Adults With Celiac Disease Often Undervaccinated Against Pneumococcal Disease

Adult patients with celiac disease (CeD) are undervaccinated against pneumococcal disease, but remedies including educational resources and pneumococcal vaccine administration during in-person gastrointestinal office visits demonstrated effectiveness at increasing vaccination rates, according to results from a prospective quality improvement study published in Digestive Diseases and Sciences.¹

Individuals with Celiac disease can face gastrointestinal complications if they consume gluten. | Image Credit: © weyo - stock.adobe.com

Celiac Disease Puts Patients At Risk for Pneumococcal Infection

Patients with CeD, a lifelong immune-mediated enteropathy caused by a reaction to eating gluten, face a chronic risk of damage to the small intestine’s lining if they consume gluten-containing foods. If the small intestine is damaged, individuals can face gastrointestinal complications such as diarrhea, fatigue, bloating, or anemia. Fortunately, when patients restrict themselves to a gluten-free diet, the prognosis for CeD is often excellent.^1,2

However, recent investigations have elucidated broader impacts of CeD, including a greater susceptibility to a wide range of infections compared with individuals without CeD. This includes pneumococcal infection, which can cause dangerous respiratory complications, especially in older or immunocompromised individuals. One meta-analysis from 2018 found that patients with CeD were almost twice as likely to contract pneumococcal virus compared with controls. Other research initiatives have attributed this heightened pneumococcal risk to functional hypersplenism in patients with CeD, resulting in neutrophil and B-cell impairment.^3,4

Accordingly, the 2023 American College of Gastroenterology update on guidelines for the diagnosis and management of CeD features a recommendation for pneumococcal vaccination. More research is required to assess the frequency of pneumococcal vaccination in patients with CeD in the United States, but early indications suggest that the population is vastly undervaccinated, comprising a major health burden and possibly putting countless patients at risk.^1,5

Patients With Celiac Disease Are Undervaccinated, But Education Improves Uptake

In the current investigation, the authors first assessed the frequency of pneumococcal disease vaccination in a retrospective cohort of adults with CeD. Then, they designed a prospective quality improvement initiative designed to improve rates of pneumococcal vaccination in patients with CeD at Cleveland Clinic. In this study portion, an educational handout was given to patients, who were then offered the pneumococcal 20-valent conjugate vaccine (PCV20). Their goal was to initiate a patient-physician discussion about vaccination, which would lead to more thorough counseling and education, ultimately leading towards the patient getting vaccinated.¹

For their retrospective analysis, 340 patients with biopsy-proven CeD were included for initial analysis to determine baseline pneumococcal vaccination rates. The average age of the cohort was 48 years, while 21% were aged 65 or older. Critically, 199 patients (59%) were unvaccinated. For the 141 vaccinated patients, 73 (52%) were considered “fully vaccinated” and 68 (48%) were “partially vaccinated.” Unsurprisingly, patients aged 65 and older were more likely to be fully vaccinated and partially vaccinated than patients aged 18 through 64 years (56% vs 12%, P < .0001; 74% vs 33%, P < .0001, respectively).¹

Next, the authors initiated their prospective quality improvement project. Adult patients who visited the celiac program at Cleveland Clinic between September 2023 and May 2024 were parsed for enrollees. In total, 241 patients were seen during that window, of which 93 were seen in person and deemed eligible for inclusion. Among these, 33 patients were already vaccinated; for the 60 remaining individuals, 42 were given the educational handout and most (62%) went on to receive PCV20 at their visit.¹

The increase in vaccination rates compared with historic numbers was deemed significant (P < .0001) and remained so when analyzing intention-to-treat of all eligible patients (P < .0001). Ultimately, patients were found to be significantly more likely to receive a pneumococcal vaccination after they received the handout (odds ratio: 13.0; 95% CI, 2.6—64.2; P < .0016).¹

Use of an educational flier could serve as a simple, effective strategy to increase pneumococcal vaccination uptake among patients with CeD. Constituting a vulnerable population, it is essential to ensure as many patients as possible are educated regarding their heightened risk, counseled on available vaccine options, and guided towards receiving a vaccine.¹

“Given the pneumococcal vaccine’s low cost, good availability, demonstrated disease reduction in at-risk patients, and high costs of disease burden, gastroenterologists have a responsibility to work proactively to improve pneumococcal disease vaccination rates in patients with CeD,” the study authors concluded. “Providing educational resources and administering PCV20 during in-person gastroenterology office visits appears to be an effective strategy to increase vaccination rates.”¹

REFERENCES

1. Payne K, Jansson-Knodell C, Trommer E, et l. Adult patients with celiac disease are under-vaccinated against pneumococcal disease: A quality improvement study. Dig Dis Sci. 2025. doi:10.1007/s10620-025-09350-y

2. Ferruggia K. FDA Grants Fast Track Designation to Drug Candidate for Celiac Disease. Pharmacy Times. Published May 30, 2025. Accessed May 15, 2025. https://www.pharmacytimes.com/view/fda-grants-fast-track-designation-to-celiac-disease-candidate

3. Simons M, Scott-Sheldon LAJ, Risech-Neyman Y, et al. Celiac Disease and Increased Risk of Pneumococcal Infection: A Systematic Review and Meta-Analysis. AJM. 2018;131(1):83-89. doi:10.1016/j.amjmed.2017.07.021

4. Sabatino AD, Rosado MM, Cazzola P, et al. Splenic Hypofunction and the Spectrum of Autoimmune and Malignant Complications in Celiac Disease. Clin Gastro Hepat. 2006;4(2):179-186. doi:10.1016/S1542-3565(05)00982-1

5. Tapia-Rubio A, Hill I, Semrad C, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Amer J Gastroen. 2023;118(1):59-76. doi:10.14309/ajg.0000000000002075