ABSTRACT
Background: Vaccination rates remain low among patients with inflammatory bowel disease (IBD) despite guideline recommendations and evidence-based publications. Reported barriers include perceived lack of benefit, fear of side effects, and inconvenience. At our IBD center we follow approximately 1700 patients. During the 2019-2020 influenza season, our vaccination rate for the entire IBD population was 40.3% and 45.5% for those receiving biologic therapies at our infusion center (n=772). We developed a quality improvement initiative to evaluate vaccination practices and to determine effective strategies to increase vaccine uptake. As a first-step, we targeted our most vulnerable and accessible population: patients receiving biologic infusions. Methods: Our initiative began in August 2020. Plan-do-study-act cycles included creation of a multi-disciplinary team to review vaccination barriers and distribution of a survey to caregivers or IBD patients >=18 years to explore vaccination decision making process, awareness of recommendations, and impact of vaccine availability in the infusion center on uptake. The next phase was optimizing access among patients receiving biologic therapies at our infusion center. The strategies we implemented included educational sessions with the division providers and infusion center nurses, creation of an Epic EMR order set, active phone screening of our population prior to infusion visits, at which point unvaccinated patients were offered the vaccine during the appointment. Chi squared analysis compared survey responses between caregivers and patients. Two proportion sample test identified differences in vaccination rates between the two influenza seasons. Results: The survey was answered by 14.4% (n=269 caregivers and n=60 patients), with 71.3% on either anti-TNF alpha (infliximab, adalimumab) or vedolizumab. Of respondents, 13.4% were unvaccinated in 2019-2020. Top reasons for non-vaccination included “unsure of safety” (31.8%), “unsure of benefit” (29.5%), and “forgot to schedule” (13.6%). Patients and caregivers had similar vaccine impressions, with no statistically significant differences (Figure 1). For the 2020-2021 season, 88.75% plan to get vaccinated and 51.7% expressed interest in receiving the vaccine during their infusion appointment. Since implementing our initiative, the vaccination rate has already increased to 59.2% compared to 45.5% (p=0.001). Conclusions: Our initiative increased vaccination rates in patients receiving biologic infusions by 13.7% thus far. Particularly during the COVID-19 pandemic, the influenza vaccine is essential to protect this vulnerable population and decrease the burden on the healthcare system. We have identified pre-screening prior to appointments and providing access in conjunction to scheduled appointments as the most effective strategies to optimize vaccination uptake.(figure presented)
ABSTRACT
COVID-19, which is caused by the single-stranded RNA severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has introduced significant therapeutic dilemmas in several areas. One of these is concern regarding the use of renin-angiotensin system (RAS) inhibitors. Dysfunction of the RAS has been observed in COVID-19 patients, but whether RAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II type-1 receptor blockers (ARBs), are associated with improved or worse clinical outcomes, remains unclear. RAS inhibitors are currently widely used in the treatment of hypertension. Emerging data suggest an increased association and a heightened mortality in patients of COVID-19 with co-morbidities such as hypertension, coronary heart disease, and diabetes mellitus, particularly in the elderly. Therefore, several recently published research papers have focused on the management of hypertension during the COVID-19 pandemic, as this co-morbidity was found to be the most common in patients with coronavirus infections. SARS-CoV-2 viral surface protein is known to attach angiotensin converting enzyme-2 (ACE-2) on the cell membrane to facilitate viral entry into the cytoplasm. While the SARS-CoV-2 viral load remains the highest in upper respiratory tract of COVID-19 patients, it has also been reported in multiple sites in COVID-19, and patients not infrequently require the Intensive Care Units (ICU) admission. However, despite the theoretical concerns of possible increased ACE2 expression by RAS blockade, there is no evidence that RAS inhibitors are harmful during COVID-19 infection, and indeed they have been shown to be beneficial in some animal studies. In this review we summarise the pathophysiology of the interaction between RAS, ACEIs/ARBs inhibitors and COVID-19, and conclude, on the basis of current data, that RAS blockade should be maintained during the current coronavirus pandemic.