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.

People are being advised to avoid crowded spaces, work from home if possible, limit close contact to people within your household and essential care providers (refer to specific recommendations in your region for guidance on bubbles or cohorts), wear a mask when in indoor public spaces and maintain a distance of two metres (six feet) from those around you.

Observe the following hygiene recommendations from Health Canada:

• Wash your hands often with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer
• Avoid touching your face with unwashed hands
• Avoid close contact with people who are sick
• When coughing or sneezing: cover your mouth and nose with your arm or tissues to reduce the spread of germs. Immediately dispose of any tissues you have used into the garbage as soon as possible and wash your hands afterwards
• Clean and disinfect frequently touched objects and surfaces, such as toys, electronic devices and doorknobs
• Stay home if you are sick to avoid spreading illness to others

Health Canada also suggests you think ahead and make a plan to ensure you have adequate supplies in case infection rates rise in the coming weeks or months. To minimize contact with other people consider grocery pick-up or delivery; and consider asking your pharmacy if it offers free medication delivery.

The Canadian Rheumatology Association is also recommending you get your vaccinations updated when possible, including seasonal influenza, pneumococcal and pertussis vaccines. These vaccines won’t prevent COVID-19 but could lessen secondary infection and will prevent illnesses that could resemble it.

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.

See the Canadian Rheumatology Association recommendations about medications. 

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

Do not put your health on hold. If you need urgent medical care, do not delay in seeking assistance. Hospitals and emergency rooms in Canada are equipped to keep people safe. It is important you seek care for your health concerns so they don’t get out of hand and lead to lasting complications or poor outcomes.

For appointments, many healthcare professionals are currently providing virtual care by telephone or internet when possible. If you have questions about your appointment, it is best to contact your healthcare provider’s office for further direction.

• INFUSIONS: If you are receiving a biologic medication at an infusion centre, you should continue to receive medications as prescribed. Some medications have injectable versions you could be switched to, if appropriate. Consult with your doctor, who can advise you if your medication frequency can be changed. If you have further questions about your infusion, consult with your rheumatologist.
• LAB TESTS: Consult with your doctor to determine if you can reduce the frequency of your lab testing, then proceed with your lab testing as directed.
• VACCINATIONS: In general, people who are receiving immunosuppressing medications should not receive live vaccines, though it is recommended they receive inactivated vaccines as indicated. It is important to get an annual flu shot and other relevant inactivated vaccines. (For more information about the flu shot, see earlier question). You can learn more in our flourish article on Vaccines and Arthritis. If you have symptoms of an infection (any infection, not just COVID), delay vaccination. Otherwise, COVID should not impact the timing of vaccinations, and the benefits of helping your body fight potential infections is greater than the potential risks and side effects.
• OTHER HEALTH ISSUES: You may wish to consider delaying unnecessary in-person visits. There are many healthcare services that can be delivered over the phone or online, and most pharmacies will deliver medication, so contact your physician or pharmacist as appropriate to confirm.

Remember, for any in-person medical appointments, confirm ahead of time if you have any flu-like symptoms and notify the site before going in case they have specific requirements for you to follow.

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.  

We know this year there appears to be an increased demand for flu shots and there are shortages in some areas of the country. People are being asked to be patient while provinces and territories work to secure enough supply to meet demand. If you have concerns about accessing the vaccine, please speak with your healthcare provider. 

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, the Pfizer vaccine was approved in early December and the Moderna vaccine was approved at the end of December. Both vaccines have begun to be administered to high priority groups.

NACI recommends that people who are immunosuppressed because of disease or medications they are taking be offered the vaccine if a risk assessment deems that the benefits outweigh the potential risks for the individual, and if informed consent includes discussion about the absence of evidence on the use of COVID-19 vaccine in this population. This could apply to people with inflammatory forms of arthritis.  For more information, visit NACI’s website (that section can be found under “Vaccines” and “Recommendations”.)

Much like the flu vaccine, you should speak with your healthcare provider to discuss the risk and benefits of your specific situation. 

The number of vaccines currently available in Canada, and that will be available in the near future, is still limited. These early supplies are first being distributed to populations at highest risk including healthcare workers, other frontline workers, and elderly.

Data assessing the risk of severe COVID-19 in rheumatology patients is limited, however studies are underway to understand whether particular patient groups should be considered for priority vaccination. The evidence so far does not suggest that people taking disease-modifying antirheumatic drugs (DMARDs) are at a higher risk of developing COVID-19 nor that their symptoms would be more severe if they did develop COVID-19. One important exception may be people taking corticosteroids. People taking these medications should speak with their doctor about the risks and benefits of taking these medications.

Public health officials in each province are currently deciding on the prioritization of groups to be vaccinated. Consideration for people living with chronic diseases are being carefully assessed, however the precise implications for people with arthritis within each province’s vaccination rollout plans have yet to be outlined.

Mass distribution of any potential COVID-19 vaccine will take some time. Federal government officials have indicated they expect everyone who wants a vaccine to be able to receive one by the fall.

For more information, visit https://www.rheumatology.org/announcements. 

The advice is the same for both adults and children. 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. COVID-19 infection does seem to be milder in children than in adults or older individuals. It is still unclear whether children and youth with arthritis have a greater risk of COVID-19 infection, or if they risk more serious illness if they do become infected.

As schools have now re-opened, 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.

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.

Symptoms of COVID-19 can vary from person to person.

The most common symptoms of COVID-19 include:

• fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
• chills
• cough that's new or worsening (continuous, more than usual)
• barking cough, making a whistling noise when breathing (croup)
• shortness of breath (out of breath, unable to breathe deeply)
• sore throat
• difficulty swallowing
• runny, stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)
• lost sense of taste or smell
• pink eye (conjunctivitis)
• headache that’s unusual or long lasting
• digestive issues (nausea/vomiting, diarrhea, stomach pain)
• muscle aches
• extreme tiredness that is unusual (fatigue, lack of energy)
• falling down often
• for young children and infants: sluggishness or lack of appetite

Call 911 if any of the following symptoms cause a health emergency:

• severe difficulty breathing (struggling for each breath, can only speak in single words)
• severe chest pain (constant tightness or crushing sensation)
• feeling confused or unsure of where you are
• losing consciousness

You can infect others even if you aren’t showing symptoms, or be infected by someone who is without symptoms. Therefore, it is important to always take precautions whether or not you or someone else appears sick.

If you are experiencing symptoms, phone ahead to your health care provider or public health authority and let them know:  

1. the symptoms you are experiencing,
2. any pre-existing conditions you are living with, and
3. any medications you are taking

…then follow their instructions.

If you were in close physical contact with anyone in the 48 hours before your symptoms began, let them know to monitor their health and to self-isolate.

If your symptoms are mild, you will probably be told to treat it like a cold or flu – isolate yourself for 14 days, get rest and drink liquids. If your symptoms are moderate or severe, you will likely be sent to the hospital where they can monitor you for complications such as pneumonia.

In general, Health Canada advises the following steps if you are sick to help reduce contact with others:

• Stay at home and self-isolate for 14 days (unless directed to seek medical care)
• If you must leave your home, wear a mask and maintain a two-metre distance from others
• Avoid individuals in hospitals and long-term care centres, especially older adults and those with chronic conditions or compromised immune systems
• Avoid having visitors to your home
• Cover your mouth and nose with your arm when coughing and sneezing
• Have supplies delivered to your home instead of running errands
  • Supplies should be dropped off outside to ensure a two-metre distance

Self-assessment tools

If you’re feeling unwell, first complete your provincial/territorial online COVID-19 self-assessment tool. Only if you’re experiencing related symptoms, call your provincial health team, and they will provide the next steps.

• Alberta then call 811
• British Columbia then call 811
• Manitoba then call
  • Winnipeg 204-788-8200, 
  • Toll-free across Manitoba 1-888-315-9257
• Newfoundland & Labrador then call 811
• New Brunswick then call 811
• Northwest Territories then call 
  • Yellowknife: 867-767-9120, 
  • Inuvik: 867-490 –2225,
  • Fort Smith: 867-872-6219 or 867-872-6221,
  • Hay River: 867-874-7201
• Nova Scotia then call 811
• Nunavut then call the COVID Hotline at 975-8601 or 1-888-975-8601 from 10 a.m. to 6 p.m.
• Ontario then call 1-866-797-0000
• Prince Edward Island then call 811
• Quebec then call 1-877-644-4545
• Saskatchewan then call 811
• Yukon then contact covid19info@gov.yk.ca

Masks

The continued spread of the coronavirus has led many jurisdictions in Canada to mandate wearing a mask or face covering when in all indoor public spaces (e.g. in stores, apartment buildings, public transit). Exemptions have been made for persons with an underlying medical condition that inhibits their ability to wear a mask. Because a person can carry the virus before they start showing symptoms or never appear symptomatic, masks can help prevent people from unintentionally infecting others. A non-medical mask doesn’t necessarily protect the person wearing it, however.

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

It’s also important to remember:

• you can’t touch a mask while you’re wearing it, or pull it under your chin for a break
• it must be changed as soon as it’s damp and either safely disposed of or carefully placed in the washing machine
• you must also wash your hands thoroughly before and after handling your mask

Note that medical masks with an ‘N95’ rating are to be reserved for front-line healthcare workers who risk potential exposure when they are working.

If you fail to follow these precautions, you could get coronavirus from handling a dirty mask.

Gloves

For the general public, wearing gloves is not necessary in most situations, like running errands. The U.S. Centers for Disease Control recommends wearing gloves when you’re cleaning or caring for someone who is sick.

If you do choose to wear gloves in public:

• wash or sanitize your hands before putting on a pair of gloves
• use well-fitting latex or vinyl gloves
• DO NOT TOUCH ANYTHING ELSE – your face, your phone, your car door handle – until you have removed your gloves and washed your hands
• when you are done with your gloves, turn them inside out and dispose of them in a garbage container with a bag liner
  • failure to dispose of your gloves in a safe and responsible manner increases the risk of exposure for yourself and others
• wash or sanitize your hands after handling or disposing of your gloves

If you fail to follow these precautions, your gloves could result in cross-contamination and expose you and others to the coronavirus.

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 and trying to develop a vaccine. Another approach is to reduce the symptoms of the disease. Some medications used to treat inflammatory arthritis, like hydroxychloroquine, colchicine and tolicizumab, 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.

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.

Early in the pandemic, there were reports of patients in some provinces experiencing challenges accessing hydroxychloroquine (HCQ, brand name Plaquenil). These temporary shortages were a result of a spike in demand and supply chain issues with some manufacturers.

Thanks to the combined efforts of governments, industry, professional associations and community stakeholders including the Arthritis Society, these issues were identified and successfully addressed, so that Canadians should no longer experience any issues accessing their needed medication. (For more information, see our advocacy page.)

We strongly support the Canadian Rheumatology Association Position Statement on COVID-19 and Hydroxychloroquine Supply and the call for priority access to HCQ for patients with rheumatic conditions to treat these chronic diseases. 

• QUEBEC RESIDENTS: Effective May 1, 2020, INESSS has lifted its restrictions (French only) on which patients could receive hydroxychloroquine, as supply has now been restored.

If you are affected by a drug shortage and have concerns or symptoms of a flare, please contact your rheumatologist. As well, self-management and lifestyle choices may help in managing your symptoms and condition. 

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.

As of now, there are NO confirmed treatments for COVID-19, either to prevent infection or relieve symptoms. All claims to the contrary from people trying to sell ‘protection’ or ‘cures’ are misleading at best, and potentially dangerous. The best way to protect yourself is still to practice physical distancing and use thorough and frequent handwashing.

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: Statement on COVID-19  
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: Statement on chloroquine and hydroxychloroquine (HCQ) 

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.