Next Article in Journal
Comparison of General Anxiety among Healthcare Professionals before and after COVID-19 Vaccination
Next Article in Special Issue
Parental Perceptions and Barriers towards Childhood COVID-19 Vaccination in Saudi Arabia: A Cross-Sectional Analysis
Previous Article in Journal
Effectiveness of COVID-19 Vaccines over 13 Months Covering the Period of the Emergence of the Omicron Variant in the Swedish Population
Previous Article in Special Issue
Moving towards Digitising COVID-19 Vaccination Certificate: A Systematic Review of Literature
 
 
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

COVID-19 Vaccines for Adults and Children with Autoimmune Gut or Liver Disease

1
Department of Gastroenterology, University Hospital Lozenetz, 1407 Sofia, Bulgaria
2
Medical Faculty, Sofia University St. Kliment Ohridski, 1407 Sofia, Bulgaria
3
Clinic of Internal Diseases, Naval Hospital—Varna, Military Medical Academy, Medical Faculty, Medical University, 9000 Varna, Bulgaria
4
Pediatric Department, University Hospital “N. I. Pirogov”,“General Eduard I. Totleben” Blvd 21, Health Care Department, 1606 Sofia, Bulgaria
5
Faculty of Public Health, Medical University Sofia, Bialo More 8 Str., 1527 Sofia, Bulgaria
6
Department of Clinical Immunology, University Hospital Lozenetz, Medical Faculty, Sofia University St. Kliment Ohridski, 1407 Sofia, Bulgaria
*
Author to whom correspondence should be addressed.
Vaccines 2022, 10(12), 2075; https://doi.org/10.3390/vaccines10122075
Submission received: 15 October 2022 / Revised: 1 December 2022 / Accepted: 2 December 2022 / Published: 5 December 2022
(This article belongs to the Special Issue Vaccination Intention against the COVID-19 Pandemic)

Abstract

:
The SARS-CoV-2 pandemic raised many challenges for all patients with chronic conditions and those with autoimmune diseases, both adults and children. Special attention is paid to their immunological status, concomitant diseases, and the need for immunosuppressive therapy. All of these factors may impact their COVID-19 course and outcome. COVID-19 vaccination is accepted as one of the most successful strategies for pandemic control. However, individuals with immune-mediated chronic diseases, including autoimmune liver and gut diseases, have been excluded from the vaccine clinical trials. Therefore, we rely on real-world data from vaccination after vaccine approval for these patients to fill the evidence gap for the long-term safety and efficacy of COVID-19 vaccines in patients with autoimmune gut and liver diseases. Current recommendations from inflammatory bowel disease (IBD) societies suggest COVID-19 vaccination in children older than 5 years old, adults and even pregnant females with IBD. The same recommendations are applied to patients with autoimmune liver diseases. Nevertheless, autoimmune disease patients still experience high levels of COVID-19 vaccine hesitancy, and more studies have to be conducted to clarify this issue.

1. Introduction

The culpable agent for the coronavirus disease 2019 (COVID-19) pandemic is the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1]. It causes acute respiratory distress syndrome (ARDS) in a large number of individuals with severe pulmonary injury [2]. However, the pandemic has raised significant concerns about managing immunocompromised patients. Recent research reveals that these patients have more severe disease courses due to their underlying changed immunological status and immunosuppressive medicines [3]. Furthermore, Kim et al. reported a 40% additional risk for in-hospital mortality and 30% for intensive care unit (ICU) admission among these patients [4].
In response to the high mortality rate and casualties of the COVID-19 pandemic globally, pharmaceutical companies have produced effective vaccines against the SARS-CoV-2 infection. Therefore, immunization against SARS-CoV-2 is considered the most suitable tool in the hands of physicians. Several vaccine candidates and tactics were developed shortly after the onset of SARS-CoV-2 pandemic [5]. However, they were not fully successful in managing or controlling the COVID-19 pandemic. The spread of COVID-19 is mostly influenced by the appearance of novel viral variants brought on by the acquisition of genetic alterations in SARS-CoV-2 in various regions of the world and subsequent rapid transmission across the continents [5].
Additionally, depending on the population and variations, the efficacy of the approved vaccinations against the newly emerging SARS-CoV-2 mutations varied. This highlights the need for a broad-spectrum vaccine that could elicit a more effective immune response toward all new variants [6].
Different types of COVID-19 vaccines have been developed, including live-attenuated vaccines, protein-based vaccines, and gene vaccines (mRNA, vector-based, and VLPs) [5,6]. Nevertheless, the hastened course of vaccine development raises several concerns, especially in particular groups of patients, such as those with an altered immune system. Moreover, many individuals with immune-mediated chronic diseases, including autoimmune liver and gut diseases, have been excluded from vaccine clinical trials [7]. This resulted in an evidence gap for the long-term safety and efficacy of COVID-19 vaccines in patients with autoimmune diseases.
Some of the theoretical concerns are related to the complex pathogenesis of autoimmune diseases, including liver and gut conditions, immunosuppressive therapy, and the cumulative risk of flare [8]. We rely on real-world data from vaccination after vaccine approval for these patients.
Nevertheless, autoimmune disease patients still experience high levels of COVID-19 vaccine hesitancy. Some concerns are stopping immunosuppression before vaccination and minimizing the risk of relapse and adverse effects. The COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, a long-term ongoing global self-reported study that includes patients with autoimmune disease, collected data on short and long-term adverse effects and disease flares in patients following COVID-19 vaccines [9,10].
A questionnaire-based study among Chinese people with IBD also showed COVID-19 vaccination hesitancy, mostly related to the history of immune-modifying therapies, potential adverse reactions, and effectiveness [11].
In this background, little is known about the vaccines’ safety profiles, effectiveness, adverse effects, and infection flare in adult and pediatric patients with autoimmune liver and gut diseases. Therefore, our mini-review aims to assess the efficacy and safety of SARS-CoV-2 immunization to prevent developing severe COVID-19 infection in this cohort of patients without interfering with their current immunosuppressive therapy.

2. Autoimmune Gut Diseases and COVID-19 Vaccines

Autoimmune diseases are characterized by hyperreactivity of the immune system and loss of immune tolerance, which damage and destroy healthy tissues, cells, and organs [12].
Patients diagnosed with inflammatory bowel disease (IBD), especially those who have undergone biological or immunosuppressive therapy, are a subject of interest due to the risk factors that arise from the illness regarding COVID-19 morbidity [13]. Currently, risk factors associated with a higher risk of infection due to IBD morbidity are nutrition status, age, comorbidity, and pharmacotherapy. The most enduring hypothesis is that malnutrition and food deficiency lead to a compromised immune response. Food deficiency relates to decreased phagocyte function and abnormal cell-mediated immunity [13]. Additionally, patients suffering from IBD often have vitamin D deficiency, increasing the severity of COVID-19 infection [14]. Going further down the road, we reviewed the role of vitamin D in deficient patients not only for COVID-19 severity but as a potential adjuvant for COVID-19 vaccination, as seen for other vaccines [15].
Many previously described studies underline that treating IBD patients with immunomodulators (TNF-antagonists, non-TNF targeted biologics), immunosuppressive therapy, or corticosteroids can increase the risk of infections, or the complications associated with various infections [16]. On the other hand, managing the activity of IBD is also of paramount importance because it plays a risk factor for infections or associated complications. That is why IBD treatment should be as optimal as possible and the treatment course uninterrupted [17,18].
Up to now, there are some clinical studies that involve patients with autoimmune gut diseases and assess the safety and effectiveness of COVID-19 vaccines. Thus, we conducted a literature review and summarize our findings in Table 1.
One of the first that reported on the COVID-19 vaccine and patients with autoimmune gut disease was Botwin et al. They discovered that only 3% had severe adverse events (that affect daily activity), mainly presented by malaise [19]. Three patients needed hospitalization (one of them for gastrointestinal complaints). Studies demonstrated that despite common adverse effects in the general population after COVID-19 vaccination, most of which are mild and local site reactions, there is a noticeable percentage, especially in patients with autoimmune rheumatic diseases [18,20,42]. The latter group mainly complained of localized pain (70.2%), fatigue (34.7%), headache (30.6%), and muscle ache (29.3%), with no serious adverse effects. Similar side effects were observed in IBD patients (Table 1).
Additionally, it was confirmed that IBD patients on advanced therapy with biological agents showed lesser adverse effects than non-IBD patients using other treatment strategies. No data exist comparing IBD patients with other patients with autoimmune diseases, i.e., rheumatoid arthritis and other rheumatic diseases. Regarding the general population, the side effects are comparable [19].
However, they also exerted decreased antibody production while on infliximab and vedolizumab [21,24]. Thus, Botwin et al.’s findings are helpful for physicians and patients by confirming the similar safety profile for mRNA vaccines for IBD patients [19]. Furthermore, the authors observed a difference in adverse reactions following the first and second doses. Higher rates of adverse reactions were found after the second dose [18,19]. However, patients who recovered from COVID-19 had more reactions than patients with no previous antispike response after the first dose but not the second one. Nevertheless, more studies are needed to confirm this observation.
Lev-Tzion et al. confirmed that the incidence rate of disease exacerbation after COVID-19 vaccination is comparable to unvaccinated IBD patients. Moreover, immunosuppressive treatment did not influence the effectiveness of the Pfizer-BioNTech BNT162 b2 vaccine [23].
Additionally, patients on immunosuppression may have reduced immune response (i.e., anti-TNFa but not azathioprine; for corticosteroids—depending on the dose) [43]. Furthermore, the Crohn’s and Colitis Foundation’s statement supports the COVID-19 vaccine in IBD patients without measuring antibody levels [44,45].
Other ongoing studies on the safety and effectiveness of COVID-19 in IBD patients are CORALE-Vaccine IBD (https://www.corale-study.org/ibd, accessed on 30 November 2022) and PREVENT COVID (with children, https://www.ibdpartners.org/preventcovid, accessed on 30 November 2022).
Thus, the Center for Disease Control and the American College of Obstetricians and gynecologists recommend COVID-19 vaccination in female IBD patients planning pregnancy and currently pregnant or lactating women [44]. However, solid organ transplantation patients may not receive sufficient protection after vaccination.
D’Amico et al. suggested more pros than cons for SARS-CoV-2 vaccination in IBD patients. However, despite insufficient data, we can extrapolate information from data reported in patients with other autoimmune diseases [46]. This is why the American College of Rheumatology recommends COVID-19 vaccines for patients with autoimmune inflammatory diseases based on the previously available data for other vaccines [47].
The recently published systemic review and meta-analysis by Sung et al. focused on efficacy, seroconversion rate (antibody titer against SARS-CoV-2 S protein), and the adverse effects in 27,454 IBD patients from 11 studies. As expected from the data from other studies, COVID-19 incidence was comparable in IBD and non-IBD patients and 8.63 times lower than observed in unvaccinated IBD patients. However, the reported adverse event rate after vaccination was 69%, the severe adverse rate was 3%, and mortality was 0% [48].
Doherty et al. published similar results in their paper—reduced immune responses after vaccination in IBD patients on anti-TNF therapy and other immunomodulators. However, the overall conclusion is that patients with IBD still benefit from COVID-19 vaccination, and recommendations included minimizing corticosteroid doses before vaccination if possible [49].
Jena et al. in their systematic review and meta-analysis on effectiveness and durability of COVID-19 vaccination in IBD patients confirmed the lower pooled seroconversion rate. However, the pooled relative risk of infection breakthrough was similar to control subjects [50]. Tabesh et al. also conducted a systematic scoping review of 15 studies, concluding that COVID-19 vaccines are effective and safe for patients with IBD on different therapeutic regimens [51].
One of the most significant limitations of the published studies so far is that they cover effectiveness or adverse effects solely, but rarely both. Additionally, adapted immunization techniques may be appropriate in some IBD patients to maximize immunogenicity, according to prior experience [52,53].
Still, the main concerns for patients with IBD remain a lack of immune protection after vaccination (17.6% of respondents), worsened adverse effects (24.6%) due to IBD, and flare following vaccination (21.1%), according to an international web-based survey [33].
Duong et al. also reported that 2/3 of surveyed IBD patients were willing to get vaccinated against COVID-19 [54], which was also reported by Hudhud et al. [55].

3. Autoimmune Liver Diseases and COVID-19 Vaccines

With the current COVID-19 pandemic on the one hand and the high percentage of liver diseases worldwide on the other, the question of SARS-CoV-2 immunization in this cohort of patients arises among physicians. Consequently, they are in a rat race to assess accurate information to help their patients.
Many reports have been published concerning the severity of COVID-19, the mortality rate, and the disease outcome in patients with liver disease [56]. Regardless of the etiologic cause, all patients with chronic liver disorders are at risk of severe COVID-19 with liver failure and other complications, i.e., cytokine storm [57].
However, the use of immunosuppressants in those patients with autoimmune liver diseases appears to be strongly associated with the severity of COVID-19. Immunosuppressive drugs, such as glucocorticoids, thiopurines, mycophenolate mofetil, and tacrolimus worsen COVID-19 severity and prognosis [58].
Additionally, it was confirmed that SARS-CoV-2 can induce autoimmunity through different mechanisms, including overstimulation of the immune system, formation of excessive neutrophil extracellular traps, development of autoantibodies, etc. [59].
An interesting multicenter network study by Singh et al. enlightened the possible reasons for poor outcomes in patients with preexisting liver disease and SARS-CoV-2 infection [60]. They compared the course of the infection and the outcome in patients with and without previous liver injury. The authors point out that patients in the liver disease group had a higher risk of mortality (p < 0.001) due to increased cirrhosis-induced proinflammatory cytokine production and the concomitant hepatopulmonary syndrome or portopulmonary hypertension, which carry a risk of respiratory failure [60].
Cirrhosis-associated immune dysfunction (CAID) refers to patients with severe liver disease who exhibit innate and humoral immunity impairments. Although the association with severe bacterial infections has already been elucidated, CAID has also been demonstrated to predispose patients to a number of viral or fungal diseases [61]. According to Marjot et al., this aforesaid immune failure was the main culprit for some severe COVID-19 consequences found in patients with decompensated cirrhosis and is culpable for the decreased immunological responses seen with existing vaccines [62]. The authors underline the significance of CAID with an example of reduced duration of humoral immunity and HBV seroconversion rates after HBV, pneumococcal, and influenza vaccination in cirrhotic patients. Based on this evidence, patients with advanced liver disease are prone to have suppressed immunological responses to SARS-CoV-2 immunization [63].
With respect to autoimmune liver diseases (ALD), a plethora of studies have reported that patients appear to be at a higher risk of infection in general, which carries an increased mortality risk [64,65].
A similar assumption has been made regarding autoimmune-induced hepatitis (AIH) and the SARS-CoV-2 virus. However, contrary to this belief, Di Giorgio et al. found that AIH patients have the exact prevalence of COVID-19 infection as the general population [66]. There have been a few occurrences of autoimmune hepatitis (AIH) following SARS-CoV-2 vaccination, all of which were entirely cured by steroid therapy. However, more data are required to support the causation [56].
The systemic review of Alhumad et al. included 275 cases from 118 articles. It demonstrated the onset of 138 cases of autoimmune hepatitis, 52 cases of portal vein thrombosis, 26 cases of elevated liver enzymes, and 21 cases of liver injury following COVID-19 vaccination [67].
However, most patients recovered fully after treatment, without serious complications or need of long-term hepatic therapy, and the causality relationship cannot be confirmed. Moreover, the number of such cases is very small compared to the millions of vaccinations, where the protective benefits outweigh the risks.
Because patients with cirrhosis are particularly vulnerable to a severe COVID-19 course and have a high mortality rate (70% in patients with Child-Pugh C), vaccination against SARS-CoV-2 should start as soon as possible [62].
Many studies have assessed the efficacy of different types of COVID-19 vaccines and their safety profiles. However, despite the inclusion of nearly 100,000 participants in the first COVID-19 conducted trials, data for patients with liver disease are extremely limited, similar to the situation mentioned above for IBD patients and overall for patients with autoimmune, inflammatory, or immune-mediated diseases. For example, in the Pfizer vaccination study, only 0.6% of the participants had liver disease, and even fewer had moderate-to-severe liver disease (<0.1%) [68]. Approximately the same percentage of patients with liver disease were also included in the Moderna trial (0.6%) [69]. We summarized COVID-19 vaccine studies on safety profile, efficacy, and adverse effects rate in pa-tients with autoimmune liver disease in Table 2.
Moreover, the Astra-Zeneca vaccine trials explicitly omitted patients with preexisting liver pathology [71]. In addition, all trials excluded the patients receiving systemic immunosuppression, thus preventing extrapolation of the data to patients with ALD or immunosuppressed liver transplant recipients. Hence, significant information about liver safety profiles is mainly unreported, except that aberrant liver biochemistry was recorded in just one of 12,021 patients who received the Astra Zeneca vaccine [72]. The paper by Mahmud et al. was the first one to our knowledge that classified the patients based on their etiology (31.3% HCV–related liver disease, 33.0% alcohol-related liver disease, and 31.6% nonalcoholic fatty liver disease (NAFLD). In addition, the authors conducted an interesting retrospective cohort study to understand the impact of the Pfizer-BioNTech and Moderna mRNA vaccines in cirrhotic patients compared to a control group of unvaccinated patients without liver injury [72]. There were 43,122 patients included. The authors reported that one shot of an mRNA vaccine was related to a 64.8% reduction in SARS-CoV-2 infections and 100% protection against hospitalization or death due to COVID-19 by 28 days following the initial dose. They also estimated that patients with decompensated cirrhosis had a lower rate of SARS-CoV-2 infections after the first dose (50.3%) than those with compensated cirrhosis (66.8%) [73].
Going further down the road, even fewer studies reported safety data from the vaccine in AIH patients and its association with the flare of the disease. For the time being, the available information came mainly from published case reports. For example, Torrente et al. reported a case of a 46-year-old female with an AIH controlled without medications who experienced a flare of the disease after the COVID-19 vaccination [74].
In addition, Cao et al. published a case report of vaccine-induced AIH exacerbation in a 57-year-old Asian female without previous medical history. However, they rejected the hypothesis of AIH onset following the COVID-19 vaccine because of the histological grade of the fibrosis (stage 2 in this case scenario), which could not be possible for such short notice [75].
Even though the literature data is scarce regarding liver transplant patients, a study by Callaghan et al. showed that the vaccination course does not decrease the number of COVID-19 patients [76]. Their research was conducted from September 2020 to August 2021. The authors included 577 liver recipients; 370 were unvaccinated, 33 received only 1 dose, and 174 patients had a full vaccination course. Nevertheless, it is crucial to underline that those who received two vaccine doses had a 20% higher probability of survival in case of contact with SARS-CoV-2 infection [76].
According to the American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver (EASL), there should be a prompt SARS-CoV-2 vaccination in patients with advanced liver injury [77]. They also recommend against live virus vaccines in patients on high-dose corticosteroids or immunosuppression therapy [77,78].
However, the immediate and long-term protective response through immunization may be insufficient due to these patients’ impaired immune responses. Therefore, AASLD also recommends a booster dose of an mRNA vaccination for all immunocompromised people who have previously received two doses of an mRNA vaccine due to their decreased response rate and greater risk of breakthrough infections [78]. According to the AASLD expert panel consensus statement, the booster shot of the mRNA vaccine should be administered at least 28 days after the last dose and should be a homologous mRNA vaccine whenever possible. In areas where the homologous shot is unavailable, the alternative (heterologous) mRNA vaccine could be used if necessary [78]. In addition, in cases of a limited supply of COVID-19 vaccine, the patients with higher Model for Endstage Liver Disease (MELD) or Child–Turcotte–Pugh scores should prioritize vaccination [78].
The growing impact of SARS-CoV-2 immunization has aroused concerns about vaccine-induced side effects. Besides systemic adverse effects (AE) such as headache, fever, fatigue, and those reported from the clinical trials (Table 2), physicians should consider reactivation of occult autoimmune diseases as a vaccine side effect [79,80].
Three case reports in the literature described AIH development several days after COVID-19 immunization. Nonetheless, the exact mechanism has not been elucidated [81,82].
In the past, this association between vaccination and autoimmune disease has been linked to using different adjuvants such as aluminum hydroxide, Toll-like receptor agonists, or lipid emulsions in developing subunit and inactivated vaccines [83,84]. However, no causal relationship has been established, even for adjuvanted vaccinations, including aluminum hydroxide or aluminum phosphate [85].
Cross-reactivity with host cells is thought to be the main villain due to the disrupted self-tolerance and promoted autoimmune reactions because of the SARS-CoV-2 infection. Consistent with this report, COVID-19 mRNA vaccines may trigger a similar effect [4,86].
Regardless, prioritizing vaccination in this cohort remains critical, considering the high percentage of COVID-19-related mortality in patients with decompensated cirrhosis. Currently, recommendations for vaccination administration in disease subpopulations are inconsistent and geographically variable. A detailed study of immunological reactions must be performed to standardize vaccination guidelines eventually. As we enter a new phase of SARS-CoV-2 immunization, it is crucial to investigate the impact of recent vaccinations on patients with various liver diseases, where information is lacking. Still, the clinical effects of the viral infection are severe. Large epidemiological studies, well supported by pharmacovigilance trials, would be of paramount significance for evaluating vaccine safety profile, its AE rates, and its association with re-/activation of an autoimmune disease. Better engagement between scientists and physicians is needed to establish the best vaccine choice for different liver disease populations.

4. Pediatric Point of View on COVID-19 Vaccines in Children with Gut and Liver Autoimmune Diseases

Gastrointestinal involvement in children associated with SARS-CoV-2 is multifaceted. Acute infection is related to various GIT symptoms such as nausea, vomiting, diarrhea, and abdominal pain [87]. According to a recent systematic review of children with COVID-19, the pooled prevalence of diarrhea is 12.4%, followed by vomiting at 10.3%, and vomiting at 5.4% [87]. In some cases, SARS-CoV-2 RNA could be detected in feces and persist even after nasopharyngeal smears are negative for up to 12 days [88]. A more prominent abdominal symptom is seen in MIS (PIMS) children [89]. In a multicenter study, Lo Vecchio et al. reported a 9.5% incidence of severe GI symptoms in Italian children with SARS-CoV2 infection. They included acute abdomen, appendicitis, intussusception, pancreatitis, abdominal fluid collection, and diffuse adenomesenteritis, frequently associated with MIS-C [89]. Acute COVID-19 infection and MIS-C could lead to a different degree of liver injury—almost always reversible and mild [90].
Children with advanced liver diseases (cirrhosis, portal hypertonia) and/or children on immunosuppressive therapy have an increased risk for severe COVID-19. Pediatric IBD (PIBD) with COVID-19 infection appears to be less severe than in adults. Children with IBD, with or without biological and/or immunosuppressive treatment, do not demonstrate a higher risk during SARS-CoV-2 infection than the general population. However, many studies emphasize the role of uninterrupted PIBD therapy since its discontinuation could cause a disease flare during COVID-19 infection [91]. On treatment with infliximab (anti-TNF therapy) as monotherapy or combination therapy, children with IBD probably will need a booster dose to provide complete protection [92]. Spencer et al. report stable seroconversion in children with PIBD after SARS-CoV-2 infection and vaccination [93].
Considering IBD children who are more prone to infections, strict routine vaccines—flu and pneumococcal vaccines—are recommended. This should also be applied to COVID-19 vaccines, although IBD children have no tendency for a severe course of disease than the general pediatrician population. However, there is an urgent need for official, internationally accepted recommendations for SARS-CoV-2 vaccination in children with IBD and other autoimmune gastrointestinal diseases. According to the advice from an international consensus meeting on SARS-CoV-2 vaccination for patients with IBD, the immunization of children with IBD will be the same as in the general pediatric population after the official SARS-CoV-2 vaccination authorization [94]. It is expected that COVID-19 vaccines would elicit an adequate immune response since immunosuppressive treatment does not reduce vaccine immunogenicity in IBD children [95].
The Crohn’s and Colitis Canada organization officially recommends that children five years of age or older with IBD receive their second dose of COVID-19 vaccination approximately 4 weeks after their first dose and their third complete COVID-19 vaccination 4–8 weeks after their second vaccine dose [96]. However, the organization also comments on the possible fourth dose in children without establishing official recommendations and specific conditions. Therefore, there are still no recommendations for the fourth dose in children aged 5–11. Additionally, after initiating mass child vaccination worldwide, no recommendations were updated for 2022.
According to a joint ESPHAGAN (European Society for Pediatric Gastroenterology, Hepatology and Nutrition) and SPLT (Society of Pediatric Liver Transplantation) position paper, children and adolescents with cirrhosis (compensated and decompensated), chronic liver disease (CLD) (including nonalcoholic fatty liver disease), and end-stage liver disease awaiting transplantation, as well as liver transplantation (LT) recipients on immunosuppressive medications, should be prioritized for early vaccine access because of their risk for poorer outcomes from SARS-CoV-2 infection [97]. Furthermore, children listed for LT can receive a two-dose-schedule vaccination. Even LT is planned between two doses. Additionally, it is not recommended to reduce immunosuppression to elicit an immune response after vaccination, nor serological testing before and after the COVID-19 vaccine. The position paper recommends SARS-CoV-2 vaccination for children 12–17 years old. After evaluating the vaccine’s safety, the same recommendation should be applied to younger children with different chronic liver diseases based on the expected benefits and confirmed safety [97]. However, ESPGHAN recommendations are not updated after the official approval from FDA and EMA for mRNA COVID vaccines in children from 5–11 years [91].
To sum up, The Crohn’s and Colitis Canada organization alone provided specific recommendations for COVID-19 vaccination in children with IBD. However, there is a lack of official guidance from established international societies and organizations. In addition, we need details on vaccination dosage and regimens (including third and following doses of reimmunization) and specific situations, such as the administration of systemic corticosteroids and immunosuppressants, including biologics.
Dailey et al. provided valuable information on the efficacy of COVID-19 vaccination on children and young adults with IBD (aged 2–26 years) [28]. As expected, and similar to the results from adults with IBD, antispike IgG antibodies were significantly lower in patients with IBD after natural infection and there was a 15-fold increased antibody response following COVID-19 vaccination. Nevertheless, after vaccination, all patients developed virus-neutralizing antibodies [28].
We also must emphasize that parents and legal guardians of children with autoimmune gut and liver diseases have concerns and fears about the SARS-CoV-2 and vaccination against it. These concerns lead to hesitation on how to proceed with immunosuppressive therapy. If we extrapolate the data for adults, it is mandatory to maintain treatment during vaccination to avoid relapses. Therefore, physicians must support them and provide the proper information to explain all the benefits and safety profiles of COVID-19 vaccines. However, all specialists need specific official recommendations and statements from the official organizations and societies for children with this condition, which should also be regularly updated considering the novel accumulated data.

5. Conclusions

The discussion about COVID-19 vaccines and GI patients with altered immune status resulted in an evidence gap for the long-term safety and efficacy of COVID-19 vaccines in patients with autoimmune diseases. In addition, some of the theoretical concerns are related to the complex pathogenesis of autoimmune diseases, including liver and gut conditions, immunosuppressive therapy, and the cumulative risk of flare. Nevertheless, data on COVID-19 vaccination for adult and pediatric patients with gut and liver autoimmune diseases showed good efficacy of mRNA vaccines. Moreover, their immunogenicity and safety profile are acceptable, with adverse effects resembling those in the general population. Still, there is a lack of official statements and recommendations, and more clinical trials are needed to confirm these data and support official recommendations.

Author Contributions

Conceptualization, M.P.-S. and T.V.; data curation, M.P.-S., P.B., V.S., S.L. and T.V.; writing—original draft preparation, M.P.-S., P.B., V.S., S.L. and T.V.; writing—review and editing, T.V.; visualization, M.P.-S.; supervision, T.V. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Tepasse, P.R.; Vollenberg, R.; Nowacki, T.M. Vaccination against SARS-CoV-2 in Patients with Inflammatory Bowel Diseases: Where Do We Stand? Life 2021, 11, 1220. [Google Scholar] [CrossRef] [PubMed]
  2. Cummings, M.J.; Baldwin, M.R.; Abrams, D.; Jacobson, S.D.; Meyer, B.J.; Balough, E.M.; Aaron, J.G.; Claassen, J.; Rabbani, L.E.; Hastie, J.; et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: A prospective cohort study. Lancet 2020, 395, 1763–1770. [Google Scholar] [CrossRef] [PubMed]
  3. Singh, A.K.; Jena, A.; Kumar-M, P.; Sharma, V.; Sebastian, S. Risk and outcomes of coronavirus disease in patients with inflammatory bowel disease: A systematic review and meta-analysis. United Eur. Gastroenterol. J. 2020, 9, 159–176. [Google Scholar] [CrossRef] [PubMed]
  4. Kim, L.; Garg, S.; O’Halloran, A.; Whitaker, M.; Pham, H.; Anderson, E.J.; Armistead, I.; Bennett, N.M.; Billing, L.; Como-Sabetti, K.; et al. Risk Factors for Intensive Care Unit Admission and In-hospital Mortality Among Hospitalized Adults Identified through the US Coronavirus Disease 2019 (COVID-19)-Associated Hospi-talization Surveillance Network (COVID-NET). Clin. Infect. Dis. 2021, 72, e206–e214. [Google Scholar] [CrossRef] [PubMed]
  5. Rabaan, A.A.; Al Mutair, A.; Hajissa, K.; Alfaraj, A.H.; Al-Jishi, J.M.; Alhajri, M.; Alwarthan, S.; Alsuliman, S.A.; Al-Najjar, A.H.; Al Zaydani, I.A.; et al. A Comprehensive Review on the Current Vaccines and Their Efficacies to Combat SARS-CoV-2 Variants. Vaccines 2022, 10, 1655. [Google Scholar] [CrossRef] [PubMed]
  6. Prates-Syed, W.A.; Chaves, L.C.S.; Crema, K.P.; Vuitika, L.; Lira, A.; Côrtes, N.; Kersten, V.; Guimarães, F.E.G.; Sadraeian, M.; da Silva, F.L.B.; et al. VLP-Based COVID-19 Vaccines: An Adaptable Technology against the Threat of New Variants. Vaccines 2021, 9, 1409. [Google Scholar] [CrossRef] [PubMed]
  7. Velikova, T.; Georgiev, T. SARS-CoV-2 vaccines and autoimmune diseases amidst the COVID-19 crisis. Rheumatol. Int. 2021, 41, 509–518. [Google Scholar] [CrossRef]
  8. Ferretti, F.; Cannatelli, R.; Benucci, M.; Carmagnola, S.; Clementi, E.; Danelli, P.; Dilillo, D.; Fiorina, P.; Galli, M.; Gallieni, M.; et al. How to Manage COVID-19 Vaccination in Im-mune-Mediated Inflammatory Diseases: An Expert Opinion by IMIDs Study Group. Front. Immunol. 2021, 12, 656362. [Google Scholar] [CrossRef]
  9. Sen, P.; Gupta, L.; Lilleker, J.B.; Aggarwal, V.; Kardes, S.; Milchert, M.; Gheita, T.; Salim, B.; Velikova, T.; Gracia-Ramos, A.E.; et al. COVID-19 vaccination in autoimmune disease (COVAD) survey protocol. Rheumatol. Int. 2021, 42, 23–29. [Google Scholar] [CrossRef]
  10. COVAD Study Group; Lilleker, J.B.; Chinoy, H. Vaccine Hesitancy in Patients with Autoimmune Diseases: Data from the COVID-19 Vaccination in Autoimmune Diseases (COVAD) Study. Indian J. Rheumatol. 2021; in press. [Google Scholar]
  11. Wu, X.; Lin, J.; Buch, H.; Ding, Q.; Zhang, F.; Cui, B.; Ji, G. The COVID-19 Vaccination Hesitancy Among the People with Inflammatory Bowel Disease in China: A Questionnaire Study. Front. Public Health 2021, 9, 731578. [Google Scholar] [CrossRef] [PubMed]
  12. Hejrati, A.; Rafiei, A.; Soltanshahi, M.; Hosseinzadeh, S.; Dabiri, M.; Taghadosi, M.; Taghiloo, S.; Bashash, D.; Khorshidi, F.; Zafari, P. Innate immune response in systemic autoimmune diseases: A potential target of therapy. Inflammopharmacology 2020, 28, 1421–1438. [Google Scholar] [PubMed]
  13. Gershwin, M.E.; Borchers, A.T.; Keen, C.L. Phenotypic and Functional Considerations in the Evaluation of Immunity in Nutritionally Compromised Hosts. J. Infect. Dis. 2000, 182, S108–S114. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  14. Garg, M.; Al-Ani, A.; Mitchell, H.; Hendy, P.; Christensen, B. Low population mortality from COVID-19 in countries south of lat-itude 35 degrees North-supports vitamin D as a factor determining severity. Aliment Pharmacol. Ther. 2020, 51, 1438–1439. [Google Scholar] [CrossRef] [PubMed]
  15. Velikova, T.; Fabbri, A.; Infante, M. The role of vitamin D as a potential adjuvant for COVID-19 vaccines. Eur. Rev. Med. Pharmacol. Sci. 2021, 25, 5323–5327. [Google Scholar] [CrossRef] [PubMed]
  16. Khan, N.; Vallarino, C.; Lissoos, T.; Darr, U.; Luo, M. Risk of infection and types of infection among elderly patients with inflam-matory bowel disease: A retrospective database analysis. Inflamm. Bowel Dis. 2020, 26, 462–468. [Google Scholar]
  17. Al-Ani, A.H.; Prentice, R.E.; Rentsch, C.A.; Johnson, D.; Ardalan, Z.; Heerasing, N.; Garg, M.; Campbell, S.; Sasadeusz, J.; Macrae, F.A.; et al. Review article: Prevention, diagnosis and management of COVID-19 in the IBD patient. Aliment. Pharmacol. Ther. 2020, 52, 54–72. [Google Scholar] [CrossRef]
  18. Spiera, E.; Agrawal, M.; Ungaro, R.C. COVID-19 mRNA Vaccine Short-Term Safety in Patients with Inflammatory Bowel Disease. Gastroenterology 2022, 162, 987–988. [Google Scholar] [CrossRef]
  19. Botwin, G.J.; Li, D.; Figueiredo, J.; Cheng, S.; Braun, J.; McGovern, D.P.; Melmed, G.Y. Adverse Events after SARS-CoV-2 mRNA Vaccination among Patients with Inflam-matory Bowel Disease. Am. J. Gastroenterol. 2021, 116, 1746–1751. [Google Scholar]
  20. Weaver, K.N.; Zhang, X.; Dai, X.; Watkins, R.; Adler, J.; Dubinsky, M.C.; Kastl, A.; Bousvaros, A.; Strople, J.A.; Cross, R.K.; et al. Impact of SARS-CoV-2 Vaccination on Inflammatory Bowel Disease Activity and Development of Vaccine-Related Adverse Events: Results From PREVENT-COVID. Inflamm. Bowel. Dis. 2022, 28, 1497–1505. [Google Scholar] [CrossRef]
  21. Wong, S.-Y.; Dixon, R.; Pazos, V.M.; Gnjatic, S.; Colombel, J.-F.; Cadwell, K.; Gold, S.; Helmus, D.; Neil, J.A.; Sota, S.; et al. Serologic Response to Messenger RNA Coronavirus Disease 2019 Vaccines in Inflammatory Bowel Disease Patients Receiving Biologic Therapies. Gastroenterology 2021, 161, 715–718.e4. [Google Scholar] [CrossRef] [PubMed]
  22. Alexander, J.L.; Liu, Z.; Sandoval, D.M.; Reynolds, C.; Ibraheim, H.; Anandabaskaran, S.; Saifuddin, A.; Seoane, R.C.; Anand, N.; Nice, R.; et al. COVID-19 vaccine-induced antibody and T-cell responses in immunosuppressed patients with inflammatory bowel disease after the third vaccine dose (VIP): A multicentre, prospective, case-control study. Lancet Gastroenterol. Hepatol. 2022, 7, 1005–1015. [Google Scholar] [CrossRef] [PubMed]
  23. Lev-Tzion, R.; Focht, G.; Lujan, R.; Mendelovici, A.; Friss, C.; Greenfeld, S.; Kariv, R.; Ben-Tov, A.; Matz, E.; Nevo, D.; et al. COVID-19 Vaccine Is Effective in Inflammatory Bowel Disease Patients and Is Not Associated with Disease Exacerbation. Clin. Gastroenterol. Hepatol. 2022, 20, e1263–e1282. [Google Scholar] [CrossRef] [PubMed]
  24. Kennedy, N.A.; Lin, S.; Goodhand, J.R.; Chanchlani, N.; Hamilton, B.; Bewshea, C.; Nice, R.; Chee, D.; Cummings, J.F.; Fraser, A.; et al. Contributors to the CLARITY IBD study. Infliximab is associated with attenuated immunogenicity to BNT162b2 and ChAdOx1 nCoV-19 SARS-CoV-2 vaccines in patients with IBD. Gut 2021, 70, 1884–1893. [Google Scholar] [CrossRef]
  25. Khan, N.; Mahmud, N. Effectiveness of SARS-CoV-2 Vaccination in a Veterans Affairs Cohort of Patients with Inflammatory Bowel Disease with Diverse Exposure to Immunosuppressive Medications. Gastroenterology 2021, 161, 827–836. [Google Scholar] [CrossRef]
  26. Hadi, Y.B.; Thakkar, S.; Shah-Khan, S.M.; Hutson, W.; Sarwari, A.; Singh, S. COVID-19 Vaccination Is Safe and Effective in Patients with Inflammatory Bowel Disease: Analysis of a Large Multi-institutional Research Network in the United States. Gastroenterology 2021, 161, 1336–1339.e3. [Google Scholar] [CrossRef]
  27. Ben-Tov, A.; Banon, T.; Chodick, G.; Kariv, R.; Assa, A.; Gazit, S. BNT162b2 Messenger RNA COVID-19 Vaccine Effectiveness in Patients with Inflammatory Bowel Disease: Preliminary Real-World Data During Mass Vaccination Campaign. Gastroenterology 2021, 161, 1715–1717.e1. [Google Scholar] [CrossRef] [PubMed]
  28. Dailey, J.; Kozhaya, L.; Dogan, M.; Hopkins, D.; Lapin, B.; Herbst, K.; Brimacombe, M.; Grandonico, K.; Karabacak, F.; Schreiber, J.; et al. Antibody Responses to SARS-CoV-2 After Infection or Vaccination in Children and Young Adults with Inflammatory Bowel Disease. Inflamm. Bowel Dis. 2021, 28, 1019–1026. [Google Scholar] [CrossRef]
  29. Kappelman, M.D.; Weaver, K.N.; Boccieri, M.; Firestine, A.; Zhang, X.; Long, M.D.; Chun, K.; Fernando, M.; Zikry, M.; Dai, X.; et al. Humoral Immune Response to Messenger RNA COVID-19 Vaccines Among Patients with Inflammatory Bowel Disease. Gastroenterology 2021, 161, 1340–1343.e2. [Google Scholar] [CrossRef]
  30. Simon, D.; Tascilar, K.; Fagni, F.; Krönke, G.; Kleyer, A.; Meder, C.; Atreya, R.; Leppkes, M.; Kremer, A.E.; Ramming, A.; et al. SARS-CoV-2 vaccination responses in untreated, conventionally treated and anticytokine-treated patients with immune-mediated inflammatory diseases. Ann. Rheum. Dis. 2021, 80, 1312–1316. [Google Scholar] [CrossRef]
  31. James, D.; Jena, A.; Bharath, P.N.; Choudhury, A.; Singh, A.K.; Sebastian, S.; Sharma, V. Safety of SARS-CoV-2 vaccination in patients with inflammatory bowel disease: A systematic review and meta-analysis. Dig. Liver Dis. 2022, 54, 713–721. [Google Scholar] [CrossRef]
  32. Pozdnyakova, V.; Botwin, G.J.; Sobhani, K.; Prostko, J.; Braun, J.; Mcgovern, D.P.; Melmed, G.Y.; Appel, K.; Banty, A.; Feldman, E.; et al. Decreased Antibody Responses to Ad26.COV2.S Relative to SARS-CoV-2 mRNA Vaccines in Patients with Inflammatory Bowel Disease. Gastroenterology 2021, 161, 2041–2043.e1. [Google Scholar] [CrossRef]
  33. Ellul, P.; Revés, J.; Abreu, B.; Chaparro, M.; Gisbert, J.P.; Allocca, M.; Fiorino, G.; Barberio, B.; Zingone, F.; Pisani, A.; et al. Implementation and Short-term Adverse Events of Anti-SARS-CoV-2 Vaccines in Inflammatory Bowel Disease Patients: An International Web-based Survey. J. Crohn’s Colitis 2022, 16, 1070–1078. [Google Scholar] [CrossRef]
  34. Caldera, F.; Knutson, K.L.; Saha, S.; Wald, A.; Phan, H.S.; Chun, K.; Grimes, I.; Lutz, M.; Hayney, M.S.; Farraye, F.A. Humoral Immunogenicity of mRNA COVID-19 Vaccines Among Patients with Inflammatory Bowel Disease and Healthy Controls. Am. J. Gastroenterol. 2021, 117, 176–179. [Google Scholar] [CrossRef]
  35. Cerna, K.; Duricova, D.; Lukas, M.; Machkova, N.; Hruba, V.; Mitrova, K.; Kubickova, K.; Kostrejova, M.; Teplan, V.; Vasatko, M.; et al. Anti-SARS-CoV-2 vaccination and antibody response in patients with inflammatory bowel disease on immune-modifying therapy: Prospective single-tertiary study. Inflamm. Bowel Dis. 2022, 28, 1506–1512. [Google Scholar] [CrossRef]
  36. Classen, J.M.; Muzalyova, A.; Nagl, S.; Fleischmann, C.; Ebigbo, A.; Römmele, C.; Messmann, H.; Schnoy, E. Antibody Response to SARS-CoV-2 Vaccination in Patients with Inflammatory Bowel Disease: Results of a Single-Center Cohort Study in a Tertiary Hospital in Germany. Dig. Dis. 2021, 40, 719–727. [Google Scholar] [CrossRef]
  37. Edelman-Klapper, H.; Zittan, E.; Shitrit, A.B.-G.; Rabinowitz, K.M.; Goren, I.; Avni-Biron, I.; Ollech, J.E.; Lichtenstein, L.; Banai-Eran, H.; Yanai, H.; et al. Lower Serologic Response to COVID-19 mRNA Vaccine in Patients with Inflammatory Bowel Diseases Treated with Anti-TNFα. Gastroenterology 2022, 162, 454–467. [Google Scholar] [CrossRef]
  38. Garrido, I.; Lopes, S.; Macedo, G. Safety of COVID-19 Vaccination in Inflammatory Bowel Disease Patients on Biologic Therapy. J. Crohn’s Colitis 2021, 16, 687–688. [Google Scholar] [CrossRef]
  39. Levine, I.; Swaminath, A.; Roitman, I.; Sultan, K. COVID-19 Vaccination and Inflammatory Bowel Disease: Desired Antibody Responses, Future Directions, and a Note of Caution. Gastroenterology 2022, 162, 349–350. [Google Scholar] [CrossRef]
  40. Rodríguez-Martinó, E.; Medina-Prieto, R.; Santana-Bagur, J.; Santé, M.; Pantoja, P.; Espino, A.M.; Sariol, C.A.; Torres, E.A. Early immunologic response to mRNA COVID-19 vaccine in patients receiving biologics and/or immunomodulators. medRxiv 2021, 78, 625. [Google Scholar]
  41. Shehab, M.; Alrashed, F.; Alfadhli, A.; Alotaibi, K.; Alsahli, A.; Mohammad, H.; Cherian, P.; Al-Khairi, I.; Thanaraj, T.A.; Channanath, A.; et al. Serological Response to BNT162b2 and ChAdOx1 nCoV-19 Vaccines in Patients with Inflammatory Bowel Disease on Biologic Therapies. Vaccines 2021, 9, 1471. [Google Scholar] [CrossRef]
  42. Esquivel-Valerio, J.A.; Skinner-Taylor, C.M.; Moreno-Arquieta, I.A.; la Garza, J.A.C.-D.; Garcia-Arellano, G.; Gonzalez-Garcia, P.L.; Almaraz-Juarez, F.d.R.; Galarza-Delgado, D.A. Adverse events of six COVID-19 vaccines in patients with autoimmune rheumatic diseases: A cross-sectional study. Rheumatol. Int. 2021, 41, 2105–2108. [Google Scholar] [CrossRef]
  43. Fagni, F.; Simon, D.; Tascilar, K.; Schoenau, V.; Sticherling, M.; Neurath, M.F.; Schett, G. COVID-19 and immune-mediated inflam-matory diseases: Effect of disease and treatment on COVID-19 outcomes and vaccine responses. Lancet Rheumatol. 2021, 3, e724–e736. [Google Scholar] [CrossRef]
  44. Chron’s and Colitis Foundations COVID-19 Vaccine Statement. Available online: https://www.crohnscolitisfoundation.org/sites/default/files/2021-01/COVID-19%20Vaccine%20Position%20Statement.pdf (accessed on 30 November 2022).
  45. Freund, O.; Tau, L.; Weiss, T.E.; Zornitzki, L.; Frydman, S.; Jacob, G.; Bornstein, G. Associations of vaccine status with characteristics and outcomes of hospitalized severe COVID-19 patients in the booster era. PLoS ONE 2022, 17, e0268050. [Google Scholar] [CrossRef]
  46. D’Amico, F.; Rabaud, C.; Peyrin-Biroulet, L.; Danese, S. SARS-CoV-2 vaccination in IBD: More pros than cons. Nat. Rev. Gastroenterol. Hepatol. 2021, 18, 211–213. [Google Scholar] [CrossRef]
  47. ACR COVID-19 Vaccine Guidance Recommends Vaccination, Addresses Immunosuppressant Drugs & Patient Concerns. Available online: https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1138 (accessed on 30 November 2022).
  48. Sung, K.-Y.; Chang, T.-E.; Wang, Y.-P.; Lin, C.-C.; Chang, C.-Y.; Hou, M.-C.; Lu, C.-L. SARS-CoV-2 vaccination in patients with inflammatory bowel disease: A systemic review and meta-analysis. J. Chin. Med. Assoc. 2021, 85, 421–430. [Google Scholar] [CrossRef]
  49. Doherty, J.; Fennessy, S.; Stack, R.; Morain, N.O.; Cullen, G.; Ryan, E.J.; De Gascun, C.; Doherty, G.A. Review Article: Vaccination for patients with inflammatory bowel disease during the COVID-19 pandemic. Aliment. Pharmacol. Ther. 2021, 54, 1110–1123. [Google Scholar] [CrossRef]
  50. Jena, A.; James, D.; Singh, A.K.; Dutta, U.; Sebastian, S.; Sharma, V. Effectiveness and Durability of COVID-19 Vaccination in 9447 Patients with IBD: A Systematic Review and Meta-Analysis. Clin. Gastroenterol. Hepatol. 2022, 20, 1456–1479.e18. [Google Scholar] [CrossRef]
  51. Tabesh, E.; Soheilipour, M.; Rezaeisadrabadi, M.; Zare-Farashbandi, E.; Mousavi-Roknabadi, R.S. Comparison the effects and side effects of COVID-19 vaccination in patients with inflammatory bowel disease (IBD): A systematic scoping review. BMC Gastroenterol. 2022, 22, 393. [Google Scholar] [CrossRef]
  52. Wellens, J.; Colombel, J.-F.; Satsangi, J.J.; Wong, S.-Y. SARS-CoV-2 Vaccination in IBD: Past Lessons, Current Evidence, and Future Challenges. J. Crohn’s Colitis 2021, 15, 1376–1386. [Google Scholar] [CrossRef]
  53. Kubas, A.; Malecka-Wojciesko, E. COVID-19 Vaccination in Inflammatory Bowel Disease (IBD). J. Clin. Med. 2022, 11, 2676. [Google Scholar] [CrossRef] [PubMed]
  54. Duong, T.A.; Bryant, R.V.; Andrews, J.M.; Lynch, K.D. Attitudes towards COVID -19 vaccination in patients with inflammatory bowel disease. Intern. Med. J. 2022, 52, 1070–1074. [Google Scholar] [CrossRef] [PubMed]
  55. Hudhud, D.; Caldera, F.; Cross, R.K. Addressing COVID-19 Vaccine Hesitancy in Patients with IBD. Inflamm. Bowel Dis. 2021, 28, 492–493. [Google Scholar] [CrossRef] [PubMed]
  56. Floreani, A.; De Martin, S. COVID-19 and Autoimmune Liver Diseases. J. Clin. Med. 2022, 11, 2681. [Google Scholar] [CrossRef] [PubMed]
  57. Taneva, G.; Dimitrov, D.; Velikova, T. Liver dysfunction as a cytokine storm manifestation and prognostic factor for severe COVID-19. World J. Hepatol. 2021, 13, 2005–2012. [Google Scholar] [CrossRef]
  58. Efe, C.; Lammert, C.; Taşçılar, K.; Dhanasekaran, R.; Ebik, B.; la Tijera, F.H.; Calışkan, A.R.; Peralta, M.; Gerussi, A.; Massoumi, H.; et al. Effects of immunosuppressive drugs on COVID-19 severity in patients with autoimmune hepatitis. Liver Int. 2021, 42, 607–614. [Google Scholar] [CrossRef]
  59. Dotan, A.; Muller, S.; Kanduc, D.; David, P.; Halpert, G.; Shoenfeld, Y. The SARS-CoV-2 as an instrumental trigger of autoimmunity. Autoimmun. Rev. 2021, 20, 102792. [Google Scholar] [CrossRef]
  60. Singh, S.; Khan, A. Clinical Characteristics and Outcomes of Coronavirus Disease 2019 Among Patients with Preexisting Liver Disease in the United States: A Multicenter Research Network Study. Gastroenterology 2020, 159, 768–771.e3. [Google Scholar] [CrossRef]
  61. Piano, S.; Brocca, A.; Mareso, S.; Angeli, P. Infections complicating cirrhosis. Liver Int. 2018, 38, 126–133. [Google Scholar] [CrossRef] [Green Version]
  62. Marjot, T.; Moon, A.M.; Cook, J.A.; Abd-Elsalam, S.; Aloman, C.; Armstrong, M.J.; Pose, E.; Brenner, E.J.; Cargill, T.; Catana, M.-A.; et al. Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: An international registry study. J. Hepatol. 2020, 74, 567–577. [Google Scholar] [CrossRef]
  63. Marjot, T.; Webb, G.J.; Barritt, A.S.; Ginès, P.; Lohse, A.W.; Moon, A.M.; Pose, E.; Trivedi, P.; Barnes, E. SARS-CoV-2 vaccination in patients with liver disease: Responding to the next big question. Lancet Gastroenterol. Hepatol. 2021, 6, 156–158. [Google Scholar] [CrossRef]
  64. Peng, X.G.; Li, Y.Y.; Chen, H.T.; Zhou, Y.; Ma, J.G.; Yin, H.M. Evolution of correlation between Helicobacter pylori infection and auto-immune liver disease. Exp. Ther. Med. 2017, 14, 1487–1490. [Google Scholar] [CrossRef] [Green Version]
  65. Mohammed, A.; Paranji, N.; Chen, P.H.; Niu, B. COVID-19 in Chronic Liver Disease and Liver Transplantation: A Clinical Review. J. Clin. Gastroenterol. 2021, 55, 187–194. [Google Scholar] [CrossRef]
  66. Di Giorgio, A.; Nicastro, E.; Speziani, C.; De Giorgio, M.; Pasulo, L.; Magro, B.; Fagiuoli, S.; D’ Antiga, L. Health status of patients with autoimmune liver disease during SARS-CoV-2 outbreak in northern Italy. J. Hepatol. 2020, 73, 702–705. [Google Scholar] [CrossRef]
  67. Alhumaid, S.; Al Mutair, A.; Rabaan, A.A.; Alshakhs, F.M.; Choudhary, O.P.; Yong, S.J.; Nainu, F.; Khan, A.; Muhammad, J.; Alhelal, F.; et al. New-onset and relapsed liver diseases following COVID-19 vaccination: A systematic review. BMC Gastroenterol. 2022, 22, 433. [Google Scholar] [CrossRef]
  68. Polack, F.P.; Thomas, S.J.; Kitchin, N.; Absalon, J.; Gurtman, A.; Lockhart, S.; Perez, J.L.; Pérez Marc, G.; Moreira, E.D.; Zerbini, C.; et al. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N. Engl. J. Med. 2020, 383, 2603–2615. [Google Scholar] [CrossRef]
  69. Baden, L.R.; El Sahly, H.M.; Essink, B.; Kotloff, K.; Frey, S.; Novak, R.; Diemert, D.; Spector, S.A.; Rouphael, N.; Creech, C.B.; et al. COVE Study Group. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N. Engl. J. Med. 2021, 384, 403–416. [Google Scholar] [CrossRef]
  70. Duengelhoef, P.; Hartl, J.; Rüther, D.; Steinmann, S.; Brehm, T.T.; Weltzsch, J.P.; Glaser, F.; Schaub, G.M.; Sterneck, M.; Sebode, M.; et al. SARS-CoV-2 vaccination response in patients with autoimmune hepatitis and autoimmune cholestatic liver disease. United Eur. Gastroenterol. J. 2022, 10, 319–329. [Google Scholar] [CrossRef]
  71. Voysey, M.; Clemens, S.A.C.; Madhi, S.A.; Weckx, L.Y.; Folegatti, P.M.; Aley, P.K.; Angus, B.; Baillie, V.L.; Barnabas, S.L.; Bhorat, Q.E.; et al. Oxford COVID Vaccine Trial Group. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: An interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 2021, 397, 99–111. [Google Scholar] [CrossRef]
  72. Alqahtani, S.; Barry, M.; Memish, Z.; Hashim, A.; Alfares, M.; Alghamdi, S.; Al-Hamoudi, W.; Al-Judaibi, B.; Alhazzani, W.; Al-Tawfiq, J.; et al. Use of COVID-19 vaccines in patients with liver disease and post-liver transplantation: Position statement of the Saudi association for the study of liver diseases and transplantation. Saudi J. Gastroenterol. 2021, 27, 201. [Google Scholar] [CrossRef]
  73. Mahmud, N.; Chapin, S.E.; Kaplan, D.E.; Serper, M. Identifying Patients at Highest Risk of Remaining Unvaccinated Against Severe Acute Respiratory Syndrome Coronavirus 2 in a Large Veterans Health Administration Cohort. Liver Transplant. 2021, 27, 1665–1668. [Google Scholar] [CrossRef] [PubMed]
  74. Torrente, S.; Castiella, A.; Garmendia, M.; Zapata, E. Probable autoimmune hepatitis reactivated after COVID-19 vaccination. Gastroenterol. Hepatol. 2022, 45 (Suppl. 1), 115–116. [Google Scholar] [CrossRef]
  75. Cao, Z.; Gui, H.; Sheng, Z.; Xin, H.; Xie, Q. Letter to the editor: Exacerbation of autoimmune hepatitis after COVID-19 vaccination. Hepatology 2021, 75, 757–759. [Google Scholar] [CrossRef]
  76. Callaghan, C.J.; Mumford, L.; Curtis, R.M.K.; Williams, S.V.; Whitaker, H.; Andrews, N.; Lopez Bernal, J.; Ushiro-Lumb, I.; Pettigrew, G.J.; Thorburn, D.; et al. NHSBT Organ and Tissue Donation and Transplantation Clinical Team. Real-world Effectiveness of the Pfizer-BioNTech BNT162b2 and Oxford-AstraZeneca ChAdOx1-S Vaccines Against SARS-CoV-2 in Solid Organ and Islet Transplant Recipients. Transplantation 2022, 106, 436–446. [Google Scholar] [CrossRef]
  77. Cornberg, M.; Buti, M.; Eberhardt, C.S.; Grossi, P.A.; Shouval, D. EASL position paper on the use of COVID-19 vaccines in patients with chronic liver diseases, hepatobiliary cancer and liver transplant recipients. J. Hepatol. 2021, 74, 944–951. [Google Scholar] [CrossRef]
  78. Fix, O.K.; Blumberg, E.A.; Chang, K.-M.; Chu, J.; Chung, R.T.; Goacher, E.K.; Hameed, B.; Kaul, D.R.; Kulik, L.M.; Kwok, R.M.; et al. American Association for the Study of Liver Diseases Expert Panel Consensus Statement: Vaccines to Prevent Coronavirus Disease 2019 Infection in Patients with Liver Disease. Hepatology 2021, 74, 1049–1064. [Google Scholar] [CrossRef]
  79. Pellegrino, P.; Clementi, E.; Radice, S. On vaccine’s adjuvants and autoimmunity: Current evidence and future perspectives. Autoimmun. Rev. 2015, 14, 880–888. [Google Scholar] [CrossRef]
  80. Gershwin, L.J. Adverse Reactions to Vaccination. Veter Clin. North. Am. Small Anim. Pract. 2017, 48, 279–290. [Google Scholar] [CrossRef]
  81. Bril, F.; Al Diffalha, S.; Dean, M.; Fettig, D.M. Autoimmune hepatitis developing after coronavirus disease 2019 (COVID-19) vac-cine: Causality or casualty? J. Hepatol. 2021, 75, 222–224. [Google Scholar] [CrossRef]
  82. Rocco, A.; Sgamato, C.; Compare, D.; Nardone, G. Autoimmune hepatitis following SARS-CoV-2 vaccine: May not be a casuality. J. Hepatol. 2021, 75, 728–729. [Google Scholar] [CrossRef]
  83. McShane, C.; Kiat, C.; Rigby, J.; Crosbie, Ó. The mRNA COVID-19 vaccine—A rare trigger of autoimmune hepatitis? J. Hepatol. 2021, 75, 1252–1254. [Google Scholar] [CrossRef]
  84. Liang, Z.; Zhu, H.; Wang, X.; Jing, B.; Li, Z.; Xia, X.; Sun, H.; Yang, Y.; Zhang, W.; Shi, L.; et al. Adjuvants for Coronavirus Vaccines. Front. Immunol. 2020, 11, 589833. [Google Scholar] [CrossRef]
  85. Mahmud, S.M.; Bozat-Emre, S.; Mostaço-Guidolin, L.C.; Marrie, R.A. Registry Cohort Study to Determine Risk for Multiple Sclerosis after Vaccination for Pandemic Influenza A(H1N1) with Arepanrix, Manitoba, Canada. Emerg. Infect. Dis. 2018, 24, 1267–1274. [Google Scholar] [CrossRef] [Green Version]
  86. Liu, Y.; Sawalha, A.H.; Lu, Q. COVID-19 and autoimmune diseases. Curr. Opin. Rheumatol. 2020, 33, 155–162. [Google Scholar] [CrossRef]
  87. Akobeng, A.K.; Grafton-Clarke, C.; Abdelgadir, I.; Twum-Barimah, E.; Gordon, M. Gastrointestinal manifestations of COVID-19 in children: A systematic review and meta-analysis. Front. Gastroenterol. 2020, 12, 332–337. [Google Scholar] [CrossRef]
  88. Xiao, F.; Tang, M.; Zheng, X.; Liu, Y.; Li, X.; Shan, H. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology 2020, 158, 1831–1833. [Google Scholar] [CrossRef]
  89. Lo Vecchio, A.; Garazzino, S.; Smarrazzo, A.; Venturini, E.; Poeta, M.; Berlese, P.; Denina, M.; Meini, A.; Bosis, S.; Galli, L.; et al. Italian SITIP-SIP Paediatric SARS-CoV-2 Infection Study Group. Factors Associated with Severe Gastrointestinal Diagnoses in Children with SARS-CoV-2 Infection or Multisystem Inflammatory Syndrome. JAMA Netw. Open 2021, 4, e2139974. [Google Scholar] [CrossRef]
  90. Lazova, S.; Alexandrova, T.; Gorelyova-Stefanova, N.; Atanasov, K.; Tzotcheva, I.; Velikova, T. Liver Involvement in Children with COVID-19 and Multisystem Inflammatory Syndrome: A Single-Center Bulgarian Observational Study. Microorganisms 2021, 9, 1958. [Google Scholar] [CrossRef]
  91. Turner, D.; Huang, Y.; Martín-De-Carpi, J.; Aloi, M.; Focht, G.; Kang, B.; Zhou, Y.; Sanchez, C.; Kappelman, M.D.; Uhlig, H.H.; et al. Corona Virus Disease 2019 and Paediatric Inflammatory Bowel Diseases: Global Experience and Provisional Guidance (March 2020) from the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology, and Nutrition. J. Craniofacial Surg. 2020, 70, 727–733. [Google Scholar] [CrossRef]
  92. Shire, Z.J.; Reicherz, F.; Lawrence, S.; Sudan, H.; Golding, L.; Majdoubi, A.; Levett, P.N.; Lavoie, P.M.; Jacobson, K. Antibody response to the BNT162b2 SARS-CoV-2 vaccine in paediatric patients with inflammatory bowel disease treated with anti-TNF therapy. Gut 2021, 71, 1922–1924. [Google Scholar] [CrossRef]
  93. Spencer, E.A.; Klang, E.; Dolinger, M.; Pittman, N.; Dubinsky, M.C. Seroconversion Following SARS-CoV-2 Infection or Vaccination in Pediatric IBD Patients. Inflamm. Bowel Dis. 2021, 27, 1862–1864. [Google Scholar] [CrossRef]
  94. Siegel, C.A.; Melmed, G.Y.; McGovern, D.P.; Rai, V.; Krammer, F.; Rubin, D.T.; Abreu, M.T.; Dubinsky, M.C. SARS-CoV-2 vaccination for patients with inflammatory bowel diseases: Recommendations from an international consensus meeting. Gut 2021, 70, 635–640. [Google Scholar] [CrossRef]
  95. Dembiński, L.; Dziekiewicz, M.; Banaszkiewicz, A. Immune Response to Vaccination in Children and Young People with Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. J. Craniofacial Surg. 2020, 71, 423–432. [Google Scholar] [CrossRef] [PubMed]
  96. Recommendations of Crohn’s and Colitis Canada on COVID-19 Vaccines in Children. Available online: https://crohnsandcolitis.ca/About-Crohn-s-Colitis/COVID-19-and-IBD/Vaccines (accessed on 10 February 2022).
  97. Nicastro, E.; Ebel, N.H.; Kehar, M.; Czubkowski, P.; Ng, V.L.; Michaels, M.G.; Lobritto, S.J.; Martinez, M.; Indolfi, G. The Impact of Severe Acute Respiratory Syndrome Coronavirus Type 2 on Children with Liver Diseases: A Joint European Society for Pediatric Gastroenterology, Hepatology and Nutrition and Society of Pediatric Liver Transplantation Position Paper. J. Pediatr. Gastroenterol. Nutr. 2021, 74, 159–170. [Google Scholar] [CrossRef]
Table 1. Summarized COVID-19 vaccine studies on safety profile, efficacy, and adverse effects rate in patients with inflammatory bowel disease.
Table 1. Summarized COVID-19 vaccine studies on safety profile, efficacy, and adverse effects rate in patients with inflammatory bowel disease.
Type of
Vaccine
Type of StudySubjectsData on Efficacy
(% Protection, Other)
Data on Safety (Main Side Effects)Reference
mRNAProspective study designAll patients included n = 246 (67% Crohn’s disease, 33% ulcerative colitis)N/AAfter the first dose (injection site reactions in 38%; fatigue/malaise 23%, headaches 14%, fever/chills 5%);
After the second dose (injection site reaction 56%; fatigue, malaise 45%, headaches 34%, fever/chills 29%)
Botwin et al. [19]
mRNA, adenoviralA prospective, observational cohort studyAll patients included n = 3316 with IBD (n = 1908, Pfizer/BioNTech; n = 1272 Moderna, n = 161, Janssen)N/ANo severe systemic reactions require emergency room visits.
After the first dose: adverse reaction injection site (66%); fever (6%), fatigue (46%), headaches (32%), muscle aches (20%);
After the second dose: adverse reaction injection site (65%); fever (25%), fatigue (46%), headaches (32%), muscle aches (12%);
Low flare rate (2%)
Weaver et al. [20]
mRNASelf-reported study84 IBD patients (23-with Crohn’s disease, 25 with ulcerative colitis) on anti-TNF therapyBiologic therapy associated with lower anti-RBD antibodiesN/AWong et ICARUS-IBD Working Group [21]
mRNAMulticenter, UK prospective, case-control study352 IBD patients on immunosuppressive therapy (thiopurine, infliximab, ustekinumab, vedolizumab, tofacitinib) and 72 healthy controlsNo significant differences in anti-SARS-CoV-2 S1 RBD antibody concentrations between the healthy control group and patients treated with thiopurine, ustekinumab, or vedolizumab, lower anti-SARS-CoV-2 S1 RBD antibody concentrations independently associated with infliximab, tofacitinib, and thiopurine, but not with ustekinumab or vedolizumab (0.84 [0.54–1.30]; p = 0.43)N/AAlexander et al. [22]
mRNAMulticenter Israeli population-based cohort study12,109 IBD patients, 4946 non-IBD controls, 707 unvaccinated IBD patients99.7% protection; patients on TNF inhibitors and/or corticosteroids did not have a higher incidence of infection; risk of exacerbation was 29% in vaccinated vs. 26% in unvaccinated IBD (p = 0.3)N/ALev-Tzion et al. [23]
mRNA and adenoviralProspective, CLARITY IBD multicenter cohort study1293 vaccinated IBD patientsanti-SARS-CoV-2 antibody concentrations reduced in patients treated with infliximab than vedolizumabN/AKennedy et al. [24]
mRNARetrospective7321 vaccinated IBD, 7376 unvaccinated IBD patientsFull vaccination associated with 69% reduced risk for COVID-19 and 80.4% effectivenessN/AKhan and Mahmud [25]
mRNARetrospective5562 vaccinated IBD, 859,017 vaccinated non-IBD patientsN/A2.2% adverse events in IBD patients on biologics/immunomodulatory therapy vs. 1.67 without such treatment; special adverse eventsHadi et al. [26]
mRNARetrospective cohort12,231 vaccinated IBD, 36,254 vaccinated non-IBD patients0.19% breakthrough infections after the second dose (7 days) and 0.14% (14 days)N/ABen-Tov et al. [27]
mRNA, adenovirus vectorProspective33 vaccinated IBD—children and young adults15 times higher levels of IgG antibodies compared to natural infection, all participants developed neutralizing antibodiesFor mRNA vaccine—sore arm, chills, fever, etc.; vector vaccine—the same; no one has contracted COVID-19 2–6 months following vaccinationDailey et al. [28]
mRNAProspective single-center317 vaccinated IBD patientsDetectable antibodies in 300/317 IBD patients; 85% in patients on corticosteroidsN/AKappelman et al. [29]
mRNAProspective, multicenter84 patients with immune-mediated disease, 8 vaccinated IBD patients90.5% of all patients with immune-mediated diseases develop IgG antibodies to SARS-CoV-2Less frequent mild adverse effects (injection site pain, headache, chills, arthralgia)Simon et al. [30]
mRNAProspective, multicenter133 patients with chronic inflammatory disease, 42 vaccinated IBD patientsN/AIncidence rate of overall adverse events—0.55; local—0.64; mainly fatigue, headache, myalgia, fever and chills; severe adverse reactions incidence rate 0.02, requiring hospitalization—0.00 and IBD flares—0.01James et al. [31]
mRNA, adenovirus vectorProspective, multicenter353 vaccinated IBD patientsHigher quantitative log10 antispike IgG after mRNA vs. adenovirusN/APozdnyakova et al. [32]
mRNAInternational web-based survey3272 IBD patientsN/A72.4% local symptoms, 51.4% systemic symptomsEllul et al. [33]
mRNACohort study122 IBD patients and 60 controls, on immunomodulating therapy97% of IBD patients developed antibodies, lower in patients than in controls, higher after Moderna vs. Pfizer; lower when on immunosuppressive therapy;OR = 0.97 significant side effects associations after full vaccinationCaldera et al. [34]
mRNA, adenovirus vectorProspective single-tertiary study602 IBD patients on immunosuppressive therapyLower Ig concentrations in patients on treatment; 97.8% seropositivity in IBD patientsN/ACerna et al. [35]
mRNA, adenovirus vectorRetrospective observational72 IBD patients;100% antibody response in patients group; reduced antibody levels in IBD vs. controls, no differences between vaccines; all IBD patients developed an immune responseLocal and systemic mild reactionsClassen et al. [36]
mRNAProspective controlled185 IBD patients, 73 healthy controls100% response following vaccination, lower in older and on anti-TNF therapyLocal pain, headacheEdelman-Klapper et al. [37]
mRNA, adenovirus vectorCohort/ real-life survey: telephone questionnaire239 IBD patients on biologicsN/AHigh acceptance rate and mild and transitory adverse reactionGarrido et al. [38]
mRNAProspective study19 IBD patients on biologics95% immune response rateN/ALevine et al. [39]
mRNAProspective study19 patients on biologics21.13-fold increase of total IgG antibodies after 1st dose, and 90-fold after second dose; % virus neutralizing antibodies was lower in IBD patientsN/ARodriguez-Martino et al. [40]
mRNA, adenovirus vectorProspective study126 IBD patients on biologics74.5–81.2% immune response in patients on anti-TNF vs. 92.8–100% on vedolizumab and ustekinumab, resp.; fewer virus-neutralizing antibody titers in patients treated with anti-TNFN/AShehab et al. [41]
Table 2. Summarized COVID-19 vaccine studies on safety profile, efficacy, and adverse effects rate in patients with autoimmune liver disease.
Table 2. Summarized COVID-19 vaccine studies on safety profile, efficacy, and adverse effects rate in patients with autoimmune liver disease.
Type of VaccineType of StudySubjectsData on Efficacy
(% Protection, Other)
Data on Safety
(Main Side Effects)
Reference
mRNAPlacebo-controlled, observer-blinded, pivotal efficacy trial (randomized 1:1 vaccine vs. placebo)All patients included n = 43,548
Patients with liver disease n = 217 (0.6%)
95% efficacy
(9 vaccinated vs. 169 controls with COVID-19)10 cases of severe COVID-19 infection vs. 9 in the placebo group
Systemic AEs:
1.
Fatigue (34–51%)
2.
Headache (25–39%)
3.
Fever (11%);
Injection site reactions:
4.
Pain (71–83%)
5.
Redness and swelling (<7%)
Serious AE <4%.
Flares: NR
Polack et al. [68]
mRNAPhase 3 randomized, observer-blinded, placebo-controlled trial was conducted at 99 centers across the United States
(randomized 1:1 vaccine vs. placebo)
All patients included n= 30420
Patients with liver disease n = 196 (0.6%)
94.1% efficacy
(11 vaccinated vs. 185 controls with COVID-19)None of the patients were with COVID-19 infection vs. 30 cases of severe COVID-19 in the placebo groupFlares: NR
Systemic AEs:
1.
Fatigue (34–38%)
2.
Headache (24–35%)
3.
Fever (<1%);
Injection site reactions:
4.
Pain (86%)
5.
Redness and swelling (<6%)
Serious AE:
Low rate after the first dose and increased to around 16% after the second dose
Baden et al. [69]
mRNA, adenovirus vectorObservational study103 patients with autoimmune hepatitis, 64 with primary sclerosing cholangitis, 61 with primary biliary cholangitis, 95 healthy controlsAnti-SARS-CoV-2 antibodies were relatively lower in patients with autoimmune hepatitis vs. healthy control and comparably low in patients on immunosuppression; a spike-specific T cell responses were undetectable in 45% of patients despite a positive serology in hepatitis patients and 87% in primary sclerosing cholangitis and primary biliary cholangitisN/ADuengelhoef et al. [70]
Adenoviral vectorBlinded, randomized, controlled trials conducted across the U.K., Brazil, and South Africa.All patients included n = 11,636
Patients with liver disease—NR
70.4% efficacy (30 vaccine recipients vs. 101 placebo-group)84 serious AEs in the vaccine group Voysey et al. [71]
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Peshevska-Sekulovska, M.; Bakalova, P.; Snegarova, V.; Lazova, S.; Velikova, T. COVID-19 Vaccines for Adults and Children with Autoimmune Gut or Liver Disease. Vaccines 2022, 10, 2075. https://doi.org/10.3390/vaccines10122075

AMA Style

Peshevska-Sekulovska M, Bakalova P, Snegarova V, Lazova S, Velikova T. COVID-19 Vaccines for Adults and Children with Autoimmune Gut or Liver Disease. Vaccines. 2022; 10(12):2075. https://doi.org/10.3390/vaccines10122075

Chicago/Turabian Style

Peshevska-Sekulovska, Monika, Plamena Bakalova, Violeta Snegarova, Snezhina Lazova, and Tsvetelina Velikova. 2022. "COVID-19 Vaccines for Adults and Children with Autoimmune Gut or Liver Disease" Vaccines 10, no. 12: 2075. https://doi.org/10.3390/vaccines10122075

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop