COVID-19 and arthritis

It’s not clear yet whether having arthritis makes you more susceptible. What we do know is that – much like seasonal flu – older adults and people with autoimmune disease like rheumatoid arthritis may be more likely to get seriously sick if they do become infected, so it’s important to take appropriate precautions. 

The main concern isn’t the virus itself, but secondary bacterial infection and other complications that may arise when your body’s defenses are in a weakened state.

Some inflammatory arthritis medications suppress the immune system, which may make you more vulnerable to infection. For most Canadians there is no need to stop medications as the risk of contracting the virus is low. For some patients, however, your physician may advise you to stop certain medications in case of infection.

It is important that you do not make any changes to your medications without consulting your physician.

In general:

If you are well, DO NOT STOP your medications

• If you have a confirmed case of COVID-19, or significant symptoms, consult your healthcare provider. You may be advised to interrupt the use of DMARDS, biologics or JAK inhibitors when you are ill.
• If you have been exposed to COVID-19 but have no symptoms, consult your healthcare provider who may advise you to temporarily interrupt your biologics or JAK inhibitors pending a negative test and/or are symptom-free for 14 days.

If you’ve stopped your medications, consult with your doctor or rheumatologist before resuming.

Many jurisdictions have implemented new telehealth consultations for rheumatology patients during this time. So please follow your local developments closely.

If you are living with arthritis, particularly inflammatory forms like rheumatoid arthritis (RA), you may wonder if getting a flu shot is right for you. Talk to your healthcare provider, of course, but in general, a flu shot is recommended for most people.  

The National Advisory Committee on Immunization (NACI) has released additional guidance on flu vaccination for the 2021-22 season. It highlighted the need to minimize the risk of COVID-19 and the flu co-circulating and also to reduce the burden on the healthcare system.    

To reduce the risk of severe illness that could potentially arise from co-infection with COVID-19 and the flu, individuals who fall into the following groups are particularly recommended to receive the flu vaccine: 

• People at high risk of severe COVID-19 related illness.

• People capable of transmitting influenza to those at high risk of severe illness related to COVID-19. 

For those who may have questions about the timing of the flu shot, NACI advises that all seasonal flu vaccines may be given at the same time as, or at any time before or after administration of other vaccines, including COVID-19 vaccines.  

More information about the flu shot is available from the Public Health Agency of Canada or your local public health department. 

For more information about arthritis and the flu vaccine, read our flourish article. 

In Canada, four vaccines have been approved for use by Health Canada as of March 11, 2021. 

Further below on this page is a brief explanation of each of them.

The National Advisory Committee on Immunization (NACI) recommends that all Canadian adults who are able to, receive a COVID-19 vaccination to protect themselves and others. 

If you have osteoarthritis
You are encouraged to get the vaccine when it is available to you. 

If you have a rheumatic disease
While people with rheumatic diseases were mostly excluded from vaccine trials, there is now evidence from real world use of COVID-19 vaccines in this population.   

Based on this new evidence, NACI updated its recommendations on May 28, 2021.

The updated recommendation is that a complete two-dose vaccine series with an mRNA COVID-19 vaccine (Pfizer-BioNTech or Moderna) should be offered to people who are immunosuppressed. NACI does note that individuals who are immunosuppressed from disease or treatment should be aware they may have a reduced immune response to any authorized COVID-19 vaccine series. For more information, visit NACI’s website (under “Vaccines” and “Recommendations”.)

As part of the update on May 28, NACI also recommended that second doses should be offered as soon as possible, with priority given to those at highest risk of severe illness and death from COVID-19. The Arthritis Society believes this includes people with arthritis who are immunocompromised or immunosuppressed and is advocating for the interval between second doses to be shortened for these individuals.

The Canadian Rheumatology Association has created a decision aid [PDF] for people with autoimmune rheumatic disease who are over 18 to use in their discussions with their health-care provider.  

Note: Decisions about the distribution of the vaccines and prioritization of specific populations are made by individual provinces or territories. For information about when you might receive the vaccine or information specific to where you live, please refer to your provincial or territorial health ministry website.

The different vaccines

Pfizer

• Was approved for use in Canada in December 2020 for individuals 16 and older.
• Has been first administered to high-risk populations (front-line health care works, long-term care residents, seniors 80+).
• Is a two-dose vaccine with the manufacturer recommending the second dose be administered 21 days later.
  • In order to vaccinate as many adults as quickly as possible, NACI recently recommended the interval between doses be extended to four months. 
• In clinical trials, it had a reported efficacy of 95 per cent. 

Moderna

• Was approved for use in Canada in December 2020 for individuals 18 and older.
• Has been first administered to high-risk populations (front-line health care works, long-term care residents, seniors 80+).
• Is a two-dose vaccine with the manufacturer recommending the second dose be administered 28 days later.
  • In order to vaccinate as many adults as quickly as possible, NACI recently recommended the interval between doses be extended to four months. 
• In clinical trials, it had a reported efficacy of 94 per cent. 

Both the Pfizer and Moderna vaccines are based on mRNA technology that work by giving your cells instructions on how to make a piece of the virus called a protein. Your immune system learns to recognize the protein. If you become infected with the virus, your body gets rid of the infection, so you don’t become sick. These vaccines do not contain the live virus that causes COVID-19.

AstraZenca

• Was approved for use in Canada at the end of February 2021.
• It's recommended for adults 30 and older.
• Is a two-dose vaccine with the manufacturer recommending the second dose be administered 28 days later.
  • In order to vaccinate as many adults as quickly as possible, NACI recently recommended the interval between doses be extended to four months. 
• In clinical trials, it had a reported efficacy of 63-82 per cent (efficacy varied depending on the timing of the second dose). 
• It’s made from a weakened version of a common cold virus (known as an adenovirus). It has been modified to look more like coronavirus – although it doesn’t cause illness. Once injected, it teaches the body's immune system how to fight the real virus, should it need to.

Johnson & Johnson 

• Was approved for use in Canada at the beginning of March 2021 for individuals 18 and older.
• Unlike the other vaccines approved for use in Canada, it is a one-dose vaccine.
• In clinical trials, it had a reported efficacy of 66-85 per cent.
• It is an adenovirus vector vaccine that uses a harmless cold virus to deliver a gene that carries the blueprint for the spiky protein found on the surface of the coronavirus. The virus enters cells, which then follow the genetic instructions to construct a replica of the coronavirus spike. The immune system uses these replicas to recognize — and respond to — the real thing if a person were to become infected.

Additional vaccines from other pharmaceutical companies are still being tested. In fact, there are 150 different vaccines at different stages of development around the world.

The benefits of the COVID-19 vaccine are:

• Prevention: while the efficacy of each vaccine differs, they are all safe and effective at preventing COVID-19 in people who get vaccinated. (For comparison, the efficacy of the flu vaccine is between 40-60 per cent each year).    
• Reduction: COVID-19 is less severe in people who get the vaccine but who still get sick.  
• Protection: getting vaccinated helps protect people around you.

There are some possible temporary side effects or risks of the COVID-19 vaccine, including:

• Sore arm at injection site
• Tiredness
• Fever, chills
• Headache
• Temporarily swollen lymph nodes
• General muscle or joint pain

For people with rheumatic disease, any decision to hold medications should be discussed between a patient and their rheumatologist or healthcare team. 

The following information from the Canadian Rheumatology Association (CRA) does offer some guidance. This is the current recommendation in Canada. 

People taking rituximab: Based on studies from other vaccines, rituximab is expected to decrease the immune response. Prior guidelines for other vaccines in patients with DMARDs have recommended that immunization be deferred to at least five months after the last dose and at least four weeks prior to the subsequent dose of rituximab. 

People taking other disease-modifying antirheumatic drugs (DMARDs): Some other DMARDs may reduce protection from the vaccine. Given the strong benefit of taking the COVID-19 vaccine, it is likely that its benefit will still be strong for most patients on these kinds of drugs. Continuing medications will often be the safest option to prevent disease flares until more evidence is available.  

The CRA's latest statement [PDF] in March 2022 says preliminary data suggests that withholding DMARDs, such as methotrexate and mycophenolate mofetil, during the COVID-19 vaccination schedule improves vaccine response. Physicians need to weigh the benefits of this with the risk for potential disease flare and such decisions should be individualized.

Canada’s National Advisory Committee on Immunization (NACI) recommends individuals who are moderately to severely immunocompromised* should receive a primary series of three doses of an authorized mRNA vaccine. In addition, NACI strongly recommends a booster (or fourth dose) for individuals who are moderately to severely immunocompromised.  

(*Immunocompromised includes individuals actively being treated with biologics that are significantly immunosuppressive.)  

The Canadian Rheumatology Association (CRA) also recently updated its position statement [PDF] in March 2022 on COVID-19 vaccination, which included the recommendation that all patients older than five and treated with certain specific medications (anti-CD20 agents, mycophenolic acid and/or glucocorticoids) should receive a third dose. A third dose should also be considered for patients on other immunosuppressive treatments (particularly abatacept, JAK inhibitors, and antimetabolites). A third dose in patients with rheumatic disease on antiTNFs can be considered, particularly if on higher doses or when combined with other DMARDs.

The Arthritis Society supports these recommendations. In order to protect the health and safety of people living with arthritis, we encourage all provinces to implement comprehensive recommendations that will best support immunocompromised patients.  

To date, all provinces have made an announcement on a third dose. They do differ, so please check your province's page for specifics:

• Alberta
• British Columbia (being offered in phases)
• Manitoba
• Newfoundland
• New Brunswick [PDF]
• Nova Scotia 
• Ontario
• Prince Edward Island
• Quebec (only in French) 
• Saskatchewan 

We are in regular communication with arthritis stakeholders and governments to ensure high-risk immunocompromised patients are protected. We will update this page as more information becomes available. 

Children between 5 and 11 years old are eligible to receive the Pfizer vaccine (10 microgram dose). Health Canada has approved both mRNA vaccines (adult dosing) for individuals between 12 and 18 years of age however, the Pfizer vaccine is currently the one recommended in this age group given the higher risk of myocarditis with the Moderna vaccine. Studies are still ongoing in children under 5.

Physical distancing and public health measures should be followed for both adults and children. Encouraging your child to wash their hands and follow good personal hygiene, including avoiding touching their face and covering their mouths and noses while coughing or sneezing, are good simple reminders. It’s also recommended anyone over the age of two, who is able to, wear a mask or face covering. 

COVID-19 infection does seem to be milder in children than in adults or older individuals. Currently, there is no evidence that children with auto-inflammatory diseases are more likely to contract COVID-19 or to have a worse case.  

As some schools across the country are offering in-person learning, you may want to discuss with your child’s rheumatologist if any additional precautions need to be taken to keep your child safe. Be prepared to discuss your child’s needs with the school and ensure it’s able to accommodate them.

Remind children to keep at least six feet away from others when possible and remind young children not to touch others or put objects or toys in their mouths. For older children/teens, encourage them to replace physical greetings like fist bumps, high fives and hugs with virtual high fives or verbal greetings.

The U.S. Center for Disease control has created a number of back to school planning checklists for parents/guardians, that include tips for in-person and virtual learning.

Cassie + Friends has also created a COVID-19 parental FAQ, which includes specific real-life examples. 

Operating rooms in many provinces have resumed non-emergency procedures, but there was already a backlog of joint replacement surgeries in much of Canada before COVID-19, and the shutdown has made those backlogs longer.

If you are one of the thousands of Canadians whose joint replacement surgery was delayed or cancelled, the best thing you can do is to keep moving and make the most of this time to prepare yourself. Our surgery resources can help you understand what to expect from your surgery, be better prepared for it and have a more successful recovery. You can also visit our flourish article on What to Do if Your Joint Surgery has Been Delayed.

In the event that you’re coping with significant pain, there are a number of things you can do to help make your wait as comfortable as possible. Above all, make sure to continue taking your medications as prescribed, do not overmedicate and stay in touch with your healthcare team. Learn more in our guide to managing chronic pain, or in our resource on Drug-Free Pain Management Options.

You may also want to keep tabs on our advocacy page, where we are calling on the federal and provincial governments to work together on a solution to address both the pre-existing joint surgery wait times and the additional backlog from the COVID-19 shutdown.

Every province is responsible for setting its own vaccination policies. 

The National Advisory Committee on Immunization (NACI) does state however: [moderately to severely immunocompromised individuals] are at a higher risk of severe outcomes of COVID-19 and also at increased risk of decreasing protection over time since vaccination. Therefore, immunocompromised individuals who already received an additional [third] dose in the COVID-19 vaccine primary series are included in those recommended to receive a booster dose six months from their last dose. 

The Arthritis Society will continue to closely monitor for announcements by NACI, the Canadian Rheumatology Association and provincial governments and update this page when any fourth-dose information becomes available. 

Here are the current fourth-dose policies for the provinces that have made announcements: 

• Alberta: Immunocompromised individuals are eligible for a fourth dose, but it must be at least five months after the third dose was administered. 
• Manitoba: recommends adults who are moderately to severely immunocompromised receive a total of four COVID-19 vaccines. The fourth dose should be given five months after the third dose for those 50+ or for individuals who live in a First Nations community, and six months after the third dose for all other adults. 
• New Brunswick: For immunocompromised adults, a booster (fourth dose) of an mRNA COVID-19 vaccine can be booked if at least five months have passed since the third dose. 
• Nova Scotia: Immunocompromised people are eligible to receive a booster dose 168 days after their third dose.  
• Ontario: For immunocompromised individuals, a three-dose series is considered a complete series. These individuals may receive a booster (fourth dose) at least 84 days after completion of the primary series. 
• Prince Edward Island: Moderately to severely compromised individuals are strongly recommended to receive a booster (fourth dose) five and a half months after the third dose.
• Newfoundland: Immunocompromised individuals can be offered a booster (fourth dose) when at least 22 weeks has passed since they received their third dose. 
• Saskatchewan: Those who are moderately to severely immunocompromised and have had three doses for their primary COVID-19 vaccination series are eligible to receive a booster (fourth dose) at least three months after their third dose.  

While the majority of Canadians have received the COVID-19 vaccination, the Public Health Agency of Canada continues to recommend the practising of all public health measures recommended by local public health authorities, including individual measures, such as wearing a mask. This is because:

• although COVID-19 vaccines approved for use in Canada provide substantial protection against severe illness, no vaccine is 100% effective

  • protection may decrease over time

• fully vaccinated individuals can still be infected and transmit the COVID-19 virus

  • however, this is less likely to occur among fully vaccinated individuals than for those who are unvaccinated or partially vaccinated

• as it gets colder and when more of our activities move indoors, we may come into closer contact with others outside of our household

When layered with other recommended public health measures, a well-constructed, well-fitting and properly worn mask can help prevent the spread of COVID-19.

Masks can help:

• contain your respiratory particles

• prevent or reduce the amount of infectious respiratory particles you inhale, particularly when wearing a well-constructed, well-fitting mask

​When to wear a mask

Make wearing a mask part of your regular routine.

Follow local public health advice on when you should wear a mask. Masks may be recommended or required in public settings like:

• stores

• schools

• businesses

• workplaces

• public transit

Even if masks aren't required in your area or the setting you’re in, wearing a mask is an added layer of protection. Whether you’re vaccinated or not, you should consider wearing one in shared spaces with people from outside of your immediate household. This is especially important indoors, whether in private or public settings.

Masks are strongly recommended in any crowded setting, including settings with vaccination requirements.

When wearing a mask, the Public Health Agency of Canada recommends:

• be made of at least three layers
  • two layers should be tightly woven material fabric, such as cotton or linen
  • the third (middle) layer should be a filter-type fabric, such as non-woven polypropylene fabric
• be large enough to completely and comfortably cover the nose, mouth and chin without gaping
• allow for easy breathing
• fit securely to the head with ties or ear loops
• be comfortable and not require frequent adjustments
• be changed as soon as possible if damp or dirty
• maintain its shape after washing and drying

Closures and stay-at-home orders can vary widely by province/territory, or even within a region.

Frontline workers, especially those who are themselves at greater risk or are living with vulnerable people (seniors, immunocompromised), should take extra precautions:

• Follow your employer’s safety protocols at all times. If you are unclear about the safety protocols in effect in your workplace, speak with your manager, HR or union representative as appropriate.
• Wash hands frequently during shifts, do not touch face without washing hands, use masks appropriately and avoid touching the inside of the mask.
• Where possible, avoid working in confined spaces and keep a safe distance from others (at least two metres/six feet). If it’s not possible to maintain that distance, the use of a face covering is recommended.
• After shifts, remove work clothes upon entering your home, remove and leave your footwear at entry, wash your hands, shower and wash your hair and put on fresh clothing before greeting others in the home.
• Advise your employer if you have been exposed to someone who is COVID-19 positive, or someone who is showing symptoms for whom the test results are pending. You may be required to stay home for up to 14 days unless otherwise advised by your doctor.
• Report any development of COVID-19 symptoms to your employer and the local health authority, and stay home unless and until directed otherwise by your doctor.

For frontline workers who are immunocompromised, there are no national standards in place. Here are some questions to consider:

• Is your autoimmune condition controlled?
• What immunosuppressants are you on?
• Can you work from home?
• Do you have adequate personal protective equipment to do your job?
• Can you be placed in an environment with limited exposure to others?
• Are you able to maintain physical distancing protocol while travelling to work?
• Speak to your doctor about your concerns.

If your doctor agrees that you are at elevated risk, you may wish to raise your concerns with your employer to see what options they might suggest. You may also wish to review the Government of Canada’s discussion of your rights and responsibilities as an employee, including your right to refuse dangerous work. At the time of writing, the existence of COVID-19 in the community has not been seen as sufficient grounds to refuse work, even for those who are immunocompromised. However, if your employer fails to adhere to mandatory safety precautions, they may be contributing to a dangerous work environment.

Researchers around the world are actively investigating treatments for COVID-19. One approach to treatment is to try to reduce the symptoms of the disease. Some medications used to treat inflammatory arthritis, like hydroxychloroquine, colchicine , tocilizumab, and sarilumab work by suppressing the body’s immune system. Drugs that blunt specific parts of the immune system are being tested to see whether they can prevent inflammation caused by COVID-19, which is a major complication in severe disease. These drugs are not being tested to directly treat the coronavirus infection, but to reduce the body’s overwhelming inflammatory response that occurs in certain infected individuals.

An early study reported in January 2021 showed treating critically ill COVID-19 patients with arthritis drugs tocilizumab or sarilumab significantly improved survival rates and reduced the amount of time patients needed intensive care. The study has not yet been peer reviewed. 

While these drugs are currently approved for some indications like inflammatory arthritis, they are not approved for the treatment of COVID-19. We will continue to monitor the situation, and in the event that one or more of these drugs are confirmed as COVID-19 treatments, we will advocate to ensure adequate supply for people who need the drugs to manage their arthritis.

The Arthritis Society is funding a research project to examine how people with arthritis are impacted by COVID-19. Find out more, and help support this important research.

With the number of patients in hospital with COVID-19 increasing during the third wave of the pandemic (April 2021), there have been reports of supply shortages of tocilizumab.  

In addition to its primary use as a treatment for inflammatory types of arthritis, it’s being used to treat moderately and critically ill COVID-19 patients in hospital.  

Currently, there are no supply issues for arthritis patients who use this drug even if doctors in hospitals are being asked to ration their use of it for COVID patients. The distribution networks are different for the drug as a hospital-based COVID treatment and as an arthritis treatment. 

We’ll continue to monitor the situation and continue to advocate to ensure people with arthritis have access to a stable supply of the medications they need. 

There is currently no publicly available scientific evidence to suggest that ibuprofen worsens the effects of the coronavirus. Patients who are using ibuprofen for other medical conditions are not being advised to stop. It is important to remember that you should not make any medication changes without consulting your physician.

To learn more about the wide range of financial support measures currently being implemented by the federal, provincial and territorial governments to best support Canadian communities, businesses, families and individuals who have been impacted by the COVID-19 pandemic, please visit:

• Canada’s COVID-19 Economic Response Plan

In addition to supports being introduced as a result of COVID-19, you may also want to learn more about previously existing government and community supports.

Specifically, to learn more about disability benefits programs offered at federal, provincial, and territorial levels of government, please visit the Government of Canada’s Disability Benefits site.

To learn more about community resources available in your specific community, please visit Canada 211, Canada’s primary source of information on government and community-based health and social services, at 211.ca, or call 2-1-1 from your phone (where service is available).

Health Canada: Information for Canadians
Canadian Rheumatology Association: COVID-19 Resource Centre
EULAR (European League Against Rheumatism): Guidance for patients with musculoskeletal disorders 
ACR (American College of Rheumatology): Message about COVID-19
Canadian Arthritis Patient Alliance: A collection of information resources for people with arthritis
Arthritis Consumer Experts: A collection of information resources for people with arthritis
Canadian Pharmacists Association: COVID-19 information 

For information about specific provinces/territories:

Ontario
British Columbia
Manitoba
Saskatchewan
Alberta
Nova Scotia
Newfoundland and Labrador
New Brunswick
Prince Edward Island
Quebec
Yukon
Northwest Territories
Nunavut

To minimize the spread of the virus, many Arthritis Society staff are currently working remotely.

Similarly, we have cancelled all in-person workshops and events until further notice. We hope to see you again soon.

In Ontario, our Arthritis Rehabilitation and Education Program (AREP) is continuing to run virtual care and education programs. If you live in Ontario, you can access more information on the AREP webpage.