By David T. Rubin, MD, Professor of Medicine, University of Chicago Medicine
(Posted to IBD-circle.within3.com on March 21, 2020)

Dear Colleagues,

I have been fielding lots of questions about whether our IBD patients on immune therapies should stay home from work. Some of this has easily been answered, as there are now nationwide recommendations for social distancing and work-from-home recommendations.

But what about our healthcare worker colleagues on immune suppressants? Should they avoid direct patient contact for the next X weeks?

There are a number of issues that factor into such decisions:

1) First, IBD is not an independent risk for infection with SARS-CoV-2 or development of COVID-19, and not all IBD meds are considered immune modifying (5-ASAs, oral budesonide, antibiotics).

2) Do patients on immune suppressants (or immune modifiers) have a higher risk of infection with SARS-CoV-2 at baseline? We do not know.

3) Do patients on immune suppressants (or immune modifiers) have a higher risk of getting COVID-19 if they get infected with SARS-CoV-2? We do not know. But there is indirect evidence from the SARS outbreak and so far in the international anecdotes described that this is not the case. In addition, there are some translational and clinical data to suggest that some of our therapies (in particular anti-TNF but perhaps others) may protect against cytokine storm or other bad outcomes.

4) Do we know what the true community prevalence of infection is? The answer to this question is decidedly no. Therefore, community exposure is another risk for these individuals, and obviously everyone is trying to reduce this with the social distancing or shelter-in-place recommendations.

5) Are all healthcare workers’ risks of SARS-CoV-2 infection during this time the same? Definitely not. While we recognize that all healthcare workers are essential at this time, some are on the front lines and clearly at higher risk of exposure than others. (examples may be our emergency medicine colleagues, infectious disease colleagues, pulmonologists, and critical care colleagues, other examples where there is just a higher risk of exposure to aerosolized virus include US, dentists, endodontists and others I am missing).

6) What are the appropriate PPE recommendations? In Korea for example, ALL healthcare workers wear surgical (non-N95) masks in the hospital and while rounding. Additional PPEs are recommended when seeing known or suspected COVID-19 patients.

Therefore, here are my suggestions for you to discuss and support for your patients and colleagues who are healthcare workers and have IBD and are on immune suppressants or immune modifiers:

1) Educate your healthcare worker colleague about what we know and what we don’t know about this infection and disease

2) Emphasize the current recommendations for appropriate social distancing, work-from-home options, and PPE utilization. Social distancing includes not congregating during rounding too. Asynchronous rounding, virtual rounding or designated individuals to see patients alone are recommended (and preserve PPEs).

3) Minimize clinic visits and medical procedures except when absolutely necessary. There should be no non-essential medical procedures at this time. (there is considerable discussion about what “elective” means in different specialties, so I have adopted the term “non-essential” instead).

4) Wear surgical masks during hospital rounds and in clinic. Meticulous hand hygiene before, during and after all interactions.

5) In specific cases, recommend not working at this time (the general time frame is until at least April 1, but I suggest April 15 for now). Examples from my own practice include:

a) an endodontist with Crohn’s disease taking Humira. His practice stopped all elective procedures, but I instructed him not to take call for emergency procedures given the high likelihood of aerosolized virus during those types of procedures.

b) an ICU nurse with Crohn’s disease taking Stelara. She works at another Chicago hospital and has been asked to care for patients with known and suspected COVID-19. I supported her request to be reassigned to other nurse duties.

 

I hope this is helpful. Please share your thoughts and ideas with me.

Thank you all, stay safe.
David

David T. Rubin, MD
Professor of Medicine, University of Chicago Medicine