COVID-19 vaccinations in patients with inflammatory bowel disease
Authors: Aditi Kumar, Mohammed Nabil Quraishi, Jonathan P Segal, Tim Raine, Matthew J Brookes
Journal: The Lancet. Gastroenterology & hepatology (2020)

Advances in the treatment of patients with inflammatory bowel disease (IBD) have substantially improved disease activity and quality of life, and reduced hospitalisation rates and the need for surgery. However, prolonged immunosuppression in these patients can result in increased susceptibility to opportunistic infections. Many of these infections are preventable through vaccination and immunisation strategies that should be undertaken as early as possible after diagnosis, because the risk of opportunistic infections increases following the first year of immunosuppressive therapy.1Fiorino G Peyrin-Biroulet L Naccarato P et al.Effects of immunosuppression on immune response to pneumococcal vaccine in inflammatory bowel disease: a prospective study.Inflamm Bowel Dis. 2012; 18: 1042-1047Crossref PubMed Scopus (145) Google Scholar The COVID-19 pandemic has led to substantial concerns for patients with IBD who are on immunosuppressive medications, many of whom are using additional protective measures. Although early COVID-19 studies have suggested that immunosuppressive medications are safe, robust and reproducible data are not available to adequately risk stratify patients with IBD, and current measures are mostly based on observational studies and theoretical risk.2Surveillance Epidemiology of Coronavirus (COVID-19) Under Research ExclusionCoronavirus and IBD reporting database: current data.https://covidibd.org/current-data/Date accessed: August 24, 2020Google Scholar Large scale, prospective, population-based registry studies and meta-analyses have identified key risk factors associated with a higher probability of mortality from COVID-19, including age, socioeconomic deprivation, diabetes, respiratory disease, obesity, and being from a Black, Asian, or other minority ethnic group.3Pan D Sze S Minhas JS et al.The impact of ethnicity on clinical outcomes in COVID-19: a systematic review.EClinicalMedicine. 2020; 23100404Summary Full Text Full Text PDF PubMed Scopus (384) Google Scholar One of the best ways to mitigate against the risk of COVID-19 is the rapid development of safe and effective vaccines. Although initial phase 1/2 studies are promising,4Folegatti PM Ewer KJ Aley PK et al.Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial.Lancet. 2020; 396: 467-478Summary Full Text Full Text PDF PubMed Scopus (1774) Google Scholar patients on immunosuppressant medications have largely been excluded from these studies, creating potential future concerns regarding safety and generalisability of outcomes for individuals with IBD. To achieve a sufficient degree of herd immunity, vaccination programmes are primarily successful only when there are high rates of coverage and acceptance. The importance of patients with IBD being included in vaccine trials is compounded by the concern that these patients have a lower response to vaccinations and that vaccinations are generally underused in this population. Melmed and colleagues5Melmed GY Ippoliti AF Papadakis KA et al.Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses.Am J Gastroenterol. 2006; 101: 1834-1840Crossref PubMed Scopus (286) Google Scholar showed that in patients with IBD there was an uptake of only 22–46% for the influenza vaccination, and a mere 9% were vaccinated for pneumococcal pneumonia, despite both vaccines being recommended in the British and European IBD guidelines for vaccinating patients.6Rahier JF Magro F Abreu C et al.Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in infalmmatory bowel disease.J Crohns Colitis. 2014; 8: 443-468Summary Full Text Full Text PDF PubMed Scopus (806) Google Scholar A patient survey showed a perceived lack of benefit from vaccination as the most frequent reason for low vaccine uptake, as well as concerns regarding side-effects, risk of disease flares, needle aversion, and inconvenience.7Huth K Benchimol EI Aglipay M Mack DR Strategies to improve influenza vaccination in pediatric inflammatory bowel disease through education and access.Inflamm Bowel Dis. 2015; 21: 1761-1768Crossref PubMed Scopus (26) Google Scholar However, in the present pandemic, both perception of risk and health awareness might be very different, with implications for vaccine acceptance. In patients with IBD who were vaccinated against influenza, an immune response was induced, but use of concomitant infliximab and immunomodulatory therapy were associated with inadequate rates of seroconversion.8Apte M Reich J Farraye FA Vaccinations for patients with inflammatory bowel disease: an updated review.Pract Gastroenterol. 2018; XLII: 64-74Google Scholar In adult populations vaccinated with the pneumococcal vaccine PSV-23, an impaired immune response was shown in patients with Crohn's disease taking combination immunosuppressive therapy.1Fiorino G Peyrin-Biroulet L Naccarato P et al.Effects of immunosuppression on immune response to pneumococcal vaccine in inflammatory bowel disease: a prospective study.Inflamm Bowel Dis. 2012; 18: 1042-1047Crossref PubMed Scopus (145) Google Scholar Other vaccines such as those against hepatitis A and B virus, tetanus, and herpes zoster have also been shown to be potentially less effective in patients with IBD than in control groups.9Stoffel NU Uyoga MA Mutuku F et al.Iron deficiency anemia at time of vaccination predicts decreased vaccine response and iron supplementation at time of vaccination increases humoral vaccine response: a birth cohort study and a randomized trial follow-up study in Kenyan infants.Front Immunol. 2020; 111313Crossref PubMed Scopus (66) Google Scholar The extent to which medications might affect vaccine response, independent of underlying disease activity, is unclear. Of note, concurrent anaemia, which is a common finding in patients with active IBD, might impair response to vaccinations.9Stoffel NU Uyoga MA Mutuku F et al.Iron deficiency anemia at time of vaccination predicts decreased vaccine response and iron supplementation at time of vaccination increases humoral vaccine response: a birth cohort study and a randomized trial follow-up study in Kenyan infants.Front Immunol. 2020; 111313Crossref PubMed Scopus (66) Google Scholar There is therefore an urgent need for better understanding of both the effectiveness of potential vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with underlying health conditions, as well as the potential impact of effective disease control on rates of vaccine response. Currently, the candidate vaccines in phase 3 trials include inactivated, mRNA, or vector-based approaches. The classic inactivated or live-attenuated vaccines raise safety concerns due to possible induction of the disease. However, the ChAdOx1 nCoV-19 trial vaccine uses a replication-deficient chimpanzee adenovirus to deliver a SARS-CoV-2 protein to induce a protective immune response. This vaccine seems to be promising for patients with IBD because adenovirus vectors do not integrate the viral genomic DNA into the host's genome, are highly immunogenic, and can induce robust innate and adaptive immune responses. The same adenovirus vaccine platform is also being assessed for use against malaria, HIV, influenza, and Ebola virus.10Zhang C Zhou D Adenoviral vector-based strategies against infectious disease and cancer.Hum Vaccin Immunother. 2016; 12: 2064-2074Crossref PubMed Scopus (80) Google Scholar Nevertheless, the phase 1/2 trials of the ChAdOx1 nCoV-19 vaccine were done on young, healthy volunteers and as such do not address the potential immunity concerns in patients with chronic diseases or those on immunosuppressants.4Folegatti PM Ewer KJ Aley PK et al.Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial.Lancet. 2020; 396: 467-478Summary Full Text Full Text PDF PubMed Scopus (1774) Google Scholar Moreover, we cannot assume that data on one vaccine type in a specific group of people can be extrapolated to other vaccine types. There needs to be a stronger emphasis on vaccinating patients with IBD within the broader health-care preventative scheme. It is important that these factors are considered when policy makers and national health services start to design and develop future COVID-19 vaccination programmes. Equitable access to COVID-19 vaccination programmes should be endorsed. If this is not feasible, then we propose that future community vaccination programmes support and promote vaccines that can be used by the high-risk cohort of patients with IBD. MJB has received grants and travel expenses from Vifor International and Tillotts Pharma, outside of the submitted work. All other authors report no competing interests.