This policy brief has been developed by the Cambodian NCD Alliance to highlight the particular vulnerability of people living with NCDs, particularly older people. The following brief summarises the latest evidence on COVID-19 and NCDs, the unique risks and challenges for Cambodia, and a number of recommendations for healthcare providers and the government in order to mitigate the risks of COVID-19 for people living with NCDs.
Policy brief: Mitigating the risks of COVID-19 for people living with NCDs
Background
Increasingly, evidence indicates that people aged 60 and older and people with pre-existing conditions are particularly susceptible to developing a more severe illness with COVID-19. This population at increased risk are people living with noncommunicable diseases (NCDs), such as diabetes, hypertension, cardiovascular disease (CVD), cancer, and chronic respiratory disease. The most serious complication of COVID-19 is a type of pneumonia that can progress to an acute respiratory distress syndrome or sepsis requiring intensive care treatment [1].
Evidence from China shows that people living with NCDs (PLWNCDs), particularly older people and those with comorbidities [2], are more likely to experience severe symptoms and higher rates of fatal disease. Data from a subset of 355 deaths in Italy showed that 99% of patients had at least one pre-existing condition (on average they had 2.7) [3]. A meta-analysis, based on eight studies in China of 46,248 infected patients, indicates those most severely affected by COVID-19 were more likely to have CVD, respiratory disease and/or hypertension [4]. Data from the US Centers for Disease Control and Prevention on 31 March 2020 also confirms that, among COVID-19 cases, the most commonly reported pre-existing conditions were diabetes mellitus, respiratory disease and CVD. Among 7,162 cases, 457 were admitted to the ICU and, of these, 358 cases (78%) had at least one pre-existing condition [5].
Data also suggests that people who smoke and those who are overweight or obese may have a higher risk of severe illness with COVID-19 [6] [7][8]. Smokers with lung disease or reduced lung capacity have an increased risk of serious illness. The possibility of transmission may also be higher as smokers touch their mouth with their hands more often [9].
The World Health Organization (WHO) have developed guidance [10] for PLWNCDs to reduce the risk of transmission to those most at-risk:
The unique risks and challenges in Cambodia
The health and economic impacts of the COVID-19 pandemic are likely to be substantial in Cambodia, with trade restrictions and thousands of job losses already announced [11]. For families who live in informal or overcrowded housing, social distancing measures may be physically and economically impossible. Families with insecure income and inadequate water, sanitation and hygiene also face challenges for basic preventive measures.
Everyone is impacted by the COVID-19 pandemic, but the impact will be felt by some more than others, exposing and exacerbating inequalities within society. The effects will be disproportionately felt by more vulnerable groups, particularly those with pre-existing NCDs. The following are specific considerations for people living with NCDs:
The availability and accessibility of medicines was already a significant barrier for people with NCDs prior to the outbreak. WHO guidance for PLWNCDs is to ensure that they have a minimum of one month’s supply of medicines or longer if possible to manage their condition. While cost is already an issue to many, possible economic disruption following a potential lockdown and/or state of emergency could further exacerbate this, as well as endanger the supply and distribution of medicines.
Undiagnosed NCDs are common in the general population, particularly hypertension and diabetes [12] [13], and as such many people do not know they are at a higher risk of severe illness with COVID-19. Risk factors for having an undiagnosed NCD include lower income levels, less education, older age, and female sex [14]. As those in poverty have a higher rate of NCDs, the most vulnerable population groups could also face more serious illness with COVID-19 [15]. The economic and physical barriers to social distancing will likely be more challenging to those in poverty.
The psychological impact of the pandemic should not be ignored. It is estimated that 40% of the population have mental health problems in Cambodia [16] and there is a considerable gap in mental health services at all levels of the health system. Furthermore, evidence from other outbreaks shows that prolonged exposure to fear and anxiety can seriously impact people’s mental health [17], particularly those with trauma, leading to an increase in depression, anxiety and loneliness. This also applies to healthcare providers who might be working longer shifts and exposed to higher levels of stress and anxiety, impacting their mental health and wellbeing.
The Cambodian health system would likely be overwhelmed if cases exponentially increased as they have in places such as Italy or Spain. The health system would be unable to treat the significant numbers of patients with progressive disease presentation who would require sophisticated intensive care treatment, such as prolonged mechanical ventilation and respiratory support. The resources required to strengthen and scale-up health system capacity to manage and treat severe and critical cases of COVID-19 are limited. Therefore, preventive public health measures must be prioritized.
Recommendations
As Cambodia implements measures to prevent the transmission of COVID-19 it will be critical to prioritize the needs of people with pre-existing NCDs, as they are particularly susceptible to worse outcomes with COVID-19. Therefore, we call on the government to consider the following recommendations to mitigate the risks to people with NCDs:
For healthcare providers:
1. Contact patients with hypertension, diabetes, CVD, chronic respiratory disease and other NCDs to make a plan for their care, and if it is possible, dispense the longest-term prescription you can (minimum of 30 days, or 2-3 months if there is adequate supply, to ensure other patients do not go without essential medicines).
2. Introduce screening for fever, clinical signs, contact and travel history for everyone at the entrance to facilities. To ensure regular services remain safe and accessible anyone with possible fever, clinical signs or history should be sent to a separate area of the facility for investigation, in line with the National COVID-19 Treatment Guideline.
3. In areas where there is an outbreak of COVID-19, encourage patients to avoid healthcare facilities unless they have symptoms or other urgent needs, to prevent exposure to the virus.
4. If a patient with pre-existing NCDs is admitted to a health facility with COVID-19, determine which medications should be continued and which should be stopped temporarily.
5. At health center-level, communicate early with commune and sangkat authorities:
to ensure PLWNCDs and their families know how to reduce risks specific to PLWNCDs;
to correct misinformation about COVID-19;
to promote preventive measures including social distancing, frequent hand washing, healthy eating, smoking cessation, and physical activity.
For the government:
1. Provide information and advice through various communication channels, specifically about the increased risk of more severe outcomes with COVID-19 for people with pre-existing NCDs, including prevention methods and what to do if they have symptoms.
2. Prioritize testing and early care for people with pre-existing NCDs.
3. Where possible build the capacity of the community-based health system to enable contact tracing, detection and treatment of COVID-19.
4. Ensure that adequate supplies of medicines and supplies for the management of pre-existing NCDs are available at all levels of the health system, particularly in primary care.
5. Consider either strengthening the capacity of pharmacies at the primary care level to dispense prescriptions for PLWNCDs; or setting up a mobile pharmacy or dispensing unit for NCD patients.
6. Consider subsidizing the cost of medicines and supplies for PLWNCDs and other immunocompromised groups.
7. Integrate public mental health interventions into preparedness and emergency response plans and increase mental health services once immediate needs for the COVID-19 response are addressed.
8. Invest in the capacity of tertiary care hospitals in order to treat severe cases of COVID-19 which are present more in PLWNCDs.
References
[1] World Health Organization, “Clinical management of severe acute respiratory infection when COVID-19 is suspected,” 2020. [Online]. Available: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
[2] Z. Wu and J. M. McGoogan, “Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China,” JAMA, 2020.
[3] “Characteristics of COVID-19 patients dying in Italy,” 2020. [Online]. Available: https://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_26_marzo_eng.pdf
[4] J. Yang et al., “Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis,” Int. J. Infect. Dis., 2020.
[5] CDC COVID-19 Response Team, “Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease,” 2020.
[6] R. Huang et al., “Clinical Findings of Patients with Coronavirus Disease 2019 in Jiangsu Province, China: A Retrospective, Multi-Center Study,” SSRN, 2020.
[7] W. Liu et al., “Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease,” Chin. Med. J. (Engl)., 2020.
[8] “Report on 196 patients critically ill with COVID-19,” 2020. Intensive Care National Audit and Research Centre. [Online]. Available: https://www.icnarc.org/About/Latest-News/2020/03/22/Report-On-196-Patients-Critically-Ill-With-Covid-19.
[9] World Health Organization, “Q&A on smoking and COVID-19,” 2020. [Online]. Available: https://www.who.int/news-room/q-a-detail/q-a-on-smoking-and-covid-19.
[10] World Health Organization, “COVID-19 and NCDs: information note,” 2020. [Online]. Available: https://www.who.int/who-documents-detail/covid-19-and-ncds.
[11] D. Hutt, “Does Cambodia’s Coronavirus Bailout Really Add Up?,” The Diplomat, 2020. [Online]. Available: https://thediplomat.com/2020/03/does-cambodias-coronavirus-bailout-really-add-up/.
[12] P. Chhoun, “High prevalence of non-communicable diseases and associated risk factors amongst adults living with HIV in Cambodia,” PLoS One, vol. 12, no. 11, 2017.
[13] S. Flessa and A. Zembok, “Costing of diabetes mellitus type II in Cambodia,” Health Econ. Rev., vol. 4, no. 24, 2014.
[14] P. Arokiasamy et al., “Chronic Noncommunicable Diseases in 6 Low- and Middle-Income Countries: Findings From Wave 1 of the World Health Organization’s Study on Global Ageing and Adult Health (SAGE),” Am. J. Epidemiol., vol. 185, no. 6, 2017.
[15] L. W. Niessen et al., “Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda,” Lancet, vol. 391, no. 10134, pp. 2036–2046, 2018.
[16] S. Jensen, “Walking above the Earth,” South East Asia Globe, 2019. [Online]. Available: https://southeastasiaglobe.com/cambodias-hidden-mental-health-problem/.
[17] I. W. C. Mak and M. C. Chu, “Long-term psychiatric morbidities among SARS survivors,” Gen. Hosp. Psychiatry, 2009.