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This article is more than 2 month old.

Managing the COVID-19 ‘Syndemic’

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It is important to acknowledge that COVID-19 is a ‘syndemic’ of non-communicable diseases (NCDs) and the SARS-CoV-2 infection. A syndemic represents a synergistic relationship between two or more diseases.

Managing the COVID-19 ‘Syndemic’
The past 18 months have significantly transformed our perception and understanding of hitherto scientific, medical, and health concepts and terminologies, though in a very unnatural and sometimes even poignant manner.
On one hand, there have been people and patients who have embarked on a holistic health journey investing efforts in preventive healthcare and a more disciplined therapy routine. On the other hand, there are reports suggesting a decline in people accessing medical care in chronic conditions management, over ‘fear of the pandemic’.
In this context, it is important to acknowledge that COVID-19 is a ‘syndemic’ of non-communicable diseases (NCDs) and the SARS-CoV-2 infection. A syndemic represents a synergistic relationship between two or more diseases, wherein the presence of one disease supports the occurrence or severity of the other disease and vice versa.
NCDs like diabetes, cardiovascular diseases, kidney diseases, and cancer, can increase the vulnerability to COVID-19 infection, especially with severe outcomes. In patients hospitalized with COVID-19, the risk of poor outcomes increases significantly in the presence of underlying comorbidities.
In a study by Prof A Ramachandran from South India, the presence of underlying kidney disease resulted in a five-fold increased possibility of poor outcomes. The risk was increased by 60 percent in presence of underlying coronary artery disease, and 40 percent in presence of underlying hypertension. In patients with diabetes who had uncontrolled blood sugar levels, the risk of death was nearly three-fold, as compared to patients with well-controlled blood sugar levels.
COVID-19 itself has the potential to cause complications across various organ systems in the long term. A recent analysis from the US Department of Veterans Affairs, suggests some crucial aspects on possible long-term sequelae of COVID-19, also known as long-COVID.
In COVID-19 survivors, beyond the first 30-days of illness, the risk of NCDs showed an increase over the six-month span. The relative risk of diabetes was observed to be 1.4-fold higher, that of heart failure 1.5-fold higher and of coronary artery disease 1.3-fold higher. The risks of thrombo-embolism, and lower respiratory diseases increased by more than 2-fold, while that of nervous system diseases increased by 1.5-fold. The overall mortality risk remained greater than 1.5-fold in COVID-19 survivors beyond 30-days of illness, over a six-month period.
Data on COVID-19 and related health impacts are still emerging from across the world, thanks to the collaboration and sharing of expertise and knowledge on not just managing the COVID-19 infection but also health thereafter. From studies so far, it is evident that the COVID-19 syndemic poses a challenge larger than we face today if not addressed with as much focus and effort as with the infection itself. That it is a silent and rather invisible outcome that makes the challenge even more pronounced.
Beyond the COVID-19 infection, the pandemic scenario itself has a significant adverse influence on NCD care. Disruption in NCD care due to pandemic stress, travel restrictions, financial and access limitations, decreased visits to physicians and laboratories, and limited lifestyle opportunities have resulted in increased health risks. The World Health Organization recognizes the disruption in NCD care due to the pandemic, as a key health priority to be addressed, for limiting a possible surge in NCD-related mortality over the next decade.
From a treatment perspective, there should be greater emphasis on telemedicine and virtual visits. We have seen in the past months the possibilities telehealth and digital health models have opened up for NCD care. With large and established healthcare delivery organisations enabling access to expert care through virtual engagement platforms, we have an opportunity to build on the current successes to make our remote care models more robust and future-ready, especially providing access beyond the urban centres and cities.
Various measures like dietary considerations, active lifestyle, weight management, etc. should be reinforced. These risk factors are implicated in both progression of NCDs (diabetes, stroke, hypertension, cancer, etc) and increasing severity of COVID complications.
Diabetes
: Telehealth services are a useful tool for patient consultation and early recognition of possible diabetes complications and signs of blood glucose dysregulation or infection. With physical distances no longer a factor, in addition to specialist consults, virtualizing care provided by diabetes educators, dieticians and specialized mental health professionals could improve access further than what was previously possible with in-person encounters.
Given the diabetes prevalence across India, here are some tips for sustained care for patients and caregivers – a. ensure enough supplies of medication, as well as, glucose needles, strips, or sensors for home use for about a month; b. access to social care professionals may be mandatory in some cases, considering that stress management is crucial for mental and overall health balance. Do not discontinue medication prescribed for hypertension, diabetes or dyslipidaemia. Regular intake of antidiabetic drugs and insulin as indicated.
Stroke: Tele-stroke services stand in need of accelerated improvement. As patients are still hesitant to visit hospitals, there is a need to establish stroke-ready ambulance services and centres to reduce the time between the incidence of stroke and access to care.
Cancer: Boost the current diagnostic and therapeutic capabilities through active learning and awareness programs integrating the need for palliative care for cancer patients in COVID times.
Vaccination for people with NCDs: Given the ongoing Covid-19 vulnerabilities among people with NCDs, prioritizing them for the vaccination process should also figure high on the agenda on health authorities.
A recent study on the NCD burden in Indian, reveals that more than two-third of individuals suffering from NCDs are in the most productive age groups--between 26-59 years.4 While the prevalence varies across geographies, diabetes emerged as the common thread featuring amongst the most prevalent NCDs across India.
COVID-19 has brought healthcare back to focus for people, Governments, healthcare institutions, service providers, and manufacturers like never before. While we manage the ‘pandemic’ needs, the looming ‘syndemic’ challenges need immediate and concerted focus to ensure health of the people and our healthcare systems in the longer term, to manage future pandemics better.
Author Dr. Shraddha Bhure is Medical Director at Boehringer Ingelheim India. Views expressed are personal