COVID-19 HAD DISPROPORTIONATE IMPACTS on RA SYMPTOMS and FUNCTION by SEX and AGE: RESULTS from the CANADIAN EARLY ARTHRITIS COHORT (CATCH)

Background: During the COVID-19 pandemic, Canadians with RA faced considerable uncertainty due to greater risk of infection, hospitalization, changing access to RA medications, and very limited access to in-person RA care. Further, to reduce transmission of the virus and COVID-related hospitalizations, stringent mitigation measures were implemented across the country to greatly reduce social contacts including curfews, limits on private gatherings and business closures. Little is known about the impact of the COVID-19 pandemic and associated mitigation efforts in RA. We hypothesized that women and younger adults with RA would report greater impairments in HRQL. Objectives: To compare changes in HRQL prior-to and during the COVID-19 pandemic by sex and age groups in real-world RA patients seen in routine practice settings. Methods: Data were from patients in the Canadian Early Arthritis Cohort (CATCH) who completed a study visit in the year prior to the COVID-19 pandemic (Mar 2019 through Feb 2020) and a repeat assessment during the pandemic period (Mar 2020-Jan 2022). RA disease activity was assessed using the RA Flare Questionnaire, a validated patient-reported measure of current RA disease symptoms (pain, stiffness, fatigue) and function (physical, participation). An RA-FQ score ≥ 20 was used to classify RA symptoms consistent with an RA infammatory fare. HRQL was assessed using PROMIS-29 Adult Profiles. We compared changes in mean Physical (PHS) and Mental Health (MHS) scores, and the proportion of patients with impairments in each domain (i.e., scores ≥ 55 for pain interference, fatigue, anxiety, depression, and sleep and ≤45 for physical function and participation) before and during the COVID-19 pandemic across sex and age groups (<40, 40-64, ≥65 years). Results: The 938 CATCH participants in the analytic sample with data available at both time periods had a mean (SD) age of 60 (13) and RA symptom duration of 5.8 (3.7) years;72% were women, 88% were white, and 64% reported >high school education. Most (80%) were in CDAI REM/LDA at the most recent visit prior to start of pandemic. The proportion of patients with RA-FQ ≥20 were similar at both time periods. While physical and emotional RA symptom impacts remained stable in men prior to and during the COVID-19 pandemic, women reported signifcant increases in anxiety and depression during the pandemic period. Younger RA patients <40 reported increases in depression, and older RA patients (65+) reported increases in anxiety and greater impacts on participation. Conclusion: Our results illustrate that while the proportions of patients with high infammatory disease activity were similar prior to and during the COVID-19 pandemic, we observed disproportionate impacts on HRQL by sex and age with a higher proportion of women, adults <40, and those ≥65 years of age experiencing greater impairments in several HRQL domains.

MORE THAN HALF of RA PATIENTS with A LIFETIME HISTORY of MOOD DISORDERS WERE ANXIOUS and DEPRESSED during the COVID-19 PANDEMIC: RESULTS from the CANADIAN EARLY COHORT (CATCH) STUDY

Background: A growing number of studies indicate the considerable mental health impacts of the prolonged COVID-19 pandemic in the general population as chronic stress is a risk factor for the development of depression and anxiety. Mood disorders are more prevalent in RA and a history of anxiety or depressive disorders increases the risk of recurrence in the future. Objectives: To compare trends in prevalence of anxiety and depressive symptoms, prior to and during the COVID-19 pandemic in RA patients with and without a lifetime history of mood disorders. Methods: Data were from RA patients diagnosed and treated for RA in rheumatology clinics across Canada enrolled in the Canadian Early Arthritis Cohort (CATCH) Study. We estimated monthly trends in prevalence of clinically sig-nifcant levels of anxiety and depression (PROMIS Depression and Anxiety 4a score 55+) from all visits between Mar 2019 and Jan 2022 and compared monthly trends in anxiety and depression in the year prior to (Mar 2019-Feb 2020) and during the pandemic (Mar 2020 to Jan 2022) stratifed by lifetime history of mood disorders. Results: 4,148 visits were completed from Mar 2019 to Jan 2022 in 1,644 RA patients with a mean (SD) age of 60 (14) and disease duration of 6 (4) years. 73% were women, 84% white, 60% had completed some post-secondary education, and 77% were in CDAI REM/LDA at the visit closest to the start of pandemic. 253 (15%) reported a lifetime history of depression and 217 (13%) a lifetime history of anxiety;8% reported prior treatment for either. Patients with a history of mood disorders had higher levels of depression and anxiety prior-to and during the pandemic compared with patients without a history of mood disorders (Table 1). Proportions were highest during COVID waves in all and were substantially higher and more variable in people with a previous history of mood disorders as compared to those without a history (Figure 1). While depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021). During the frst 22 months of the COVID-19 pandemic, the proportion of patients with depression and anxiety increased in all groups. More than half of those with a history of emotional distress had clinically signifcant levels of depression and anxiety;proportions were highest during COVID waves in all and were substantially higher in people with previous history as compared to those without a history (see Figure 1). Whereas depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021). Conclusion: Symptoms of anxiety and depression were common in Canadian adults with RA prior to and after the onset of the COVID-19 pandemic. Whereas others have found that high levels of depression and anxiety occurred early in the pandemic but declined fairly rapidly in the general population1, emotional distress was not attenuated over time in this large cohort of RA patients. Individuals reporting lifetime history of mood disorders were more than twice as likely to report anxiety and depression, with depression peaking early in the pandemic and anxiety growing with each successive wave in the frst year. The results demonstrate the importance of applying a lifetime perspective as previous episodes of anxiety and depression may be an important marker of increased vulnerability and recurrence in RA patients, particularly during the pandemic.

SAFETY and IMMUNOGENICITY of COVID-19 VACCINES in PATIENTS with IMMUNE MEDIATED INFLAMMATORY DISEASE

Background: COVID-19 vaccination strategies have evolved with increasing vaccine availability and emerging vaccine safety data. While data on immuno-genicity and safety of COVID vaccination strategies exists, there is limited data for people with immune mediated infammatory diseases (IMIDs) such as infam-matory arthritis (IA), systemic autoimmune rheumatic disease (SARD), infam-matory bowel disease (IBD) and multiple sclerosis (MS). Objectives: In IMID patients treated with homologous or heterogeneous COVID vaccines, to compare post vaccine IMID disease activity and COVID antibody responses. Methods: Between March 2021 and Dec 2021, patients with IA (n= 70;77% rheumatoid arthritis), SARD (n=82;70% lupus), IBD (n= 92;40% crohn's), and MS (n= 71;77% RRMS) self-reported COVID illness and exposure risks, and disease activity prior to and 1 month post both COVID-19 vaccinations (V1 and V2). Disease activity was assessed by the Systemic Lupus Activity Questionnaire (SLAQ) for SARDs, the RAPID-3 and RA fate index for IA, the IBD Symptoms Inventory-short form (IBDSI) and IBD fare index for IBD and the 25 meter walk and 9 hole peg test and Expanded Disability Status Scale (EDSS) for MS. Patient reported fare state was assessed using the relevant questions these indices (SLAQ 'Have you had a fare?';RA Flare index 'Are you in a fare?';IBD fare 'My IBD is sometimes to continously active'). Disease activity and serum anti-spike, anti-receptor binding domain (RBD) and anti-nucleocapsid (NC) IgG antibody titers at 30 days post V2 were compared across vaccine courses and to age-sex matched vaccinated blood donor controls (CNTS). Results: Patients were predominantly female (79.7%), with a mean (standard deviation-sd) age of 56 (15) years;8% had suspected or diagnosed COVID-19 illness;1.2% positive anti-NC (Table 1). For all IMIDS, the majority received mRNA vaccines-BNT162b2 (BNT) or mRNA1273 (V1 74%;V2 97%;) the rest received ChAdOx1 viral vector vaccines;71% received homologogous vaccines (ChAdOx1-ChAdOx n=6;BNT-BNT n=174;mRNA1271-mRNA1273 n=21;ChAdOx1-BNT n=36;ChAdOx1-mRNA1273 n=30;BNT-mRNA1273 n=15;mRNA1273-BNT n=3;other n=4). For most IMIDs, disease activity was similar before and after each vaccination. Post V2 disease activity did not differ between homologous versus heterologous vaccines nor by vaccine type (RAPID3;SLAQ, 25 meter walk and 9 hole peg test and EDSS overall and subscales, IBDSI overall and subscales all p=NS). In 254 IMIDs, most seroconverted (anti-spike 86%;anti-RBD 96%). Seroconversion rates for CNTS were 98.1% for anti-Spike and 3.5% for anti-NC. Antibody titers were higher following homologous mRNA (BNT or mRNA12723) than homologous vector vaccine (Figure 1). For IMIDs primed with ChAdOx vector vaccine, boosting with BNT or mRNA1273 generated similarly increased anti-Spike and anti-RBD titers. Conclusion: Heterologous COVID vaccination improves seroconversion rates following a viral vector vaccine and does not lead to disease fare in most IMID patients. While data is needed to assess vaccine effectiveness, duration of immu-nogenicity and effects of subsequent vaccination, this work supports mixing COVID vaccines for IMID patients.

PSYCHOSOCIAL IMPACTS of the COVID-19 PANDEMIC on ETHIOPIAN and CANADIAN RHEUMATOLOGY PATIENTS

Background: The Coronavirus-2019 (COVID-19) pandemic increased psychosocial distress in the general population and in patients with rheumatic disease. Limited data exists on the impact of COVID-19 in rheumatology patients living in Africa. Objectives: To describe COVID-19 related illness and psychosocial impact in Ethiopian (ET) rheumatology patients attending the only public rheumatology clinic in Ethiopia (Tikur Anbessa Specialized Hospital (TAH) in Addis Ababa). To compare fndings in ET with fndings in Canadian (CA) rheumatology patients. Methods: Between May 1 and Oct 31 2021, 130 patients attending the TAH rheumatology clinic answered questions related to COVID-19 infection, symptoms and testing, and psychosocial impacts of the COVID-19 pandemic. We assessed depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7;GAD7), COVID-19 stress factors and coping measures, Resilience (Brief Resilience Scale-BRS) and medication compliance (Morisky medication adherence scale-4 item;MAS4). Rheumatic disease severity was assessed with the Routine Assessment of Patient Index Data-3 (RAPID-3). Questionnaires were translated to Amharic. Descriptive statistics are reported [mean (standard deviation), median (25%, 75%) number and percent.)] and compared to data of 97 CA patients with rheumatoid arthritis (RA) and lupus patients from Quebec1. Results: ET patients were mainly female (71%) with a mean (SD) age of 47 (16), and resided in the capital city (Addis Ababa) (72%). Half had RA or lupus. A quarter of patients had moderate to severe rheumatic disease severity desite good medication adherence [MAS4 score of 3(2,4)]. Most (89%) reported no COVID-19 symptoms since the beginning of the pandemic, were not tested for COVID-19 and reported few risk factors for COVID-19 exposure. Eight (6%) ETs were diagnosed with COVID-19;2 required hospitalization. Diagnosed patients reported a median of 2 COVID-19 symptoms (range 0-8;mainly cough, fever and malaise). Within the entire cohort, depression (PHQ9= 10 or above) and anxiety (GAD7=10 or above) were more frequent in ETs than CAs (depression 30% vs 3%;anxiety 16% vs 1%) yet nearly half (47%) of ETs had normal or high resilience levels. The most common COVID-19 stressors were risk of contracting COVID illness personally [ETs vs CAs risk ratio(95% confdence limits-CL);0.67 (0.5, 0.99)] or of loved one [0.56 (0.36, 0.86)]. More ETs reported COVID-19 related stress related to difficulty obtaining food, medicine or other essentials [1.74, (1.00-3.0)], and getting needed supports [1.97 (1.03, 3.77)] (Table 1). CAs and ETs used similar levels of problem solving [median (25%,75%) CA 3.3 (2.8, 3.3), ET 3.5 (3.0, 3.7)] and emotion-focus [CA 2.5 (2.2, 3.1);ET 3.3 (2.8, 3.7)] coping strategies. Conclusion: During the COVID-19 pandemic, depression was more common in ETs compared to CAs with rheumatic disease. COVID-19-related stressors due to insecurity in obtaining the basic essentials and support were more pronounced in ETs. Differences between ETs and CA in these stressors may refect local public health and economic supports. There were no differences in coping strategies.