New SSCD Vaccination Recommendations Include a Few Caveats

April 25, 2024

The discredited theory that childhood vaccinations cause autism, and the alarm over isolated severe reactions to COVID-19 vaccination have contributed to vaccination unease among many. People with cancer, diabetes and autoimmune diseases like celiac disease have been particularly concerned about whether their condition exacerbates risks from receiving or not receiving certain vaccinations. 

The Society for the Study of Celiac Disease (SSCD) emphasizes the importance of vaccinations for the general population, and in particular, for those with celiac disease. Specifically, they have responded to common concerns voiced by clinicians and their patients in the celiac disease community with updated recommendations. 

Experience as Teacher 
To date, there is a paucity of large studies on vaccinations in people with celiac disease. To establish recommendations, the SSCD largely relies, instead, on the collective experience of celiac disease specialists. These specialists, as a rule, see low adverse event rates and no higher risks associated with vaccination in people with celiac disease than in the general public.  
“While we don’t have a robust body of research on this, we see no evidence that people with celiac disease should avoid these vaccines,” said Benjamin Lebwohl, MD, Director of Clinical Research at the Celiac Disease Center at Columbia University, and a past president of the SSCD. “In the absence of evidence to the contrary, we base our recommendations on the potentially severe risks and outcomes from infection.”

Extra Vigilance Recommended
With a few exceptions, the SSCD recommends that people with celiac disease proceed with the same vaccinations, on the same schedules. However, to address the higher susceptibility to disease or attenuated responses to vaccination, the SSCD guidance includes these caveats: 

Influenza, Pneumonia, Shingles 

  • In influenza, a large study found a higher risk of hospitalization among people with celiac disease. Therefore, the SSCD encourages close adherence to the general recommendations of an annual vaccination for people ≥6 months old. 
  • In examining pneumococcal infection outcomes, multiple studies have demonstrated that people with celiac disease have an increased risk of severe infection, likely due to functional hyposplenism. The SSCD  recommends vaccination against pneumococcus for children <2 years and adults ≥19 years.
  • People with celiac disease may also have a higher incidence of illness from the herpes zoster virus (shingles), but there is only a moderately increased risk in people under 50 years. Therefore, the zoster vaccination is recommended for adults ≥50 in this population, as in the general population. People with celiac disease should be sure to receive the two-dose series of the vaccine to help boost protection.
Two Doses for Hep B 
Evidence is mounting that responses to the hepatitis B vaccine may be attenuated in some people with celiac disease.  The standard two-dose regimen of this vaccine is recommended. 

A Green Light for COVID Vaccination 
As the controversy over vaccinations against SARS-CoV-2 took center stage in 2021, many people -- and in particular many with autoimmune conditions -- had their antennae up. Concerns within the celiac disease community included the potential of the vaccine to elicit unanticipated adverse events, worsen their condition, trigger other autoimmune conditions, or to simply not work effectively. 

A large COVID-19 study looked at differing vaccination responses among people with celiac disease. To probe the associations, 13,638 people with celiac disease and 4,157 without celiac disease, across 16 countries, completed an online survey between April 2022 and July 2022. Vaccines and doses, side effects and adverse events (thrombosis, myocarditis, anaphylactic reaction, and hospitalization related to the vaccine) were queried, and their results published in abstract form in the Journal of the Canadian Association of Gastroenterology and Gastroenterology.

“Importantly, no significant difference in adverse events were found,” said Maria Pinto-Sanchez, MD, the Director of the Celiac Clinic at McMaster University, and principal investigator on the study. 

“Overall, there were no differences in the rate of side effects or adverse events to COVID vaccines in celiac versus non-celiac. In those with celiac disease, we found only a slightly higher rate of flu-like symptoms or pain and swelling at the injection site upon the second dose compared to people without celiac disease. This was lower in both the study and control groups receiving the Pfizer vaccine,” she said.

People with and without celiac disease were found to mount an equivalent response to the COVID vaccine. Considering the high morbidity risk for all who contract COVID, the SSCD recommends immunization and boosters annually or as they become available for new strains.

No Gluten in Vaccines
The statement also attempts to put another common concern – gluten in vaccines - to rest. Reactions to vaccinations often mimic symptoms experienced from gluten exposure, including muscle aches and headache. Understandably, people with celiac disease may wonder if their symptoms are due to a gluten exposure from the vaccine itself. 

“We know for sure that no vaccine contains gluten as a listed active or inactive ingredient. Still, a vigilant patient with celiac disease may contact the pharmaceutical company that makes the vaccine and ask about possible gluten content. Then it goes up various channels, and they may get an equivocal response response rather than a definite ‘no’,” Lebwohl said. 

“This leads to more worry and even vaccine hesitancy, particularly if they have had post-vaccine symptoms, but it is just indicative of a cross-industry reluctance to make guarantees on any product ingredients,” he said.
The SSCD’s statement sends a message that vaccines do not contain gluten, and that they are safe for people with celiac disease.

For Greater Confidence
Numerous experts in celiac disease put their heads together to develop these recommendations, with the effort led by Daniel Leffler, MD, Treasurer of the SSCD.  

“Particularly after the strong findings in the COVID-19 study, we felt it was incumbent on us to review all the available literature and offer guidelines. We want clinicians to be able to answer patients’ questions and have a strong basis for their recommendations, and we want people with celiac disease to move forward in their vaccination decisions with confidence,” he said.

The Society for the Study of Celiac Disease (SSCD) is a society of medical, scientific and allied health professionals in the field of celiac disease.The organization’s overall mission is to advance the fields of celiac disease and gluten-related disorders by fostering research and by promoting excellence in clinical care, including diagnosis and treatment of patients with these conditions. As part of this mission, the SSCD provides expert updates on important topics in celiac disease to patient organizations and clinicians. If you have questions about the SSCD or would like to suggest a topic, please visit our website: https://www.theceliacsociety.org


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