Burden of Non-Communicable Diseases during COVID-19 Pandemic

With the increased spread of COVID-19 across the globe, the rate of NCDs has been on the rise. The coronavirus has caused huge disruptions to the health services while at the same time leading to rising countries’ NCD burden, since those living with NCDs are at high risk of becoming severely ill with long term complications. The ability of countries to address and respond to NCDs is an iterative process and requires synergy with the health system over long periods of time.

The direct healthcare system factors leading to an increase in prevalence of NCDs could be as follows:

• Decrease in inpatient volume due to cancellation of elective care.
• Government or public transport lockdowns hindering access to the health facilities for patients.
• NCD related clinical staff deployed to provide COVID-19 relief.
• Insufficient staff to provide rehabilitation services.
• Closure of population-level screening programmes.
• Closure of OPD related to disease specific consultation.
• Insufficient staff and safety equipment like PPE kits, masks, etc. available for health care providers to provide services.
• Closure of outpatient NCD services as per government directive.
• Decrease in outpatient volume due to patients not presenting.
• Inpatient services/hospital beds not available.
• Unavailability/Stock out of essential medicines, medical diagnostics or other health products at health facilities.

However, the indirect healthcare system factors could be:

• Medical staff and FLWs burnout.
• Long term care, facility location.
• Dietary shifting to unhealthy food choices.
• Increase in domestic violence, child abuse.

A number of evidence have proven that many people who have experienced COVID-19 are left with chronic, multi-organ symptoms, which is informally known as "long COVID" or "post-acute COVID-19 syndrome." Long COVID will significantly increase demand for NCD care since it is not limited to an older age. Therefore, it is expected from governments to build stronger, robust and fairer health systems to better protect populations suffering from NCDs, prioritising the pandemic recovery and response policies. The unmet burden of NCDs can lead to both health and economic consequences at global, country, household and individual levels, resulting in severe disability, premature deaths, and billions of dollars in economic loss each year.Therefore, there are some statements and practice guidelines given by selected major professional societies regarding NCD Care [System-Wise] during COVID-19 Pandemic;

Resources:

1. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
2. //ncdalliance.org/sites/default/files/resource_files/NCDA%27s%20Long%20COVID%20briefing%20note_2020_21May_Final.pdf
3. Chang, AY, Cullen, MR, Harrington, RA, Barry, M (Stanford University, Stanford, CA, USA). The impact of novel coronavirus COVID-19 on noncommunicable disease patients and health systems: a review (Review). J Intern Med, 2021; 289: 450– 462. //doi.org/10.1111/joim.13184
4. Modesti, P.A., Wang, J., Damasceno, A. et al. Indirect implications of COVID-19 prevention strategies on non-communicable diseases. BMC Med 18, 256 (2020). //doi.org/10.1186/s12916-020-01723-6

COVID-19 has been having adverse effects on pre-existing non-communicable diseases in terms of disease progression and development. Patients with chronic diseases like cancer, CVD, DM, COPD are much more likely to show severe symptoms and fatal outcomes due to the virus. This was basically seen because of chronic inflammation and elevated expression of SARS-CoV 2 receptor present in some organs. Direct damage to major organs due to the same were observed for example, cardiac injury, acute kidney injury, septic shock, multi-organ failure, etc. Adverse reactions between medications for NCDs and progression of the virus have been observed. COVID 19 is leaving patients with negative health effects even after recovering from it. Acute damages from the virus can also convert into chronic conditions like cardiomyopathy and respiratory function decline. COVID 19 is also inducing conditions that are likely to develop into NCDs. Furthermore, COVID 19 and NCDs are linked by some common risk factors mentioned below:

1. Advanced age
2. Male sex
3. Certain ethnicities/races
4. Obesity
5. Smoking
6. Poverty

Preventive measures for COVID like home isolation, lockdowns, etc is contributing to unhealthy lifestyles (smoking, alcohol consumption, poor diet, physical inactivity) which acts as predisposing factors for NCDs. Lastly, COVID 19 has impacted all sorts of policies, budgets, governance, health care systems, resources (food, education, money, etc) which is leading to deviation of all the resources being allocated for NCDs to patients impacted from the virus leaving chronically ill patients with nothing in hand and hence worsening their situation even more.

Resorces: //www.ncbi.nlm.nih.gov/pmc/articles/PMC8056943/

  //www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline .

The COVID-19 pandemic and noncommunicable diseases (NCDs) have resulted in a deadly interplay, with people living with NCDs being at higher risk of severe illness and death from COVID-19.It is estimated that almost a quarter of the global population lives with at least one NCD, which puts them at higher risk from the coronavirus. COVID-19 and NCDs have reinforced one another’s impact, leading to them being identified as a  that disproportionately impacts the poorest communities around the world and exacerbates health inequalities in every country. The emergence of long COVID has important implications for people living with or at risk of NCDs, in addition to the direct impacts of the pandemic on people living with NCDs which include the acute illness and disruptions of essential NCD care.Although long COVID appears to be more common in older people, it can affect people of all ages, including young people without previous health conditions. In rare cases, children have also been reported to be affected. However, health status prior to acute COVID-19, including the presence of co- morbidities and living with obesity, as well as being female, appear to be linked to the development of long COVID. Due to the global prevalence of the COVID-19 pandemic, long COVID may be appreciably more common and appears to affect a broader number of organs, leading to a significant impairment in their functions in some cases.Patients with pre-existing cardiovascular disease (CVD) are amongst those with the highest risk of adverse outcomes from COVID-19. COVID-19 can cause a fulminant myocarditis associated with acute heart failure and Cardio shock as well as asymptomatic myocardial inflammation Chronic respiratory diseases are amongst the greatest potentiators of SARS-CoV-2 infection and mortality Although most patients who survive acute COVID-19 infection make a full clinical recovery, there have also been reports of lasting lung injury, dubbed post-COVID-19
fibrosis Sufferers of haemoglobinopathies such as sickle cell disease and thalassaemia are at heightened risk of negative outcomes from COVID-19SARS-CoV-2 has been noted to be associated with a potent coagulopathic state, manifesting as thromboses in multiple vascular territories including the brain, lung and heart Those living with neurologic disorders shoulder an excess burden of COVID-19’s pathophysiologic and societal impacts Patients with chronic illnesses specifically weakening the respiratory muscles (e.g. amyotrophic lateral sclerosis, myasthenia gravis (MG)) are at high risk for respiratory decompensation from SARS-CoV-2 infectionThose suffering from substance abuse and addiction represent a particularly vulnerable population during the COVID-19 crisis.many patients at highest risk of adverse outcomes, like those with psychotic illnesses such as schizophrenia or bipolar disorder, may be lost to acute care.Social isolation can lead to dangerous self-medicating behaviours such as excessive alcohol, tobacco and illicit drug abuse Patients with autoimmune disorders, inflammatory diseases and organ transplants are particularly susceptible to SARS-CoV-2, as many are on immunosuppressive drugs including corticosteroids and biologics such as TNF⍺ inhibitorsDiabetics have had some of the highest COVID-19-related case fatality and complication rates, possibly due to uncontrolled diabetes mellitus being an immunocompromised state

References

1Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497– 506.
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2 World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020. 2020.
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3Toner E, Waldhorn R. What US Hospitals Should Do Now to Prepare for a COVID-19 Pandemic. Baltimore, MD, USA: Johns Hopkins Center for Health Security 2020.
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The coronavirus disease (COVID-19) has critically impacted global health systems and economies both in the developed and developing worlds, but especially in developing countries, already struggling to address the preexisting burden of diseases with limited resources, the situation has become even more challenging.

The COVID-19 pandemic is the most serious public health challenge today and is responsible for two concurrent global crises: the health crisis and an economic crisis. Only an appropriate policy response will determine the impact of pandemics on human health and economic well-being. It is clear that the pandemic will seriously undermine global efforts to attain sustainable development goals.

Among the major challenges are increased indoor time leading to increased exposure to other behavioral risk factors for noncommunicable diseases (NCDs) such as unhealthy diet, alcohol use, stress, inadequate access to essential medicines. Further travel or transport restrictions leading to inaccessibility to health care centers, early detection and laboratory testing for NCD patients, and increased susceptibility in health care settings for chronic disease patients.

Thus, the strategies are required to address this comorbidity which may include integration and convergence of the existing communicable and NCD programs, strengthening primary health care for universal health coverage, updating guidelines, enhancing surge capacity, and multisectoral participation. It is essential to assess the prevalent gaps, mobilization of resources, evidence-based policymaking, strengthen health systems financing and leadership, and effective partnerships for addressing health disparities and inequities which are further accentuated by the COVID-19 pandemic.

Cardiovascular diseases, cancers, chronic respiratory diseases, diabetes, and chronic kidney disease are among the leading causes of death and disability in India.  
COVID-19 and non-communicable diseases (NCDs) are closely interconnected.  Individuals with preexisting chronic conditions  are more likely to have severe symptoms and fatal outcomes from COVID-19. Preexisting conditions may contribute to adverse outcomes of COVID-19 through mechanisms such as chronic inflammation and elevated expression of SARS-CoV-2 receptor (i.e., angiotensin-converting enzyme-2) in certain organs and  direct damage by SARS-CoV-2 to major organs (e.g., cardiac injury, arrhythmia, septic shock, acute kidney injury, and multi-organ failure ) may worsen preexisting conditions.
COVID-19 infections and major NCDs are linked by common risk factors such as advanced age, male sex, certain ethnicities or races, obesity, smoking, and poverty .
COVID-19 and NCDs are both influenced by major upstream determinants that range from policies and governance, health systems, economic development, social equity, education, and food security, to environmental changes.

COVID-19 and NCDs -

Cardiovascular disease -  COVID-19 can cause a fulminant myocarditis associated with acute heart failure and cardiogenic shock as well as asymptomatic myocardial inflammation .
Pulmonology - Chronic respiratory diseases are amongst the greatest potentiators of SARS-CoV-2 infection and mortality . Cigarette smoking has been an independent risk factor for COVID-19 susceptibility, with higher case fatality rate amongst men than women possibly due to the higher rates of smoking amongst men. Most patients who survive acute COVID-19 infection make a full clinical recovery, there have also been reports of lasting lung injury, dubbed post-COVID-19 fibrosis . This potential syndrome could cause permanent pulmonary degradation in those already living with chronic lung disease whilst creating new patients with interstitial lung disease.

Through the causative agent SARS-CoV-2, COVID-19 spreads quickly in a community and overwhelms the healthcare system if left uncontrolled. COVID-19 differs from major NCDs in that it has a clear cause, rapid transmission, and a lack of effective treatments. However, as the pandemic is prolonged, researchers are gaining a deepened understanding of the multifaceted link between COVID-19 and NCDs . First, pathophysiological pathways and mechanisms in disease development and progression are shared between COVID-19 and NCDs. Although all populations are generally vulnerable to SARS-CoV-2 infection, individuals with preexisting chronic conditions such as cancer, CVD, diabetes, and chronic obstructive pulmonary disease are more likely to have severe symptoms and fatal outcomes from COVID-19, as demonstrated by evidence from multiple populations .Preexisting conditions may contribute to adverse outcomes of COVID-19 through mechanisms such as chronic inflammation and elevated expression of SARS-CoV-2 receptor (i.e., angiotensin-converting enzyme-2) in certain organs . Furthermore, direct damage by SARS-CoV-2 to major organs (e.g., cardiac injury, arrhythmia, septic shock, acute kidney injury, and multi-organ failure may worsen preexisting conditions. In addition, there have been concerns over potential interactions between medications for NCDs such as angiotensin-converting enzyme inhibitors and COVID-19 progression .COVID-19 can also leave patients with sustained negative health effects even after recovery. Some of the acute damage from COVID-19 can progress into long-lasting chronic conditions, such as respiratory function decline and cardiomyopathy . Long-term follow-ups are thus essential in order to observe chronic conditions among COVID-19 survivors.

Second, COVID-19 infections and major NCDs are linked by common risk factors such as advanced age, male sex, certain ethnicities or races, obesity, smoking, and poverty .On the one hand, these conventional risk factors for NCDs impose barriers against effective measures to prevent COVID-19, such as the use of personal protective equipment, social distancing, and personal hygiene ; on the other hand, some of these risk factors, such as advanced age, male sex, and obesity, lead to adverse outcomes in individuals with COVID-19. Containment and mitigation measures for COVID-19, including home containment, social distancing, and travel restrictions, can contribute to unhealthy lifestyles and risk behaviors such as a low-quality diet, smoking, excessive alcohol drinking, and physical inactivity ,which predispose individuals to the risk and development of NCDs .Such impacts can be particularly relevant since COVID-19 is unlikely to disappear and strict preventive measures will not be lifted in the short run.

According to the WHO report on noncommunicable diseases (NCDs) and COVID-19, the new coronavirus can affect people in all age groups, but the risk is high in older age group and people with preexisting NCDs. These NCDs include cardiovascular diseases, chronic respiratory disease (chronic obstructive pulmonary disease [COPD]), diabetes, and cancer. Specifically, many of the older patients who become severely ill have evidence of underlying illness such as cardiovascular disease, liver disease, kidney disease, or malignant tumors.The most common comorbidity observed in COVID-19 patients who were admitted in the critical care units in most countries were hypertension, diabetes, and chronic respiratory problems. Available data show that the percentages of deaths observed in COVID-19 patients at global level with preexisting conditions such as cardiovascular disease (13.2%), diabetes (9.2%), chronic respiratory disease (8%), hypertension (8.4%), and cancer (7.6%) are higher as compared to patients without coexisting conditions (0.9%).

Although the overall fatality rate of COVID-19 is relatively low, older adults and patients with comorbidities are more likely to have severe disease and subsequent mortality. The most commonly reported noncommunicable diseases that have been shown to predict poor prognosis in patients with COVID-19 include diabetes mellitus (DM), hypertension, cerebrovascular disease, coronary artery disease (CAD), and COPD.[

Prevention of NCDs is important since the true scale of at-risk groups is probably underestimated, given that many cases of hypertension and diabetes are undiagnosed.[26] Communities and health systems need to be adaptive to both support and manage the increased risks of people with known NCDs and exercise sensitivity about the vulnerability of the large population with undiagnosed NCDs and those increased risk of NCDs.

The COVID-19 response and continued and strengthened focus on NCD prevention and management are key and interlinked aspects of public health at the present time. The strategies for this should focus on the implementation of the NCD essential services or policies along with the communicable disease programs or policies. Health promotion [21] activities should be streamlined as prevention is the only option for COVID-19 at present for the general public and health-care workers without any effective treatment. Strengthen risk communication on COVID-19 and NCDs, raise the priority given to NCDs during the COVID-19 outbreak situation through better advocacy, and promote the dissemination of communication and information on COVID-19 and NCDs.

Reference:JS Thakur, Ronika Paika, Sukriti Singh, Jai Prakash Narain
International Journal of Noncommunicable Diseases 5 (2), 29, 2020

Due to the continuous increase in Covid cases, most of the other diseases have comparatively been sidetracked. Especially from Non-communicable diseases. But it has been observed that covid patients with the comorbidities of Kidney disorders, diabetes mellitus, stroke, cancer, cardiovascular diseases have to face more repercussions and are considered to be risk group.

The antivirals provided for the treatment of covid are certainly contraindicated with the patients who have comorbidities of renal disorders and liver disorders. Even the administration of steroids leads to tremendous variation in sugar levels because of which the patients already having the comorbidities of the same suffer from uncontrolled sugar levels. Some patients even get the comorbidity of diabetes mellitus due to the same. The fatality rate of such patients having non -communicable disease are also more.

Moreover, the other NCD patients who have not suffered from covid also miss their routine checkups due to the current situation. The screening provisions for the NCDs had also come to a halt because of which the proper population suffering is unknown. Hence the NCDs are acting as a double burdens in the present scenario.

Burden of Non-Communicable diseases during COVID-19:

         • Non- Communicable Diseases (NCD's) include heart disease, stroke, diabetes, cancer and so on..

        • Rise of NCD'S includes Tobacco usage, physical inability, unhealthy food habits. 

COVID-19 & NCD'S:

        • COVID-19 disease Burden & mortality in India is mainly associated with;

             ☆ Greater state level of NCD'S and risk factors especially obesity and diabetes. 

            ☆Financially also many people affected like cancer they didn't get  bed facilities also.

COVID-19 and non-communicable diseases (NCDs) are closely interconnected. Underlying chronic conditions such as cardiovascular disease (CVD) and diabetes are predictors for severe illness and death from COVID-19.Accumulating evidence shows that certain types of acute damage to multiple organs in patients with COVID-19 may persist after hospital discharge.In addition, containment and mitigation measures for COVID-19, such as home containment, social distancing, and travel restrictions, make it difficult for patients to access routine diagnosis and treatment services for NCDs. Such diseases can have lasting and even fatal consequences if acute services cannot be provided in a timely manner, such as dialysis for diabetic kidney disease, surgical procedures for coronary heart disease, and chemotherapy for acute myeloid leukemia. Although the current global focus is on combating the acute health threat of COVID-19, the ramifications of the pandemic in relation to the global burden of NCDs still need to be systematically assessed.

Citation:

//www.ncbi.nlm.nih.gov/pmc/articles/PMC8056943/

The early stages of the COVID-19 pandemic have focused on containing SARS-CoV-2 infection and identifying treatment strategies. While controlling this communicable disease is of utmost importance, the long-term effect on individuals with non-communicable diseases (NCD) is significant.Although certain NCDs appear to increase the severity of COVID-19 and mortality risk, SARS-CoV-2 infection in survivors with NCDs may also affect the progression of their pre-existing clinical conditions.

Infection containment measures will have substantial short- and long-term consequences such as:

• Social distancing and quarantine restrictions will reduce physical activity and increase other unhealthy lifestyles, thus increasing NCD risk factors and worsening clinical symptoms.
• Vitamin D levels might decrease and there might be a rise in mental health disorders.
• Many countries have made changes to routine management of NCD patients, e.g., cancelling non-urgent outpatient visits, which will have important implications for NCD management, diagnosis of new-onset NCDs, medication adherence, and NCD progression.

Some of the effects of Covid-19 on patients with NCDs are:

• Confinement-induced decreases in physical activity levels and increases in sedentary behavior may provoke a rapid deterioration of cardiovascular health and premature deaths among populations with increased cardiovascular risk.
• Young adults have experienced increased levels of anxiety and depression during the pandemic.
• As a precautionary approach, oncology practices implemented specific measures such as reducing the number of patients in outpatient clinics, reducing unnecessary or elective procedures, and discharging patients from inpatient services. Patients with cancer are a vulnerable population, and they are prone to many harms during such pandemics, including susceptibility to life-threatening infections and interruption of their cancer or usual medical care.
• It is known that older adults and those with chronic obstructive pulmonary disease, heart disease, diabetes, chronic kidney disease, and obesity are at increased risk for severe COVID-19 requiring hospitalization.Hypertension has been the most frequent comorbidity in COVID-19 patients.
• Diabetes causes an increase in risk of thromboembolic events as it is tied to a prothrombotic state that results from an imbalance of clotting factors and fibrinolysis. COVID-19 increases coagulation activity even further, thus putting the lives of diabetic patients at risk.
• People with obesity have an increased prevalence of diseases like renal insufficiency, cardiovascular diseases, Type 2 diabetes mellitus, certain types of cancers, and a significant degree of endothelial dysfunction. These conditions are major risk factors for disease severity and mortality associated with COVID-19. This makes obesity, particularly ominous in COVID-19. 

Thus, we need to put in more effort to reduce the burden of Covid-19 on non-communicable diseases.

Citations:

Palmer K, Monaco A, Kivipelto M, Onder G, Maggi S, Michel JP, Prieto R, Sykara G, Donde S. The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing. Aging Clin Exp Res. 2020 Jul;32(7):1189-1194. doi: 10.1007/s40520-020-01601-4. Epub 2020 May 26. PMID: 32458356; PMCID: PMC7248450.

Peçanha T, Goessler KF, Roschel H, Gualano B. Social isolation during the COVID-19 pandemic can increase physical inactivity and the global burden of cardiovascular disease. Am J Physiol Heart Circ Physiol. 2020 Jun 1;318(6):H1441-H1446. doi: 10.1152/ajpheart.00268.2020. Epub 2020 May 15. PMID: 32412779; PMCID: PMC7303725.

Due to their chronic and sometimes life-long nature, NCDs often require repeated interactions with the health system over long periods of time. This includes disease management involving access to essential medicines or rehabilitation services. Not receiving the care needed often has devastating consequences for persons living with NCDs. The unmet burden of NCDs can lead to both health and economic consequences at global, country, household and individual levels, resulting in severe disability, premature deaths, and billions of dollars in economic loss each year .
With the rapid spread of COVID-19 across the world, the ability of countries to address and respond to NCDs has been impacted. The virus has caused broad disruptions to health services while at the same time drawing attention to countries’ NCD burden, as those living with NCDs are
at increased risk of becoming severely ill with the virus

For example, screening, case identification, and referral systems for cancer have all been affected by the COVID-19 pandemic which has resulted
in a substantial decrease in cancer diagnoses . The reduction in admission to hospital of patients with acute coronary syndrome often results in increases in out-of-hospital deaths and long-term complications of myocardial infarction . Disruption in rehabilitation services for people with NCDs
in various countries has potentially impacted their functional outcomes and consequently increased the burden of care

There has not been comprehensive information gathered about the countries in which disruption of NCD related services has occurred nor the extent of those disruptions and the factors associated to those disruptions (such as inclusion in COVID-19 Strategic Plans). That information is important to a) understand how countries need to be supported during the response to COVID-19, b) plan how to build back better health systems with integrated NCD services after the pandemic and c) shed light to the consequences of the disruptions in people’s lives. In line with this, the objective of this study was to gain direct in-depth knowledge from countries on the extent to which NCDs services have been affected during the COVID-19 response.

Source : //www.who.int

COVID-19 and non-communicable diseases are closely interconnected. Underlying chronic conditions such as cardiovascular disease (CVD) and diabetes are predictors for severe illness and death from COVID-19. Evidence shows that certain types of acute damage to multiple organs in patients with COVID-19 may persist after hospital discharge. In addition, containment and mitigation measures for COVID-19, such as home containment, social distancing, and travel restrictions, make it difficult for patients to access routine diagnosis and treatment services for non-communicable diseases. Such diseases can have lasting and even fatal consequences if acute services cannot be provided in a timely manner, such as dialysis for diabetic kidney diseases, surgical procedures for coronary heart disease, and chemotherapy for acute and chronic cancers. Although the current global focus is on combating the acute health threat of COVID-19, the pandemic in relation to the global burden of non-communicable diseases still needs to be systematically assessed.

@sai-darpan yes, burden of the non communicable diseases have increased and need to be addressed after the pandemic.