We read with interest the position statement of the British Society of Gastroenterology Inflammatory Bowel Disease (IBD) section and IBD Clinical Research Group.1Alexander JL Moran GW Gaya DR et al.SARS-CoV-2 vaccination for patients with inflammatory bowel disease: a British Society of Gastroenterology Inflammatory Bowel Disease section and IBD Clinical Research Group position statement. Although we largely agree with the key messages that SARS-CoV-2 vaccination should be strongly supported for patients with IBD and that the anticipated risks are low, we wish to raise a few relevant remarks based on previously published studies on vaccination for other pathogens in this patient group. Alexander and colleagues1Alexander JL Moran GW Gaya DR et al.SARS-CoV-2 vaccination for patients with inflammatory bowel disease: a British Society of Gastroenterology Inflammatory Bowel Disease section and IBD Clinical Research Group position statement. rightfully argue that the response to pneumococcal, influenza, and hepatitis A vaccination in patients with IBD receiving immunosuppressive agents is diminished compared with that in control individuals. However, we disagree that the response to vaccination in patients receiving anti-tumour necrosis factor (anti-TNF) agents is lower than that in patients receiving conventional immunomodulators. In a systematic review and meta-analysis of 17 studies, we showed that patients with IBD using anti-TNF agents were more likely to seroconvert after the first dose of hepatitis A vaccine (OR 12·1, 95% CI 2·14–68·2) than were patients using conventional immunomodulators.2Garcia Garrido HM Veurink AM Leeflang M Spijker R Goorhuis A Grobusch MP Hepatitis A vaccine immunogenicity in patients using immunosuppressive drugs: a systematic review and meta-analysis. Regarding pneumococcal vaccination, a study involving 141 patients with IBD showed that the response to pneumococcal vaccination was not inferior (63%) in patients receiving anti-TNF therapy compared with patients receiving conventional immunomodulators (60%).3van Aalst M Garcia Garrido HM van der Leun J et al.Immunogenicity of the currently recommended pneumococcal vaccination schedule in patients with inflammatory bowel disease. Patients on combination therapy had a significantly lower response (52%) than did those receiving either anti-TNF therapy or conventional immunomodulators. A systematic review on pneumococcal vaccination comprising 2077 participants found a superior response in patients using an anti-TNF treatment compared with those using conventional immunomodulators. One explanation could be that anti-TNF agents cause a more specific inhibition of the immune system than do conventional immunomodulators.4van Aalst M Langedijk AC Spijker R de Bree GJ Grobusch MP Goorhuis A The effect of immunosuppressive agents on immunogenicity of pneumococcal vaccination: a systematic review and meta-analysis.It should be noted that approved SARS-CoV-2 vaccines are very different from the currently licenced vaccines that were previously tested in patients with IBD. Both the mRNA and adenovirus vector vaccines encode the production of SARS-CoV-2 spike protein, leading to the production of neutralising antibodies and virus-specific T-cell responses.5COVID-19 vaccines: modes of immune activation and future challenges. We agree that, in the current absence of immunogenicity studies and the unfortunate situation of vaccine paucity, patients with IBD should accept whichever approved vaccine is offered to them. However, we hypothesise that mRNA vaccines might prove to be the better option for patients with IBD using immunosuppressants than might adenovirus vector vaccines for two reasons. First, the licenced adenovirus vector vaccines (ie, Janssen or Oxford/AstraZeneca) are less effective than mRNA vaccines (ie, Pfizer/BioNTech or Moderna) in healthy individuals. Thus, effectiveness in immunocompromised individuals is expected to be lower as well, even though optimal protection of this susceptible population is needed. Second, the adenovirus vector formulation might generate adenovirus-specific immunity, which might limit the effectiveness of booster doses that could be necessary for immunocompromised individuals.5COVID-19 vaccines: modes of immune activation and future challenges.

We declare no competing interests.

References1.Alexander JL Moran GW Gaya DR et al.

SARS-CoV-2 vaccination for patients with inflammatory bowel disease: a British Society of Gastroenterology Inflammatory Bowel Disease section and IBD Clinical Research Group position statement.

Lancet Gastroenterol Hepatol. 6: 218-2242.Garcia Garrido HM Veurink AM Leeflang M Spijker R Goorhuis A Grobusch MP

Hepatitis A vaccine immunogenicity in patients using immunosuppressive drugs: a systematic review and meta-analysis.

Travel Med Infect Dis. 321014793.van Aalst M Garcia Garrido HM van der Leun J et al.

Immunogenicity of the currently recommended pneumococcal vaccination schedule in patients with inflammatory bowel disease.

Clin Infect Dis. 70: 595-6044.van Aalst M Langedijk AC Spijker R de Bree GJ Grobusch MP Goorhuis A

The effect of immunosuppressive agents on immunogenicity of pneumococcal vaccination: a systematic review and meta-analysis.

Vaccine. 36: 5832-58455.

COVID-19 vaccines: modes of immune activation and future challenges.

Nat Rev Immunol. 21: 195-197Article InfoPublication HistoryIdentification

DOI: https://doi.org/10.1016/S2468-1253(21)00148-5

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ScienceDirectAccess this article on ScienceDirect Linked ArticlesSARS-CoV-2 vaccination for patients with inflammatory bowel disease: a British Society of Gastroenterology Inflammatory Bowel Disease section and IBD Clinical Research Group position statement

SARS-CoV-2 has caused a global health crisis and mass vaccination programmes provide the best opportunity for controlling transmission and protecting populations. Despite the impressive clinical trial results of the BNT162b2 (Pfizer/BioNTech), ChAdOx1 nCoV-19 (Oxford/AstraZeneca), and mRNA-1273 (Moderna) vaccines, important unanswered questions remain, especially in patients with pre-existing conditions. In this position statement endorsed by the British Society of Gastroenterology Inflammatory Bowel Disease (IBD) section and IBD Clinical Research Group, we consider SARS-CoV-2 vaccination strategy in patients with IBD.

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We thank Garcia Garrido and colleagues for their comments on the British Society of Gastroenterology Inflammatory Bowel Disease (IBD) and IBD Clinical Research Group section position statement1 and the studies cited in their Correspondence, including the valuable meta-analysis of the impact of immunosuppression on pneumococcal vaccination.2 However, the results of this meta-analysis should be interpreted with caution in patients with IBD, as most of the studies included (18 of 22) were from patients with other immune-mediated inflammatory diseases (mostly rheumatoid arthritis), in which the only conventional immunomodulator reported was methotrexate.

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