Forecasting the Incidence and Prevalence of Inflammatory Bowel Disease: A Canadian Nationwide Analysis

INTRODUCTION

Canada has a high burden of inflammatory bowel disease (IBD). Historical trends of IBD incidence and prevalence were analyzed to forecast the Canadian burden over the next decade.

METHODS

Population-based surveillance cohorts in 8 provinces derived from health administrative data assessed the national incidence (2007-2014) and prevalence (2002-2014) of IBD. Autoregressive integrated moving average models were used to forecast incidence and prevalence, stratified by age, with 95% prediction intervals (PI), to 2035. The average annual percentage change (AAPC) with 95% confidence interval (CI) was calculated for the forecasted incidence and prevalence.

RESULTS

The national incidence of IBD is estimated to be 29.9 per 100,000 (95% PI 28.3-31.5) in 2023. With a stable AAPC of 0.36% (95% CI -0.05 to 0.72), the incidence of IBD is forecasted to be 31.2 per 100,000 (95% PI 28.1-34.3) in 2035. The incidence in pediatric patients (younger than 18 years) is increasing (AAPC 1.27%; 95% CI 0.82-1.67), but it is stable in adults (AAPC 0.26%; 95% CI -0.42 to 0.82). The prevalence of IBD in Canada was 843 per 100,000 (95% PI 716-735) in 2023 and is expected to steadily climb (AAPC 2.43%; 95% CI 2.32-2.54) to 1,098 per 100,000 (95% PI 1,068-1,127) by 2035. The highest prevalence is in seniors with IBD (1,174 per 100,000 in 2023; AAPC 2.78%; 95% CI 2.75-2.81).

DISCUSSION

Over the next decade, the Canadian health care systems will contend with the juxtaposition of rising incidence of pediatric IBD and a rising prevalence of overall IBD driven by the aging population.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Epidemiology of IBD

Inflammatory bowel disease (IBD), consisting of Crohn's disease and ulcerative colitis, is recognized across the world, though Canada has among the highest burdens of IBD in the world. The Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC) led a six-province study that demonstrated the compounding prevalence of IBD in Canada from 400 per 100,000 in 2002 to 636 per 100,000 in 2014. The prevalence in 2023 is estimated at 825 per 100,000, meaning that over 320,000 people in Canada are living with IBD. Prevalence is forecasted to rise by 2.44% per year such that 1.1% of the population, 470,000 Canadians, will live with IBD by 2035. The overall incidence of IBD in 2023 is 30 per 100,000 person-years, indicating that over 11,000 Canadians will be newly diagnosed with IBD in 2023. Incidence is forecasted to rise by 0.58% per year up to 32.1 per 100,000 by 2035. The rising incidence of IBD is propelled by pediatric-onset IBD, which is rising by 1.23% per year from 15.6 per 100,000 in 2023 to 18.0 per 100,000 in 2035. In contrast, incidence rates among adults and seniors are relatively stable. Understanding the determinates of IBD has expanded through prospective cohort studies such as the Crohn's and Colitis Canada Genetic, Environmental, Microbial (CCC-GEM) project. Consensus recommendations towards diet, lifestyle, behavioural and environmental modifications have been proposed by international organizations with the goal of optimizing disease control and ultimately preventing the development of IBD. Despite these efforts, Canadian healthcare systems will need to prepare for the rising number of people living with IBD.

Adverse Events and Serological Responses After SARS-CoV-2 Vaccination in Individuals With Inflammatory Bowel Disease

INTRODUCTION

We determined adverse events after 4 doses of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccine in those with inflammatory bowel disease (IBD), associations between antibodies and injection site reactions (ISR), and risk of IBD flare.

METHODS

Individuals with IBD were interviewed for adverse events to SARS-CoV-2 vaccine. Multivariable linear regression assessed the association between antibody titers and ISR.

RESULTS

Severe adverse events occurred in 0.03%. ISR were significantly associated with antibody levels after the fourth dose (geometric mean ratio = 2.56; 95% confidence interval 1.18-5.57). No cases of IBD flare occurred.

DISCUSSION

SARS-CoV-2 vaccines are safe for those with IBD. ISR after the fourth dose may indicate increased antibodies.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Executive Summary

The burden of inflammatory bowel disease (IBD) (i.e., associated direct and indirect costs, prevalence of disease, personal impact to the individual and to caregivers) continues to increase in Canada. The prevalence of IBD has increased since Crohn's and Colitis Canada's 2018 Impact of IBD report from an estimated 270,000 Canadians living with IBD in 2018 to an estimated 322,600 Canadians living with IBD today in 2023. Consequently, associated costs of IBD have also dramatically increased from an estimated $2.57 billion in 2018 to an estimated $5.38 billion in 2023; this increase is due to multiple factors including increased prevalence of disease, inflation, and additional identified factors (e.g., presenteeism, costs of childcare). Beyond the economic impact of IBD, these diseases have a significant impact on people living with the disease and their caregivers, including different presentations of disease, different commonly associated extra-intestinal manifestations or comorbid conditions, and different barriers to accessing care. In this supplementary issue, we review: Evolving trends in the epidemiology of IBD; updated estimates of indirect and direct costs (including out-of-pocket costs) associated with IBD; information specific to IBD in children, adolescents, and seniors; issues related to IBD pertaining to sex and gender; information specific to risks associated with COVID-19 and cancer related to IBD; an overview of current treatments for IBD; and evolving care models, including access to care.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Special Populations-Children and Adolescents with IBD

Rates of inflammatory bowel disease (IBD) in Canadian children and adolescents are among the highest in the world, and the incidence is rising most rapidly in children under five years of age. These young children may have either a typical form of IBD with multi-factorial aetiology, or they may have a monogenic form. Despite the growing number of children in Canada living with this important chronic disease, there are few available medical therapies approved by Health Canada due to the omission of children from most clinical trials of newly developed biologics. As a result, off-label use of medications is common, and physicians have learned to use existing therapies more effectively. In addition, most Canadian children are treated in multidisciplinary, specialty clinics by physicians with extra training or experience in IBD, as well as specialist nurses, dietitians, mental health care providers and other allied health professionals. This specialized clinic approach has facilitated cutting edge research, led by Canadian clinicians and scientists, to understand the causes of IBD, the optimal use of therapies, and the best ways to treat children from a biopsychosocial perspective. Canadians are engaged in work to understand the monogenic causes of IBD; the interaction between genes, the environment, and the microbiome; and how to address the mental health concerns and medical needs of adolescents and young adults transitioning from paediatric to adult care.

The 2023 Impact of Inflammatory Bowel Disease in Canada: The Influence of Sex and Gender on Canadians Living With Inflammatory Bowel Disease

Sex (the physical and physiologic effects resulting from having specific combinations of sex chromosomes) and gender (sex-associated behaviours, expectations, identities, and roles) significantly affect the course of inflammatory bowel disease (IBD) and the experience of living with IBD. Sex-influenced physiologic states, like puberty, the menstrual cycle, pregnancy, and andropause/menopause may also impact and be impacted by IBD. While neither Crohn's disease nor ulcerative colitis is commonly considered sex-determined illnesses, the relative incidence of Crohn's disease and ulcerative colitis between males and females varies over the life cycle. In terms of gender, women tend to use healthcare resources at slightly higher rates than men and are more likely to have fragmented care. Women are more commonly prescribed opioid medications and are less likely than men to undergo colectomy. Women tend to report lower quality of life and have higher indirect costs due to higher rates of disability. Women are also more likely to take on caregiver roles for children with IBD. Women with IBD are more commonly burdened with adverse mental health concerns and having poor mental health has a more profound impact on women than men. Pregnant people with active IBD have higher rates of adverse outcomes in pregnancy, made worse in regions with poor access to IBD specialist care. The majority of individuals with IBD in Canada do not have access to a pregnancy-in-IBD specialist; access to this type of care has been shown to allay fears and increase knowledge among pregnant people with IBD.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Indirect (Individual and Societal) and Direct Out-of-Pocket Costs

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one's ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn's and Colitis Canada's 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.

The 2023 Impact of Inflammatory Bowel Disease in Canada: COVID-19 and IBD

The COVID-19 pandemic had a monumental impact on the inflammatory bowel disease (IBD) community. At the beginning of the pandemic, knowledge on the effect of SARS-CoV-2 on IBD was lacking, especially in those with medication-suppressed immune systems. Throughout the pandemic, scientific literature exponentially expanded, resulting in clinical guidance and vaccine recommendations for individuals with IBD. Crohn's and Colitis Canada established the COVID-19 and IBD Taskforce to process and communicate rapidly transforming knowledge into guidance for individuals with IBD and their caregivers, healthcare providers, and policy makers. Recommendations at the onset of the pandemic were based on conjecture from experience of prior viruses, with a precautionary principle in mind. We now know that the risk of acquiring COVID-19 in those with IBD is the same as the general population. As with healthy populations, advanced age and comorbidities increase the risk for severe COVID-19. Individuals with IBD who are actively flaring and/or who require high doses of prednisone are susceptible to severe COVID-19 outcomes. Consequently, sustaining maintenance therapies (e.g., biologics) is recommended. A three-dose mRNA COVID-19 vaccine regimen in those with IBD produces a robust antibody response with a similar adverse event profile as the general population. Breakthrough infections following vaccine have been observed, particularly as the virus continues to evolve, which supports receiving a bivalent vaccine booster. Limited data exist on the impact of IBD and its therapies on long-term outcomes following COVID-19. Ongoing research is necessary to address new concerns manifesting in those with IBD throughout the evolving pandemic.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Treatment Landscape

The therapeutic landscape for inflammatory bowel disease (IBD) has changed considerably over the past two decades, owing to the development and widespread penetration of targeted therapies, including biologics and small molecules. While some conventional treatments continue to have an important role in the management of IBD, treatment of IBD is increasingly moving towards targeted therapies given their greater efficacy and safety in comparison to conventional agents. Early introduction of these therapies-particularly in persons with Crohn's disease-combining targeted therapies with traditional anti-metabolite immunomodulators and targeting objective markers of disease activity (in addition to symptoms), have been shown to improve health outcomes and will be increasingly adopted over time. The substantially increased costs associated with targeted therapies has led to a ballooning of healthcare expenditure to treat IBD over the past 15 years. The introduction of less expensive biosimilar anti-tumour necrosis factor therapies may bend this cost curve downwards, potentially allowing for more widespread access to these medications. Newer therapies targeting different inflammatory pathways and complementary and alternative therapies (including novel diets) will continue to shape the IBD treatment landscape. More precise use of a growing number of targeted therapies in the right individuals at the right time will help minimize the development of expensive and disabling complications, which has the potential to further reduce costs and improve outcomes.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Cancer and IBD

Cancer is a major cause of morbidity and mortality among people with inflammatory bowel disease (IBD). Intestinal cancers may arise as a complication of IBD itself, while extra-intestinal cancers may arise due to some of the immunosuppressive therapies used to treat IBD. Colorectal cancer (CRC) and small bowel cancer risks remain elevated among persons with IBD as compared to age-and sex-matched members of the general population, and the lifetime risk of these cancers is strongly correlated to cumulative intestinal inflammatory burden. However, the cumulative risk of cancer, even among those with IBD is still low. Some studies suggest that IBD-CRC incidence has declined over the years, possibly owing to improved treatment standards and improved detection and management of early neoplastic lesions. Across studies of extra-intestinal cancers, there are generally higher incidences of melanoma, hepatobiliary cancer, and lung cancer and no higher incidences of breast cancer or prostate cancer, with equivocal risk of cervical cancer, among persons with IBD. While the relative risks of some extra-intestinal cancers are increased with treatment, the absolute risks of these cancers remain low and the decision to forego treatment in light of these risks should be carefully weighed against the increased risks of intestinal cancers and other disease-related complications with undertreated inflammatory disease. Quality improvement efforts should focus on optimized surveillance of cancers for which surveillance strategies exist (colorectal cancer, hepatobiliary cancer, cervical cancers, and skin cancers) and the development of cost-effective surveillance strategies for less common cancers associated with IBD.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Direct Health System and Medication Costs

Healthcare utilization among people living with inflammatory bowel disease (IBD) in Canada has shifted from inpatient management to outpatient management; fewer people with IBD are admitted to hospitals or undergo surgery, but outpatient visits have become more frequent. Although the frequency of emergency department (ED) visits among adults and seniors with IBD decreased, the frequency of ED visits among children with IBD increased. Additionally, there is variation in the utilization of IBD health services within and between provinces and across ethnocultural and sociodemographic groups. For example, First Nations individuals with IBD are more likely to be hospitalized than the general IBD population. South Asian children with Crohn's disease are hospitalized more often than their Caucasian peers at diagnosis, but not during follow-up. Immigrants to Canada who develop IBD have higher health services utilization, but a lower risk of surgery compared to individuals born in Canada. The total direct healthcare costs of IBD, including the cost of hospitalizations, ED visits, outpatient visits, endoscopy, cross-sectional imaging, and medications are rising rapidly. The direct health system and medication costs of IBD in Canada are estimated to be $3.33 billion in 2023, potentially ranging from $2.19 billion to $4.47 billion. This is an increase from an estimated $1.28 billion in 2018, likely due to sharp increases in the use of biologic therapy over the past two decades. In 2017, 50% of total direct healthcare costs can be attributed to biologic therapies; the proportion of total direct healthcare costs attributed to biologic therapies today is likely even greater.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Mental Health and Inflammatory Bowel Disease

Psychiatric disorders are 1.5 to 2 times more prevalent in persons with inflammatory bowel disease (IBD) than in the general population, with pooled prevalence estimates of 21% for clinical anxiety and 15% for depression. Rates are even higher when considering mental health symptoms, as nearly one-third of persons with IBD experience elevated anxiety symptoms and one-quarter experience depression symptoms. Rates of these symptoms were much higher during periods of disease activity, more common in women than men, and more common in Crohn's disease than ulcerative colitis. There is robust evidence of the detrimental effects of comorbid depression and anxiety on the subsequent course of IBD based on longitudinal studies tracking outcomes over time. However, psychiatric disorders and IBD have bidirectional effects, with each affecting risk of the other. Elevated mental health concerns have been consistently associated with greater healthcare utilization and costs related to IBD. There is some signal that low resilience in adolescence could be a risk factor for developing IBD and that enhancing resilience may improve mental health and intestinal disease outcomes in IBD. Psychological therapies used to treat anxiety and depression occurring in the context of IBD have been shown to significantly improve the quality of life for persons with IBD and reduce anxiety and depression. There is less evidence in regard to the impact of psychotropic medications on mental health or disease outcomes in persons with IBD. There is consensus, however, that mental health must be addressed as part of comprehensive IBD care for children and adults.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Special Populations-IBD in Seniors

Approximately one out of every 88 seniors has inflammatory bowel disease (IBD), and this is expected to increase in the future. They are more likely to have left-sided disease in ulcerative colitis, and isolated colonic disease in Crohn's disease; perianal disease is less common. Other common diagnoses in the elderly must also be considered when they initially present to a healthcare provider. Treatment of the elderly is similar to younger persons with IBD, though considerations of the increased risk of infections and malignancy must be considered when using immune modulating drugs. Whether anti-TNF therapies increase the risk of infections is not definitive, though newer biologics, including vedolizumab and ustekinumab, are thought to be safer with lower risk of adverse events. Polypharmacy and frailty are other considerations in the elderly when choosing a treatment, as frailty is associated with worse outcomes. Costs for IBD-related hospitalizations are higher in the elderly compared with younger persons. When elderly persons with IBD are cared for by a gastroenterologist, their outcomes tend to be better. However, as elderly persons with IBD continue to age, they may not have access to the same care as younger people with IBD due to deficiencies in their ability to use or access technology.

A170 ADVERSE EVENTS & SEROLOGICAL RESPONSES FOLLOWING SARS-COV-2 VACCINATION IN INDIVIDUALS WITH INFLAMMATORY BOWEL DISEASE

Background

The rapid development and distribution of SARS-CoV-2 vaccines has raised concerns surrounding vaccine safety in immunocompromised populations, such as those with inflammatory bowel disease (IBD).

Purpose

We described adverse events (AEs) following SARS-CoV-2 vaccination in those with IBD and determined relationships between AEs to post-vaccination antibody titres.

Method

Individuals with IBD from a prospective cohort in Calgary, Canada (n=670) who received a 1^st, 2^nd, 3^rd, and/or 4^th dose of a SARS-CoV-2 vaccine (Pfizer-BioNTech, Moderna, and/or AstraZeneca) were interviewed via telephone for AEs using the Adverse Events Following Immunization form. Subsequently, we assessed injection site reaction as a specific AE outcome. Multivariable logistic regression models were used to assess the association between anti-SARS-CoV-2 spike protein antibody (anti-S) levels within 1–12 weeks of vaccination and injection site reaction following 1st, 2nd, and 3rd dose vaccination. Models were adjusted for age, sex, IBD type, IBD medications, vaccine type, and prior COVID-19 infection. Additionally, we evaluated the risk of flare of IBD within 30 days of vaccination via chart review.

Result(s)

Table 1 describes AEs in individuals with IBD following 1^st dose (n=331), 2^nd dose (n=331), 3^rd dose (n=195), and 4^th dose (n=100) of a SARS-CoV-2 vaccine. AEs were reported in 83.3% of participants after 1^st dose, 79.1% after 2^nd dose, 77.4% after 3^rd dose, and 67.0% after 4^th dose. Injection site reaction (pain, redness, etc.) was the most common AE (50.8% of AEs), with fatigue and malaise (18.1%), headache and migraine (8.6%), musculoskeletal discomfort (8.2%), and fever and chills (6.5%) also commonly reported. Multivariable logistic regression determined no associations between anti-S concentration and injection site reaction for all doses. Age above 65 years was associated with decreased injection site reaction following 1^st and 3^rd doses, while female sex and mRNA vaccine type were associated with increased injection site reaction following 1^st and 2^nd doses. Prior COVID-19 infection, IBD type, and medication class were not associated with injection site reaction with any dose. Only one participant was diagnosed with a severe AE requiring hospitalization: Immune thrombocytopenic purpura (ITP) following 2^nd dose of a Pfizer vaccination. No cases of IBD flare occurred within 30 days of vaccination.

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Conclusion(s)

AEs following SARS-CoV-2 vaccination are generally mild and become less common with each consecutive dose. Antibody levels following each dose of the vaccine were not associated with injection site reactions. Females, those under 65 years of age, and those administered mRNA vaccines were more likely to experience an injection site reaction. Prior COVID-19 infection, IBD type, and IBD medication class did not predict injection site reactions. Vaccination was not associated with IBD flare within 30 days of vaccination.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding;

Helmsley

Disclosure of Interest

A. Markovinovic: None Declared, M. Herauf: None Declared, J. Quan: None Declared, L. Hracs: None Declared, J. Windsor: None Declared, N. Sharifi: None Declared, S. Coward: None Declared, L. Caplan: None Declared, J. Gorospe: None Declared, C. Ma Grant / Research support from: Ferring, Pfizer, , Consultant of: AbbVie, Alimentiv, Amgen, Ferring, Pfizer, Takeda, , Speakers bureau of: AbbVie, Alimentiv, Amgen, Ferring, Pfizer, Takeda, R. Panaccione Grant / Research support from: AbbVie, Ferring, Janssen, Pfizer, Takeda, Consultant of: Abbott, AbbVie, Alimentiv, Amgen, Arena, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Genentech, Gilead Sciences, GlaxoSmithKline, Janssen, Merck, Mylan, Oppilan Pharma, Pandion Therapeutics, Pandion Pharma, Pfizer, Progenity, Protagonist, Roche, Sandoz, Satisfai Health, Schering-Plough, Shire, Sublimity Therapeutics, Takeda, Theravance, UCB, Speakers bureau of: AbbVie, Arena, Celgene, Eli Lilly, Ferring, Gilead Sciences, Janssen, Merck, Pfizer, Roche, Sandoz, Shire, Takeda, R. Ingram: None Declared, J. Kanji: None Declared, G. Tipples: None Declared, J. Holodinsky: None Declared, C. Berstein Grant / Research support from: AbbVie, Amgen, Janssen, Pfizer, Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Takeda, D. Mahoney: None Declared, S. Bernatsky: None Declared, E. Benchimol: None Declared, G. Kaplan Grant / Research support from: Ferring, Speakers bureau of: AbbVie, Janssen, Pfizer

A193 DEMOGRAPHIC, SOCIAL AND OCCUPATIONAL FACTORS THAT PREVENTED EXPOSURE TO SARS-COV-2 IN INFLAMMATORY BOWEL DISEASE PATIENTS DURING THE COVID-19 PANDEMIC: A PROSPECTIVE COHORT STUDY

Background

The COVID-19 pandemic caused by the SARS-CoV-2 virus is a rapidly evolving public health emergency in which mundane behaviors such as grocery shopping or restaurant dining are considered high-risk for some, such as persons with inflammatory bowel disease (IBD) who are often immunodeficient due to medications. Research on the behavioral exposures experienced by populations with IBD during the COVID-19 pandemic are lacking.

Purpose

We aim to better understand how the behaviors of persons with IBD are associated with COVID-19 diagnoses.

Method

We conducted a prospective serosurveillance cohort study in Calgary to assess exposure to SARS-CoV-2 from Nov. 1, 2020 to Aug. 8, 2022 in 485 individuals with IBD. A diagnosis of SARS-CoV-2 was defined as a molecular-confirmed PCR test, a self-report home antigen test, or a positive nucleocapsid antibody level. Participants completed a self-report electronic questionnaire on social and occupational risk activities stratified across two time periods: Jan. 2020 to Mar. 2020 (before lockdown) and post-Jun. 2020 (post lockdown). Univariate analyses (χ² and Fischer’s exact if n≤5) were performed on social activities that occurred following the lockdown among those with IBD who were and were not diagnosed with COVID-19. Occupational exposures were compared across essential workers (EW) (i.e., frontline workers at high risk of COVID) and non-EWs.

Result(s)

Overall, 37.5% (n=182) of our cohort was diagnosed with COVID-19. Seniors were less likely to be infected with COVID-19 (22.7%) compared to those under the age of 65 (40.8%) (p=0.002). A greater proportion of females (42.6 %) compared to males (32.5%) were COVID positive (p=0.02). Those with Crohn’s disease (38.3%) were as likely to test positive for COVID-19 as those with ulcerative colitis (36%) (p=0.65). COVID positive patients were less likely to have 4 vaccine doses (28.5%) compared to those who tested negative (71.5%) (p=0.4).

Statistically significant decreases (p<0.001) in engagement post-Jun. 2020 were observed for: bar use (11.6% to 2.1%), visiting a friend (44.5% to 15.2%), having visitors over (38.7% to 12.1%), restaurant dining (38% to 9%), indoor fitness (31.9% to 8.4%), and transit use (11% to 1.3%). There was an increase in regular use of outdoor fitness (31.9% to 67.1%, p<0.003).

Persons with IBD who tested positive for COVID-19 were more likely to regularly dine in a restaurant (16.8% vs. 4.7% for COVID negative, p<0.001), engage in indoor fitness activities (14% vs. 5.1%, p<0.001), and travel outside Calgary (21% vs. 11.2%, p=0.004) post-lockdown.

Post-lockdown, a greater proportion of EW were COVID positive (50.4%) compared to non-EW (38.6%) (p=0.04).

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Conclusion(s)

Over a two-year period, two-thirds of our cohort did not test positive for COVID-19. Those with IBD who avoided COVID tended to be older, male, have 4 doses of vaccine, and reduce their risk of exposure through social and occupational modifications, perhaps in response to public health guidance.

Disclosure of Interest

None Declared

A35 FORECASTING THE INCIDENCE AND PREVALENCE OF INFLAMMATORY BOWEL DISEASE: A CANADIAN NATION-WIDE ANALYSIS

Background

Canada is currently in the third epidemiological stage in the evolution of IBD: compounding prevalence. A high incidence of IBD, in conjunction with low mortality, leads to a steadily rising prevalence over time. By understanding historical epidemiological trends, we can forecast incidence and prevalence into the future to inform healthcare systems in Canada of the rising burden of IBD to society.

Purpose

To analyze past epidemiological trends in order to forecast the overall incidence and prevalence of IBD, Crohn’s disease (CD), and ulcerative colitis (UC) and stratified by age (<18, 18-64, 65+).

Method

Canadian population-based administrative data was acquired from: AB, BC, SK, MB, QC, and ON. Data were age and sex standardized to the matching year and provincial data aggregated into a representative sample of the Canadian population for prevalence (2002-2014) and incidence (2007-2014: 5-year washout period). Incidence and prevalence (per 100,000 persons) were calculated, with 95% confidence intervals (CI), using Canadian population estimates from Statistics Canada for IBD, CD, UC (IBD-unclassifiable+UC). Autoregressive Integrated Moving Average models were created, and rates forecasted from 2014 to 2035 with 95% prediction intervals (PI). Poisson (or negative binomial) for incidence and log binomial regression for prevalence estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

The 2014 incidence of IBD in Canada was 28.4 per 100,000 (95%CI: 27.8, 29.0) and forecasted to significantly increase (AAPC: 0.58%; 95%CI: 0.04, 1.04) from 30.0 per 100,000 in 2023 to 32.1 (95%PI: 27.9, 36.3) in 2035. Pediatric onset IBD was 13.9 per 100,000 (95%CI: 13.0, 14.9) in 2014 and is forecasted to significantly increase to 18.0 per 100,000 (95%PI: 15.7, 20.2) in 2035 with an AAPC of 1.23% (95%CI: 0.76, 1.63). Adult and elderly onset incidence rates were forecasted to remain stable. Prevalence of IBD increased between 2002 (389 per 100,000) and 2014 (636 per 100,000) and is forecasted to continue to climb by an AAPC of 2.44% (95%CI: 2.34, 2.53). In 2023, the prevalence of IBD is 825 per 100,000. By 2035 prevalence is forecasted to climb to 1075 per 100,000 (95%PI: 1047, 1103) with 470,000 Canadians living with IBD. Prevalence across all age strata were forecasted to significantly increase. The highest AAPC was seen in the elderly (2.76%; 95%CI: 2.73, 2.79) with a prevalence of 841 per 100,000 (95%CI: 834, 849) in 2014 and forecasted to climb to 1534 per 100,000 (95%PI: 1519, 1550) in 2035.

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Conclusion(s)

Incidence of IBD continues to rise in Canada, driven by pediatric-onset IBD. In 2023, over 320,000 Canadians (0.83%) will be living with IBD. By 2035 prevalence will exceed 1% of the population with approximately 470,000 individuals in Canada with IBD. Future research should establish the environmental determinates of IBD that may influence temporal trends in the incidence of IBD, while healthcare systems adapt to the compounding prevalence of IBD.

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CIHR, Other

Please indicate your source of funding;

The Leona M. and Harry B. Helmsley Charitable Trust

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc., L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A210 THE BURDEN OF IBD HOSPITALIZATION IN CANADA: AN ASSESSMENT OF THE CURRENT AND FUTURE BURDEN IN A NATION-WIDE ANALYSIS

Background

Hospitalizations pose a significant burden on both the individual and the healthcare system. Those with inflammatory bowel disease (IBD) are at increased risk of hospitalization as compared to the general population due to flaring of disease activity and complications related to IBD. The advent of biologics over the past twenty years may have influenced the rates of hospitalization for IBD.

Purpose

To assess current and forecast the overall hospitalization rates of those with IBD stratified by types of hospitalizations (all cause hospitalizations, IBD-related, and IBD-specific).

Method

Population-based administrative data on hospitalization of IBD (2002-2014) were obtained from: AB, BC, MB, and SK. Data were age and sex standardized to the matching year and aggregated into a representative sample of the Canadian population. Hospitalization rates were assessed as follows: 1. All cause hospitalizations: all admissions regardless of indication; 2. IBD-specific: an admission directly resulting from IBD (e.g., IBD-flare); 3. IBD-related: an admission for IBD, or a symptom or comorbidity associated with IBD (e.g. rheumatoid arthritis). Using prevalence estimates from the provinces, hospitalization rates (per 100 persons with IBD) were calculated, with 95% confidence intervals (CI). Autoregressive Integrated Moving Average models were created to estimate number of hospitalizations and corresponding prevalence to forecast hospitalization rates to 2030 with 95% prediction intervals (PI). Poisson (or negative binomial) regression estimated the Average Annual Percentage Change (AAPC), with 95% CIs, of the forecasted data.

Result(s)

In 2002 there were 35.3 per 100 (95%CI: 34.7, 35.9) all cause hospitalizations for IBD patients and this decreased to 24.9 per 100 (24.5, 25.2) in 2014. Similar trends were seen for IBD-specific hospitalizations [16.8 per 100 (95%CI: 16.4, 17.2) in 2002 to 8.7 per 100 (95%CI: 8.5, 9.0) in 2014] and IBD-related (22.6 per 100 (95%CI: 22.1, 23.1) in 2002 to 13.4 per 100 (95%CI: 13.2, 13.7) in 2014). When forecasted out to 2030 all hospitalization types were significantly decreasing—the AAPC for all cause hospitalizations was -2.12% (95%CI: -2.31, -1.93), -3.77% (95%CI: -4.63, -3.08) for IBD-specific, and -3.09% (95%CI: -3.65, -2.62) for IBD-related. By 2030, the rates of hospitalization are forecasted to be 17.0 per 100 (95%PI: 16.2, 17.9), 4.6 per 100 (95%PI: 3.7, 5.4), and 7.9 per 100 (95%PI: 6.9, 8.9) for all cause, IBD-specific, and IBD-related, respectively.

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Conclusion(s)

In Canada, rates of hospitalizations for those with IBD have decreased from 2002 to 2014. The use of anti-TNF therapy in conjunction with the evolution of clinical monitoring, management and guidelines, likely has contributed to dropping hospitalization rates. Forecast models estimate a continued drop in hospitalization rates out to 2030. Importantly, healthcare resource planning should account for the shift from hospital-based to clinic-centric models of IBD care.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

A188 INFORMING IMMUNOCOMPROMISED POPULATIONS: AN EFFECTIVE AND EFFICIENT COVID-19 KNOWLEDGE TRANSLATION STRATEGY

Background

Throughout the COVID-19 pandemic, one of the major challenges was conveying expert health information, which was evolving rapidly, to confer population-level advice; this was especially relevant to at risk groups, such as those who are immunocompromised due to conditions like inflammatory bowel disease (IBD) or medications to manage disease.

Purpose

To provide sufficient information to those with IBD (>0.75% of the Canadian population or roughly 300,000 individuals) and their carers to allow self assessment of personal risks related to COVID-19.

Method

On March 17, 2020, Crohn’s and Colitis Canada (CCC) convened the COVID-19 & IBD Taskforce comprised of adult and pediatric gastroenterologists, IBD nurses, infectious disease experts, scientists, public health officials, communication and government relations experts, and patient advisors. The taskforce met weekly (later monthly) to synthesize rapidly evolving information on COVID-19 and personal risk assessment. Expert reviews of population-level recommendations were tailored to the IBD community and communicated through website FAQs and infographics; a public-oriented burden report with foci on additional special populations (e.g., pregnant people, pediatrics, seniors), IBD medications, and mental health and access to care during the pandemic; and through a moderated, online webinar series. The 1- to 2-hour webinar recordings were then curated into 3- to 5-minute video clips to answer specific questions and uploaded to CCC’s YouTube page. YouTube and website metrics show the continued efficacy of this strategy.

Result(s)

More than 24,778 households registered for the first 23 webinars, with more than one third registering for more than one webinar. As of April 1, 2021 (just after the 23^rd webinar), there have been 54,136 views of the archived full (1- to 2-hour) webinars and a further 78,862 views of individual webinar segments (3- to 5-minute curated clips), for a total of 126,187 views. Additionally, traffic to the CCC website increased exponentially with 484,755 unique views to the COVID-19 web pages, viewed for up to 28.29 minutes. Since April 2021, after an additional seven webinars, these numbers have continued to swell to 33,243 (registrants), 81,370 (webinar views), 92,862 (segment views), and 810,156 (unique website views); this is demonstrative of the continued impact of the electronic knowledge translation strategy.

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Conclusion(s)

While many within the IBD community were secluded during the early portions of the pandemic due to lockdown restrictions and public health advice not tailored to immunocompromised individuals, advice tailored to this community and presented through electronic methods proved to be an effective and efficient knowledge translation strategy.

Please acknowledge all funding agencies by checking the applicable boxes below

CCC

Disclosure of Interest

None Declared

A169 THE DIRECT COSTS OF INFLAMMATORY BOWEL DISEASE IN CANADA: A POPULATION-BASED ANALYSIS OF HISTORICAL AND CURRENT COSTS

Background

Inflammatory bowel disease (IBD) is a costly disease to manage due to hospitalizations, regular ambulatory monitoring, and expensive pharmaceutical therapies. While hospitalization rates have fallen, the increased use of biologics have escalated the cost of care to the healthcare system.

Purpose

To assess historical direct healthcare costs of the IBD population in Canada.

Method

Population-based administrative costing data were obtained from: Alberta, British Columbia, and Manitoba. Costs were calculated based on administrative data (2009 to 2016) which captured: hospitalizations, physician costs, ambulatory care such as: emergency visits, day surgery, and colonoscopy (AB only), and medication costs of IBD-specific medications, such as: mesalamine, biologics, steroids, and immunomodulators. Costs were converted to 2020 dollars using the consumer price index. Average annual cost per person (ACPP) was calculated for each province. Using province specific IBD prevalence estimates these ACPP were meta-analyzed to obtain the annual weighted costs, with 95% confidence intervals (CI), and these costs underwent meta-regression to ascertain the average annual change in cost per year. An Autoregressive Integrated Moving Average model was created to estimate the ACPP in 2023 with 95% prediction intervals (PI). Canada-wide total direct care costs of IBD patients, in billions (B), were calculated using the ACPP, Canada-specific IBD prevalence estimates (historical and forecasted), and total Canadian population calculations from Statistics Canada (historical and forecasted).

Result(s)

In 2009 the ACPP was $7000 (95%CI: 5389, 8610), representing $1.18B (95%CI: 0.91B, 1.45B) in direct healthcare costs in Canada for all IBD patients. The ACPP in 2016 was increased to $10,336 (95%CI: 6803, 13869), which equates to $2.37B (95%CI: 1.56B, 3.18B) per year in direct healthcare costs. From 2009 to 2016, the ACPP increased an average of $450 (95%CI: 132, 767) per year. If these historical trends continue to 2023 the ACPP is forecasted to be $13,333 (95%PI: 12827, 13839) per person per year. The largest contributor to these costs is medications—accounting for an estimated 50% of the total costs of IBD patients.

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Conclusion(s)

The direct healthcare cost of IBD has risen steadily from 2009 to 2016 when the healthcare system spent over $10,000 per person with IBD and $2.37B nationwide. The primary driver of costs is medical management. Forecast models estimate that the annual cost may be over $13,000 per person in 2023. However, these estimates do not account for advent and increased uptake of novel biologics and small molecules, nor the downward cost pressure of biosimilars. These costs are those paid directly by the healthcare system and do not account for those born by the individual—it is estimated that the true cost of IBD (direct and indirect) is much higher.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR

Disclosure of Interest

S. Coward: None Declared, E. Benchimol Consultant of: Hoffman La-Roche Limited and Peabody & Arnold LLP for matters unrelated to medications used to treat inflammatory bowel disease and McKesson Canada and the Dairy Farmers of Ontario for matters unrelated to medications used to treat inflammatory bowel disease., C. Bernstein Grant / Research support from: Unrestricted educational grants from Abbvie Canada, Janssen Canada, Pfizer Canada, Bristol Myers Squibb Canada, and Takeda Canada. Has received research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, and Takeda., Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, J. A. Avina-Zubieta: None Declared, A. Bitton: None Declared, L. Hracs: None Declared, J. Jones Consultant of: Janssen, Abbvie, Pfizer, Takeda, Speakers bureau of: Janssen, Abbvie, Pfizer, Takeda, E. Kuenzig: None Declared, L. Lu: None Declared, S. Murthy: None Declared, Z. Nugent: None Declared, A. Otley Grant / Research support from: Unrestricted educational grants from AbbVie Canada and Janssen Canada, Consultant of: Advisory boards of AbbVie Canada, Janssen Canada and Nestle, R. Panaccione Consultant of: Abbott, AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pendopharm, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz, Satisfai Health, Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Theravance Biopharma, Trellus, Viatris, UCB. Advisory Boards for: AbbVie, Alimentiv (formerly Robarts), Amgen, Arena Pharmaceuticals, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Genentech, Gilead Sciences, Glaxo-Smith Kline, JAMP Bio, Janssen, Merck, Mylan, Novartis, Oppilan Pharma, Organon, Pandion Pharma, Pfizer, Progenity, Protagonist Therapeutics, Roche, Sandoz Shire, Sublimity Therapeutics, Takeda Pharmaceuticals, Speakers bureau of: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, Takeda Pharmaceuticals, J.-N. Pena-Sanchez: None Declared, H. Singh Consultant of: Pendopharm, Amgen Canada, Bristol Myers Squibb Canada, Roche Canada, Sandoz Canada, Takeda Canada, and Guardant Health, Inc.,, L. Targownik Grant / Research support from: Investigator initiated funding from Janssen Canada, Consultant of: [Advisory board] AbbVie Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, Roche Canada, and Sandoz Canada, J. Windsor: None Declared, G. Kaplan Grant / Research support from: Ferring, Janssen, AbbVie, GlaxoSmith Kline, Merck, and Shire, Consultant of: Gilead, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, and Takeda

The Global Incidence of Peptic Ulcer Disease Is Decreasing Since the Turn of the 21st Century: A Study of the Organisation for Economic Co-Operation and Development (OECD)

INTRODUCTION

Peptic ulcer disease (PUD) is a common cause of hospitalization worldwide. We assessed temporal trends in hospitalization for PUD in 36 Organisation for Economic Co-operation and Development (OECD) countries since the turn of the 21st century.

METHODS

The OECD database contains data on PUD-related hospital discharges and mortality for 36 countries between 2000 and 2019. Hospitalization rates for PUD were expressed as annual rates per 100,000 persons. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs) for each country, which were pooled using meta-analyses. The incidence of PUD was forecasted to 2021 using autoregressive integrated moving average and Poisson regression models.

RESULTS

The overall median hospitalization rate was 42.4 with an interquartile range of 29.7-60.6 per 100,000 person-years. On average, hospitalization rates (AAPC = -3.9%; 95% CI: -4.4, -3.3) and morality rates (AAPC = -4.7%; 95% CI: -5.6, -3.8) for PUD have decreased from 2000 to 2019 globally. The forecasted incidence of PUD hospitalizations in 2021 ranged from 3.5 per 100,000 in Mexico to 92.1 per 100,000 in Lithuania. Across 36 countries in the OECD, 329,000 people are estimated to be hospitalized for PUD in 2021.

DISCUSSION

PUD remains an important cause of hospitalization worldwide. Reassuringly, hospitalizations and mortality for PUD have consistently been falling in OECD countries in North America, Latin America, Europe, Asia, and Oceania. Identifying underlying factors driving these trends is essential to sustaining this downward momentum.

Global Hospitalization Trends for Crohn's Disease and Ulcerative Colitis in the 21st Century: A Systematic Review With Temporal Analyses

BACKGROUND & AIMS

The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century.

METHODS

We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries.

RESULTS

Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence).

CONCLUSIONS

Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems.

Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Acute pancreatitis is a common disease with significant associated morbidity and mortality. We performed a systematic review and meta-analysis of population-based studies to explore the changing temporal trends of acute pancreatitis incidence globally.

METHODS

We performed a systematic literature search to identify population-based studies reporting the annual incidence of acute pancreatitis. Abstracts were assessed independently to identify applicable articles for full-text review and data extraction. Joinpoint temporal trend analyses were performed to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs). The AAPCs were pooled in a meta-analysis to capture the overall and regional trends in acute pancreatitis incidence over time. Temporal data were summarized in a static map and an interactive, web-based map.

RESULTS

Forty-four studies reported the temporal incidence of acute pancreatitis (online interactive map: https://kaplan-acute-pancreatitis-ucalgary.hub.arcgis.com/). The incidence of acute pancreatitis has increased from 1961 to 2016 (AAPC, 3.07%; 95% CI, 2.30% to 3.84%; n = 34). Increasing incidence was observed in North America (AAPC, 3.67%; 95% CI, 2.76% to 4.57%; n = 4) and Europe (AAPC, 2.77%; 95% CI, 1.91% to 3.63%; n = 23). The incidence of acute pancreatitis was stable in Asia (AAPC, -0.28%; 95% CI, -5.03% to 4.47%; n = 4).

CONCLUSIONS

This meta-analysis provides a comprehensive overview of the global incidence of acute pancreatitis over the last 56 years and demonstrates a steadily rising incidence over time in most countries of the Western world. More studies are needed to better define the changing incidence of acute pancreatitis in Asia, Africa, and Latin America.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Children and Expectant Mothers With Inflammatory Bowel Disease

Coronavirus disease 2019 (COVID-19) in children with inflammatory bowel disease (IBD) typically results in a mild infection, similar to those without IBD. Children and adolescents have less severe manifestations of COVID-19 compared to older people, whether or not they have IBD. However, some IBD medications (in particular, corticosteroids) are associated with more severe COVID-19. During the first year of the global pandemic, more IBD care was provided with online technology, necessitated by efforts to reduce hospital and clinic visits. Additionally, non-endoscopic monitoring of inflammation has been required due to the cancellation of non-urgent procedures, resulting in longer endoscopy wait-times. In contrast, pregnant people (with and without IBD) who contract COVID-19 are at increased risk of severe manifestations, death and preterm delivery, making them a priority for severe acute respiratory syndrome coronavirus 2 protective measures and vaccination. Few studies have examined effect of COVID-19 on IBD-related disease activity in pregnant people with IBD. The pandemic has significantly affected the mental health and sense of well-being of children and their families, as well as pregnant people with IBD. These groups were much more likely to experience anxiety and depression compared with prior to the pandemic, even while concern has mostly abated regarding the effect of IBD medications and COVID-19 severity. Unfortunately, the availability of mental health care providers who specialize in people with IBD has not kept pace with the increasing demand.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Health Care Delivery During the Pandemic and the Future Model of Inflammatory Bowel Disease Care

The SARS-CoV-2 pandemic has had a profound impact on inflammatory bowel disease (IBD) health care delivery. The implementation of necessary public health restrictions has restricted access to medications, procedures and surgeries throughout the pandemic, catalyzing widespread change in how IBD care is delivered. Rapid large-scale implementation of virtual care modalities has been shown to be feasible and acceptable for the majority of individuals with IBD and health care providers. The SARS-CoV-2 pandemic has exacerbated pre-existing barriers to accessing high-quality, multidisciplinary IBD care that addresses health care needs holistically. Continued implementation and evaluation of both synchronous and asynchronous eHealthcare modalities are required now and in the future in order to determine how best to incorporate these modalities into patient-centred, collaborative care models. Resources must be dedicated to studies that evaluate the feasibility, acceptability and effectiveness of eHealth-enhanced models of IBD care to improve efficiency and cost-effectiveness, while increasing quality of life for persons living with IBD. Crohn's and Colitis Canada will continue to play a major leadership role in advocating for the health care delivery models that improve the quality of life for persons living with IBD.

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

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.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Mental Health and Quality of Life

There has been a dramatic rise in mental health difficulties during the coronavirus disease 2019 (COVID-19) pandemic. While young adults have the lowest risk of hospitalization and mortality due to COVID-19, they have been identified as being at highest risk of detrimental mental health outcomes during the pandemic, along with women, those with lower socioeconomic status and those with pre-existing mental health conditions. Somewhat of a crisis in mental health has emerged across the general population through the evolution of the pandemic. A national Canadian survey identified a quadrupling of those experiencing pervasive elevated anxiety symptoms early in the pandemic compared to pre-pandemic levels, and a doubling of those with pervasive elevated depressive symptoms. Independent of the pandemic, persons with inflammatory bowel disease (IBD) can face multiple challenges related to their disease, which can result in a significant psychosocial burden and psychologic distress. Anxiety and depression have been found to be more prevalent in persons with IBD. Many potential factors contribute to the increased psychologic distress and negative impacts on mental health of the COVID-19 pandemic on persons with IBD. These include the fears of contracting COVID-19 or infecting other people. Many believe that IBD or its treatments predispose them to an increased risk of COVID-19 or a worse outcome if acquired. Concerns about access to health care add to mental distress. People with IBD generally report lower quality of life (QOL) compared to community controls. Psychologic interventions, in addition to adequate disease control, have been shown to improve health-related QOL. Uncertainty is another factor associated with reduced health-related QOL. Most studies suggest that persons with IBD have suffered QOL impairment during the pandemic in comparison to the pre-pandemic period. Uncertainties brought on by the pandemic are important contributors for some of the reduction in QOL.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: COVID-19 Vaccines-Biology, Current Evidence and Recommendations

The COVID-19 pandemic has ushered a globally focused vaccine development program that produced multiple successful vaccines within a year. Four SARS-CoV-2 vaccines have been approved for use in Canada, using two different technologies, all of which have shown excellent efficacy in reducing the rate of symptomatic COVID-19 infection and 100% efficacy in preventing death from COVID-19. People with inflammatory bowel disease (IBD), like many others with immune-mediated chronic diseases, were excluded from the pivotal trials of these vaccines, leading to early hesitancy by regulatory bodies to endorse administering the vaccines to these groups. However, recent data has shown that the adverse event rate to SARS-CoV-2 vaccine among people with IBD is similar to the general population. Early data has further shown that people with IBD are capable of mounting a robust immune response to SARS-CoV-2 vaccines, particularly following a second dose, whereas the response to the first dose is blunted in those receiving anti-TNF therapy or conventional immunosuppressants (azathioprine, 6-mercaptopurine, methotrexate). Based on these data and evidence from previous vaccine programs among people with IBD, multiple national and international expert panels have recommended that individuals with IBD receive complete vaccination against SARS-CoV-2 as soon as possible.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Risk Factors and Medications

Inflammatory bowel disease (IBD) is a disease that results from dysregulation of the immune system and frequently requires medications that can affect the immune response to infections; therefore, it was imperative to quickly understand the risk of coronavirus disease 2019 (COVID-19) infection on persons living with IBD and how that risk may be increased by commonly used IBD medications. The IBD research community in Canada and beyond quickly established collaborative efforts to better understand the specific risk posed by COVID-19 on persons with IBD. We learned that IBD itself was not a risk factor for death or serious complications of COVID-19, and that most commonly used drug classes (with the notable exception of corticosteroids) do not increase the risk of COVID-19-related adverse outcomes. The risk factors for serious complications and death from COVID-19 appear to be similar to those identified in the wider population; those being advanced age, having pre-existing heart or lung disease, and smoking. We recommend that persons with IBD do not alter their course of therapy to avoid complications of COVID-19, though the indiscriminate use of corticosteroids should be avoided. Persons with IBD should follow the same public health recommendations as the general population to reduce their personal risk of acquiring COVID-19.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Executive Summary

Persons with inflammatory bowel disease (IBD) make up more than 0.75% of the Canadian population in 2021. Early in the COVID-19 pandemic, individuals with IBD, particularly those on immunosuppressive therapies, were concerned that their health status may place them at higher risk of contracting COVID-19 or experiencing more severe disease course if infected with SARS-CoV-2. In response, Crohn’s and Colitis Canada developed the COVID-19 and IBD Taskforce in March 2020 to rapidly synthesize the evolving knowledge of COVID-19 as relevant to Canadians with IBD. The Taskforce communicated expert information directly to the Canadian IBD community through online tools and a webinar series. In order to understand the full impact of COVID-19 on the IBD community, Crohn’s and Colitis Canada commissioned a policy report that was informed through a systematic literature review and synthesized across working groups along the following domains: Epidemiology, Children and Expectant Mothers with IBD, Seniors with IBD, Mental Health, Risk Factors and Medications, Vaccines, and Healthcare Delivery during the Pandemic and the Future Model of IBD Care. This report from Canadian physicians, researchers, and IBD community representatives highlights the physical, mental, and health systems impact of COVID-19 on the entire spectrum of the IBD community, including children, adolescents, adults, seniors, and pregnant people with IBD. This executive summary provides an overview of the crucial information from each of the chapters of the policy report, supplemented with additional information made available through Crohn’s and Colitis Canada’s webinar-based knowledge translation platform.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Epidemiology-The Trends of Disease Over Time

At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there were many unknowns: transmission vectors of the virus, appropriate intervention strategies and if being immunocompromised due to inflammatory bowel disease (IBD), for example, or medications put a person at increased risk for severe COVID-19. Imposing and relaxing of public health restrictions at different times and in different regions in Canada led to different epidemiologies of the virus in different provinces and territories. In order to understand the waxing and waning of waves of the COVID-19 pandemic, it is necessary to understand the effective reproductive number (R _t ) and the countervailing forces that exert upward or downward pressure on the spread of the virus at a given point in time. As many regions in Canada deal with a third wave, the primary forces affecting the R _t of severe acute respiratory syndrome coronavirus 2 are variants of concern and the increasing vaccinations of Canadians leading to increased population-level immunity. Fortunately, for the IBD population, current research suggests that those with IBD are not at increased risk of contracting COVID-19, nor of having a more severe disease course when compared to the general population.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Seniors With IBD

The risk of hospitalization and death from Coronavirus disease-19 (COVID-19) increases with age. The extreme elderly have been particularly vulnerable, with those above the age of 80 having a case-fatality rate as high as 15%. Aging of the immune system can lead to impaired inflammatory responses where eradication of an organism such as Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV2) is inadequate but is exaggerated in such a way as to enhance pneumonia and acute respiratory distress syndrome. Frailty and comorbidity are both more common in the elderly, and these can enhance the morbidity and mortality from COVID-19. Studies from Northern California and Italy suggest that elderly persons with inflammatory bowel disease (IBD) were more likely to acquire SARS-CoV-2 infection than youths with IBD. While the specific impact of age-related comorbidity is less well established among people with IBD who acquire COVID-19, data from the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD) database reported that having two or more chronic illnesses was independently associated with developing severe COVID-19 among people with IBD. Despite having exaggerated auto-inflammatory responses, people with IBD do not appear to have an overall increased risk of developing severe COVID-19 than the general population. However, whether seniors with IBD do worse once they acquire COVID-19 compared with seniors without IBD is not known. The advent of telehealth care has posed an information technology challenge for many seniors with and without IBD. Most persons with IBD have expressed satisfaction with virtual IBD health care (phone or video-based visits). While the elderly may have less robust immune responses to vaccinations, learning from experiences with other vaccination programs, especially influenza, have shown that vaccinating seniors decreases both morbidity and mortality and, in turn, healthcare resources.

A246 THE GLOBAL INCIDENCE OF ACUTE PANCREATITIS IS INCREASING OVER TIME: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Acute pancreatitis is a common disease with significant associated morbidity and mortality. Historically, acute pancreatitis has been considered a disease with multiple etiologies and risk factors but is driven by alcohol and biliary disease. Multiple studies have shown that the incidence of acute pancreatitis is increasing globally among both adults and children.

Aims

The purpose of this study was to assess temporal trends in incidence of acute pancreatitis globally.

Methods

We performed a systematic literature search to identify population-based studies reporting the annual incidence of acute pancreatitis. Abstracts were independently assessed in duplicate to identify applicable papers for full-text review and data extraction. Joinpoint temporal trend analyses were performed to calculate the average annual percent change (AAPC) with 95% confidence intervals (CI). The AAPCs were pooled in a meta-analysis to capture the overall and regional trends in acute pancreatitis incidence over time. Temporal data were summarized in a static map and an interactive, web-based map to illustrate global differences.

Results

Forty-five studies reported the temporal incidence of acute pancreatitis (static map provided, online interactive map: https://kaplan-acute-pancreatitis-ucalgary.hub.arcgis.com/). The incidence of acute pancreatitis has increased from 1961 to 2016 (AAPC = 2.89%; 95% CI: 2.26, 3.52; n=41). Increasing incidence was observed in North America (AAPC = 2.71%; 95% CI: 1.93, 3.50; n=10) and Europe (AAPC = 2.79%; 95% CI: 1.95, 3.63; n=24). The incidence of acute pancreatitis was stable in Asia (AAPC = −0.28%; 95% CI: −5.03, 4.47; n=2).

Conclusions

This meta-analysis provides a comprehensive overview of the global incidence of acute pancreatitis over the last five decades and demonstrates a steadily rising incidence over time in most countries of the Western world. More studies are needed to better define the changing incidence of acute pancreatitis in Asia, Africa and Latin America.

Funding Agencies

None

The four epidemiological stages in the global evolution of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a global disease; its evolution can be stratified into four epidemiological stages: Emergence, Acceleration in Incidence, Compounding Prevalence and Prevalence Equilibrium. In 2020, developing countries are in the Emergence stage, newly industrialized countries are in the Acceleration in Incidence stage, and Western regions are in the Compounding Prevalence stage. Western regions will eventually transition to the Prevalence Equilibrium stage, in which the accelerating prevalence levels off as the IBD population ages and possibly as a result of an unexpected rise in mortality during the COVID-19 pandemic. Mitigating the global burden of IBD will require concerted efforts in disease prevention and health-care delivery innovations that respond to changing demographics of the global IBD population. In this Perspective, we summarize the global epidemiology of IBD and use these data to stratify disease evolution into four epidemiological stages.

Temporal and spatial effect of air pollution on hospital admissions for myocardial infarction: a case-crossover study

BACKGROUND

In studies showing associations between ambient air pollution and myocardial infarction (MI), data have been lacking on the inherent spatial variability of air pollution. The aim of this study was to determine whether the long-term spatial distribution of air pollution influences short-term temporal associations between air pollution and admission to hospital for MI.

METHODS

We identified adults living in Calgary who were admitted to hospital for an MI between 2004 and 2012. We evaluated associations between short-term exposure to air pollution (ozone [O₃], nitrogen dioxide [NO₂], sulfur dioxide [SO₂], carbon monoxide [CO], particulate matter < 10 μm in diameter [PM₁₀] and particulate matter < 2.5 μm in diameter [PM_2.5]), and hospital admissions for MI using a time-stratified, case-crossover study design. Air Quality Health Index (AQHI) scores were calculated from a composition of O₃, NO₂ and PM_2.5. Conditional logistic regression models were stratified by low, medium and high levels of neighbourhood NO₂ concentrations derived from land use regression models; results of these analyses are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

From 2004 to 2012, 6142 MIs were recorded in Calgary. Individuals living in neighbourhoods with higher long-term air pollution concentrations were more likely to be admitted to hospital for MI after short-term elevations in air pollution (e.g., 5-day average NO₂: OR 1.20, 95% CI 1.03-1.40, per interquartile range [IQR]) as compared with regions with lower air pollution (e.g., 5-day average NO₂: OR 0.90, 95% CI 0.78-1.04, per IQR). In high NO₂ tertiles, the AQHI score was associated with MI (e.g., 5-day average OR 1.13, 95% CI 1.02-1.24, per IQR; 3-day average OR 1.13, 95% CI 1.04-1.23, per IQR).

INTERPRETATION

Our results show that the effect of air pollution on hospital admissions for MI was stronger in areas with higher NO₂ concentrations than that in areas with lower NO₂ concentrations. Individuals living in neighbourhoods with higher traffic-related pollution should be advised of the health risks and be attentive to special air quality warnings.

Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis that defines the worldwide incidence of celiac disease (CD) and examines temporal trends.

METHODS

MEDLINE and EMBASE were searched for population-based studies reporting the incidence of CD in the overall population, children, or adults. No limits were placed on year or language of publication. Studies solely examining at-risk populations (e.g., patients with type 1 diabetes) were excluded. Random-effects models were performed to meta-analyze sex- and age-specific incidence in the 21st century. Temporal trend analyses assessed the average annual percent change in CD incidence over time.

RESULTS

Of 11,189 citations, 86 eligible studies were identified for inclusion, of which 50 were deemed suitable for analyses. In the 21st century, the pooled female incidence of CD was 17.4 (95% confidence interval [CI]: 13.7, 21.1) (I = 99.5%) per 100,000 person-years, compared with 7.8 (95% CI: 6.3, 9.2) (I = 98.6%) in males. Child-specific incidence was 21.3 per 100,000 person-years (95% CI: 15.9, 26.7) (I = 99.7%) compared with 12.9 (95% CI: 7.6, 18.2) (I = 99.9%) in adults. Pooling average annual percent changes showed the incidence of CD to be increasing by 7.5% (95% CI: 5.8, 9.3) (I = 79.6%) per year over the past several decades.

DISCUSSION

Incidence of CD is highest in females and children. Overall, the incidence has been significantly rising in the latter half of the 20th century and into the 21st century throughout the Western world. Population-based studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of CD.

A28 RELATIVE RATES OF ULCERATIVE COLITIS TO CROHN’S DISEASE: PARALLEL EPIDEMIOLOGIES IN NEWLY VS. HIGHLY INDUSTRIALIZED COUNTRIES

Background

Inflammatory bowel disease (IBD) first presents in a population as cases of ulcerative colitis (UC) followed by cases of Crohn’s disease (CD). Newly industrialized countries (NIC) show a prallel epidemiology of IBD to highly industrialized countries (HIC) in the previous century; one marker of this is the relative incidence/prevalence rates of UC to CD, which approximates 1 over time.

Aims

Provide evidence for the UC:CD ratio as a proxy for disease penatrance in a population.

Methods

Systematic review of MedLine and Embase for studies reporting incidence or prevalence of UC and CD. Log-linear regression (by region and NIC/HIC [2019 United Nations definitions]) was used to calculate average annual percent change (AAPC) and associated 95% confidence intervals (CI). Data were plotted on an online, interactive map to show trends (link provided).

Results

We extracted data from 218 studies compising population-level data from 69 countries. We found negative AAPCs as the prevalence ratio of UC:CD significantly decreased over time in East Asia, West Asia, North Europe, and South Europe; 6/12 global regions displayed significantly decreasing incidence ratios. No AAPC was found to be significantly increasing (Table 1). When examing HIC/NIC, we found a significant effect of NIC on the UC:CD prevalence ratio after 2000 (AAPC:−3.83;95%CI:−6.28,−1.31) while HIC regions remained stable (AAPC:2.14;95%CI:−1.40,5.82). Looking at all available data, both HICs and NICs show significantly decreasing UC:CD prevalence ratios (HIC:AAPC:−3.72;95% CI:−4.46,−2.97; NIC:AAPC:−2.62;95%CI:−4.13,−1.08).

Conclusions

In some HICs (eg. Canada), the UC:CD incidence ratio was &lt;1 in the earliest available data (1966), explaining the stable AAPC in North America (AAPC:−0.24;95%CI:−1.12,0.65). However, in NICs (eg. Southern Asia), the AAPC is rapidly decreasing (AAPC:−24.68;95%CI:−37.85,−8.71) as areas like Sri Lanka rapidly fall from an incidence ratio of 7.5 (2007) to 2.8 (2012), mimicking trends in IBD epidimeology of HICs in the previous century.

Funding Agencies

None

A64 HOSPITALIZATION IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED COMPARISON OF DEFINITIONS

Background

Most administrative studies of hospitalization in inflammatory bowel disease (IBD) use two definitions: IBD in any diagnostic position (IBD-ANY), and IBD as the most responsible diagnostic (IBD-MRD). There is a third less commonly used definition: total hospitalization; this definition captures all hospitalizations of prevalent IBD patients and therefore it can give a more realistic picture of the burden of IBD.

Aims

To compare differing definitions (total, IBD-ANY, and IBD-MRD) of hospitalizations.

Methods

A previously defined population-based IBD prevalent cohort for Alberta (n=30,698) was used to pull all hospital admissions from the Discharge Administrative Database (DAD; 2002–2015). Three hospitalization definitions were used: i. Total (all hospitalizations of prevalent cohort independent of presence of code for IBD); ii. IBD-ANY (code for IBD [K50.x; K51.x] contained in any diagnosis field); and, iii. IBD-MRD (most responsible diagnosis was IBD). Age- and sex- standardized rates (2015 Canadian population) were calculated using the prevalent population. Log-linear regression was performed to calculate Average Annual Percentage Change (AAPC) with associated 95% confidence intervals (CI) of each type of hospitalization. We assessed the top five most common most-responsible diagnosis codes for hospitalizations that were contained in the total hospitalizations but not an IBD-ANY hospitalization.

Results

From 2002 to 2015, 63.5% of IBD prevalent patients in AB had ≥1 hospitalization; 44.2% had ≥1 IBD-ANY hospitalization; 28.6% had ≥1 IBD-MRD hospitalization; and, 40.6% had a hospitalization that did not contain a code for IBD. All hospitalization rates decreased significantly over time. Of the top five most common most responsible diagnosis, contained in admissions that were not IBD-ANY, three were gastroenterological: i. K52.9 (non-infective gastroenteritis); ii. A09.9 (diarrhea and gastroenteritis of presumed infectious origin); and, iii. Z43.2 (attention to ileostomy).

Conclusions

Total hospitalizations is an important measure to report since accounting for all hospitalizations of IBD patients is necessary in order to allocate healthcare resources appropriately. To be able to ensure these patients receive the care they need we need to be able to accurately assess the true burden of IBD.

Funding Agencies

CIHR

The Impact of Inflammatory Bowel Disease in Canada 2018: A Scientific Report from the Canadian Gastro-Intestinal Epidemiology Consortium to Crohn's and Colitis Canada

Canada has among the highest rates of IBD in the world, and the number of people living with these disorders is growing rapidly. This has placed a high burden on the health care system and on the Canadian economy—a burden that is only expected to grow in the future. It is important to understand IBD and its impact on Canadian society in order to appropriately plan for health care expenditures, reduce the burden on patients and their families, and improve the quality of life for those afflicted with IBD. In Canada, there is a lack of public awareness of the impact of Crohn’s disease and ulcerative colitis. Raising awareness is crucial to reducing the social stigma that is common with these diseases and to help individuals maximize their overall quality of life. A better public understanding of IBD can also help to raise and direct funds for research, which could lead to improved treatments and, ultimately, to a cure. This report from Canadian clinicians and researchers to Crohn’s and Colitis Canada makes recommendations aimed at the public, policy-makers, scientific funding agencies, charitable foundations and patients regarding future directions for advocacy efforts and areas to emphasize for research spending. The report also identifies gaps in knowledge in the fields of clinical, health systems and epidemiological research.