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Frequently asked questions about Coronavirus (COVID-19)

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Am I at risk?

Yes.The British Society for Rheumatology (BSR) has issued a risk scoring guide chart, which you can view here

(If you are not sure about the distinction between these types of medicines you can order, for free, our Medications in RA booklet or visit our medication section.)

It really depends if you are on mono-therapy biologic therapy or on combination therapy. Mono-therapy would be a biologic e.g. adalimumab without also taking methotrexate whereas combination is with another medication e.g. methotrexate. If you are on monotherapy and have no other underlying conditions or on high dose steroids you will NOT be in the ‘shielding’ group. Please take a look at the scoring criteria in the chart above published by the British Society for Rheumatology which will give you an indication as where you are on the ‘risk’ levels. Your rheumatology departments will be contacting all those in the ‘shielding’ category. Please note the BSR has issued this guidance but it is not mandatory and it will be up to your treating physicians who know your circumstances best to make that final decision.

This level of data is not yet available however there is a Global Registry that has just launched and NRAS urges people with RA and JIA to participate. The Global #Rheumatology Alliance needs to understand how coronavirus affects rheumatic, autoimmune and autoinflammatory diseases in Europe. If you are an adult or child with RA or JIA please  join the registry at www.jarproject.org/covid.

There is also lots of other COVID19 research and data gathering happening very rapidly to find out more read the latest COVID-19 updates and COVID-19 research opportunities.

Medication

It is vitally important to keep your RA as well controlled as possible. If you come off your medication(s) you have a very high likelihood of going into RA Flare. Due to the massive impact of this virus on the health service you would more than likely be unable to get to see your GP or rheumatology team for any sort of speedy intervention. You may be advised to pause your medications if you are showing symptoms of COVID-19 but you should seek proper medical advice from speaking to 111 and ideally your rheumatology team.

This is a difficult question to answer because there is such a spectrum of expression of RA. But broadly speaking, RA does increase vulnerability and particularly if it is active. Again why it is so important to keep your RA as under control as possible by adhering to taking your medications AS prescribed. Most RA treatments are immunosuppressant, some more than others depending on dosage. The BSR scoring chart above should help clarify this and help you assess your level of risk.

The European Medicine Agency (EMA) has shared this information on this. The EMA is aware of reports, especially on social media, which raise questions about whether non-steroidal anti-inflammatory medicines (NSAIDs) such as ibuprofen could worsen coronavirus disease (COVID-19).

There is currently no scientific evidence establishing a link between ibuprofen and worsening of COVID‑19. EMA is monitoring the situation closely and will review any new information that becomes available on this issue in the context of the pandemic.

Read more: https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19

Shielding and clinically extremely vulnerable

You will have received a letter, text or other communication from the government or your local NHS if you have been classified as ‘clinically extremely vulnerable’. This list is added to on an ongoing basis, and if you are in doubt, you should ask your healthcare professional

Advice on shielding differs across the UK— please see below for the latest guidance in your area in the England, Northern Ireland, Scotland or Wales.

Your immediate family/those you live with only really need to self-isolate if you have symptoms of COVID19. The person with symptoms should self isolate for 7 days and those in direct contact for 14 days. If you are self-isolating because you are in the high risk or very high-risk category then close family members should be taking extra precautions and practicing enhanced social distancing to keep you safe. If possible sleeping in a separate room, using separate bathroom facilities would be best but not always possible so following all the guidance for family as outlined in the government advice https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/

Vaccines and COVID-19 treatment

Watch our Facebook Live from 21 December on COVID-19 Vaccine and Rheumatoid Arthritis (RA) here.

NRAS do our very best to bring you the most up to date and evidenced-based reliable information and guidance.
Here is what we know so far about COVID-19 vaccination for people with inflammatory arthritis.

There will be further updates over the coming weeks and months as new information becomes available and things are moving so rapidly in this space– please check back here frequently.

People with RA or JIA often have very different symptoms as well as different treatment pathways and potentially living with other conditions. It is therefore impossible for us to give any advice on a case-by-case basis, your own rheumatology team who know you and your full medical history should be consulted if the following frequently asked questions don’t answer your query fully.

People who are most at risk of being seriously ill if they contract coronavirus are being prioritised to get the Pfizer/BioNTech vaccine first as well as their health professionals and carers. The Joint Committee on Vaccination and Immunisation (JCVI) has issued information and guidance on how the NHS will commence the UK wide vaccination programme.  Details of this guidance can be accessed in full HERE.

This priority list is as follows:
1. Residents in a care home for older adults and their carers.
2. All those 80 years of age and over and frontline health and social care workers.
3. All those 75 years of age and over.
4. All those 70 years of age and over and ‘clinically extremely vulnerable’ individuals.
5. All those 65 years of age and over.
6. All those aged 16 to 64 years with health conditions putting them at higher risk of serious disease/mortality.
7. All those 60 years of age and over.
8. All those 55 years of age and over.
9. All those 50 years of age and over.

At this time, the vaccine is being offered in some hospitals to:

  • Some people aged 80 and over who already have a hospital appointment in the next few weeks.
  • People who work in care homes.
  • Health care workers at high risk.

The vaccine will be offered more widely, and at other locations, as soon as possible.

WAIT TO BE CONTACTED

The NHS will let you know when it is your turn to have the vaccine.
It is important not to contact the NHS for a vaccination before then.

Generally, yes.

People with auto-immune conditions who were considered to have well controlled disease for at least 6 weeks before were included in the clinical trials. There was no significant difference in their response to the vaccine. So, at this time there is no reason why someone with stable disease should not be offered the vaccine. However further analysis of data is ongoing. At present, there is no specific evidence from trials of this vaccine in groups of people with RA or JIA. It is therefore not currently known whether the vaccine may trigger a general flare in some cases.

Vaccines can be produced in one of 3 ways.

1) They take a bit of the virus and inject it into the body. There is no chance it can cause the virus as it’s only one small part (usually proteins which go to make up the virus) which the body can then recognise at a later date.

2) They take a virus, attenuate it (weaken it) to make it safe and then inject it into a person. Such as BCG (vaccine against TB). This type is risky for immunosuppressed people as it does not always respond the same way for them.

The third way of developing a vaccine, which is what they have done with the Oxford vaccine is as follows;

3) They take another/different ‘live’ virus, one completely harmless to humans which in the case of the Oxford vaccine is a harmless weakened adenovirus that usually causes the common cold in chimpanzees. This adenovirus has been genetically changed so that it is impossible for it to grow/replicate in humans. The protein of the virus they want to provide immunity against i.e. COVID-19 is then tagged onto this adenovirus.  Which means that the original replication-deficient virus is like a delivery van that takes the protein marker to where it needs to be within the body, to do what it needs to do.

This also makes it safer to give to children, the elderly and anyone with a pre-existing condition such as diabetes. Chimpanzee adenoviral vectors are a very well-studied vaccine type, having been used safely in thousands of subjects.

As the Pfizer/BioNTech vaccine, is not a LIVE vaccine it will be safe to take however it may not have as strong a response. As mentioned earlier, if you have complex disease and/or other co-morbidities it is best to discuss this with your rheumatologist. There is currently no firm evidence available to make a recommendation in this area.

The COVID-19 vaccine requires two doses, three weeks apart and will not be effective until a few weeks after the second dose. This would require a significant pause to treatment as a result and therefore it is unlikely to be recommended due to the risk of flares.

Advice may vary on a case-by-case basis to maximise the chance of effect from the vaccine whilst managing your disease activity. It is important to discuss the timing of your vaccine with your consultant if you are due to have an infusion of rituximab.

The latest guidance for clinicians from the British Society for Rheumatology on this topic can be found here.

In summary:

Existing guidance prior to the pandemic is that patients should be up-to-date with vaccinations before rituximab treatment, as vaccination may not be as effective if given after. BSR advise that:

  • Where clinically possible, COVID-19 vaccines should be given four weeks or more before rituximab
  • Be aware that there may be a sub-optimal response to COVID-19 vaccines, especially for people within six months of the last dose of rituximab, or those who must have maintenance treatment due to their underlying clinical condition
  • Where clinically appropriate, consideration should be given to using alternative therapies to rituximab, because of the potential that after rituximab there may be sub-optimal response to a COVID-19 vaccine. This should be on a case-by-case basis, balancing the need for rituximab and the suitability of alternative therapies for the relevant clinical situation.

The Pfizer/BioNTech vaccine does not contain living organisms (they are not ‘live’), and so is currently considered safe for people with disorders of the immune system.

You can read more about why vaccines are safe and important HERE.

According to the JCVI Green Book there are very few individuals who cannot receive the vaccine.

The guidance for those in doubt is to seek advice from the relevant health care practitioner.

Yes – as to date we don’t know yet how long immunity will last after contracting coronavirus.

There should be at least 14 days between having the flu jab and getting the COVID vaccine. It is still really important to get your flu jab so if you are being offered the flu vaccine now then we would strongly recommend you attend for vaccination as it may be sometime (weeks or months) before you’re invited to get the COVID19 vaccine.

The COVID-19 vaccination will reduce the chance of you getting severe COVID-19 disease and therefore it is generally recommended that people with inflammatory arthritis should have the vaccine. It may take a week or two after the second dose for your body to build up protection. No vaccine is 100% effective – some people may still get COVID-19 after having a vaccination, but this should be less severe.

The NHS will offer a COVID-19 vaccination to all people who are in the ‘clinically extremely vulnerable’ group and those with underlying health conditions putting them at higher risk of serious disease and mortality. Whether you are offered the vaccine may depend on the severity of your condition.

At present we do not have comparative data for the long-term effectiveness of vaccination regimes where two doses which are given just three weeks apart or at longer intervals as the government are currently recommending on the advice of experts including the Joint Committee on Vaccination and Immunisation. What is clear is that a good degree of immunity to SARS-CoV-2 is likely to result soon after the first immunisation and that this should help reduce the spread of the virus from one person to another as well as providing a good level of protection from COVID-19. Experts from the Joint Committee on Vaccination and Immunisation have expressed confidence that 12 weeks is a reasonable interval between the two doses that will help “to achieve good longer-term protection” against the virus.

At the present time, there is no definitive answer, however being on any medications which dampen down the immune system, will not change the safety of the vaccine as they have been shown to be safe. It may alter how well the vaccine works but the response rate is still well above what you need to be protected. What we do know is that the COVID-19 vaccines are low risk and being vaccinated is the best way to protect yourself and others against coronavirus. If you are taking medication such as methotrexate, or biologic drugs (which include biosimilars), your immune system is still able to fight off infections, just not quite as well as other people and so your risk of complications from coronavirus itself could be increased. It is therefore likely that you will be on the priority list for any COVID-19 vaccine. But because your immune system is able to able to respond to infections, you are still able to have vaccines that are ‘live’ vaccines, no matter what medicine you take for your rheumatoid arthritis. There is data available from studies of vaccination for other indications in people living with rheumatoid arthritis who take biologics and concomitant methotrexate which show that such individuals can still make a good immune response to the administered vaccine. However, methotrexate may reduce the response. In the case of vaccination for seasonal influenza, it has been shown that temporary discontinuation of methotrexate for 2 weeks after vaccination improves the protective response to seasonal influenza vaccination without increasing rheumatoid arthritis disease activity. Therefore, your rheumatology team may suggest that you miss one or two doses of methotrexate around the time of your COVID-19 vaccination. The dosage of methotrexate also varies considerably from person to person so we cannot give a blanket response and it is always best to speak with your own rheumatology nurse or consultant who knows your specific treatment regime.

General Information about the COVID19 vaccine

The COVID-19 Pfizer/BioNTech vaccine is given as an injection into your upper arm. It is given as two separate doses, at least 21 days apart.

After you have had the first dose you need to plan to attend your second appointment. You will be given a record card with your next appointment written on it for an appointment in 21 or 28 days.

It is important to have both doses of the vaccine to give you the best protection.

Keep your record card safe and make sure you keep your next appointment to get your second dose.

Additional COVID-19 vaccines are being trialled and their method of administration may vary. We will update this information and guidance as new vaccines are approved for use by the NHS.

At present, there are two vaccines approved for use in the UK  the Pfizer/BioNTech one and the Oxford/Astra Zeneca vaccine. Both have met strict standards of safety, quality and effectiveness set out by the independent Medicines and Healthcare products Regulatory Agency (MHRA).

Another COVID-19 vaccine has been Moderna has been approved by the EMA (European Medicine Agency) for us in Europe.

Any coronavirus vaccine that is approved must go through all the clinical trials and safety checks all other licensed medicines go through. The UK has some of the highest safety standards in the world. The development of the vaccines has been an unprecedented achievement but always at the ‘speed of science’ not compromising safety in any way. Take a look at the National Institute of Health Research animation that explains a bit more about how the vaccines were developed at such speed: https://www.youtube.com/watch?v=VpIsvIWJ5u4

Women who are pregnant or breastfeeding
The vaccines are not currently recommended during pregnancy. If you are pregnant or breastfeeding, you should not have the COVID-19 vaccine. If you think you may be pregnant or are planning a pregnancy within three months of the first dose you should wait until your pregnancy is completed before you are vaccinated. You should have the vaccine as soon as possible afterwards if eligible. You should avoid becoming pregnant until at least two months after the second dose of the vaccine.

At present there is no evidence suggesting that the COVID-19 vaccine is unsafe if you are pregnant or breastfeeding. This is cautionary advice until more evidence is available confirming you can be offered the vaccine.

A person with a confirmed anaphylactic reaction to any components of the vaccine
If you have a known anaphylactic (severe allergic i.e. if you regularly carry an epipen) reaction to any of the components of the vaccine, you will be advised not to have the vaccination. The Pfizer/BioNTech vaccine does not contain any animal products or egg.

We do not yet know whether the COVID-19 vaccine will stop you passing on the virus. So, it is important to follow the guidance in your local area to protect those around you.

Like all medicines, vaccines can cause side-effects. Most of these are mild and short-term, and not everyone gets them.

Very common side-effects include:

  • having a painful, heavy feeling and tenderness in the arm where you had your injection. This tends to be worst around 1-2 days after the vaccine.
  • feeling tired.
  • headache.
  • general aches, or mild flu-like symptoms.

It is not possible to contract COVID-19 infection from having the vaccination.

Although feeling feverish is not uncommon for 2 to 3 days, a high temperature is unusual and may indicate you have COVID-19 or another infection. You can rest and if you would normally be able to safely take painkillers, such as a normal dose of paracetamol (follow the advice in the packaging), then you can do so to help you feel better.

Symptoms following vaccination normally last less than a week. If your symptoms seem to get worse or if you are concerned, call NHS 111. Even if you do have symptoms after the first dose, you will most likely be recommended to have the second dose. Although you may get some protection from the first dose, having the second dose will give you the best protection against the virus. However, this advice may depend on the severity of your side-effects and you should discuss this with your consultant if unsure.

If you do seek advice from a doctor or nurse, make sure you tell them about your vaccination (show them the vaccination card if possible) so that they can assess you properly.

You can report suspected side effects to vaccines and medicines online through the Yellow Card scheme.  For more information on the scheme you can read our article at www.nras.org.uk/give-side-effects-the-yellow-card

It is very rare for anyone to have a serious reaction to the vaccine (anaphylaxis). If this does happen, it usually happens within minutes. Staff giving the vaccine are trained to deal with allergic reactions and treat them immediately.

NIHR has produced a great short video to answer just that question https://www.youtube.com/watch?v=VpIsvIWJ5u4

In short, there are some key reasons

  • Existing expertise and knowledge as well as an unprecedented collaboration
  • Time, resource, funds made readily available
  • Ease of recruiting volunteers to participate in trials
  • Sharing of ongoing data reports with MHRA (regulatory and approval body)

44,000 people from 6 countries participated in the Pfizer/BioNTech clinical trials across 150 trial sites. Half of those people will have been given the vaccine and half a placebo and their progress will be followed up for 2 years. Ongoing monitoring is vital and will be conducted to gather Real World Evidence.

Oxford & Astra Zeneca vaccine and the Moderna vaccine should give further options in the vaccination national roll out once/if approved by MHRA. As soon as further information on these vaccines are available we will share it here.

Further Reading

Guidelines – England, Scotland, Northern Ireland and Wales

England

The Government website has the latest updates here: https://www.gov.uk/coronavirus.

Scotland

You should follow the advice for your area’s protection level. You can check the latest guidance and access more information here: https://www.gov.scot/publications/covid-shielding/

Wales

The Welsh Government website has the latest updates here: https://gov.wales/coronavirus.

Northern Ireland

Brexit

There currently are no problems with supply chain as far as we know but we are in communication with the National Clinical Homecare Association and all pharmaceutical companies who will keep us updated if there any issues in the future. Below is a link for information on how home care services may be impacted.

https://www.clinicalhomecare.org

Employment & benefits

If you are designating in the very, high-risk group requiring shielding but are able to work from home then your employer should be allowing you do to so if that is possible.

However, if your job role is not one that can be done working from home or you are a Key Worker then your employer may consider you for Furlough Leave (see information on the Government Job Retention Scheme). This scheme has been extended by the Chancellor until 31st March 2021 and will review the scheme in January.

Yes – if you are unable to do your job from home and otherwise would be made redundant your employer should consider utilising the Government Job Retention Scheme)

If your employer is not wanting to put you on furlough leave but you stay away from work due to government guidance on self isolating for your own and your families protection you can be paid Statatory Sick Pay and you DO NOT need to provide a GPs fit for work note for your employer to claim SSP.

Up to date advice is available for Employees at https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/covid-19-guidance-for-employees

Up to date advice for employers and businesses available at https://www.gov.uk/government/publications/guidance-to-employers-and-businesses-about-covid-19/guidance-for-employers-and-businesses-on-coronavirus-covid-19

Information available for self-employed people is available at https://www.gov.uk/guidance/coronavirus-covid-19-what-to-do-if-youre-self-employed-and-getting-less-work-or-no-work

This is the government’s key scheme to support employees who cannot work through Coronavirus pandemic.  The Chancellor has extended the scheme until 31st March 2021 and will review the scheme in January.

‘If you and your employer both agree, your employer might be able to keep you on the payroll if they’re unable to operate or have no work for you to do because of coronavirus (COVID-19). This is known as being ‘on furlough’.’ – gov.uk

An employee on furlough leave is paid 80% of their usual wages, up to a monthly cap of £2,500. The Employer can if they are able and choose to do so, pay the 20% to bring pay up to the full 100%. For some lower-paid employees, if the remaining 20% is not covered by the employer, they may also be eligible for Universal Credit.

If you’re furloughed, you are allowed NOT allowed to work for your employer who is claiming this funding however you are allowed to work for and be paid by another company. You are also allowed to volunteer to support local help hubs etc.

The minimum time you can be on furlough leave is three weeks.

Employers can read more about furlough here: https://www.gov.uk/guidance/claim-for-wages-through-the-coronavirus-job-retention-scheme

Statutory Sick Pay SSP can be paid for up to two weeks. From the third week, employees can if necessary be placed on furlough. 

A GP note is not required: ‘If the absence is related to COVID-19 and the employee has followed government guidance to self-isolate, there will be entitlement to SSP from Day 1 although the employee must still have been absent for a minimum of 4 days. 

The changes can apply retrospectively from 13 March 2020. 

Employers cannot claim for the Coronavirus Job Retention Scheme payments and SSP payments for the same employee.

People who need to stay home because of coronavirus can now get an online “isolation” note.

The notes mean people can provide evidence to their boss that they’ve been advised to self-isolate due to the virus and can’t work.

In an effort to reduce pressure on GP surgeries, the notes can be obtained without contacting a doctor or even leaving the house.

Anyone who claims Universal Credit or Employment and Support Allowance because of coronavirus will not be required to provide a fit note or isolation note.

The new isolation notes can be accessed through the NHS 111 online website. You can go straight to the isolation note page here: https://111.nhs.uk/isolation-note.

If your employer dismisses you as a result of you being unable to work due to you being the shielding group or high risk group with an isolation note, then you may have a claim for automatic unfair dismissal.

If an employee is still being asked to go out to work and they believe they’re at risk because they’re in one of the vulnerable groups, it’s important they talk to their employer.

If they cannot follow guidance on social distancing at work or during travel to work, they should tell their employer they need to follow government advice and stay at home.

It could be unlawful discrimination on the grounds of pregnancy, disability or age if an employer either:

  • unreasonably tries to pressure someone to go to work
  • unreasonably disciplines someone for not going to work

This is changing all the time so it is best to get the most up to date information on the gov.uk website. However, as per Government directives issued Monday 25th March – ALL workers should be, where possible, working from home or if the business is a non-essential and employees can’t work from home because of the nature of the business then on furlough leave.

Key workers should be speaking with their line managers if they are concerned that continuing to work would put them or their colleagues or those people they are interacting within danger of contracting COVID19. 

The government has produced guidance to help ensure workplaces are as safe as possible: https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19