key: cord-0865008-oiit0gt5
authors: Liu, Ming; Gao, Ya; Zhang, Yuejun; Shi, Shuzhen; Chen, Yamin; Tian, Jinhui
title: The association between severe or death COVID-19 and autoimmune disease: a systematic review and meta-analysis
date: 2020-06-02
journal: J Infect
DOI: 10.1016/j.jinf.2020.05.065
sha: 0044630ae2776e15502fe61afd0cb4c6afbf14c5
doc_id: 865008
cord_uid: oiit0gt5

nan

coronavirus", "coronavirus disease 2019", "SARS-CoV-2", "severe acute respiratory syndrome coronavirus 2", "autoimmune disease", "clinical characteristic", "clinical feature", "risk factor", and "comorbidities". In addition, we searched the Reference lists of eligible studies and relevant reviews to find potentially eligible studies (See search strategy of PubMed in Appendix Table 1 ). Study inclusion criteria: (1) Patient was diagnosed as COVID-19 by the laboratory;

(2) Provided data of autoimmune disease with severe or non-severe or between death and survivors. Study exclusion criteria: (1) studies did not provide the prevalence of autoimmune disease; (2) studies without comparisons (severe versus non-severe patients, death versus survival); (3) studies sample size is less than 10 patients; (4) abstracts, news, comments, editorials and review articles. According to the published studies [2] , the severity of disease was defined mainly on the basis of the symptoms present at diagnosis (e.g. patients with pulse oxygen saturation (SpO 2 ) less than 90%, or need of intensive care unit (ICU) care, or with acute respiratory distress syndrome).

Study selection and data extraction were been independently conducted by two reviewers. Disagreements were resolved by consensus or by a third investigator. We extracted the following abstracted data: first author, year of publication, country of the corresponding author, publication language, recruitment time frame, age and sex of patients, sample size, number of participants in severe (or death) and non-severe (or survival) disease groups, and outcomes of interest. The primary outcome was the association autoimmune disease and risk of severe disease in patients with COVID-19.

The secondary outcome was the association autoimmune disease and risk of mortality in COVID-19 patients.

Review Manager 5.3 (Nordic Cochrane Centre, Copenhagen, Denmark) was used to estimate pooled odds risk (OR) and its 95% confidence interval (CI) for dichotomous outcomes using the Mantel-Haenszel statistical method with the random-effects model.

We used the I 2 statistic to assess the heterogeneity, value of <25%, 26-50%, and >50% considered as low, moderate, and high degrees of heterogeneity, respectively.

Subgroup analysis was conducted for the secondary outcome between different countries. In addition, we also conducted sensitivity analysis by excluding studies published in Chinese to assess the stability of the results.

A total of 2472 records were obtained through systematic electronic searches and other ways. After screening titles, abstracts, and full texts, 6 studies [1, 3-6] were included for analysis (See flowchart in Appendix Figure 1 ). All studies were published in 2020, incorporated a total of 2091 patients (1192 males, 57.01%). The sample size of patients per study ranged from 109 to 1000. Only one study from USA [7] , five studies from China [1, [3] [4] [5] [6] . One study published in Chinese [4] , and five studies published in English [1, 3, [5] [6] [7] . See detail in Table 1 . The range of quality scores was 5 to 8, with a median of 7 (7.17±1.17) (Appendix Table 2 ). The meta analysis showed that autoimmune disease was associated with a 1. COVID-19 is an acute inflammatory infectious disease. It is now generally accepted that the occurrence of autoimmune diseases is related to autoinflammatory [7] . Over the course of the COVID-19 pandemic, Zachary SW and colleagues proposed three key reasons that COVID-19 may affect patients with autoimmune diseases [8] .

Understanding how COVID-19 is associated with rheumatic diseases is imperative for rheumatology health professionals and people living with rheumatic diseases [8] . Our study showed that autoimmune disease was slightly associated with increased risk of severe and mortality of COVID-19 disease through meta-analysis, but the statistical difference was not significant. In terms of treatment and prognosis, COVID-19 patients combined with autoimmune diseases may not need special attention. Nevertheless, we cannot let our guard down. Because our study was limited by small sample size, and five included studies are from China, the results should be interpreted with caution. In addition, researchers should also pay attentions to the effect of the types of autoimmune diseases and treatment drugs on treatment and prognosis.

In conclusion, we should not relax our focus on the COVID-19 patients with autoimmune diseases. More high-quality studies from different regions are needed to better understand the association between COVID-19 disease and autoimmune diseases. 

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The authors declare that they have no competing interests. 

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The Rheumatology Community responds to the COVID-19 pandemic: the establishment of the COVID-19 global rheumatology alliance