Coronavirus Disease-2019 Infection among Asians with Autoimmune Rheumatic Diseases—Single Centre Experience in Malaysia

Abstract

Objectives
The coronavirus disease-2019 (COVID-19) pandemic had swiped through the globe since March 2020, claiming many lives. Patients
with autoimmune rheumatic diseases (ARD) are potentially at high-risk for severe infection and poor outcome, due to concomitant
co-morbidities, disease activity, and immunosuppressive (IS) therapy. We conducted a retrospective observational study to examine
the severity and outcome of COVID-19 infection among the Asian population.
Materials and Methods
The cases were identified through our local healthcare network and patients’ own narration, from March 2020 until April 2022.
The data were analyzed with both parametric and non-parametric tests using StatPlus, which included Kruskal-Wallis ANOVA and
logistic regression.
Results
A total 71 cases of COVID-19 infection were recorded, with 9 recurrent infections. All patients were South East Asians and the
majority (95.8%) were female. Their median age was 39-years-old. The most common diagnosis was systemic lupus erythematosus
(SLE) (56.5%), followed by rheumatoid arthritis (RA) (27.4%). Most patients (54.9%) attained remission and low disease activity for
ARD prior to infection. As per treatment, 56.3% of patients were prescribed at least one IS. Fifty-nine point two percent (59.2%)
had used steroids, with a mean dose of 6.8±10.5 mg once daily. The COVID-19 infection was asymptomatic and mild in most cases
(81.7%). Twelve point seven percent (12.7%) of patients were in severe and critical stages. The case fatality rate was 4.2%. Prior to
infection, only 57.7% of patients had a complete vaccination (≥2 doses). Seventy-seven point five percent (77.5%) had at least 1
risk factor portending severe infection. Univariate logistic regression (LR) analyses showed severe COVID-19 infection could be
predicted by number of vaccines received, ARD activity and COVID-19 variant type. The use of IS could be associated with better
infection outcomes (full recovery without sequelae) and reduced fatality. The type of IS used might affect the infection outcomes too.
In patients with complete vaccination, active ARD could predict severe infection. Better infection outcomes could be associated with
use of IS. In contrary, risk of fatality could be higher in patients with active ARD and use of high-dose steroids. Further multivariate
LR analyses however, did not reveal any predictive factors associated with severe infection, poor infection outcomes and case fatality.
Conclusion
Our study showed that ARD patients are potentially at risk of severe COVID-19 infection and poor outcomes especially in active
ARD state. IS use may be associated with better infection outcomes, perhaps through immunomodulatory effects. In patients with
complete vaccination, active ARD and high-dose steroids could be the significant confounding factors. The limitations of this study
are the small sample size, and potential bias and error.