Management of non-communicable disease patients during the COVID-19 pandemic

Introduction

Background

Non-communicable diseases (NCDs) refer to a range of diseases that are not associated with any infectious agent, are non-contagious, and are long-term (often lifelong), slowly progressing, and chronic (1). The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges to the management of NCDs, posing significant risks to individuals with pre-existing conditions and disrupting healthcare systems worldwide. This paper provides a comprehensive overview of the multifaceted strategies and interventions employed to navigate the complexities of NCD management during the pandemic (2).

Rationale and knowledge gap

The pandemic has disrupted traditional healthcare delivery models, leading to delays in NCD screenings, (early) diagnoses, and proper treatments. Patients with conditions such as cardiovascular diseases, diabetes, cancer, and respiratory illnesses have faced heightened susceptibility to severe illness from COVID-19, necessitating innovative approaches to ensure their uninterrupted access to essential healthcare services, while minimizing exposure risks to the virus(es) (3). Healthcare providers have rapidly embraced telemedicine, remote monitoring, and digital health solutions to deliver virtual consultations, monitor patient progress remotely, and manage medications, since early in the pandemic (4). These technological innovations have not only facilitated continuity of care but have also empowered patients to actively participate in self-management and preventive care efforts, particularly in the context of social distancing measures and lockdown restrictions. Furthermore, community-based interventions and multidisciplinary collaborations have emerged as pivotal strategies to address the complex needs of NCD patients during the pandemic (4). Leveraging partnerships between healthcare providers, public health agencies, and community organizations, initiatives such as mobile clinics, home visits, and peer support programs have assisted with mitigating barriers to healthcare access and to promote holistic approaches to NCD management (5). However, challenges have persisted in ensuring equitable access to care, addressing digital disparities, and to sustain long-term adherence to treatment regimens among NCD patients (6). Future research and policy endeavors must prioritize strategies to strengthen healthcare systems’ resilience, promote health equity, and integrate NCD care within broader public health emergency preparedness frameworks (6). In conclusion, the COVID-19 pandemic has catalyzed transformative shifts in the management of NCD patients, underscoring the importance of innovation, collaboration, and equity in handling the intertwined challenges of public health emergencies and chronic disease management.

Objective

Our experience with challenges in management of NCDs over the pandemic lead us to prepare a review, enriched by evidence from published articles based on similar topics, namely, changes in hospital admissions, mortality rates, vaccine-related issues, and the need for change in care settings in management of NCDs during the pandemic, with special emphasis on severity of COVID-19 infections in this group compared to their counterparts without NCDs. We also summarized potential effects of long COVID-19 cases on burden of NCDs on health care system in years to come.

The review aimed to examine the status of NCDs amidst the COVID-19 pandemic, to reiterate its significance as a public health problem, and to comprehensively analyze the pandemic’s impact on such as diseases, with regards to patient referrals, disrupted services, risk factors, and expenditures.

NCDs

NCDs are known as common, multifactorial public health problems that arise as a result of different combinations of genetic, environmental, physiological, and behavioral factors (2). These diseases are generally chronic in nature, have a long and rather slow course, may be identified late in its course, negatively impact the individual’s quality of life, require advanced expertise for treatment, have frequent complications that can result in death and/or disability, and are associated with high-cost monitoring and treatment (2). The most common of these diseases are cardiovascular diseases, diabetes, chronic obstructive pulmonary disease (COPD), and various cancers (2).

According to the public release of the World Health Organization (WHO) in 2023, NCDs result in 41 million deaths annually, accounting for 74% of total deaths worldwide. Of those, 17 million are under the age of 70 years and 86% fall into the category of ‘premature death’ (2).

The most significant known risk factors associated with the development of NCDs include tobacco use, physical inactivity, harmful alcohol consumption, unhealthy diet, and air pollution (2). Tobacco use is the most common, yet, modifiable risk factor for NCDs. Globally, approximately 8 million people die each year due to tobacco use-related reasons (2). Annually, 1.8 million deaths are attributed to excessive salt/sodium intake, and another 830,000 to inadequate physical activity (2,7). Four significant metabolic factors (high blood pressure, overweight/obesity, hyperglycemia, and hyperlipidemia) are held responsible for the increase in NCD risk (7).

The prevalence of NCDs affects individuals, families, and societal layers, directly impacting the healthcare system (8). Cardiovascular disease and mental disorders are the costliest diseases among NCDs (8). While these diseases already represent a significant economic burden for high-income countries, they are also increasingly important in middle- and low-income countries (8).

General characteristics of NCDs during the pandemic period

The WHO declared this disease, now named COVID-19, as a pandemic on March 11, 2020 (9). During the COVID-19 pandemic, individuals with NCDs—have become more vulnerable compared to general population (10). Although the likelihood of contracting the circulating virus may be similar for these patients, they tend to experience a more severe form of COVID-19, once infected (11). Moreover, as the damage to the immune system increases, underlying clinical symptoms related to NCDs worsen, as well (12). Established risksfor clinical deterioration include, firstly, the presence of angiotensin-converting enzyme 2 (ACE-2) receptors, used by the virus to enter the host body, and the cytokine storm syndrome, which is a severe hyperinflammatory response to the virus entryIndividuals with NCDs are considered at high risk for both, as supported by many studies. The most adverse indirect effect of COVID-19 on NCDs is avoidance in health seeking behaviors for timely routine check-ups, timely treatment and/or care due to fear of contracting COVID-19. This avoidance leads to delaya in diagnosis/treatment in acutesituations, besides cancellation or postponement of periodic appointments with eventual spiraling of disease out of control. Delays in diagnostic and therapeutic procedures may also occur due to slowdown of routine hospital operations (12). Xu et al. claimed that the cytokine storm observed in COVID-19 affects the extent of end-organ damage in individuals with chronic diseases, increasing mortality rates (13).

Pandemic and NCDs epidemiology

With rapid spread of COVID-19 worldwide and based on countries’ capacities to address and respond to NCDs, individuals with conditions such as cardiovascular disease and diabetes have experienced rapid disease progression, and increased severity, besides higher vulnerability to virus transmission, with ultimately higher fatality rates (14,15). A clear link was revealed between NCDs and COVID-19 (14,15). During the pandemic, prevalence of cardiovascular disease and hypertension among COVID-19 patients were reportedly ranged from 4.7% to 17.5%, and 15.6% to 38.6%, respectively (12,16). Individuals with cardiovascular disease were revealed to experience more severe cases of COVID-19 compared to those without such diseases; they tend to have higher rates of hospitalization, with greater disease fatality, as well (17).

According to International Diabetes Federation estimates for global prevalence of diabetes, the number of diabetics aged 20–79 years will reach 578 million by 2030, and 700 million by 2045, excluding potential impact of COVID-19 (18). Estimated prevalence of diabetes among those with COVID-19 experience have been shown to vary between 14% and 44% (19-21). The rates of severity, hospitalization and fatality of COVID-19 infection has been shown to be higher among diabetics compared to their nondiabetic counter parts (12,22).

Research early in the pandemic estimated prevalence of cancer varied between 1.2% and 4.0% (16,23). COVID-19 has been particularly deadly in cancer patients. COVID-19 fatality rates were higher, especially among cases of lung cancer, hematological cancers, and non-pulmonarysolid organ cancers (12).

COVID-19 has been claimed to exacerbate respiratory diseases, COPD, in particular (24). A strong association was shown between COPD and severe illness, hospitalization, and death due to COVID-19 (25).

Authors’ recently introduced term “syndemic” fits very well to explain co-occurrence of COVID-19 and NCDs at unexpectedly high case numbers in populations (26).

Published data reveals increased fatality in COVID-19 in presence of NCDs and established risk factors at disease onset (27). Similarly, increased morbidity and mortality of NCDs during the pandemic may be attributed to the exacerbation of existing conditions by adverse effects of COVID-19 infection on tissues and systems. Individuals with NCDs might also be affected by stay-home orders, restrictions on transportation, access to healthcare, inadequate or delayed care, and/or due to self-avoidance of hospital use. High percentages of delayed or missed diagnoses in the pandemic with reduced frequency of routine follow-up visits, and inadequate outpatient care due to limited appointment times, with restricted hospital beds for required hospitalizations might adversely affect NCDs management over the pandemic (27).

In a cohort study, Leite et al. noted a disproportional decrease in hospital admissions for women, those with lower income levels, and those with comorbid conditions over the pandemic which suggest an increase in inequity in patient care (28).

Besides the pandemic-associated adverse effects on management of NCDs during the acute phase of COVID-19 in these patients, potential complications and disability in the years to come is also of concern. Appropriate adjustments may be crucial in future NCD action plans, based on such evaluation and monitoring (10). After COVID-19, some acute damage can become permanent, leading to long-term chronic conditions such as decreased respiratory function (29). In parallel, studied on prolonged COVID-19 among NCDs patients are clearly warranted to predict related disease burden in upcoming years (30). In this context, it is also important to distinguish between chronic diseases directly caused by COVID-19 and NCDs, aggravated by COVID-19. While the management of co-existing diseases will be facilitated with return of routine healthcare services, the prediction of the additional/new burden of NCDs in the years to come is important. With a total of 704,753,890 (April 13, 2024, Worldometer, Coronavirus) confirmed COVID-19 cases globally, even a low percentage of these appearing as patients with chronic diseases arising COVID-19-complications strengthening healthcare facilities and specialties in terms of both quantity and quality in this regard will be important (31).

What is the long-COVID-19?

It is argued that attention should be paid to the persistent symptoms such as shortness of breath, chest pain, fatigue, headache, brain fog, and palpitations in individuals who have recovered from COVID-19, as these may indicate the destruction caused by the virus and long-term damage (32). This condition is often referred to as “long COVID-19” in many sources. The consequences, such as reduced workforce participation and inability to work due to the current health condition caused by prolonged COVID-19, are noteworthy (33). Extended COVID-19 leads to increased healthcare needs, and the monitoring of these individuals is crucial. Necessary identifications should be made within healthcare systems, and individuals should be monitored and ensured proper care (26).

It is estimated that many systemic diseases worsen after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. During this process, individuals have been reported to receive new diagnoses such as pulmonary fibrosis, myocarditis, newly diagnosed diabetes, stroke, and others due to the effects of COVID-19 (34). There is serious global concern regarding the long-term adverse effects of COVID-19, particularly on cardiovascular health and mortality, based on available evidence (32). It is predicted that in the coming years, there may be a decrease in life expectancy in communities when the exacerbating effects of prolonged COVID-19 on underlying diseases and the neglect and delays in the care of existing conditions are considered together (35). However, additional studies are needed to provide sufficient evidence regarding the absolute prevalence of these problems, associated risk factors, and estimations through calculations based on populations in specific communities/countries.

While health is considered as a fundamental human right, the high numbers of COVID-19 cases and low vaccination rates in countries with existing inequalities suggest that there will likely be a relatively high number of long COVID-19 cases as well. This situation could exacerbate existing inequalities. Efforts should be made globally to allocate resources towards reducing the burden of NCDs caused by COVID-19, supporting health, social care, and well-being on a global scale through humanitarian efforts. It is important to allocate resources, especially vaccinations, on the basis of fairness to address this issue effectively.

The “pandemic agreement”, expected to be ratified by 194 member countries of the WHO on March 13, 2024, aims to promote international collaboration in preventing, preparing for, and responding to future pandemics. It seeks to address deficiencies in global responses to the COVID-19 pandemic and to improve support among member countries to safeguard national healthcare systems by identifying areas of low capacity. According to the latest publicly available (dated 13 March), the overall objective of this new pandemic agreement is to help the world “prevent, prepare for and respond to pandemics”. Among the provisions included (all of which are still being negotiated) are definitions and principles, aspirational goals for improving pandemic preparedness, response capacities and supply chain (36). At this stage, while making forward-looking plans, widespread vaccination is still considered the most important tool we have for reducing the pandemic and associated morbidity and mortality.

Vaccination against COVID-19

COVID-19 vaccines, which received emergency use authorization starting from January 22, 2022, are available. Priority has been given to vaccinating individuals with NCDs in many countries, and COVID-19 vaccines have been particularly recommended for them (37).

When cardiac effects were examined, it was observed that COVID-19 vaccines were associated with a short hypertensive response (38). However, it has also been argued that the post-vaccination change could reveal an underlying existing pathology (39). It has been shown that the development of myocarditis and pericarditis after mRNA COVID-19 vaccines is rare (40). It should be noted that these effects occur predominantly in males aged 12–17 years after the second dose of the vaccine. However, no significant difference has been found between the second and third doses of the vaccine (41,42). Vaccines have not been associated with cardiac arrest and sudden death (43,44). The benefits of the COVID-19 vaccine for both personal and public health outweigh minor cardiac risks by a significant margin (45).

There is no evidence to suggest that COVID-19 vaccines increase the risk of diabetes (46). However, an article suggests that there may be a complex, bidirectional relationship between vaccination and diabetes. Vaccination may contribute to worsening blood sugar levels in diabetic patients, and diabetic patients may have a lower antibody response after vaccination compared to the general population (47).

From a pulmonary perspective, it has been observed that hypoxia and dyspnea develop within 1–3 days after vaccination (48). Additionally, a few cases have been reported where the vaccine has caused interstitial lung disease (49-51).

The protective effect of the vaccine against death, intensive care unit admission, and hospitalization due to COVID-19 is undeniably high and significant. The urgent need for vaccination should also be considered. Public confidence in vaccines should not be undermined. Vaccine adverse effects should be regularly monitored and transparently shared for all COVID-19 vaccines under development (52).

Pandemic and NCDs risk factors

When developments in terms of NCD risk factors during the pandemic are examined, it is observed that behavioral NCD risk factors such as physical inactivity, unhealthy diet, tobacco, and harmful alcohol use have increased in communities due to mandatory quarantine, restrictions on social gatherings, and the maintenance of physical distance between individuals (53,54). Additionally, restrictions, quarantine processes, and the loneliness created by an unknown new disease have led to increased emotional stress, depression, anxiety, domestic violence, and symptoms of existing psychological illnesses. In a study, it was observed that during curfews and restrictions implemented to prevent the spread of COVID-19, the frequency of smoking increased among nearly half of smokers (53,54). Brooks et al. reported that about 35% of participants reported an increase in both the quantity and frequency of alcohol consumption compared to before the restrictions (53,54). Data suggest that preventive measures against exposure in the pandemic, such as curfews due to COVID-19, the transition of work to online platforms, and closure of schools have resulted in increased indoor living times, leading to unhealthy eating habits, disrupted regular physical activity, and disrupted healthy sleep patterns. Significant increase in obesity, physical inactivity, and smoking have been claimed to lead serious exacerbating effects on NCDs (54). In contrary, in a study conducted in Turkey, only 4% of the participants reported an increase in smoking and alcohol consumption during the pandemic, whilst 11% reported a decrease; suggesting that the effects of life changes over the pandemic might have different outcomes in populations (55). It has been observed that individuals with already diagnosed NCDs experienced worsening of their health conditions due to lack of timely follow-up during the COVID-19 process, were at higher risk when facing COVID-19 and that incidence of comorbidities increased due to the prolonged effects of COVID-19 during this period (4).

A study on nutrition and sleep habits found that 47.8% of participants gained weight during the pandemic, 43.5% reported an increase in sleep duration, 70.4% reported an increase in snacking frequency after meals, and more than 60% preferred foods high in carbohydrates and sugar (56). Poelman et al. also found in their study that overweight and obese participants, particularly, had an increased risk of unhealthy eating compared to normal-weight individuals (57).

Age, ethnicity, tobacco use, and poverty, among other NCD risk factors, have also been identified as risk factors for COVID-19, leading to higher morbidity and mortality rates among the NCD population (58). When considered as a whole, known risk factors for NCDs have become more prevalent and increased during the pandemic period. Therefore, even if the pandemic subsides, these risks have the potential to increase the incidence and prevalence of NCDs and their impact on associated quality of life losses should be investigated.

Management of NCDs in hospitals during the pandemic period

With the onset of the COVID-19 pandemic, especially during the initial stages, many countries and hospitals faced the need to reallocate resources such as physicians, nurses, other healthcare staff, hospital beds, rooms, and intensive care units for use by COVID-19 patients. As a result, particularly in situations where the healthcare system was overwhelmed, primary care services, curative services, and rehabilitation services were all disrupted, leading to unmet health needs of patients (59). Regarding primary care services, the most notable disruption has been observed in routine screening and medical imaging programs provided for management of NCDs. Based on experiences of health care professionals, the most prominent reduction in healthcare resources due to COVID-19 adversely affected care fordiabetes (38%), followed by COPD (9%), hypertension (8%), and ischemic heart diseases (7%) (60). Many patients have been observed delays or missed routine screening and preventive services either due to public closures or the restricted care services (61). In many countries, COVID-19 intervention plans have prioritized adjustments related to diabetes services and dialysis services, aiming to ensure continuity of care. However, routine patient care plans and programs have been disrupted and elective procedures have taken precedence, leading to significant delays in access (62). In many countries, hospital wards and intensive care beds have been reserved mainly for COVID-19 patients, even surgeries were resecheduled to the time when beds became available (63). Disruption in rehabilitation services has been significantly overlooked compared to that in other health care service areas (62).

Closure policies implemented to prevent the spread of infection during the pandemic, disruptions and restrictions in public transportation, compulsory focus on COVID-19 cases in healthcare workforce planning, cancellation of outpatient clinic appointments, as well as personal factors, such as fear of disease transmission, might all have resulted in neglect/postponing of NCD visits during the pandemic (64). A guide published for the COVID-19 period, revealed additional challenges due to sudden appointment and surgery cancellation processes based on the need for reorganization of healthcare personnel (65). WHO reporte that all health services and staff were redirected to work with COVID-19 cases in 13% of the countries. According to this report, 75% of countries reported no disruption in data collection for NCDs through passive surveillance, with the note that in 94% of countries health personnel responsible of NCD management continue to their work besides the additional COVID-19 related workload. Thus, even if the work seem to continue uninterrupted, the quality was likely to be hampered.The Southeast Asia Region ranks highest among regions experiencing disruptions, with 50% report rates for inability to collect NCDs data (62).

A UK healthcare system report revealed the most significant decrease in hospital admissions for conditions such as atrial fibrillation, chronic heart disease, stroke, diabetes, and COPD and linked this to difficulties in accessing healthcare professionals during the pandemic. Appointments postponed by elderly patients themselves were mainly linked to avoid COVID-19 risk in the hospitals (66).

In a our hospital-based cohort, published earlier, variations in hospital admissions over the pandemic were compared to the same period preceding the pandemic. Admission rates decreased significantly, yet, this variation was not correlated with national COVID-19 case number, suggesting that restricted appointments and beds for NCD patients could have been a major barrier to access, rather than individuals self-hesitancy (67). There are studies supporting that physicians themselves avoided unnecessary face-to-face evaluations (14%), 35% conducted evaluations in a mixed format, whilst 45% managed the process entirely over the phone (68). The guide of the Pan American Health Organization recommended in 2020 to strengthen and expand the telemedicine system for isolation against COVID-19, protection from infectious diseases, and the follow-up of chronic diseases (65). The widespread adoption of telemedicine practices in many countries over the past 4 years could at least partially be related to COVID-19-related concerns of the physicians and patients, alike (61).

Early pandemic experiences on hospital service utilization signaled that similar to COVID-19 cases, their long-term complications might lead to an impending public health crisis, especially in countries with weak health systems. During recurring waves of COVID-19 and quarantine measures, health policymakers must adopt a comprehensive health strategy that considers existing health service conditions, and delivery networks to ensure access for the most vulnerable individuals (69).

Increase in NCDs and health expenditures during the pandemic period

During the COVID-19 pandemic, NCDs continued as a major public health problem in many countries, their burden was straining over the pandemic given the shared pool of resources within the healthcare system (30). Especially in high and upper-middle-income countries, national COVID-19 intervention plans have included essential services for NCDs to ensure the continuity of care, yet, their impact was beyond capacities in developing countries. Already inadequate health budgets in countries of the Africa before COVID-19 might not been sufficient for reallocations as number of COVID-19 cases were rising (62).

Evidence suggests that individuals residing in remote areas are disproportionately affected by COVID-19: higher morbidity was observed in low-income neighborhoods, and the likelihood of survival for patients in under-resourced hospitals was much lower compared to patients of well-resourced hospitals. Altogether, the ultimate burden of diseases and related health expenditures should be evaluated with attention to social determinants of health (70).

It was predicted before the COVID-19 pandemic that global health spending would increase until 2030, with the most significant driver being NCDs. Considering the impact of prolonged COVID-19 and expectedly higher rates for NCD incidence in near future, it is essential to make feasible and sustainable health plans, to ensure sufficient and cost-effective public health investments (71).

NCDs are chronic conditions such as cardiovascular diseases, diabetes, and cancer that require long-term management. During the COVID-19 pandemic, these diseases became even more challenging to manage due to disruptions in regular healthcare services and increased patient vulnerability. Managing NCDs in hospitals has required significant adaptation, with healthcare providers needing to balance the demands of COVID-19 care and ongoing chronic disease management; this led to delayed/missing care for NCD patients. The pandemic has significantly altered the epidemiology of NCDs via pandemic-associated lifestyle changes, increasing social and mental stress, reducing physical activity, leading to sleep disturbances, all of which appear to be risk factors for NCDs. Augmented socioeconomic inequalities have further worsened NCD incidence and prevalence. Long-COVID-19, a condition, where symptoms persist long after the initial infection, has further complicated the health landscape by exacerbating existing NCDs, or triggering new ones. Vaccination against COVID-19 has been crucial in protecting NCD patients from severe illness, though vaccine hesitancy and access issues have posed challenges. Consequently, the pandemic has led to an increase in NCD prevalence and a surge in related health expenditures, stressing the need for resilient healthcare systems.

Conclusions

At this stage of the pandemic, it is anticipated that NCDs numbers will be boosted in years to come due to delays in early diagnosis, disruptions in disease management and monitoring, due to direct and indirect effects of COVID-19 management strategies. The associated disease burden will have direct and indirect effects on the healthcare system. Public health workers, policymakers, and implementers need to have a robust baseline evaluation at this stage, maintain surveillance activities uninterrupted, and integrate necessary structural changes into the existing system. Information obtained from vaccine-related adverse effects and prolonged COVID-19 should also be closely monitored and transparently shared with both healthcare professionals and the public. It is essential to draw attention to the heterogeneity between countries in diagnosis, treatment, and reporting systems; tracking local variants is invaluable. Besides timely use of information from international resources, countries need to conduct their own monitoring activities for COVID-19 and NCD profiles over time, should draw attention to existing differences (if any). The number of tests performed, access to testing, the validity of post-vaccination/disease tests, and the monitoring of post-disease developments would be essential for future calculations of “additional” disease burden and costs. The “pandemic burden” should not only be calculated in the acute phase but also monitored in the following years so that countries can calculate the time, manpower, and financial resources they will allocate to pandemic planning based on this total burden.

Acknowledgments

We thank members of Hacettepe University Faculty of Medicine Department of Public Health Division of Epidemiology for providing time flexibility and moral support.

Footnote

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-67/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-67/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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