Abstract
This paper offers practical and feasible actions to be implemented at patient, healthcare provider and community level to combat COVID-19 while attending, maintaining and strengthening ongoing health management in people with lung diseases https://bit.ly/30yNyhP
Introduction
The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1, 2]. The World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on 11 March, 2020, demanding effective national and global mitigation measures, strong public health response and coordination. To date, the SARS-CoV-2 pandemic has affected over 5 million individuals worldwide with an overall 7.02% (median 3.41%, ranges 0.06% to 31.25%) case fatality ratio (European Center for Disease Prevention and Control dashboard: www.ecdc.europa.eu, as of 22 May, 2020) [3]. This ratio may be overstated since it is based primarily on hospitalised or notified cases.
Lung diseases affect hundreds of millions of people around the world across all ages and levels of socioeconomic status. According to the Global Burden of Diseases (GBD) Study 2017, there were 3.2 million deaths due to COPD and 495000 deaths due to asthma [4]. Furthermore, all-age prevalent cases of chronic respiratory diseases (CRDs) totalled 545 million, of which approximately 50% were due to COPD and the other 50% to asthma [5].
Despite a high burden of CRDs worldwide, CRDs (such as asthma or COPD) have not been consistently identified as a significant comorbidity for COVID-19 [6]. For example, in Wuhan, the prevalence of asthma in COVID-19 patients was merely 0.9% [7], compared to markedly higher prevalence rates of 4.5% to 9% among US COVID-19 patients [8, 9]. In the UK, about 14% of admitted COVID-19 patients had asthma [10], and the ISARIC (International Severe Acute Respiratory and Emerging Infection Consortium) also reported similar prevalence rates (16% with chronic pulmonary disease and 13% with asthma) [11]. In contrast, the US CDC reported CRDs (mainly asthma) as the second most prevalent comorbid condition in hospitalised COVID-19 patients aged 18–29 years [12].
These reported discrepancies may be attributable to the overall under-diagnosis of CRDs, some level of protection provided by atopy [13], or the use of inhaled corticosteroids [14]. It is unclear whether patients with asthma or COPD are at higher risk of developing COVID-19 and if the risk varies depending on other socioeconomic and demographic factors [12, 15]. For example, the risk of COVID-19 infection may be higher in individuals with chronic diseases and who are in low- and middle-income countries (LMICs) with a high prevalence of malaria, pulmonary tuberculosis or HIV co-infection. In many LMICs, accessibility to healthcare in general is suboptimal, and has worsened, not only through COVID-related lockdowns, but also by resource diversion/transfer to treat COVID-19 [16, 17]. Therefore, ensuring healthcare support for vulnerable populations in LMICs, such as timely access to adequate treatments for CRDs and other infectious diseases (tuberculosis, HIV and malaria), is paramount. Others have also suggested that therapies used by patients with CRDs may reduce the risk of infection or of developing symptoms leading to diagnosis [15]. Lower respiratory function, ineffective immunity and treatments that may increase their susceptibility to infection, are possible causes of their higher risk of unfavourable outcomes after a common cold, influenza or other infections [18–22]. Worsening respiratory symptoms may be a result of their underlying disease or a consequence of the superimposed infection [20]. Reports from various countries ranked CRDs among the most frequent comorbidities associated with ICU admissions, need for mechanical ventilation and deaths [15, 20, 23, 24]. A recent systematic review and meta-analysis [25] also reported a four-fold increased odds of development of severe COVID-19 associated with COPD and two-fold odds related to ongoing smoking and the development of severe COVID-19. However, today, there is still uncertainty regarding the actual magnitude of the risks of unfavourable outcomes attributable to COVID-19 in patients with CRDs.
Further research is needed to fully understand the association between underlying CRDs and COVID-19.
Action proposals
The authors of this paper are active members of the Global Alliance against chronic Respiratory Diseases (GARD, www.gard-breathefreely.org/), a WHO alliance consists of national and international organisations, medical and scientific societies, patient organisations, institutions and agencies, all working with the common goal of reducing the global burden of CRDs. GARD members are frontline healthcare providers and researchers from over 80 countries. Our shared vision is a world where all people breathe freely and our activities are divided into four areas: advocacy, partnership, national plans on prevention and control and surveillance. In this document, we summarise our hands-on experience and lessons learned according to three perspectives: 1) patient level: interactions with healthcare providers; 2) healthcare provider level: real-time experience sharing; and 3) community level: environmental impact, air pollution.
Our main focus remains on actions concerning CRDs in the context of the pandemic. Globally, many people with underdiagnosed and undertreated CRDs are at risk of complications from COVID-19. We should therefore ask: What can we do about it? Our reflections and experiences are still evolving with the pandemic, and we hope that they may foster deeper thoughts and considerations into how to move forward in relation to the heavy respiratory burden in times of COVID-19.
Patient level (including interactions with healthcare providers)
Using the National Health Insurance data between January 2000 and August 2003 to study the impacts of the previous severe acute respiratory syndrome (SARS) epidemic on medical service utilisation in Taiwan, Chang et al. [26] reported significant reductions in ambulatory care (23.9%) and inpatient care (35.2%) during the 2002–2004 SARS epidemic. This was largely attributed to the fears of SARS that generated a widespread avoidance of the healthcare system.
Preliminary reports have suggested that this may also be occurring in the COVID-19 pandemic [27]. During the pandemic, people in many cities across the world were ordered to comply with social distancing, to stay at home and work from home. Individuals with a chronic condition, such as asthma and COPD, may opt to stay home, even when their symptoms flare up, rather than to seek healthcare. In general, mid- or long-term isolation or quarantine may be associated with increased levels of depression, stress and anxiety [28], and worsened symptom control and decreased quality of life in people with asthma and COPD [29–32]. Post-SARS, chronic disease patients not affected by SARS presented with worsened disease/symptom control [26].
Today, face-to-face medical consultation is not the only option. With the wide usage of smartphones, patients and healthcare providers are able to use readily available apps with videos (e.g. Facetime or WhatsApp) or audio via phone to conduct e-consultation and to provide routine and unscheduled “virtual visits” [33–35]. This may help patients reduce their anxiety and depression, empower disease self-management, and protect patients and healthcare workers during the pandemic. However, this may increase health inequity as technology use is not evenly distributed across global populations and may be particularly absent in the most at risk populations for age, cultural, education and financial reasons. COVID-19 has affected vulnerable populations disproportionately across China and the world [36]. Solid social and scientific evidence to tackle health inequity in the current COVID-19 pandemic is in urgent need.
This is a unique opportunity to promote and implement health literacy measures for the general population, with a focus on COVID-19 and CRDs. The public is anxious and eager for information. Regretfully, the information on the internet is frequently misleading, often driving one's attention away from the most important measures for prevention, early diagnosis, home isolation and identification of symptoms requiring medical care [37]. All organisations devoted to CRDs must communicate regularly with the public to deliver the key messages supported by science and endorsed by the health authorities. Communications with the use of infographics should be considered so that everyone will be able to absorb and use it. Proposed actions are outlined in table 1.
Proposed actions at the patient level
Healthcare provider level (including real-time experience sharing)
COVID-19 is a novel coronavirus disease. As such, the effectiveness of prevention measures, therapy options, variant phenotypes, morbidity and mortality risks, short- and long-term disease sequelae, mental health consequences and length of immunity remains unknown. Today, we are still questioning whether COVID-19 is just a respiratory disease, or affects other systems too, as suggested by cutaneous manifestations [38, 39], acute gastro-intestinal [40] and neurological symptoms, and cardiovascular complications in recently infected COVID-19 patients [41, 42]. Furthermore, many recovered patients continue to manifest non-respiratory symptoms and neurological morbidities which indicate the virus may have also attacked other organs such as the brain, and not just the lungs [15, 41, 43]. Further research is needed about management at home, including protection of other family members, rehabilitation, diet and the organisation of care.
Early in the epidemic, many patients were ventilated due to acute and severe respiratory failure, and many of them did not survive. The wide use of ventilation revealed a global shortage of ventilators and oxygen supply. With the shortage of medical supplies, healthcare providers started to implement other treatment options and some of them may not have proven useful. The use of applications such as WhatsApp, Skype, Facebook Messenger and WeChat has allowed frontline healthcare providers to communicate with each other and share their patient experiences and consult each other in real time [44]. This collegial support has shortened the distance between people and broken communication barriers. However, information overload is a risk for busy clinicians; therefore, there is a need for a strong direction from public health authorities.
During these difficult times of fighting COVID-19, healthcare professionals must be highly valued; this includes appropriate remuneration, rigorous protection and explicit reassurance that any health consequences of incidental COVID-19 will be compensated. Their confidence is built upon the support and crisis preparedness of their healthcare system. However, the latter varies throughout the world and warrants a higher level of collaboration in order to reduce inequalities. Proposed actions are outlined in table 2.
Proposed actions at the healthcare provider level
Community level (including environmental impact, air pollution)
Air pollution has been termed the “silent killer” by the World Health Organization as it poses a great environmental risk to health and yet often is unnoticed. Furthermore, air pollution abatement has faced multiple challenges and, with population growth and expansion of industries, many questioned whether air pollution could be ameliorated.
In February and March 2020, many cities across the world launched social distancing strategies attempting to curtail the spread of COVID-19. Cities all over the world are now observing record low levels of air pollution. For example, ambient levels of nitrogen dioxide (NO2), one of the main traffic-related pollutants, have declined by 70% to 80% in Barcelona, 40% in London, and 50% in New York [45] and has decreased in many cities across the world [46–48]. This “short-term” reduction in air pollution is a positive aspect of the pandemic; however, if this short-term “improvement” will be associated with any significant health benefits, remains to be seen. Nonetheless, it demonstrated that abating air pollution is achievable. Communities that are educated and engaged more easily adhere to and are involved in epidemic prevention and treatment measures [49], although this also depends on infrastructures, institutions and resources [17].
It is possible that during these unusual times of less air pollution and extreme measures to avoid transmission of respiratory viruses, there is a decline in morbidity and mortality due to respiratory diseases unrelated to COVID-19, particularly those due to acute respiratory infections and/or exacerbations of CRDs. It is fundamental to reinforce surveillance and research to demonstrate how populations could benefit from more rigorous control of air pollution and transmission of respiratory viruses in general. Proposed actions are outlined in table 3.
Proposed actions at the local and community level
Conclusion
Worldwide, COVID-19 has infected over five million people, killed hundreds of thousands and has forever changed our daily life and the way we interact with each other. At the same time, globally 1000 people die from asthma every day and many of these deaths are premature and preventable with proper and timely management (www.globalasthmareport.org/burden/mortality.php). Therefore, it is paramount to minimise the potential “collateral damage” to patients from suboptimal management of CRDs during the pandemic.
To combat the unprecedented global atrocity of COVID-19, we observe that healthcare professionals are united to face this deadly and fast-spreading virus, finding strength, compassion, courage and solidarity among peers who are committed to prevent, manage and rehabilitate patients with this life-threatening ailment, at all levels. Now, more than ever, there is an urgent need to bridge individual and population needs, and this can only be done with engagement and interaction among public health, primary and secondary care.
The COVID-19 pandemic, while devastating, has created a remarkable worldwide opportunity for individuals, organisations and countries to excel in solidarity, collaboration and partnership, sharing resources and experiences which are essential to control the pandemic, reduce the death toll and attenuate the socio-economic and psychological consequences from isolation, unemployment and poverty.
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Acknowledgement
All authors are active leaders of organisations comprising the network of the Global Alliance against chronic Respiratory Diseases (GARD), but the content and opinions expressed in this paper are those of the authors and they do not purport to reflect the opinions, views, positions or standing policies of any organisations, agencies or institutions which the authors are affiliated with.
Footnotes
Conflict of interest: T. To has nothing to disclose.
Conflict of interest: G. Viegi has nothing to disclose.
Conflict of interest: A. Cruz has nothing to disclose.
Conflict of interest: L. Taborda-Barata reports honoraria from AstraZeneca, Novartis, Menarini and Vitoria Laboratories as payment for giving scientific lectures in the context of training sessions in the respiratory field or allergy, for healthcare professionals.
Conflict of interest: M. Asher has nothing to disclose.
Conflict of interest: D. Behera has nothing to disclose.
Conflict of interest: K. Bennoor has nothing to disclose.
Conflict of interest: L-P. Boulet has nothing to disclose.
Conflict of interest: J. Bousquet reports personal fees for advisory board work, consultancy and lectures from Chiesi, Cipla, Hikma, Menarini, Mundipharma, Mylan, Novartis, Purina, Sanofi-Aventis, Takeda, Teva and Uriach, and owns shares in KYomed-Innov, outside the submitted work.
Conflict of interest: P. Camargos has nothing to disclose.
Conflict of interest: C. Conceiçao has nothing to disclose.
Conflict of interest: S. Gonzalez Diaz has nothing to disclose.
Conflict of interest: A. El-Sony has nothing to disclose.
Conflict of interest: M. Erhola has nothing to disclose.
Conflict of interest: M. Gaga reports grants and personal fees from Novartis and Menarini, grants from Galapagos and Elpen, personal fees from BMS, MSD and AZ, outside the submitted work.
Conflict of interest: D. Halpin reports personal fees from AstraZeneca, Chiesi, GlaxoSmithKline, Novartis, Pfizer and Sanofi, personal fees and non-financial support from Boehringer Ingelheim and Novartis, outside the submitted work.
Conflict of interest: L. Harding has nothing to disclose.
Conflict of interest: T. Maglakelidze has nothing to disclose.
Conflict of interest: M.R. Masjedi has nothing to disclose.
Conflict of interest: Y. Mohammad has nothing to disclose.
Conflict of interest: E. Nunes has nothing to disclose.
Conflict of interest: B. Pigearias has nothing to disclose.
Conflict of interest: T. Sooronbaev has nothing to disclose.
Conflict of interest: R. Stelmach reports grants from São Paulo Research Foundation and MSD, grants and personal fees from Novartis, grants, personal fees and non-financial support from AstraZeneca and Chiesi, personal fees and non-financial support from Boehringer Ingelheim, outside the submitted work.
Conflict of interest: I. Tsiligianni reports grants from Elpen and GSK Hellas, personal fees from Novartis, Boehringer Ingelheim, GSK and Menarini, outside the submitted work.
Conflict of interest: L.T. Tuyet Lan has nothing to disclose.
Conflict of interest: A. Valiulis has nothing to disclose.
Conflict of interest: C. Wang has nothing to disclose.
Conflict of interest: S. Williams has nothing to disclose.
Conflict of interest: A. Yorgancioglu has nothing to disclose.
- Received May 10, 2020.
- Accepted June 5, 2020.
- Copyright ©ERS 2020
This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.
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