key: cord-1041512-mpf4oghl
authors: To, Teresa; Viegi, Giovanni; Cruz, Alvaro; Taborda-Barata, Luis; Asher, Monica; Behera, Digambar; Bennoor, Kazi; Boulet, Louis-Philippe; Bousquet, Jean; Camargos, Paulo; Conceiçao, Claudia; Gonzalez Diaz, Sandra; El-Sony, Asma; Erhola, Marina; Gaga, Mina; Halpin, David; Harding, Letitia; Maghlakelidze, Tamaz; Masjedi, Mohammad Reza; Mohammad, Yousser; Nunes, Elizabete; Pigearias, Bernard; Sooronbaev, Talant; Stelmach, Rafael; Tsiligianni, Ioanna; Tuyet Lan, Le Thi; Valiulis, Arunas; Wang, Chen; Williams, Sian; Yorgancioglu, Arzu
title: A Global Respiratory Perspective on the COVID-19 Pandemic: Commentary and Action Proposals
date: 2020-06-25
journal: Eur Respir J
DOI: 10.1183/13993003.01704-2020
sha: cfff4c315fc737b358ce92b2be6b535308b6ebf7
doc_id: 1041512
cord_uid: mpf4oghl

This paper offers practical and feasible actions to be implemented at patient, health care provider and community level to combat COVID-19 while attending, maintaining and strengthening ongoing health management in people with lung diseases.

The novel coronavirus disease is caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [1, 2] . The World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on March 11, 2020, demanding effective national and global mitigation measures, strong public health response and coordination. To date, the SARS-CoV-2 pandemic has affected over 5 million individuals worldwide with an overall 7.02% (median: 3.41%, ranges: 0.06% to 31.25%) case-fatality ratio (European Center for Disease Prevention and Control dashboard:

www.ecdc.europa.eu, as of May 22, 2020) [3]. This ratio may be overstated since it is based primarily on hospitalized or notified cases.

Lung diseases affect hundreds of millions of people around the world across all ages and levels of socioeconomic status. According to the Global Burden of Diseases (GBD) Study 2017, there were 3.2 million deaths due to Chronic Obstructive Pulmonary Disease (COPD) and 495 thousand deaths due to asthma [4] . Furthermore, all-age prevalent cases of chronic respiratory diseases (CRDs) totalled 545 million, of which approximately 50% due to COPD and the other 50% to asthma [5] .

Despite a high burden of CRDs worldwide, CRDs (such as asthma or COPD) have not been consistently identified as a significant comorbidity for COVID-19 [6] . For example, in Wuhan, the prevalence of asthma in COVID-19 patients was merely 0.9% [7] compared to a markedly higher prevalence rates of 4.5% to 9% among the US COVID-19 patients [8, 9] . In the UK, about 14% of admitted COVID-19 patients had asthma [10] , and the ISARIC (International Severe Acute Respiratory and Emerging Infection Consortium) also reported similar prevalence rates (16% with chronic pulmonary disease and 13% with asthma) [11] . In contrast, the US CDC reported CRDs (mainly asthma) as the second most prevalent comorbid condition in hospitalized COVID-19 patients aged 18-29 years [12] .

These reported discrepancies may be attributable to the overall under-diagnosis of CRDs, some level of protection provided by atopy [13] , or the use of inhaled corticosteroids [14] . It is unclear whether patients with asthma or COPD are at higher risk to develop COVID-19 and if the risk varies depending on other socioeconomic and demographic factors [12, 15] . For example, the risk of COVID-19 infection may be higher in individuals with chronic diseases and who are in low-and middle-income countries (LMICs) with a high prevalence of malaria, pulmonary tuberculosis, or HIV co-infection. In many LMICs, accessibility to healthcare in general is suboptimal, and have worsened not only by COVID-related lockdowns, but also by resource diverted/transferred to COVID-19 [16, 17] . Therefore, ensuring healthcare support to vulnerable populations in LMICs, such as timely access to adequate treatments for CRDs and other infectious diseases (TB, HIV and malaria) is paramount. Others have also suggested that therapies used by patients with CRDs may reduce the risk of infection or of developing symptoms leading to diagnosis [15] . Lower respiratory function, ineffective immunity and treatments that may increase their susceptibility to infection, are possible causes of their higher risk of unfavourable outcomes after a common cold, influenza or other infections [18] [19] [20] [21] [22] . Worsening respiratory symptoms may be a result of their underlying disease or a consequence of the superimposed infection [20] . Reports from various countries ranked CRDs among the most frequent comorbidities associated with ICU admissions, need for mechanical ventilation and deaths [15, 20, 23, 24] . A recent systematic review and meta-analysis [25] also reported a 4-fold increased odds of COPD and the development of severe COVID-19 and a 2-fold odds of ongoing smoking and the development of severe COVID-19. However, today, there is still uncertainty regarding the actual magnitude of the risks of unfavorable outcomes attributable to COVID-19 in patients with CRDs.

Further research is needed to fully understand the association between underlying CRDs and COVID-19.

The authors of this paper are active members of the Global Alliance against chronic Respiratory Diseases (GARD, https://gard-breathefreely.org/), a WHO alliance consists of national and international organizations, medical and scientific societies, patient organizations, institutions and agencies, all working with the common goal of reducing the global burden of CRDs. GARD members are frontline health care providers and researchers from over 80 countries. Our shared vision is a world where all people breathe freely and our activities are divided into four areas: advocacy, partnership, national plans on prevention and control and surveillance. In this document, we summarize our hands-on experience and lessons learned according to three perspectives: 1) patient level: interactions with health care providers; 2) health care provider level: real-time experience sharing; and 3) community level: environmental impact, air pollution.

Our main focus remains on actions concerning CRDs in the context of the pandemic.

Globally, many people with underdiagnosed and undertreated CRDs, are at risk of complications from COVID-19. We should therefore ask: What can we do about it? Our reflections and experiences are still evolving with the pandemic, and we hope that they may foster deeper thoughts and considerations into how to move forward in relation to the heavy respiratory burden in times of COVID-19.

Using the National Health Insurance data between January 2000 and August 2003 to study the impacts of the previous severe acute respiratory syndrome (SARS) epidemic on medical service utilization in Taiwan, Chang et al. reported significant reductions in ambulatory care (23·9%) and inpatient care (35·2%) during the 2002-2004 SARS epidemic [26] . This was largely attributed to the fears of SARS that generated a widespread avoidance of the health care system.

Preliminary reports suggested that this may also be occurring in the COVID-19 pandemic [27] . During the pandemic, many cities across the world were ordered to comply with social distancing, to stay at home and work from home. Individuals with a chronic condition such as asthma and COPD may opt to stay home, even when their symptoms flare up, rather than to seek health care. In general, mid-or long-term isolation or quarantine may be associated with increased levels of depression, stress and anxiety [28] , and worsened symptom control and decreased quality of life in people with asthma and COPD [29] [30] [31] [32] .

Post-SARS, chronic disease patients not affected by SARS presented with worsened disease/symptom control [26] .

Today, face-to-face medical consultation is not the only option. With the wide usage of smartphones, patients and health care providers are able to use readily available apps with videos (e.g. Facetime or WhatsApp) or audio via phone to conduct e-consultation and to provide routine and unscheduled "virtual visits" [33] [34] [35] . This may help patients reduce their anxiety and depression, empower disease self-management, and protect patients and health care workers during the pandemic. However, this may increase health inequity as technology use is not evenly distributed across global populations and may be particularly absent in the most at risk populations for age, cultural, education and financial reasons. COVID-19 has affected vulnerable populations disproportionately across China and the world [36] . Solid social and scientific evidence to tackle health inequity in the current COVID-19 pandemic is in urgent need. This is a unique opportunity to promote and implement health literacy measures for the general population, with a focus on COVID-19 and CRDs. The public is anxious and eager for information. Regretfully, the information on the internet is frequently misleading, often driving one's attention away from the most important measures for prevention, early diagnosis, home isolation and identification of symptoms requiring medical care [37] . All organizations devoted to CRDs must communicate regularly with the public to deliver the key messages supported by science and endorsed by the health authorities. Communications with the use of infographics should be considered so that everyone will be able to absorb and use it. See proposed actions outlined in Table   1 .

COVID-19 is a novel coronavirus disease. As such, the effectiveness of prevention measures, therapy options, variant phenotypes, morbidity and mortality risks, short-and long-term disease sequelae, mental health consequences and length of immunity remains unknown.

Today, we are still questioning whether COVID-19 is just a respiratory disease, or affects other systems too, as suggested by cutaneous manifestations [38, 39] , acute gastro-intestinal [40] , neurological symptoms and cardiovascular complications in recently infected COVID-19 patients [41, 42] . Furthermore, many recovered patients continue to manifest nonrespiratory symptoms and neurological morbidities which indicate the virus may have also attacked other organs such as the brain, and not just the lungs [15, 41, 43] . Further research is needed about management at home including protection of other family members, rehabilitation, diet, and the organization of care.

Early in the epidemic, many patients were ventilated due to acute and severe respiratory failure, and many of them did not survive. The wide use of ventilation revealed a global shortage of ventilators and oxygen supply. With the shortage of medical supplies, health care providers started to implement other treatment options and some of them may not have been proven useful. The use of chatbots such as WhatsApp, Skype, Facebook

Messenger and WeChat has allowed frontline health care providers to communicate with each other and share their patient experiences and consult each other in real time [44] . This collegial support has shortened the distance between people and broken communication barriers. However, information overload is a risk for busy clinicians, therefore there is a need for a strong direction from public health authorities.

During these difficult times of fighting COVID-19, health care professionals must be highly valued, including appropriate remuneration, rigorously protected and explicitly reassured any health consequences of an incidental COVID-19 will be compensated. Their confidence is built upon the support and crisis preparedness of their health care system. However, the latter varies throughout the world and warrants a higher level of collaboration in order to reduce inequalities. See proposed actions outlined in Table 2 .

Air pollution has been termed the "silent killer" by the World Health Organization as it poses a great environmental risk to health and yet often is unnoticed. Furthermore, air pollution abatement has faced multiple challenges and, with population growth and expansion of industries, many questioned whether air pollution could be ameliorated.

In February and March 2020, many cities across the world launched social distancing strategies attempting to curtail the spread of COVID-19. Cities all over the world are now observing record low levels of air pollution. For example, ambient levels of nitrogen dioxide (NO 2 )-one of the main traffic-related pollutants-have declined by 70% to 80% in Barcelona, 40% in London, and 50% in New York [45] and other cities across the world [46] [47] [48] . This "short-term" reduction in air pollution is a positive news out of the pandemic, however, if this short-term "improvement" will be associated with any significant health benefits, remains to be seen. Nonetheless, it demonstrated that abating air pollution is achievable. Communities that are educated and engaged more easily adhere to and are involved in epidemics prevention and treatment measures [49] , although this will also depend on infrastructures, institutions, and resources [17] .

It is possible that during these unusual times of less air pollution and extreme measures to avoid transmission of respiratory viruses, there is a decline in morbidity and mortality due to respiratory diseases unrelated to COVID-19, particularly those due to acute respiratory infections and/or exacerbations of CRDs. It is fundamental to reinforce surveillance and research to demonstrate how populations could benefit from more rigorous control of air pollution and transmission of respiratory viruses in general. See proposed actions outlined in Table 3 .

Worldwide, COVID-19 has infected over five million people, killed hundreds of thousands and forever changed our daily life and the way we interact with each other. At the same time, globally 1,000 people die from asthma every day and many of these deaths are premature and preventable with proper and timely management (http://www.globalasthmareport.org/burden/mortality.php).

Therefore, it is paramount to minimize the potential "collateral damage" to patients from suboptimal management of CRDs during the pandemic.

To combat the unprecedented global atrocity of COVID-19, we observed that health care professionals are united to face this deadly and fast-spreading virus, finding strength, compassion, courage and solidarity among peers who are committed to prevent, manage and rehabilitate patients with this life-threatening ailment, at all levels. Now, more than ever, there is an urgent need to bridge individual and population needs and this can only be done with engagement and interaction among public health, primary and secondary care.

The COVID-19 pandemic, while devastating, has created a remarkable worldwide opportunity for individuals, organizations and countries to excel in solidarity, collaboration and partnership, sharing resources and experiences which are essential to control the pandemic, reduce the death toll and attenuate the socio-economic and psychological consequences from isolation, unemployment and poverty.

All authors are active leaders of organizations comprising the network of the Global Alliance against chronic Respiratory Diseases (GARD), but the content and opinions expressed in this paper are those of the authors and they do not purport to reflect the opinions, views, positions or standing policies of any organizations, agencies or institutions which the authors are affiliated with.

 Endorse and encourage compliance with recommendations on national plans and guidelines against global pandemics that were put forward by WHO.  Promote and implement health literacy measures to the general population, with a focus on CRDs and symptoms such as cough and breathlessness in the context of epidemics and pandemics.  Advocate and promote acceleration of R&D in novel and neglected infectious diseases, preparedness against pandemics in the context of an international network.  Advocate data collection on characteristics of COVID-19 in regard to its infectiveness and tropism to respiratory cells and risk of interstitial pneumonia and ARD (acute respiratory distress).  Partner with and support countries, health care professionals and researchers in investigating how differently COVID-19 affects different vulnerable populations (e.g. older adults versus children, men versus women, those with any underlying respiratory diseases, different comorbidities, different socioeconomic status), which may yield insights into disease pathogenesis, informing precision-health management and development of therapeutics.  Partner with and support GARD countries, health care professionals and researchers in studying the risk of COVID-19 among people with CRD.  Develop and implement strategies to offload the overstretched health care systems (overworked, overexposed health care and essential service workers) by supporting selfmanagement, and reducing avoidable hospital admissions from CRD.  Enforce/ensure institutional and local plans pertaining to sufficient essential supplies (e.g.

personal protective equipment (PPE), diagnostic and screening tests, medications etc.) in combating an epidemic/pandemic, i.e. improve epidemic preparedness.

 Promote strong and regular interaction with respiratory patient groups and associations for articulated actions regarding validated patient information on COVID-19 infection and CRDs  Direct patients to reliable websites such as the WHO COVID19 dashboard (https://www.who.int/emergencies/diseases/novel-coronavirus-2019) and the International Primary Care Respiratory Group (IPCRG, https://www.ipcrg.org/news/covid-19-open-sourcesources-of-information) for Q&A.  Emphasize to patients the importance of hand-washing, social and physical distancing, stay at home and maintain self-isolation if infected.  Raise awareness of the importance of good practice of disease self-management (e.g. asthma, COPD), healthy life styles (healthy-eating, quit smoking, exercise, etc.) to help reduce comorbidities that make individuals more susceptible to COVID-19 infection or severe progression.  Explain to patients the importance of not discontinuing their CRD medications (e.g. ICS), but when in doubt, contact their health care provider (https://www.who.int/emergencies/diseases/novel-coronavirus-2019).  Promote smoking cessation (including water pipe or hookah) as not only is smoking a recognized risk factor for many chronic diseases including COPD, hypertension, cardiovascular disease, and respiratory tract infections, it has been reported that smoking is also most likely associated with the negative progression and adverse outcomes (including ICU support, mechanical ventilation and death) of COVID-19 [50] , and the sharing of a mouth piece in water pipe smoking could facilitate the transmission of COVD-19.  Underscore the importance for patients with sleep respiratory disorders (SRD) to continue with the continuous positive airway pressure (CPAP) therapy during the pandemic in order to maintain high level of immunological defenses.  Support and share information on occupational risks and COVID-19 (e.g. health care workers and other essential service workers). 

 Support and participate in new and ongoing development of COVID-19 mHealth and app technologies designed for early screening and daily management of infected patients.  Deploy mHealth and disease self-management programmes/tools, which are especially relevant when patients and families are in self-isolation.  Support and strengthen official online platforms for regional and global networks of health care providers sharing practical experience in dealing with COVID-19.  Support and promote a concerted effort that may lead to a shared approach in making decisions in self-management programmes targeting high-risk populations.

 Follow evidence-based scientific reports and WHO recommendations on effective and efficacious diagnostic tests and treatments for COVID-19.  Increase the production and provision of personal protective equipment (PPE) to all health care workers in all settings in all countries.  Increase the manufacture and supply of sufficient respiratory ventilators to meet the global needs for COVID-19, across all continents and health care settingsacute, primary/pediatrics, community or long-term care.  Ensure co-ordination between primary and secondary care in terms of adequate and welldefined integrated care pathways for CRD patients, in the context of COVID-19 and other future epidemics / pandemics, with clear guidelines for referral.  Support the logistics of facility cleaning and clinical waste disposal for community services.  Establish a compensation process for those who have been infected at work by the COVID-19 (work-related disease).

 Promote and ensure validated and adequate training on various aspects of COVID-19 and other emergent infections and their effects on CRDs to health care staff, at different levels of care and locations.  Promote and support innovative, high quality, clinical and translational research focusing on optimization of prevention, diagnosis and treatment of COVID-19 pandemic as well as its effects on CRD patients.  Promote large collaborative, multinational epidemiological studies as well as randomized controlled trials to assess the relevance of factors such as BCG vaccination in protection against COVID-19, namely in patients with CRD.  Support creation of international networks and registries of clinical research on COVID- 19 and CRDs. 

 Comply with WHO recommendations on prevention and containment of new severe epidemics.

 Align all action with the motto expressed in the Helsinki statement "Health in all policies: framework for country action".

 Focus on the effective implementation of guidelines, regulations, and instructions with relevant authorities.  Ensure full regional ownership of nationally coordinated actions.  Ensure adequate national co-ordination and integration of activities with clear overall objectives, focused goals and measures, in a prioritized way.  Ensure an updated, practical and real notion of each country's critical preparedness and readiness for preventive and response actions to Covid-19 and other, future severe pandemics, not only in terms of health care infrastructures, institutional capacity and skills but also regarding other institutions and the community at large.  Adequately identify strengths and weaknesses in countries' global strategy, as well as in health care and community settings regarding CRDs in the context of severe pandemics, as well as limited resources that may hinder adequate approaches.  Strive to develop community capacity regarding CRDs and severe epidemics, integrated into a national strategy and policy.  Ensure adequate planning of risk communication regarding pandemics and CRDs, as well as community engagement in actions that may be both global but also tailored to the specific level of health literacy and cultural context of each population, aiming at reducing health inequalities.  Ensure all actions are inclusive of vulnerable population groups, and their needs are prioritized when appropriate.  Ensure that there is adequate accessibility to healthcare and medication for patients with CRD, during the pandemic.  Endeavour to have adequate monitoring of all actions integrated into countries' policies and strategies regarding CRD management in the context of severe pandemics.  Endeavour to have actions guided by the "One Front, Many Actions" approach, with integrated, articulated, complementary, necessarily supervised and multiple-level organized actions impacting upon management of CRDs in the context of COVID-19 and other future pandemics, not only within each country but also in collaborative efforts among different countries, as has already been initiated by CPLP (Portuguesespeaking countries), in terms of a common webpage hyperlink to country-level dedicated epidemiological statistics and other relevant information on COVID-19 (http://gard-cplp.ihmt.unl.pt/index.html).

 Follow-up (short and longer-term, clinical as well as functional) of infected patients regardless of age (infants, children, adolescents, adults and elderly) is important to monitor disease and symptom severity and treat accordingly, as well as identifying possible long-term consequences.  Use objective measures for monitoring including pulse oximetry, and where possible, spirometry, CO diffusing capacity, impulse oscillometry, and lung clearance index.

 Support surveillance (testing, screening, diagnosing, contact tracing, treating, and following-up) and reporting of COVID-19 disease burden and epidemiology by countries/regions which will help understand the differential impact attributable to geographic variations.  Access reliable dashboards (e.g. WHO, https://www.who.int/emergencies/diseases/novel-coronavirus-2019, European Center for Disease Prevention and Control www.ecdc.europa.eu, Johns Hopkins https://coronavirus.jhu.edu/map.html, GARD https://gard-breathefreely.org/covid19/ etc.) on pandemic surveillance and statistics.  Keep abreast of the pandemic locally and worldwide in order to act accordingly.  Ensure COVID-19 surveillance of vulnerable populations in low and middle income countries (LMICs), particularly in areas of high prevalence of HIV, malaria and tuberculosis (TB).  Ensure that public health surveillance is not just diverted towards COVID-19 but is also kept, together with accessibility to adequate treatments, in other infectious diseases (namely TB, HIV and malaria) and chronic respiratory diseases, particularly in LMICs.  Partner with respective government agencies to enforce the ongoing fight against air pollution and climate change.  Include in pre-graduation curriculum (medical, nursing and allied health sciences):

catastrophe health care management, as well as preparedness, with an emphasis on epidemics, pandemics and global security.  Support and provide resources for efficient and effective local surveillance systems.  Use/support continuing medical education programs to update knowledge on new infectious disease.  Support investment in training health care professionals and the public in understanding risk, how tests are used, and in risk communication to avoid unnecessary alarm and/or complacency in uncertain times.

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