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      Effect of COVID-19 lockdown on patients with chronic diseases

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          Background and aims

          We sought to measure the effect of lockdown, implemented to contain COVID-19 infection, on routine living, the health of patients with chronic diseases and challenges faced by them.


          A semi-structured online questionnaire was generated using “Google forms” and sent to the patients with chronic diseases using WhatsApp. Data were retrieved and analyzed using SPSS.


          Out of 181 participants, 98% reported effect of lockdown on their routine living while 45% reported an effect on their health. The key challenges due to lockdown were to do daily exercise, missed routine checkup/lab testing and daily health care.


          It is important to strategize the plan for patients with chronic diseases during pandemic or lockdown.


          • The patients living with chronic diseases are more vulnerable to the lockdown.

          • Lockdown has effected the routine living and health of the patients with chronic diseases.

          • People with mental health issues might have more effect of the lockdown.

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          Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals

          Currently most global healthcare resources are focused on coronavirus disease (COVID-19). This resource reallocation could disrupt the continuum of care for patients with chronic diseases. We aimed to evaluate the global impact of COVID-19 on routine care for chronic diseases. (see Table 1 ) Table 1 Responses from healthcare professionals who completed the online survey between March 31 and April 23, 2020. Table 1 Survey questions No. (%) Healthcare profession (n = 202) Primary care physician 75 (37.1) Hospital physician 40 (19.8) Nurse 46 (22.8) Other 41 (20.3) 

 How are you continuing to provide routine chronic disease management care for your patients? (n = 202) Face-to-face 29 (14.4) Telephone 90 (44.6) Both (face-to-face and telephone) 70 (34.7) Other 13 (6.4) 

 How has the management of chronic disease care for your patients been since the outbreak of COVID-19? (n = 202) Very poor 9 (4.5) Poor 39 (19.3) Fair 96 (47.5) Good 52 (25.7) Excellent 6 (3.0) 

 What effect do you think changes in healthcare services has had on your patients with chronic disease since the outbreak of COVID-19? (n = 200) No effect 5 (2.5) Mild effect 61 (30.5) Moderate effect 92 (46.0) Severe effect 42 (21.0) 

 How frequently have your patients been impacted by medication shortages since the start of COVID-19? (n = 201) Never 32 (15.9) Rarely 37 (18.4) Sometimes 96 (47.8) Often 35 (17.4) Always 1 (0.5) 

 Has the mental health of your patients worsened since the outbreak of COVID-19? (n = 200) Yes (most patients) 41 (20.5) Yes (some patients) 118 (59.0) No, it has stayed the same 36 (18.0) No, it has improved 5 (2.5) We developed an English language nine-item online survey targeted at healthcare professionals (HCPs) across the globe, using a drop-down menu format. Prior to dissemination the survey was tested by a group of HCPs for the time to complete and to ensure no questions were distressing. The survey was administered between March 31 and April 23, 2020. The survey link was posted to social media (including Twitter, Facebook, and Instagram), websites, and mailing lists. The posts were sharable to facilitate snowball sampling. Informed consent was obtained. Descriptive analyses were performed. 202 HCPs from 47 countries responded; 47% from Europe, 20% Asia, 12% South America, 10% Africa, 9% North America, 2% Oceania. 75 (37%) were primary care physicians, 40 (20%) hospital physicians, 46 (23%) nurses, and 41 (20%) other HCPs (Table). Only 14% reported continuing face-to-face care for all consultations, whilst the majority reported a change to either a proportion (35%) or all now being carried out by telephone (45%). HCPs who selected other (6%), highlighted use of telemedicine where online video consultations were being used through Zoom, Skype, WhatsApp, Facebook messenger. Some reported home visits, or cancellation of all outpatient appointments. Diabetes (38%) was the condition reported to be most impacted by the reduction in healthcare resources due to COVID-19, followed by chronic obstructive pulmonary disease (COPD, 9%), hypertension (8%), heart disease (7%), asthma (7%), cancer (6%) and depression (6%) (Figure). Additionally, the two most common co-occurring chronic diseases for which care was impacted by COVID-19 were diabetes and hypertension (30%), diabetes and COPD (13%), heart failure and COPD (8%) (Figure). Whilst the overall management of chronic disease care for patients was reported to be fair (48%) or good (26%), most HCPs (67%) rated moderate or severe effects on their patients due to changes in healthcare services since the outbreak. Moreover, 80% reported the mental health of their patients worsened during COVID-19 (Table). Findings from this global survey showed HCPs have adapted to new ways of delivering care using telemedicine in order to reduce face-to-face contacts. Adapting new ways of virtual healthcare and digital technologies is imperative to allow HCPs to continue routine appointments. Further, the use of apps can support self-management of chronic conditions, i.e. continuous glucose monitoring enables support with diabetes. However, the majority of people with non-communicable diseases live in low-middle income countries, where these technologies may not be widely available or practical [1]. Moreover, those with multiple chronic conditions may rely heavily on regular check-ups or hospital appointments to manage risk factors, are left trying to adapt to non-face-to-face interactions, or experiencing delay in treatment which may potentially have severe consequences. Limitations of this survey include that it was only disseminated in English, as part of our networks we may have preferentially approached those working in diabetes. Also, difficulty in obtaining responses from HCPs when workloads may have already increased considerably. There will be heterogeneity between countries in that some countries are currently not as affected by the virus compared to others, and regulations of lockdown and social distancing differ by country, thus further research is required. To avoid a rise in non-COVID-19-related morbidity and mortality, including increased depression and anxiety, it is important that patients with chronic diseases continue to receive care in spite of the pandemic [2]. Our study found that this is currently being done through face-to-face consultation in clinics (away from COVID-19 patients) or through virtual communication.Fig. 1 Fig. 1 Chronic disease and comorbidities most impacted by COVID-19 due to the reduction in care, based on responses by healthcare professionals who completed the online survey between March 31 and April 23, 2020 Fig. 1 Funding/support The National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC-EM). Ethical approval and informed consent All participants gave informed consent at the start of the survey and no confidential data was collected, as all responses remained completely anonymous. This study has been approved by the University of Leicester College of Life Sciences Committee for Research Ethics Concerning Human Subjects (Non-NHS). Declaration of competing interest The authors have no conflict of interest to declare.
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            Effect of COVID-19 Pandemic and Lockdown on Children With Gastrointestinal Disorders

             Eyad Altamimi (2020)
            To the Editor Introduction Coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), has spread rapidly worldwide [1]. Since first identified on late December 2019 till now, more than two million get infected and more than 150,000 died [2]. This pandemic has overwhelmed healthcare systems and adversely affected an unprecedented number of people [2]. While children have shown resilience and milder symptoms, older adults and those with comorbidities such as diabetes mellitus and cancer seem to manifest more severe forms of this infection and have a higher risk of mortality [3]. The governments of many countries have resorted to the restrictive measures of lockdown and curfew to control the spreading of this disease. The common measures of social distancing, hand hygiene, and reduced hospital visits would apply to all patients [4]. Contact numbers of the treating physician/registered nurse need to be available to reserve in-person consultations for emergencies only [3]. This study reflects on the effect of the COVID-19 pandemic and the restrictive measures on children with known gastrointestinal diseases and has cited examples from Jordan, a country where specific health measures were taken to help those with chronic medical conditions. The repercussions of the enforced lockdown have been discussed under the following sub-headings: Nutritional effect, General considerations of COVID-19 on the gastrointestinal system, and Specific crisis management of children with chronic gastrointestinal disorders, such as chronic constipation, non-alcoholic fatty liver disease (NAFLD), irritable bowel syndrome (IBD), peptic ulcer disease (PUD), eosinophilic esophagitis (EoE), celiac disease, cirrhosis, milk protein allergy, and functional gastrointestinal disorders (FGIDs). Nutritional effect COVID-19 is not expected to affect the nutritional status unless the primary presentation is a gastrointestinal disorder that can lead to dehydration. In contrast, patients with significant malnutrition are considered immunodeficient [5], putting them at greater risk of acquiring infections. Theoretically, patients with severe malnutrition are at an increased risk of acquiring COVID-19 and developing a severe disease course. Till date, the effect of the pandemic in areas with a high prevalence of famine and malnutrition has been limited, if not under-reported. Areas affected by famine such as sub-Saharan African countries and those with a high population density, poor sanitation, and restricted opportunities to maintain proper personal hygiene are conducive to the spread of this disease. On the other side of the spectrum, the risk of significant weight gain during enforced lockdown is apparent. Children’s physical activity has become limited while their use of electronic devices for online learning and entertainment has dramatically increased their “screen-time”. Vulnerable children of financially insecure families may be at a risk of malnutrition secondary to limited access to food or changes in eating patterns. Hidden hunger occurs when the quality of food eaten does not meet the micronutrient requirements, and the limited sun exposure during the lockdown may worsen vitamin D deficiency or cause a sub-clinical deficiency to become apparent. Although acute manifestations of vitamin D deficiency are not obvious, its chronic deficiency could affect the immune system. Patients with very low vitamin D levels have a subnormal immune defense. Although there has been no research on the effect of vitamin D levels on COVID-19 susceptibility, extrapolating data on vitamin D supplementation and acquiring respiratory tract infection [6], it may not be unreasonable to supplement children with the maintenance dose of vitamin D during the lockdown. General considerations of COVID-19 on the gastrointestinal system For fecal-oral transmission of COVID-19, the SARS-CoV-2 may spread through the fecal-oral route as it replicates actively in human intestinal epithelium and is shed in stools. Active viral shedding could continue up to 7 days after its clearance from the nasopharynx [7, 8]. Pediatric patients have a higher risk of transmitting the disease due to their poor hand washing techniques. Children should be taught the importance of maintaining personal hygiene after using the washroom through the use of simple easy-to-understand language. Angiotensin-converting enzyme-2 (ACE-2) receptors are abundant at the enterocytes of the ileum and colon. ACE-2 represents the port of entry to the cells, where it replicates and then is shed in the stool of infected patients. This explains the fecal-oral route transmission and the gastrointestinal symptoms of COVID-19 [9]. Gastrointestinal manifestations include diarrhea, vomiting, and abdominal pain, and these manifestations may be the earliest presenting symptoms of COVID-19. Among patients infected, almost one-fourth had gastrointestinal presentations [3]. Direct viral infection, immune-mediated injury, or drug induced liver damage during the treatment of COVID-19 could lead to mild elevations of liver enzymes, although severe liver damage has been reported in some cases [10]. COVID-19 should be suspected in case of a positive contact history even in the absence of respiratory symptoms. To increase the detection rate, it may be worthwhile to perform the liver function tests in these contacts, especially since jaundice is not a common symptom of COVID-19 liver disease. Specific crisis management of children with chronic gastrointestinal disorders As COVID-19 and SARS-CoV-2 are new, the literature on its impact on children with complex and underlying medical conditions is limited. Children are expected to have same spectrum of disease as adults, but with milder severity [3, 8]. Inputs on how to maintain the medical management of some specific gastrointestinal disorders during this pandemic are discussed below. Chronic constipation Functional constipation defined as constipation with no organic etiology is the most common cause of constipation worldwide [11]. An increase in the risk factors like low fiber diet, decreased fluid intake and decreased physical activity may be seen during enforced lockdown. Therefore, caregivers of these children are encouraged to continue their medications and maintain adequate hydration to combat this risk. On the other hand, those children who developed constipation due to their refusal to use the school toilets may benefit from the increased time spent at home. NAFLD NAFLD is estimated to affect 3-12% of children, which will increase up to 80% of obese children [12]. The main interventions in the management of NAFLD are diet modification and increased physical activity, and these are to be continued as closely as possible. Although the recommended level of activity might be difficult to attain at this time, the food intake and type of foods consumed (healthy, home cooked food vs. fast food) can be regulated while the children stay at home. In addition, the availability of smart devices in almost every home provides multiple options via fitness apps and videos to choose appropriate indoor physical activities. Another issue in NAFLD patients is the concomitant presence of metabolic disorders like diabetes. COVID-19 is known to be more severe in patients with underlying medical conditions and they need to take extra-precautions regarding social distancing and personal hygiene. Medical follow-up for such patients needs to be delayed if possible to limit their exposure to the hospital environment during this pandemic. IBD Children with IBD should continue their medications and be mindful of their self-hygiene. Many of the drugs used to treat IBD suppress the immunity; however, they are unlikely to increase the risk of acquiring the disease [13]. If the patient develops COVID-19, dose-adjustment or discontinuation of steroids may be required [13]. Patients receiving biologic agents for IBD can continue their doses as scheduled. Stopping the treatment for IBD altogether would worsen the patients’ clinical condition without significant reduction of the risk of contracting COVID-19. Routine follow-up and endoscopic procedures may need to be delayed [14]. PUD and gastroesophageal reflux disease A surge in the incidence of reflux disease could be expected at this stressful time [15]. Gastric acidity represents a major defense mechanism against swallowed pathogens, and till date, there have been no data associating the neutralization of gastric pH with proton pump inhibitors, with the risk of this infection. Standard measures of protection should be followed. EoE There is not enough information to document the effect of this pandemic and lockdown on the patients with EoE. Theoretically, noncompliance to medications may cause recurrence of symptoms and impaction of food in the esophagus requiring urgent upper endoscopy. All patients undergoing such endoscopies should be dealt with as suspected cases of COVID-19. The endoscopy team must comply with the published precautionary instructions and should have adequate training in donning and doffing personal protective equipment [14]. Treatment of EoE with local steroids (budesonide) is unlikely to increase the risk of COVID-19 and can be continued. Celiac disease Data on the relation between celiac disease and COVID-19 is almost non-existent. Celiac disease is a chronic autoimmune enteropathy that is managed with a gluten free diet. Patients are encouraged to continue their diet despite limited availability due to food supply chain disruptions. Patients with stable celiac disease are immunocompetent, but non-compliant patients with active celiac disease might have a higher risk than the general population. In Jordan, the Celiac Disease Care Society freely delivered gluten-free flour to the doors of registered celiac patients with the cooperation of civil defense forces. The society team make themselves available for consultations and nutritional advices. Chronic liver disease/cirrhosis Although the spectrum of disorders leading to cirrhosis and its pathophysiology in the pediatric age group varies widely from that seen in adults, adopting general treatment modalities for cirrhosis is the most appropriate approach at this time. Patients with cirrhosis and those receiving immunosuppressive therapy are theoretically at increased risk of acquiring COVID-19 [16]. Practicing universal precautions in healthcare is mandatory. Till date, no recommendations have been made to reduce the dose of immunosuppressant therapy in these patients. Regular workup of patients with compensated cirrhosis for varices and risk assessment for hepatocellular carcinoma can be delayed. Those with decompensated liver cirrhosis would require additional vaccination (i.e. pneumococcal and flu vaccines) and prophylaxis for peritonitis and encephalopathy to reduce the likelihood of deterioration that warrants in-hospital treatment [17]. The European Association for the Study of the Liver advises against performing liver biopsies to assess NAFLD or mild elevation of liver enzymes even in patients with a high probability of autoimmune hepatitis and to defer it until an appropriate time [16]. Children maintained on special formulas Some children require special formula for the management of metabolic disorders like galactosemia and tyrosinemia, and for treating gastrointestinal disorders like protein intolerance or short bowel syndrome. Alteration or substitution of one formula for another is to be done under the advice of the treating physician or an expert dietitian only. Constant efforts are required to ensure the availability of formula to families in need. In a country with limited resources like Jordan, lactose-free formula may be considered in older galactosemic patients if soya-based formula becomes unavailable. Patients who are allergic to stable cow’s milk protein could use the readily available hydrolyzed formulations if the recommended extensively hydrolyzed formula is in short supply during this crisis. FGIDs Lockdown may affect children with FGID in multiple ways. The disruption of routine, lack of social contacts, unfamiliar distance learning and worry about their exams may worsen their symptoms [18]. Simultaneously, the home environment in some families may turn hostile with increased stress regarding threats of financial insecurity and domestic abuse, both of which are conducive for the development of FGID in susceptible children. Parental support, coping exercises, and providing online resources on stress management would help in improving the patients’ symptoms. This lockdown has also exposed the need for developing resources in non-English languages. In Jordan, the civil defense forces have aided patient movement for health interventions (including drug administration) to the hospital and back, and arranged the home-delivery of medications for patients with chronic medical conditions. In conclusion, COVID-19 represents a serious threat to health worldwide. The restrictive measures adopted by governments to control the pandemic may have adverse effects on societal health. Children seem to be more resilient to the infection and manifest milder symptoms. However, children with chronic gastrointestinal disorders may face specific challenges brought about by the enforced lockdown and these need to be addressed. As we are continuing to learn about this novel viral infection, we have little literature to rely on and data regarding its effects on the pediatric population is miniscule. This paper has tried to address the common pediatric gastrointestinal issues and reflects on some of the specific measures that can be adopted during this pandemic.

              Author and article information

              Diabetes Metab Syndr
              Diabetes Metab Syndr
              Diabetes & Metabolic Syndrome
              Diabetes India. Published by Elsevier Ltd.
              27 August 2020
              27 August 2020
              [a ]Pakistan Health Research Council, Head Office, Islamabad, Pakistan
              [b ]Department of Life Sciences, University of Management & Technology (UMT), Lahore, Pakistan
              [c ]Department of Medicine, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
              [d ]Department of Economics, Finance and Statistics, Jönköping University, Jönköping, Sweden
              [e ]Department of Biosciences, COMSATS University Islamabad (CUI), Islamabad, Pakistan
              Author notes
              []Corresponding author. Research Officer, Pakistan Health Research Council, G-5/2, Islamabad, Pakistan. arif289@ 123456gmail.com
              © 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.

              Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.


              covid-19, chronic diseases, lockdown


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