& Available Resources regarding Coronavirus disease COVID-19
We are aware of the growing uncertainty surrounding the current corona virus outbreak. This page should provide access to key resources and information related to this disease, especially as it pertains to South African citizens, and moreover for people living with rheumatic diseases.
All healthcare practitioners caring for patients with rheumatic diseases should be well studied, on the principles of managing patients responsibly during the COVID-19 pandemic. Importantly, in the methods to contain spread through infection prevention and control strategies.
For up to date information on coronavirus in South Africa we refer you to the following essential links:
- National Institute for Communicable Diseases (NICD) (Most comprehensive resource specific to SA – for patients and doctors)
- National Department of Health SA
- COVID-19 Corona Virus South African Resource Portal
- Lancet Laboratories Corona Virus information hub (Information of sites for testing)
Other international sites of interest:
& Quick facts
- SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2 is the causative pathogen for coronavirus disease 2019 (COVID-19)
- Common symptoms of COVID-19: fever ≥ 38◦C, cough, shortness of breath, sore throat
- Person under investigation (PUI): Persons with acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever ≥ 38°C (measured) or history of fever
In the 14 days prior to onset of symptoms, met at least one of the following epidemiological criteria:
- Were in close contact with a confirmed or probable case of SARS-CoV-2 infection;
- Had a history of travel to areas with local transmission of SARS-CoV-2; (NB Affected countries will change with time, consult the NICD website for current updates);
- Worked in, or attended a health care facility where patients with SARS-CoV-2 infections were being treated
- Admitted with severe pneumonia of unknown aetiology
- Close contact: A person having had face-to-face contact or in a closed environment with a COVID-19 case; this includes, amongst others, all persons living in the same household as a COVID-19 case and, people working closely in the same environment as a case. A healthcare worker or other person providing direct care for a COVID-19 case, while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection). A contact in an aircraft sitting within two seats (in any direction) of the COVID-19 case, travel companions or persons providing care, and crew members serving in the section of the aircraft where the index case was seated.
- Confirmed case: A person with laboratory confirmation of SARS-CoV-2 infection, irrespective of clinical signs and symptoms.
- Probable case: A PUI for whom testing for SARS-CoV-2 is inconclusive (the result of the test reported by the laboratory) or for whom testing was positive on a pan-coronavirus assay.
& Rheumatic diseases information
We suggest visiting these useful links for information pertaining to the management of patients with rheumatic diseases in the midst of the coronavirus pandemic:
Medical practitioner resources
- EULAR Guidance for patients COVID-19 outbreak
- Message from ACR regarding Corona virus 2019
- BSR’s Covid-19 – Update for members
- Department of Rheumatology, UCT patient information sheet
- Red Cross Children’s Hospital COVID-19 guidelines
- Information for patients Johns Hopkins Rheumatology
- Coronavirus: No-Panic Helpguide by 1mg
- EULAR Guidance for patients COVID-19 outbreak
- Paediatric Rheumatology European Society recommendations
- Information for parents from HealthyChildren.org on coronavirus
- Information for parents from HealthyChildren.org on talking to children about disasters
for practicing rheumatologists & patients
We urge all doctors to familiarize themselves with the NICD guidelines for management of COVID-19.
4.1. Outpatient service
- Wherever possible, we suggest pre-visit screening of all outpatients prior to their appointments. This would involve telephonic (preferred) or email correspondence. Patients exposed to someone with COVID-19 or with a recent history (after February 15th) of travel to high risk countries, as well as those displaying symptoms of possible COVID-19 should be rescheduled.
- If asymptomatic or very mild symptoms, patients should contact the NICD on the COVID-19 public hotline: 0800 029 999 or Lancet laboratories 0861 LANCET (526238) for information on testing and testing sites nearby.
- Patients with suspected COVID-19 who are severely ill should be directed to their nearest hospital, alerting the unit of their arrival to ascertain appropriate precautions.
- If patients are otherwise well, provide the option of telephonic consultation, to limit human contact.
- Patients should be screened again on the day of their visit prior to consultation. Consider limiting/ prohibiting accompanying visitors to limit the chance of spread where possible.
- Observe strict infection control practices and limit unnecessary contact; follow social distancing practices as much as possible. Details pertaining to this and more is available via NICD website nicd.ac.za and the resources listed under section 3 above.
- There is much debate surrounding the use of masks. We advise discussing this with your onsite infection prevention and control team or alternatively seek guidance from the national governance sites (incl. NICD). Hand washing/sanitizing between patients according to guidelines is essential.
- We suggest identifying a place to isolate potential cases and have surgical masks available for suspected cases, until patients can be directed to suitable testing sites, on/off property.
4.2. Inpatient service
- Where possible, admissions should be limited to patients who absolutely require in-hospital care, and for the shortest periods as necessary.
- Once more emphasis on infection prevention and control practices as stipulated by your facility.
- Patients with rheumatic diseases admitted for suspected COVID-19 infection should be treated primarily by the admitting physicians and designated staff. If rheumatology input is required, ascertain whether this can be achieved via telephonic consultation. If not, once again observe the appropriate level of personal protection as stipulated by your facility.
- It is prudent to remember that patients with rheumatic diseases are susceptible to many other infections, including PJP, TB and other pneumonias, which can be mistaken for COVID-19 infection. Diagnosis and management should consider all possibilities.
4.3. Frequently asked questions
- What is the risk of my patient contracting COVID-19 and what are their risks if tested positive?People with systemic rheumatic diseases (SRDs) like rheumatoid arthritis, lupus, scleroderma, spondyloarthritis and other connective tissue disorders may be more susceptible to COVID-19 infection, and to more severe manifestations of disease. This could be related to the disease itself, associated comorbidities and/or the medications used to treat these conditions, particularly immunosuppressive treatments. There is limited data to support this supposition however as the disease develops we will have a better understanding of the impact on people with rheumatic diseases.Up till now, risk factors for severe coronavirus disease presentations include older age (>65 years); pregnant females; hypertension; diabetes; coronary artery disease and underlying chronic lung disease.
- How does one advise a patient regarding their medication?There is a heightened anxiety surrounding the use of immunosuppressive treatments, including conventional DMARDs, but particularly biologics and targeted synthetic agents. Currently, there is insufficient data to provide definitive advice for changes in medication. We can however extrapolate from evidence related to the management of infections in patients with SRDs:-
- Patients who do not present with symptoms of COVID-19 and who have not come into close contact with a PUI (see definitions above ) should continue their chronic medication, including immunosuppressive therapies like biologics.
- Patients who are well, but where there has been close contact with a COVID-19 positive person, we suggest testing despite deviation from NICD guidelines (if uncertain – contact NICD hotline 0800 029 999), particularly in those patients who fulfill any one of the previously defined high risk factors. We would suggest:-
- Consider limiting use of anti-inflammatories, such as NSAIDs and prednisone at doses >5mg/day unless absolutely necessary. If patients are already on prednisone, they should be advised not to stop suddenly.
- If a patient is taking conventional DMARDs such as methotrexate, chloroquine, salazopyrine or leflunomide, they should be advised to continue their treatment unless there is a high index of suspicion for infection. This should be a joint decision between doctor and patient, particularly if the disease is quiescent, where one might consider interrupting therapy while a potential risk exists. Chloroquine may be continued.
- If a patient tests positive for COVID-19 or has symptoms of possible COVID-19 (awaiting results), one should discontinue biologic and targeted synthetic DMARDs based on standard practice for infections in these therapeutic users. The decision to stop conventional DMARDs should be a joint decision between doctor and patient, taking into consideration the severity of the disease, presence of risk factors for poor COVID-19 outcomes and the activity of the underlying rheumatic condition. Chloroquine may be continued. If a patient is on prednisone, this should not be abruptly stopped for fear of worsening the infection; one should rather attempt to wean to lower doses if possible. Treatment should only be reinstituted once the infection is controlled and the patient is better, and only after consultation with the treating rheumatologist.
- Despite the postulated risk of ACE-inhibitors and ARBs worsening COVID-19, international cardiology guidelines advise against stopping these treatments, as there is currently no conclusive evidence to support this hypothesis.
- A note on steroids: The latest NICD guidelines throws caution on the routine use of systemic corticosteroids for treatment of COVID-19, unless indicated for another reason. This is based on lack of evidence to suggest benefit, and potential to harm. This does not imply that patients or doctors should discontinue steroids due to a fear of worsening COVID infection.
- Some additional considerations:-
- Patients who have been on long-term corticosteroid therapy should be advised not to abruptly discontinue their treatment. Sudden stopping could result in adrenal crisis which could mimic SIRS or septic shock and confound presentations of possible or confirmed COVID-19.
- We suggest that rheumatic patients on long-term corticosteroids who develop moderate to severe COVID-19 infection; or mild disease with risk factors for severe disease (see NICD for definitions); receive stress doses of corticosteroids i.e. hydrocortisone 100mg 8 hourly to prevent addisonian crisis.
- Some additional considerations:-
- Regarding ACE inhibitors (ACEi) and Angiotesin receptor blockers (ARBs)
- Despite the postulated risk of ACE-inhibitors and ARBs worsening COVID-19, international cardiology guidelines advise against stopping these treatments, as there is currently no conclusive evidence to support this hypothesis. Discontinuing or switching may be unnecessarily deleterious to patients.
- Local guidelines from the NICD has since stated clearly that pending further evidence, it is not recommended to switch patients off ACEi or ARBs unless there are other medical reasons to do so.
- A note on NSAIDs: Guidance regarding the use of NSAIDs in COVID-19 disease has been extremely ambiguous. There is no conclusive evidence to suggest that NSAIDs worsen COVID-19 outcomes (refer to FDA and EMA statement on NSAIDs).
- Nonetheless, in line with our NICD guidelines, where short-term fever or pain relief is required, it may be prudent to avoid this class of agents where possible.
- Most importantly for our patients, especially spondyloarthritis patients, where NSAIDs form part of their chronic treatment, evidence is not definitive enough to recommend discontinuation.
- Are there any special medications that could benefit my patients?There are as yet no specific therapies approved for the treatment of COVID-19. Mild disease presentations should be treated symptomatically. Severe disease management centres upon cardiorespiratory support. Some experimental treatment regimens for severe disease presentations showing good results include chloroquine, ritonavir or lopinavir and tocilizumab, often in combination.AS per the recently updated NICD guidelines – Chloroquine at doses of 10mg/kg base for 2 days then 5mg/kg base for 1 day, can be considered for severe disease or mild disease with risk factors. This treatment regimen however is not fully validated and may be subject to change as new data emerges.
- What should I do, personally, if a patient I have consulted with tests positive for COVID-19?Refer to the definitions of PUI and close contact. If one meets the criteria, one should follow the procedures for testing and quarantine as stipulated by the NICD. Contact the NICD or your infectious diseases department if in any doubt.We advise to prevent this potential situation by following the suggestions provided earlier (4.1 and 4.2). We also advise ensuring meticulous infection prevention and control to avoid being a PUI.
- Should I offer my patients their regular vaccinations?Yes. It is advisable for all patients to get their seasonal influenza vaccine and pneumococcal vaccines as indicated by their disease and therapies. This will avoid secondary infections which may mask or worsen COVID-19 disease.
- What additional advice should I give my patients regarding contracting COVID-19?I would reinforce the importance of hand hygiene, general hygiene, limiting human contact and social distancing practices, especially around patients that are ill. Education is key. Please utilize the patient resources listed under section 3 above.
meetings and events
In an attempt to contain the spread of coronavirus, we have decided to suspend all meetings and public gatherings organized by SARAA until further notice.
We will keep you informed once activities return to normal.
COVID-19 Global Rheumatology Alliance
SARAA has joined many other international societies in supporting the ACR, in the development of a global registry to capture data on COVID-19 in patients with rheumatic disease. This registry is projected to be available by March 20-27th 2020.
Watch this space. We will keep you informed as to how contribute, in this much needed process.
interesting reading material.
- Preparedness and vulnerability of African countries against importations of COVID-19 a modelling study
- Immune responses in COVID-19 and potential vaccines Lessons learned from SARS and MERS epidemic
- The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak
- Of chloroquine and COVID-19
- KCC COVID19 Evidence Summary
- Am I part of the cure or part of the disease
- EMA Advice on NSAIDs
- FDA Advice for NSAIDs