|Year : 2021 | Volume
| Issue : 3 | Page : 252-256
Impact of COVID-19 on noncommunicable diseases (NCDs)
Manoj Arajanbhai Suva1, Viraj Ramesh Suvarna1, Viswanathan Mohan2
1 Eris Lifesciences Limited, Commerce House-4, Prahlad Nagar, Ahmedabad, Gujarat, India
2 Department of Diabetology, Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialities Centre, Chennai, Tamil Nadu, India
|Date of Submission||07-Aug-2020|
|Date of Decision||09-Nov-2020|
|Date of Acceptance||13-Nov-2020|
|Date of Web Publication||30-Sep-2021|
Mr. Manoj Arajanbhai Suva
Eris Lifesciences Limited, Commerce House-4, Prahlad Nagar, Ahmedabad 380015, Gujarat.
Source of Support: None, Conflict of Interest: None
Since December 2019, a novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), pandemic has affected more than 18.6 million people worldwide. Male gender, older age, obesity, and comorbid noncommunicable diseases (NCDs) like diabetes, hypertension, cardiovascular disease (CVD), chronic respiration illnesses, and cancer have higher risk and fatal outcome of COVID-19. India has a huge burden of NCDs and their associated risk factors which could act in harmony with COVID-19 to produce severe and fatal outcome. Till date the specific treatment options for COVID-19 are elusive and as NCDs are reported as the main causative risk factors for COVID-19 which can worsen the outcome, the focus should be made on continuing and improving the healthcare facilities related to the prevention, management, and control of NCDs. The management of NCDs in the context of SARS-CoV-2 infection are quite challenging. The restrictive measures imposed by governments all over the world such as complete or partial lockdown, travel restrictions, and physical distancing to contain the spread of SARS-CoV-2 infection have affected the people with NCDs by limiting their access to healthcare facilities, physical activity access to healthy food, and even to medicines and essential supplies. These factors increase the risk of developing obesity, diabetes, and CVDs. This article reviews the burden of NCDs in India, the cross-connection between NCDs and COVID-19, disruptions of healthcare services for NCDs, and proposes research priorities during COVID-19 for effective management and control of NCDs.
Keywords: Cardiovascular diseases, COVID-19, diabetes, healthcare services, hypertension, noncommunicable diseases (NCDs)
|How to cite this article:|
Suva MA, Suvarna VR, Mohan V. Impact of COVID-19 on noncommunicable diseases (NCDs). J Diabetol 2021;12:252-6
| Introduction|| |
A novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected the entire world since December 2019 and World Health Organization (WHO) has declared it as a pandemic. As of 31 October 2020, there have been 45,428,731 confirmed cases of COVID-19, including 1,185,721 deaths, reported to the WHO. COVID-19 has affected over 166 countries globally, with most of the cases being reported from USA, Europe, Asia, and Eastern Mediterranean region. The SARS-CoV-2 is rapidly spreading in India and has already affected more than 8 million people and more than 121,641 deaths have been reported.,, The COVID-19 pandemic has significantly diminished the provision of health services for noncommunicable diseases (NCDs) all over the world. About 41 million deaths were reported due to NCDs last year which accounted for 71% of all deaths worldwide. Every year, NCD is found out to be a culprit for death of 15 million people aged between 30 and 69 years and 85% of these premature deaths are reported in low and middle income countries (LMICs). Various risk factors such as male gender, older age, and comorbid NCDs are found to be associated with severe and fatal COVID-19 outcome.
| Burden of NCDs in India|| |
India contributes to 18% of the world’s population and populations of many states of India are similar to those of large countries. NCDs and their risk factors are major health burden in India and, moreover, the age of onset of NCDs is much younger in India. Over the years, the prevalence of NCDs has increased markedly in India. According to the Global Burden of Disease Study 2016 conducted in India, NCDs contributed to about two-thirds (61.8%) of the deaths which includes cardiovascular diseases (CVDs; 28.1%), chronic respiratory diseases (10.9%), neoplasms (8.3%), diabetes and other urogenital, blood, and endocrine diseases (6.5%), digestive diseases (2.2%) and chronic liver disease and cirrhosis (2.1%). The risk of premature deaths below 70 years of age due to NCDs is 23%. According to International Diabetes Federation (IDF), 463 million people have diabetes in the world, and out of this, an estimated 77 million people are in India. The prevalence of diabetes is found to be 8.9% in India according to the IDF. The ICMR – INDIAB study showed that an epidemiological transition is taking place with the diabetes epidemic now shifting to lower socioeconomic groups, especially in urban areas of states with higher GDP. In India, more than 200 million adults have hypertension (overall prevalence 30.7%), yet only one out of seven patients have their hypertension under control., In India, overall CVDs contributed 28.1% of the total deaths and 14.1% of the total disability-adjusted life-years (DALYs) in 2016. The crude cancer incidence rate in India increased by 28.2% from 63.4 per 100,000 in 1990 to 81.2 per 100,000 in 2016. Chronic obstructive pulmonary disease (COPD) and asthma were responsible for 75.6% and 20% of the chronic respiratory disease total DALYs, respectively, in 2016. The number of cases of COPD in India increased from 28.1 million to 55.3 million from 1990 to 2016. The contribution of chronic respiratory diseases to the total DALYs in India increased from 4.5% to 6.4% from 1990 to 2016 which is 32% of the total global DALYs. As per the Global Burden of Disease Study 2016, ischemic heart disease, COPD, cerebrovascular disease, and diarrhoeal disease were among the five leading individual causes of DALYs. It is well known that Indians have a high propensity for all these NCDs and hence an empirical evaluation is needed to assess the impact of COVID-19 on NCDs in these populations. Overall prevalence of comorbidities in Indian population is shown in [Table 1].
| Cross-connection Between COVID-19 and NCDs|| |
Although the overall case fatality rate (CFR) of COVID-19 is low (about 2.49% in India), older adults and patients with co-morbid condition(s) are more likely to have severe disease and subsequent higher mortality. The most commonly reported NCDs that have been shown to predict poor prognosis in COVID-19 patients include diabetes mellitus (DM), hypertension, cerebrovascular disease, coronary artery disease (CAD), asthma, COPD, chronic kidney or liver disease, obesity, and congenital or acquired immunodeficiency states., Patients with uncontrolled diabetes are reported to have underlying immunodeficiency, which may make them more susceptible to COVID-19 complications. Various studies showed that humoral innate immunity is compromised in patients with poorly controlled diabetes, thereby allowing unopposed proliferation of the SARS-CoV-2 virus within the body. Studies with whole blood, peripheral blood mononuclear cells (PBMCs), and isolated monocytes of diabetic patients found to have overproduction of pro-inflammatory cytokines response such as interleukin (IL)-1, IL-6, IL-8, and tumor necrosis factor-α (TNF-α). Angiotensin-converting enzyme 2 (ACE2) is a critical component of the renin–angiotensin–aldosterone system (RAAS) which is an important regulator of blood pressure, inflammation, and fibrosis and involved in pathophysiology of hypertension, CVD, and chronic kidney disease.
| Clinical Studies on Worse Outcomes of COVID-19 in Those with NCDs|| |
Initial study from Zhongnan Hospital in Wuhan, China, reported that among the 138 patients with COVID-19-infected pneumonia, 36 patients (26.1%) required admission in intensive care unit (ICU) because of complications including acute respiratory distress syndrome (ARDS), and arrhythmia and shock. Out of 36 patients, 26 patients (72.2%) had co-morbid disease/conditions compared to 37.3% of patients who did not require ICU admission. Another study from Wuhan Jin Yin-tan hospital (Wuhan, China) reported that among 52 critically ill adult patients with SARS-CoV-2 pneumonia admitted in ICU, 21 (40%) patients had chronic illness (diabetes, cardiac diseases, pulmonary diseases and cerebrovascular diseases). Largest data of 44,672 confirmed cases of COVID-19 published by the Chinese Center for Disease Control and prevention reported the overall CFR of 2.3%. In patients with comorbid disease conditions, the CFR was found to be increased (10.5% for CVD, 7.3% for diabetes, 6.3% for COPD, 6% for hypertension, and 5.6% for cancer). A study by Zhang et al. on 140 hospitalized COVID-19 patients reported that 30% patients had hypertension and 12.1% had diabetes. A retrospective multicenter study by Zhou et al. on 191 patients found that 91 (48%) patients had comorbidities such as hypertension (58 [30%] patients), diabetes (36 [19%] patients), and coronary heart disease (15 [8%] patients) and also had higher mortality rate. Risk factors associated with in-hospital death included COPD (OR = 5.4), coronary heart disease (OR = 21.40), diabetes (OR = 2.85), and hypertension (OR = 3.05). A study by Guan et al. on 1099 patients with laboratory-confirmed COVID-19 reported that 173 patients had severe COVID-19 disease. Patients with severe disease had a higher prevalence of diabetes (16.2% vs 5.7%), hypertension (23.7% vs 13.4%), CAD (5.8% vs 1.8%), COPD (3.5% vs 0.6%), cerebrovascular disease (2.3% vs 1.2%), and chronic renal disease (1.7% vs 0.5%) compared with those with nonsevere disease. A recent systematic review and meta-analysis conducted on seven studies (1576 COVID-19 patients) concluded that the most prevalent comorbidities were hypertension (21.1%), diabetes (9.7%) CVD (8.4%), and respiratory disease (1.5%). Hypertension, respiratory disease, and CVD had pooled odds ratio (OR) of 2.36, 2.46, and 3.42, respectively, for having severe COVID-19 compared to nonsevere patients. According to the IstitutoSuperiore di Sanità, Italy on 11 March 2020, 12,462 confirmed COVID-19 cases and 827 deaths were reported. Among death cases, more than two-thirds of patients had comorbidities such as diabetes, CVDs, or cancer.
| Worldwide Disruption of NCDs Services|| |
According to a WHO survey conducted on 155 countries during a 3-week period stated that the prevention and treatment services for NCDs have been severely disrupted during the COVID-19 pandemic. This situation is of great significance because people suffering from NCDs are more prone to develop severe COVID-19-related illness and mortality rates. Many patients suffering from NCDs such as diabetes, CVDs, and cancer needing treatment have not been receiving the medicines and health services they need since the beginning of COVID-19 pandemic. It is crucial for all the countries to find innovative ways to ensure that essential services for NCDs are continued even during this period. About 49% of the countries surveyed have partially or completely disrupted services for diabetes and diabetes-related complications treatment; 53% for treatment for hypertension; 31% for cardiovascular emergencies, and 42% for cancer treatment. Other NCD services which are disrupted include asthma services, palliative care services, and dental care among others. Rehabilitation is considered as important measure for healthy recovery following severe illness from COVID-19. Thus it is worrisome that 63% of countries these services have been disrupted. In Italy, about 68% of patients had hypertension and 31% had type 2 diabetes among people who died of COVID-19. In India, in March 2020, compared to the previous year, 30% fewer acute cardiac emergencies reached health facilities in rural areas. In the Netherlands, as a result of lockdown, there was 25% reduction in the number of people newly diagnosed with cancer. In Spain, among patients with severe COVID-19 disease, 43% had existing CVDs. Main causes of NCDs service disruption observed in 75% of countries out of 122 countries are listed in [Table 2].
|Table 2: Main causes of NCDs service disruption in majority of countries|
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| Strategies for Prevention, Management, and Control of NCDs During COVID-19|| |
Mathur and Rangamani have highlighted the key strategies to strengthen the healthcare system for addressing NCDs during COVID‑19 phase in India and to develop a framework of research priorities for prevention, management, and control of NCDs and this is shown in [Figure 1].
| The Way Forward|| |
Prevention, management, and control of NCDs should be the foremost priority during this COVID-19 pandemic as the evidences suggest that the NCDs are major risk factors for morbidity and mortality among patients with COVID-19. Moreover, restrictive measures implied by the government such as lockdown, travel restrictions, and physical distancing to reduce the spread of SARS-CoV-2 infection have in many countries affected the people suffering from NCDs by limiting their access to healthcare facilities, physical activity, and to healthy and fresh foods. All these risk factors have increased vulnerability to obesity and increased risk of diabetes and CVDs. Experience and evidence of previous pandemics have highlighted the NCDs if proper precautions are not taken to tackle stressful situations resulting from economic slowdown, travel and other restrictions, changes in health behaviors and delay in routine medical visits and laboratory tests. Overall, all these factors can hinder optimum NCD management. For people with NCDs who have inadequate access to medicines or to doctors, provisions should be made to ensure the use of telemedicine with support of local or community doctors and pharmacists to renew or extend drug prescriptions and also by arranging home delivery of essential NCD medicines. Government should make efforts at the community level to prioritize and ensure continued healthcare services, access to household food items and provide special arrangements for families with NCD patients to quarantine if contracted with SARS-CoV-2. People with NCDs should have access to support for management of NCDs as they might be unaware of the additional risks posed on them due to COVID-19. Additionally, online information should be made available regarding importance of healthy eating, adequate exercise and maintaining stress free and good mental health. For effective SARS-CoV-2 infection control, the policies should be made to prioritize the laboratory testing for early detection of COVID-19 among people with NCDs and also separate provisions should be made for the contact tracing of people with NCDs and ensuring their regular follow-up.,
| Conclusion|| |
COVID-19 pandemic has imposed a new burden on healthcare system and especially on the prevention and management of NCDs. These new challenges have enabled the healthcare system of the countries to pay greater attention to develop a strong healthcare system and building healthier and resilient community that would be less vulnerable to future pandemics. There is a strong need to pay equal attention towards prevention and management of both communicable diseases and NCDs in long run and to build synergies across healthcare platforms. During such pandemics, government policies should target those at risk with more localized interventions rather than the entire population, otherwise it may results in mass fear, confusion, and significant misallocation of resources. Moreover, as COVID-19 still continues to spread among globally, it is not too late to move focus from sole COVID-19 mortality to addressing the underlying risk factors of morbidity and mortality. This means that enough efforts should be taken for effective control of NCDs among populations where they are also a pandemic in their own way. India is home to over 1.35 billion people (second in the world) of whom the hypertension and diabetes prevalence are 28.9% and 7.3%, respectively. Considering these facts it is necessary to address the existing comorbidities and advise these high-risk groups to take extra precautions not to contract the SARS-CoV-2. Frequent hand washing with soap or sanitizer, using face masks/shield, following physical distancing norms, adhering to good diet and maintaining respiratory hygiene are the need of the hour.
Financial support and sponsorship
This review was not supported by any funding.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pal R, Bhadada SK. COVID-19 and non-communicable diseases. Postgraduate Med J 2020;96:429-30. doi: 10.1136/postgradmedj-2020–137742.
World Health Organization (WHO). WHO Coronavirus Disease (COVID-19) dashboard. Available from https://covid19.who.int/. [Last accessed on 2020 October 31].
COVID19 India. Available from https://www.covid19india.org/. [Last accessed on 2020 October 31]
Dyer O. Covid-19: Pandemic is having “severe” impact on non-communicable disease care, WHO survey finds. BMJ 2020;369:m2210.
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.
International Diabetes Federation (IDF). Available from https://idf.org/our-network/regions-members/south-east-asia/members/94-india.html. [Last accessed on 2020 October 31].
Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al
; ICMR–INDIAB Collaborative Study Group. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR-INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 2017;5:585-96.
World Health Organization (WHO). Cardiovascular disease. Available from https://www.who.int/cardiovascular_diseases/hypertension-control-india/en/. [Last accessed on 2020 October 31]
Ramakrishnan S, Zachariah G, Gupta K, Shivkumar Rao J, Mohanan PP, Venugopal K, et al
; CSI-Great India BP Campaign Investigators. Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey. Indian Heart J 2019;71:309-13.
India State-Level Disease Burden Initiative CVD Collaborators. The changing patterns of cardiovascular diseases and their risk factors in the states of India: The Global Burden of Disease Study 1990–2016. Lancet Glob Health 2018;6:e1339-51. doi: 10.1016/S2214-109X(18)30407–8
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. doi: 10.1016/S1470-2045(18)30447–9
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. doi: 10.1016/S2214-109X(18)30409-1
Ram VS, Babu GR, Prabhakaran D. COVID-19 pandemic in India: Is the curve now flat? Eur Heart J 2020;41:3874-6. doi: 10.1093/eurheartj/ehaa493
Nandi A, Balasubramanian R, Laxminarayan R. Who is at the highest risk from COVID-19 in India? Analysis of health, healthcare access, and socioeconomic indicators at the district level. medRxiv2020:1-14. doi: 10.1101/2020.04.25.20079749
Joshi SR. Indian COVID-19 risk score, comorbidities and mortality. J Assoc Physicians India 2020;68:11-2.
Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 1999;26:259-65.
Simões e Silva AC, Flynn JT. The renin-angiotensin-aldosterone system in 2011: Role in hypertension and chronic kidney disease. Pediatr Nephrol 2012;27:1835-45. doi: 10.1007/s00467-011-2002.
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. doi: 10.1001/jama.2020.1585
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. doi: 10.1016/S2213-2600(20)30079-5
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. doi:10.1001/jama.2020.2648
Zhang JJ, Dong X, Cao YY, Yuan Y-D, Yang Y-B, Yan Y-Q, et al
. Clinical characteristics of 140 patients infected by SARS-CoV- 2 in Wuhan, China. Allergy 2020;75:1730-41. doi: 10.1111/all.14238
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al
. Clinical course and risk factors formortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohortstudy. Lancet 2020;395:1054-62. doi: 10.1016/S0140-6736(20)30566-3
Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al
. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20. doi: 10.1056/NEJMoa2002032
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.
Remuzzi A, Remuzzi G. COVID-19 and Italy: What next? Lancet 2020;395:1225-8.
World Health Organization (WHO). COVID-19 significantly impacts health services for noncommunicable diseases. Available from https://www.who.int/news-room/detail/01-06-2020-covid-19-significantlyimpacts-health-services-for-noncommunicable-diseases. [Last accessed on 2020 August 7]
World Health Organization (WHO). Rapid assessment of service delivery for NCDs during the COVID-19 pandemic. Available from https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic. [Last accessed on 2020 August 7]
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. doi: 10.4103/jncd.jncd_33_20 [Full text]
Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: Evidence from meta-analysis. Aging (Albany NY) 2020;12:6049-57. doi: 10.18632/aging.103000
Kluge HHP, 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.
World Health Organization (WHO). Available from https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/news/news/2020/6/prevention-and-control-of-ncds-at-core-of-covid-19-response. [Last accessed on 2020 August 07]
[Table 1], [Table 2]