Last Updated: January 26, 2022
WE RECOMMEND THAT ALL IBD PATIENTS AGED 5 AND OLDER RECEIVE A COMPLETE SERIES (3 DOSES) OF THE COVID-19 VACCINE AS SOON AS POSSIBLE, unless advised otherwise by their doctor.
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Disclaimer: These recommendations are made based on the best available current information, and are consistent with other professional organizations including the Canadian Association of Gastroenterology, and the International Organization for the Study of Inflammatory Bowel Disease (IOIBD). These recommendations apply only to the currently available mRNA and non-replicating adenovirus vector vaccines, and not necessarily for vaccines that may be approved in the future. These recommendations are subject to change as new data and information are generated. As new scientific evidence becomes available, these recommendations may be revised by Crohn’s and Colitis Canada.
People with IBD (children 5 years of age or older and adults) should receive a third full COVID-19 vaccination 4-8 weeks after their second vaccine dose. In the case of Moderna vaccine, this should not be 'booster' (half-dose) version of the vaccine, but the full strength version.
Although the data are limited, Crohn’s and Colitis Canada supports a 4th dose of a COVID-19 vaccine for individuals with IBD who are immunocompromised by their medications, given the potential for benefit and the low risk of harm, particularly in regions with high transmission of the virus. While studies establishing the ideal timing between doses are pending, we recommend following the provincial health authorities time recommendations of 3-6 months between 3rd and 4th doses. We recommend following public health precautions (e.g. mask mandates), as we await data on the duration and amount of protection from a 4th dose of a vaccine.
Crohn's and Colitis Canada STRONGLY RECOMMENDS a 4th dose of a COVID-19 vaccine if you have been taking systemic steroids (prednisone, methylprednisolone, hydrocortisone) at any time after your first COVID-19 vaccine. Steroids have been demonstrated to result in a faster decrease in antibodies to COVID-19 in vaccinated individuals. In someone who has used steroids, the 4th dose of the COVID-19 vaccine should be given 3 months after the 3rd dose. In someone who is currently using steroids (>20 mg/day, or in children >0.5 mg/kg/day), the 4th dose of COVID-19 vaccine should be given 1-3 months after the 3rd dose.
Crohn's and Colitis Canada also recommends of 4th dose of a COVID-19 vaccine in IBD patients who have moderate or severely active inflammation, moderate or severe malnutrition, or require parenteral nutrition (intravenous nutrition through a central line).
We recommend you speak to your doctor about the benefits and risks of a 4th dose of the COVID-19 vaccine. Information on vaccine safety and possible side effects is provided here: https://www.canada.ca/en/public-health/services/vaccination-children/safety-concerns-side-effects.html
Take the vaccine that is available to you now (same or different type) as it is anticipated to offer better protection against Omicron than just two doses.
Children with IBD (aged 5 and older) should receive their second dose of COVID-19 vaccination approximately 4 weeks after their first dose. They should receive a third dose 4-8 weeks after the second dose. For children aged 5-11, at this time, it is not known if a 4th dose will be required, however recommendations will be released when more scientific evidence is available.
If required, Crohn's and Colitis Canada's Task Force has developed a third vaccine recommendation letter that people with IBD can provide to pharmacies and other COVID-19 distribution sites.
Unimmunized people with IBD should receive the COVID-19 vaccine immediately. Vaccines have proven effective at preventing severe COVID-19 (hospitalization, death) in patients with IBD, even against variants of concern. People with IBD who are using immunosuppression therapy should not delay subsequent doses of their COVID-19 vaccine beyond the time recommended by the manufacturers.
People with IBD, regardless of vaccination status, should wear a mask in indoor spaces with other people whose vaccination or COVID-19 status are uncertain. Cloth masks are not recommended. KN95 or N95 masks are preferred, however, a 3- or 4-ply surgical mask may be acceptable
People with IBD, regardless of vaccination status, should practice physical distancing, use good hand hygiene, and follow the recommendations of the COVID-19 & IBD Task Force and national public health authorities.
Employers and schools should consider mandatory vaccination policies so as to minimize the risk of serious and deadly COVID-19 in people living with Crohn's disease and ulcerative colitis.
The distribution of the vaccine is under the control of provincial governments and local health authorities.
Please click here to download a copy of our COVID-19 Vaccination info sheet.
Please click here to learn more about anti-viral treatments if you contract COVID-19.
In December 2020, Health Canada authorized the use and distribution of vaccines (Pfizer/BioNTech, Moderna, AstraZeneca and Johnson & Johnson) for protection against SARS-CoV-2 (COVID-19). None of the approved vaccines for COVID-19 in Canada are ‘live’ vaccines. The Task Force has developed a single page info sheet (PDF) that can be downloaded and printed. It summarizes key points from the recommendations on this page. Please click here to download a copy of our COVID-19 Vaccination info sheet.
On August 24, 2021, the Crohn's and Colitis Canada COVID-19 and IBD Task Force convened to discuss the issue of booster vaccines in people with inflammatory bowel disease (IBD). The Task Force members reviewed the latest pre-print manuscript (not yet peer-reviewed) from the CLARITY-IBD study, and research in people without IBD who have compromised immune systems. The CLARITY-IBD study demonstrated that people with IBD who are using anti-TNF biologic therapies generally responded well to two doses of either an mRNA vaccine (BNT162b2, produced by Pfizer/BioNTech) or adenovirus-vector vaccine (ChAdOx1 nCOV-19, produced by Oxford/AstraZeneca), although not as well as people using vedolizumab to treat their IBD (a biologic that does not systemically suppress the immune system). In addition, the concentration of anti-COVID antibodies in people using infliximab dropped below the level thought necessary to provide immunity approximately 14–18 weeks after the second dose, which was not seen in those on vedolizumab or in healthy controls. The authors concluded that people with IBD receiving systemic immune-suppressing therapy should carefully follow public health guidelines on masking and physical distancing and should be considered for booster doses to improve immunity.
Crohn's and Colitis Canada supports the Centers for Disease Control (CDC) recommendations and NACI recommendations that people on high-dose corticosteroids and other immune suppressing medications (including anti-TNF biologics) should receive booster doses. Systemic corticosteroids have consistently been associated with severe COVID-19 and death in people with IBD in the SECURE-IBD registry. There is emerging data (from the CLARITY-IBD study and SECURE-IBD registry) that IBD patients who are immunocompromised may be at risk for serious and life-threatening COVID-19.
On December 10th 2021, the COVID-19 Task Force reviewed the growing body of research and recommended that people with IBD should receive their third dose of the COVID-19 vaccine 4 to 8 weeks after their second dose. These recommendations are particularly important during the fifth wave in Canada, when the Omicron variant of SARS-CoV-2 is the predominant strain.
The Omicron variant is spread much more easily. Receiving three doses of an mRNA vaccine is effective at preventing infection with SARS-CoV-2 and highly effective against severe COVID-19. The third dose is a way of enhancing this immunity. In addition, we recommend that people with IBD use masks when indoors and ensure physical distancing when associating with unvaccinated people, or people with unknown vaccine status. People who are immunosuppressed should consider the use of KN-95 or N-95 grade masks to reduce the likely of infection.
RECOMMENDATIONS FOR EMPLOYERS AND SCHOOLS
Approximately 1 in 140 people in Canada live with IBD, one of the highest rates in the world. Crohn's and Colitis Canada asks employers and schools to consider that most people with IBD are immunosuppressed, and may not mount as good a response to vaccination as other people (especially as immunity wanes over time). We must act to protect people who are vulnerable to COVID-19. Requiring employees, students, and teachers to be vaccinated is one of the best ways to prevent the spread of COVID-19.
Therefore, the Crohn’s and Colitis Canada COVID-19 and IBD Task Force strongly encourages employers and schools to consider mandatory vaccination policies so as to minimize the risk of serious and deadly COVID-19 in people living with Crohn's disease and ulcerative colitis. In addition, requiring masks while indoors, physical distancing, and proper ventilation will make workplaces and schools safer for vulnerable people, and for us all.
COVID-19 Vaccine Recommendation Letter (Third Dose)
Crohn's and Colitis Canada's Task Force has developed a third COVID-19 vaccine recommendation letter that people with IBD can provide to pharmacies and other COVID-19 distribution sites. The letter can be signed by your primary healthcare provider or IBD specialist. While we recommend a third dose occur 4 to 8 weeks after the second dose, local health authorities retain the right to limit access to vaccines at their discretion.
The QR codes on the letter can be scanned to view these vaccine recommendations and members of the COVID-19 Task Force.
Please click here to download or print a PDF copy of the letter.
COVID-19 Vaccines and IBD Infosheet
The Task Force has also developed a single page info sheet (PDF) that can be downloaded and printed. It summarizes key points from the recommendations on this page.
Please click here to download a copy of our COVID-19 Vaccination info sheet.
The distribution of the vaccine is under the control of provincial governments and local health authorities. Your health care provider does not have direct access to the vaccine and is not responsible for prioritizing when the vaccine is available to different populations.
For information and contact details on how to register to get a COVID vaccine in your region, please click on your province of residence below:
What are the vaccines for COVID-19?
Currently, Health Canada has approved four vaccines: the Pfizer/BioNTech mRNA vaccine, the Moderna mRNA vaccine, the University of Oxford/AstraZeneca/COVISHIELD non-replicating adenovirus vector vaccine and the Johnson & Johnson’s (Janssen) non-replicating adenovirus vector vaccine. As of December 18, 2021, only the mRNA vaccines (from Pfizer/BioNTech and Moderna) are available to Canadians.
The mRNA vaccines have a novel “mechanism of action” compared to traditional vaccines that inject either a diluted virus or proteins of a virus. Both mRNA vaccines target the spike protein that sits on the surface of the virus (SARS-CoV-2), which is the part of the virus that allows it to attach to human cells and begin replicating.
Non-replicating adenovirus vector vaccines means the adenovirus is a ‘skeleton’ used to carry the COVID-19 spike genetic material. The adenovirus vector cannot replicate and therefore cannot cause disease. The vector virus uses the machinery of our cells to produce the spike component of the COVID-19 virus.
Our immune system naturally recognizes the spike protein as foreign and triggers our body to develop antibodies against the protein. This allows the body to quickly and effectively fight off future infections of the intact COVID-19 virus.
None of these vaccines are considered “live virus vaccines”, and therefore they cannot cause disease in anyone, including people who are immunosuppressed. While the clinical trials did not include patients who were immunosuppressed, real-world experience in patients with Crohn's and ulcerative colitis, and those who use medications which suppress the immune system has demonstrated vaccine effectiveness at preventing hospitalization and death, and studies have not demonstrated that receiving any COVID-19 vaccine increased the risk of adverse events in people with IBD.
Have the vaccines for COVID-19 been studied in people with IBD?
Vaccines to SARS-CoV-2—the virus that causes COVID-19—hold the promise of protecting individuals who are immunocompromised, such as people on immunosuppressive medications for their IBD. The effectiveness and safety of the COVID-19 vaccines in people with immune-mediated diseases or immunocompromised populations was not evaluated in the original clinical trials, however have been assessed since then the real-world (using large datasets) and in research studies. They have been shown to be effective at preventing infection, and serious complications of COVID-19 in people living with IBD.
The current vaccines approved by Health Canada, were not studied in people with IBD in the clinical trials. Initial randomized controlled vaccine trials excluded people with immune-mediated conditions, autoimmune diseases, and those on immunosuppressive therapy.
Since then, many people with IBD around the world have received these vaccines. To date, increased risk of adverse events or safety concerns have not been reported. Additionally, international studies like CLARITY IBD and ICARUS-IBD are recruiting and monitoring IBD patients before and after they are vaccinated.
What is the impact of IBD on vaccine effectiveness?
Many individuals with IBD are prescribed medications that may reduce the immune response (due to lower antibody titres and other immune system changes) following vaccination as compared to the general population. This means people with IBD may not be as protected against COVID-19 from the vaccine as others, or they may require booster doses of the vaccines due to decreasing antibodies over time. However, a reduced immune response to a vaccine does not mean a vaccine is ineffective.
Overall, non-live vaccines (e.g., influenza, zoster, Hepatitis B) are widely recommended for immunocompromised individuals, including people with IBD on immunosuppressive medications. Reduced effectiveness due to immune suppression is NOT a reason to avoid these COVID-19 vaccines. Even partial protection against COVID-19 is preferable to not having protection at all.
Results of CLARITY IBD and ICARUS-IBD:
Both the CLARITY IBD study and ICARUS-IBD study found that people with IBD who are immunosuppressed responded less effectively to the first dose of the vaccine, measured by levels of antibodies to the SARS-CoV-2 virus. However, both studies reported excellent response after two vaccine doses, or after one vaccine dose in people who previously had COVID-19.
Antibody levels give an indication but not the full picture of the strength of our immune system to fight viruses. Therefore, we recommend getting the first dose of the COVID-19 vaccine as soon as it is available. Also, if possible, we recommend that people with IBD on immunosuppressants receive the second dose of vaccine according to manufacturer recommendations (3 to 4 weeks after the first dose).
Are COVID-19 vaccines safe for people with IBD?
Prior vaccine studies (i.e., non-COVID-19 vaccines) have not shown the risk of side effects from vaccines is different for people with IBD compared to the general population. The novel mRNA vaccines have not been studied in those with IBD. The safety of novel mRNA vaccines have been assessed in real-world studies of people with IBD, and no evidence of increased risk of side effects has been reported.
There is no reason to believe the COVID-19 vaccines would be more risky or unsafe for people with IBD. There is no evidence to date that non-live vaccines cause disease or IBD flare-ups when given to people with IBD. The CLARITY IBD and ICARUS-IBD studies, which examine immunity after vaccination in IBD patients, have not reported any unexpected problems with safety of the vaccines.
Can vaccines trigger an IBD flare?
While the mRNA and non-replicating adenovirus vector vaccines have not been studied in those with IBD, there is no evidence to date that other non-live vaccines cause IBD flare-ups. Small studies have not shown any risk of flare-ups in IBD patients receiving COVID-19 vaccines. We do know individuals with IBD who contract COVID-19 often pause their immunosuppressing medication while recovering from infection, which in turn may cause a flare of their IBD. The CLARITY IBD and ICARUS-IBD studies, which examine immunity after vaccination in IBD patients, have not reported any unexpected flares of IBD in patients who get the vaccines.
What are the Canadian recommendations for COVID-19 vaccines for people with IBD?
The National Advisory Committee on Immunization (NACI) has made the following recommendation to the Public Health Agency of Canada:
“NACI recommends that a complete COVID-19 vaccine series may be offered to individuals who are immunosuppressed due to disease or treatment in the authorized age group in this population, if a risk assessment deems that the benefits outweigh the potential risks for the individual, and if informed consent includes discussion about the absence of evidence on the use of COVID-19 vaccine in this population.”
The Canadian Association of Gastroenterology has provided the following guidelines:
“Specifically, in patients with IBD not on immunosuppressive therapy, we recommend the COVID-19 vaccine be given (strong recommendation, moderate-certainty of evidence). In patients with IBD on immunosuppressive therapy, we suggest the COVID-19 vaccine be given (conditional recommendation, low-certainty of evidence).”
What are Crohn’s and Colitis Canada’s recommendations for COVID-19 vaccines for people with IBD?
People with IBD, whether on immunosuppressive medications or not, should receive a full series (3 doses) of the COVID-19 vaccine as soon as possible. The risk of side effects is very low, and the benefits of the vaccines far outweigh the risks.
These recommendations are aligned with the Canadian Association of Gastroenterology and the International Organization for the study of IBD (IOIBD).
When should I get the COVID-19 vaccine?
People with IBD should get a COVID-19 vaccine at the first available opportunity, as determined by the rules in each province. There is no research to support “timing” the vaccine at a certain point in the cycle of biologic medication infusions/injections. People with IBD who are taking steroids should discuss with their doctor whether to get the vaccine while on steroids, or whether to wait until the steroids are tapered off.
If I decided to delay getting a vaccine for a few months, does that mean I should never get a COVID-19 vaccine?
No! New information is becoming available all the time. However, with the rising fifth wave due to the Omicron variant means now is the time to get vaccinated! Please speak to your doctor about the benefits of the vaccine in your specific circumstance.
I am pregnant. Should I get a COVID-19 vaccine?
Yes. Research studies have found that pregnant women are at increased risk for severe COVID-19 if they are infected with the SARS-CoV-2 virus. This includes an increased risk of ICU admission, needing mechanical ventilation and death. There are also increased risks to the baby, such as stillbirth and preterm birth. The Society of Obstetricians and Gynaecologists of Canada recommend the COVID-19 vaccine be offered to all pregnant and breastfeeding women.Some provinces, such as Ontario, are prioritizing pregnant women to receive the vaccine earlier than other groups because their risk of severe COVID-19 is higher.
Where can I receive more information about COVID-19 and vaccines for those with IBD?
The Public Health Agency of Canada has extensive information on the vaccines available for COVID-19, their safety and effectiveness.
In March 2020, Crohn’s and Colitis Canada created the COVID-19 and IBD Taskforce. The Taskforce has met regularly since March 12, establishing recommendations for people with IBD during the pandemic. The Taskforce recommendations are communicated directly with the IBD community through Crohn’s and Colitis Canada’s COVID-19 and IBD Webinars that started on March 19 2020.
The webinars (~1.5 hours) are co-moderated by Dr. Gil Kaplan and Dr. Eric Benchimol, who provide regular updates and lead a Q&A segment with guest panelists. A recording of each webinar is available on Crohn’s and Colitis Canada’s website and YouTube channel. The webinar series has discussed COVID-19 vaccines in people with IBD. These webinars will continue throughout the pandemic as a source of communication to the IBD community.
If you require more information or support, please click here.
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