Prevention of COVID-19 in patients with inflammatory bowel disease in Wuhan, China

Abstract

As recently outlined by Ren Mao and colleagues 1 in The Lancet Gastroenterology & Hepatology, patients with inflammatory bowel disease (IBD) are at increased risk of opportunistic infections. Particular attention is therefore required for these patients during the ongoing coronavirus disease 2019 (COVID-19) pandemic. 318 patients with IBD (114 with Crohn's disease, 204 with ulcerative colitis) were registered in a prospective database at the Regional Medical IBD Center of China, Renmin Hospital of Wuhan University, Wuhan, China, between Jan 1, 2000, and Dec 8, 2019. Patients' clinical characteristics and their location relative to the COVID-19 outbreak are shown in the appendix (pp 2–4). Median age was 39·2 years (IQR 15–79); 33 (10%) were older than 60 years. 49 (15%) patients (22 [19%] of those patients with Crohn's disease, 27 [13%] of those with ulcerative colitis) had other chronic medical conditions (appendix p 2). 35 (31%) of the patients with Crohn's disease and 93 (46%) of those with ulcerative colitis had active IBD. More than two-thirds (246 [77%]) lived and worked near Huanan seafood supermarket (≤30 km), the suspected location from which SARS-CoV-2 emerged (appendix p 4). We recorded the times and frequency of received alerts and information from our team, self-prevention measures, and confirmed or suspected diagnosis of COVID-19 between Dec 8, 2019, and March 30, 2020. Between Jan 3 and March 30, 2020, five (2%) patients had been hospitalised for severe active IBD during the COVID-19 outbreak, including one with Crohn's disease, who underwent emergency surgery for intestinal perforation, and one pregnant patient with Crohn's disease in whom preterm delivery was induced (appendix pp 2–3). Before the outbreak, 40 (13%) patients had been treated with corticosteroids, 35 (11%) with azathioprine, 37 (12%) with thalidomide, and 20 (6%) with infliximab; nine (3%) patients were enrolled in clinical trials (appendix pp 2–3). Between Jan 31 and March 30, 20 (6%) patients required medical management of disease flare, which was treated preferentially with exclusive enteral nutrition for Crohn's disease (n=15) and steroids (n=18), with a median time to review of 1·3 days (IQR 1·0-2·3). On Jan 3, 2020, we temporarily ceased infliximab infusions and immunosuppressive treatment for all patients, in accordance with national Chinese Society of Gastroenterology guidelines, 2 altering treatment to 5-aminosalicylic acid (37 patients) or thalidomide (43 patients; with 25 patients receiving both medications) depending on the patients' condition. On Jan 3, we sent educational and instructional alerts and messages to the online IBD groups of our outpatients via WeChat, with all patients responding to our alerts (table ). Within 3 days, most patients reported that they maintained good hand hygiene, sought medical assistance online rather than in person, and kept track of fever and respiratory symptoms; all confirmed notification of our information for self-prevention and all patients kept up to date on official news on COVID-19 (table). Most patients decreased the time they spent outside the home, wore masks when outside, and purchased masks for storage; most patients were very satisfied with our team's work (table). Table Responses to WeChat alerts Alerts on Jan 3, 2020 (n=318) Upgraded alerts on Jan 13, 2020 (n=318) Time from alert to patient response (days; median [IQR]) 1·8 (1·0–3·4) 1·2 (1·0–2·3) Responded to our alert 318 (100%) 318 (100%) Overall service satisfaction Very satisfied 300 (94%) 318 (100%) Satisfied 18 (6%) 0 Not satisfied 0 0 Reduced time spent outside* 291 (92%) 318 (100%) Attended any social gathering 0 0 Wore masks when outside 284 (89%) 318 (100%) Purchased masks for storage 246 (77%) 318 (100%) Maintained hand hygiene† 296 (93%) 318 (100%) Route of care Sought medical care or contacted doctors and pharmacies online 289 (91%) 318 (100%) Sought medical care in person 27 (8%) 0 Did not seek care 2 (1%) 0 Noted educational and instructional information sent by mobile messages and WeChat 318 (100%) 318 (100%) Maintained awareness of COVID-19 symptoms‡ 318 (100%) 318 (100%) Monitored social news on COVID-19 318 (100%) 318 (100%) COVID-19=coronavirus disease 2019. * Patients who had to leave their homes were outside for the shortest time necessary. † Cleaning hands with soap and using an alcohol-based sanitiser, especially before meals, after toilet use, and immediately after returning home. ‡ Fever and respiratory symptoms. On Jan 8, 2020, the first confirmed case of COVID-19 was diagnosed at our hospital, in the pulmonology department. On Jan 12, a second patient was diagnosed, in our gastroenterology department (appendix p 5). On Jan 13, we updated our alerts (table) and actions and implemented an updated model of care. All inpatients with IBD were placed in single-occupancy rooms. We sent daily alerts to outpatients with IBD with recommendations to stay at home if possible, encourage use of N95 masks for those with recent treatment with biologics and immunosuppressants, and to keep in daily contact with our IBD team. For patients with low health literacy and education, we remained in contact via phone calls. We mailed trial drugs to those in clinical trials who lived further from our hospital (>1 h driving distance), to reduce exposure to hospital facilities. By Jan 13, most patients with IBD in our hospital were discharged, IBD clinics were closed, and routine, non-urgent medical care was moved online. We published online recommended guidelines and precautions for prevention of COVID-19 in the IBD population. 2 On Jan 22, we sent alerts to outpatients to be aware of atypical COVID-19 (ie, confirmed COVID-19 with only gastrointestinal symptoms and no fever) and to maintain self-isolation, and sent alerts via public news media (major newspapers and periodicals) on Jan 24, when the shutdown of Wuhan was announced and domestic social lockdown and quarantine controls were instituted. With the escalation of our alerts, all of our patients reported within 2 days that they wore masks when outside, purchased masks for storage, decreased time spent outside, and were very satisfied with our information and service (table). Throughout this period (Jan 3 to March 30), a weekly multidisciplinary meeting with surgical, medical, and radiological teams was maintained to discuss hospitalised patients in critical or severe condition and formulate management plans. We sent a questionnaire to our patients on Feb 10, regarding their exposure history (ie, contact with confirmed or suspected cases of COVID-19), potential risk factors for exposure (eg, populated places and contact with health-care workers), telehealth outpatient visits, and recent symptoms (including fever and respiratory and gastrointestinal symptoms). In response, 24 (8%) patients reported risk factors for exposure to SARS-CoV-2, including one patient who reported contact with an individual with confirmed COVID-19 (appendix p 2). As of March 30, none of our registered patients with IBD had reported concern over respiratory symptoms and none had confirmed or suspected COVID-19. COVID-19 was excluded in 29 patients, including 20 patients with disease flare and six active cases, by diagnostic chest CT scans and virological testing. Patients with IBD are susceptible to frequent and severe infections. IBD treatment teams need to put emphasis on risk assessment, prevention strategies, patient education, and effective therapies. 2 Mass awareness of important prevention and protection strategies is paramount and might go beyond what is currently recommended in some guidelines. 3 Despite such guidelines, cases of COVID-19 have been reported in patients with IBD in many countries, including France, Italy, Spain, and the USA.4, 5 Our recommendations extend beyond the so-called shielding procedures described in other guidelines and resulted in no cases of COVID-19 being reported among our patients. At the height of a pandemic, assuming mass community spread is vital and implementation of strict criteria for patients on immunosuppression is crucial. We believe that our long-term relationships with our patients and understanding of their individual risk factors, along with routine emphasis on patient education, contributed to their adherence to our recommendations. Another crucial component is having a method of communication between patients and their IBD teams that allows concerns to be addressed in a timely fashion; our median times to response were within 1 day. We further discuss and evaluate our approach in the appendix (pp 6–9). Of note, given high rates of community transmission and the large number of confirmed COVID-19 cases in China, the Chinese Society of Gastroenterology recommended withholding immunosuppressive therapies, on the basis of potential increased risk of infection and worsening of COVID-19 disease course, especially in high-risk areas such as Wuhan. 2 However, local guidelines and isolation measures should be dictated by the background rate of COVID-19 in the community. Nonetheless, we believe our experiences could provide a model of care to prevent COVID-19 in patients with IBD.