|Year : 2020 | Volume
| Issue : 2 | Page : 76-82
COVID-19 and noncommunicable diseases: Identifying research priorities to strengthen public health response
Prashant Mathur, Sukanya Rangamani
National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bengaluru, Karnataka, India
|Date of Submission||31-May-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||08-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Prashant Mathur
National Centre for Disease Informatics and Research, Indian Council of Medical Research, II Floor of Nirmal Bhawan, ICMR Complex Poojanhalli Road, Off NH-7, Adjacent to Trumpet Flyover of BIAL Kannamangala Post, Bengaluru - 562 110, Karnataka
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19) pandemic is the most important global public health event of this century, and India is among the first 15 countries with affected persons. Persons with male gender, older age, and preexisting noncommunicable diseases (NCDs) are found to be associated with severe and fatal disease. Specific treatment modalities for COVID-19 are still elusive. NCDs are reported as presenting symptoms in COVID-19 patients, and preexisting NCD can worsen COVID-19 prognosis. The management of NCDs in the context of COVID-19 infection is challenging. India poses a huge burden of NCDs and their risk factors which could synergize with COVID-19 for serious illness and outcome. This article reviews and proposes a research agenda for COVID-19 and NCDs in the ambit of strategic approach: review of adequacy of existing mechanisms to tackle NCDs and their risk factors, strengthen the evidence base, enable remote access health-care service delivery, strategically revamp health systems to become more responsive, integrated, and universal, encourage all-round innovation through collaborations and partnerships, and empower community actions for home-based care. The key research domains are burden and epidemiology, health-care delivery, use of technology, sectoral approach, surveillance-monitoring-evaluation, behavioral and communication research, and governance and policy. Within each domain, key research priorities are identified which would be cross-cutting across more domains.
Keywords: Coronavirus disease 2019, noncommunicable diseases, public health response, research priorities
|How to cite this article:|
Mathur P, Rangamani S. COVID-19 and noncommunicable diseases: Identifying research priorities to strengthen public health response. Int J Non-Commun Dis 2020;5:76-82
|How to cite this URL:|
Mathur P, Rangamani S. COVID-19 and noncommunicable diseases: Identifying research priorities to strengthen public health response. Int J Non-Commun Dis [serial online] 2020 [cited 2021 Dec 2];5:76-82. Available from: https://www.ijncd.org/text.asp?2020/5/2/76/288253
| Introduction|| |
Coronavirus disease 2019 (COVID-19) pandemic is the most important global public health event of this century, and India is among the first 15 countries affected by it. A cluster of pneumonia cases of unknown etiology was reported from the city of Wuhan, in the Hubei province of China, in December 2019. A novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the causative agent of the disease which was subsequently termed as the COVID-19 by the World Health Organization (WHO). SARS-CoV-2 mainly affects the lower respiratory tract and manifests as pneumonia in humans. It is a betacoronavirus, an enveloped single-stranded long RNA virus with a high propensity to replicate in a host cell and similar to the earlier reported SARS-CoV and MERS-CoV. Geographical clustering in genomic sequences has been observed in countries, and more studies are needed to understand the evolutionary history of the virus strains in different countries and the linkage to biologic properties and clinical manifestation., The median incubation period is on an average 5–6 days and maximum of 14 days. Presymptomatic infection has been documented in contact tracing and investigations of clusters of confirmed cases. Population density, population behavior (physical distancing), geographic area (urban/rural), public health system response (testing and contact tracing), and measures (travel restrictions and school closures) determine the control of the pandemic.,,
All age groups, male preponderance, all health conditions, and socioeconomic-geographic diverse populations have been reported to be infected. Data from China's Infectious Disease Information System has indicated that most cases were asymptomatic and mild (81%), 14% had severe, and 5% had critical clinical manifestations. The overall case-fatality rate was 2.3% among which cases aged >80 years had the highest case fatality rate of 14.8%. Severe critical and fatal disease occurs more commonly among age group >65 years. Preexisting conditions such as smoking, obesity, hypertension, cardiovascular, and respiratory disease were associated with severe, critical, or fatal COVID-19 as compared to those with less severe disease., Case fatality increased with age, especially in countries with a significant proportion of elderly as in Italy, the USA, and the UK, and had a significant impact on health-care resources. There is no specific treatment available yet, although several research studies are underway globally.
The WHO declared it as a Public Health Emergency of International Concern on January 11, 2020, and finally as a global pandemic on January 30, 2020. India had recognized the potential problem and set up its response mechanisms by mid-January 2020, which was way ahead of several other countries. The COVID-19 epidemic is expected to continue for a long time with the relaxation of lockdown and identification of new infection clusters.
| Burden of Noncommunicable Diseases in India|| |
Noncommunicable diseases (NCDs) and their risk factors pose a significant health burden globally. In India, the age of onset of NCDs is in young adults. More than two-third (61.8%) of the deaths in India are contributed by NCDs (cardiovascular diseases – 28.1%, chronic respiratory diseases – 10.9%, neoplasms – 8.35%, diabetes – 6.5%, and other urogenital, blood, and endocrine diseases). The risk of premature deaths (<70 years) due to NCDs is 23%. The prevalence of NCDs in all age groups has increased over the years. The age-standardized diabetes prevalence increased by 29·7% (95% U.I. 26·5–32·6) from 1990 to 2016 and was associated with the epidemiological transition of the states. The crude incidence of cancers increased by 28.2% (1990–2016). The crude prevalence of COPD and asthma increased in the same time period contributing to 75% disability-adjusted life years (DALYS) and 20% DALYS of all chronic respiratory diseases in 2016. Ischemic heart diseases, chronic obstructive pulmonary diseases, and stroke are among the five leading contributors for DALYs.
The leading risk factors for NCDs include use of tobacco, alcohol, inadequate fruit and vegetable intake, high systolic blood pressure, high fasting plasma glucose, drug abuse, high total cholesterol, high body mass index and low physical activity and air pollution. Dietary risks and high systolic blood pressure were the leading risk factors for ischemic heart diseases and stroke. The increase in prevalence of NCDs and risk factors were linked to the epidemiological and health transition of the different states, as reported in India's state-level disease burden assessment.
| Identifying Research Priorities for Addressing Noncommunicable Diseases and Coronavirus Disease 2019|| |
COVID-19 being a new disease entity with varied biological, pathogenetic mechanisms, clinical manifestations, and epidemiology calls for an innovative approach for research. As several research priorities emerge, attention to research in NCDs needs focus to reduce avoidable long-term morbidity and mortality. Studies will encompass research in basic science (virus biology and pathogenesis), clinical research, epidemiological, operational, implementation, intervention trials, vaccines and diagnostics, translational, behavioral, communication and advocacy, innovations in technology, health technology assessments, and policy.
The review shall identify key strategies to strengthen health system response to address COVID-19 and NCDs and develop a framework of research priorities for NCD prevention, management, and control in India. The overall guiding principles for the NCD-COVID-19 research agenda are:
- Review of adequacy of existing mechanisms to tackle NCDs and their risk factors
- Strengthen the evidence base
- Enable remote access health-care service delivery
- Strategically revamp health systems to become more responsive, integrated and universal
- Encourage all-round innovation through collaborations and partnerships
- Empower community actions for home-based care.
Accordingly, we would like to propose the following key research priorities [Figure 1] under major domains of NCD-related research for COIVD-19.
Burden and epidemiology
Research done using epidemiological tools generates analytical information on the magnitude, distribution, determinants, correlations, trends, projections of diseases, and their risk factors and provides solutions for health interventions and their monitoring. At present, the understanding of COVID-19 with NCDs is driven by hospital-based studies that describe the clinical and mortality determinants. There is a need to improve the robustness of evidence for guiding action and evaluation.
- Undertake complete well-designed epidemiological assessment of NCDs and their risk factors at a national and subnational level using standardized tools and methods
- Strengthen mortality surveillance at national and subnational levels with the generation of disaggregated data and ascertainment of multiple causes of death
- Characterize social, cultural, and economic determinants of behavioral risk factors and their impact on NCDs and COVID-19
- Epidemiological characterization of interactions of other health conditions in relation to the occurrence, progress, and outcomes of NCDs, for example, tuberculosis, BCG vaccination, malaria, H1N1, and other CoV exposures
- Clinicoepidemiological studies to generate the evidence on assessment and management (therapeutic drugs, drug interactions, and processes) of NCDs in COVID-19 and characterize the pathophysiological mechanism of NCDs in COVID-19
- Development and refinement of existing methods and tools for assessing NCD related mortality, morbidity, risk factors, and determinants so that they are simple, flexible, with high accuracy and predictive value. Local adaptations and contextualization must be done to improve its validity, acceptability, and comparability of results
- Improve timeliness of evidence availability using innovative tools and methods (use of IT networking)
- Identify rapid methods of assessments in view of prevailing restrictions of social distancing, no crowding, travel, and hygiene
- Periodic burden estimation studies to guide policies and further epidemiological studies
- Developing risk and vulnerabilities scores for clinical use having good predictive discrimination
- Establishing disease registries and building linkages with other databases
- Optimal utilization of health technology assessment and health impact assessment tools.
Primary health-care facilities are patients' first point of contact with health services and hence the most appropriate place for patient screening and early disease detection, continuous care provision for uncomplicated patients, and referral of patients to specialists. Chronic disease management should be coordinated across all health-care settings and providers and focus on interventions at individuals, health delivery systems or its selected components, and follow a system-wide or population health approach.
- Develop appropriate case management guidelines for different levels of health-care services to include pharmaceutical-based and behavior change approaches
- Strengthen mechanisms for early detection, screening, referral systems, and provision of quality management services
- Develop a strategy for monitoring of services provided to assess coverage, incident cases, and compliance with management
- Identify tools to provide care based on people's needs and an ability to identify people with different levels of need
- Develop cost-effective strategies for a comprehensive risk reduction at community and individual levels in diverse cultural and socioeconomic settings. Strategies for primary prevention without the need for individual-level risk assessment or monitoring of biochemical safety parameters (e.g., polypill)
- Scoping studies for optimal utilization of AYUSH on promotive and curative aspects of NCDs
- Evaluate strategies used in empowering communities for prevention and control of NCDs and COVID-19
- Assess different strategies, organizational models, interventions, and technologies (e.g. IT) for risk reduction and early detection/treatment
- Develop and evaluate models for reorienting health systems in delivering affordable and equitable health care through a universal health-care approach
- Develop and disseminate structured knowledge for health promotion
- Collate culturally specific and nationally/subnationally appropriate resources for training health-care workforce
- Develop integrated training of the health workforce to deliver universal health care
- Develop strategies for task shifting by involving lay people and volunteers for chronic care and health promotion and including home-based care
- Identify modes of effective public–private partnerships that ensure that disadvantaged communities have adequate resource allocations in health care and in preventative practice
- Encourage the use of remote methods to access health care, for example, telemedicine, hub and spoke models
- Strengthen linkages between tertiary, secondary, and primary health-care delivery to strengthen optimal monitoring and follow-up
- Ensure the continuity of care for NCDs and mental health by prioritizing testing and early care for persons with preexisting NCDs
- Develop and implement specific disease guidance and digital health-care solutions (clinical decision support systems)
- Undertake studies that ensure universal health care.
Use of technology
In the present nationwide lockdown and restricted movements thereafter, the health-care services were severely disrupted for non-COVID-19 patients. It impacted seeking medical advice, monitoring of disease, treatment protocols, availability of laboratory investigations, access to medicines, and palliative care. However, what also played an important role was the use of technological support – telemedicine, remote/home-based vital monitoring devices, solutions to minimize physical proximity with COVID-19 patients, use of drones to deliver medication supplies, etc. Thus, technological advances are needed to fulfill the needs related to ease of reporting and monitoring, communication, home-based life support, maintaining essential supplies of medications, and encourage the empowerment of patients in self-management of health conditions and pathways for acute care.
- Evaluate digital health-care solutions for cost-effectiveness and cost–benefit analysis
- Assess patient and caregivers literacy for digital solutions and identify enablers and disablers for adopting technology in self-care
- Scope the regulatory and clinical care practice laws to position technology for health care
- Address ethical issues of remote models of health-care provision
- Create and assess technology platforms for collaboration and development (data repositories, data sharing policy, and incubators)
- Evaluate current electronic health records guidelines for expansion to newer models of health-care provision
- Evaluate devices and IT-linked solutions for the validity of home-based monitoring and reporting.
India's health care is organized under three broad groups of institutions: public sector (largely funded by the government), private sector (largely funded by private funding sources), and civil society (represented by the community-based organizations). Health-care interventions require actions within each sector and between more than one sector. In addition, several other distant and proximal determinants such as income inequalities, migration, lifestyle changes, and the impact of media need to be addressed. The present response of the government of India has clearly exemplified the importance and willingness of collaboration and partnerships of “whole of government” and “whole of society” in tackling the pandemic and its consequences.
- Identification of opportunities for NCD prevention and control through existing health programs, for example, tuberculosis, HIV/AIDS, and child health programs
- Involving a wide range of stakeholders such as individuals, voluntary and community sector, clinicians, private industry, and public services
- Use education and funding as levers to increase opportunities for health promotion, disease prevention, and early detection and management
- Create service networks and pathways that cut-across health, social care, and sectoral boundaries
- Define pathways for engagement with other sectors and develop a framework to foster common understanding between sectors
- Strategies for engaging businesses for health-study marketing techniques and marketing data derived from commercial companies on behavior modification; assess what kind of innovations in NCD care are adopted
- Create sustainable public forums that raise awareness of issues relating to NCDs
- Undertaking health impact assessments on a regular basis for any public policy.
Surveillance, monitoring, and evaluation
A robust surveillance system provides timely, accurate, and relevant health information for formulating and evaluating evidence-based policies. A common set of core indicators is needed for each component of the surveillance system that monitors exposures (risk factors and determinants), outcomes (morbidity and mortality), and health-system responses (interventions and capacity). This would translate to informed decisions on resource allocation to improve equity and quality of health services in the country. Investing in comprehensive health information and NCD surveillance system at the national level with the use of information and communication technology will provide rich data for supporting decision-making, health-care delivery, and management of health services at the national- and sub-national levels. The COVID-19 pandemic could trigger a syndemic, which calls for a comprehensive system of surveillance.
- Generate evidence on “what works” in terms of modifying the target outcome/s, feasibility, acceptability, repeatability, economic implications, equity, and political appropriateness
- Strength capacity for data analytics, information generation, dissemination, interpretation, and usage
- Build a critical mass of policy entrepreneurs to engage with planners and policymakers, who will bridge between researchers and policymakers
- Align research program timelines to those of policy and program requirements. In the present COVID-19 pandemic, there are no prior policies or programs available. Hence, surveillance programs can help in identifying priority policy and programmatic requirements
- Develop indicators for monitoring progress at various levels of health care as well as relevant to the stakeholders involved
- Develop comprehensive and sustainable databases for NCDs and risk factors (including nonhealth determinants)
- Periodic evaluation studies will help in identifying knowledge and implementation gaps
- Integrate chronic disease monitoring and surveillance within the infectious disease surveillance
- Innovation in population health surveillance.
Behavioral and communication research
COVID-19 pandemic has singularly brought out the focus of vulnerabilities of people with NCDs and its risk factors either due to increased susceptibility and severe outcomes from the infection and the consequences of lack of access or disruption to continued care for their NCDs. Health system preparedness and action to address the above concerns have to align risk communication and sustaining healthy practices by communities and individuals. Research is needed on how people and communities understand the role of behavioral change (risk of COVID-19 and NCDs), and what kind of communication strategies will influence the knowledge, beliefs, attitudes, and practices of communities.
- Developing strategies to enhance authentic information on COVID-19 and NCDs and sharing knowledge with communities to avoid false messaging
- Conduct research on communication strategies that address socioeconomic and cultural contexts
- Review policy and program implementation for gaps in communication strategies in NCD management
- Develop feasible technology solutions for urban/rural/remote areas to share knowledge with people and address their concerns on NCDs and COVID-19
- Evaluate social media platforms to understand communication strategies for behavior change in NCDs and COVID-19.
Governance and policy
The determinants of NCDs and their risk factors lie outside the realm of health sector. To reduce the future burden of NCDs, a strong call for prevention and control of risk factors and determinants is required. These include economic, labor and employment, migration, and health in all policies. Within the health sector, a revamped governance system will facilitate uninterrupted delivery of health-care services in restricted environments. Policies should focus on three pillars of “Mobilise, strengthen and act.” COVID-19 and its impact on NCDs have shown that it is crucial to mobilize stakeholders, strengthen the existing health system and partnerships with patient groups, community, nongovernmental agencies, funders, and act immediately to keep up the momentum in NCD prevention and control.
- Scope international and national experiences on governance in health for research, health-care provision, and health policy for NCDs
- An evaluation of existing health-care service delivery systems in the universal health care (UHC) lens
- Policy levers to facilitate suitable action at state and national levels
- Mechanisms for collaborations and partnerships
- Policy research – national and international.
| Conclusion|| |
COVID-19 pandemic is characterized with attenuation of innate immunity and a pro-inflammatory response which could accelerate many NCDs and their occurrence. Several steps taken to minimize the spread of infection, social distancing, restricted mobility, and advise to stay indoors have resulted in disruption of routine health-care access and service delivery and supplies to essential food, medicines, and diagnostics. The consequent economic situation could increase stress levels to impact NCDs. Since the scale of risk for NCDs is still not clear, strong NCD preventive and early diagnosis steps will be required to protect individuals and vulnerable groups.
Thus, the framework of research priorities proposed can strategically guide the preparedness of the health system to include NCDs in the humanitarian response to COVID-19.
Financial support and sponsorship
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.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al
. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
Mavian C, Pond SK, Marini S, Magalis BR, Vandamme AM, Dellicour S, et al
. Sampling bias and incorrect rooting make phylogenetic network tracing of SARS-COV-2 infections unreliable. Proc Natl Acad Sci 2020;117:12522-3.
Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al
. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health 2020;8:e488-96.
Nussbaumer-Streit B, Mayr V, Dobrescu AI, Chapman A, Persad E, Klerings I, et al
. Quarantine alone or in combination with other public health measures to control COVID-19: A rapid review. Cochrane Database Syst Rev 2020;4:CD013574.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.
Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al
. Prevalence of comorbidities and its effects in coronavirus disease 2019 patients: A systematic review and meta-analysis. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 2020;94:91-5.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al
. Comorbidity and its impact on 1590 patients with COVID-19 in China: A nationwide analysis. Eur Respir J 2020;55:2000547.
CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) – United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:343-6.
Banerjee A, Pasea L, Harris S, Gonzalez-Izquierdo A, Torralbo A, Shallcross L, et al
. Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: A population-based cohort study. Lancet 2020;395:1715-25.
Chatterjee P, Nagi N, Agarwal A, Das B, Banerjee S, Sarkar S, et al
. The 2019 novel coronavirus disease (COVID-19) pandemic: A review of the current evidence. Indian J Med Res 2020;151:147-59.
] [Full text]
Dandona L, Dandona R, Kumar GA, Shukla DK, Paul VK, Balakrishnan K, et al
. Nations within a nation: Variations in epidemiological transition across the states of India, 1990-2016 in the Global Burden of Disease Study. Lancet 2017;390:2437-60.
Tandon N, Anjana RM, Mohan V, Kaur T, Afshin A, Ong K, et al
. The increasing burden of diabetes and variations among the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1352-62.
India State-Level Disease Burden Initiative Cancer Collaborators. The burden of cancers and their variations across the states of India: The Global Burden of Disease Study 1990-2016. Lancet Oncol 2018;19:1289-306.
Salvi S, Kumar GA, Dhaliwal RS, Paulson K, Agrawal A, Koul PA, et al
. The burden of chronic respiratory diseases and their heterogeneity across the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1363-74.