Survey on the continued impact of COVID‐19 on immunocompromised patients in rheumatology
Year: 2023
Type: article
Study design: Observational Study
Abstract: The COVID-19 pandemic rapidly transitioned from strict to relaxed policies that resembled pre-COVID-19 conditions. This shift may be harmful to the physical and mental health of immunocompromised patients as they navigate returning to in-person work and social activities. Patients with autoimmune and inflammatory rheumatic diseases are immunocompromised, most commonly due to immunosuppressive medications, but also due to their disease and end organ damage. Immunocompromised patients have significantly lower seroconversion rates after COVID-19 vaccination, putting them at an increased risk of COVID-19 infection (Lee et al., 2022; Tang et al., 2021). Patients with rheumatic disease also have lower vaccine responses, particularly if taking immunosuppressive medications (Furer et al., 2021). Overall, patients with rheumatic disease have higher rates of infection and increased mortality from COVID-19 compared to the general population (Conway et al., 2022; D'Silva & Wallace, 2021). Patients with rheumatic disease may have significant concerns about their ongoing risk (Yong, 2022) since the rollback of policies and mandates that had previously provided protection against COVID-19 transmission. Furthermore, they may be experiencing more difficulty engaging in various activities of daily living. Some patients may have self-modified their immunosuppressive treatment, which may predispose them to an increased risk of disease flare. The purpose of this study was to describe the impact of relaxed COVID-19 policies on the mental health and social behaviours of adult patients in our rheumatology clinic. We also explored the association between anxiety and depression and social, travel, and work activities. This was a survey conducted at the University of Vermont Medical Center (UVMMC) Rheumatology clinic. UVMMC is a 620-bed academic medical centre located in Burlington, Vermont, USA, which serves approximately 1 million people in Vermont and northern New York. The Rheumatology clinic includes 8 physicians, 2 fellowship trainees, and 1 nurse practitioner with approximately 13,000 patient visits annually. Eligible patients were adults aged 18 years and older who had an immunocompromising condition defined as such by the treating clinician at the time of a clinic visit (e.g. ankylosing spondylitis, inflammatory arthritis, systemic lupus erythematosus, psoriatic arthritis, rheumatoid arthritis, vasculitis), who were on immunosuppressive medications. Patients completed the survey alone in a clinic examination room, with an estimated time of completion of less than 5 min. The paper survey was distributed by a convenience sample to patients at the conclusion of a follow-up visit between June and July 2023. Notably, this was a period of time when statewide hospitalizations for COVID-19 in Vermont were low, reported as below 10 new COVID-19 admissions per 100,000 people per day (Vermont Department of Health, 2023). Survey questions focused on behaviours and perceptions of COVID-19, and were adapted from previously published surveys, including the Pandemic (COVID-19) Anxiety Travel Scale (Zenker et al., 2021), COVID-19 Fears Questionnaires for Chronic Medical Conditions (Wu et al., 2020), COVID-19 Anxiety Syndrome Scale (Nikčević & Spada, 2020) and the Socio-Behavioural Impact of COVID-19 questionnaire (Bandhu Kalanidhi et al., 2021). The survey also asked about rheumatology medications and adherence (Chan et al., 2020), whether the patient had ever had COVID-19, had ever received a prescription for nirmatrelvir/ritonavir, how COVID-19 had impacted employment, if applicable, anxiety symptoms using the General Anxiety Disorder-7 (GAD-7) (Ruiz et al., 2011) and depression symptoms using the Patient Health Questionnaire-2 (PHQ-2) (Arroll et al., 2010). GAD-7 was considered positive at a score of 10 or higher and the PHQ-2 was considered positive at a score of 3 or higher. The survey was anonymous and self-reported, and responses were not verified with electronic health record data. This survey was approved as exempt research by the University of Vermont Committees on Human Research (STUDY00002604). Data were entered and managed using REDCap electronic data capture tools hosted at the University of Vermont (Harris et al., 2009). Analyses were descriptive and exploratory, conducted in STATA Version 16.1 (Stata Corporation, College Station, TX), with P < 0.05 required for statistical significance. Separate exploratory analyses were conducted evaluating dichotomous measures of anxiety, depression, history of COVID-19, and current employment with the remaining survey responses using Wilcoxon rank sum tests or Fisher's exact tests. There were no a priori hypotheses, no corrections for multiple comparisons, and no formal sample size calculations. The goal was to collect between 100 and 150 surveys based on feasibility. A total of 101 patients completed the survey. The patients were 61.1 years of age on average (standard deviation of 15.7 years). Forty-nine patients reported being employed at the time of the survey. The most frequently reported conditions were rheumatoid arthritis (43%), psoriatic arthritis (23%), inflammatory arthritis (23%), and systemic lupus erythematosus (13%). The most commonly reported medications included methotrexate (43%), prednisone (23%), and tumour necrosis factor alpha inhibitors (21%). Six percent of patients screened positive for depression on the PHQ-2 and 4% scored positive for anxiety on the GAD-7. Eleven percent of patients reported sometimes, often, or always taking less immunosuppressive medication than instructed and 4% reported sometimes, often, or always altering the dose of their rheumatology medications. Seventy-five patients reported having had COVID-19% and 30% reported receiving a prescription for nirmatrelvir/ritonavir. A quarter of patients agreed or strongly agreed they were concerned about travelling and planning their vacation because of COVID-19. A minority of patients reported continuing to practice COVID-19 avoidance behaviours and a minority reported feeling worried or impacted by COVID-19 (Table 1). For the patients who reported being currently employed, patients agreed or strongly agreed COVID-19 impacted their job in the following ways: I have missed out on social interactions with my coworkers (35%), I have missed out on networking and/or career advancement opportunities (20%), I have missed out on career/job opportunities (18%) and I have had difficulty performing my job (11%) (Table 2). The majority of exploratory comparisons were not statistically significant. Scoring positively on the GAD-7 was associated with “I worry I will be infected and experience more severe complications because of my condition” (P = 0.001). Screening positively for depression on the PHQ-2 was associated with “I have missed out on networking and/or career advancement opportunities” (P = 0.009). This study demonstrates that a minority of immunocompromised rheumatology patients remain concerned about their risk of contracting COVID-19 infection. For those who were concerned, there was an adverse impact on their social, work related, and recreational travel activities. There were positive correlations between work related limitations and depression, and concern for infection and anxiety. Our results found that very few immunocompromised patients reported continuing to practice COVID-19 mitigation behaviours, such as masking. This discordance could be due to external factors such as peer pressure, a feeling of confidence that treatments such as nirmatrelvir/ritonavir are available, or that prior infection with COVID-19 did not result in severe morbidity. This finding is in contrast to other recent data. A general population survey of people aged 18–64 years in Italy found 39% of respondents were using masks indoors and 5% were using masks outdoors between the study time frame of June and September 2022 (Rigo et al., 2023). Given that most data regarding mitigation behaviours was collected during a time of high COVID-19 prevalence, further research regarding the current state of mitigation behaviours across populations is needed. The most significant limitation of our study was that the COVID-19 surveys available in the literature were primarily developed during the height of the pandemic and may not represent the best domains for measuring behaviours and perceptions when COVID-19 prevalence is low, as it was during our survey. Also, survey data were self-reported and inclusion criteria were not verified by the electronic health record. However, surveys were only provided to patients who had a rheumatologist-diagnosed immunocompromising condition. Based on our method for obtaining surveys, there is no way to calculate the response rate. This sample represents a single institution, primarily a white population of rheumatology patients. Although a minority of immunocompromised patients reported concerns, clinicians need to recognise and support them. In particular, some patients may require medical documentation for employment accommodations such as working remotely or requesting others wear masks to allow them to continue working in a safe and productive manner, without fear of retribution or loss of career and networking opportunities. Further studies looking at workplace safety for immunocompromised individuals could clarify what accommodations are recommended for those who are at high risk of infection. Bonita Libman is responsible for the conceptualisation of the study idea, is the Principal Investigator and oversees all aspects of the study. Juvena R. Hitt is responsible for data collection and analysis. Amanda G. Kennedy drafted the manuscript. All authors participated in survey design, data interpretation, revision, and final approval of the manuscript. None. None of the co-authors have any conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Source: Musculoskeletal Care
DOI: 10.1002/msc.1845
Institutions: University of Vermont Medical Center, University of Vermont
Language: English
Topic: COVID-19 and Mental Health
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: hybrid
Estimated APC paid: $2,940
OpenAlex ID: W4389037204