Farewell to COVID...

Whilst the 5th wave of the coronavirus epidemic is slowing down, and health control measures are being eased throughout Europe, knowledge related to the Covid infection and vaccination is summarized, with special focus on patients with autoimmune/inflammatory rheumatic diseases.

According to the January proposal of the National Public Health Center (NPHC), non-vaccinated, but infected peoplemay be vaccinated without any waiting period, and before the vaccination it is not necessary to check for acquired immunity. Immunity acquired by infection is not equal to being vaccinated. The entire vaccination protocol should be carried out in all cases.

According to epidemiologists, the 3rd vaccine or booster should be given a minimum of 4, and a maximum of 6 months after the first 2 doses. The choice of the type of the vaccine is the task of the physician responsible for the vaccination. There is no contraindication for any combination of the vaccines. Only half doses of the Moderna vaccine should be given. According to the vaccination protocol, an adverse anaphylaxis reaction after the first vaccination is the only contraindication for further vaccinations. The booster is very important because it increases the immunity to Covid back up to 80-90%.

Experts have stated that the 5th wave of the pandemic peaked in Budapest at the end of January. The omicron variant is responsible for this wave. It is not likely that those who have been infected by omicron will catch the same variant in a couple of weeks.Furthermore, immunity acquired following a previous coronavirus variant does not protect against a future one. That is the reason why it is so vital to get the 3rd and even the 4th vaccine. The decision whether the 4th vaccine should and can be given is the responsibility of the vaccinating physician. The criteria of the 4th vaccination are being over 18 years of age and having had the 3rd vaccine more than 4 months ago. To determine the feasibility of the vaccination is a joint decision of the vaccinating physician and the GP.

The 3rd vaccine is even more strongly recommended for patients with autoimmune/inflammatory rheumatic diseases particularly those under immunosuppressive/immunomodulant therapy for the last 3 months. After the 3rd vaccine, as well, a one-week drug holiday is required concerning the following medicines: biological treatments, JAK inhibitors, metotrexate in a dose of >20mg/wk, azathioprin in a dose of > 3mg/kg/die and GCs in high dose (>20mg PED/die) or in medium dose (>10mg PED/die) for a longer time (>30days). (PED: prednisolone equivalent dose).

Of course, in the case of an active disease, it is not advised to get the 3rd vaccine, either.

General hygienic precautions are especially important for patients with autoimmune/inflammatory rheumatic diseases (keeping distance, washing hands, wearing a mask). Further basic principles are the following:

• according to a joint decision of the physician and patient, the risk of infection is necessary to be minimized in all cases (public transport, enclosed spaces), telemedicine must also be considered.

• GCs should be given in the lowest possible dose, continuous GC therapy should be followed.

• Sudden stopping of GCs is forbidden, independently of a possible exposition or infection.

• Maintaining the full dose of ACE inhibitors from among the internal medical drugs is particularly important.

In a non-Covid state, in the case of a stable disease, the medical treatment including GCs should be continued unchanged. Check-ups can be postponed.

In the case of a non-infected and non-exposed newly diagnosed active disease the same treatment should be given as if it were in Covid-free times.

In a Covid state GC therapy, should also be continued. In the case of Covid exposition, SSZ, HCQ and NSAIDs can be given, other disease modifying drugs (DMARDs) should be suspended until 2 weeks of symptom-free state. IL 6 inhibitor tocilizumab can also be continued, as we know it is the drug that is employed in the case of a cytokine storm, the most serious life-threatening complication of Covid infection. TNFa inhibitors are less harmful than the previously mentioned DMARDs.

In the case of Covid infection SSZ, HCQ should also be stopped, and in the case of respiratory distress, NSAIDs should not be continued either.

Resuming medical therapy after COVID infection is possible, in the case of a mild infection a 7-14 days symptom-free period is needed; in the case of a PCR-positive, but symptom-free state, 10-14 days observation is required.  In the case of a Covid infection the resumption of medical treatment is dependent on the seriousness of the infection.

In Hungary, the number of vaccinated people is approximately 6.5 milllion, of whom 6 million have received the 2nd, and nearly 4 million the 3rd vaccine. The number of active cases decreased below 200k during the last week-end.

The 5th wave of the pandemic is coming to an end. In spite of its incredible spreading rate, omicron could not result in such a serious pandemic as the alpha and the delta variants, owing to the vaccines developed and the number of already infected (in the European region 60% of the population have been infected by omicron). It is the first time we can really believe that herd immunity against coronavirus will be realized. Experts say that a new epidemic can be expected at the end of this year, but - similarly to influenza -   it will remain at endemic levels. However, they warn that SARS CoV 2 coronavirus has surprised us many times before, so we have to remain vigilant.