Crohn’s and Colitis Canada’s 2021 Impact of COVID-19 & Inflammatory Bowel Disease in Canada: A Knowledge Translation Strategy

Abstract The prevalence of inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, in Canada, is over 0.75% in 2021. Many individuals with IBD are immunocompromised. Consequently, the World Health Organization’s declaration of a global pandemic uniquely impacted those with IBD. Crohn’s and Colitis Canada (CCC) formed the COVID-19 and IBD Taskforce to provide evidence-based guidance during the pandemic to individuals with IBD and their families. The Taskforce met regularly through the course of the pandemic, synthesizing available information on the impact of COVID-19 on IBD. At first, the information was extrapolated from expert consensus guidelines, but eventually, recommendations were adapted for an international registry of worldwide cases of COVID-19 in people with IBD. The task force launched a knowledge translation initiative consisting of a webinar series and online resources to communicate information directly to the IBD community. Taskforce recommendations were posted to CCC’s website and included guidance such as risk stratification, management of immunosuppressant medications, physical distancing, and mental health. A weekly webinar series communicated critical information directly to the IBD community. During the pandemic, traffic to CCC’s website increased with 484,755 unique views of the COVID-19 webpages and 126,187 views of the 23 webinars, including their video clips. CCC’s COVID-19 and IBD Taskforce provided critical guidance to the IBD community as the pandemic emerged, the nation underwent a lockdown, the economy reopened, and the second wave ensued. By integrating public health guidance through the unique prism of a vulnerable population, CCC’s knowledge translation platform informed and protected the IBD community.


Introduction
Roughly 300,000 people are living with inflammatory bowel disease (IBD) in Canada in 2021, and this number is expected to exceed 400,000 by 2030 (1)(2)(3). The prevalence of IBD in Canadians is estimated to have risen roughly 50% in the last 10 years (from 0.55% of the Canadian population in 2010 to 0.76% in 2020), and is expected to increase to 1% of the Canadian population by 2030 ( Figure 1) (2,4). Seniors (those aged 65+) with Crohn's disease or ulcerative colitis represent the fastest-growing group of Canadians with IBD and face complications associated with longer disease duration alongside other age-related comorbidities (5,6). On the opposite end of the age spectrum, children with IBD are at risk of unique disease complications, such as impairment of linear growth, and may respond differently to treatments or be at greater risk of related side effects as compared to adults (7).
The World Health Organization (WHO) declared the novel SARS-CoV-2 outbreak a global pandemic on March 11, 2020 (8); this immediately raised concerns among individuals suffering from immune-mediated diseases and their healthcare providers. Given the paucity of knowledge early in the pandemic, the rapid dissemination of information, and the potential susceptibility of immunocompromised people living with IBD, the Scientific and Medical Advisory Council (SMAC) of Crohn's and Colitis Canada (CCC) instituted a task force to make evidence-based recommendations to people with IBD. In order to deliver expert recommendations and answers to the IBD community, CCC launched a knowledge translation initiative consisting of a webinar series and online resources.
In this article, we detail the dynamic and iterative process of the knowledge translation initiatives developed to inform and protect the IBD community during the first year of the pandemic.

CROHN'S AND COLITIS CANADA'S COVID-19 AND IBD TASKFORCE
On March 12, 2020, the SMAC of CCC met to discuss the COVID-19 pandemic and its potential impact on the IBD community. Together with CCC leadership, the Council agreed that a broader group of experts was necessary to determine recommendations for the IBD community considering the general lack of knowledge on risk factors and scarcity of supporting scientific evidence. On March 17, 2020, the COVID-19 and IBD Taskforce convened via videoconference with representatives from across Canada, including: adult and pediatric gastroenterologists (GIs), IBD nurses, infectious

Key Points
• During the COVID-19 pandemic, one of the most essential health services has been the communication of expert health information and population-level advice; for the IBD population, this was achieved through expert-created online materials and frequent webinars geared towards a public audience.
• Because the epidemiology of the COVID-19 pandemic differed by region, emphasis is placed on providing the best information possible so that people with IBD can assess their personal risk based on personal health risk factors, ability to stay home, and the state of local outbreaks.
• In addition to increased web content and topical webinars, one of the most effective tools at communicating expert information to the IBD population were short topical videos spliced from the full webinar series that allowed individuals to search and find answers to specific questions related to their personal risk and/or the COVID-19 pandemic. diseases experts, scientists, public health officials, communications and government relations experts, and patient advisors ( Figure 2).
The Taskforce met weekly from March 17, 2020 through June 16, 2020 during the first wave of the pandemic in Canada, and reconvened with monthly meetings in September 2020 to address the second wave. The main deliverable of this group was guidance for the IBD community with the caveat that COVID-19 knowledge was evolving rapidly, and recommendations would be reviewed and revised regularly. Topics covered during these online videoconferences largely reflected questions and concerns posed directly by the IBD community and informed the knowledge translation campaign championed by CCC.
Over the course of the pandemic, it became clear that Canada's COVID-19 epidemiology differed by region. The central prairie region (Manitoba and Saskatchewan) and most of the Atlantic region (New Brunswick, Prince Edward Island, Nova Scotia, and Newfoundland and Labrador) initially had low to medium case counts, but were able to limit the spread of the virus early on and experienced fewer total cases (9). In order to respect the local epidemiology of the pandemic in different jurisdictions within Canada, an emphasis was placed on providing the most up-to-date information available, and encouraging the IBD community to assess their personal risk. However, viewers were urged to contact their own healthcare providers for individual health advice. The general guidance provided considered factors such as age, medications, and comorbid conditions.

TASKFORCE RECOMMENDATIONS
Recommendations were based on available evidence that included guidelines from gastroenterology societies (e.g., the International Organization for the Study of IBD [IOIBD]), experience from prior viral outbreaks, and current public health guidance modified for the needs of the IBD community (9)(10)(11). Recommendations were dynamic as knowledge and global penetrance of SARS-CoV-2 was expanding rapidly; thus, recommendations were frequently updated to reflect new data and were communicated to the IBD community in almost real-time. The Taskforce determined that recommendations should be presented within the context of various risk factors such as: age, comorbidities, status of disease (i.e., new diagnosis, current or recent flare, or remission), and medications (e.g., corticosteroids, biologics). The goal was to offer guidance to the IBD community so that individuals could assess their own IBD profile and minimize their own personal risk. Recommendations were posted to CCC's website. An explicit statement that the recommendations should supplement, but not replace, the recommendations made by an individual's physician or local public health authority was included in all communication. Detailed information made available included FAQ sheets and video clips from a weekly webinar series (Table 1). Over the first six months of the pandemic, recommendations evolved. New evidence emerged regarding risk factors, transmissibility, and medications that may exacerbate negative outcomes from agencies like the Public Health Agency of Canada, the WHO, and Centers for Disease Control in the United States (9,12,13). The breadth of knowledge regarding COVID-19 and IBD-specific risk factors also grew (14,15).
Our understanding of COVID-19 outcomes specific to the IBD community came through multiple data sources (16,17), including the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) registry (14,15). SECURE-IBD is a physician self-report database that collects information on global cases of COVID-19 occurring in people with IBD (14,15). The registry data includes: disease type (Crohn's disease or ulcerative colitis), disease activity (remission, mild, moderate/severe, unknown), age, sex, medications for IBD, country of origin, and outcomes of COVID-19 Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. S2 S13 (recovery, hospitalization, death). An online interactive map displays the data captured in SECURE-IBD (18). The first case was reported to the registry on March 13, 2020, and as of March 19, 2021, 5596 cases have been reported to the registry. Based on the SECURE-IBD data, the most significant risk factors for negative outcomes of COVID-19 were identified as age, active disease (defined by physician global assessment), and prednisone use (14,15). Moreover, people with IBD on biologics did not have increased risk of severe complications of COVID-19 (i.e., need for hospitalization, intensive care, or death). The evidence from the registry supported a central message of the CCC COVID-19 and IBD Taskforce: People with IBD in clinical remission on medications and without infectious symptoms should not stop their treatments. This message was consistently delivered through the three waves of the pandemic that saw daily cases of COVID-19 diagnosis in Canada peak at over nearly 9000 cases per day in April 2021 ( Figure 3).

WEBINAR SERIES
The core strategy of the knowledge translation initiative was a weekly webinar series moderated by the co-chairs of the CCC COVID-19 and IBD Taskforce (GGK & EIB). These webinars were developed as the primary mechanism to communicate critical information directly to the IBD community in a manner that was accessible to a broad audience. The webinars were promoted through email membership and volunteer lists compiled by CCC, as well as CCC's social media network (Facebook, Twitter and Instagram). As with the topics for Taskforce discussion, content was developed based on questions received directly from the IBD community in a questionnaire filled out during registration for the webinars, from the live chat during the webinar broadcast, or from the postwebinar surveys deployed to all webinar registrants. The direct connection to people with IBD and their families addressed the critical requirement for effective knowledge translation with information directly relevant to the audience (19).
Questions and concerns were discussed by Taskforce members who collectively determined suitable experts to participate in upcoming webinars as panellists (Figure 2). An illustrative example was the concerns expressed by many individuals regarding infusion clinics very early on in the pandemic: Were they safe, and should those scheduled for infusions keep their appointments? The Taskforce gathered a panel of representatives from infusion clinics across the country to share how they were working together to ensure everyone's safety through measures that include: Physical distancing (the removal of some infusion chairs to allow for physical distancing during treatment), sanitation, and pre-screening. The resulting webinars were wellreceived and encouraged the IBD community to express further

COVID-19-and-IBD/Diet-and-Nutrition
Your wellbeing Overviews mental health and wellness, including mechanism for coping with stress and anxiety.

https://crohnsandcolitis.ca/About-Crohn-s-Colitis/ COVID-19-and-IBD/Mental-Health-and-Wellness
Information for health professionals Section for healthcare professionals including an overview of the SECURE-IBD Registry and resources for their persons with IBD. https://crohnsandcolitis.ca/About-Crohn-s-Colitis/

Guidance/Recommendations
Travel and physical distancing Discusses restrictions on travel and appropriate physical distancing during the pandemic.

https://crohnsandcolitis.ca/About-Crohn-s-Colitis/ COVID-19-and-IBD/Guidance/Medications
Children and teens Reviews the risk associated with COVID-19 for children and adolescents with IBD. Discussion of risks associated with returning to in-person school.

https://crohnsandcolitis.ca/About-Crohn-s-Colitis/ COVID-19-and-IBD/Guidance/Children-with-IBD
Reopening of the economy Provides guidance for adults and seniors with IBD as the lockdown ended and the economy re-opened.

https://crohnsandcolitis.ca/About-Crohn-s-Colitis/ COVID-19-and-IBD/Guidance/Pregnancy-and-Newborns
Family members of patients with IBD Explains actions that family members can take to support their household member with IBD.

https://crohnsandcolitis.ca/About-Crohn-s-Colitis/ COVID-19-and-IBD/Guidance/Family-Membersof-People-with-IBD
Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. S2 S15 concerns and topics of importance, including: Mental health; children; pregnancy; risk factors of specific medications; and what to do as businesses, the economy and schools reopened. The format of every webinar included an introduction by CCC; an update on the epidemiology of COVID-19 by SMAC Chair, Dr. Gilaad Kaplan; an update of the Taskforce recommendations and review of changes to the website by SMAC Chair-Elect, Dr. Eric Benchimol; followed by the topic segment, usually a guest presentation on the topic and a panel discussion with experts. After each webinar, a pertinent discussion was selected to produce two-to-five-minute segments and posted online.
The epidemiologic update included weekly presentations using data from Johns Hopkins University to illustrate the global epidemiology of COVID-19 (20), data from Public Health Agency of Canada that illustrated the details (including health outcomes) of confirmed Canadian cases of COVID-19 (9), and an update from the SECURE-IBD registry that illustrated IBD-specific cases of COVID-19 (14,15,18). The epidemiology update was usually followed with one or two case studies prepared for a lay audience to illustrate a key piece of evidence, such as projected possible waves of COVID-19 in comparison to the 1918 influenza pandemic, or case studies that highlight risk of virus transmission. After the epidemiology and Taskforce recommendation updates, webinars focused on a particular topic in an episodic nature where a panel of experts was invited to give presentations to the audience or have a virtual round-table discussion. The topics covered in each of the webinars, as well as the confirmed COVID-19 cases globally, in Canada, and in SECURE-IBD at the time of each webinar are presented in Table 2.
A detailed Frequently Asked Questions document was developed from the webinar presentations that was curated into a web-based information source on the CCC website. The answers to the questions contained links to pertinent clips from webinars in order to provide more detailed information and an alternate form of information delivery. The webinars were archived on CCC's YouTube channel, and on CCC's webpage. View counts of the archived videos were typically four to five times those of the live webinars ( Table 2). For specific topics related to recommendations made on the guidance webpages, webinar videos were spliced into segments of 5 min or less and embedded next to the recommendations on the webpage; this allowed readers of the webpage to watch the related webinar segment with experts discussing the reasoning and scientific evidence behind the recommendations.

IMPACT
The webinars and digital CCC resources were promoted through social media and email notifications to the IBD Title

CONCLUSION
CCC was able to quickly assemble the COVID-19 and IBD Taskforce at the outset of the global pandemic. The Taskforce members have met and continue to meet regularly in an effort to ensure that the IBD community has the best available information to support them as they navigate a new reality with COVID-19. Direct communication from the Taskforce and the expert community in Canada to people with IBD and caregivers through a webinar series was an effective and efficient knowledge translation vehicle. The spring webinars ably guided the vulnerable IBD community from a population-wide lockdown in March 2020 through to an understanding of risk and appropriate measures to ensure physical and mental health during the re-opening of the country over the summer and through the