19 July 2021

The first sign it might not all be okay

COVID-19

Editorial comment

Covid-19 brought greater uncertainty to already somewhat uncertain diseases. In the beginning, we feared high infection and death rates for our rheumatic disease patients. Thankfully, our patients were dealt a hand that was good enough. Although many took shielding precautions, such specific destruction did not eventuate. Data has now suggested that rheumatic disease patients did not suffer poor covid outcomes disproportionately, but it was never clear whether this was a product of physiology or behaviour.

Subsequently, we have had reason to take reassurance or concern for different patients of ours, for both covid-19 outcomes and vaccination response, although we still remain uncertain – and that’s even before we consider variants of concern, of ever increasing concern. The somewhat abstract risk of vaccine immunogenicity for influenza, and how to balance the impact of our medicines on this, has been replaced by a much more confrontational question with covid. While definitive answers may only be known after the fact, it seems that it would be preferable to have an intact immune system in the first place.

Of course, we must be strong in our endorsement of vaccination to our patients. No conversation is futile – sometimes the best choice is made only after the truth arrives multiple times from multiple directions. Even if our patients’ immunogenic response to the vaccine is imperfect, it remains substantially better than that without the vaccine.

It also bears remembering that, according to reports, the index case from the Delta outbreak facing NSW and Victoria right now was an individual who declined one vaccine in order to wait for another. We ignore these salutary lessons at our peril, but public policy is unlikely to wait for the small minority of society that our patients ultimately represent.

Most of us will have observed the public discourse around our country’s covid future with an eye on the fate of our patients, in the context of Delta and beyond. We are an environment where their capacity to resist covid-19 will, in the medium-term due course, be tested country-wide for the first time. The supposition, presuming Covid Zero is economically and culturally unsustainable in the long term, is this: a personal responsibility to opt in to vaccinate, to individually protect, without clear sight as to whether effective herd immunity to protect the vulnerable, can be relied upon.

What this means for our rheumatic disease patients is unclear. We hope and pray that vaccination will be enough, but as we now read, the CDC is clearly suggesting more may be needed. By the time we in Australia need it, we will not need to look hard to find informative precedents.

Other countries, such as the US and UK, will be our test cases; one person’s ‘Freedom Day’ will be another’s high stakes gamble and, like any other bet, the strong hope is to win but losing remains a distinct possibility. Will public health instructions to shield sufficiently protect our patients? What will this mean for their everyday lives? Will they need extra vaccinations in a country where we have already struggled for supply? Our patients balance risk and benefit all the time, but they may be forced to double down their stakes very soon.