Yes, multiple vaccines are currently in various stages of testing and a number of vaccines have been approved in Canada and other countries, with more to come. Many companies have been working on developing a vaccine, using different technologies. This is good news, as it increases the chances of having a number of effective and safe options. As well, it will make it easier to produce enough vaccines for everyone who wants to be vaccinated, than if we were relying on only one producer.

Health Canada approved the Pfizer-BioNTech vaccine for SARS-CoV2 (the virus that causes COVID-19) on December 9, 2020, the Moderna vaccine on December 23, 2020, the Oxford-AstraZeneca vaccine on February 26, 2021, and the Johnson & Johnson (Janssen) vaccine on March 5, 2021 (the first one-shot COVID-19 vaccine). It also approved the Pfizer-BioNTech’s new bivalent COVID-19 vaccine, which targets the Omicron BA.5 and BA.4 subvariants on October 7, 2022.  How the different vaccines will be used in the rolling-out of the vaccination program has not yet been communicated by the Public Health Offices. At this point, people are not able to choose their vaccine, as it depends on availability at the time of rolling out.

Paxlovid is a pill approved by Health Canada that was shown in a randomized trial by its creator, Pfizer, to reduce the risk of hospitalization or death by 89 per cent compared to placebo in high-risk adults with COVID-19. Treatment must be started within five days of symptoms onset, the earlier the better.

The medication is intended for people at higher risk of severe illness, such as due to age, underlying health conditions, medications that suppress the immune system, or those who are unvaccinated.

Study participants in the company’s clinical trials were unvaccinated, with mild-to-moderate COVID-19, were not hospitalized and were considered high risk for hospitalization due to health problems like obesity, diabetes or heart disease. Fewer than one per cent of patients taking the medication needed to be hospitalized and none of them died. In the placebo group, seven per cent of patients were hospitalized and seven died.

The Pfizer-BioNTech’s bivalent COVID-19 vaccine targets the Omicron BA.5 and BA.4 subvariants, the virus strains currently responsible for almost all infections in Canada (88% of infections were BA.5 and 9% were BA.4 in mid-September 2022), as well as the original strain of the virus. It has been approved for use as a booster in people 12 years of age and older. It will be available shortly in most provinces. This is the second combination vaccine approved by Health Canada. In September 2022, Health Canada approved the use of Moderna’s bivalent COVID-19 vaccine, which targets the original virus and the first Omicron variant, BA.1.

Pfizer-BioNTech: approved for five and above. On September 20, 2021, Pfizer announced the results of their clinical trial showing that a pediatric dose of the Pfizer-BioNTech COVID-19 vaccine yielded as good an immune response in children aged 5 to 11 as in teenagers and young adults, with similar rates of side effects and no safety concerns observed. On November 19, 2021, Health Canada approved the Pfizer BioNTech COVID-19 vaccine in children aged 5 to 11, based on expert review of effectiveness and safety data provided by the company. The immune response to the vaccine of children in that age group was similar to that of people aged 16 to 25, and the vaccine was found to be 90.7% effective at preventing COVID-19 disease after two doses of the vaccine. No safety concerns were identified in the 3,100 children aged 5-11 who received the vaccine as part of the clinical trial. Health Canada has authorized a two-dose regimen of 10 micrograms to be administered three weeks apart, which is a lower dose than the 30 micrograms two-dose regimen authorized for people 12 years of age and older. However, the National Advisory Committee on Immunization is recommending the two doses be given eight weeks apart because of evidence of better immunity with a longer interval between doses and because data suggests this may reduce the risk of myocarditis after the second dose, a very rare side effect of the vaccine observed in adolescents and young adults.

Pfizer-BioNTech’s Bivalent COVID-19 Vaccine (targeting Omicron BA.5 and BA.4 subvariants): Approved for use as a booster in people 12 years of age and older.

Moderna: Approved for 6 months and above.

Health Canada approved the Moderna vaccine against COVID 19 for children 6 months to 5 years old. Clinical trials conducted in Canada and the US showed the vaccine was effective at preventing severe infections, and was safe in this age group. No cases of myocarditis were observed (inflammation of the heart muscle, seen in youth over 16 yrs old). Doses are adjusted for children, with two doses taken at least 8 weeks apart, and 8 weeks after an infection for children who have had COVID.

In BC, the vaccine will be available for children aged 6 months to 5 years starting August 2, 2022. Parents should register their kids under 5 in the province’s vaccine booking system, so they will be invited for an appointment when the vaccination is rolled out or when their child turns 6 mos.

Oxford-AstraZeneca: ages 18-55

Johnson & Johnson (Janssen): ages 18 and above

All vaccines work by presenting to your immune system proteins (called antigens) that your body recognizes as foreign. This trains your immune system to recognize the SARS-CoV2 virus and mount an immune response (i.e. develop antibodies) that will protect you if you are exposed to the virus at a later date.  For SARS-CoV2 it is the spike protein on the virus (what gives the virus its crown appearance). The main differences between the vaccines is what method is used to make the protein and present it to the immune system in a way that allows the body to make antibodies against it.

The Pfizer-BioNTech and Moderna vaccines are messenger RNA vaccines, which contain the genetic coding for the spike protein, stored in a lipid nanoparticle. This is read by your cells’ own protein-making machinery to produce antigens, which then trigger an immune response. There is no risk of getting the disease, because the vaccines don’t include virus particles. There is also no risk of genetic modification of your own DNA because the messenger RNA works downstream from the DNA and does not interact with your genes. The drawback is that the vaccines need to be stored at very cold temperatures. The Pfizer-BioNTech vaccine needs to be kept at extremely cold temperatures (-80 to -60 ◦C), the Moderna vaccine at regular freezer temperatures (-20 ◦C).

The Oxford/Astra-Zeneca and the Johnson & Johnson (Janssen) vaccines are viral vector vaccines, which contain a harmless version of a virus (the vector) to deliver the genetic coding for the spike protein, and instruct the cells to produce large amounts of antigen. There is no risk of getting COVID-19 because the virus used is not SARS-CoV2 but a harmless one. The vaccine can be stored at fridge temperature.

People who take medications that suppress the immune system are told that they should not take any “live vaccines”. These are vaccines that contain the actual virus that causes the disease but in an attenuated form, i.e. a weakened version of the virus that can replicate but doesn’t cause the disease. Examples are yellow fever and measles vaccines. In people with weakened immune system, there is a small risk that the attenuated virus could cause the disease. This is different from “inactive vaccines” which contain a virus whose genetic material has been destroyed so that it cannot infect cells and replicate (e.g. flu vaccines). Although a few live attenuated COVID-19 vaccines are being tested in trials (e.g. the BCG vaccine), none of the vaccines which are currently approved for use, or in the process of obtaining approval, are live vaccines. Therefore, there is no reason to believe that the currently available vaccines would be unsafe for immunocompromised people.

However, the vaccines which have been approved by Health Canada, have not been tested in people with compromised immune systems, as they were excluded from the original trials.

The National Advisory Committee on Immunization, the scientific body advising Health Canada on vaccinations, acknowledges the absence of efficacy or safety data for people taking medications that suppress the immune system, and recommends that risks and benefits be individually assessed by patients and their treating physician, on a case-by-case basis, to take into consideration the risk of each patient for SARS-CoV2 exposure and other factors or conditions that may influence a person’s risk of severe COVID-19 disease. Rheumatology professional organizations, including the Canadian Rheumatology Association, the American College of Rheumatology, and the British Society of Rheumatology state that patients with auto-immune diseases and patients taking immunosuppressant medications should receive the vaccine (unless they have allergies to components of the vaccine), with timing of vaccination following the public health prioritization criteria in their province. However, they should be counseled about the unknown safety and efficacy, and the potential for lower effectiveness than in people not taking immunosuppressive medications.

The BC Centre for Disease Control has published a clinical guidance document for persons with autoimmune rheumatic diseases with regards to COVID-19 vaccines. To view that document, click here. 

The Canadian Rheumatology Association (CRA) is closely monitoring the COVID-19 vaccines (Pfizer BioNTech, Moderna, Oxford-AstraZeneca and Johnson & Johnson) in Canada. Click here to view the CRA’s position statement, which includes recommendations on the use of these vaccines for patients under the care of a rheumatologist. Looking for a French version? Please click here.

For the Canadian Rheumatology Association’s Recommendation on Covid-19 Vaccination in Persons with Autoimmune Rheumatic Disease, please click here. Looking for a French version? Please click here. If you would like to submit a public comment on these recommendations, please click here.

The Canadian Rheumatology Association, under the leadership of Arthritis Research Canada’s Dr. Glen Hazlewood and with input from the Canadian Arthritis Patient Alliance (CAPA), has developed a Decision Aid for the COVID-19 Vaccine in Patients with Autoimmune Rheumatic Diseases, available at www.rheum.ca/decision-aid. To access a French version of the Decision Aid, please click here.

For most medications for arthritis and auto-immune diseases, no changes are needed at the time of vaccination, except the following:

• If you are taking methotrexate or a JAK Inhibitor (e.g. tofacitnib, baricitnib or upadacitnib), skip your medication for one week after each vaccine dose.
• If you are taking abatacept weekly injections, skip the week before and the week after your vaccine dose.
• If you are taking IV cyclophosphamide, take your vaccine at least one week prior to your IV infusion.
• If you are taking rituximab or ocrelizumab, have your first vaccine dose 4 weeks prior to your scheduled infusion and delay your infusion to 2-4 weeks after your second vaccine dose.
• If you are taking prednisone at a dose of 20 mg per day or higher, wait to receive your vaccine until you are at a dose lower than 20 mg per day.
• If you are on any other medications, even if they suppress the immune system, you don’t need to make any changes to your medications when you receive the vaccine.

For more detailed information on the recommendations, see the guidance document from the American College of Rheumatology.

In large trials, the Pfizer-BioNTech and Moderna vaccines were found to be highly effective, preventing 95% of infections, across all ages, gender, races and ethnicities represented in the trials. These vaccines were not tested in people under the age of 16, or pregnant women, or people on immunosuppressive medications.

Reports of the Oxford/Astra-Zeneca vaccine’s efficacy vary across the different trials conducted and ranges in the 60s and 70s % effectiveness at preventing any infections (76% was the result in the most recent mid-trial analysis reported by the company on March 25), with a much higher effectiveness at preventing severe infections (with no reports of hospitalization or death in people who received the vaccine). This is a lower “overall” efficacy rate than was demonstrated in clinical trials for the Pfizer-BioNTech and Moderna vaccines (approved in Canada); however, the effectiveness at preventing serious outcomes of COVID-19 was excellent. Of the 5,258 people in the trials who received the vaccine, 64 got COVID-19 but none of them needed hospitalization or died from COVID-19. The vaccine is felt to be effective against the UK variant of the SARS-CoV2 virus, but not the South Africa variant. Given the lower overall efficacy, this vaccine would not be the preferable one for people who are taking immunosuppressive medications, in whom we expect that vaccination may be less effective due to their medications hampering the immune response to the vaccine.

The Johnson & Johnson vaccine is the first one-shot vaccine and can be stored at fridge temperature. In a large trial of 43,000 people across many countries, the vaccine was found to be 66% effective overall at preventing infections, and 85% effective at preventing severe infections. The effectiveness of the vaccine in a given country depends in part on the amount of variants in that country. The effectiveness of the vaccine, in the US, where less variants were present at the time of testing, was 72%. Protection starts 2 weeks after receiving the vaccine and full immunity is reached after 4 weeks.

Some of the vaccines require two doses. The Pfizer-BioNTech doses are administered three weeks apart, the Moderna doses, four weeks apart and the Oxford/Astra-Zeneca, 8-12 weeks apart. Full immunity is reached one week after the second dose, however they offer good protection 1-2 weeks after the first dose. This has led to the recommendation of increasing the timing between the two doses to allow more people to receive the first dose, when vaccine supply is limited. People may be less protected in between the two doses, than if they had received both doses, and we don’t know what the level of protection is after one dose for people on immunosuppressants, but this should not affect the long-term efficacy of the vaccine, once both doses have been administered.

The Johnson and Johnson Vaccine requires only one dose. Protection starts 2 weeks after receiving the vaccine and full immunity is reached after 4 weeks.

It is not known how long the immunity will last after vaccination, but studies will measure the levels of immune protection over time as people get vaccinated, and booster doses will be recommended accordingly.

All COVID-19 vaccines are a little less effective against the delta variant (for example, the Pfizer vaccine is 6 per cent less effective). However, the vaccines are still effective and vaccination is worthwhile. It is important for people to know that two doses of the vaccine are necessary for good protection against the variants. So people should go for their second dose if they have not done so.

The delta variant is currently the variant of greatest concern in Canada and worldwide. It is the main virus type circulating in Canada. A study published in the New England Journal of Medicine that looked specifically at effectiveness of the vaccines against the variants showed that:

Two doses of the Pfizer mRNA vaccine were 94 per cent effective in preventing symptomatic infection from the alpha variant (the original virus) and 88 per cent from the delta variant. Similar protection is expected from the Moderna vaccine, which is also an mRNA vaccine.

The AstraZeneca vaccine was 74.5 per cent effective in preventing symptoms from the alpha variant (the original virus) and 67 per cent from the delta variant.

It is essential that people receive two shots of the vaccines, as protection is low after only one dose:

One dose of the Pfizer’s shot was only 36 per cent effective, and one dose of AstraZeneca’s vaccine was around 30 per cent effective.

Studies are ongoing to determine if booster shots (i.e. a third dose) will be needed and at what time after the second dose, as studies have shown declining antibody titers (a type of blood test that determines the presence and level (titer) of antibodies in the blood) after 6 months, as expected after any vaccine. The clinical significance of this still needs to be determined, including what level of antibody is needed to give people good protection against the disease.

The main side-effects are pain at the injection site and flu-like symptoms. Fatigue, headaches and joint pains have been reported.

Due to recent reports of two cases of severe allergic reactions (anaphylaxis-like) during the vaccination campaign in Britain, the Pfizer-BioNTech vaccine should not be used in people with a history of severe allergic reactions (anaphylaxis).

Safety surveillance systems have identified increased risks of inflammation of the heart muscle (myocarditis) and of the lining around the heart (pericarditis) following vaccination with the Pfizer BioNTech COVID-19 vaccine. However, these instances are very rare and benefit-risk assessments, where modelling analyses are used to predict risks of severe outcomes from COVID-19 and risks of vaccine side-effects, conclude that the benefits outweigh the risks in children. Ongoing safety is being monitored.

The Health Canada approval requires companies to continue monitoring for side-effects as vaccination is rolled out in the community, and to report on safety results from the continuation of the clinical trials for longer periods of time.

The Oxford-AstraZeneca vaccine has been linked to very rare events of blood clots in the brain (cerebral venous sinus thrombosis) in people under the age of 55, especially women, in ongoing surveillance studies of its safety in Europe. The events are extremely rare (one or two per million people vaccinated ). Scientists think this is due to the vaccine stimulating the creation of antibodies that make the platelets stick together, forming a clot.

As a result NACI (The National Advisory Committee on Immunization) is recommending to halt the use of the vaccine in people under the age of 55 until this has been investigated further. This condition has not been observed in people over the age of 55, and although the vaccine had not initially been tested in the older population, more recent studies have shown that it is effective at preventing severe infections (e.g. hospitalizations and deaths from COVID-19) in people over the age of 65. Therefore NACI recommends that this vaccine be used in people over age 55.

Vaccination started across Canada with the Pfizer-BioNTech vaccine the week of December 14. Distribution was initially complicated by the need for superfreezers to keep the Pfizer-BioNTech vaccines at extremely cold temperatures. With the approval of the Moderna vaccine on December 23rd, more widespread vaccination was possible. The timing of vaccination roll-out has been difficult to predict due to limitations and delays in vaccine supply to Canada.

In BC, the Ministry of Health aims to vaccinate 400,000 people (10% of the population) by March 2021, and all people who want the vaccine by September 2021. A vaccination rate of 60-70% is expected by September 2021, which will reduce the rate of transmission in the community enough to provide good protection to people who cannot receive the vaccine (i.e. reach community immunity).

The initial doses of the vaccines will be distributed to long-term care homes for residents and staff, front-line health care workers in direct contact with COVID-19 patients. Next in line will be seniors over the age of 80, people who are under-housed, people living in remote and isolated Indigenous communities, and other health care workers. It is expected that by April, in Phase 3 for BC, people with underlying health conditions making them more vulnerable, which includes people receiving immunosuppressant medications that increase the risk of infection, will be prioritized. Front-line workers including teachers, grocery store workers, firefighters and people working in food processing plants will also be prioritized. As more vaccines become available, vaccines will be distributed according to age categories, in descending order.

We recommend you follow the public health plan for vaccination roll-out in your Province (see below). In BC, immunization clinics will be set-up by health authorities. People will be able to pre-register on-line or by phone before vaccination, just before they become eligible. This will facilitate roll-out. More details about the registration process are expected to be announced in February.

In BC, people who have taken medications that suppress the immune system will be eligible for priority vaccination as part of phase 3 which starts in April, under the medically vulnerable conditions. People are eligible if they have taken the medications at any time since December 15, 2020, except for Rituximab, they are eligible if they took it any time since February 2020.

People will receive the Moderna or Pfizer vaccine.

The list of medications for arthritis or autoimmune rheumatic diseases include:

• All biologic agents, for people with arthritis this includes anti-TNFs (etanercept, adalimumab, infliximab, golimumab, certolizumab), anakinra, abatacept, anti-IL6 (tocilizumab or sarilumab), rituximab, secukinumab, ixekizumab, and ustekinumab
• Targeted agents, oral JAK inhibitors (tofacitnib, baricitnib, upadacitnib)
• DMARDs and other immunosuppressants; azathioprine, methotrexate, cyclophosphamide, cyclosporine, leflunomide, mycophenolate mofetil, tacrolimus, sirolimus
• Steroids received orally or by injection (prednisone, dexamethasone, hydrocortisone, methylprednisolone)

People identified as eligible, based on records of medications dispensed in pharmacies in BC, will receive a letter from the Ministry of Health. Letters will be mailed in phases, starting March 24 and should arrive by April 15. You must bring the letter to your vaccination appointment.

You will be able to book appointments beginning March 29, 2021 by phoning your health authority. The letter will include information on how to book your appointment. The provincial vaccination online registration and booking system is expected to be launched April 6.

If you have not received a letter by April 15, you should contact the provincial call centre or visit the get vaccinated provincial online registration and booking system, to confirm whether you are on the list of clinically vulnerable people. If you think you should be eligible and you are not on the list, you should contact your physician or nurse practitioner to confirm your eligibility. Letters will be mailed to the home address on file with your Personal Health Number (PHN) based on medications dispensed in BC pharmacies.

For a list of all eligible conditions, under the medically vulnerable category, visit  https://www2.gov.bc.ca/gov/content/covid-19/vaccine/cev

Please visit your province/territory’s COVID-19 resource page for information about vaccines:

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Nunavut

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

For information on Canada’s COVID-19 vaccine rollout plan, please visit the Government of Canada’s website here.

The National Advisory Committee on Immunization (NACI) has recommended a third dose of the COVID vaccine for people who are immunocompromised due to their health condition or due to medications that suppress the immune system. For a list of the specific conditions and medications for which a third dose is recommended click here.

In British Columbia, the Public Health Office has followed the recommendations of NACI and all the groups included in NACI’s recommendations, as well as people on dialysis for kidney disease, are eligible for a third dose of the vaccine. This includes people with rheumatic diseases on steroids (i.e. prednisone), immunosuppressant medications (like azathioprine, mycophenolate), most DMARDs (including methotrexate, leflunomide, but not sulfasalazine or hydroxychloroquine) and biologic agents. Click here for a list of clinically extremely vulnerable indications in BC.

Data from vaccine studies suggests that for people taking medications that suppress the immune system, or with diseases that compromise the immune system, such as people with malignancies or organ transplants, two doses of the vaccine may not be sufficient to mount an adequate immune response against the virus causing COVID-19. A third dose will allow them to achieve a better immune response to protect them from symptomatic infection, especially against variants.

A booster is when people have mounted a good immune response to a vaccine, but the response gradually wanes over time and an additional dose of the vaccine is necessary to maintain a good response over time.

NACI is recommending a booster dose, in anticipation of another wave in the fall 2022. The best timing to get your booster dose is unclear. Some provinces are offering boosters now to all adults who received their last dose more than 6 months ago. Others will offer it early in the fall.

In BC, seniors age > 70, indigenous people age > 55, and people taking medications that suppress the immune system, are eligible for another booster dose now. Others will be eligible in the fall.

Dr. Diane Lacaille is the Canadian lead on a worldwide alliance to collect information on rheumatology patients with COVID-19. This study can provide important insights on how the COVID-19 infection impacts our patients, and how arthritis medications may add to the risk of infection.

The UNIFIED Study addresses the impact of COVID-19 on medication use and mental health for people with arthritis. This study seeks to better understand the experiences of individuals with rheumatic diseases and immunosuppressive conditions during the COVID-19 pandemic.

Dr. Catherine Backman and her team’s study to explore the health benefits of everyday activities for people with inflammatory arthritis has been adapted in response to COVID-19. A newly added component will assess the effects of self-isolation and staying at home. By better understanding how arthritis and social isolation affect the daily activities that support the health and well-being of people with and without inflammatory arthritis, this research will help improve arthritis self-management studies, rehabilitation programs and public heath recommendations.

Jenny Leese, Arthritis Research Canada trainee and member of the research team led by Senior Research Scientist, Dr. Linda Li – shares an update about two current rheumatoid arthritis studies: OPAM-IA and OPERAS, and how they have been adapted in response to COVID-19.

Both studies will examine how are COVID-19 and B.C’s pandemic response (e.g. social distance and stay-at-home orders) affecting physical activity and self-care management for people with rheumatoid arthritis. Additionally, the team will explore mental and physical health, diet, finances, and access to essential medications. By better understanding the impacts of COVID-19, our research can help improve self-care strategies and rehabilitation services for arthritis management.

Dr. Linda Li’s research on active self-management of arthritis has been adapted to address the impact of COVID-19. The OPERAS study tracks the physical health and self-management of people with RA and will be monitoring changes in patients’ health and physical activity during and after COVID-19. This new information will help researchers better understand and improve care for people with rheumatoid arthritis.

Learn more about the OPERAS study:
https://www.arthritisresearch.ca/research/active-self-management-of-rheumatoid-arthritis-utilizing-a-fitness-tracker-2/

Dr. Antonio Aviña-Zubieta, Senior Research Scientist at Arthritis Research Canada will be conducting research to look at whether drugs used to treat arthritis (e.g., rheumatoid arthritis, lupus, psoriatic arthritis, and ankylosing spondylitis) increase the risk of contracting COVID-19, and if these drugs increase or decrease the risk of a severe COVID-19.

Funding for this project is provided by Michael Smith Foundation for Health Research.

Learn more about this research:
https://www.arthritisresearch.ca/new-research-on-covid-19-and-immunosuppressive-medications-may-provide-answers-for-people-with-rheumatic-diseases/

British Columbians are working hard to minimize the spread of the COVID-19 virus. However, with the pandemic still ongoing, it is important to understand the risk factors for COVID-19, especially in individuals with immunosuppression. Dr. Antonio Aviña-Zubieta, a senior scientist of rheumatology at Arthritis Research Canada, and a group of researchers at the organization are exploring these risk factors and the outcomes of COVID-19 in order to help Canadians live better, longer lives. This video describes the research study and its potential implications on COVID-19 prevention and control.

Learn more about this research:
https://www.arthritisresearch.ca/research/what-is-the-real-risk-of-getting-covid-19-and-how-serious-can-it-be-for-british-columbians-who-are-taking-medications-that-affect-their-immune-system/

• The government and public health officials are encouraging workers to continue working from home if possible. Therefore, if you are able to do your job well from home, you should continue to do so. This is the safest option for everyone.

• If your employer asks you to return to work on site, and it is safe to do so, you are obliged to return.

• However, you have a right to inquire about your workplace’s COVID19 Safety Plan, which is mandated by the Province of BC and WorkSafe BC. Your workplace is required to make this plan available to all workers (posted on site, or on the web). https://www.worksafebc.com/en/about-us/covid-19-updates/covid-19-returning-safe-operation

• You should review the plan and, keeping your workflow in mind, be satisfied that all the required measures recommended by WorkSafe BC have been put in place to mitigate the risk of COVID-19 transmission. If you feel they are not, you have the right to request that the recommended measures be put in place, or that the workflow be changed (if possible). There should be a system in place for you to express your concerns to your employer.

• If you are on medications that suppress your immune system and your job involves direct contact with other people in such a way that the risk of COVID19 transmission cannot be fully mitigated, and you can perform the essential duties of your job from home, you can request a job accommodation to work from home. If you cannot do the essential duties of your job from home, you should discuss with your rheumatologist the extent to which your medications increase your risk and the degree of risk of transmission based on your job duties, and if necessary, explore options for not returning to work (e.g. medical leave, leave of absence).

• Because every work situation differs, the WorkSafe BC COVID19 guidelines outline principles rather than specific measures.

• The principles to keep in mind are that risk is increased: 1) when people work in close physical proximity, and the longer the contact the higher the risk; as well as 2) when people touch the same surfaces, and the shorter the time in-between contacts the higher the risk.

• Has your workplace adequately examined the workflow of your job to identify risk of transmission? Have they involved frontline workers, as well as Health and Safety committees, and supervisors in evaluating risks?

• If your job tasks or work flow process involves working in close proximity to clients, are measures in pace to either increase the distance to > 6 feet, or install a physical barrier (e.g. plexiglass)? If not possible, will you be provided with personal protective equipment?

• If your job tasks or work flow process involves working in close proximity to other colleagues, are measures in place to increase the distance between colleagues ( > 6 feet), to install physical barriers (e.g. separators between desks), or to reduce occupancy at the same time (e.g. rotating tasks, staggering work shifts).

• Has your workplace identified surfaces that are touched by multiple people, or tools, machinery or equipment that are shared while working, and put in place protocols for reducing contamination (e.g. cleaning in between use, providing hand sanitizer)?

• Has your workplace identified places where people gather (e.g. lunch rooms, meeting rooms, elevators) and posted occupancy limits that permit physical distancing?

• Is your workplace providing easy access to hand sanitizer or hand washing stations, especially for use before and after use of common spaces, or commonly touched surfaces (e.g. elevators, kitchen, and photocopiers)? Are they regularly cleaning / disinfecting common areas?

• Does your workplace have strict policies mandating that workers stay home if they have any symptoms of cold, flu or COVID19, and has that policy been communicated to all workers?

• If your work involves a service to the public, are procedures in place to screen for COVID19 symptoms, and signs posted to that effect.

• Work from home if possible. If unable to do all work from home, reschedule some tasks to do some from home and some from the office and choose a time when fewer workers are present.

• Ensures the proper safety measures are in place to mitigate COVID19 risk, as described above.

• Practice physical distancing from other co-workers and clients (more than 6 feet away); and/or limit the amount of time you are in close contact with others.

• Think of where people congregate at work (e.g. lunch rooms, meetings rooms, and photocopier) and avoid common areas or use them when less crowded.

• Think of surfaces touched by others and use hand sanitizer before and after touching them (e.g. door knobs, light switches, elevator buttons, coffee maker, fridge door, handles, phones, equipment, shared tools).

• Consider bringing your own tools, cutlery, and kitchen items.

• Practice frequent handwashing, especially before eating.

• Avoid touching your face, eyes, nose and mouth.

• Avoid using public transit if you can. If you must use transit, request a job accommodation to adjust your work hours so you travel during less crowded times. Avoid touching common surfaces in transit. Use hand sanitizer when you do.

• As people are now working from home for extended periods of time, it is important to pay attention to how you work at home.

• Ensure your workspace at home as a proper ergonomic set up that allows you to work with a good posture, with your body and spine well aligned, and your joints in the resting/neutral position and well supported.

• Make sure your computer, chair, and table set up allow you to have your arms at your side without shrugging your shoulders, your elbows at 90 degrees, and your wrist straight in the neutral position. Your chair should allow your knees and hips to be at the same height and your feet to touch the ground (or use a foot rest).

• Take breaks regularly to avoid prolonged sitting. Use the 20/20/20 rule: every 20 minutes, take a 20 seconds break to stretch and look 20 feet away from your screen.

• Keep good work routines, with regular start time and end of workday. This will help maintain good work-life balance.

• If possible, maintain boundaries between work and home life. Working from home can allow work to encroach on personal time, and vice-versa. Childcare during COVID-19 can make this difficult.

• Avoid social isolation. Work is a common source of social interactions. Make sure you remain connected with others, at work and outside of work.

• Take care of your emotional well-being.

• In light of observations that patients taking ibuprofen may have more severe respiratory illness when affected by COVID-19, the WHO had recommended to avoid using ibuprofen to treat symptoms of COVID-19 and to use acetaminophen instead to treat fever or headaches. Since then, the WHO has retracted their statement due to lack of good quality evidence. Health Canada has followed WHO’s advice. Since the issue is not clear, we recommend avoiding the use of non-steroidal anti-inflammatory drugs, also called NSAIDs, if not necessary to control pain. We recommend trying acetaminophen on a regular schedule up to the maximum recommended dose of 3 grams per day to control arthritis pain, and consider using NSAIDs only if there are no other options for pain control.

• Examples of non-steroidal anti-inflammatory medications include ibuprofen (Advil), naproxen (Aleve), diclofenac (Voltaren), indomethacin (Indocid), celecoxib (Celebrex), meloxicam (Mobicox) and Naprosyn. If you are unsure if your medication is an NSAID, contact your pharmacist.

• Please click the links below for recommendations from:

WHO

Health Canada

Currently, there is no specific data on SARS-CoV-2 in patients with rheumatologic disease or immunosuppression. However, the medications listed do suppress the immune system and therefore increase the risk of having a more severe infection if patients come in contact with the virus. Therefore, people on these medications are considered at high risk and should take extra precautions to avoid contact and should seek medical attention if they have any symptoms, following the local directives for testing and accessing health care if symptoms.

• It is not recommended for people to stop their DMARD medications if they have no symptoms of COVID-19 as uncontrolled inflammation due to the arthritis can be harmful for the body’s response to the virus.

• Stopping prednisone abruptly is also dangerous to one’s health, as the body’s own production of cortisol is suppressed.

• It is unclear if people should interrupt therapy during episodes of infection (i.e. if symptomatic or positive for COVID-19), as some of the severe manifestations of COVID-19 are due to the body’s immune response to the virus and, therefore, in theory some medications used to treat auto-immune diseases might be helpful. However, good evidence is still lacking. Patients should talk to their rheumatologist or prescribing doctor prior to discontinuing any of their medications. This is a complex decision based on the specific medication used, assessment of risk factors, other chronic diseases, and of the specific situation.

• There is some suggestion that hydroxychloroquine (Plaquenil), chloroquine (not available in North America), and anti-IL-6 drugs tocilizumab (Actemra) and sarilumab (Kevzara) may benefit those hospitalized with severe COVID-19 infection. This is not proven.

There are currently no prophylactic or therapeutic measures beyond supportive care recommended for this virus. Testing of potential therapies is underway in many countries, and the work to develop a vaccine is also moving forward. However, it is unclear when these will be available.

• Patients who are on DMARDs, prednisone, or biologics should avoid contact with people who are sick with COVID-19 or who are at high risk (e.g. returning from travel) and should limit the number of visitors to their homes.

• The BCCDC and other sources have underscored the importance of hand hygiene, with frequent and effective hand washing (for 20 seconds) with soap and water.

• One can use alcohol-based hand sanitizer if soap and water are not available.

• As important as hand washing is, avoiding to touch one’s face, mouth and eyes (i.e. all mucous membranes) and thoroughly washing hands before, if necessary to do so.

• Social distancing (i.e. staying at least 2 metres away from others), working from home, and avoiding public spaces or public transit, etc., are all recommended measures for reducing the risk of contact with cases in the community. The main mode of transmission is through droplets from an infected person that are spread through coughing and sneezing, as well as through airborne transmission.

• Recommendations about wearing masks have changed since the onset of the pandemic and vary according to region. Although BC is not mandating it, Health Canada and the US Center for Disease Control (CDC) recommend that people wear masks when outside of the house, especially in more crowded environments, such as in public transit or when doing errands. For this purpose, disposable surgical masks, or home made masks that fit snugly from the bridge of the nose to under the chin, suffice. This is primarily to prevent the spread of the virus from people who have no symptoms and may not be aware they are carrying the virus. However, it also protects the person wearing the mask to some extent. If in contact with a person with known COVID19, a special kind of mask, called an N95 mask, is necessary for better protection.

• It is recommended to frequently wash and commonly touched surfaces such as: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks, steering wheels, keys with household cleaners. Washing with household cleaners will remove the virus from surfaces. Using disinfectants after washing, gives the additional protection of killing viruses. Alcohol based products (> 70%), diluted bleach (1:9 dilution with water – never mix bleach with other cleaning products) and other EPA-registered household disinfectants can be used. Coronaviruses are susceptible to soap and detergents. Further information is available on the BCCDC website.

• Washing clothing or linen items with the highest heat appropriate for the item and using the dryer is also an effective means of cleaning cloth items. The virus is susceptible to heat.

• Do not share food, drinks, utensils, and do not eat from buffets, etc.

• Do not shake hands.

• When coughing or sneezing, cough or sneeze into a tissue or the bend of your arm, not your hand. Dispose of any tissues you have used as soon as possible in a lined waste basket and wash your hands afterwards.

• Patients should make sure they have received all appropriate vaccinations, including seasonal influenza, pneumonia, pertussis, and shingles vaccines. These will not prevent COVID-19, but will protect against those diseases, which if you had them (e.g. influenza) would likely make you more susceptible to more severe COVID-19 infection and vice versa.

• In addition, patients should keep ample stocks (e.g. one-month supply) of necessary medications on hand in case they are prevented from refilling prescriptions in a timely manner.

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Arthritis Research Canada/Arthrite-recherche Canada is collaborating with the COVID-19 Global Rheumatology Alliance on an international initiative collecting information on rheumatology patients with COVID-19 from around the world. By gathering data specific to rheumatology patients, the Alliance will gain important insights on how COVID-19 impacts rheumatology patients, and more specifically, how autoimmune diseases and immunosuppressive medications influence the risk of infection and the outcomes of COVID-19.

A separate initiative by the COVID-19 Global Rheumatology Alliance, is collecting information from adults (and parents of children) with rheumatic diseases to gain a better understanding of how the COVID-19 pandemic is impacting people living with rheumatic diseases. If you would like to participate, please visit https://rheum-covid.org/patient-survey/

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This study seeks to better understand the experiences of individuals with rheumatic diseases and immunosuppressive conditions during the COVID-19 pandemic.

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This project will investigate whether an online intervention app can improve a patient’s ability to manage his or her rheumatoid arthritis. The “On-demand Program to EmpoweR Active Self-management” (OPERAS) links to a Fitbit Flex and combines disease activity monitoring and physical activity counselling.

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OPERAS (On-demand Program to EmpoweR Active Self-management) is an easy to use web/mobile app designed for people with RA to track their health. This app helps people to “see” how their symptoms and physical activity levels change over time, together with the treatment they use. During the COVID-19 pandemic, this information can be helpful for people with RA to plan all the things that they juggle in their self-care.

A first Arthritis Wellness Conversation hosted by Chronic Wellness Radio host, Sandra Sova. Members of our Patient Advisory Board share their personal stories and tips on coping with COVID-19. Joined by our Associate Scientific Director, Diane Lacaille to provide her expert insights.

• The Canadian Government

• BC Centre for Disease Control

• COVID-19 Information and Resources

• Work-from-Home Ergonomics

• COVID-19 Precautions: Transit Safety Tips

• OP-ED – Staying happy while staying home: Lessons from occupational therapy