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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 252-256

Impact of COVID-19 on noncommunicable diseases (NCDs)


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 Submission07-Aug-2020
Date of Decision09-Nov-2020
Date of Acceptance13-Nov-2020
Date of Web Publication30-Sep-2021

Correspondence Address:
Mr. Manoj Arajanbhai Suva
Eris Lifesciences Limited, Commerce House-4, Prahlad Nagar, Ahmedabad 380015, Gujarat.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOD.JOD_75_20

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  Abstract 

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

How to cite this URL:
Suva MA, Suvarna VR, Mohan V. Impact of COVID-19 on noncommunicable diseases (NCDs). J Diabetol [serial online] 2021 [cited 2021 Nov 30];12:252-6. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/3/252/327315




  Introduction Top


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.[1],[2],[3] 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).[4] 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 Top


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%.[5] 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.[6] 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.[7] 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.[8],[9] In India, overall CVDs contributed 28.1% of the total deaths and 14.1% of the total disability-adjusted life-years (DALYs) in 2016.[10] 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.[11] 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.[12] 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.[5] 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.[13] Overall prevalence of comorbidities in Indian population is shown in [Table 1].
Table 1: Overall prevalent cases of NCDs in Indian population[14]

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  Cross-connection Between COVID-19 and NCDs Top


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.[1],[15] 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).[16] 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.[17]


  Clinical Studies on Worse Outcomes of COVID-19 in Those with NCDs Top


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.[18] 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).[19] 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).[20] A study by Zhang et al. on 140 hospitalized COVID-19 patients reported that 30% patients had hypertension and 12.1% had diabetes.[21] 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).[22] 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.[23] 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.[24] 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.[25]


  Worldwide Disruption of NCDs Services Top


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.[26] 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.[27] 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[27]

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  Strategies for Prevention, Management, and Control of NCDs During COVID-19 Top


Mathur and Rangamani[28] 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].
Figure 1: Framework of research priorities during COVID-19 for NCDs[28]

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  The Way Forward Top


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.[29] 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.[30],[31]


  Conclusion Top


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.



 
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