key: cord-0915451-pkoyohof authors: D’Amico, Ferdinando; Danese, Silvio; Peyrin-Biroulet, Laurent; Ailsa, Hart; Kucharzik, Torsten; Magro, Fernando; Rahier, Jean-François; Siegmund, Britta; van der Woude, C. Janneke; Vavricka, Stephan R. title: Inflammatory bowel disease management during the COVID-19 outbreak: a survey from the European Crohn’s and Colitis Organization (ECCO) date: 2020-04-30 journal: Gastroenterology DOI: 10.1053/j.gastro.2020.04.059 sha: 7e974586886697fc600311d132da46d3226c8b6d doc_id: 915451 cord_uid: pkoyohof nan None. As of December 2019, some cases of pneumonia of unknown origin were reported in Wuhan, China 1 . Over the course of a few weeks, a new coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified, leading to the onset of coronavirus disease 2019 (COVID-19) 2 . COVID-19 primarily causes respiratory symptoms but it was also associated with gastrointestinal effects 3, 4 . The virus was genetically similar to its predecessor, severe acute respiratory syndrome coronavirus (SARS-CoV), although it had greater person-to-person transmission capacity 5 . In a very short time it spread worldwide, forcing the World Health Organization (WHO) to declare the state of pandemic 6 . Many preventive measures were taken to reduce contagion, including recommendations for the use of masks and gloves, greater attention to hand hygiene, social distancing, quarantine, and lockdown of non-essential activities 7, 8 . In this context of global urgency, physicians are dealing with difficult and never experienced situations 9 . Little is known about this new viral agent and the information obtained evolve continuously, making patient management even more complex. In addition, the lack of evidence is highlighted for the management of IBD patients treated with immunosuppressive drugs or biological agents as occurs for chronic inflammatory bowel diseases (IBD). In fact, it is uncertain whether Crohn's disease (CD) and ulcerative colitis (UC) are associated with an increased risk of infection and whether some drugs modulating the immune system contribute to the risk of exposure 10 . Importantly, no specific recommendations from international organizations were available regarding management of IBD patients at the time of the survey. For this reason, we designed a survey to investigate current management of IBD patients and to define fears and difficulties that physicians were facing during the global SARSCoV-2 pandemic. A 39-question anonymous websurvey was conducted with the logistic support of the European Crohn's and Colitis Organization (ECCO) between 20 and 30 March 2020. All ECCO members were invited to participate in this survey through collective e-mails. The questionnaire mainly consisted of multiple-choice questions while only three questions assessed the physicians' fear of infectious risk in non-IBD and IBD patients using a numerical scale from 0 to 10. We collected data on the number of positive COVID-19 cases, diagnostic approach in asymptomatic patients, discontinuation of immunosuppressive and biological drugs (Supplementary Table 1 ). We also investigated the recommendations given to patients, the preventive measures for patients and physicians (e.g. masks, gloves, goggles, and disinfectants), and any organizational changes imposed by hospitals. Physician demographics and incidence of COVID-19 among IBD patients are summarized in Supplementary were also asked to quantify (from 0 to 10) their fear that IBD and non-IBD patients could be infected with SARS-CoV-2. The average fear value was greater for IBD patients than non-IBD patients (6.58, standard deviation (SD) = 2.08 vs 5.16, SD = 2.13). It is important to underline that a high average fear value was detected for IBD patients treated with immunosuppressant drugs or biologics (7.45, SD =1.95). Finally, a quarter of physicians was optimistic about the rapid resolution of the pandemic, while 106 (18.5%) and 319 (55.9%) subjects were uncertain or not optimistic respectively. According to most of the survey participants, the coronavirus test should not be performed in asymptomatic non-IBD patients (80.5%) (Table 1) . Similarly, in IBD patients without symptoms suggestive of infection, the swab should not be performed (75.1%). In asymptomatic IBD patients treated with immunosuppressants and biologics, the test was considered unnecessary by about two thirds of physicians. On the other hand, in IBD patients with suspicious symptoms, systematic coronavirus testing was supported by 312 participants (54.6%), while the remaining half of respondents discredited this approach. Most respondents (80.1%) believed that the use of protective aids (e.g. mask, gloves) was effective in preventing viral transmission ( Table 2) . Only a small percentage of persons denied or was uncertain about their efficacy (8.6% and 11.3% respectively). Protections during an IBD patient consultation were used by three quarters of physicians and the most adopted aids were disinfectants (88.4%), masks (72.4%), gloves (56%), and goggles (9%). About a quarter of physicians did not use protections during their consultations. SARS-CoV-2 test was performed only in 40 asymptomatic subjects (7%), while the remaining physicians were not tested. Most physicians (87%) received information from their center regarding the management of COVID-19 patients, while only 74 respondents (13%) were not given indications ( Table 2 ). Three quarters of physicians were satisfied with the recommendations received, while a low percentage of persons was unsatisfied or uncertain (19.3% and 8.1% respectively). As for treatment, most physicians (72.5%) thought they knew how to properly manage patients with suspicious symptoms of COVID-19, while few subjects were uncertain (14.5%) or believed they did not know how to manage appropriately COVID-19 patients (13%). Most respondents believed that IBD were not associated with an increased risk of infection (54.4%), while a significant group of physicians speculated that immunosuppressive and biological drugs could be a predisposing factor of infection (67.7%). Accordingly, the fear that IBD patients could be infected with SARS-CoV2 was greater than the fear for non-IBD patients and this data was further emphasized in IBD patients receiving IBD drugs. Physicians' fears of being infected with the new coronavirus and of infecting patients were common (57.7% and 81.8%). In addition, a significant percentage of people (30.3%) reported fear of dying from COVID-19. Most of the respondents (73.7%) reported being stressed by the pandemic situation and 35.6% of the physicians declared they worked more than the standard number of hours. These results are in line with a cross-sectional study assessing the mental health burden of Chinese health-care workers 11 . The majority of workers (75%) were stressed and professionals personally involved in diagnosis, treatment, and care of COVID-19 patients had a greater risk of psychological burden 11 . From the diagnostic point of view, common opinion was not to perform the test for coronavirus in asymptomatic subjects regardless of IBD or immunosuppressive treatment. On the other hand, only a small number of physicians had been tested (7%). Preventive measures were not adopted by all respondents during their consultations and although extensive use of disinfectants and masks, gloves and goggles were used less frequently. These data should be underlined in light of the high rate of health care personnel recently diagnosed with COVID-19 12, 13 . Moreover, the increasing evidence of fecal-oral transmission of the virus suggests the need to implement the use of gloves and goggles 14, 15 . It is also interesting to note that although the use of protective aids was considered important to prevent infection, a high percentage of physicians did not recommend the use of protective aids for IBD patients during their daily life (47%). Interestingly, only a small group of physicians stopped immunosuppressive or biological treatments (9.6%) and the most discontinued drugs were thiopurines, steroids, and anti-TNFs (72.7%, 43.6% and 30.9%). In a recent study conducted in an IBD center in Wuhan, all IBD treatments were stopped 16 . Over a period of about two months, no IBD patient was infected with the new coronavirus and drug discontinuation was suggested as a viable option to reduce the risk of infection 16 . On the other hand, in an Italian study 17 , 522 IBD patients were continuously treated with biological and immunosuppressive therapies and no case of infection was found after more than one month of follow up. Long-term data are needed to define which is the best strategy. Importantly, stopping therapy exposes patients to a greater risk of disease recurrence and therefore this decision should be individualized 18, 19 . In fact, the International Organization of IBD (IOIBD) has recommended discontinuing immunomodulators (thiopurine and methotrexate) and tofacitinib in positive SARS-CoV2 patients and all therapies systematically in patients with confirmed diagnosis of COVID-19 20 . In the remaining cases, the decision should be made by the physician, in agreement with the patient, based on the risk / benefit ratio of each patient. As regards the work organization, most of the consultations were rescheduled and the start of new biological therapies was frequently postponed. This strategy was also supported by the Chinese gastroenterology society, which first had to deal with COVID-19 outbreak, and should allow to reduce travels and person-to-person contacts 21 knowledge. In conclusion, the SARS-CoV2 pandemic has revolutionized the management of IBD patients, forcing physicians to face new problems and make decisions in the absence of certainties to prevent viral transmission. Further studies are needed to clarify the relationship between COVID-19 and IBD and to define the best approach for patient management. National and international registries could be useful to monitor the epidemiological data of the virus in IBD and to identify the characteristics of COVID-19 in our patients. • Immunosuppressive and biological drugs should not be discontinued as a preventive strategy in IBD patients without symptoms suggestive of COVID-19 • The SARS-CoV-2 test should not be performed in IBD patients without symptoms suggestive of COVID-19 • All physicians should use protective aids (e.g. gloves, masks, and disinfectants) during outpatient visits • Physicians should discourage all non-essential travel and recommend protective aids to their patients during daily life activities • Will patients who stopped IBD drugs experience IBD flares leading to hospitalizations and surgeries? • Should we favor ambulatory treatment (subcutaneous injections, oral administration) over intra-venous administration? • Is the initiation of IBD drugs (steroids, immunosuppresants, and biologics) safe during the COVID-19 pandemic? A Novel Coronavirus from Patients with Pneumonia in China A new coronavirus associated with human respiratory disease in China Clinical Characteristics of Coronavirus Disease 2019 in China COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding WHO Director-General's opening remarks at the media briefing on COVID-19 -23 Advice for public Covid-19 -The Law and Limits of Quarantine | NEJM Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home Are patients with inflammatory bowel disease at increased risk for Covid-19 infection? Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease Epidemiology of Covid-19 in a Long-Term Care Facility in King County Effect of gastrointestinal symptoms on patients infected with COVID-19 Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission COVID-19: Gastrointestinal Manifestations and Potential Fecal-Oral Transmission Protection of 318 Inflammatory Bowel Disease Patients from the Outbreak and Rapid Spread of COVID-19 Infection in Wuhan Uneventful course in IBD patients during SARS-CoV-2 outbreak in northern Italy Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn's disease European Crohn's and Colitis Organisation Topical Review on Treatment Withdrawal Update on COVID19 for Patients with Crohn's Disease and Ulcerative Colitis | IOIBD Responding to COVID-19: Perspectives from the Chinese Society of Gastroenterology Author names in bold designate shared co-first authorship We gratefully thank the ECCO Office for the logistic support in this survey. Many thanks to all physicians that completed the survey.