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COVID-19 vaccine and IBD

COVID-19 vaccine and IBD

Patients with inflammatory bowel disease (IBD) are frequently treated with immunosuppressive medications.

By Associate Professor Britt Christensen 

Key Messages

Prior to COVID-19 vaccine access, most recommendations and publications reported on preventing COVID-19 infection in immunocompromised patients by encouraging social exclusion. 

It was evident early in the pandemic that immune-compromised patients would be faced with additional concerns and consequences regarding both infection with SARS-CoV-2 and vaccination against COVID-19. It has therefore become a priority of my research activities to help address these concerns. 

As a researcher at the University of Melbourne and The Royal Melbourne Hospital, I lead a team of clinician scientists looking at multiple facets of IBD including the pathogenesis of IBD, monitoring and optimisation techniques and the development of new treatment strategies. 

Our team realised early on that there was a need for ongoing, updated information around SARS-CoV-2 infection and prevention in immunocompromised individuals for both patients and clinicians. This led to our review article published in Alimentary Pharmacology and Therapeutics early last year summarising the issues around prevention, diagnosis and management of COVID-19 infection in patients with IBD and highlighted that patients with IBD were unlikely to be at increased risk of being infected with SARS-CoV-2 or developing serious COVID-19. 

The exception to this was patients on high dose corticosteroids who may be more likely to develop serious complications from COVID-19. We therefore recommended that patients stay on maintenance medical therapy with the aim to reduce flares, prevent the need for corticosteroids and prevent inpatient admission where patients may be more likely to be exposed. These conclusions have since been confirmed in prospective studies around the world. Our research group published a further review article on COVID-19 vaccination and IBD which highlighted that COVID-19 vaccination is safe in IBD patients and is recommended early. We also concluded that high dose corticosteroids may reduce the immune response to COVID-19 vaccination and therefore in areas of low community transmission, it may be prudent to withhold vaccination in patients on high dose corticosteroids until they are on equivalent doses of prednisolone <20mg per day. 

Undergoing the process of this vaccine review highlighted to our team the knowledge gap regarding immune responses to COVID-19 vaccination in patients with autoimmune conditions on a range of immunosuppressive medications.

Remarkably, within 18 months of the beginning of the pandemic, nine COVID-19 vaccines worldwide have been approved. However, clinical trials for these vaccines have excluded patients who are immunocompromised or been exposed to immunosuppressive medications within 3-6 months of vaccine administration. Therefore, the efficacy and safety of COVID-19 vaccines in these patient cohorts remains to be determined. 

This led our research team to Professor Katherine Kedzierska’s incredible lab at The Doherty Institute. Together with my fellow Eva Zhang, Dr Katherine Bond Head of Microbiology at The Royal Melbourne Hospital and Oahn Nguyen an NHRMC Fellow at The Doherty Institute, we have set up the exciting collaborative research study, Immune Responses to COVID-19 Vaccination in Immunocompromised Hosts (IRVAX).

This single site prospective observational cohort study aims to characterise the immune responses to COVID-19 vaccines in patients with autoimmune conditions including inflammatory bowel disease, rheumatological and dermatological diseases who are taking immunosuppressant medications including biological agents. 

107 patients have been recruited and serial blood tests before and after their first, second and, where applicable, third (both primary and booster) COVID-19 vaccine are being collected. We are analysing antibody and T cell response at these various time-points and differences in the immune response in this immunosuppressed group will be compared to healthy controls. We will also evaluate immune responses stratified by immunosuppressive medication regimen, autoimmune condition and type of vaccine received. 

This study will be one of the first to characterise the T cell response in addition to B cell response to COVID-19 vaccination in patients with autoimmune conditions on a range of immunosuppressants. It will also be the first study to describe the immune response to third dose primary vaccination and booster vaccination in an immunocompromised cohort with autoimmune diseases and one of the first to be able to compare these results to healthy controls. This study will allow us to accurately determine whether and to what degree immunosuppressive medications have an impact on the immune response to vaccination. This will be practice changing and provide the evidence required to develop accurate guidelines regarding vaccine timing, dosing and protection in this vulnerable group. 

References

  1. Rubin DT, Abreu MT, Siegel CA et al. Management of patients with Crohn’s disease and ulcerative colitis during the coronavirus disease-2019 pandemic: results of an international meeting. Gastroenterology. 2020 (In Press) (part of international meeting)
  2. Al-Ani A… Christensen B. Review Article: Prevention, diagnosis and management of COVID-19 in the inflammatory bowel disease patient. Aliment Pharmacol Ther. 2020 Jul;52(1):54-72. doi: 10.1111/apt.15779.Epub 2020 May 26
  3. Al-Ani A… Christensen B. Practical management of inflammatory bowel disease patients during the COVID-19 pandemic: expert commentary from the Gastroenterological Society of Australia Inflammatory Bowel Disease faculty. Intern Med J. 2020 July. Doi: 10.1111/imj/14889
  4. Garg M… Christensen B. Low Population MortalityFrom COVID-19 in Countries South of Latitude 35 Degrees North-supports Vitamin D as a Factor Determining Severity. Authors’ Reply. Aliment Pharmacol Ther. 2020 Jun;51(12):1438-1439. doi: 10.1111/apt.15796.Epub 2020 May 12
  5. Garg M, Christensen B, et al. Gastrointestinal ACE2, COVID-19 and IBD–opportunity in the face of tragedy? 2020 doi: 10.1053/j.gastro.2020.04.051
  6. Al-Ani A… Christensen B. Authors’ Reply to Letter: IBD Nurse – Pivotal Role in the Time of the Pandemic. Aliment Pharcol Ther. In Press. 2020
  7. A-Ani A…. Christensen B. Authors Reply To Letter: Is Pneumococcal Vaccination Safe During Covid-19 Pandemic? Aliment Pharcol Ther. In Press. 2020
  8. Seigal C, Christensen B et al. Review Article: Guidance for Restarting Inflammatory Bowel Disease Therapy in Patients Who Withheld Immunosuppressant medications During COVID-19. J Crohn’s Colitis. In Press. 2020
  9. Prentice RE, Al-Ani A, Christensen B. Managing COVID-19 in patients with inflammatory bowel disease: navigating unprecedented challenges. Internal Medicine Journal. 2021 Feb 1;51(2).
  10. Prentice R, Rentsch C, Al-Ani AH, Zhang E, Johnson D, Halliday J, Bryant R, Begun J, Ward M,7 Lewinden PJ, Connor SJ, Ghaly S , Christensen B. Review Article: SARS-CoV-2 Vaccination in Patients with Inflammatory Bowel Disease. GastroHep 2021 Accepted. In Press
  11. Al-Ani AH, Prentice RE, Rentsch C, Christensen B. SARS-CoV-2 infection in two inflammatory bowel disease patients treated with dual targeted therapy-Authors’ reply. Aliment Pharmacol Ther. 2021:766-7.