COVID-19 and IBD//
Kaplan GG, Windsor JW, Crain J, Barrett L, Bernstein CN, Bitton A, Chauhan U, Coward S, Fowler S, Ghia JE, Gibson DL, Griffiths AM, Jones JL, Khanna R, Kuenzig ME, Lakatos PL, Lee K, Mack DR, Marshall JK, Mawani M, Murthy SK, Panaccione R, Seow CH, Targownik LE, Zelinsky S, Benchimol EI. Crohn's and Colitis Canada's 2021 Impact of COVID-19 & Inflammatory Bowel Disease in Canada: A Knowledge Translation Strategy. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S10-S19.
The prevalence of IBD, Crohn's disease and ulcerative colitis, in Canada, is over 0.75% in 2021. Many individuals with IBD are immunocompromised. Consequently, the World Health Organization's declaration of a global pandemic uniquely impacted those with IBD. Crohn's and Colitis Canada (CCC) formed the COVID-19 and IBD Taskforce to provide evidence-based guidance during the pandemic to individuals with IBD and their families. The Taskforce met regularly through the course of the pandemic, synthesizing available information on the impact of COVID-19 on IBD. At first, the information was extrapolated from expert consensus guidelines, but eventually, recommendations were adapted for an international registry of worldwide cases of COVID-19 in people with IBD. The task force launched a knowledge translation initiative consisting of a webinar series and online resources to communicate information directly to the IBD community. Taskforce recommendations were posted to CCC's website and included guidance such as risk stratification, management of immunosuppressant medications, physical distancing, and mental health. A weekly webinar series communicated critical information directly to the IBD community. During the pandemic, traffic to CCC's website increased with 484,755 unique views of the COVID-19 webpages and 126,187 views of the 23 webinars, including their video clips. CCC's COVID-19 and IBD Taskforce provided critical guidance to the IBD community as the pandemic emerged, the nation underwent a lockdown, the economy reopened, and the second wave ensued. By integrating public health guidance through the unique prism of a vulnerable population, CCC's knowledge translation platform informed and protected the IBD community.
Murthy SK, Kuenzig ME, Windsor JW, Ghia JE, Griffiths AM, Panaccione R, Seow CH, Benchimol EI, Bernstein CN, Bitton A, Huang JG, Jones JL, Lee K, Kaplan GG, Mukhtar MS, Tandon P, Targownik LE Gibson D. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: COVID-19 Vaccines-Biology, Current Evidence and Recommendations. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S54-S60.
The COVID-19 pandemic has ushered a globally focused vaccine development program that produced multiple successful vaccines within a year. Four SARS-CoV-2 vaccines have been approved for use in Canada, using two different technologies, all of which have shown excellent efficacy in reducing the rate of symptomatic COVID-19 infection and 100% efficacy in preventing death from COVID-19. People with IBD, like many others with immune-mediated chronic diseases, were excluded from the pivotal trials of these vaccines, leading to early hesitancy by regulatory bodies to endorse administering the vaccines to these groups. However, recent data has shown that the adverse event rate to SARS-CoV-2 vaccine among people with IBD is similar to the general population. Early data have further shown that people with IBD are capable of mounting a robust immune response to SARS-CoV-2 vaccines, particularly following a second dose, whereas the response to the first dose is blunted in those receiving anti-TNF therapy or conventional immunosuppressants (azathioprine, 6-mercaptopurine, methotrexate). Based on these data and evidence from previous vaccine programs among people with IBD, multiple national and international expert panels have recommended that individuals with IBD receive complete vaccination against SARS-CoV-2 as soon as possible.
Jones JL, Benchimol EI, Bernstein CN, Huang JG, Marshall JK, Mukhtar MS, Murthy SK, Nguyen GC, Kaplan GG, Kuenzig ME, Tandon P, Targownik LE, Windsor JW, Bitton A. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Health Care Delivery During the Pandemic and the Future Model of Inflammatory Bowel Disease Care. Journal of the Canadian Association of Gastroenterology 2021 Oct 26;4(Suppl 2): S61-S67.
The SARS-CoV-2 pandemic has had a profound impact on IBD health care delivery. The implementation of necessary public health restrictions has restricted access to medications, procedures and surgeries throughout the pandemic, catalyzing widespread change in how IBD care is delivered. Rapid large-scale implementation of virtual care modalities has been shown to be feasible and acceptable for the majority of individuals with IBD and health care providers. The SARS-CoV-2 pandemic has exacerbated pre-existing barriers to accessing high-quality, multidisciplinary IBD care that addresses health care needs holistically. Continued implementation and evaluation of both synchronous and asynchronous eHealthcare modalities are required now and in the future in order to determine how best to incorporate these modalities into patient-centred, collaborative care models. Resources must be dedicated to studies that evaluate the feasibility, acceptability and effectiveness of eHealth-enhanced models of IBD care to improve efficiency and cost-effectiveness, while increasing quality of life for persons living with IBD. Crohn's and Colitis Canada will continue to play a major leadership role in advocating for the health care delivery models that improve the quality of life for persons living with IBD.
Graff LA, Fowler S, Jones JL, Benchimol EI, Bitton A, Huang JG, Kuenzig ME, Kaplan GG, Lee K, Mukhtar MS, Tandon P, Targownik LE, Windsor JW, Bernstein CN. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Mental Health and Quality of Life. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S46-S53.
There has been a dramatic rise in mental health difficulties during the coronavirus COVID-19 pandemic. While young adults have the lowest risk of hospitalization and mortality due to COVID-19, they have been identified as being at highest risk of detrimental mental health outcomes during the pandemic, along with women, those with lower socioeconomic status and those with pre-existing mental health conditions. Somewhat of a crisis in mental health has emerged across the general population through the evolution of the pandemic. A national Canadian survey identified a quadrupling of those experiencing pervasive elevated anxiety symptoms early in the pandemic compared to pre-pandemic levels, and a doubling of those with pervasive elevated depressive symptoms. Independent of the pandemic, persons with IBD can face multiple challenges related to their disease, which can result in a significant psychosocial burden and psychologic distress. Anxiety and depression have been found to be more prevalent in persons with IBD. Many potential factors contribute to the increased psychologic distress and negative impacts on mental health of the COVID-19 pandemic on persons with IBD. These include the fears of contracting COVID-19 or infecting other people. Many believe that IBD or its treatments predispose them to an increased risk of COVID-19 or a worse outcome if acquired. Concerns about access to health care add to mental distress. People with IBD generally report lower quality of life compared to community controls. Psychologic interventions, in addition to adequate disease control, have been shown to improve health-related quality of life. Uncertainty is another factor associated with reduced health-related quality of life. Most studies suggest that persons with IBD have suffered quality of life impairment during the pandemic in comparison to the pre-pandemic period. Uncertainties brought on by the pandemic are important contributors for some of the reduction in quality of life.
Targownik LE, Bernstein CN, Lakatos PL, Murthy SK, Benchimol EI, Bitton A, Huang JG, Kuenzig ME, Jones JL, Kaplan GG, Lee K, Mukhtar MS, Tandon P, Windsor JW, Panaccione R. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Risk Factors and Medications. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S40-S45.
IBD is a disease that results from dysregulation of the immune system and frequently requires medications that can affect the immune response to infections; therefore, it was imperative to quickly understand the risk of COVID-19 infection on persons living with IBD and how that risk may be increased by commonly used IBD medications. The IBD research community in Canada and beyond quickly established collaborative efforts to better understand the specific risk posed by COVID-19 on persons with IBD. We learned that IBD itself was not a risk factor for death or serious complications of COVID-19, and that most commonly used drug classes (with the notable exception of corticosteroids) do not increase the risk of COVID-19-related adverse outcomes. The risk factors for serious complications and death from COVID-19 appear to be similar to those identified in the wider population; those being advanced age, having pre-existing heart or lung disease, and smoking. We recommend that persons with IBD do not alter their course of therapy to avoid complications of COVID-19, though the indiscriminate use of corticosteroids should be avoided. Persons with IBD should follow the same public health recommendations as the general population to reduce their personal risk of acquiring COVID-19.
Bernstein CN, Singh H, Murthy SK, Nguyen GC, Benchimol EI, Bitton A, Kuenzig ME, Huang JG, Jones JL, Lee K, Targownik LE, Windsor JW, Mukhtar MS, Tandon P, Kaplan GG. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Seniors With IBD. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S34-S39.
The risk of hospitalization and death from COVID-19 increases with age. The extreme elderly have been particularly vulnerable, with those above the age of 80 having a case-fatality rate as high as 15%. Aging of the immune system can lead to impaired inflammatory responses where eradication of an organism such as SARS-CoV2 is inadequate but is exaggerated in such a way as to enhance pneumonia and acute respiratory distress syndrome. Frailty and comorbidity are both more common in the elderly, and these can enhance the morbidity and mortality from COVID-19. Studies from Northern California and Italy suggest that elderly persons with IBD were more likely to acquire SARS-CoV-2 infection than youths with IBD. While the specific impact of age-related comorbidity is less well established among people with IBD who acquire COVID-19, data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) database reported that having two or more chronic illnesses was independently associated with developing severe COVID-19 among people with IBD. Despite having exaggerated auto-inflammatory responses, people with IBD do not appear to have an overall increased risk of developing severe COVID-19 than the general population. However, whether seniors with IBD do worse once they acquire COVID-19 compared with seniors without IBD is not known. The advent of telehealth care has posed an information technology challenge for many seniors with and without IBD. Most persons with IBD have expressed satisfaction with virtual IBD health care (phone or video-based visits). While the elderly may have less robust immune responses to vaccinations, learning from experiences with other vaccination programs, especially influenza, have shown that vaccinating seniors decreases both morbidity and mortality and, in turn, healthcare resources.
Benchimol EI, Carroll MW, Geist R, Griffiths AM, Huang JG, Mack DR, Bernstein CN, Bitton A, Jones JL, Kaplan GG, Kuenzig ME, Lee K, Mukhtar MS, Murthy SK, Tandon P, Targownik LE, Windsor JW, Seow CH. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Children and Expectant Mothers With Inflammatory Bowel Disease. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S27-S33.
Canada has among the highest rates of IBD in the world, and the number of people living with these disorders is growing rapidly. This has placed a high burden on the health care system and on the Canadian economy-a burden that is only expected to grow in the future. It is important to understand IBD and its impact on Canadian society in order to appropriately plan for health care expenditures, reduce the burden on patients and their families, and improve the quality of life for those afflicted with IBD. In Canada, there is a lack of public awareness of the impact of Crohn's disease and ulcerative colitis. Raising awareness is crucial to reducing the social stigma that is common with these diseases and to help individuals maximize their overall quality of life. A better public understanding of IBD can also help to raise and direct funds for research, which could lead to improved treatments and, ultimately, to a cure. This report from Canadian clinicians and researchers to Crohn's and Colitis Canada makes recommendations aimed at the public, policy-makers, scientific funding agencies, charitable foundations and patients regarding future directions for advocacy efforts and areas to emphasize for research spending. The report also identifies gaps in knowledge in the fields of clinical, health systems and epidemiological research.
Coward S, Windsor JW, Kuenzig ME, Bitton A, Bernstein CN, Jones JL, Khanna R, Lee K, Murthy SK, Targownik L, Benchimol E, Huang JG, Mukhtar MS, Tandon P, Kaplan GG. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Epidemiology-The Trends of Disease Over Time. Journal of the Canadian Association of Gastroenterology 2021 Nov 5;4(Suppl 2): S20-S26.
At the beginning of the COVID-19 pandemic, there were many unknowns: transmission vectors of the virus, appropriate intervention strategies and if being immunocompromised due to IBD, for example, or medications put a person at increased risk for severe COVID-19. Imposing and relaxing of public health restrictions at different times and in different regions in Canada led to different epidemiologies of the virus in different provinces and territories. In order to understand the waxing and waning of waves of the COVID-19 pandemic, it is necessary to understand the effective reproductive number ( ) and the countervailing forces that exert upward or downward pressure on the spread of the virus at a given point in time. As many regions in Canada deal with a third wave, the primary forces affecting the of severe acute respiratory syndrome coronavirus 2 are variants of concern and the increasing vaccinations of Canadians leading to increased population-level immunity. Fortunately, for the IBD population, current research suggests that those with IBD are not at increased risk of contracting COVID-19, nor of having a more severe disease course when compared to the general population.
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; Sep 24: 1-11.
The aim of this cross-sectional study was to use an extended common sense model (CSM) to evaluate the impact of fear of COVID-19 on quality of life (QoL) in an international inflammatory bowel disease cohort. An online study involving 319 adults (75% female, mean (SD) 14.06 (15.57) years of symptoms) completed the Gastrointestinal Symptom Rating Scale, Brief Illness Perceptions Questionnaire, Fear of Contracting COVID-19 Scale, Brief-COPE, Depression, Anxiety and Stress Scale, and the EUROHIS-QOL. The extended CSM had an excellent fit (χ2 (9) = 17.06, p = .05, χ2/N = 1.90, RMSEA = 0.05, SRMR = 0.04, CFI = .99, TLI = .97, GFI = 0.99), indicating the influence of gastrointestinal symptoms on QoL was mediated by illness perceptions, fear of COVID-19, adaptive and maladaptive coping, and psychological distress. Interventions targeting the fear of COVID-19 in the context of an individual’s perceptions will likely enhance QoL during the pandemic.
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; Sep 7:1-12.
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 Psychosomatic Research 2021; Sep: 148: 110561.
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.
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.
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.
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.
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.