COVID 19 — Some lessons and many more to learn

Coronavirus disease 19 (COVID-19) caused by the SARS-CoV-2 coronavirus first emerged in December 2019 in the city of Wuhan, China, with transmission rates that increased until it was declared a pandemic in March 2020 by the World Health Organization (WHO).¹ In Colombia, the first case was reported on March 6 of the same year.² With the passage of time, the society as a whole was immersed in the endemic phase of the disease.¹

This potentially fatal disease has had a special impact on those patients with risk factors such as high blood pressure, diabetes and obesity.³ Recently, additional risk factors such as asthma, kidney disease, hypothyroidism, malnutrition, and autoimmune disease were included. This last group is made up of patients who receive immunomodulatory or immunosuppressive management as the standard treatment for these pathologies.³ Based on meta-analyses data, a higher prevalence of SARS-CoV-2 infection has been identified in patients with rheumatic diseases (RR = 1.53 [95% CI = 1.16–2.01]), compared with the general population. The probabilities of hospitalization, admission to the ICU, and mechanical ventilation were similar, however, the mortality rate is higher (OR = 1.74 [95% CI = 1.08–2.80]).⁴ Data published by the National Institute of Health of Colombia (INS) in the month of June 2022, report that a total of 6,151,354 confirmed cases of COVID-19 were diagnosed in the country, with a mortality rate of 2.28%. From the analysis of comorbidities in the deceased patients, the presence of autoimmune disease was identified in 253 cases; however, 14,843 are still under study.⁵

Quickly, international and national scientific societies became involved in the process of establishing a series of recommendations for the general population and for the population at risk, within which it should be highlighted the prompt publication of the recommendations generated by the Colombian Association of Rheumatology on the management of adult patients with rheumatic diseases in the context of SARS-CoV-2/COVID-19 infection.⁶ These recommendations place emphasis on continuing the medication required so far, being necessary to suspend it in the case of diagnosis of the disease.⁶ Few options of pharmacological treatment have proven to be effective, to date the treatments with more evidence are dexamethasone or its equivalents, and tocilizumab is used in severe cases.³ The aspects of effectiveness related to the use of tofacitinib and colchicine are addressed in the current issue of this publication.

The COVID-19 pandemic had a negative effect on the control and management of the rheumatic disease. An observational study conducted by the group of the Pan American League of Associations of Rheumatology (PANLAR) in 19 Latin American countries, identified that the pandemic situation led to the interruption of at least one disease modifying drug in 23.4%, and the reasons most frequently related to the interruption were the fear of contact with the virus or economic problems, with self-reports of increased disease activity.⁷ Subsequently, after starting vaccination and prioritizing patients with rheumatic diseases, a gradual recovery of normality in daily life was achieved, however, there was uncertainty regarding the relapses or adverse events related to a new type of vaccines. As the vaccination advanced, it was demonstrated that there is no increase in adverse events or relapses with disease activity compared to the general population.⁸ However, these doubts continue to be a limitation of adherence to the recommendations on vaccination and subsequent boosters.⁹ In this issue, in what is of great interest, a case of onset of rheumatoid arthritis symptoms in the context of vaccination is presented, which allows opening the discussion in relation to the potential inflammatory effect as a trigger of the disease in susceptible patients.

The presence of symptoms after the infection has been described as the post-COVID-19 syndrome. In a Spanish cohort of patients with rheumatic disease, 68.57% reported at least one persistent symptom. The most frequent symptoms were dyspnea, fatigue and chest pain.¹⁰ An increase in the frequency of symptoms compatible with fibromyalgia and with higher scores has been identified in those patients with previous COVID-19 infection.¹¹ For this reason, it is essential to be attentive to the impact of this infection on the course of the disease, which makes the review of fibromyalgia very relevant in the new era of the SARS-COV-2 infection and the post-COVID-19 syndrome. Another important aspect to consider is the effect of multisystem inflammatory syndrome and the consequences associated with the presence of Guillain–Barré syndrome, aspects that are evaluated in this issue, with a systematic review and meta-analysis and a narrative review, respectively.

Therefore, in the case of rheumatic diseases, it is the duty of the rheumatologists to ensure that the disease of the patients is well-controlled and that their symptoms and immune dysfunction are adequately regulated, as this can help protect them from a state of immune dysregulation caused by the COVID-19. In turn, it is necessary to continue promoting vaccination and be attentive to the status of comorbidity associated with postCOVID-19.

Vaccination is essential to control the COVID-19 pandemic, however, its progress varies between countries, and global inequity in vaccines has been a global public health problem. According to the Human Development Index as an indicator, it was identified that the South American countries had a moderate level of vaccination, in addition to the low access to vaccination in African countries.¹² For this reason, it is necessary to continue promoting equitable access to treatment, preventing social disparity from having a negative impact on the prognosis of the patients, seeking to maintain the adequate health status of the general population, including the patients with rheumatic diseases.

Currently there are great reflections due to the situation that has been experienced and suffered as a result of the pandemic, which has uncovered great social inequities that make dying of COVID a probability, but dying of hunger a certainty. The response of science with vaccines was accurate and timely; however, the lack of education has made it impossible for vaccination to be universal. Furthermore, the myths and pseudosciences have prevented many people from receiving this benefit. There is a great challenge for doctors who face this pandemic: to attend the post-pandemic with science as the flag and knowledge as a work tool; get closer to the people and seek to be pedagogues of the society. Much is demanded of science and little is invested in it, it is asked to provide answers in the face of adversity, but it is ignored when it does not seem useful. This pandemic has taught us that without science there is no future and that the worst problems of society: poverty, inequality and corruption cannot be addressed.¹³