The dysfunctional immune system along with the use of immunosuppressive drugs with additional comorbidities in patients with musculoskeletal and rheumatic conditions increase their susceptibility to infections. [12] The outbreak of novel coronavirus did not show major evidence that patients with rheumatic diseases are at higher risk for worse outcomes compared to other comorbidities. [6, 7] This does not mean worse outcomes should not be anticipated as COVID-19 in a rheumatic patient has been reported with a high rate of acute respiratory distress syndrome (ARDS) and high mortality rate.[8] This should alarm rheumatologists to be more alert regarding COVID-19.
There can be a potential chance of serious infections in diseases like connective tissue diseases (CTD), systemic lupus erythematosus (SLE), scleroderma, vasculitis, polymyositis, CTD related interstitial lung disease (ILD), rheumatoid arthritis (RA) related ILD, etc. receiving anti-rheumatic agents like conventional disease-modifying drugs (csDMARDs), mycophenolate mofetil, Janus kinase(JAK) inhibitors, biological agents and glucocorticoids. [9, 13] Majority of our participants have autoimmune rheumatic disease requiring some form of immunosuppression (56.9 %) with others either not sure of their diagnosis; fibromyalgia, gout and degenerative diseases. We did not assess the exact number of patients on immunosuppressive drugs and the degree of immunosuppression as most of the patients from Nepal are unlikely to know the exact names and dosing of the medications.
British Society for Rheumatology (BSR) has described risk stratification based on immunosuppressant given to the patients. Patients under immunosuppressive medications excluding hydroxychloroquine and sulphasalazine should self-isolate or maintain social distance.[13] Many patients are on steroids or more than one of these drugs thus increasing the overall risk of contracting COVID-19. They also recommend against withdrawal or dose reduction of ongoing DMARDs because the resulting flare might increase the need for steroid administration further increasing the risk of infection. In our study, maximum patients were not sure if they were at an increased risk for COVID-19 infection due to their disease condition or due to the medication they were taking. Some assumed that the chance of getting infected is more if they are under immunosuppressant due to their ongoing medications and a proportionate number of patients had reduced the dosage by self. Few patients (4.2 %) had stopped their ongoing medications.
Some commonly used drugs in rheumatology like hydroxychloroquine might have some role in inhibition of SARS-CoV-19 by interfering with the glycosylation of cellular receptors and increasing endosomal pH required for viral fusion. [14] Thus, has been recommended for prophylaxis and treatment of COVID-19 infection. This might lead to a false sense of security and irresponsible high-risk practice amongst patients taking these medications. In contrast to our expectations, only 13.7 % of patients considered themselves to have a protective effect with their medications while 86.3 % denied or were unsure of this theory. Along with hydroxychloroquine, some studies showed medications like JAK inhibitors, IL-1 inhibitors, Il-6 inhibitors, and some intravenous immunoglobulins might have some protective actions in COVID-19 infection. [15]
Routine vaccination against pneumonia and flu is recommended before initiation of any DMARDs. However, in low-middle income countries like Nepal, this practice is seldom followed. As there was an increasing trend of self-seeking for a flu vaccination during the swine and bird-flu epidemics, we also surveyed a change in this practice in our patients after the COVID-19 pandemic. The majority (96.9 %) however denied changing their behavior regarding vaccination practice. The participants, as shown by the results in the knowledge domain of the survey, were aware of the disease. However, results also showed that they were unsure specifically when the relationship between susceptibility to COVID-19 and their disease or anti-rheumatic drugs were considered.
Nepal being in stage 2 of the COVID-19 epidemic, the knowledge regarding the general symptoms, transmission and preventive measures in patients with rheumatic disease should be considered acceptable. This unexpected level of awareness without any formal educational programs could be attributed to the access to information via internet and social-media. This might also translate to a potential participation bias where patients with access to internet would have participated more in the online survey. However, in the current scenario of strict social-distancing, authors believe that this was the best method available to understand the patient perceptions.
Currently, the actual disease manifestations and the outcomes in COVID-19 infected cases remains unclear. Thus, to fill this vacant space with accurate information the rheumatologist, researchers, and patients worldwide came together to form an alliance, the COVID-19 Global Alliance. The alliance in association with Asia Pacific League of Associations for Rheumatology (APLAR) has started a survey for patients to acquire insight about the ways to prevent or treat COVID-19 in the potentially vulnerable population. This survey is one of the first type of KAP conducted in Nepal among rheumatic patients regarding COVID-19. As the relationship between disease susceptibility and severity in patients on anti-rheumatic drugs become clearer, it seems prudent that the patients are updated by the clinicians and societies regarding the preventive measures frequently to improve the outcomes.