COVID-19 and Paediatric Inflammatory Bowel Disease

Initial concerns that people with IBD would be at high risk, particularly those on immunomodulators and biologics, resulted in many ‘shielding’ themselves in their homes for months; sometimes this was at governmental suggestion, sometimes medical suggestion and sometimes self-imposed by patients or their families. The ECCO COVID Taskforce has, however, recently summarised that IBD per se is not a risk factor for COVID-19 [1]; it has advised testing for all symptomatic IBD patients and adaptations to disease management – re-evaluation of treatment (corticosteroids in particular), postponement of non-urgent surgeries and endoscopies, implementation of online consultancy and limitation of hospitalisation and surgery to the most urgent cases.

Unlike in the case of influenza and other common respiratory infections, children and young people have lower COVID-19 infection rates than adults and are also low ‘spreaders’ of SARS-CoV-2. They mainly have asymptomatic infection, and very rarely need hospitalisation with COVID-19. Severe disease is rare and death exceptionally rare in hospitalised cases [2]. It is speculated that this may be due to high rates of common cold due to the four endemic coronaviruses which cause waves of infection in schools; this may provide partial immunity to COVID-19.

A key publication on global experience and provisional guidance on COVID-19 in paediatric IBD (PIBD) (with P-ECCO former chairs prominent) to March 2020 from the Porto paediatric IBD group of ESPGHAN was vital in allaying fears of PIBD patients and their families and providing measured guidance [3]. This confirmed that COVID-19 cases were rare in PIBD in Europe, Israel, China and South Korea, with no reported hospitalisations or deaths. It was advised that standard PIBD treatment be continued, given that delay in infusions in endemic areas had been associated with disease flares, including hospitalisations. The most important outcome was the reassurance based on global experience that PIBD teams could provide to their patients and families at a time when multiple nations were already in lockdown or were entering it. So, what is the global situation in October 2020? The best available resource is SECURE-IBD, the COVID-19 and IBD reporting database, which monitors and reports international paediatric and adult outcomes. As of October 13, 2020, 2623 cases had been reported with an overall ICU/ventilator/death rate of 6% (including a death rate of 3%); 265 of these cases occurred in those aged 0–19 years, with a 1.1% ICU/ventilator rate and zero deaths.

Disturbing reports began from April 2020 onwards of MIS-C, the WHO term for a multisystem inflammatory disorder of children and young people temporally associated with SARS-CoV-2. This severe disease phenotype was hyperinflammatory and with features similar to toxic shock syndrome and Kawasaki disease; it was described in the first published cases from the UK as PIMS-TS (paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2). The wide spectrum of MIS-C presentations is now recognised, with one report where prior anti-TNF therapy may have attenuated the course in a 10-year-old girl with Ulcerative Colitis [4]. The reports of MIS-C have markedly diminished over summer 2020, but attention remains focussed on this presentation as COVID-19 rates are currently rising precipitously again in Europe (and globally).

References

1. Magro F, Rahier J-F, Abreu C, et al. Inflammatory Bowel Disease Management During the COVID-19 Outbreak: The Ten Do’s and Don’ts from the ECCO-COVID Taskforce. J Crohns Colitis. 2020;14:S798–806.
2. Swann OV, Holden KA, Turtle L, et al. Clinical characteristics of children and young people admitted to hospital with COVID-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. 2020 Aug 27; doi: 10.1136/bmj.m3249 [Epub ahead of print].
3. Turner D, Huang Y, Martín-de-Carpi J, et al. Corona virus disease 2019 and paediatric inflammatory bowel diseases: global experience and provisional guidance (March 2020) from the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2020;70:727–33.
4. Meredith J,  Khedim C-A, Henderson P,  Wilson DC,  Russell RK. Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in a patient receiving Infliximab therapy for Inflammatory Bowel Disease. J Crohns Colitis. 2020 Sep 30; doi: 10.1093/ecco-jcc/jjaa201. [Epub ahead of print].