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The treatment concepts for patients with chronic inflammatory bowel disease (IBD), which is subdivided into Crohn’s disease (CD) and ulcerative colitis (UC), have changed markedly in recent decades. Currently, many patients are started early on long-term treatment with classic immunosuppressive agents or anti-TNF-alpha antibodies (TNF-blockers). TNF-blockers have also been approved for a wide range of rheumatological and dermatological indications and are now the best-selling single preparations in Germany (1, 2). The “classic” immune suppressants azathioprine and methotrexate are being used more commonly as well: in 2009, the overall expenditures for these two drugs in Germany were higher than in 2008 by 4% and 10%, respectively (1). These figures imply that an increasing number of patients are being treated with potent immune suppressants. Impaired defenses against infection are both a potential sequela of a chronic inflammatory disease and a potential side effect of immunosuppressive treatment (3, 4). There have been reports of infections that could have been prevented by vaccination, including infection with the hepatitis B virus, the human papilloma virus, the varicella-zoster virus, and the influenza virus, among patients with IBD being treated with either the “classic” immune suppressants or TNF-blockers (5– 8). In the case of pneumococcal infection, the intensity of immunosuppressive treatment appears to be associated with the severity of infection, which ranges to the life-threatening Waterhouse-Friderichsen syndrome (9– 12). A IBD patient’s risk of developing an infectious disease is elevated even in the absence of immunosuppresive treatment. A recent study showed that IBD patients are 57% more likely to develop herpes zoster than normal controls, with an absolute risk of 0.89% per year, as determined from data on more than 22 000 patients (13). Consensus papers have, therefore, been issued both by the European Crohn’s and Colitis Organisation and by the German Society of Digestive and Metabolic Diseases (Deutsche Gesellschaft fur Verdauungs- und Stoffwechselkrankheiten) recommending the determination of vaccination status in IBD patients, followed by the administration of all vaccinations that have not been given or are not up to date, if applicable. The authors, however, have gained the impression from everyday clinical practice that IBD patients often have a deficient vaccination status. The purpose of this exploratory study is to assess the vaccination status of IBD patients and, in particular, to determine what reservations, if any, the patients had against the vaccinations recommended by the The German Standing Vaccination Committee (Standige Impfkommission, STIKO) (table 1). We present our findings here and suggest that they may be relevant to patients with other types of chronic inflammatory disease as well. Table 1 Recommended vaccinations for adult patients with chronic inflammatory diseases*

Patients with chronic inflammatory diseases are at elevated risk of infections that can be prevented by vaccination. This elevated risk is due not just to these patients' primary illnesses, but also to the immunosuppressive treatment that they often receive. We studied the vaccination rate in a random sample of patients with two types of inflammatory bowel disease (IBD), namely, Crohn's disease and ulcerative colitis. In particular, we asked unvaccinated patients why they had re-fused the vaccine.From April to September 2009, we gave a 38-item questionnaire to 203 consecutive patients with IBD (57% with Crohn's disease, 63% female, median age 36 years) who had not received vaccination counseling for at least one year, and inspected the patients' vaccination cards. We compared the findings to the current recommendations of the German Federal Standing Committee on Vaccination (Ständige Impfkommission).83% of the patients had a vaccination card. Substantial deficiencies in vaccination were found. Only 67% of the patients had been immunized against tetanus in the previous 10 years, and only 21% against pertussis. Only 28% were vaccinated against seasonal influenza in 2008, and only 9% had ever received anti-pneumococcal vaccine. A subgroup analysis in which we compared 39 patients taking TNF-blockers to 67 patients who never had any type of immunosuppressive treatment revealed no difference in vaccination rates. 80% of all patients said they were willing to receive all of the officially recommended vaccinations. 22% of all patients said they avoided vaccinations for fear of side effects, while 15% said they did so because their immune system was supposedly "not intact", and 9% because they feared vaccination would worsen their IBD.In this random sample, the vaccination rate fell far behind the recommendations. In particular, there was a marked discrepancy between patients' willingness to be vaccinated and the actual provision of vaccination. These findings imply that physicians need to be more aware of the possibly inadequate vaccination state of their immunosuppressed patients.