Last updated: September 14, 2021
WE RECOMMEND THAT ALL IBD PATIENTS RECEIVE THE COVID-19 VACCINE AS SOON AS POSSIBLE, unless advised otherwise by their doctor.
In December 2020, Health Canada authorized the use and distribution of two mRNA vaccines (Pfizer/BioNTech and Moderna) and two non-replicating adenovirus vector based vaccines (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.
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. 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.
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 INFLAMMATORY BOWEL DISEASE ON MEDICATIONS THAT SUPPRESS THE IMMUNE SYSTEM SHOULD BE INCLUDED WITH OTHER IMMUNOCOMPROMISED POPULATIONS RECEIVING BOOSTER DOSES OF COVID-19 VACCINES
Summary of recommendations:
We recommend that people with IBD who are receiving medications that suppress their immune system (systemic corticosteroids, thiopurines, methotrexate, and biologics) have access to booster COVID-19 vaccines between 14–18 weeks after their second vaccine dose. Thank you to Quebec, Ontario, Prince Edward Island, and British Columbia for including this community in their recommendations for a third COVID-19 vaccination. Please click here to help encourage other provinces do the same by sending a letter to your local government representatives.
Crohn's and Colitis Canada's Task Force has developed a third vaccine (booster) recommendation letter that people with IBD can provide to pharmacies and other COVID-19 distribution sites.
We recommend that unimmunized people with IBD receive the COVID-19 vaccine as soon as possible. Vaccines have proven effective at preventing severe COVID-19 (hospitalization, death), even against variants of concern. People with IBD who are using immunosuppression therapy should not delay the second dose of their COVID-19 vaccine beyond the time recommended by the manufacturers.
While COVID-19 vaccines continue to be studied, those with IBD, regardless of vaccination, should practice physical distancing, wear a mask, use good hand hygiene, and follow the recommendations of the COVID-19 & IBD Task Force and national public health authorities.
We strongly encourage 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.
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.
Provincial governments in Canada are currently considering who should receive booster doses of mRNA vaccines. Potential recipients include seniors, people with cancer on active therapy, and people who have received transplants. Crohn's and Colitis Canada supports the Centers for Disease Control (CDC) 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.
In light of this growing body of research, the Crohn’s and Colitis Canada COVID-19 and IBD Task Force recommends that people with IBD who are systemically immunosuppressed (using medications like systemic corticosteroids, thiopurines, methotrexate, or biologics) should have the ability to access booster COVID-19 vaccination 14–18 weeks after their second dose. Crohn's and Colitis Canada continues to recommend that people with IBD receive two doses of any COVID-19 vaccine available (whether they are immunosuppressed or not). These recommendations are particularly important during the fourth wave in Canada, when the Delta variant of SARS-CoV-2 is the predominant strain.
The Delta variant is spread more easily and is associated with an increased risk of hospitalization. Receiving two doses of an mRNA or adenovirus-vector vaccine is effective at preventing infection with SARS-CoV-2 and highly effective against severe COVID-19. Vaccine booster doses are 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.
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 resources
COVID-19 Vaccine Recommendation Letter (Third Dose)
Crohn's and Colitis Canada's Task Force has developed a third COVID-19 vaccine (booster) 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 8 to 16 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 Vaccine Advocacy (Third Dose)
Thank you to Quebec, Ontario, Prince Edward Island, and British Columbia for including this community in their recommendations for a third COVID-19 vaccination.
Please click here to help encourage other provinces do the same by sending a letter to your local government representatives.
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.
How to book a vaccine appointment
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:
frequently asked questions on vaccines
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.
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 cancer or who use medications which suppress the immune system has not demonstrated that receiving any COVID-19 vaccine increased the risk of adverse events in this population.
How effective are the vaccines to SARS-CoV-2 that are approved by Health Canada?
The Pfizer/BioNTech mRNA vaccine and the Moderna mRNA vaccine have been shown in large, randomized controlled trials to be roughly 95% effective. What does 95% effective vaccine mean? The mRNA vaccine was given to ~15,000 people and only five developed COVID-19, but none were seriously ill. Another ~15,000 people were given a placebo shot, and 90 developed COVID-19, with several becoming severely ill.
By comparing the vaccinated group and the placebo group, we can see that these vaccines are highly likely to prevent getting COVID-19 and to reduce the severity of the disease if a vaccinated person does contract COVID-19.
In similar large, randomized clinical trials, the AstraZeneca vaccine has been shown to be roughly 62% effective whereas the Janssen vaccine has been shown to be 66% effective. However, these trials were conducted later in 2020 and in parts of the world where “genetic variants of concern” were more prevalent (e.g. South Africa and Brazil). Therefore, the rates of effectiveness should not be compared to earlier trials. In addition, all of these vaccines are nearly 100% effective at preventing severe COVID-19 disease (hospitalization and death).
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. However, the effectiveness and safety of the COVID-19 vaccines in people with immune-mediated diseases or immunocompromised populations are currently unknown.
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. Unlike other vaccine types, there is little information in the general population either, as this is a new type of vaccine, however that is rapidly changing as large numbers of vaccine are given around the world. The use of adenovirus vectors has been well studied by scientists.
There are currently several clinical trials using the adenovirus vectors for protection against infections such as the Ebola virus, HIV, and tuberculosis. However, patients with IBD were not included in the trials of the COVID-19 adenovirus vector vaccines, and therefore no data are available for safety in IBD patients.
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. We do not have data on the use of mRNA and adenovirus vector vaccines in people with IBD at this point, but the risk is likely low. 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 be offered the COVID-19 vaccine after informed consent. Informed consent should be based on a discussion between the patient and healthcare provider, and should balance the safety of the vaccine, the lack of evidence in IBD patients, the risk factors that could result in severe COVID-19 in the IBD patient, and the underlying prevalence of COVID-19 in the patient’s community. After these factors are discussed with the patient, and if the patient wishes to receive the COVID-19 vaccine, it should be provided to them.
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 decide 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. If you and your healthcare provider think your risk of COVID-19 infection is low, and you want to wait until there is more information on COVID-19 vaccines for people with IBD, that is an option. With more information, you can assess your risks and benefits again in a few months and reconsider the vaccine at that time. Saying you want to delay until there is more information does NOT mean you should never get the vaccine.
Since the mRNA vaccines seem to have higher efficacy than the non-replicating adenovirus vector vaccines, should I try to get the mRNA vaccine?
You should get the first vaccine that is offered to you, no matter which brand or type. The effectiveness of the non-replicating adenovirus vector vaccines are just as high at preventing hospitalization and death as other successful vaccines, and will contribute to herd immunity. The trials for the non-replicating adenovirus vector vaccines run by Oxford/AstraZeneca and Janssen took place later in 2020 and in parts of the world where “genetic variants of concern” were more prevalent (South Africa and Brazil).
In addition, the criteria needed to test people in the trials for the adenovirus vector vaccines were less stringent, so more mild cases were probably diagnosed in the Oxford/AstraZeneca and Janssen trials. These would all result in the appearance of lower vaccine effectiveness in those trials. Therefore, the rates of effectiveness should not be compared to earlier trials. In addition, all of these vaccines are nearly 100% effective and preventing severe COVID-19 disease (hospitalization and death). Therefore, all of these vaccines will protect you from hospitalization and death, which are the most important outcomes to prevent.
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.
There is news that the AstraZeneca vaccine may cause blot clots. Should I avoid the AstraZeneca vaccine?
No. The non-replicating adenovirus vector vaccines (from AstraZeneca and Johnson & Johnson) may be associated with a rare, serious immune disorder called Vaccine-Induced Immune Thrombocytopenia (VIIT). This condition results in antibodies to a molecule on platelets (one of the clotting factors in blood) called PF4, resulting in their activation and potentially serious blood clots.
The risk of this condition is approximately 1 in 250,000 people who receive the vaccine in Canada. Because it is so rare, researchers have been able to identify risk factors in people who get this condition. Based on current information, it does not occur with increased frequency in people who have hypertension (high blood pressure), previous blood clots, bleeding disorders, HELLP Syndrome (in pregnancy), or a family history of clots.
As of April 2021, the risk of contracting COVID-19 and dying in Canada far outweighs the risk of developing a blood clot from these vaccines. For this reason, on April 23, 2021, NACI recommended that the AstraZeneca vaccine could be offered to anyone 30+ years old because the benefits outweigh the risks. If you have questions about the safety of the COVID-19 vaccines, speak to your doctor and read the Public Health Agency of Canada page on immunizations.
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 National 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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