Role of gastroenterologists and healthcare providers in promoting COVID-19 immunization among individuals with inflammatory bowel disease: A systematic review and meta-analysis on a global scale

ABSTRACT

Individuals with Inflammatory Bowel Disease (IBD) are more susceptible to experiencing severe complications of COVID-19 if infected. Nevertheless, sub-optimal immunization rates have been reported among these patients. Our study aims to assess COVID-19 VH among a global population of patients with IBD and to investigate the role of healthcare professionals, particularly gastroenterologists, in promoting immunization. Twenty-six studies were systematically selected from scientific articles in the MEDLINE/PubMed, WoK, and Scopus databases from January 1, 2020, to September 15, 2023. The pooled prevalence of COVID-19 VH was 27.2% (95%CI = 20.6–34.2%). A significant relationship was evidenced between COVID-19 vaccine compliance and receiving advice from gastroenterologists or healthcare providers (OR = 2.77; 95%CI = 1.79–4.30). By leveraging their knowledge of IBD, familiarity with patient histories, and trusted patient-doctor relationships, gastroenterologists are pivotal in promoting vaccination. This patient-centered care is crucial in increasing vaccine acceptance among individuals with IBD, contributing to better public health outcomes.

KEYWORDS:

• Crohn’s disease
• ulcerative colitis
• vaccine hesitancy
• SARS-CoV-2
• biological drugs
• immunosuppressive therapy
• immunization rates
• vaccine compliance

Introduction

Inflammatory Bowel Disease (IBD) represents a complex group of chronic inflammatory conditions primarily affecting the gastrointestinal tract. This group includes Crohn’s disease and ulcerative colitis, the most commonly recognized forms of IBD. IBD exhibits a distinctive epidemiological profile with a global reach. While traditionally associated with high-income countries and regions, its incidence and prevalence have steadily risen worldwide, leading to a shifting epidemiological landscape.¹

The etiology of IBD is complex and likely involves a combination of genetic, environmental, and immunological factors.^2,3 Genetic predisposition plays a significant role, with a higher risk observed in individuals with a family history of the disease. Environmental factors, such as diet, smoking, and microbial exposures, have also been implicated in IBD development. Moreover, shifts in the gut microbiome composition have garnered attention as potential contributors.^2,3 While ongoing research endeavors to unravel the intricate relationship, it remains clear that individuals afflicted with IBD confront an elevated susceptibility to complications arising from infectious diseases.^2,3 This heightened risk is underpinned by a confluence of factors, including the utilization of immunosuppressive medications for inflammation management, an increased likelihood of coexisting chronic health conditions compared to their IBD-free counterparts, and the advanced age often associated with immunocompromised states.^4–6

In the context of the COVID-19 pandemic, individuals with IBD do not exhibit a heightened risk of SARS-CoV-2 infection compared to the general population.⁷ However, they are more susceptible to experiencing severe complications if infected. Factors associated with a higher risk of severe COVID-19 outcomes in IBD patients include older age, the presence of two or more comorbidities, the use of systemic corticosteroids, and the use of sulfasalazine or 5-aminosalicylate medications. Furthermore, studies suggest that older adults with IBD may face an increased risk of COVID-19 hospitalization.^8–10 COVID-19 vaccines have demonstrated high effectiveness, immunogenicity, and safety in preventing the above described complications.^11–15 Despite the initial absence of evidence from phase III studies, phase IV studies have provided sufficient data to enable international gastroenterology scientific societies and public health institutions to recommend COVID-19 vaccination for patients with IBD and immunocompromised individuals.^16–18

Despite the potential benefits of vaccination, sub-optimal immunization rates have been reported among patients with IBD. Kwon HJ et al.¹⁹ reported a vaccine coverage for at least one dose of 60% among 1,349 US patients with IBD. A survey set in Kuwait evidenced an immunization rate of 42% among 280 patients, without significant difference between subjects with Crohn’s disease and subjects with ulcerative colitis.²⁰ Vaccine hesitancy (VH), defined as a state of indecisiveness regarding a vaccination decision, independently of behavior,²¹ in this population, is a phenomenon already studied in the literature; indeed, low vaccine attitude for other vaccine-preventable diseases are reported, and several determinants have been associated to VH.^22–24 Among these, the role of healthcare professionals, particularly gastroenterologists, is recognized as one of the most essential factors of hesitancy or compliance.^25–27 Indeed, the healthcare professionals’ advice seems to be able to improve the attitude of patients with IBD toward vaccine-preventable diseases.^25–27

In this context, our study has the primary objective of assessing COVID-19 VH among a global population of patients with IBD by conducting a comprehensive systematic review and meta-analysis. Furthermore, we aim to identify key determinants contributing to VH and investigate potential strategies to enhance vaccine acceptance. Our specific focus will be on the pivotal role of healthcare professionals, particularly gastroenterologists, in promoting vaccination and enhancing vaccine compliance among their patients.

Material and methods

The systematic review protocol was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.²⁸ It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the reference number CRD42023469180. The review question was formulated using the Population, Intervention, Comparison, and Outcome (PICO) framework: “What is the extent of COVID-19 vaccine hesitancy among patients with IBD worldwide, and what factors contribute to their vaccine attitudes?.”

Search strategy and selection criteria

A systematic search was conducted in the Scopus, MEDLINE/PubMed, and ISI Web of Knowledge databases to identify relevant articles. The search encompassed research articles, brief reports, letters, and editorials published from January 1, 2020, to September 15, 2023. The search strategy was: (hesitan* OR compliance OR attitude OR acceptance OR reluctance) AND (vaccin*) AND (COVID* OR coronavirus OR sars-cov-2) AND (“Inflammatory bowel disease” OR IBD OR crohn OR “ulcerative colitis”). Only studies in English with full text were considered. Abstracts from conferences lacking full-text, reviews, meta-analyses, papers without epidemiological data, clinical trials, and studies unrelated to the review’s purpose (e.g., vaccine immunogenicity, seroprevalence, safety, etc.) were excluded. Authors of studies were contacted for additional information if necessary. Two reviewers independently screened titles and/or abstracts of identified papers, applying predefined inclusion and exclusion criteria. Any discrepancies were documented and resolved through consensus.

Quality assessment

The methodological quality of the included quantitative studies was assessed utilizing the Newcastle – Ottawa Scale (NOS).²⁹ Two researchers independently conducted the assessment of bias risk for each study. Any discrepancies that arose were documented and resolved through consensus.

Data extraction

Two independent researchers reviewed all relevant studies and independently extracted data, which were put in a chart with their characteristics, to qualitatively compile the results (Table 1). Any discrepancies were resolved by consensus between the researchers.

Table 1. Characteristics of the selected studies included in the meta-analysis and systematic review.

Author	Year	Quality	Sample	n. of hesitant patients	Third additional dose hesitants	Country	Population	Study period	Definition of VH
Mikhael E	2023	m	201	51		Lebanon	Adults	2020–2022	Vaccination Perceptions
Principi M	2023	h	346	17		Italy	Adults	April 2021	Vaccination intent
Ramos L	2023	h	254		15	Spain	Adults	October – December 2021	Third dose vaccination willingness
Cao Y	2022	h	418	263		China	Adults	January – July 2021	COVID-19 vaccination hesitancy
Caron B	2022	m	104	47		France	Adults	January – February 2021	Vaccination willingness
Clarke K	2022	h	239	118		US	Adults	January – May 2021	Hesitancy was defined to include responses of being undecided, somewhat likely to refuse or refusing the vaccine.
Costantino A	2022	h	1,252	222		Italy	Adults	February 2021	Vaccination willingness
Duong TA**	2022	m	340	116		Australia	Adults	March – April 2021	Vaccine attitude
Ferreiro-Iglesias R	2022	h	1,302	407		Spain	Adults	October – December 2020	Vaccination willingness
Herman HS	2022	h	210	25		US	Adults	May – June 2021	Vaccine hesintancy defined as: “Likely will become vaccinated later this year, but not immediately” “Unsure if they will get the vaccine” “Do not want the vaccine”
Hu S	2022	h	288	79		China	Adults	September – December 2021	Vaccine attitude
Hudhud D*	2022	m	45	2		US	Adults	unknown	Vaccine attitude
Lodyga M	2022	h	267	77		Poland	Adults	September 2021 - November 2021	Vaccine attitude
Orfanoudaki E	2022	h	1,007	493		Greece	Adults	April – September 2021	Vaccination Perceptions
Shehab M	2022	m	499		209	Kuwait	Adults	January – March 2022	Third dose vaccination willingness
Zhang E	2022	h	441	30		Australia	Adults	October 2021 - November 2021	Vaccine attitude
Crispino F*	2021	m	276	128		Italy	Adults	April 2021	Vaccination willingness
Dalal RS	2021	m	906	313		US	Adults	December 2020 - January 2021	Vaccination intent
Napolitano D	2021	m	310	262	-	Italy	Adults	Not reported	Vaccination intent
Nishida Y	2021	h	187	19		Japan	Adults	June – August 2021	Vaccine attitude
Viola A**	2021	h	523	71		Italy	Adults	October 2020 - June 2021	Patients were prospectively stratified into three categories: (1) ‘vaccinated,’ patients who had received at least one dose of vaccine or accepted the booking at the vaccination center within the study period; (2) ‘procrastinators,’ patients who temporarily did not want to get vaccinated because of concerns about potential adverse events; (3) ‘strongly opposed,’ patients who did not want to get vaccinated in any circumstances.
Walldorf J**	2021	m	1,032	428		Germany	Adults	January – February 2021	Vaccine attitude
Wu X	2021	h	543	268		China	Adults	December 2020 - January 2021	Vaccine attitude
Only qualitative studies
Bhat S**	2021	-	-	-	-	US	-	September – October 2020
Papa A*	2021	-	-	-	-	Italy	-	-
Papa A*	2021	-	-	-	-	Italy	-	-

*letter/commentary.

**short report.

The determinants of VH, as well as opportunities for vaccination offer and possible strategies to be applied, were extracted from the entirety of available studies, and their respective outcomes were juxtaposed, with particular emphasis placed on the evidence presented across multiple included papers. The main focus has been set to investigate the role of gastroenterologists and healthcare professionals in promoting immunization. These topics were elaborated based on information from the included studies and synthesized in the systematic review paragraph.

Main outcome and pooled analysis

A meta-analysis was conducted to estimate the COVID-19 VH among patients with IBD, with a sub-analysis performed to estimate VH based on geographical regions. In the meta-analysis, the pooled proportion was calculated using the Freeman-Tukey double arcsine transformation to stabilize variances, and the DerSimonian-Laird weights were applied for random effects models. Pooled prevalence and associated 95% Wald confidence intervals were graphically represented using a forest plot.

Odds ratios (ORs) and their corresponding 95% confidence intervals (95%CIs) were utilized as general outcome variables to evaluate the relationship between vaccination compliance and guidance provided by gastroenterologists and healthcare professionals in promoting immunization. ORs and standard errors were derived from the 95% CIs, with additional logarithmic transformation performed to stabilize the variance and normalize the distribution. The OR in the meta-analysis was calculated using the inverse variance and DerSimonian-Laird weights for random effects models, and a forest plot was generated.

Heterogeneity was assessed using the inverse-variance random-effects model, with a significance level set at p < .05. The I index was estimated to gauge heterogeneity, with interpretations as follows: 0% to 40% indicating no significant heterogeneity, 30% to 60% indicating moderate heterogeneity, 50% to 90% indicating substantial heterogeneity, and 75% to 100% indicating considerable heterogeneity.

Three sensitivity analyses were conducted to evaluate stability, including:

• A sub-analysis considering only high-quality studies.

• A sub-analysis based on study sample size (343+ vs. <343 patients), with the median value of the sample from included studies used to define the cutoff.

• Exclusion of one study at a time to assess potential distortions and ensure the robustness of conclusions.

Statistical analyses were performed using STATA MP18 software.

Results

Identification of relevant studies

The process of article selection adhered to the PRISMA guidelines,²⁸ with the flowchart illustrating this procedure presented in Figure 1. Initially, a total of 165 articles were sourced from three databases: 48 from ISI Web of Knowledge, 68 from Scopus, and 49 from MEDLINE/PubMed. After eliminating duplicate articles across databases and applying the predetermined inclusion and exclusion criteria, 31 studies were deemed eligible. Within this selection, three studies were excluded due to unavailability of full text, and two did not meet the inclusion criteria. Consequently, 26 studies were deemed eligible and fulfilled the inclusion criteria,^30–55 among which 23 were included in the quantitative analysis^30–52 (Table 1). Overall, 28 studies were excluded for failing to meet the specified criteria.

Figure 1. Flowchart of the bibliographic research.

Quality assessment

The NOS was diligently employed to evaluate the quality of the quantitative studies included in the analysis. Results indicated that 60.9% of the studies attained a high-quality rating (Table 1).

Pooled analysis

The pooled prevalence of COVID-19 VH among 9,927 patients was estimated at 27.2% (95%CI: 20.6–34.2%; I² = 98.3%; p-value for heterogeneity < 0.0001; Figure 2). Upon exclusively considering high-quality articles, the pooled prevalence decreased to 25.4% (95%CI: 16.5–35.5%; I² = 98.8%; p < .0001). Comparing studies based on sample size, the pooled VH was 28.4% (95%CI: 18.6–39.4%; I² = 98.3%; p < .0001) in studies with a sample size larger than 343 patients and 26.0% (95%CI: 18.0–34.4%; I² = 95.6%; p < .0001) in studies with a smaller sample size (p-value for the test of heterogeneity between sub-groups = 0.734). Furthermore, sensitivity analysis by excluding one study at a time revealed no significant distortion from any specific paper.

Figure 2. Forest plot of the pooled prevalence of COVID-19 vaccine hesitancy.

The prevalence of vaccine uptake for the third dose, estimated among 753 patients, was 27.3% (95%CI: 24.2–30.5%). Due to the limited number of eligible studies investigating this topic (n = 2), sensitivity analyses were not performed.

In the sub-analysis by continents, the pooled prevalence of VH was 32.9% (95%CI: 21.6–45.3%; I² = 97.5%; p < .0001) in Asia, 27.8% (95%CI: 18.7–37.9%; I² = 98.6%; p < .0001) in Europe, 19.4% (95%CI: 1.0–51.1%) in North America, and 16.7% (95%CI: 14.1–19.4%) in Oceania (Figure 3). The p-value for the test of heterogeneity between subgroups was 0.006. Sensitivity analyses did not reveal any significant distortion.

Figure 3. Forest plot of the pooled prevalence of COVID-19 vaccine hesitancy, per continent.

A significant relationship was evidenced between COVID-19 vaccine compliance and receiving advice from a gastroenterologist or healthcare professional regarding COVID-19 vaccination (OR: 2.77; 95%CI: 1.79–4.30; I² = 43.0%; p = .170; Figure 4).

Figure 4. Forest plot of the association between COVID-19 vaccine compliance and receiving advice from a gastroenterologist or healthcare professional regarding COVID-19 vaccination.

Systematic review

Role of healthcare professionals in promoting immunization

In the context of vaccination decision-making, patients with IBD have identified several key groups as valuable sources of guidance. Gastroenterologists emerged as the most commonly mentioned by patients, followed by general practitioners, pharmacists, and IBD nurses.⁴⁵ Notably, Napolitano D et al.⁴⁸ specifically examined the role of IBD nurses in promoting vaccination among Italian patients with IBD. Their findings indicated that IBD nurses are perceived as competent by patients, suggesting an opportunity for them to organize educational events within IBD clinics aimed at increasing vaccination rates by providing informative sessions to patients. Additionally, Caron B et al.³⁴ proposed that patient associations can serve as essential intermediaries between healthcare providers and patients, advocating for increased involvement in patient management. These groups may enhance patient compliance with healthcare providers’ recommendations by fostering close collaboration.

Communication with patients

The significance of the patient’s relationship with their gastroenterologist and healthcare provider is emphasized in two key aspects: as a source of relief and as a vital information resource.^{30,33,34,36,37,40,44–46,55} As elucidated by Łodyga M et al.,⁴² healthcare professionals must engage in comprehensive discussions with patients, carefully evaluating the pros and cons of vaccination to arrive at informed decisions tailored to each individual’s unique circumstances. Ensuring effective management of patients with IBD requires that gastroenterologists maintain up-to-date knowledge regarding the efficacy and safety of the SARS-CoV-2 vaccine. This empowers them to furnish patients with IBD clear and well-founded information and guidance.^34,39,54 Furthermore, an imperative task lies in presenting a comprehensive description of the favorable risk-benefit ratio, supported by transparent efficacy data, and offering reassurance regarding vaccine safety.⁵⁵ IBD providers should take on the role of COVID-19 vaccine advocates for their patients, providing apt counseling and leveraging available resources to ensure equitable vaccine access among their patient cohort.⁴¹ Frequent interactions with healthcare providers and secure vaccination options within IBD centers have been identified as significant factors contributing to enhanced patient vaccination attitudes.^31,47 Moreover, establishing dedicated services can bolster adherence to vaccination programs for patients with IBD, fortifying their protection against vaccine-preventable diseases.⁴¹

IBD centers

The performance of IBD centers before the vaccination campaign was assessed in a study by Bhat S et al.⁵³ In this study, the authors interviewed providers from 75 IBD centers across the United States in September and October 2020. The findings revealed that approximately 36% of the respondents faced challenges in administering vaccines due to one or more of the following barriers: (i) inability to stock vaccines due to cost constraints; (ii) inadequate storage facilities; (iii) a shortage of staff for vaccine administration; (iv) concerns related to reimbursement. General concerns surrounding vaccine provision included issues with reimbursement, insufficient time to obtain a vaccine history, and limitations in terms of time, supplies, and resources for vaccine administration. Regarding the prospective COVID-19 vaccine, 85% of providers expressed their intention to recommend it to their patients. However, it was reported that only 27% of the centers would likely stock the vaccine once it became available.⁵³

Strategies to enhance vaccine uptake

Numerous strategies have been proposed to enhance compliance with vaccination among IBD patients. These strategies encompass referring patients to primary care, providing prescriptions for vaccinations at pharmacies, utilizing electronic health records for patient and provider reminders, improving the convenience and accessibility of vaccination services, targeting specific population groups, and enlisting influential individuals to advocate for vaccination promotion.^53,54 Papa A et al.⁵⁴ suggested that openly declaring a healthcare provider’s vaccination status, such as using “I am vaccinated” pins or stickers or via social media campaigns, could be a significant motivational tool to steer patients toward vaccination choices. Hudhud D et al.⁴¹ presented the outcomes of an initiative designed to educate IBD patients and address their concerns regarding vaccinations. In this initiative, the authors developed an informative video focused on COVID-19 vaccines to assess whether such an intervention could enhance patients’ willingness to receive the COVID-19 vaccine. The video, featuring a gastroenterologist as the presenter, delved into the rationale behind COVID-19 vaccines and emphasized their efficacy and safety, particularly concerning patients with IBD. Following the video presentation, a survey covered demographic inquiries, vaccination intentions, and vaccination-related concerns. This initiative targeted unvaccinated patients at their centers once the COVID-19 vaccine had become widely available to all adults in the United States. A total of 45 patients participated in the initiative. After watching the video, 43 of the 45 respondents expressed being “absolutely certain” or “very likely” to receive the COVID-19 vaccine. Furthermore, 35 of the 45 patients found the information presented in the video to be “very helpful” or “somewhat helpful” in making informed decisions regarding COVID-19 vaccination.

Determinants of vaccine hesitancy

Gastroenterologists and healthcare providers need to be well-informed about the recognized determinants of VH. This knowledge enables a more precise understanding of patients’ requirements and facilitates effective strategies to address their concerns and promote vaccination. Numerous studies have pinpointed key factors contributing to negative attitudes toward vaccination, including a lack of information about vaccines, concerns about vaccine safety, a history of prior COVID-19 infection, distrust in pharmaceutical companies, and fear of potential adverse events.^{31–32,34–36,40–42,44–45,47–49,52} Several authors have reported that patients often express concerns that vaccination could worsen their preexisting conditions, such as IBD and other chronic illnesses.^{33,36,40,42,45} The impact of medications on vaccine attitudes remains unclear.^35,39,51,52 Influence from family members and friends and a sense of social responsibility to protect vulnerable individuals have been observed to affect vaccination compliance.^{30,42,45,46,51} Furthermore, individuals who perceive themselves at a higher risk for COVID-19 tend to exhibit a more positive attitude toward vaccination.^36,42,43,45 Conversely, those relying heavily on mass and social media for information tend to have higher vaccine hesitancy.^37,42 In contrast, individuals with higher levels of education and access to information from credible scientific sources tend to be more accepting of vaccines.^{36,37,39,45,47} Notably, a significant determinant of vaccination compliance is the individual’s history of prior vaccinations, particularly the influenza vaccine.^{36,37,42,46,50,51} Gender-wise, higher compliance rates are often observed among males,^{36–38,51,52} and various studies have suggested reduced hesitancy among older individuals.^{33,35,37,39,42,49,50} Understanding these factors is crucial for healthcare providers to effectively address vaccine hesitancy among their patients, particularly in promoting COVID-19 vaccination

Critical issues

Some studies have raised concerns about the effectiveness of gastroenterologists in promoting immunization. For instance, Ferreiro-Iglesias R et al.³⁸ found that although physicians generally supported the SARS-CoV-2 vaccine, IBD patients were unwilling to accept vaccination. Łodyga M et al.⁴² reported that a significant proportion of unvaccinated individuals cited contraindications provided by doctors as their reason for not getting vaccinated, along with the requirement for specialist certificates before vaccination qualification.

Discussion

Our meta-analysis determined that the VH among patients with IBD worldwide is approximately 27.2% (95% CI = 20.6–34.2). When comparing this figure to COVID-19 VH rates reported for other high-risk subgroups, we find similarities with patients with diabetes (28%; 95% CI = 16–42%),⁵⁶ lower rates compared to pregnant and breastfeeding women (48%; 95% CI = 43–53%)⁵⁷ and people living with HIV (38%; 95% CI = 31–44%),⁵⁸ and higher rates compared to healthcare workers (13%; 95% CI = 7–21%).⁵⁹ Disparities in vaccine adoption become evident in our continent-based sub-analysis, with higher adoption rates observed in Western countries and lower rates in Asia. These disparities are not unexpected, as the scientific literature consistently underscores reduced vaccine coverage in less developed countries compared to their counterparts in more developed regions. Such discrepancies primarily stem from socioeconomic factors and barriers to vaccine accessibility.^60,61

Our meta-analysis has evidenced a statistically significant association between a favorable COVID-19 vaccine attitude and receiving guidance from a gastroenterologist or healthcare provider (OR = 2.8; 95%CI = 1.8–4.3). Our findings underscore the pivotal role gastroenterologists and healthcare providers play in promoting COVID-19 vaccination among individuals with IBD. Through resolving concerns, providing accurate information, and cultivating trust, gastroenterologists can contribute significantly to the enhanced protection and outcomes of individuals with IBD throughout the pandemic. Notably, our findings align with a 2021 systematic review that explored vaccination rates for influenza, pneumococcal pneumonia, and hepatitis B vaccines and the determinants of VH among individuals with IBD. This review revealed suboptimal vaccine coverage within this subgroup, highlighting the crucial role of gastroenterologists in educating and initiating vaccination among their patients. Insufficient vaccine-related knowledge and an inadequate awareness of the necessity for vaccination emerged as the primary reasons for VH.⁶² The literature also delves into the impact of consultations with other specialists, demonstrating that appropriate consultations can improve patient attitudes.^25–27 A 2019 study assessed the influence of specialized infectious disease consultations on vaccination coverage rates among patients with gastrointestinal cancer or IBD, revealing a significant enhancement in patients’ knowledge about vaccination and vaccination coverage as a result of such consultations.⁶³ Additionally, Narula et al.⁶⁴ reported a high frequency of H1N1 vaccination among patients with IBD who visited their General Practitioner at least once annually. In light of these findings, the opportunity to work within multidisciplinary teams emerges as a promising approach for patient management and optimizing immunization rates.⁶⁵

The involvement of gastroenterologists in advocating for vaccinations among patients with IBD is crucial. These specialized medical professionals possess a deep understanding of the unique healthcare requirements of individuals with IBD. They can offer personalized advice concerning the safety and effectiveness of vaccines, providing reassurance tailored to the needs of this at-risk group. Drawing on their expertise, gastroenterologists can offer well-informed recommendations that account for each patient’s disease status, treatment regimen, and overall health condition. This proactive approach not only prioritizes the well-being of patients with IBD but also supports broader public health objectives by encouraging vaccination uptake within this frail population. Indeed, gastroenterologists’ depth of knowledge and close patient-provider relationships with individuals suffering from IBD can significantly enhance their ability to address the specific factors contributing to VH, as highlighted in our review. Firstly, gastroenterologists’ extensive understanding of IBD and its nuances allows them to provide tailored patient information. They can explain how vaccines interact with the unique aspects of IBD, assuaging concerns about potential exacerbation of their condition. This personalized approach is more likely to resonate with patients who might be hesitant due to the fear of worsening their IBD symptoms. Secondly, these specialists are well-versed in the medications and treatments used in IBD management. They can discuss the compatibility of vaccines with ongoing treatments, addressing any misconceptions or fears regarding potential interactions. This expertise helps patients make informed decisions about vaccination. Moreover, the established trust and rapport between patients and gastroenterologists create a conducive environment for open dialogue. Patients are more likely to express their concerns, allowing gastroenterologists to provide targeted reassurance and address misconceptions, ultimately alleviating vaccine hesitancy. By leveraging their knowledge of IBD, familiarity with patient histories, and trusted patient-doctor relationships, gastroenterologists are pivotal in promoting vaccination and tailoring their approach to each patient’s needs and concerns. This patient-centered care is crucial in increasing vaccine acceptance among individuals with IBD, contributing to better public health outcomes.

Maintaining current knowledge about vaccines in the context of IBD is paramount for gastroenterologists.²⁷ Their expertise ensures that patients receive accurate and personalized advice, considering the specific nuances of their condition, medications, and individual health status. Staying updated allows gastroenterologists to navigate potential interactions between IBD treatments and vaccines, minimizing risks and maximizing benefits. This proactive approach safeguards patient well-being and fosters patient trust in their gastroenterologists, facilitating better compliance with vaccination recommendations and contributing to overall public health efforts.⁶⁶

One primary limitation of our meta-analysis was the significant heterogeneity observed among the included studies, as indicated by the I² values. However, the utilization of a random-effects analysis helped mitigate this potential bias to some extent. Additionally, the majority of research in this area has primarily originated from developed nations, with a notable lack of studies from regions such as Africa and South America. As a result, a significant portion of the global landscape remains underrepresented in the existing literature. Nevertheless, our review and meta-analysis possess a notable strength in the form of a substantial sample size derived from the aggregation of selected studies. This increased sample size has positively influenced the statistical analysis and contributed to a more comprehensive understanding of COVID-19 vaccine hesitancy among individuals with IBD. However, a notable strength of our study lies in estimating the OR on the association between COVID-19 vaccine compliance and the influence of gastroenterologists and healthcare providers. This aspect had not been previously assessed in the existing literature.

In summary, fostering collaboration among a diverse team of healthcare professionals involved in the care of individuals with IBD, including general practitioners, public health experts, and specialists, is highly recommended. While there have been challenges and concerns regarding VH among some IBD patients, mainly related to misinformation, fear of exacerbating existing conditions, and distrust in pharmaceutical companies, gastroenterologists can play a crucial role in addressing these issues. By providing accurate information, discussing the benefits and risks of vaccination, and actively advocating for vaccination, gastroenterologists and healthcare providers can help increase vaccine acceptance rates within this vulnerable patient population. This role appears to be crucial, extending beyond direct patient care to include preventing complications from infectious diseases. Exacerbations of IBD can lead to increased hospitalizations, placing a more significant burden on specialists, escalating clinical challenges, and incurring additional community expenses. Equally important is the active involvement of healthcare facilities in vaccination strategies, proactively offering vaccinations to chronic patients, as evidenced in the literature for other high-risk populations.^67,68 Integrating infectious risk mitigation into the care pathways of IBD patients is of utmost importance. By reducing the likelihood of complications, we can improve patient management, enhance their quality of life, and reduce hospitalizations, mortality rates, and associated complications.

Footnote page

The study was funded by the Italian Ministry of Health, RC2023.

The authors declare that they have no competing interests.

The manuscript has not been presented at a meeting.

Abbreviations

IBD	=	Inflammatory Bowel Disease
CDC	=	Center for Disease Control and Prevention
WHO	=	World Health Organization
VH	=	Vaccine Hesitancy

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.