Dear Patient

Our practice is open with special adjustments during the COVID-19 pandemic. Only patients with appointments who have been screened before the appointment will be seen for face-to-face consultations. An open-door walk-in service is not currently appropriate. I am concerned about your well-being in these very testing times. Please take exceptional care of yourself and take every precaution to safeguard the health of others. Please contact us if you are uncertain of how to protect yourself and other patients.

Unfortunately, many of our patients are more vulnerable than healthy people, due to immunosuppression and other factors including high age, diabetes, hypertension, asthma and other diseases. I have consulted with local infection doctors (Microbiologists) and also took guidance from guidelines of the EULAR (European Rheumatology Society) and British Rheumatology Society (BSR), in order to advise patients how to best protect themselves.

Patients need to limit/avoid travel if they are immunosuppressed and vulnerable. Please stay at home or work from home if you are at high risk.
In the rest of this document, I will provide advice on how you can assess and manage your risk.

In the unfortunate event that you suspect that you suffer from the COVID-19 disease contact and make use of service centres for COVID-19 disease that can best help you with diagnostic testing and treatment. The treating doctor may want to discuss your rheumatology treatment with me and is welcome to do so.

Therefore please do not come to our surgery...

• If you are diagnosed with COVID–19 disease.
• If you suspect that you have been in contact with the virus causing COVID-19 disease.
• If you show symptoms that may indicate COVID-19 disease such as a new onset of fever, cough, tiredness, shortness of breath, runny nose or sore throat or loss of smell and taste.  Some people can also present with diarrhoea and vomiting. Kindly then you need to be tested at the nearest Corona Virus testing centre, or your GP, as is available and appropriate to you.
• If you are in isolation because you are infected by the virus and have not yet been cleared of risk of infecting others.
• If you are in quarantine because of the exposure of yourself or a family member that is infected or exposed by the virus.

This is because our practice is geared for rheumatology and immunosuppressed patients and not for infectious diseases. As you can understand infected patients poses risk to immunosuppressed patients.

How do we provide a service to our patients?
For new patients face to face consultations are booked and appropriate screening will be done before the visit. We may need to limit the number of people in ours rooms and might ask you to wait in the car if we exceed the allocated people in the rooms. 

Measures to prevent exposure include:
General measures are important for everybody including hand washing, social distancing, and avoidance of gatherings of people and avoiding all unnecessary human contact. Kindly remember to sanitize objects entering your house.
Fortunately, the fatty skin of the virus is vulnerable to 20 (or more) seconds of soap washing (and drying afterwards), and alcohol-containing sanitizers of more or less 60%. The alcohol solution must not be too high – it needs water to dissolve the virus. Diluted hypochlorite (Eg Jic/bleach) solution in water is also effective.

To vaccinate or not to vaccinate – that is the question...

Important points to consider:

• We have 2 vaccines approved by SAPRA Johnson and Pfizer in South Africa for emergency use.
  The Pfizer vaccine now has full approval by the FDA in America. “Today, the U.S. Food and Drug Administration approved the first COVID-19 vaccine. The vaccine has been known as the Pfizer-BioNTech COVID-19 Vaccine, and will now be marketed as Comirnaty (koe-mir’-na-tee), for the prevention of COVID-19 disease in individuals 16 years of age and older. The vaccine also continues to be available under emergency use authorization (EUA), including for individuals 12 through 15 years of age and for the administration of a third dose in certain immunocompromised individuals.” 23 Aug 2021. From https://www.fda.gov/
  
• Patients with a rheumatologic disease are more vulnerable for severe disease than others and it is not practically possible to avoid the virus forever. We also do not yet have any specific treatment for COVID19, the only real defence is vaccines. Current popular “remedies” do not have scientific data to prove efficacy and safety.
• Vaccines have been extensively researched, and there is an abundance of post-market surveillance data. Over 4 billion dosages have been given worldwide. Only properly conducted clinical trials provide robust data that can be used to make treatment decisions. Double-blind randomized clinical studies provide rational decisions for evidence-based medicine.
• The vaccines are safe and effective and serious side effects are rare, of short duration and not serious
• Mild side effects after the vaccine are actually reassuring that the vaccine is eliciting an immune response to defend you against the COVID infection.
• Vaccines are very cost-effective

Only a collective effort will ensure a safe and COVID unrestricted future. This is certainly a great objective to achieve.

NB: Before going for the vaccine please discuss the timing of the vaccination and your regular rheumatologic medication with your Rheumatologist.  You may need to temporarily interrupt taking some of your chronic medicine or treatments. 

Immunosuppressive therapy may lessen the efficacy of vaccines and boosters may be important

Let us all expedite our efforts for a healthy future.

Please read the British Society of Rheumatology guidelines that follows. 

Sincerely
Dr FN van Zyl
012 652 9531 / 082 450 2857

COVID-19 Guidelines for Rheumatology patients
(compiled by Dr FN van Zyl, based on the British Society of Rheumatology)
 
The British Society of Rheumatology (BSR) provides the following guidance calculating risk and provide guidelines to take special care (the following information is quoted/extracted from their website: https://www.rheumatology.org.uk/ Accessed 29 March 2020)
 
Risk stratification of patients with autoimmune rheumatic diseases

• Score of 3 or more: patients to shield
• Score of 2: patients to self-isolate or maintain social distance at their discretion
• Score of 1 or less: patients to maintain social distance

Risk factors listed:
Regarding Steroid Use

• Corticosteroid dose of ≥20mg (0.5mg/kg) prednisolone (or equivalent) per day for more than four weeks: Score 3
• Corticosteroid dose of ≥5 mg prednisolone but <20mg (or equivalent) per day for more than four weeks: Score 2

Regarding immunosuppressive use

• Cyclophosphamide at any dose orally or IV within last six months: Score 3
• One immunosuppressive medication*, biologic/monoclonal ** or  biologic small molecule immunosuppressant***: Score 1 (So, if you are using a biological treatment, without Methotrexate or Leflunomide – Arava/Rheumalef, your score is 1)
• Two or more immunosuppressive medication*, biologic/monoclonal** or small molecule immuno suppressant***: Score 2  (So if you use a biological in combination with Methotrexate or Leflunomide – Arava/Rheumalef, your score = 2)

Any one or more of these other chronic diseases as risk factors - added risk: age>70, Diabetes Mellitus, pre-existing lung disease, renal impairment, history of ischaemic heart disease or hypertension: Score 1

• if you use one immunosuppressive medication and have another chronic disease such as diabetes you score is 2 (added risk)
• If you use two or more immunosuppressive medications and have another chronic disease, then your score is 3 (added risk)

Hydroxychloroquine, Sulfasalazine alone or in combination: Score = 0 (This mean that people on Hydroxychloroquine and Sulfasalazine alone or in combination does not have additional risk and can proceed to maintain social distance.)

* Immunosuppressive medications include Azathioprine, Leflunomide, methotrexate, Mycophenolate (mycophenolate mofetil or mycophenolic acid), ciclosporin, cyclophosphamide, tacrolimus, sirolimus.
Immunosuppressive medications do NOT include Hydroxychloroquine or Sulphasalazine either alone or in combination.
 
** Biologic / monoclonal includes: Rituximab within last 12 months; all anti-TNF drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilar variants of all of these); Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab; Sarilumumab
 
*** Biologic small molecules include: all JAK inhibitors – baracitinib, tofacitinib etc” – we do not have them in RSA. (If you are on a medical trial you may be on other biologics like JAC inhibitors – contact the trial doctors for info please)

Shielding:

• The British Society of Rheumatology defines shielding as: (https://www.rheumatology.org.uk/ Accessed 29 March 2020) 
• Shielding is a measure to protect extremely vulnerable people by minimising interaction between those who are extremely vulnerable and others.
• Who needs shielding?? Patients with a score of 3.
• This means that those who are extremely vulnerable should not leave their homes, and within their homes should minimise all non-essential contact with other members of their household.
• This is to protect those who are at very high risk of severe illness from coronavirus (COVID-19) from coming into contact with the virus.
• If you think you have a condition which makes you extremely vulnerable you are strongly advised to shield yourself, to reduce the chance of getting coronavirus (COVID-19) and follow the face-to-face distancing measures below.

The measures are:
Strictly avoid contact with someone who is displaying symptoms of coronavirus (COVID-19). These symptoms include high temperature and/or new and continuous cough.

1. Do not leave your house.
2. Do not attend any gatherings. This includes gatherings of friends and families in private spaces, for example, family homes, weddings and religious services.
3. Do not go out for shopping, leisure or travel and, when arranging food or medication deliveries, these should be left at the door to minimise contact.
4. Keep in touch using remote technology such as phone, internet, and social media.
5. Do use telephone or online services to contact your GP or other essential services.

We know that stopping these activities will be difficult. You should try to identify ways of staying in touch with others and participating in your normal activities remotely from your home. However, you must not participate in alternative activities if they involve any contact with other people.”

What should you do if you have someone else living with you?  (More advice from British society of Rheumatology)
While the rest of your household is not required to adopt these protective shielding measures for themselves, we would expect them to do what they can to support you in shielding and to stringently follow guidance on social distancing.

• Minimise as much as possible the time other family members spend in shared spaces such as kitchens, bathrooms and sitting areas, and keep shared spaces well ventilated.
• Aim to keep 2 metres (3 steps) away from people you live with and encourage them to sleep in a different bed where possible. If you can, you should use a separate bathroom from the rest of the household. Make sure you use separate towels from the other people in your house, both for drying themselves after bathing or showering and for hand-hygiene purposes.
•  If you do share a toilet and bathroom with others, it is important that they are cleaned after use every time (for example, wiping surfaces you have come into contact with). Another tip is to consider drawing up a rota for bathing, with you using the facilities first.
•  If you share a kitchen with others, avoid using it while they are present. If you can, you should take your meals back to your room to eat. If you have one, use a dishwasher to clean and dry the family’s used crockery and cutlery. If this is not possible, wash them using your usual washing up liquid and warm water and dry them thoroughly. If you are using your own utensils, remember to use a separate tea towel for drying these.

We understand that it will be difficult for some people to separate themselves from others at home. You should do your very best to follow this guidance and everyone in your household should regularly wash their hands, avoid touching their face, and clean frequently touched surfaces.
If the rest of your household stringently follow advice on social distancing and minimise the risk of spreading the virus within the home by following the advice above, there is no need for them to also shield alongside you.