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.

Practice physical distancing. When outside, make sure to avoid crowds and maintain a distance of 2 metres (6 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
• Avoid touching your eyes, nose or mouth, especially 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.

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, our experts advise the usual interruption of DMARDS, biologics and JAK inhibitors when you are ill

(Developed by the American College of Rheumatology (ACR) COVID-19 Clinical Guidance Task Force – draft summary approved by the ACR Board of Directors April 11, 2020)

If you’ve stopped your medications, consult with your doctor or rheumatologist before resuming. In general, our experts recommend restarting your medications once you have had two negative COVID-19 tests or are symptom-free for 48-72 hours. (This could be two weeks or more after the first onset of symptoms.) There is a risk of arthritis flare if you withhold your prescribed medications too long, so consult with your doctor.

See the Canadian Rheumatology Association recommendations about medications. 

Many jurisdictions are beginning to implement new telehealth consultations for rheumatology patients during this time. So please follow your local developments closely. (See the provincial health ministry links under “Where can I get more information?”)

Symptoms of COVID-19 resemble a cold or flu, and may include a fever, cough, difficulty breathing, and pneumonia (in advanced cases).

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 your symptoms are mild, you will probably be told to treat it like a cold or flu – isolate yourself, 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 (unless directed to seek medical care)
  • if you must leave your home, wear a mask or cover your mouth and nose with tissues, and maintain a 2-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 2-metre distance

Self-assessment tools

If you’re feeling unwell, first complete your provincial 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
• 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

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 eyes, nose or mouth 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.

If/when your child’s school reopens, you will want to discuss with your child’s rheumatologist when it might be appropriate for them to return to school, and what additional precautions to take, if any. Be prepared to discuss your child’s needs with the school and ensure they are able to accommodate them.

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 center, 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. 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. (NOTE: A vaccine for COVID-19 is at least several months away.)
• 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.

Masks and gloves are part of what is known as “personal protective equipment” (PPE). While they are essential for front-line health workers, their value to the general public is limited, and only if they are used and disposed of properly.

Masks

The continued spread of the coronavirus has led Canada’s chief public health officer Dr. Theresa Tam to suggest that it is “sensible” for Canadians to wear homemade masks while in public in situations where it may be difficult to ensure appropriate physical distancing, such as on public transit or in grocery stores or pharmacies. Because a person can carry the virus before they start showing symptoms, masks can help prevent people from unintentionally infecting others. A non-medical mask doesn’t necessarily protect the person wearing it, however.

Homemade masks should be made from fabric with a tight weave in multiple layers, drawn tight against the face around the nose and mouth. A bandana around your face will not be effective.

The U.S. Centers for Disease Control have provided a pattern for making a homemade mask that can help reduce the chances of the wearer spreading COVID-19 when used appropriately. See the pattern here: Cloth mask pattern and instructions.  Wearing a mask will not protect you from infection, but it can help prevent you from spreading the virus, even if you don’t have any symptoms.

Experts caution that wearing face masks can actually be dangerous because people overestimate the level of protection offered and neglect physical distancing rules and thorough hand washing.

If you do choose to wear a mask in public:

• it must be well-fitting over your mouth and nose
• 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 every minute they are working.

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

Gloves

It is unclear whether wearing gloves offers the general public any additional protection. As with masks, they may actually be dangerous, as people can overestimate any protection offered and risk cross-contamination if not handled properly.

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
• wipe down and sanitize the exterior of everything you touch – including shopping carts, packaging – and then sanitize your gloves again
• 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
  • if you do not have access to a lined garbage container, put the gloves in a Ziploc-style bag, seal it and store it until you can dispose of it safely
• 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.

Provinces are gradually going to relax stay-at-home protocols in the coming weeks and months. Each province will set its own rules for which sectors and industries may reopen first, which other activities may resume, and on what schedule. Check for updates on your province’s restart plans at the province-specific links shown below (under “Where can I find more information?”).

Frontline workers, especially those who are themselves 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 representation 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 2 metres/6 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.

Operating rooms in some provinces are starting to resume 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.

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. Learn more in our guide to managing chronic pain.

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.

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.

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.

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.

We will continue to monitor, and in the event one or more are confirmed as COVID-19 treatments, we will advocate to ensure adequate supply for people who need the drugs to manage their arthritis.
 

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. 

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 and provincial 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 for INDIVIDUALS & FAMILIES
• Canada’s COVID-19 Economic Response Plan for BUSINESSES

In addition to new 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, Arthritis Society offices across the country are closed and staff are temporarily working from home.

Similarly, we have cancelled all in-person workshops and events until late May 2020 at the earliest.