Testing times

European life will never be the same again.¹ The coronavirus pandemic has, and will, dramatically change how medicine is practised now and in the future. It also brings home, in case we did not realise it, how we are all interconnected and interdependent. What can we do to help in these uncertain times?

The SARS-CoV-2 virus is highly contagious–it does not respect borders, countries, societies, communities or families. Even with most of the world in lockdown, clinicians are battling with support measures for those with severe COVID-19. Healthcare resources are being diverted pragmatically to source masks, virology services, personal protective equipment and ventilators as well as building field hospitals and, sadly, morgues. Emergency care is taking over the time, resources and premises normally used for routine care. The loss of sexual and reproductive health services, deemed by some governments as non-essential, poses significant challenges for all of us.

It is likely that the amount of time dedicated to sexual intercourse (at least with regular partners) during social distancing, isolation and working from home has increased. Lockdowns and travel restrictions are hampering access to contraceptive supplies and services across the world.² These factors could lead to millions of additional unintended pregnancies, millions of unsafe abortions and thousands of resultant deaths.

History has taught us that sexual and reproductive health and rights are often casualties of conflicts and emergencies³ – this virus is no different as it wreaks havoc globally. The incidence of domestic violence,⁴ rape (and likely STIs too) increases while access to services become almost non-existent. Rape and domestic violence increase the need for emergency contraception, abortion and contraception in the first instance. As always, marginalised individuals and communities suffer proportionately more.

The reported demand for condoms has risen sharply⁵ as accessibility to contraception and abortion is significantly reduced. Yet condom manufacture is not considered an essential service and some condom factories, importantly in Asia, are in lockdown.

We need to be innovative in our service provision; in this we need national authorities to react swiftly to facilitate this. Health Ministries need to be ready to make emergency modifications to relevant regulations, for example those that insist upon multiple doctors’ signatures, face-to-face consultations and waiting periods. Drug regulators need to urgently vary licences to make a range of prescription-only contraceptive products available under the supervision of a pharmacist.

New, simplified guidelines and protocols are being written speedily.^6,7 Telemedicine with video consultations and remote prescribing are now the new reality. This cannot be done without the support of pharmacies–who are themselves subject to increased workload and conddstrained by breakdowns in supply chains, particularly from China and India.⁸ Infection testing can be done in some places using postal services e.g., https://sh24.org.uk/sexual-health/stis.

The European Society of Contraception and Reproductive Health, in an endeavour to support our colleagues and provide the best service possible in the circumstances, proposes the following measures:

1. Adoption or extension of new models of care such as task-sharing.⁹

2. Remote consultations and prescribing for complex contraception needs and, particularly, for medical abortion at home (telemedicine).¹⁰

3. The extended use of long-acting reversible contraception (etonogestrel implants and 52 mg levonorgestrel-releasing intrauterine contraceptives) up to one year beyond their lifespan.¹¹

4. The use of oral progestogen-only contraception as a supplement to, or a substitute for, existing contraceptive methods, where appropriate.

5. Continued use of combined oral contraception over time for low-risk users, without the need for routine cheques.

These are simple measures that, with the support of pharmacies, will support a continued service and, although not ideal, will hopefully ameliorate the situation and relieve the plight of many people in these unprecedented times.

欧洲的生活将不同于往常¹ 。冠状病毒的流行现已经并将会极大地改变现在和未来的医疗。如果我们还未意识到人类是如何相互联系并且相互依存的, 这次冠状病毒的流行将让我们认识到这一点。在这个充满不确定性的时代, 我们能做些什么？

SARS-CoV-2病毒传染性极强, 它不分国界、国家、社会、社区和家庭。即使世界上大部分地区都已封锁, 临床医生仍在为那些新冠肺炎重症患者提供支持并奋斗。医疗卫生资源正大量分配到口罩、病毒学、个人防护设备和呼吸机, 以及建造野战医院, 可悲的是, 还有停尸房。紧急护理正在占用常规护理的时间、资源和场地。一些政府将性健康和生殖健康服务视为是非必要的, 其损失给所有人带来了重大挑战。

远程社交、隔离与居家办公期间, 性交（至少是与固定性伴侣）的时间似乎更多了。封锁与出行限制使得全世界对避孕措施的获取受阻²。这将额外增加数百万的意外妊娠与不安全流产, 以及因此导致的数以千计的死亡。

历史教育我们：性和生殖健康以及权利常是矛盾和紧急事件的牺牲品³——新冠病毒也是如此, 因为它在全球范围内造成了严重破坏。家暴⁴、强奸(可能还有性传播感染)的发生率增加, 而获得医疗服务的机会几乎不存在。强奸和家暴首先会增加紧急避孕、人工流产和避孕的需求。与平常一样, 被边缘化的个人和社区遭受的比例更大。

据报道, 由于进行避孕和人工流产的可行性明显减少, 所以对避孕套的需求急剧上升⁵。然而, 避孕套的生产并不认为是必须的, 一些生产避孕套的工厂, 特别是在亚洲, 已经停产。

医疗服务的供给方面需要创新；为此, 国家机构应当迅速采取措施以加快这一进程。卫生部门应当随时做好针对相关法规进行紧急修改的准备, 例如那些需要多名医生签字、当面问诊和耗时等候的法规。药品监管机构需要紧急更改许可证, 使得处方类避孕药在通过药师的监管后便可获得。

简化的新版指南和医疗方案正在迅速编写^6,7。具备视频问诊和远程处方功能的远程医疗现在已成为新现实。没有药店的支持, 就无法做到这一点。药店会承受更大的工作量, 并受到供应链中断的限制, 尤其是来自中国和印度的供应链⁸。可以在某些地方使用邮政进行感染试验, 例如https：// sh24.org.uk/sexual-health/stis。

为在这种情况下为支持我们的同行并尽可能提供最好的医疗服务, 欧洲避孕与生殖健康学会提出了以下措施：

1. 采用或扩展新的护理模式, 例如分担任务⁹。

2. 针对复杂的避孕需求, 尤其是在家进行药物流产（远程医疗）的远程问诊和开处方¹⁰。

3. 长效可逆避孕药（依托孕烯植入剂和52 mg左炔诺孕酮宫内节育器）到使用期限后延长使用一年¹¹。

4. 在适当的情况下, 使用单一孕激素口服避孕药作为对现有避孕方法的补充或替代。

5. 低风险使用者可继续使用复方口服避孕药, 无需常规检查。

在药店的支持下, 这些简单的措施可以提供持续的医疗服务, 虽然不理想, 但有望在这个前所未有的时期改善局面、缓解很多人的困境。

Disclosure statement

No potential conflict of interest was reported by the author(s).