Características associadas ao Covid-19 em pacientes com doença reumática na América Latina

Despite the fact that Latin American patients with rheumatic diseases  reported to  the COVID-19 Global Rheumatology Alliance registry had a higher rate of ARDS and used glucocorticoids more frequently and at a higher dose, their mortality rate was similar to that of patients from the rest of the world.

Poverty and healthcare access impact on the risk of COVID-19, being 1746.84/100 000 for people in poor neighborhoods and 2600.46/100 000 people in the wealthy neighborhoods in New York. The role of social determinants of health is even more impressive  in terms of prognosis, given the risk of death is more than two times higher in very high poverty neighborhoods than in low poverty neighborhoods in New York (242.3 vs 104.88/100 000 people) (17). Given trends seen in other countries, we could assume that the pandemic would hit Latin America very hard. In fact, as of May 22nd, Chile had 3012 confirmed cases per million people, Mexico 462/1000 000, Peru 3299/1 000 000 and Brazil 1459/1 000 000, compared to US with 4765/1 000 000, Russia 2176/1 000 000 or France 2209/1 000 000. The high case counts in Latin American are despite the fact that the epidemic started later in this region (18). Mortality due to COVID-19 in Latin America ranged between 1.02 % (Chile) and 10.9% (Mexico); however, it is important to point out that these rates depend on the number of tests performed which is very different across countries (18). Latin America has less than 2.5 physicians and nurses per 1 000 people in 10 out of 20 countries; for example, Guatemala has 0.4 physicians per 1 000 people, Nicaragua 1.0/1 000, Peru  1.3/1 000, Paraguay 1.4/1 000, Bolivia, Dominican Republic and El Salvador 1.6/1 000, Ecuador 2.0/1 000, Brazil and Colombia 2.2/1 000; and US and Canada have 2.6/1 000 people. Furthermore, in Latin America, the health workforce is concentrated in large cities and only Costa Rica, Cuba and Uruguay invest more than 6% of their Gross Domestic Product in health (3,4). The lower frequency of use of biologic DMARDs in patients reported to the registry is likely consistent with lower access to healthcare and specialty medications in Latin America. Additionally, in a recent report, including six systemic autoimmune disease (SLE, systemic sclerosis, idiopatic inflammatory myopathies, Sjögren’s syndrome, mixed connective tissue disease and ANCA-associated vasculitis), the age-standardized mortality rate was lower in Europe than in the rest of regions, including Latin America, and the largest difference was present in SLE patients; in this group, Latin American patients had 5 fold higher age-standardized mortality rate than European patients. However, whether the difference is due to the genetic background of these individuals, environmental factors, health care, social determinants of health  or a combination of these factors remains to be elucidated (19). Taking together, we should expect that the mortality rate would be higher in this region than in the rest of the world, but, as of now, the limited data presented do not support this assertion.

At the present time, it is difficult to state if the higher frequency of complications (ARDS or need for ventilatory support) in the Latin American population is due to their sociodemographic characteristics or the precarious healthcare systems serving this population, or if it is due to other factors, like the occurrence of adverse events to the treatments given for COVID-19, the severity of the underlying disease (based on the more frequent use of conventional DMARDs) or immunogenetic factors. Another factor that could be higher doses of prednisone, which has been reported as a predictive factor of hospitalization in the C19-GRA registry or the lower use of anti-TNF, reported as a protective factor of hospitalization in the same registry (16) or even to the occurrence of adverse events to the treatments given for COVID-19.

One of the strengths of this study is that it includes the largest registry of patients with rheumatic disease and COVID-19. The C19-GRA registry includes cases from all around the world. Also, this study highlights the importance of examining the impact of COVID-19 on the daily lives of rheumatic disease patients.

However, this study has some limitations. First, as the registry is voluntary, it does not capture all cases of COVID-19 in patients with rheumatic diseases. Second, the relatively small number of cases reported in Latin America and the lack of extensive population testing strategies in most Latin American countries, precludes us from identifying all cases, may lead to selection bias and prevents us from doing more detailed multivariable analyses. As case entry across Latin America grows, we hope to be able to do comparisons across countries in future analyses. Third, as not all the countries have included patients in the registry, it is possible to have some bias in reporting. However, it is important to point out that the countries with the highest number of COVID-19 cases  have included patients in the registry. Fourth, as the indication of hospitalizations varies among the countries due to several factors, including their regulations regarding hospital admissions and the numbers of hospital beds and cases, it is likely that not all hospitalizations reflect the same degree of disease severity.

This communication should reinforce the importance of reporting COVID-19 cases in people with rheumatic diseases in Latin America and around the world, in order to have evidence which hopefully will translate into better recommendations and treatment for our patients.