COVID-19 and IBD//

Publications

Ng SC, Mak JWY, Hitz L, Chowers Y, Bernstein CN, Silverberg MS. COVID-19 Pandemic: Which IBD Patients Need to Be Scoped-Who Gets Scoped Now, Who Can Wait, and how to Resume to Normal. Journal of Crohns Colitis. 2020; 21; (Supplement-3): S791-S797.  

Endoscopy is an essential component in the management of IBD. There is a risk of SARS-CoV-2 transmission during endoscopic procedures. The International Organization for the study of IBD [IOIBD] has developed 11 position statements, based on an online survey, that focus on how to prioritise endoscopies in IBD patients during the COVID-19 pandemic, alternative modes for disease monitoring, and ways to triage the high number of postponed endoscopies after the pandemic. We propose to pre-screen patients for suspected or confirmed COVID-19 and test for SARS-CoV-2 before endoscopy if available. High priority endoscopies during pandemic include acute gastrointestinal bleed, acute severe ulcerative colitis, new IBD diagnosis, cholangitis in primary sclerosing cholangitis, and partial bowel obstruction. Alternative modes of monitoring using clinical symptoms, serum inflammatory markers, and faecal calprotectin should be considered during the pandemic. Prioritising access to endoscopy in the post-pandemic period should be guided by control of COVID-19 in the local community and availability of manpower and personal protective equipment. Endoscopy should be considered within 3 months after the pandemic for patients with a past history of dysplasia and endoscopic resection for dysplastic lesion. Endoscopy should be considered 3-6 months after the pandemic for assessment of postoperative recurrence or new biologic initiation. Endoscopy can be postponed until after 6 months of pandemic for routine IBD surveillance and assessment of mucosal healing.

Hayes B, Apputhurai P, Mikocka-Walus A, Barreiro-de Acosta M, Bernstein CN, Burgell R, Burisch J, Bennebroek Evertsz F, Ferreira N, Graff LA, Trindade IA, Gearry R, Lo B, Mokrowiecka A, Moser G, Petrik M, Stengel A, Knowles SR. Extending the common sense model to explore the impact of the fear of COVID-19 on quality of life in an international inflammatory bowel disease cohort. Journal of Clinical Psychology in Medical Settings 2021; in press. 

Mikocka-Walus A, Bennebroek Evertsz F, Jedel S, Graff LA, van Tilburg MAL, Ferreira N, Skvarc D, Knowles S, Mokrowiecka A, Stengel A, Gearry R, Bernstein CN, Burisch JM, Barreiro Acosta M, Trindade I. Exploring the relationship between self-isolation and distress among people with gastrointestinal disorders during the COVID-19 pandemic. Journal of Clinical Psychology in Medical Settings 2021; in press. 

 

This study aimed to explore the association between perceived isolation and symptoms of distress in people with GI disorders at the time of the pandemic; and to examine factors which moderate this relationship. This online cross-sectional survey was advertised in May-September 2020 via patient organisations and associated social media. Overall, 831 people (82% female, mean age 49 years) from 27 countries participated. A significant relationship between social isolation and psychological distress was noted (r = .525, p < .001). GI symptoms moderated the association between isolation and distress (B = .047, t = 2.47, p = .015). Interventions targeting these factors may help to reduce distress in people with GI disorders at the time of major stressors such as the COVID-19 pandemic.

Ferreira N, Mikocka-Walus A, van Tilburg MAL, Graff LA, Apputhurai P, Barreiro-de Acosta M,Bennebroek Evertsz F, Burisch J, Lo B, Petrik M, Trindade IA, Jedel S, Moser G Mokrowiecka A, Bernstein CN, Dan Dumitrascu D, Ford AC, Stengel A, Richard Gearry R, Knowles SR. The impact of the coronavirus (Covid-19) pandemic on individuals with gastrointestinal disorders: a protocol of an international collaborative study. Journal of Psychosomaic Research 2021; in press.

The COVID-19 pandemic has had a significant impact on mental health across the globe. People living with a chronic gastrointestinal (GI) disorder might be particularly at risk of mental health complications given higher rates of comorbid anxiety and depression compared to the healthy population. As GI disorders affect up to 40% of the population worldwide, this international collaborative study seeks to evaluate the extent of the impact of the COVID-19 pandemic on GI symptoms specifically and more generally on the well-being of those living with chronic GI conditions. A longitudinal survey with three time points (baseline, 6-month, and 12-month) will be conducted online. Adult participants with GI disorders from multiple countries will be recruited via patient associations, social media advertising, utilizing snowball sampling. Participants will be invited to complete a battery of questionnaires including demographic and health parameters, and measures of gastrointestinal symptoms, fear of COVID-19, perceived impact of COVID-19, illness perceptions, coping, depression, anxiety, stress, catastrophizing, and quality of life, using validated measures where available. Statistical analyses will include univariate descriptive models, multivariate models utilizing regression, mediation, and moderation, and latent growth models.

This project may present novel information to the field of psychogastroenterology and may provide crucial information regarding the areas of impact for individuals with GI disorders during and following the pandemic. Further, this information can guide healthcare providers and patient associations on how to target support related to the pandemic mental health sequelae for these patients.

Mikocka-Walus A, Skvarc D, van Tilburg MAL, Barreiro-de Acosta M, Bennebroek Evertsz F, Bernstein CN, Burisch J, Ferreira N, Gearry RB, Graff LA, Jedel S, Mokrowiecka A, Stengel A, Knowles S. COVID-19-related personal product shortages are associated with psychological distress in people living with gastrointestinal disorders: A cross-sectional survey. Neurogastrointestinal Motility 2021; in press. 

 

The mental health response to the coronavirus (COVID-19) pandemic-related product shortages in those living with chronic gastrointestinal (GI) disorders has received little attention. We aimed to explore the association between the pandemic-related product shortages and psychological distress in people with GI disorders. This online cross-sectional survey was nested within an ongoing, international, prospective study of well-being in people with GI disorders. The study was advertised in multiple countries in May-September 2020 via patient organizations and social media. The primary outcome measure was distress, evaluated by the Depression Anxiety Stress Scale. We utilized linear regressions, adjusting for covariates and testing individual moderation effects. Overall, 831 people completed the survey from 27 countries, of whom 82% were female (mean age = 49 years). The most common disorders included inflammatory bowel disease (n = 322), celiac disease (n = 273), and irritable bowel syndrome (n = 260). Significant problems accessing food were reported by 19.8%, non-medical therapies by 16%, toilet paper by 10.8%, and essential medication by 8.9% of the sample (>5% pain medication). There was a positive association between toilet paper and pain medication shortages and distress, and a negative association between food shortages and distress. Significant moderation effects were identified for COVID-19 prevalence and toilet paper and food shortages, and between COVID-19 fear and pain medication shortages.

In summary this study documented a significant relationship between product shortages and psychological distress, which were associated with COVID-19 prevalence and fear. Strategies addressing COVID-19 fear could potentially modify the relationship between shortages and distress.

Siegel CA, Melmed GY, McGovern DP, Rai V, Krammer F, Rubin DT, Abreu MT, Dubinsky MC; International Organization for the Study of Inflammatory Bowel Disease (IOIBD); International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) (Dr  Bernstein is a member of group authorship). SARS-CoV-2 vaccination for patients with inflammatory bowel diseases: recommendations from an international consensus meeting. Gut 2021; 70(4): 635-640. 

 

Members of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD) used the modified Delphi method to develop consensus statements regarding SARS-CoV-2 vaccination for patients with IBD. The main characteristics of this technique include expert opinion with anonymous voting on statements, iteration with controlled feedback of group opinion and statistical aggregation of the group response.

 

Highlighted themes of accepted statements related to SARS-CoV-2 vaccination for patients with IBD by the IOIBD

  • Patients with IBD should be vaccinated against SARS-CoV-2.

  • The best time to administer SARS-CoV-2 vaccination in patients with IBD is at the earliest opportunity to do so.

  • SARS-CoV-2 vaccines including messenger RNA vaccines, replication-incompetent vector vaccines, inactivated vaccines and recombinant vaccines are safe to administer to patients with IBD.

  • SARS-CoV-2 vaccination should not be deferred because a patient with IBD is receiving immune-modifying therapies.

  • Patients with IBD vaccinated with SARS-CoV-2 should be counselled that vaccine efficacy may be decreased when receiving systemic corticosteroids.

Rubin DT, Abreu MT, Rai V, Siegel CA; International Organization for the Study of Inflammatory Bowel Disease (Dr Bernstein is a member of group authorship). Management of Patients With Crohn's Disease and Ulcerative Colitis During the Coronavirus Disease-2019 Pandemic: Results of an International Meeting. Gastroenterology 2020;159(1):6-13. 

 

International Organization for the Study of IBD (IOIBD) used the established RAND/UCLA method, which uses a Delphi panel approach to address the appropriateness of specific medical interventions or medical decisions. We used a modified RAND panel to allow for a rapid cycle of 2 rounds of voting by the expert panel. The panel was presented a web-based questionnaire that included clinical scenarios specific to patients with IBD during the COVID-19 pandemic. The questionnaire was created and iteratively improved by 3 of the authors and then distributed electronically to the respondents. The panelists included the membership of IOIBD in addition to other invited specialists in IBD. Respondents rated each of the patient scenarios on a scale of 1–9, such that statements rated 1–3 are considered inappropriate, 4–6 are uncertain, and 7–9 are appropriate. After the first round of anonymous voting, the first webinar occurred and related content was reviewed as summarized and the results of the first round of voting were reviewed. The subsequent discussion focused on scenarios that had a median in the uncertainty range and those with a high standard deviation. The goal of the discussion was to understand views of the panel in preparation for a second round of voting, not necessarily to achieve consensus. The second round questionnaire was nearly identical to the first, except for clarifying a few of the original scenarios and adding 2 additional sections that were not covered in round 1 (how to manage patients in IBD clinical trials and when to restart medications if they were being held for active COVID-19 infection)

 

Of the 76 statements in the second-round survey, 26 were rated as appropriate, 19 as uncertain, and 31 as inappropriate. Although agreement is not required, there was agreement (DI of <1) in 64 of 76 scenarios (84%).

 

Below are some of the key statements:

  • The panel agreed that having IBD (either Crohn’s disease or ulcerative colitis) did not increase the risk of becoming infected with SARS-CoV-2 or developing COVID-19 and having an ostomy or J-pouch did not increase the risk for COVID-19.

  • The panel agreed that it is safe to continue to receive infusions in an infusion center, assuming that the infusion center has a SARS-CoV-2 screening protocol in place.

  • The group was in agreement that it is appropriate to reduce the dose or discontinue prednisone to prevent infection from SARS-CoV-2, but voted that it was inappropriate to reduce the dose or stop other IBD therapies to prevent infection from SARS-CoV-2.

  • There were mixed responses related to the other clinical scenarios and therapies. The key findings regarding the management of medical therapy for IBD in the setting of the COVID-19 pandemic are summarized in Figure 1 .

  • In regards to the scenario of a patient receiving combination therapy of an anti-tumor necrosis factor (TNF) and immune modulator, the group was uncertain if the immune modulator should be dose reduced to potentially modify the risk of infection with SARS-CoV-2, but was in agreement and did vote that it is appropriate to discontinue the immune modulator in a patient who is known to be infected with SARS-CoV-2 or when a patient develops COVID-19.

  • In the scenario of a patient who stopped IBD medications because either they tested positive for SARS-CoV-2 infection or had COVID-19, the group voted that it is appropriate to restart their medications if they do not develop symptoms after 2 weeks, or when symptoms have completely resolved.

  • The group was in agreement and voted it was appropriate to postpone nonessential endoscopic procedures.

  • Furthermore, the panel voted that patients in clinical trials should continue those therapies unless they become infected by SARS-CoV-2 or develop COVID-19.

  • The group voted that it was appropriate to discontinue the clinical trial drug if a patient tests positive for SARS-CoV-2 or develops COVID-19, but there was some disagreement in the responses.

 

Bernstein CN, Ng, SC, Banerjee R, Steinwurz F, Shen B, Carbonnel F, Hamid S, Sood A, Yamamoto-Furusho JK, Griffiths A, Benchimol E, Travis S, Lopes S, Rubin DT, Kaplan GG, Armstrong D, Gearry R, and the IBD-Emerging Nations Consortium and the WGO IBD Task Force on COVID-19. Worldwide management of inflammatory bowel disease during the COVID-19 pandemic: An international survey. Inflammatory Bowel Diseases 2021; 27: 836-847. 

Persons with inflammatory bowel disease (IBD) may be particularly vulnerable to COVID-19 either because of their underlying disease or its management. Guidance has been presented on the management of persons with IBD in the time of this pandemic by different groups. We aimed to determine how gastroenterologists around the world were approaching the management of IBD. Members of the World Gastroenterology Organization (WGO) IBD Task Force contacted colleagues in countries largely beyond North America and Europe, inviting them to review the WGO website for IBD and COVID-19 introduction, with links to guideline documents, and then to respond to 9 ancillary open-ended management questions. 52 gastroenterologists from 33 countries across 6 continents completed the survey (April 14 to May 16, 2020). They were all adhering for the most part to published guidelines on IBD management in the COVID-19 era. Some differences and reductions in services related to access, and some related to approach within their communities in terms of limiting virus spread. In particular, most gastroenterologists reduced in-person clinics (43 of 52), limited steroid use (47 of 51), limited elective endoscopy (45 of 52), and limited elective surgeries (48 of 51). If a patient was diagnosed with COVID-19, immunomodulatory therapy was mostly held.

In most countries, the COVID-19 pandemic significantly altered the approach to persons with IBD. The few exceptions were mostly based on low burden of COVID-19 in individual communities. Regardless of resources or health care systems, gastroenterologists around the world took a similar approach to the management of IBD.

Chen Y, Yu Q, Farraye FA, Kochhar GS, Bernstein CN, Navaneethan U, Wu K, Zhong J, Schwartz DA, Wu H, Zheng JJ, Iacucci M, Kiran RP, Shen B. Patterns of endoscopy during COVID-19 pandemic: a global survey of interventional inflammatory bowel disease practice. Intestinal Research 2020; in press.

 

Performance of diagnostic or therapeutic endoscopic procedures in IBD patients can be challenging during a viral pandemic; the main concerns being the safety and protection of patients and health care providers. The aim of this study was to identify endoscopic practice patterns and outcomes of IBD and coronavirus disease 19 (COVID-19) with a worldwide survey of health care providers. A 20-item survey questionnaire was sent to physician members of the American Society for Gastrointestinal Endoscopy Special Interest Group in Interventional IBD, Chinese IBD Society Endoscopy Interest Group, and the China Crohn's and Colitis Foundation. A total of 141 respondents submitted valid responses. Nighty-five respondents (67.9%) reported that at least 25% of their scheduled emergent endoscopic procedures were canceled or postponed during the pandemic. Fifty-six respondents (40.0%) have performed emergent endoscopy during the pandemic. A few respondents (9/140, 6.4%) estimated that more than 25% of their patients had worsened disease due to delayed or canceled emergent endoscopy procedures. More than 80% of respondents believed that personal protective equipment (PPE) for the endoscopy team, room sterilization, and pre-procedure screening of patients for COVID-19 were necessary. Out of 140 respondents, 16 (11.4%) reported that several of their patients had COVID-19. Eight clinicians (5.7%) reported that they or their endoscopy colleagues developed work-related COVID-19.

We concluded that cancellation of elective and emergent endoscopy in IBD care during the pandemic was common. Few respondents reported that their patients' disease conditions worsened due to the cancellation of the endoscopy procedure. Most respondents voiced the need for proper PPE during the procedure regardless of patients' COVID-19 status and screening the patients for COVID-19.

Chen Y, Hu S, Wu H, Farraye FA, Bernstein CN, Zheng JJ, Kiran RP, Shen B. Patterns of care for inflammatory bowel disease in China during the COVID-19 pandemic. Lancet Gastroenterology and Hepatology 2020; 5: 632-634.

 

We did a survey involving patients with IBD to analyze their feedback on their care during the early and late phases of the COVID-19 outbreak in China. 2277 participants completed the survey. 880 (39%) were women and 1397 (61%) men; 1639 (72%) had Crohn’s disease and 555 (24%) had ulcerative colitis. 111 (5%) respondents were from Hubei province. Of  the 2277 respondents, 1134 (50%) were employed full or part time. Most (934 [82%] of 1134) had to work at home during the pandemic and 443 (39%) reported reduced income (appendix). More than 50% of the respondents reported some degree of mood changes, with the peak of the frequency of moderate-to-severe psychological change in the middle of the outbreak in China—ie, mid-February, 2020. Many (1331 [58%] of 2277) respondents were worried about the risk for SARS-CoV-2 infection for themselves and their family and more than half (1184 [52%]) were concerned about the difficulty in seeing physicians Almost three-quarters of patients (1691 [74%]) reported that their disease state was stable during the initial outbreak (from January to March, 2020) and 1842 (81%) reported that their disease remained stable in the later phase (ie, mid-April, 2020). 137 (6%) patients were admitted for IBD flares and 23 (1%) had surgery. 639 (28%) patients used telemedicine—of whom 487 (76%) sought help from IBD health-care providers online—and 847 (37%) of 2277 patients had face-to-face visits. Most patients (1744 [77%]) did not change IBD medications during the outbreak. Of the 533 patients with a change in medications, the main reasons for the change were recommendations from treating physicians (157 [30%]), being unable to receive intravenous infusions (151 [28%]), and the availability of physicians or facilities (148 [28%]). Most respondents (1606 [71%] of 2277) were still able to obtain oral medications online (1125 [49%]) or from hospital pharmacies as before (481 [21%]). By mid-April, 2020, most (1628 [71%]) were able to obtain oral medicines from their hospital pharmacies as before The results from this large survey suggest that the COVID-19 pandemic affects patients with IBD medically, psychosocially, and financially. Most respondents’ disease remained stable. Respondents using maintenance therapy and those requiring medication adjustments because of disease flares often met logistical challenges. The availability of telemedicine and online drug delivery services might have eased some of the burden. Psychosocial and economic effects of the pandemic on IBD care are common. The long-lasting effects will need to be studied over time.