Abstract
Aim: To evaluate the impact of the coronavirus disease 2019 pandemic (COVID-19) on the access to rheumatology care for patients with chronic rheumatic diseases (CRD) in the Arab countries.
Method: A web-based cross-sectional survey was designed by the Arab Adult Arthritis Awareness group (AAAA) consisting of 16 rheumatologists representing countries from the Arab League of Associations for Rheumatology (ArLAR) and was validated by the ArLAR scientific committee. The survey was disseminated online through social media and patients’ association channels between May 8 and May 22, 2020. The steering committee developed recommendations to improve the care of patients with CRD during the COVID-19 pandemic.
Results: A total of 2163 patients were included in the analysis; 72% were female; mean age was 40 years (SD 11.9). The Levant, the Gulf, and North Africa contributed almost equally to the sample. The pandemic had a significant negative impact on rheumatology visits in 82% of cases, access to hydroxychloroquine (47%), and chronic medication persistency (28%). The negative impact on rheumatology visits was associated with female gender, country, medication non-persistency, isolation due to COVID-19, and impact on mental health. Sixty-one patients (2.8%) stated that they had COVID-19, 5% said that a close contact was infected, and 47% were in isolation because of COVID-19.
Conclusion: The current study highlights the deleterious consequences of the COVID-19 pandemic on the continuity of rheumatology care. Therefore, an action plan, including establishing a telemedicine platform, securing drug availability, and promoting medication persistence through the appropriate communication channels, is strongly recommended.
Introduction
The coronavirus disease 2019 (COVID-19) emerged in December 2019 in Wuhan, China, and quickly became a global outbreak and a significant public health issue.1,2 On January 30, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern,3 and, on March 20, 2020, due to the devastating number of new cases reported globally, WHO declared it as a pandemic.4 At the time of drafting this manuscript (June 5, 2020), the WHO reported more than 6.5 million COVID-19 cases and 387 155 deaths.COVID-19 is caused by a novel coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that can cause illness ranging from the common cold to the SARS. To date, no antiviral treatment or vaccine has been explicitly recommended. Therefore,applying preventive measures to control the infection is the most critical intervention. In consequence, on top of its significant public health impact, the pandemic had a major influence on social interactions and global economies, as countries locked down and social distancing measures were imposed by governments worldwide.Patients living with chronic rheumatic diseases (CRD) require an additional consideration with regard to this pandemic. Many of these patients are immunocompromised and generally vulnerable to infection. Whether they have a higher risk of infection with SARS-CoV-2 is uncertain,7-12 and although several recommendations were developed worldwide,13-17 strong evidence is lacking to guide treatment decisions. Moreover, difficulty in accessing the rheumatology clinic drove some patients to self-modify their treatment,18 which put them, along with the significant stress factor, at high risk of CRD flare. Furthermore, since some rheumatology drugs are thought to have potential activity against SARS-CoV-2, such as chloroquine,
hydroxychloroquine (HCQ), anti-interleukin (IL)6 agents, anti-IL1 agents, and Janus kinase inhibitors, a drug shortage was witnessed in many countries, making these essential drugs inaccessible to the rheumatology patients who need them.
In the Arab countries, a special interest group, the Arab Adult Arthritis Awareness group (AAAA), consisting of 16 rheumatologists representing 14 countries from the Arab League of Associations for Rheumatology (ArLAR)22 was formed in 2019 with the mission to improve patient awareness about CRD. Since the beginning of the COVID-19 pandemic, the group has spread awareness and issued guidance to Arab patients with CRD, through its vast network of social media and connections with individuals and patients’ associations. However,the impact of the COVID-19 pandemic on patients with CRD remains poorly understood. In this regard, the AAAA network offers a unique opportunity to investigate this impact, concerning access to rheumatology Infection Control care, chronic medications as well as other significant components.
1.1 | Objectives
The primary objective of the study was to evaluate the impact of the COVID-19 pandemic on the access to rheumatology care for patients with CRD in Arab countries.
2.2 | Statistical analysis
For the analysis, the countries of residence were grouped into 3 regions: Levant (Iraq, Jordan, Lebanon, Palestine, Syria), Gulf (Bahrain,Kuwait, Oman, Qatar, Kingdom of Saudi Arabia [KSA], Oman, United Arab Emirates [UAE]) and North Africa (Algeria, Egypt, Libya,Morocco, Sudan, Tunisia).Continuous variables were expressed as mean and standard deviation and categorical variables as numbers and percentages. A comparison of the patients’ characteristics and responses between the Arab countries was performed using the Pearson Chi-square or Fisher test for the categorical variables and the t test or analysis of variance for the continuous variables.Univariate and multivariable logistic regression analyses were conducted to identify factors associated with the following dependent variables: access to the rheumatology clinic, mental impact of COVID-19 (both transformed into binary variables), and personal infection with SARS-CoV-2. All independent variables with a P value ˂0.1 in the univariate analysis were taken into account in the multivariable logistic regression analysis; P values <.05 were accepted as statistically significant. All statistical analyses were performed using SPSS v25.0 (IBM).
3 latent infection | RESULTS
3.1 | Descriptive analysis of the HANDLING study patients (Table 1)
The link to the survey in the 3 languages was clicked on 3749 times.A total of 2190 patients participated in the survey and completed the questionnaire, 1971 in Arabic, 175 in French, and 44 in English.Five responses with missing data and 22 responses from non-Arab countries were eliminated. In total, 2163 responses were analyzed (Figure 1: Flowchart of the study participants Table 1).The mean age of participants was 40.0 years (SD 11.9). Seventy-two percent were female. Around half of the participants were unemployed (51.1%), and around a third were full-time employed.
Thirty-four percent were from the Levant, 31% were from the Gulf,and 30% were from North Africa. Age and gender were similar across the 3 regions (P = .814 and P = .863, respectively).When asked about their attitude toward telemedicine, 98.8% said that they would accept a teleconsultation (50% through the internet and 48.8% through a telephone contact).Also, to get information about COVID-19, the patients relied mostly on social media (73%), followed by television (51%). They used newspapers as a source of information in 8% and radio in 6% only. They relied on their healthcare provider (HCP) for information in 30% of cases and their friends and family in 20%.decreased access to HCQ (P < .001), use of precautions (P < .001),use of a mask (P < .001), personal infection with SARS-CoV-2 (P = .024) and contact infection with SARS-CoV-2 (P = .007), isolation due to COVID-19 (P < .001) and negative impact on income (P < .001). In multivariable analysis (Table 4), all remained significantly associated, except for the close-contact infection with SARS-CoV-2 . 3.2.3 | Personal infection with SARS-COV2 Sixty-one patients (2.8%) stated that they were selleck products infected with SARS-CoV-2, 5% reported that a close contact was infected, and 47% were in isolation because of COVID-19. The infection with SARS-CoV-2 was statistically correlated with the country of residence (P = .006). Among the 61 cases, 28 were from Iraq, 12 from KSA, 9 from Morocco, 6 from Egypt, 2 from Algeria, and 1 from Social Media Report,29 64.3% of social media users were aged less than 30 years. On the other hand, the gender of participants (72% females) rather reflected the profile of patients with CRD.10,28 The same report indicated that 32% of social media users were female, whereas the published cohorts of patients with CRD reported a female prevalence of 72%.Around 60% of our population were from 3 countries: Iraq, KSA, and Egypt. This high contribution reflects the large populations in these countries. They account for 173 million inhabitants among the 333 million inhabitants in the ArLAR countries (52%).
The percentage of patients infected with SARS-CoV-2 in our sample was low (2.8%). Although there was most probably a selection bias toward less severe cases, this low prevalence is in line with previous publications. In a cohort of 3591 CRD patients from Madrid, a city that was severely affected by the pandemic, 123 COVID-19 cases were reported (3.4%),30 and hospital admissions related to COVID-19 occurred in 54 patients (1.36%).The most used source of information about COVID-19 was social media. This was most probably biased toward overestimation since the survey was conducted mainly on social media. However, it highlights the importance of this communication channel when there is a need to convey general guidance to patients. Facebook is the most used platform in the Arab countries, with 156 million users in 2017.