A global example in the fight against COVID-19 and for the future of our specialty

Today, in the midst of a pandemic, we need to contribute with our limited capacity to keep up with a fast and unprecedented explosion of data. A recent study has stated that, from a pool of over 61.000 indexed publications in the area of COVID-19 for the year 2020, almost 1000 are related to the field of rheumatology (1)

Fortunately, during these past months of confusion and frustration, the rheumatology community responded rapidly, coming together virtually, collecting and analyzing data, generating knowledge and disseminating it widely to improve the care of patients with rheumatic diseases. Social media platforms have allowed patients, physicians, researchers, and other stakeholders to collaborate in a unique project to try to understand the impact of the COVID-19 pandemic in patients with these diseases (2)

When reports of the  global spread of COVID-19 were shared on twitter, the rheumatology network  immediately perceived the need for information regarding the risk and severity of infection for people with rheumatic diseases as well as for the potential role of some of the  drugs we frequently use as treatment for complications of COVID-19 infection. A gathering of more than 300 rheumatologists, researchers and patients from around the globe met for all intents and purposes, and in an exceptionally brief timeframe, created the COVID-19 Global Rheumatology Alliance (GRA) (3) The idea for the alliance was initially developed through conversations on social media, with twitter facilitating a rapid information exchange between researchers and clinicians. International collaborators from across five continents were recruited from personal and professional networks to provide complementary areas of expertise. As the need of ongoing sharing of information developed, rheumatologists moved the discussion from twitter to zoom and to slack, a web-based instant-messaging platform that allows users to collaborate in real-time by sharing ideas, questions, articles and other resources. Representatives from various disciplines (community and academic), research fields (basic science, translational and clinical) and patient groups have brought a variety of perspectives to the collaboration This reveals that there has been a priority throughout this process for welcoming all potential participants with an interest in joining this global effort (4).

The exceptional health crisis around COVID-19 convened all medical forces, including, among others, emergency physicians, infectious diseases specialists and internists in order to deal with this situation in the best way possible. As specialized internists, rheumatologists were an important component particularly when drugs, new and old which we handle routinely, appeared to have a role in the management of this pandemic (5). COVID-19 is a complex opponent. Enhanced infectivity, prolonged incubation period, asymptomatic transmission and significant mortality, in particular from the cytokine storm induced by the illness, have precipitated this global health crisis. While the cytokine storm syndrome in COVID‐19 provides a prime example for the need to collaborate in order to find the quickest route to a solution, it is by no means the only area of COVID‐19 disease that will benefit from this collaborative approach. (6) 

We have learnt during these few months  that people with rheumatic diseases are not significantly more susceptible to initial infection with SARS coronavirus-2 (SARS-Cov-2) compared to the general population. The risk of severe outcomes in patients with rheumatic diseases is closely tied to age and comorbidities, similar to the general population. Furthermore, data from 600 patients in the COVID-19 GRA registry, shows that most immunosuppressive drugs, including biologics and targeted synthetic agents, are not associated with a significantly higher risk of hospitalization (7). However, moderate to high dose glucocorticoids are the one class of medication associated with a higher risk of hospitalization and severe outcomes in patients with Inflammatory Bowel Disease and COVID infection  in both the GRA and SECURE- registries (8).

In Latin America around 10.000.000 cases have now been recorded, of whom 366,637 people have died and 8,537,563 are considered to be cured. Confirmed cases of COVID-19, including 1.025.729 deaths, reported to WHO up to October 10, 2020: Brazil (4.847.092), Colombia (835.339), Peru (818.297), Argentina (765.002) and Mexico (748.315) are within the top 10 countries with most cases reported. And deaths: Brazil (144.680), Mexico (78.078), Peru (32.535), Colombia (26.196) and Argentina (20.288).  According to WHO statistics, no region has been hit harder by the virus in the world in terms of deaths (9) . So many patients, deaths and painful experiences in our part of the world.

In the current issue of this journal, we have the first data from latin american rheumatic patients published by the GRA (10). For two months, from March to May of this year, data from 74 patients with rheumatic diseases from Latin America were collected using  data from patients from the rest of the world collected as of April 20, 2020 as a comparison (n=583). RA (35% and 39%, respectively) and SLE (22% vs 14%, respectively) were the most common diagnoses in both groups. Psoriatic arthritis was less frequent in patients reported by providers in Latin America than other countries (3% vs 13%, p=0.02). Latin American patients used conventional DMARDs (81% vs 66%, p=0.01), antimalarials  (38% vs 21%, p<0.01) and glucocorticoids (51% vs 31%, p<0.01) more frequently than patients from the rest of the world, but biologic DMARDs were less frequently used (16% vs 35%, p<0.01). Mortality was similar among both groups (12% vs 11%, p=0.88), but hospitalization was more frequent among patients from Latin America (61% vs 45%, p=0.02). 

In addition to other factors, such as the significant weight of cardiovascular illness, diabetes and lung disease, combined with the high global prevalence of infections such as malaria, dengue, tuberculosis and HIV, are likely to worsen the outcomes of the pandemic in low and middle-income countries. Furthermore, individuals with rheumatic diseases in Latin America may have more disadvantages than those in developed countries, particularly related to access to regular health services and adequate treatment before the pandemic (11,12) . These issues are further exacerbated during the COVID-19 pandemic.

In parallel with the pandemic we have had an infodemic with a wealth of information, misinformation and bad information that has complicated the message from “science”  to the general population.It is imperative that precise scientific information be used  to consistently convey a message suitable for the general population and we should use all the appropriate channels for this (13). According to Solomon et al “During COVID-19, communication with the public has been a major difficulty. Most of the problems have been with inconsistencies in simple messages – “wear a mask”, “get tested if you display any symptoms”, “do not drink chlorine bleach” (no, chlorine is not the same as hydroxychloroquine), etc.” . Some of the communication issues  have been related to  more complex scientific aspects: Does hydroxychloroquine work to prevent or treat COVID-19? Are NSAIDs dangerous to people with COVID-19? Should DMARDs be discontinued to prevent an infection or during a known infection? These are questions with evolving answers that have been the focus of ongoing studies. Good public health messaging but without adequate data is dangerous (14).

Besides the Global Alliance collaboration, ACR, EULAR, PANLAR and other rheumatology societies and its members around the globe deserve our admiration for their leadership and for supporting the needs of patients with rheumatic diseases during the COVID-19 pandemic . Despite all the global effort, whether patients with rheumatic disease have better or worse outcomes with this disease is unknown for now, but the pandemic has underlined that close teamwork in the rheumatology community will continue to provide the best answers to these questions (15 ). The global scientific community should continue to collaborate with adequate data coming from all over the world, so we can develop a better understanding of how the virus affects rheumatic disease patients. The rheumatological community has done an excellent job (16).We have learned a lot from the virus and its effects on all  spheres of  society. However, this is only the beginning of a long pathway to unfold the countless mysteries of a virus that is here to stay.

The work done by the rheumatologists to try to understand the problems generated by the virus is a good global example that should be promoted in the study of other pathologies. 

1. Calabrese LH, Calabrese C., Reflections on rheumatological aspects of COVID-19. Curr Opin Rheumatol. 2020;32(5):427-428. doi: 10.1097/BOR.0000000000000733
2. Wallace ZS, Bhana S, Hausmann JS, Robinson PC, Sufka P, Sirotich E, Yazdany J, Grainger R. The Rheumatology Community responds to the COVID-19 pandemic: the establishment of the COVID-19 global rheumatology alliance. Rheumatology (Oxford). 2020 Jun 1;59(6):1204-1206. doi: 10.1093/rheumatology/keaa191
3. Robinson, PC, Yazdany, J. The COVID-19 Global Rheumatology Alliance: collecting data in a pandemic. Nat Rev Rheumatol; doi: https://doi.org/10.1038/s41584-020-0418-0.
4. Hausmann JS, Sufka P, Bhana S, Liew JW, Machado PM, Wallace ZS, et al. Conducting research in a pandemic: The power of social media. Eur J Rheumatol 2020; 10.5152/eurjrheum.2020.2066
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8. Brenner EJ, Ungaro RC, Gearry RB, Kaplan GG, Kissous-Hunt M, et al. Corticosteroids, But Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results From an International Registry. Gastroenterology. 2020 ;159(2):481-491.e3. doi: 10.1053/j.gastro.2020.05.032.
9. World Health Organization. WHO coronavirus disease (COVID-19) dashboard. [cited 2020 October 3]. Available from: https://covid19.who.int 
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16. Felten R, Chatelus E, Arnaud L.How and why are rheumatologists relevant to COVID-19? Joint Bone Spine 2020;87(4):279-280. doi: 10.1016/j.jbspin.2020.04.006.