Strategies for reducing chronic disease burden during pandemics

1. Introduction

The impact of coronavirus disease 2019 (COVID-19) on individuals with chronic diseases has been substantial and concerning. Several studies indicate a notable prevalence of chronic diseases among COVID-19 patients, with rates spanning 20-30% for general cases and escalating to 50-80% for severe infections. Notably, hypertension, diabetes, and cardiovascular disorders emerge as the most prevalent comorbidities in this group [1,2], with associated odds ratios for mortality being 1.48, 3.39, and 2.25, respectively [3]. Hypertension has been associated with increased severity, ICU admission, and mortality [4]. Similarly, individuals with Chronic Liver Disease (CLD) exhibited considerably higher chances of experiencing severe COVID-19 complications and mortality [4].

A systematic review and meta-analysis included 217 observational studies from 26 countries, involving 624,986 patients. It found that COVID-19 patients with chronic diseases such as hypertension, COPD, obesity, cerebrovascular disease, chronic liver disease, chronic renal disease, cancer, and hyperlipidaemia were more likely to experience severe symptoms, require ICU admission, and face a higher risk of mortality. Asthma was associated with a reduced risk of COVID-19 mortality [5]. Another systematic review, which analysed 42 studies involving 423,117 patients, emphasized the role of comorbidities like COPD, CVD, diabetes, hypertension, obesity, and cancer in increasing the risk of mortality. It also highlighted the impact of demographic variables like older age, male gender, and smoking status [6]. The ripple effects of a pandemic can significantly disrupt healthcare delivery, presenting challenges to the diagnosis, treatment, and ongoing monitoring of chronic diseases [7,8].

Therefore, this editorial aims to shed light on strategies that can reduce the burden of chronic disease during a pandemic. Given the heightened vulnerabilities and health risks that these individuals face during such events, it’s essential to address these concerns. The overarching goal is to enhance healthcare system resilience, ensure effective disease management, and foster a society more adept at managing public health crises in the future.

This editorial investigates the connection between COVID-19 pandemic and chronic diseases, an area which has taken on increased significance due to its profound effects on individuals with pre-existing conditions and chronic illnesses. By exploring the increased risks and complications associated with pre-existing conditions, this editorial underlines the urgent need for tailored healthcare systems such as diversifying supply chains, augmenting digital health capabilities, prioritizing mental well-being of frontline staff, in order to foster a more resilient infrastructure capable of managing both chronic conditions as well as pandemic challenges effectively.

1.1. Conceptual framework

This editorial examines the significant impact of COVID-19 on patients with chronic conditions, highlighting how these conditions exacerbate the severity and outcomes of the infection. It then shifts focus to long-COVID syndrome, a post-infection condition characterized by persistent symptoms, potentially including blood clots and autoimmunity, and discusses various management strategies. The piece also explores the systemic, healthcare professional-related, and patient-specific challenges posed by pandemics, such as resource diversion, medication shortages, and the mental health stressors faced by healthcare workers. It further delves into the pandemic’s impact on patient behaviour and treatment adherence. In response to these challenges, the editorial proposes mitigation strategies to enhance healthcare system resilience, including creating dedicated units for chronic diseases, stockpiling medications, and embracing digital health solutions. The editorial places emphasis on supporting healthcare professionals’ mental well-being and on implementing public health campaigns for safe healthcare access during pandemics. It also highlights the importance of diversifying supply chains and understanding patient perspectives to improve public health communication. Lastly, the editorial suggests future research directions in areas like digital health solutions for chronic disease management, the interplay between infectious and chronic conditions, and the economic evaluations of healthcare strategies.

1.2. Long-COVID-19

Long-COVID, also known as post-COVID syndrome, is characterized by a range of symptoms persisting for three months or longer after the initial COVID-19 infection [9,10]. These symptoms can include impaired energy, cognitive function, sense of smell or taste, anxiety, depression, headaches, shortness of breath, and heart palpitations, varying from mild to debilitating. The complexity of long COVID arises from its diverse symptoms linked to the initial infection, encompassing conditions similar to lung, heart, neurological, or psychological disorders [11].

The exact causes of long COVID are not fully understood but are believed to involve factors such as tiny blood clots affecting organ function, inflammation, autoimmune reactions, viral persistence in the body, and psychological impacts of severe illness. These contribute to the varied and persistent symptoms experienced by individuals with long COVID [11].

Management of long COVID varies based on its symptoms and causes, with no single approach fitting all patients. It often involves trying multiple options to find what works for each individual. Treatments may include medications for specific symptoms, Stellate Ganglion Block or Olfactory Retraining for loss of smell and taste, physical therapy, pulmonary rehabilitation, and counselling for psychological effects [11].

Early care tips for long COVID include allowing ample time for recovery, maintaining hydration and healthy eating, focusing on resistance exercises initially, optimizing sleep, and engaging in olfactory retraining for persistent taste or smell issues. The global prevalence of long COVID underscores the need for resilient healthcare systems capable of providing multidisciplinary care, including long-term symptom monitoring, physical rehabilitation, mental health, and social services support [11].

1.3. Understanding the problem

The global surge in chronic diseases during the COVID-19 pandemic can be understood through various pathways, namely system-related, healthcare professional-related, and patient-related.

System-related pathways highlight the structural and logistical challenges posed by pandemics. For instance, healthcare systems experienced immense pressure when essential resources were redirected to manage the outbreak, significantly limiting regular care for those with chronic illnesses [12]. The pandemic also induced shortages of essential medications due to hoarding and off-label use, affecting individuals dependent on them for conditions like rheumatoid arthritis and other autoimmune disorders. Interruptions in global trading channels and supply chains further exacerbated the accessibility of these medications, potentially having dire consequences for those with chronic illnesses. Surveys indicated that approximately 51% of participants faced medication-related problems during the pandemic, with 19.6% encountering difficulties obtaining them, largely due to the closure of doctors’ offices for in-person visits [13]​. In the aftermath of the COVID-19 outbreak, certain medications saw increased discontinuation rates; specifically, norgestrel-ethinyl estradiol and dexmethylphenidate HCL experienced rises by 0.62% and 2.84%, respectively [14]. The demand for sedatives and analgesics rose by 51% and 67% respectively during March (2020) in the United States, with both categories having fill rates of less than 100%, indicating concerns for impending shortages that could adversely affect the management of chronic pain and other conditions requiring these medications [15].

Healthcare professional-related pathways emphasize the human component within healthcare systems. Healthcare professionals, especially nurses, faced considerable mental health challenges, including anxiety, depression, and stress during the pandemic [16]. The mental well-being of healthcare providers can profoundly influence the quality of care delivery; heightened stress or mental health challenges may lead to mistakes in treating chronic diseases that require precise management.

Patient-specific pathways delve into the individual experiences of those impacted by the pandemic. Fears of exposure to the virus deterred many individuals with chronic conditions from seeking care, potentially resulting in their conditions being unmanaged or sub-optimally managed due to deferred or missed medical attention. Disruptions during the pandemic also curtailed access to healthy foods and opportunities for physical activity, potentially driving up obesity rates and complicating diabetes management for those affected [17]. Moreover, COVID-19 often synergized with chronic diseases, producing severe disease courses with exacerbated outcomes for individuals with pre-existing conditions, further intensified by the virus’s proliferation [18].

1.4. Mitigation strategies

Literature review did not identify studies that specifically addressed reducing the chronic disease burden during a pandemic, nor any clinical trials or interventions targeting chronic diseases. However, some studies did explore methods to improve care for individuals living with chronic conditions. Therefore, to mitigate the global impact of chronic diseases during an epidemic, coordinated efforts are needed from nations, health authorities, pharmaceutical companies, healthcare professionals, and patients (Table 1).

Table 1. Mitigation strategies to reduce the chronic disease burden during a pandemic.

Strategies	Summary
Health System Contingency Plans	Develop dedicated units for chronic diseases Stockpile essential medications Enhance digital healthcare integration Bolster local pharmaceutical production Diversify supply chains
Support for Healthcare Workers	Implement mental health support systems for frontline workers Conduct regular mental health check-ins Introduce relaxation techniques Offer counselling services Provide educational programs on mental health management for healthcare professionals
Public Health Campaigns	Educate individuals about safe healthcare access during pandemics Utilize telemedicine and home monitoring systems Minimize virus exposure risks Promote community programs for healthy foods and safe physical activities Offer tailored mobile apps and online platforms for chronic conditions Ensure continuous care and patient engagement during health crises
Diversified Supply Chains	Prioritize regional and domestic production of essential medications Create a safety net for global crises Reduce reliance on globalized supply routes Ensure healthcare system stability Boost domestic economies
Digital Health Advancements	Develop advanced telemedicine services Implement remote patient monitoring systems Introduce digital prescription services Ensure continuity of patient care with limited physical interactions Focus on infrastructure development for digital health Enhance data security measures
Patient Perspectives in Public Health	Address public health communication deficiencies Tackle patient avoidance of essential treatments Research ways to improve clarity and accessibility in public health messaging Focus on direct patient engagement
Research Avenues in Healthcare	Explore long-term efficacy of digital health solutions for chronic disease management Investigate impact of infectious diseases on chronic conditions Study patient motivations during health crises Conduct economic evaluations of strategies like domestic pharmaceutical manufacturing

Health systems should have a robust contingency plan for future health crises to address the structural and logistical challenges posed during pandemics. It’s crucial to establish dedicated units or facilities for managing chronic diseases, ensuring that resources aren’t solely redirected towards immediate crises. Stockpiling essential medications can guard against shortages arising from hoarding or off-label use. Enhancing digital integration in healthcare can alleviate medication discontinuation issues by granting patients access to necessary medications, even when in-person visits are restricted. Bolstering local pharmaceutical production and diversifying supply chains can insulate against global trading interruptions, guaranteeing consistent medication supply. An illustrative example of organizational resilience during health crises is the Veterans Health Administration’s contingency staffing program for primary and mental health teams [19].

For the human element within the healthcare system, mental health support systems for healthcare professionals, particularly frontline workers, are paramount. Introducing regular mental health check-ins, relaxation techniques, and offering counselling services can help address the increased levels of stress and anxiety they experience. A comprehensive review on the interventions to support the mental health and well-being of front-line healthcare workers during pandemics has also been conducted, emphasizing the need for mental health support intervention [20]. Moreover, educational programs can arm healthcare professionals with tools and strategies for managing their own mental health, ensuring they maintain the highest standards of care while optimizing quality.

Public health campaigns are crucial in guiding individuals on safely accessing healthcare during pandemics. Telemedicine and home monitoring systems enable patients to continue receiving care without the fear of virus exposure. Community programs that offer access to healthy foods and promote safe physical activities should be prioritized. Mobile apps and online platforms, tailored for those living with chronic conditions, provide exercise regimens and nutrition advice, helping to counteract challenges posed by limited outdoor activity. An ongoing trial evaluated the benefits of an m-Health solution designed specifically for chronic patients during the COVID-19 pandemic and confirmed its efficacy in enhancing patient engagement and treatment adherence [21]. Moreover, research and education focusing on infectious diseases like COVID-19 can empower individuals to manage their health effectively, even in the face of global health threats

2. Expert opinion

Chronic diseases, in tandem with the COVID-19 pandemic, highlighted the intricate challenges within healthcare systems. Individuals with chronic ailments faced heightened risks during this pandemic, underscoring the need for health strategies that consider such populations during crises.

Diversified supply chains are pivotal for healthcare stability. The pandemic exposed a heavy reliance on globalized supply routes for essential medications. Moving forward, nations might prioritize bolstering regional and domestic production capacities. Doing so can offer a safety net during global crises and concurrently boost domestic economies.

Furthermore, the rising importance of digital health is undeniable. As the pandemic limited physical interactions, digital health solutions offered a semblance of continuity in patient care. The benefits of advanced telemedicine, remote patient monitoring, and digital prescriptions are not just of convenience but may be integral to addressing healthcare challenges in coming years. However, while the immediacy of these solutions is acknowledged, there is a compelling need for further research. Infrastructure development, data security, and enhancing digital health literacy might be areas warranting attention.

The mental well-being of healthcare professionals demands careful attention. Data underscores their profound mental stress during the pandemic; addressing their mental health is not only an ethical imperative but also directly influences the quality of patient care. In future healthcare emergencies, strategies that prioritize the mental well-being of frontline workers should be central, though this approach requires deeper exploration in various healthcare contexts.

Additionally, patient perspectives present a complex puzzle. The pandemic revealed glaring deficiencies in public health communication, leading many patients to avoid essential medical treatments and services. While the profusion of online information might have appeared to be a solution, it often exacerbated confusion, a fascinating avenue for research into enhancing clarity and accessibility in public health messaging. Direct engagement with patients might yield nuanced insights, strengthening trust between stakeholders in decision-making processes.

In a forward-looking stance, there are several research avenues that seem promising. The efficacy of digital health solutions, especially in the long-term management of chronic diseases, needs rigorous investigation. Likewise, a deeper understanding of how infectious diseases exacerbate chronic conditions could offer insights into patient care and preventive strategies. Behavioural aspects, including understanding patient motivations during health crises, could guide effective interventions. Lastly, economic evaluations, particularly of strategies like domestic pharmaceutical manufacturing, may inform future policy decisions.

3. Conclusion

The challenges posed by the COVID-19 pandemic underscore the need for strategies tailored to individuals with chronic conditions, considering their increased vulnerability during health crises. Current findings suggest that healthcare systems should prioritize diversified supply chains, maximize the use of digital health, and emphasize the mental well-being of frontline staff. Collaboration among all stakeholders, from healthcare providers to patients, will be essential to develop an infrastructure that can effectively manage both chronic diseases and pandemics simultaneously.

Ahmad Z. Al Meslamani
College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
[email protected]

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Acknowledgements

None.

Declaration of funding

The paper was not funded.

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.