|Year : 2020 | Volume
| Issue : 2 | Page : 29-35
COVID-19 and noncommunicable diseases: Impact and the strategic approaches
JS Thakur1, Ronika Paika1, Sukriti Singh2, Jai Prakash Narain3
1 Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 MM Medical College and Hospital, Solan, Himachal Pradesh, India
3 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia; Former Director, communicable Diseases, WHO Regional Office for South-East Asia, New Delhi, India
|Date of Submission||02-Jun-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Prof. J S Thakur
Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
The coronavirus disease (COVID-19) has critically impacted global health systems and economies both in developed and developing world, 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 pandemic on human health and economic well-being. It is clear that the pandemic will seriously undermine global efforts to attain the sustainable development goals. Among the major challenges are increased indoor time leading to increased exposure of 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 centres, 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.
Keywords: Approaches, COVID-19, impact and strategies, noncommunicable diseases
|How to cite this article:|
Thakur J S, Paika R, Singh S, Narain JP. COVID-19 and noncommunicable diseases: Impact and the strategic approaches. Int J Non-Commun Dis 2020;5:29-35
|How to cite this URL:|
Thakur J S, Paika R, Singh S, Narain JP. COVID-19 and noncommunicable diseases: Impact and the strategic approaches. Int J Non-Commun Dis [serial online] 2020 [cited 2021 Aug 5];5:29-35. Available from: https://www.ijncd.org/text.asp?2020/5/2/29/288255
| Introduction|| |
The World Health Organization (WHO) named new coronavirus strain as COVID-19 and recognized the outbreak to be a Public Health Emergency of International Concern on January 30, 2020, and declared it as a pandemic on March 11, 2020. So far, globally (until May 10, 2020), 215 countries, territories, provinces, and 3917,366 people are affected with COVID-19 and 274,361 deaths reported.
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 global statistics on COVID-19 also shows that the death rate is 21.9% in the age group of above 80 years, 8% in the age group between 70 and 79 years, and further 3.6% in the age group of 60–69 years of age group. 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%).
Indeed, the COVID-19 pandemic has created major dilemmas for providers in all areas of health-care delivery, including cancer centers. The rapid spread of SARS-CoV-2, the virus which causes COVID-19 disease, combined with an unprecedented, near-complete global lockdown, has laid bare the weaknesses in health systems. Lack of adequate health-care infrastructure and human resources, serious supply-chain disruptions, and widespread fear among patients and health-care workers have resulted in patient care and safety being seriously compromised. The current review was undertaken to understand the impact of COVID-19 pandemic on the prevailing high burden of chronic NCDs and strategic approaches required to address comorbidity due to COVID-19 and NCDs.
| Methodology|| |
The review on the impact of COVID-19 pandemic on NCDs was undertaken. We searched the Internet using keywords (”COVID-19” OR “novel coronavirus” OR “corona virus”) AND (”NCDs” OR (”noncommunicable diseases” OR “chronic diseases” OR “comorbidities”) AND “impact” AND “strategies” AND “prevention” OR “prevention and control”) on PubMed and Google Scholar. We searched open access websites of National Ministry, WHO Situation reports, press releases, and other agencies involved in COVID-19 prevention and control in relation to NCDs or chronic diseases.
| Results|| |
The COVID-19 response may hinder the access and quality of essential health services for NCDs which are already leading causes of morbidity and mortality globally, except Africa. Population affected with NCDs is experiencing more severe disease and poorer outcomes when infected. COVID-19 may disrupt whole of society approaches for NCDs, disrupt medicine supplies, divert resources and services, and compromise further meager financial resources allocated to addressing NCDs.
Impact of COVID-19 on existing epidemic of noncommunicable diseases: Morbidity and mortality
The existing epidemic of NCDs which is responsible for 72% of the deaths globally has been an aggravating factor for the adverse outcomes of the COVID-19. Among NCDs, the leading causes of morbidity are cardiovascular diseases, cancer, stroke, chronic respiratory diseases, diabetes mellitus, and chronic kidney diseases as per the global burden of disease estimates of 2016. According to the WHO, NCDs are the number one killer in the South East Asia region in the age group of 30–70 years for the year 2016. Certainly, in the COVID-19 pandemic, vulnerable groups are not only elderly people but also those with ill health and comorbidities.
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. In India, 86% of COVID-19 patients had comorbid conditions such as diabetes, chronic kidney problems, hypertension, or heart ailments, revealing that an underlying illness makes a person more susceptible to infection by the coronavirus. The age distribution shows that 63% of the deaths were in the group of 60 years and above, 30% between 40 and 60 years, and 7% below 40 years. Wang et al. reported in the study from China that out of total 138 patients hospitalized by novel coronavirus infection, 26.1% of patients with COVID-19 shifted to intensive care unit (ICU), 72.2% had concurrent comorbidities, as opposed to only 37.3% of patients who did not require ICU care. Chronic hypertension and other cardiovascular comorbidities were more frequent among COVID-19 deceased patients i.e. 48% and 14% than recovered patients which is 24% and 4% respectively. Further, a study has shown that among the 32 nonsurvivors from a group of 52 ICU patients, the most distinctive preexisting noncommunicable comorbidities were cerebrovascular diseases (22%) and diabetes (22%). Of the 1099 confirmed patients with COVID-19 reported in a study, 173 had severe disease; as compared to those with nonsevere disease, patients with severe disease had a higher prevalence of hypertension (13.4% vs. 23.75%), DM (5.7% vs. 16.2%), CAD (1.8% vs. 5.8%), COPD (0.6% vs. 3.5%), and cerebrovascular disease (1.2% vs. 2.3%). A recently conducted meta-analysis concluded that hypertension, respiratory system disease, and cardiovascular disease had an odds ratio (OR) of 2.36, 2.46, and 3.42, respectively, for severe disease as compared to nonsevere disease.
An age >65 years, CAD, congestive heart failure, cardiac arrhythmia, COPD, and current smoking were associated with a higher risk of in-hospital death. Furthermore, various reports suggested that there is an independent relationship of older age, underlying cardiovascular disease (CAD, heart failure, and cardiac arrhythmias), current smoking, and COPD with death in COVID-19. In this multinational observational study involving patients hospitalized with COVID-19, it was confirmed from observations, suggesting that underlying cardiovascular disease is independently associated with an increased risk of in-hospital death.
In a systematic review on the prevalence of comorbidities and COVID-19, prevalent comorbidities were hypertension (21.1%) and diabetes (9.7%), followed by cardiovascular disease (8.4%) and respiratory system disease (1.5%). Among the comparison group between severe and nonsevere patients, the pooled OR of hypertension, respiratory system disease, and cardiovascular diseases was 2.36, 2.46, and 3.42, respectively.
Diseases such as hypertension, diabetes, respiratory system disease, cardiovascular disease, and their susceptibility conditions may be linked to the pathogenesis of COVID-19. Chronic diseases share several standard features with infectious disorders, such as the proinflammatory state and the attenuation of the innate immune response. For instance, diabetes occurs in part because the accumulation of activated innate immune cells in metabolic tissues leads to the release of inflammatory mediators, especially interleukin-1β and tumor necrosis factor-alpha, which promote systemic insulin resistance and β-cell damage. In addition, metabolic disorders may lead to low immune function by impairing macrophage and lymphocyte function, which may increase the susceptibility of people to complications.
Impact on socioeconomic aspects and on sustainable developmental goals
The COVID-19 pandemic is associated with two concurrent global crises: health crisis and economic crisis. This crisis threatens the health-care systems and government policies. The policy response will determine the impact of pandemic on human health and in attaining the sustainable development goals (SDGs), placing a large responsibility on policymakers. From health system point of view, COVID-19 pandemic has caused an unprecedented challenge for health-care systems worldwide. In developing countries with a lack of universal health coverage (UHC), where the market plays a dominant role, the cost of care would also depend on the capacity of health services and commodities in those contexts. Such economic failures may adversely effect the diverse health services during managing COVID-19. Therefore, health systems in low- and middle-income countries (LMICs) that are often under-resourced and over-burdened are likely to incur a high cost of care and associated economic failures when addressing COVID-19.
Another major economic challenge during COVID-19 would be a high out-of-pocket (OOP) expenditure in developing countries due to high burden of NCDs and the health-care organizations operate within pluralistic health systems incurring OOP for health services. This economic burden is likely to increase during COVID-19 unless state-sponsored diagnostic and therapeutic financing is made available. An increased OOP is associated with subsequent poverty, unemployment, and other socioeconomic consequences, which may affect individuals and populations in the post-COVID-19 era.
Furthermore, in context of NCDs, already there is a high burden, which may increase the hospitalization and mortality across populations when co-occurring with COVID-19. From an economic perspective, such adverse health outcomes will affect the economic returns on existing and newly adopted strategies of health systems financing. In addition, many people with NCDs may experience restricted mobility due to lockdown or lack of transportation, which will affect their access to health services during COVID-19.
The COVID-19 pandemic has affected global developmental and health objectives at a much broader scale. The major impacts will be observed in the UN SDGs, especially SDG3 which is “good health and well-being.” This may slow the progress on SDGs even further, combining the fluctuating economy with rising mortality in countries at every level of development. Global response to COVID-19 therefore should focus on sustainability and on equitable and affordable health care for all. Various studies suggest that it might take more than a decade globally to recover societally and economically from the pandemic and this may significantly hinder progress in Sustainable Development Agenda (SDGs) 2030. Increasing burden due to mortality and morbidity due to COVID-19 and comorbidities poses a greater challenge to the existing health systems, especially in LMICs. The quality, quantity, and equity of services have been impacted because of the imbalance created by COVID-19. From health systems financing point of view, the priority lies in the strengthening frontline services for pandemic response and supportive health financing policies. As per the WHO's guidance on health financing policy, the focus should be on strengthening health system resilience, health security, and UHC. The action pertains to raising the adequate revenues for health systems, organizing those revenues in order to maximize risk-sharing across the entire population, and spending in the best way to improve the health of all citizens of a country.
Impact on prevention and control of noncommunicable diseases
Over the past few years, the global priorities have been moving toward UHC, promoting health and well-being, and protecting against health emergencies. Prevention and control of NCDs is important during this pandemic because NCDs are major risk factors for patients with COVID-19. In addition, some of the restrictive measures such as lockdowns, social distancing, and travel restrictions to reduce the spread of infection in many countries impact specifically on people living with NCDs by limiting their activity, hampering their ability to secure healthy foods, and to access preventive or health promotion services. Evidence from this and previous pandemics suggests that without proper management, chronic conditions can worsen due to stressful situations resulting from restrictions, insecure economic situations, and changes in normal health behaviors. The disruption of routine health services and medical supplies can lead to increase in morbidity, disability, and avoidable mortality among NCD patients. The specific priorities in relation to challenges  and risk of NCDs are presented in [Table 1].
|Table 1: Challenges, risks, and specific priorities for noncommunicable diseases during the coronavirus disease pandemic|
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Strategic approaches for addressing the noncommunicable disease agenda in COVID-19 pandemic
Overall health system strengthening is required in the implementation of policies, governance health-care delivery systems additional health workforce and infrastructure, to manage the people living with NCDs, prevent and control their risk factors during the COVID-19 outbreak, with a particular focus on most vulnerable to the impact of COVID-19.
The need for an hour is the evidence generation because as of now globally or nationally, there are no dedicated guidelines available to combat the comorbid condition of COVID-19 and NCDs. This situation represents a major threat to fragile health systems and emphasizes the need for innovative integrative approaches to health-care delivery. Health services need to be reorganized to address populations' needs holistically and effectively leverage resources in already resource-limited settings.
Access and delivery of quality health care should be reinforced and implemented at primary health-care (PHC) level within the framework of health system strengthening. Competencies need to be developed around services provided for comorbidity rather than specific diseases. New models of integration within the health sector and other sectors should be explored and further evidence generated to inform policy and practice to combat the double burden of this COVID-19 and existing epidemic of NCDs. The priority setting is required in the area of prevention, surveillance, management, and governance to combat the current situation.
The key preventive strategies include reviewing existing and emerging evidence related to NCD and risk factors, determining implications for NCDs related services and programs directed at vulnerable populations; reinforcement of the existing strategies designed for prevention and control of NCDs keeping in view the threats to regulatory framework, models of health promotion should be adopted; however, the focus and funding for prevention for the general public is poor or missing in many countries including India. Focusing on integrated surveillance for both NCDs and communicable diseases including epidemiological investigations, trend analysis, and forecasting will be necessary to better understand the relationship between NCDs, their risk factors, and predisposition to the COVID-19 as well as their influence on the course and outcome of the disease.
For management, practical guidance should be followed for the continuity of essential health and community services along with the health promotion activities such as communication messages on COVID-19 and NCDs. Furthermore, implementation of WHO guidance on resuming health services and activities in a postpeak COVID-19 scenario this should be given the highest priority.
From governance and advocacy perspective, while keeping in view of the UHC, convergence between the socioeconomic development emergency and NCD responses should be bridged. Addressing COVID-19 and NCD comorbidities, implementation of innovative approaches such as digital health-care solutions, real-time epidemiology, use of artificial intelligence and multisectoral or intersectoral participation of different ministries in the social, economic, environmental policies, and further investments for health in these systems should be considered as a priority.
Furthermore, along with the evidence generation and priority setting in different areas of NCD prevention and control, there is a need for integration of this public health emergency, i.e., COVID-19, into the existing programs related to NCDs such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, National Programme for Healthcare of Elderly, and National Tobacco Control Programme. Health planners and policy makers need to agree that health systems must address populations holistically and not address diseases in a discrete manner. An integrated approach seeks to address health problems by providing services in a comprehensive manner.
Given the scarcity of resources in priority setting, all resources, both human and financial, need to be integrated to address the major disease burdens affecting communities. Integrated interventions are possible at all levels, including health facility, community, and household. In terms of priority setting, the integration of the communicable disease programs should be used to address required improvements in the health system and generic issues such as human resources, financing, drug supply, quality assurance, and health information management system. Evidence suggests that prevention and control of NCDs are best implemented at PHC level, so frameworks and structures need to be set up such for example supply chain management, training and capacity building, surveillance, supervision, and monitoring and evaluation need to be restructured to be able to address health problems in an integrated manner. A case study by taking India as an example for the strategic approaches is depicted in the [Figure 1].
|Figure 1: Strategic framework with case study from India. NPCDCS - National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, NPHE - National Programme on Healthcare for Elderly, NTCP - National Tobacco Control Programme, NMHP - National Mental Health programme, NPPC - National Programme for Palliative care|
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Many existing health interventions are an example of the integration of the programs which are interconnected such as in NCDs, tuberculosis with diabetes, etc., Prevention packages for NCDs can also be integrated as addressing behavior risk factors of NCDs will also impact on the prevention of many communicable diseases, for instance, avoiding tobacco use and harmful use of alcohol, and eating a healthy diet will also promote a stronger immune system less prone to infection. Furthermore, some of the risk factors for the NCDs which include unhealthy diet, stress, alcohol, and tobacco use are linked to COVID-19.
Both COVID-19 and NCDs have a diminishing impact on global and national income, productivity, and household expenditure, leading to overall impact on the economic growth of a country. Evidence suggests that health is an important factor in economic development which calls for a global approach to address health for development. Therefore, multisectoral action beyond the health sector is required.
| Discussion|| |
The impact of COVID-19 response measures on NCDs is multifaceted. Physical distancing or quarantine can lead to poor management of NCD behavioral risk factors, including unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol. Evidence suggests that without proper management, chronic conditions can worsen due to stressful situations resulting from restrictions, insecure economic situations, and changes in normal health behaviors. As with other health service and preventive programs, the delayed routine medical appointments and tests can delay NCD management, while physical distancing, restricted access to PHC units, pharmacies, and community services, alongside a reduction of transport links, all disrupt continuity of care for NCD patients. The disruption of routine health services and medical supplies risks increasing morbidity, disability, and avoidable mortality over time in NCD patients.
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. 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  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.
It is necessary to strengthen the primary care and referral services, so that population health can be served without disrupting existing models of delivering health services. In addition, special attention should be given to elderly, adults, and other vulnerable groups addressing the specific health needs of those population.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al
. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Leung C. Clinical features of deaths in the novel coronavirus epidemic in China. Rev Med Virol 2020;30:e2103.
China Medical Treatment Expert Group for COVID-19. Comorbidity and its Impact on 1,590 patients with COVID-19 in China: A Nationwide Analysis; 2020.
Pramesh CS, Badwe RA. Cancer management in India during Covid-19. N Engl J Med 2020;382:e61.
GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1151-210.
Pal R, Bhadada SK. COVID-19 and non-communicable diseases. Postgrad Med J 2020. pii: postgradmedj-2020-137742.
Ministry of Health and Family Welfare, Government of India. New Delhi: Press Release; 7 April, 2020.
Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al
. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: Retrospective study. BMJ 2020;368:m1091.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al
. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.
Morgan AD, Zakeri R, Quint JK. Defining the relationship between COPD and CVD: What are the implications for clinical practice? Ther Adv Respir Dis 2018;12:1753465817750524.
Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al
. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: A systematic review and meta-analysis. Int J Infect Dis 2020;94:91-5.
Dooley KE, Chaisson RE. Tuberculosis and diabetes mellitus: Convergence of two epidemics. Lancet Infect Dis 2009;9:737-46.
Odegaard JI, Chawla A. Connecting type 1 and type 2 diabetes through innate immunity. Cold Spring Harb Perspect Med 2012;2:a007724.
Thakur J, Prinja S, Garg CC, Mendis S, Menabde N. Social and Economic Implications of Noncommunicable diseases in India. Indian J Community Med 2011;36:S13-22.
The Socioeconomic Impact of COVID-19 in the Asia Pacific. Bangkok: United Nation Development Programme; April, 2020.
Boutayeb A, Boutayeb S. The burden of non communicable diseases in developing countries. Int J Equity Health 2005;4:2.
Kluge HH, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, et al
. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020;395:1678-80.
Thakur JS, Jaswal N, Grover A, Kaur R, Jeet G, Bharti B, et al
. Effectiveness of district health promotion model (Hoshiarpur Ambala model): An implementation experience from two districts from Northern part of India. Int J Non Commun Dis 2016;1:122-30.
Thakur JS, Jaswal N, Grover A. Is focus on prevention missing in national health programs? A situation analysis of IEC/BCC/health promotion activities in a district setting of Punjab and Haryana. Indian J Community Med 2017;42:30-6.
] [Full text]
Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al
. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.
International Diabetes Federation. IDF Diabetes Atlas. 9th
ed.. Brussels: International Diabetes Federation; 2019.
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