Understanding COVID-19 Risk in Patients With Immune-Mediated Inflammatory Diseases: A Population-Based Analysis of SARS-CoV-2 Testing.

OBJECTIVE: To investigate the incidence of and factors associated with SARS-CoV-2 testing and infection in immune-mediated inflammatory disease (IMID) patients versus matched non-IMID comparators from the general population. METHODS: We conducted a population-based, matched cohort study among adult residents from Ontario, Canada, from January 2020 to December 2020. We created cohorts for the following IMIDs: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis, ankylosing spondylitis, systemic autoimmune rheumatic diseases, multiple sclerosis (MS), iritis, inflammatory bowel disease (IBD), polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 patients without IMIDs based on sociodemographic factors. We estimated the incidence of SARS-CoV-2 testing and infection in IMID patients and non-IMID patients. Multivariable logistic regressions assessed odds of SARS-CoV-2 infection. RESULTS: We studied 493,499 patients with IMIDs and 2,466,946 patients without IMIDs. Patients with IMIDs were more likely to have at least 1 SARS-CoV-2 test versus patients without IMIDs (27.4% versus 22.7%), but the proportion testing positive for SARS-CoV-2 was identical (0.9% in both groups). Overall, IMID patients had 20% higher odds of being tested for SARS-CoV-2 (odds ratio 1.20 [95% confidence interval 1.19-1.21]). The odds of SARS-CoV-2 infection varied across IMID groups but was not significantly elevated for most IMID groups compared with non-IMID comparators. The odds of SARS-CoV-2 infection was lower in IBD and MS and marginally higher in RA and iritis. CONCLUSION: Patients across all IMIDs were more likely to be tested for SARS-CoV-2 versus those without IMIDs. The risk of SARS-CoV-2 infection varied across disease subgroups.

Longitudinal immune changes during and after recent flares in lupus

BackgroundPrevious studies suggest substantial immunologic heterogeneity in lupus. However, the majority of these studies were cross-sectional in nature. Here we followed flaring and quiescent patients longitudinally to determine how their immunologic profile changes over time. MethodsForty-seven SLE patients with a recent flare (change in clinical SLEDAI ≥ 2 in the past month that prompted a change in therapy), 25 quiescent SLE patients (clinical SLEDAI = 0 for ≥ 1 year with no increase in immunosuppressive treatment , ≤ 10 mg prednisone, matched for disease duration) and 16 healthy controls (HC) were recruited. The peripheral blood immunologic profile at baseline and follow-up (every 6 months for 1 year, COVID permitting) was examined by multi-parameter flow cytometry. Expression of interferon (IFN)-induced proteins that correlated with gene expression was examined in immune populations of interest using CyTOF.ResultsUsing unsupervised clustering, incorporating all subjects and visits, four distinct immunologic profiles were seen: Cluster 1, with increased levels of activated B cells and age- associated B cells (ABCs);Cluster 2, with Tfh and Tph expansion;Cluster 3, with reduced levels of innate, naïve B, and Tfh cells;and Cluster 4 with expansion of Th1 and innate immune cells relative to other clusters. Although patients with new-onset flares were found in all clusters, Cluster 1 had the highest number of these patients, whereas Cluster 4 has the highest number of patients who were inactive at baseline, as well as HC. Patients moved between clusters over time and/or in response to treatment. A substantial proportion of flaring patients in Cluster 3 transitioned to Cluster 1 on follow-up, suggesting that B cell changes accumulate post-flare. Similar findings were seen for myeloid populations in a smaller subset of patients that transitioned from Cluster 3 to 4. In general, patients in Cluster 1, 2, or 4 at baseline tended to remain in the same cluster subsequently, with a notable exception being patients with early disease (< 6 months duration), where switching between clusters was frequent. Patients in Cluster 1 at follow-up were more likely to remain active or flare than those in Cluster 4. Analysis of IFN-induced protein expression, revealed considerable variability in the levels of these proteins between immune populations in the same patient and between patients, with significantly higher levels in flaring than in quiescent patients in most immune populations. Cluster 1 visits tended to have higher levels of IFN-induced proteins than Cluster 4 visits, particularly within B cell populations and the T helper cell populations that support their activation.ConclusionAccumulation of activated B cells and ABCs can occur during or after flare, is associated with high levels of IFN-induced proteins in these populations, and defines patients who are more likely to have ongoing disease activity or subsequent flares.

COVID-19 Hospitalizations, Intensive Care Unit Stays, Ventilation, and Death Among Patients With Immune-mediated Inflammatory Diseases Compared to Controls.

OBJECTIVE: To investigate coronavirus disease 2019 (COVID-19) hospitalization risk in patients with immune-mediated inflammatory diseases (IMIDs) compared with matched non-IMID comparators from the general population. METHODS: We conducted a population-based, matched cohort study using health administrative data from January to July 2020 in Ontario, Canada. Cohorts for each of the following IMIDs were assembled: rheumatoid arthritis (RA), psoriasis, psoriatic arthritis (PsA), ankylosing spondylitis, systemic autoimmune rheumatic diseases (SARDs), multiple sclerosis (MS), iritis, inflammatory bowel disease, polymyalgia rheumatica, and vasculitis. Each patient was matched with 5 non-IMID comparators based on sociodemographic factors. We compared the cumulative incidence of hospitalizations for COVID-19 and their outcomes between IMID and non-IMID patients. RESULTS: A total of 493,499 patients with IMID (417 hospitalizations) and 2,466,946 non-IMID comparators (1519 hospitalizations) were assessed. The odds of being hospitalized for COVID-19 were significantly higher in patients with IMIDs compared with their matched non-IMID comparators (matched unadjusted odds ratio [OR] 1.37, adjusted OR 1.23). Significantly higher risk of hospitalizations was found in patients with iritis (OR 1.46), MS (OR 1.83), PsA (OR 2.20), RA (OR 1.42), SARDs (OR 1.47), and vasculitis (OR 2.07). COVID-19 hospitalizations were associated with older age, male sex, long-term care residence, multimorbidity, and lower income. The odds of complicated hospitalizations were 21% higher among all IMID vs matched non-IMID patients, but this association was attenuated after adjusting for demographic factors and comorbidities. CONCLUSION: Patients with IMIDs were at higher risk of being hospitalized with COVID-19. This risk was explained in part by their comorbidities.

Exploring the Mental Health Needs of Persons With Autoimmune Diseases During the Coronavirus Disease 2019 Pandemic: A Proposed Framework for Future Research and Clinical Care.

Although the coronavirus disease 2019 (COVID-19) pandemic has been associated with increased psychological distress globally, it poses unique challenges to persons who are potentially more vulnerable to its effects, including patients with autoimmune disease. In this article, we review the published literature and media reports to determine factors that may contribute to mental health challenges in persons with autoimmune disease. We then explore existing mental health interventions that have been developed for use in COVID-19 and in patients with autoimmune disorders in general. We identified several potential contributors to psychological distress in patients with autoimmune disease during the pandemic, as follows: feelings of discrimination related to societal response to COVID-19, fear of infection and uncertainty related to immunosuppressive medication, diminished access to usual care and resources, previous health-related trauma, and the exacerbating effect of social isolation. Drawing from existing literature, we synthesize the identified evidence to develop a proposed framework for researching and managing mental health challenges in autoimmune disease during the pandemic and its aftermath.