. Simple colitis index �10 with affected general condition. 2. Fever �38 °C. 3. Altered immunocompetence due to diseases or drugs like TNFα-inhibitors, azathioprin or corti- costeroids in doses � the equivalent of predniso- lone 12,5 mg pr. day. 4. Ongoing use of antibiotics. 5. Known allergy to any of the ingredients in the vaccine. 6. Pregnancy and lactation. Written informed consent was obtained from each patient, and the protocol was approved by Regional Commitee for Medical Research Ethics, Norwegian Medicines Agency and Norwegian Social Science Data Service. The patients were treated with a currently available oral vaccine containing the Salmonella Ty21a strain (Vivotif®, Berna) using the standard dosage for such vaccination against typhoid fever. One enterocapsule was taken with drinking water on day one, three and fi ve. The patients took the capsules at home and noted on a report form when they were taken. Current medication was not changed unless medically indicated during the test period. Thus, seven ulcerative colitis patients were on oral or rectal medication with 5-ASA, two of these were steroid dependant, one using oral pred- nisolon 10 mg daily, the other hydrocortisone enema daily. Bowel symptoms before treatment, on day 5, 15, and 90 from treatment start were scored. We used special diaries allowing scoring of disease activity index, the Harvey-Bradshaw Simple Index of Crohn’s Disease Activity for patients with Crohn’s disease, or the simple Clinical Colitis Activity Index (Walmsley) for patients with ulcer- ative colitis (6–8). The patients were examined with fl exible sig- moidoscopy by one of the investigators. To confi rm the diagnosis, biopsies for histopathologic exami- nation were taken from the recto sigmoid mucosa. Macroscopic changes in the mucosa were moni- tored by fl exible sigmoideoscopy, at treatment start and at the following three consultations. The endoscopic changes were graded according to a simple scale: normal = 0, redness and edema = 1, erosions = 2, ulcers = 3. (9) Blood tests were not included in the study because typically such tests give very little informa- tion as long as IBD activity is low to moderate. Statistics Data were analysed using the GraphPad Prism 5.0 (GraphPad Software Inc., U.S.A.) statistical soft- ware package. Differences between means were evaluated with nonparametric two-tailed Wilcoxon matched pairs test. P values less than 0.05 were considered statistically signifi cant. Results At fi rst follow-up, 5 days after last vaccination day, there was a signifi cant improvement of clinical symptoms, as compared with baseline, and, on aver- age, this improvement remained for the following three months (Fig. 1). None of the patients became worse during the fi rst fi ve days. But one patient with a 17 years history of ulcerative colitis, who was on prednisolone 10 mg pr. day at the start, had a fl are-up of symptoms after 15 days and had to increase the dose to 30 mg prednisolone per day. Disease activity 120 Live typhoid vaccine for IBD-patients Drug Target Insights 2008:3 was only slightly changed for the patients with Crohn’s disease. A seemingly endoscopic improve- ment did not reach statistical signifi cance (Fig. 2). No adverse effects appeared in any of the patients. Discussion We used a vaccine that has been in extensive use for decades in the combat of typhoid and paratyphoid fever. Its effi cacy and safety is well documented through mass studies and millions of vaccinations world wide (10). But the vaccine contains live microbes that are supposed to alert the host’s immune system through contact with intestinal mucosal immune receptors. It was unknown whether this contact would worsen the already infl amed mucosa of IBD-patients. Our previous patient contacts suggested there might be a period of slight exacerbation of symptoms after vaccina- tion. We therefore followed up our patients closely, both endoscopically and with respect to symptoms, but no such early exacerbation was observed. Because the patients had symptoms at baseline, we could not withdraw their current treatment with 5-ASA or prednisolone, as this could have wors- ened their condition. Already at day fi ve of treatment, a signifi cant improvement without any initial exacerbation was recorded. This fi nding encourages an active attitude to protect IBD-patients with vaccination when typhoid is a relevant threat. Whether the vaccine has a real therapeutic effect in IBD, cannot be properly answered by this small pilot study. Both placebo effect and simultaneous medication infl uence our results. Still there was an improvement that we had not otherwise expected. An actual therapeutic effect of live typhoid vaccine in IBD can therefore not be excluded. Also, the suggestion is in fact supported by several prior experimental studies. In animal models, the gut fl ora is essential for the development of colitis, and colitis may be infl uenced by antibiotics and certain strains of live bacilli able to alter or suppressing the fl ora. Thus, oral administration of Lactobacillus and Bifi do- bacterium attenuated DSS-colitis in mice (11; 12), while administration of the probiotic mixture VSL#3 (a mixture of bifi dobacteria, lactobacilli, and streptococcus salivarius) to mice with IL-10 defi ciency also reduced microscopic infl ammation along with a reduction in mucosal secretion of TNF-α and IFN-γ (13). A vaccine stimulates the immune system’s targeted defence against defi ned pathogens, with- out having their mutilating effect. In addition to protection against specifi c microbes, vaccines may also strengthen the general defence mecha- nisms of the intestinal mucosa. An apparently irrelevant vaccine for the gastrointestinal tract proved to have an effect on the mouse colon, as a three-component Bordetella pertussis vaccine attenuated colitis in Gαi2-defi cient mice (4). And administration of recombinant cholera toxin sub- unit B has been shown to inhibit murine TNBS experimental colitis (3). Cholera toxin may promote the induction of Th2 and Tr1 cells, enhance IL-10 production and inhibit secretion Figure 1. As compared with baseline, symptoms decreased signifi cantly fi ve days after oral treatment with live typhoid vaccine. Improvement persisted three months later. * = p < 0.05. ● = ulcerative colitis. ○ = Crohn’s disease. Figure 2. Endoscopic fi ndings after oral treatment with live typhoid vaccine. Improvement appeared in some individuals but did not reach statistical signifi cance for the whole group. Error bars = SD. 121 Nysæter and Berstad Drug Target Insights 2008:3 of IL-12 and TNF-α (14). Whether Salmonella Ty21a has similar effects, has not been shown. But experiments by Neish et al. showed that cells with previous contact with apathogenic salmo- nella got decreased infl ammatory response when subsequently exposed to pathogenic strains (15). A vaccine against enterotoxigenic Eschericia coli (ETEC) composed of a live, attenuated Salmonella vector-expressing enterotoxigenic E. coli fimbriae, stimulated a biphasic Th cell response when given orally and suppressed the normally produced proinfl ammatory response. The vaccine reduced the production of TNF-α, IL-1 and IL-6, while it increased production of IL-4, IL-10, and IL-13 (5). These results indicate that selected strains of microbes or vaccines may have a benefi cial effect on a chronically infl amed mucosa in animal mod- els of IBD. Also in human IBD the interplay between intestinal microfl ora and the gut seems to have a key role (16). The mucosa senses the lumi- nal microbes through its complex system of recep- tors. Production of anti-microbial factors like defensins is one of the results, thereby supporting the intestinal surface with a protective layer that stops microbial invasion of the intestinal wall. Some microbes evade these protective mecha- nisms, by tolerating the defending peptides or down-regulating the sensing mechanisms of the mucosa, and thereby manage to invade the host. Pathogenic Salmonella is able to down-regulate the production of defensins, (17), and Shigella seems to suppress the production of cathelicidin, another important defence molecule of the colonic mucosa (18). In the case of NOD2/CARD 15 muta- tions, as seen in about one third of patients with Crohn’s disease, the host has a defect sensing of microbes. Parallel to this a reduced amount of defensin (HD5) in terminal ileum of Crohn’s dis- ease patients has been reported (19). In these patients the amount of microbes inside the mucus covering the terminal ileal mucosa is also severely increased (20). These genetic and protective factors have not been examined in our pilot study as it contains very few Crohn’s patients. But a thera- peutic effect of vaccination might well be related to some change in these parameters. In ulcerative colitis, the findings are more obscure, but here too the intestinal mucus layer is abnormally infested with microbes, suggesting a defective mucosal protection. Recent clinical studies have given hope that altering or up-regulating the mucosal immune system may improve IBD-patients’ health. Stimulation of the mucosa by means of apatogenous paracites (21) or by granulocyte macrophage colony-stimulating factor (GM-CSF) both seem to have a therapeutic effect (22). This may signal a new policy in the treatment of IBD; to stimulate the mucosal immune system in a well designed way instead of applying a regimen for general immunosuppresion. The positive results of the present study support the idea of applying immunostimulation in the treatment of IBD, and further studies along these lines are warranted. Statement of Interests Declaration of personal interests: None. Declaration of funding interests: This study was fully funded by Helse Vest RHF, project number 911305. References [1] Sands, B.E., Cuffari, C., Katz, J., Kugathasan, S., Onken, J., Vitek, C. and Orenstein, W. 2004. Guidelines for immunizations in patients with infl ammatory bowel disease. Infl amm. Bowel Dis., 10:677–92. [2] Melmed, G.Y. 2006. Patients with infl ammatory bowel disease are at risk for vaccine-preventable illnesses. The American journal of gastroenterology, 101:1834–40. [3] Boirivant, M., Fuss, I.J., Ferroni, L., De Pascale, M. and Strober, W. 2001. Oral administration of recombinant cholera toxin subunit B. inhibits IL-12-mediated murine experimental (trinitrobenzene sul- fonic acid) colitis. J. Immunol., 166:3522–32. [4] Ohman, L. 2005. Acellular Bordetella pertussis vaccine enhances mucosal interleukin-10 production, induces apoptosis of activated Th1 cells and attenuates colitis in Galphai2-defi cient mice. Clinical and experimental immunology, 141:37–46. [5] Jun, S., Gilmore, W., Callis, G., Rynda, A., Haddad, A. and Pascual, D.W. 2005. A live diarrheal vaccine imprints a Th2 cell bias and acts as an anti-infl ammatory vaccine. J. Immunol., 175:6733–40. [6] Harvey, R.F. and Bradshaw, J.M. 1980. A simple index of Crohn’s- disease activity. Lancet, 1:514. [7] Higgins, P.D., Schwartz, M., Mapili, J., Krokos, I., Leung, J. and Zimmermann, E.M. 2005. Patient defi ned dichotomous end points for remission and clinical improvement in ulcerative colitis. Gut., 54:782–8. 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