Global rheumatology in the time of COVID-19.

At the 2019 American College of Rheumatology (ACR) annual meeting, we chaired a session entitled “Frontiers and Opportunities in Global Rheumatology Research”, which was a call to action for the rheumatology community to think globally about the burden of rheumatic and musculoskeletal diseases. The current outbreak of a novel coronavirus has caught the attention of the medical community and the world at large. A local outbreak of a respiratory illness was first reported to WHO on Dec 31, 2019, in Wuhan, China. The causative agent was identified as a novel coronavirus now known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the resulting disease is now known as coronavirus disease 2019 (COVID-19). The virus spread quickly throughout China, and subsequently the world. At the time of the ACR session in November, 2019, no-one could have imagined the global pandemic that is now unfolding.

The rheumatology community has responded rapidly to SARS-CoV-2, a highly contagious virus with a case fatality rate ranging from 0·9% overall to 5·0–10·0% in patients older than 70 years in the Chinese population. There is substantial concern among rheumatologists regarding a potentially increased risk of infection and death among patients who are immunosuppressed, including those with rheumatic disease. Few data on this possible risk exist to date; at the time of this Correspondence being published, there is a registered retrospective study in China for patients with rheumatic disease and a case series from the USA listing rheumatic disease as a pre-admission comorbidity. As studies regarding treatments for and outcomes of COVID-19 emerge, it seems possible that immunomodulation could alter the disease course of COVID-19. Many reports have cited the use of medications commonly found in the rheumatology armamentarium for the management of COVID-19, including hydroxychloroquine, glucocorticoids, intravenous immunoglobulin, anti-interleukin (IL)-1 and anti-IL-6 therapies, and Janus kinase inhibitors. The world is watching with great interest to see if those drugs can save lives during this pandemic. In addition to the rapid progression of respiratory failure, COVID-19 seems to be most fatal when it triggers a cytokine storm. However, there are currently no tools to identify patients at greatest risk of developing this complication, and the mechanisms by which this reaction occurs in the setting of COVID-19 are not fully understood.

In the rheumatology community, an international coalition, the COVID-19 Global Rheumatology Alliance, has come together to launch a global registry of patients with rheumatic and musculoskeletal diseases with COVID-19, for physicians worldwide to report these cases of COVID-19 and support the collection of patient-reported cases. The alliance was developed and publicised through social media, email listservs, and personal and professional networks. Within 48 h of inception, the COVID-19 Global Rheumatology Alliance had engaged rheumatologists across six continents; support from non-profit organisations promoting the health of patients with rheumatic diseases and major rheumatology journals followed soon after, with approximately 100 organisations endorsing the alliance at the time of this Correspondence. The COVID-19 Alliance will obtain data on any patient with rheumatic disease who tests positive for SARS-CoV-2, capturing the range from mild to severe cases, with the goal of informing risk and best practice during the outbreak. With this novel pathogenic threat, there is much that is not yet known, and many ways this virus could impact the rheumatology community (panel ).

Elucidating the host response to viral infection and risk factors for progression to severe or critical disease and mortality, particularly in the context of the aging immune system

Identifying potential genetic susceptibility factors that influence the risk of acquisition of SARS-CoV-2 and mortality from COVID-19

Identifying optimal management strategies for patients on immunosuppressant medications with consideration of SARS-CoV-2

Understanding the short-term and long-term multisystem effects of COVID-19

Measuring the outcomes of patients with specific rheumatological conditions who are infected with SARS-CoV-2

Addressing anticipated drug shortages for hydroxychloroquine, tocilizumab, anakinra, and other medications commonly in use in rheumatology

Working through unprecedented logistical and ethical challenges (eg, rapidly setting up global registries and en masse transitions to telehealth)

COVID-19=coronavirus disease 2019. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.

The global coordinated and rapid response to this devastating outbreak shows the tenets of global health: that humans are all connected, and that the health of a person in one part of the world is relevant to the health of humans everywhere. Rheumatology professionals care for patients with diseases that have a high risk of morbidity and mortality and manage rare diseases; a global collaboration enables these professionals to collect enough data to inform clinical decisions. The sharing and dissemination of information about the diagnosis and management of rheumatic diseases worldwide is important at all times, but is especially crucial during these uniquely uncharted times. Rheumatologists are managing a new threat, but the development of tools, such as telehealth platforms and open-source algorithms, can help inform strategies for global education and communication within the rheumatology community beyond the COVID-19 threat. We believe that the global community created in this dire time has the power and commitment to remain unified when the pandemic has passed. Our modern world is more interconnected now than during any era before; let the rheumatology community reflect that, now and after the COVID-19 pandemic.