COVID-19 and IBD//

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Publications

Bowdish DME, Chandran V, Hitchon CA, Kaplan GG, Avina-Zubieta JA, Fortin PR, Larché MJ, Boire G, Gingras AC, Dayam RM, Colmegna I, Lukusa L, Lee JLF, Richards DP, Pereira D, Watts TH, Silverberg MS, Bernstein CN, Lacaille D, Benoit J, Kim J, Lalonde N, Gunderson J, Allard-Chamard H, Roux S, Quan J, Hracs L, Turnbull E, Valerio V, Bernatsky S, SUCCEED investigative team. SUrveillance of responses to COVID-19 vaCcines in systEmic immunE mediated inflammatory Diseases (SUCCEED). Journal of Rheumatology 2024; Jul 1;51(7):721-727.

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Objective: To determine how serologic responses to coronavirus disease 2019 (COVID-19) vaccination and infection in immune-mediated inflammatory disease (IMID) are affected by time since last vaccination and other factors.

Methods: Post-COVID-19 vaccination, data, and dried blood spots or sera were collected from adults with rheumatoid arthritis, inflammatory bowel disease, systemic lupus erythematosus, ankylosing spondylitis and spondylarthritis, and psoriasis and psoriatic arthritis. The first sample was collected at enrollment, then at 2 to 4 weeks and 3, 6, and 12 months after the latest vaccine dose. Multivariate generalized estimating equation regressions (including medications, demographics, and vaccination history) evaluated serologic response, based on log-transformed anti-receptor-binding domain IgG titers; we also measured antinucleocapsid IgG.

Results: Positive associations for log-transformed anti-receptor-binding domain titers were seen with female sex, number of doses, and self-reported COVID-19 infections in 2021 to 2023. Negative associations were seen with prednisone, anti-tumor necrosis factor agents, and rituximab. Over the 2021-2023 period, most (94%) of antinucleocapsid positivity was associated with a self-reported infection in the 3 months prior to testing. From March 2021 to February 2022, anti-N positivity was present in 5% to 15% of samples and was highest in the post-Omicron era, with antinucleocapsid positivity trending to 30% to 35% or higher as of March 2023. Antinucleocapsid positivity in IMID remained lower than Canada's general population seroprevalence (> 50% in 2022 and > 75% in 2023). Time since last vaccination was negatively associated with log-transformed anti- receptor-binding domain titers, particularly after 210 days.

Conclusion: Ours is the first pan-Canadian immune-mediated inflammatory diseases assessment of how vaccine history and other factors affect serologic COVID-19 vaccine responses. These findings may help individuals personalize vaccination decisions, including consideration of additional vaccination when > 6 months has elapsed since last COVID-19 vaccination/infection.

 

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Habib M, Dayam RM, Hitchon CA, Chandran V, Fortin PR, Bowdish D, Gingras AC, Larche MJ, Colmegna I, Lukusa L, Lee J, Pereira D, Bernstein CN, Lalonde N, Turnbull E, Bernatsky S, and SUCCEED investigative team. Duration of Post-vaccination Neutralizing Antibodies to SARS-COV2 and Medication Effects in Immune-mediated Inflammatory Diseases: Results from the SUCCEED Initiative. ACR Open Rheumatology 2024; Sep;6(9):581-586.

 

Background: In the face of the ongoing circulation of SARS-CoV-2, the durability of neutralization post-COVID-19 vaccination in immune-mediated inflammatory disease (IMID) is a key issue, as are the effects of medications.

Methods: Adults (n=112) with IBD, psoriasis/psoriatic arthritis, rheumatoid arthritis, spondylarthritis, and systemic lupus were recruited from participating Canadian medical centers from 2021 to 2023. We focused on log-transformed neutralization (lentivirus methods) as a continuous outcome, with separate models for wild-type and Omicron strains BA.1 and BA.5.

Results: Compared with 30-120 days postvaccination, subsequent periods were associated with greater neutralization in unadjusted models for wild-type, BA.1, and BA.5 strains and against the BA.1 strain in adjusted models. Rituximab was associated with lower neutralization for the BA.1 strain in adjusted models, with a similar trend for BA.5. In methotrexate users, there were trends for less neutralization of BA.1 and BA.5 in all unadjusted models, whereas in adjusted models, there was significantly lower neutralization only for the wild type. Three or more doses and Omicron-specific vaccines were both independently associated with better neutralization ability for all three strains. A COVID-19 infection within six months before sampling was associated with higher neutralization of wild type and BA.1 in adjusted analyses. Anti-tumor necrosis factor agents were associated with lower neutralization ability for BA.5 in adjusted analyses.

Conclusion: Neutralization responses in immunosuppressed individuals with IMID were durable over time and were augmented by more than three doses and Omicron-specific vaccines. Less neutralization was seen with certain medications. Our work clarifies the joint effects of vaccine history, infection, and medications on COVID-19 immunity.

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Lo B, Trindade IA, Ferreira M, Acosta MB, Knowles SR, Burisch J, Bernstein CN, Mokrowiecka A, Mikocka-Walus A, Gearry RB. Fear of COVID-19 among persons with inflammatory bowel disease as compared to persons with other gastrointestinal conditions. Turkish Journal of Gastroenterology 2022; 33: 664-672.

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Although several studies have reported the impact of fears relating to COVID-19 on several chronic illnesses, there are few studies focused on gastrointestinal conditions. Therefore, the aim of this study was to compare the fear of COVID-19 in patients with IBD to other gastrointestinal conditions and how the fear of COVID-19 manifests across different demographical backgrounds among inflammatory bowel disease respondents. Participants with gastrointestinal conditions (age at least 18) were recruited from 27 countries. Demographic, clinical, and psychosocial information was collected. An adapted scale for IBD patients measuring the fear of COVID-19 and gastrointestinal-specific fear of COVID-19 was used. Results: In 831 participants (312 IBD), only significant increases in gastrointestinal-fear of COVID-19 were found in between IBD and other gastrointestinal conditions (mean [standard deviation]: 13.5 [5.5] vs 10.9 [5.0], P < .01). Among IBD respondents, persons on sick leave had significantly more fear of COVID-19 than those employed (median [IQR], 31.0 [28.5-39.5] vs 26.0 [20.0-33.0], P = .035) and significantly more gastrointestinal-fear of COVID-19 compared to the employed (18.0 [14.5-22.0] vs 13.0 [9.0-17.0], P = .033) or respondents outside of the labor market (12.0 [7.0-16.0], P = .022). Persons living in a rural setting had significantly more fear of COVID-19 compared to persons living in regional setting (29.5 [22.0-37.8] vs 25.0 [20.0-31.3], P = .007) and gastrointestinal-fear of COVID-19 (15.0 [11.0-19.8] vs 12.0 [9.0-16.0], P = .02). Conclusion: Respondents with IBD are more afraid of COVID-19 regarding their disease; especially, persons on sick leave or persons living in a rural setting. This should be taken into consideration to personalize the support that health care providers can offer in mitigating fear related to COVID-19.

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Quan J, Ma C, Panaccione R, Hracs L, Sharifi N, Herauf M, Markovinovic A, Coward S, Windsor JW, Caplan L, Ingram RJM, Charlton C, Kanji JN, Tipples G, Holodinsky JK, Bernstein CN, Mahoney DJ, Bernatsky S, Benchimol EI, Kaplan GG and the STOP COVID-19 in IBD Research Group. Serological responses to the first four doses of SARS-CoV-2 vaccine in patients with inflammatory bowel disease. Lancet Gastroenterology and Hepatology 2022; 7:1077-1079.

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Although serological response to SARS-CoV-2 may wane overtime, those who are immunocompromised may not mount or sustain an adequate immune response post-infection. A multicenter study in the United Kingdom demonstrated a diminished serological response to SARS-CoV-2 in individuals with IBD on TNF antagonists, but not on vedolizumab. We assessed the prevalence of antibodies to SARS-CoV-2 in those with IBD during the second wave of the pandemic in Canada and evaluated the presence of antibodies up to 10 months following diagnosis of COVID-19.  Individuals with Crohn’s disease CD or ulcerative colitis were identified through a survey of gastroenterologists in Calgary, Alberta, Canada. Individuals with IBD were stratified into two cohorts: 1) Serosurveillance defined as those who were not previously diagnosed with COVID-19; and 2) COVID-19 recovered, defined as those with a confirmed diagnosis of SARS-CoV-2 infection. A positive antibody test was defined as an Index Signal/Cut-off (S/C) ≥ 1.4 as per manufacturer’s instructions. The assay has been validated with a 95% sensitivity and 100% specificity 12 days following symptom onset and correlates to neutralizing antibodies.  We assessed the proportion of individuals with IBD who mounted an antibody response among those undergoing serosurveillance and among those following infection with SARS-CoV-2 from October 23, 2020 to March 17, 2021. Among individuals with IBD who recovered from COVID-19 infection, a logistic regression model assessed the effect of time from diagnosis to serology testing on nucleocapsid positivity adjusted for age, sex and anti-TNF use.  Results In total, 230 individuals with IBD underwent serological assessment including 196 undergoing serosurveillance and 34 individuals with IBD recovered from known COVID-19. Two individuals tested positive for nucleocapsid antibody for a seropositivity of 1.03% (95% CI: 0.13 to 3.67). Among those who recovered from COVID-19, 52.9% (95% CI: 35.1 to 70.2) overall had a positive nucleocapsid antibody test. 51%  of the serosurveillance cohort was on anti-TNF therapy compared to 62.8% of COVID-19 recovered patients (p>0.05). Among those who recovered from COVID-19, anti-TNF use was similar in those who were nucleocapsid antibody positive (66.7%) and negative (56.3%) (p>0.05). The proportion of patients who were nucleocapsid antibody positive fell from 76.9% (95% CI: 46.2, 95.0) at 0 to 59 days from diagnosis to 61.5% (95% CI: 31.6, 86.1) at 60 to 119 days. No patients were nucleocapsid antibody positive after 119 days. The likelihood of testing positive for nucleocapsid antibody was associated with time from diagnosis (Odds Ratio=0.97 per day; 95% CI: 0.95 to 0.99) after adjusting for age, sex, and anti-TNF use. An interactive dashboard displaying these data is here: Conclusions: These data have important clinical implications for individuals with IBD, particularly those who are immunocompromised. Serosurveillance studies in IBD are likely only reliable for a 2-3 month window of testing and may underestimate seroprevalence by up to a25% of the population. Moreover, 3 months after COVID-19 diagnosis, patients with IBD should be considered susceptible to SARS-CoV-2 even after recovering from infection. While early data suggest that patients with IBD have a robust serological response after completing mRNA vaccine series, our data highlight the importance of studying sustained antibody response over time in order to develop strategies to ensure durable protection and inform public health policy.

 

 

 

Quan J, Ma C, Panaccione R, Hracs L, Sharifi N, Herauf M, Makovinović A, Coward S, Windsor JW, Caplan L, Ingram RJM, Kanji JN, Tipples G, Holodinsky JK, Bernstein CN, Mahoney DJ, Bernatsky S, Benchimol EI, Kaplan GG; STOP COVID-19 in IBD Research Group. Serological responses to three doses of SARS-CoV-2 vaccination in inflammatory bowel disease. Gut 2023; 72:802-804.

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Despite recommendations for three-dose vaccine regimens for individuals with IBD, the uptake has been low in this population. We examined the serological response following three doses of mRNA SARS-CoV-2 vaccines in persons with IBD, the factors associated with antibody titres and the decay of antibody titres over time. Adults aged 18 years or older with a confirmed diagnosis of IBD who received three doses of an mRNA SARS-CoV-2 vaccine (Pfizer-BioNTech BNT162b2 mRNA (Comirnaty) or NIH-Moderna mRNA-1273 (Spikevax)) were recruited from 25 June 2021 to 6 January 2022. Serum samples were drawn at least 1 week following the third dose of vaccine and processed by Alberta Precision Laboratories using the Abbott SARS-CoV-2 IgG II Quant assay to detect antibodies to the S1 subunit of the spike protein (anti-S). The threshold for seroconversion was defined as ≥50 AU/mL for anti-S antibodies. Age, sex, vaccination date and type, IBD type, and IBD medications at time of vaccination were collected through medical chart review. Vaccine schedule between second and third vaccine doses was defined as ‘scheduled’ for 4–18 weeks between dose administration and ‘delayed’ for >18 weeks. Prior history of COVID-19 was defined by either nucleocapsid seroconversion or molecular-confirmed diagnosis of SARS-CoV-2 infection via PCR. Geometric mean titres with associated 95% CIs were used to report anti-S concentrations. Multivariable linear regression was used to determine the effect of independent predictors determined a priori on log-transformed anti-S concentration. Exponentiated coefficients represented the fold change (FC) associated with each binary covariate and the FC in log anti-S concentration per unit change for continuous variables. Results: In total, 232 participants (mean age 52.7 years;42.7% male) with IBD and three doses of an mRNA vaccine were included. The seroconversion rate among this sample was 99.6% and the geometric mean titre was 14 569 AU/mL (95% CI 12 846 to 16 472 AU/mL). Multivariable linear regression identified significantly increased log anti-S concentration for prior SARS-CoV-2 infection (FC: 1.97 (95% CI 1.22 to 3.18)) and decreased log anti-S concentration for corticosteroid use (FC: 0.07 (95% CI 0.03 to 0.20). Antibodies decayed by 12% per week (95% CI 8% to 15%) following third dose vaccination. Age, sex, IBD type, vaccine type and vaccine schedule were not associated with anti-S concentration. The data can be viewed in an online dashboard (https://kaplan-gi.shinyapps.io/COVID_Serology/) using the Shiny: Web Application Framework for R package. A three-dose SARS-CoV-2 vaccination regimen for individuals with IBD has been proposed based on impaired serological responses to two-dose regimens. Our study demonstrates near complete seroconversion and high antibody titres following a three-dose mRNA vaccine regimen, similar to an American cohort of individuals with IBD that demonstrated a robust antibody response following an extra dose from the initial vaccine series. Conclusions: Antibody responses following three doses are consistently high across all IBD therapies for maintenance of remission, including biologic and immunomodulator therapies. In contrast, prednisone use at the time of vaccine dosing was associated with lower antibody responses. Our study also indicated significant decay of antibody titres over time following third-dose vaccination at a rate of 12% per week. While these data support widespread implementation of a three-dose vaccine regimen, future studies are necessary to determine if additional doses will be required to maintain sufficient antibody levels over time.

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Dolovich CL, Shaffer SR, Graff LA, Singh H, El Gabalawy R, Shaw S, Bernstein CN. The association between increased maladaptive health behaviors and elevated mental health symptoms during the COVID-19 pandemic in IBD. Journal of Canadian Association of Gastroenterology 2023; Sep 13;6(5):179-185.

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Our aim was to assess the association between maladaptive health behaviors and elevated mental health symptoms during the COVID-19 pandemic among persons with IBD. Participants of the population-based University of Manitoba IBD Research Registry (n=2942) were invited to participate in a survey November 2020, regarding their experiences during the COVID-19 pandemic. Maladaptive health behaviors included increased use of alcohol, marijuana, and cigarettes, and reduced exercise relative to pre-pandemic levels. Clinically significant mental health symptoms were defined by the presence of elevated anxiety, depression, and/or post-traumatic stress. Adjusted logistic regression assessed the odds of elevated mental health symptoms predicted by maladaptive health behaviors, stratified by gender. Results: Of 1363 (46%) respondents, 319 (23%) had elevated MH symptoms. Those with elevated mental health symptoms were older (mean age 54) and predominantly female (70%). The odds of any elevated mental health symptoms were approximately 2 to 4 times greater among those who experienced maladaptive health behaviors during the pandemic including: increased alcohol use [aOR 2.14, 95%CI (1.50-3.05)], males who increased marijuana use [aOR 4.18, 95%CI (1.18-14.74)], females who increased smoking cigarettes [aOR 3.68 (1.15-11.86)] and any maladaptive health behavior [aOR 1.93 (1.44-2.60)]. Conclusion: During the COVID-19 pandemic persons with IBD who experienced any maladaptive health behavior was associated with double the likelihood of experiencing clinically significant mental health symptoms. For persons with elevated mental health symptoms, it is important for healthcare providers to recognize the association of increased maladaptive behaviors. Alternatively, if it is determined that mental health symptoms predated maladaptive health behaviors then, inquiries into mental health and providing appropriate referrals should be pursued. 

 

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Shaffer SR, Jackson GL, Chochinov S, Dolovich C, Graff LA, El-Gabalawy R, Shaw SYN, Singh H, Bernstein CN. The Impact of COVID-19 on Health Anxiety and Perceived Stress Among Persons with IBD: A Population-representative Study. Journal of Canadian Association of Gastroenterology 2023; Nov 12;6(6):244-254.

 

The Covid-19 pandemic has broadly impacted the mental health of individuals worldwide, especially with restrictions including social distancing and quarantining. We sought to understand how the COVID-19 pandemic affected adults with a chronic health issue, IBD, using a population-based sample. Participants in the University of Manitoba IBD Research Registry were invited to participate in a survey regarding their experiences during the second Covid-19 wave in autumn 2020. We assessed rates and predictors of health anxiety and perceived stress using validated measures, as well stressors during the Covid-19 pandemic across multiple dimensions, including their disease, access to therapy, and access to care.  Results: 1384 (47.1%) persons responded, with mean age 58.0, 40.6% reported male gender, and 46.9% had Crohn’s disease. Almost three quarters (73.7%) had increased stress during the Covid-19 pandemic, with 37.7% having increased stress about their IBD, and 33.6% worried about their IBD worsening. 46.0% felt increased stress about accessing their doctor or nurse, and 56.5% felt they had good access to their gastroenterologist. Elevated stress and health anxiety were seen in 63.5% and 17.2% of respondents, respectively. Younger age and being on immune-modifying therapy was predictive of increased health anxiety and stress. Longer IBD duration was associated with decreased stress, including those on IMT. Conclusions: Persons with IBD had high rates of stress and health anxiety early in the COVID pandemic, especially among those on immune modifying therapy. It will be important to determine how this evolved over time and to what extent this impacted on disease course.

 

 

Markovinović A, Quan J, Herauf M, Hracs L, Windsor JW, Sharifi N, Coward S, Caplan L, Gorospe J, Ernest-Suarez K, Ma C, Panaccione R, Ingram RJM, Kanji JN, Tipples G, Holodinsky JK, Bernstein CN, Mahoney DJ, Bernatsky S, Benchimol EI, Kaplan GG; STOP COVID-19 in IBD Research Group; STOP COVID-19 in IBD Research Group. Adverse Events & Serological Responses Following SARS-CoV-2 Vaccination in Individuals with Inflammatory Bowel Disease. American Journal of Gastroenterology 2023 Sep 1;118(9):1693-1697.

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We determined adverse events after 4 doses of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine in those with IBD, associations between antibodies and injection site reactions, and risk of IBD flare.  Individuals with IBD were interviewed for adverse events to SARS-CoV-2 vaccine. Multivariable linear regression assessed the association between antibody titers and injection site reactions. Results: Severe adverse events occurred in 0.03%. Injection site reactions were significantly associated with antibody levels after the fourth dose (geometric mean ratio = 2.56; 95% confidence interval 1.18-5.57). No cases of IBD flare occurred. We concluded that SARS-CoV-2 vaccines are safe for those with IBD. Injection site reactions after the fourth dose may indicate increased antibodies.

 

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Hitchon CA, Mesa C, Bernstein CN, Marrie RA, O’Brien S, Card C, Kim J. Immunogenicity and safety of mixed COVID-19 vaccine regimens in patients with immune mediated inflammatory diseases: a single-centre prospective cohort study. BMJ Open 2023; May 30;13(5):e071397.

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Among persons with immune-mediated inflammatory diseases who received SARS-CoV-2 vaccines, we compared postvaccine antibody responses and immune-mediated inflammatory diseases disease activity/states. This is a single-centre prospective cohort study conducted in specialty ambulatory clinics in central Canada. People with inflammatory arthritis (n=78; 77% rheumatoid arthritis), systemic autoimmune rheumatic diseases (n=84; 57% lupus), inflammatory bowel disease (n=93; 43% Crohn's) and multiple sclerosis (n=72; 71% relapsing-remitting) (female 79.4%, white 84.7%, mean (SD) age 56.0 (14.3) years) received COVID-19 vaccinations between March 2021 and September 2022. The primary outcome was postvaccination anti-spike, anti-receptor binding domain (anti-RBD) and anti-nucleocapsid (anti-NC) IgG antibodies tested by multiplex immunoassays compared across vaccine regimens and with responses in 370 age-matched and sex-matched vaccinated controls. The secondary outcomes were COVID-19 infection and self-reported immune-mediated inflammatory diseases disease activity/state. Results: Most (216/327, 66.1%) received homologous messenger RNA (mRNA) (BNT162b2 or mRNA1273) vaccines, 2.4% received homologous ChAdOx1 and 30.6% received heterologous vaccines (23.9% ChAdOx1/mRNA, 6.4% heterologous mRNA) for their first two vaccines (V1, V2). Seroconversion rates were 52.0% (91/175) for post-V1 anti-spike and 58.9% (103/175) for anti-receptor binding domain; 91.5% (214/234) for post-V2 anti-spike and 90.2% (211/234) for anti-RBD; and were lower than controls (post-V2 anti-spike 98.1% (360/370), p<0.0001). Antibody titres decreased 3 months after V2 but increased 1 month after the third vaccine (V3) and 1 month after the fourth vaccine (V4) (BAU/mL median (IQR), anti-spike 1835 (2448) 1 month post-V2, 629.1 (883.4) 3 months post-V2, 4757.5 (7033.1) 1 month post-V3 and 4356.0 (9393.4) 1 month post-V4; anti-RBD 1686.8 (2199.44) 1 month post-V2, 555.8 (809.3) 3 months post-V2, 4280.3 (6380.6) 1 month post-V3 and 4792.2 (11 673.78) 1 month post-V4). If primed with a vector vaccine, an mRNA vaccine increased antibody titres to those comparable to homologous mRNA vaccines. Anti-receptor binding domain and anti-spike titres were higher in anti-NC seropositive (n=31; 25 participants) versus seronegative samples (BAU/mL median (IQR) anti-receptor binding domain 11 755.3 (20 373.1) vs 1248.0 (53 278.7); anti-spike 11 254.4 (15 352.6) vs 1313.1 (3106.6); both p<0.001). Immune-mediated inflammatory diseases disease activity/state and rates of self-reported moderate or severe immune-mediated inflammatory diseases flare were similar across vaccinations. Conclusion: Heterologous COVID-19 vaccination improves seroconversion rates following a vector vaccine and does not lead to immune-mediated inflammatory diseases disease flare. Immune-mediated inflammatory diseases benefit from at least three vaccines.​​

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Knowles SR, Möller SP, Stengel A, Mikocka-Walus A, Ferreira N, Trindade IA, Mokrowiecka A, Burisch J, Barreiro-de Acosta M, Bernstein CN, Lo B, Skvarc D. Exploring the impact of COVID-19 related perceptions on psychological distress and quality of life in an international gastrointestinal cohort over time guided by the common sense model. Journal of Clinical Psychology in Medical Settings 2023; Dec; 30 (4):804-820.

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The aim of this longitudinal study was to examine changes in COVID-19 and illness-related perceptions, gastrointestinal symptoms, coping, catastrophising, psychological distress, and QoL during the COVID-19 pandemic. A total of 831 adults with a gastrointestinal condition completed an online questionnaire at baseline (May-October 2020). Of those, 270 (32.5%) participants (85.2% female, mean age = 47.3 years) provided follow-up data (March-May 2021). Repeated-measures multiple analysis of variance and a cross-lagged panel model were used to test the study hypotheses. Gastrointestinal symptoms and COVID-19 perceptions at follow-up were strongly predicted by their baseline values, while illness perceptions were predicted by baseline gastrointestinal symptoms. Cross-lagged relationships indicated a reciprocal relationship between gastrointestinal symptoms and psychological distress. Moreover, gastrointestinal symptoms had substantial predictive utility, strongly predicting future gastrointestinal symptoms, and to a lesser extent, more negative illness perceptions, greater psychological distress, and greater use of adaptive coping strategies across time.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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; Mar;34(3):e14198.

 

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.

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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.

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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.

 

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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. 

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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.

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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.

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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.

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