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      The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing


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          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; 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. We may have opportunities to learn from this unprecedented crisis on how to leverage healthcare technologies and improve procedures to optimize healthcare service provision. This article discusses how the COVID-19 outbreak and related infection control measures could hit the most frail individuals, worsening the condition of NCD patients, while further jeopardizing the sustainability of the healthcare systems. We suggest ways to define an integrated strategy that could involve both public institutional entities and the private sector to safeguard frail individuals and mitigate the impact of the outbreak.

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          Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy

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            Covid-19 — Navigating the Uncharted

            The latest threat to global health is the ongoing outbreak of the respiratory disease that was recently given the name Coronavirus Disease 2019 (Covid-19). Covid-19 was recognized in December 2019. 1 It was rapidly shown to be caused by a novel coronavirus that is structurally related to the virus that causes severe acute respiratory syndrome (SARS). As in two preceding instances of emergence of coronavirus disease in the past 18 years 2 — SARS (2002 and 2003) and Middle East respiratory syndrome (MERS) (2012 to the present) — the Covid-19 outbreak has posed critical challenges for the public health, research, and medical communities. In their Journal article, Li and colleagues 3 provide a detailed clinical and epidemiologic description of the first 425 cases reported in the epicenter of the outbreak: the city of Wuhan in Hubei province, China. Although this information is critical in informing the appropriate response to this outbreak, as the authors point out, the study faces the limitation associated with reporting in real time the evolution of an emerging pathogen in its earliest stages. Nonetheless, a degree of clarity is emerging from this report. The median age of the patients was 59 years, with higher morbidity and mortality among the elderly and among those with coexisting conditions (similar to the situation with influenza); 56% of the patients were male. Of note, there were no cases in children younger than 15 years of age. Either children are less likely to become infected, which would have important epidemiologic implications, or their symptoms were so mild that their infection escaped detection, which has implications for the size of the denominator of total community infections. On the basis of a case definition requiring a diagnosis of pneumonia, the currently reported case fatality rate is approximately 2%. 4 In another article in the Journal, Guan et al. 5 report mortality of 1.4% among 1099 patients with laboratory-confirmed Covid-19; these patients had a wide spectrum of disease severity. If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively. 2 The efficiency of transmission for any respiratory virus has important implications for containment and mitigation strategies. The current study indicates an estimated basic reproduction number (R0) of 2.2, which means that, on average, each infected person spreads the infection to an additional two persons. As the authors note, until this number falls below 1.0, it is likely that the outbreak will continue to spread. Recent reports of high titers of virus in the oropharynx early in the course of disease arouse concern about increased infectivity during the period of minimal symptoms. 6,7 China, the United States, and several other countries have instituted temporary restrictions on travel with an eye toward slowing the spread of this new disease within China and throughout the rest of the world. The United States has seen a dramatic reduction in the number of travelers from China, especially from Hubei province. At least on a temporary basis, such restrictions may have helped slow the spread of the virus: whereas 78,191 laboratory-confirmed cases had been identified in China as of February 26, 2020, a total of 2918 cases had been confirmed in 37 other countries or territories. 4 As of February 26, 2020, there had been 14 cases detected in the United States involving travel to China or close contacts with travelers, 3 cases among U.S. citizens repatriated from China, and 42 cases among U.S. passengers repatriated from a cruise ship where the infection had spread. 8 However, given the efficiency of transmission as indicated in the current report, we should be prepared for Covid-19 to gain a foothold throughout the world, including in the United States. Community spread in the United States could require a shift from containment to mitigation strategies such as social distancing in order to reduce transmission. Such strategies could include isolating ill persons (including voluntary isolation at home), school closures, and telecommuting where possible. 9 A robust research effort is currently under way to develop a vaccine against Covid-19. 10 We anticipate that the first candidates will enter phase 1 trials by early spring. Therapy currently consists of supportive care while a variety of investigational approaches are being explored. 11 Among these are the antiviral medication lopinavir–ritonavir, interferon-1β, the RNA polymerase inhibitor remdesivir, chloroquine, and a variety of traditional Chinese medicine products. 11 Once available, intravenous hyperimmune globulin from recovered persons and monoclonal antibodies may be attractive candidates to study in early intervention. Critical to moving the field forward, even in the context of an outbreak, is ensuring that investigational products are evaluated in scientifically and ethically sound studies. 12 Every outbreak provides an opportunity to gain important information, some of which is associated with a limited window of opportunity. For example, Li et al. report a mean interval of 9.1 to 12.5 days between the onset of illness and hospitalization. This finding of a delay in the progression to serious disease may be telling us something important about the pathogenesis of this new virus and may provide a unique window of opportunity for intervention. Achieving a better understanding of the pathogenesis of this disease will be invaluable in navigating our responses in this uncharted arena. Furthermore, genomic studies could delineate host factors that predispose persons to acquisition of infection and disease progression. The Covid-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging infectious pathogens and the need for constant surveillance, prompt diagnosis, and robust research to understand the basic biology of new organisms and our susceptibilities to them, as well as to develop effective countermeasures.
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              Patients with mental health disorders in the COVID-19 epidemic

              More than 60 000 infections have been confirmed worldwide in the coronavirus disease 2019 (COVID-19) epidemic, with most of these cases in China. Global attention has largely been focused on the infected patients and the frontline responders, with some marginalised populations in society having been overlooked. Here, we write to express our concerns with regards to the effect of the epidemic on people with mental health disorders. Ignorance of the differential impact of the epidemic on these patients will not only hinder any aims to prevent further spread of COVID-19, but will also augment already existing health inequalities. In China, 173 million people are living with mental health disorders, 1 and neglect and stigma regarding these conditions still prevail in society. 2 When epidemics arise, people with mental health disorders are generally more susceptible to infections for several reasons. First, mental health disorders can increase the risk of infections, including pneumonia. 3 One report released on Feb 9, 2020, discussing a cluster of 50 cases of COVID-19 among inpatients in one psychiatric hospital in Wuhan, China, has raised concerns over the role of mental disorders in coronavirus transmission. 4 Possible explanations include cognitive impairment, little awareness of risk, and diminished efforts regarding personal protection in patients, as well as confined conditions in psychiatric wards. Second, once infected with severe acute respiratory syndrome coronavirus 2—which results in COVID-19—people with mental disorders can be exposed to more barriers in accessing timely health services, because of discrimination associated with mental ill-health in health-care settings. Additionally, mental health disorder comorbidities to COVID-19 will make the treatment more challenging and potentially less effective. 5 Third, the COVID-19 epidemic has caused a parallel epidemic of fear, anxiety, and depression. People with mental health conditions could be more substantially influenced by the emotional responses brought on by the COVID-19 epidemic, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population. Finally, many people with mental health disorders attend regular outpatient visits for evaluations and prescriptions. However, nationwide regulations on travel and quarantine have resulted in these regular visits becoming more difficult and impractical to attend. Few voices of this large but vulnerable population of people with mental health disorders have been heard during this epidemic. Epidemics never affect all populations equally and inequalities can always drive the spread of infections. As mental health and public health professionals, we call for adequate and necessary attention to people with mental health disorders in the COVID-19 epidemic.

                Author and article information

                Aging Clin Exp Res
                Aging Clin Exp Res
                Aging Clinical and Experimental Research
                Springer International Publishing (Cham )
                26 May 2020
                26 May 2020
                : 1-6
                [1 ]Oliba, Rome, Italy
                [2 ]GRID grid.8142.f, ISNI 0000 0001 0941 3192, Catholic University of the Sacred Heart, ; Rome, Italy
                [3 ]HEC, 1, Rue de la Liberation Jouy en Josas, Paris, France
                [4 ]GRID grid.24381.3c, ISNI 0000 0000 9241 5705, Division of Clinical Geriatrics, Department of NVS, Center for Alzheimer Research, Karolinska Institutet, , Karolinska University Hospital, Theme Aging, ; Stockholm, Sweden
                [5 ]GRID grid.9668.1, ISNI 0000 0001 0726 2490, Institute of Public Health and Clinical Nutrition, , University of Eastern Finland, ; Kuopio, Finland
                [6 ]GRID grid.7445.2, ISNI 0000 0001 2113 8111, Ageing and Epidemiology (AGE) Research Unit, School of Public Health, , Imperial College London, ; London, UK
                [7 ]GRID grid.416651.1, ISNI 0000 0000 9120 6856, Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, , Istituto Superiore di Sanità, ; Rome, Italy
                [8 ]GRID grid.418879.b, ISNI 0000 0004 1758 9800, CNR-Neuroscience Institute, ; Aging Branch, Padua, Italy
                [9 ]GRID grid.8591.5, ISNI 0000 0001 2322 4988, Department of Geriatrics and Rehabilitation, , Medical University of Geneva, ; Geneva, Switzerland
                [10 ]Pfizer GEP SLU, Upjohn, Madrid, Spain
                [11 ]Medical Affairs, Upjohn Hellas Ltd (Division of Pfizer), Athens, Greece
                [12 ]Upjohn (Division of Pfizer), Surrey, UK
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                Funded by: FundRef http://dx.doi.org/10.13039/100009032, Pfizer UK;

                covid-19,sars-cov-2,chronic diseases,ncd,elderly,frailty,coronavirus


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