Management of coexisting conditions in the context of COVID-19

Last reviewed: 7 May 2023

Last updated: 10 Aug 2022

This page compiles our content related to Management of coexisting conditions in the context of COVID-19. For further information on diagnosis and treatment, follow the links below to our full BMJ Best Practice topics on the relevant conditions and symptoms.

This page summarizes important considerations for the care of people with coexisting medical conditions during the COVID-19 pandemic. Key points from guidance and position statements are summarized for each condition, and there is a link to the main BMJ Best Practice topic. This overview topic is continually reviewed and updated, and more conditions will be added to this list.

Our full topic on Coronavirus disease 2019 (COVID-2019) includes information on diagnosis and management, as well as prevention, differential diagnosis, epidemiology, etiology, prognosis, and complications.

Considerations for perinatal care

Severity of COVID-19 in pregnant women

Pregnant women are at risk of more severe COVID-19 infection and should take extra precautions, especially those above 28 weeks' gestation.[1][2][3][4][5]

Pregnancy increases the risk of hospitalization, intensive care admission, and receipt of mechanical ventilation.[2][6] Pregnant women should be counseled about the risk of severe illness from COVID-19 and the importance of preventive measures.[6]

Risk factors for hospital admission with COVID-19 infection during pregnancy include: being unvaccinated; being from a black, Asian, or other minority ethnic group; having a BMI of 25 or more; prepregnancy comorbidity (such as diabetes or hypertension); age 35 or older; increased socioeconomic deprivation.[7][8] In the US, Hispanic and non-Hispanic black women also seem to be disproportionately affected by SARS-CoV-2 infection during pregnancy.[6]

Maternal COVID-19 is associated with a higher risk of preeclampsia/eclampsia, preterm birth, birth by emergency cesarean section, prolonged maternal admission following birth, venous thromboembolism, myocardial infarction, and maternal mortality or serious morbidity from obstetric complications.[7][9][10][11][12][13][14][15][16][17] Preexisting comorbidities, high maternal age, prepregnancy obesity, gestational diabetes, pregestational diabetes, preeclampsia, and nonwhite ethnicity are associated with more severe COVID-19 disease during pregnancy.[2][11][18][16]

Disease severity is associated with higher rates of preterm birth, cesarean delivery, maternal intensive care admission, neonatal intensive care admission, and maternal death.[2][19][20] Maternal SARS-CoV-2 status does not appear to affect postpartum hemorrhage, infant 5-minute APGAR score, or birth weight for gestational age.[9][21]

Impact of maternal COVID-19 infection on the neonate

Infants born to mothers who test positive for SARS-CoV-2 have an increased risk of admission for neonatal care, prolonged neonatal admission, hyperbilirubinemia, respiratory distress syndrome, and any other respiratory disorder.[12][21][22] A US study found that risk for stillbirth was higher among women who had COVID-19 at delivery hospitalization compared with those without COVID-19; association was higher during period of Delta-variant predominance compared with the period before Delta.[23]

Fewer than 2% of babies born to mothers with COVID-19 have confirmed SARS-CoV-2 infection. Transmission may occur in utero, perinatally, or in the early postnatal period. Severe maternal infection, maternal death, maternal admission to an intensive care unit, and postnatal maternal infection were associated with an increased risk of SARS-CoV-2 positivity in the newborn.[24]

Vaccination of pregnant and lactating women

Pregnant women should be advised to take up the influenza vaccine.[7] Guidance is available on use of COVID-19 vaccines during pregnancy.[25] In the US, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend COVID-19 vaccination for all people who are pregnant, breast-feeding, trying to get pregnant now, or might become pregnant in the future.[26][27] In the UK, guidance advises that pregnant women should be offered vaccination at the same time as nonpregnant women, based on their age and clinical risk group.[7][28] Women who are breast-feeding may also be offered any suitable COVID-19 vaccine.[28] Local guidance should be followed.

Vaccination with an mRNA vaccine is 89.5% effective against SARS-CoV-2 infection 7 days after the second dose.[29] There is no association between COVID-19 vaccination during pregnancy and spontaneous abortion, postpartum hemorrhage, chorioamnionitis, cesarean delivery, neonatal intensive care admission, 5-minute APGAR score <7, stillbirth, preterm birth, or small for gestational age infant.[29][30][31][32] [33][34][35][36][37] Vaccination is associated with a significantly decreased risk of stillbirth, compared with unvaccinated women (OR 0.85, 95% confidence interval [CI] 0.73 to 0.99).[29] Unvaccinated women are more likely to be admitted to hospital with COVID-19, compared with vaccinated women.[38][39]

In a retrospective observational cohort study, women who received a SARS-CoV-2 vaccine during pregnancy were more likely to have fever, malaise/fatigue, local reactions, and lymphadenopathy/lymphadenitis, compared with women who did not receive a SARS-CoV-2 vaccine. No serious acute adverse events that were evaluated (cerebral venous sinus thrombosis, encephalitis or myelitis, myocarditis or pericarditis, pulmonary embolism, or Guillain-Barré syndrome) occurred more frequently in vaccinated women than among matched unvaccinated controls.[40]

Analysis of pregnancies occurring during clinical trials of the AZD1222 (AstraZeneca) vaccine demonstrated no difference in rates of conception between women who received the SARS-CoV-2 vaccine and women who received the control vaccine.[41] Cohort data have also suggested that administration of COVID-19 mRNA vaccines is not associated with oocyte or embryo development, implantation, or early pregnancy loss in patients undergoing IVF.[42]

The number needed to vaccinate (NNV) to prevent one symptomatic case of COVID-19 has been calculated as between 41 and 206 pregnant women. The NNV to prevent severe COVID-19 is between 412 and 2058. Numbers needed to harm are 37,037 for vaccine-related myocarditis and 48,780 for vaccine-related thrombosis with thrombocytopenia syndrome.[43]

Transfer of SARS-CoV-2 antibodies to cord blood and breast milk after maternal vaccination has been described.[44][45][46][47] Maternal and neonatal anti-SARS-CoV-2 antibody titers are higher following a third (booster) dose of mRNA vaccine in the second trimester, compared with a two-dose primary vaccination course in the second trimester.[48] Case-control studies have found that maternal completion of a 2-dose mRNA COVID-19 vaccination series during pregnancy is associated with a reduced risk of COVID-19 hospitalization among infants aged <6 months.[49][50][51]

Considerations for mental health of pregnant women

Pregnant women have reported higher levels of distress and psychiatric symptoms during the COVID-19 pandemic.[52] A report from the UK’s Centre for Mental Health and the Maternal Mental Health Alliance completed a rapid evidence review of the impact of COVID-19 on mental health during pregnancy and after birth, and found that women experiencing financial insecurity or racial inequality had a higher risk of poor mental health.[53]

Prenatal and intrapartum care

Women are advised to continue routine prenatal care, and the nationally recommended schedule of prenatal care should be offered in full wherever possible.[7]

Considerations for intrapartum care include:

Women should be offered SARS-CoV-2 testing on admission to the maternity unit.[7]
Scheduled induction and cesarean delivery may continue if indicated, but if the patient screens positive for suspected COVID-19 infection, individual assessment should be made to determine if it is safe to reschedule.[7][54] COVID-19 status alone is not an indication for cesarean delivery.[55]
Continuous fetal monitoring using cardiotocography during labour is not indicated for asymptomatic women who test positive for SARS-CoV-2, unless there is another indication for monitoring (e.g. previous cesarean delivery). Women with confirmed or suspected symptomatic COVID-19 should be offered continuous fetal monitoring during labor and vaginal birth.[7]
Home birth may still be considered for low-risk pregnancies, where appropriate support can be provided.[7]

Considerations for newborn care

The American Academy of Pediatrics has published guidance on the care of babies born to mothers who have COVID-19.[56]

Observational cohort studies have found that the risk of the newborn acquiring SARS-CoV-2 infection is low when contact and droplet precautions are taken to protect the newborn from maternal respiratory secretions.[57][58][59] A mask should be worn, and meticulous breast and hand hygiene performed, for direct skin-to-skin contact between mother and child.[1][56]

Clinicians should attend deliveries according to their normal institutional policies; maternal COVID-19 infection alone is not an indication to attend.[60] Neonatal resuscitation should follow current national and European guidelines.[60]

Breast-feeding should be encouraged; the benefits substantially outweigh the risks of transmission.[4][55] There is currently no evidence that COVID-19 can be transmitted through breast milk.[7][54][61][62] Women who are breastfeeding may be offered any suitable COVID-19 vaccine.[27][63]

Babies should not wear face masks or other face coverings because this may risk suffocation.[7]

Considerations for patients with dermatologic conditions receiving drugs that affect the immune response

People with inflammatory skin diseases have a higher risk of COVID-19 related death than the general population, after adjusting for confounding and mediating factors (hazard ratio 1.07, 96% CI 1.02 to 1.11). They are also at higher risk of hospital and critical care admission. South Asian people and mixed ethnicity people with inflammatory skin diseases are at higher risk of COVID-19-related death, compared with white people with inflammatory skin diseases.[64]

People taking tumor necrosis factor inhibitors, interleukin (IL)-12/IL-23 inhibitors, or IL-17 inhibitors do not have an increased risk of COVID-19-related critical care admission or death, compared with people taking standard systemic therapy (e.g., methotrexate).[64]

The International Psoriasis Council advises that the benefits and risks of using immunosuppressive therapy should be carefully weighed for each patient who is at higher risk of severe illness because of their age or comorbidities.[65] The US National Psoriasis Foundation COVID-19 Task Force does not recommend that patients stop their biologic or oral therapies for psoriasis and/or psoriatic arthritis; any decision to start or stop a biologic or oral systemic therapy should be individualized and involve a healthcare provider.[66]

Advice on COVID-19 vaccination for patients having or scheduled to have immunosuppressive therapy is available and should be consulted.[63][67]

Expert recommendations are available for the management of psoriasis, autoimmune bullous disease (pemphigus, pemphigoid, dermatitis herpetiformis) and atopic dermatitis (eczema) during the pandemic.[65][68][69][70]

Considerations for patients with dermatologic conditions receiving oral retinoids

The UK Medicines and Healthcare products Regulatory Agency has published guidance to assist safe prescribing of oral retinoids during the pandemic. Consultations for considering a first prescription of oral retinoids should take place face-to-face, where possible. If this is not possible, a remote appointment must include the same full risk-benefit discussion as a face-to-face appointment. If the patient is <18 years, a parent or guardian should be involved for part of the initial consultation. Advice is given for home pregnancy testing to fulfil the requirements of the Pregnancy Prevention Programme, and for monitoring blood tests and psychiatric symptoms.[71]

Considerations for endoscopy

Upper gastrointestinal (GI) endoscopy is a high-risk procedure for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Lower GI endoscopy also carries a risk of SARS-CoV-2 infection. European and Asia-Pacific guidelines make recommendations for upper and lower GI endoscopy during the COVID-19 pandemic.[72][73][74]

GI endoscopy should always be performed for:

Acute upper/lower GI bleeding with hemodynamic instability
Anemia with hemodynamic instability
Capsule endoscopy/enteroscopy for urgent or emergent bleeding
Foreign body in esophagus
High-risk foreign body in stomach
Obstructive jaundice
Acute ascending cholangitis.

The guidance advises on prioritization and deferral of procedures for other indications.

Considerations for patients receiving systemic anticancer therapy

Patients with cancer are at higher risk of hospitalization, severe disease, and death from COVID-19 than patients with no comorbid conditions.[75][76][77] Studies of the effect of systemic anticancer therapy on COVID-19 infection outcomes report mixed results. An observational study of patients referred to oncology services in Europe reported that delivery of cancer therapy (chemotherapy, immunotherapy and targeted therapy) was not associated with case severity or mortality.[78] An observational study from the US also found that administration of cytotoxic chemotherapy was not associated with severe or critical COVID-19. Patients with active lung or hematologic malignancies, baseline neutropenia, or lymphopenia at COVID-19 diagnosis had worse outcomes.[79] Another cohort study found that patients who had received cancer treatment within 3 months before COVID-19 diagnosis had a significantly higher risk of adverse outcomes compared with patients without cancer, and patients with no recent cancer treatment had similar outcomes to those without cancer.[80] Data from the UK Coronavirus Cancer Monitoring Project (UKCCMP) found that patients with hematological malignancies had increased susceptibility to severe acute respiratory syndrome coronavirus 2 and also had more severe COVID-19 disease compared with patients with solid organ tumors; recent chemotherapy conferred an additional risk.[81] Analysis of US health-insurance claims data found that lung cancer, leukemias, and lymphomas were significant risk factors for fatal COVID-19 in patients <70 years.[82] Among patients with a recent cancer diagnosis, African-American patients had a significantly higher risk of COVID-19 than white patients.[77] In Europe, day 14 case fatality rate for patients with solid or hematologic malignancies and confirmed severe acute coronavirus 2 (SARS-CoV-2) infection decreased over the course of the pandemic, from 25.6% in the first major outbreak (February to June 2020) to 16.2% in the second major outbreak (July 2020 to February 2021). Risk of complications requiring hospitalization and/or antiviral therapy also decreased during the second major outbreak compared with the first.[83] One cohort study reported outcomes for children and adolescents (<19 years) with cancer and COVID-19 infection. Almost 20% of patients had severe or critical COVID-19 infection, and 3.8% died from COVID-19. Residence in a low, lower-middle, or upper-middle income country, age 15-18 years, lymphopenia, neutropenia, and intensive treatment were associated with increased risk of severe or critical illness.[84] Outcomes of patients with cancer may be affected by post-COVID-19 sequelae.[85]

The most common presenting symptoms of COVID-19 in patients with cancer are fever, cough, and acute dyspnea.[78] However, patients may present with atypical symptoms of COVID-19, and other conditions, notably neutropenic sepsis and pneumonitis, can mimic COVID-19.[86][87] Patients with a fever or other symptoms of infection should have a comprehensive evaluation.[87]

UK guidelines recommend that systemic anticancer treatment should be deferred, if possible, in patients who have COVID-19 until at least 10 days have elapsed since a positive test for SARS-CoV-2 and any significant symptoms have resolved.[86] Systemic anticancer treatment may be continued if necessary for urgent control of the cancer; a shared decision should be reached with the patient.[86]

UK guidelines recommend that the highest priority for systemic anticancer treatments should be:[86]

Curative treatment with a high (more than 50%) chance of success
Adjuvant or neoadjuvant treatment that adds at least 50% chance of cure to surgery or radiation therapy alone or treatment given at relapse.

NHS England has made recommendations for treatment change options for systemic anticancer therapy (SACT). These take into account the degree of immunosuppression caused by the treatment, the ability to administer treatment in a setting that reduces exposure to COVID-19, resource availability, feasibility, and capacity.[88]

The European Society for Medical Oncology (ESMO) has published guidance on management of cancer patients during the COVID-19 pandemic and recommends that the benefit/risk ratio may need to be reconsidered in some patients. ESMO considers patients receiving chemotherapy and those who have received chemotherapy in the last 3 months to be at risk. ESMO suggests that decisions for starting or continuing cancer therapy are discussed for both patients who do not have COVID-19 infection, and those who do have COVID-19 infection but are asymptomatic or paucisymptomatic, and are still fit and willing to be treated after explanation of the risks and benefits.[89] Cancer care prioritization and intensity should be adapted to the pandemic scenario.[90]

ESMO suggests the following patient prioritization:[89]

High priority: patient condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g., significant overall survival gain and/or substantial improvement in quality of life [QoL])
Medium priority: patient situation is noncritical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority
Low priority: patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is nonpriority based on the magnitude of benefit (e.g., no survival gain with no change nor reduced QoL).

ESMO advise that where feasible, all cancer patients admitted to hospital for cancer treatment should be tested for SARS-CoV-2, irrespective of chest radiographic findings or symptoms, if considered at high risk of mortality from SARS-CoV-2 infection. Clinicians should rapidly review the patient’s clinical presentation, their clinical, travel and epidemiological history and planned procedures to ascertain their risk of infectiousness. Healthcare professionals should use personal protective equipment meticulously. Clinicians should consider giving granulocyte colony stimulating factor to elderly patients with comorbidities and patients with an intermediate or high risk of febrile neutropenia, to reduce the risk of febrile neutropenia. Prophylaxis against venous thromboembolism is recommended for patients with cancer and COVID-19. Immune checkpoint inhibitors should not be delayed or withheld in the adjuvant/neoadjuvant setting where there is a significant survival benefit. If a patient receiving immune checkpoint inhibitor therapy for an approved indication tests positive for SARS-CoV-2, the immune checkpoint inhibitor therapy should be withheld until recovery. Tyrosine kinase inhibitors may be withheld until recovery in patients who develop COVID-19 and have oncologically stable disease.[90]

The US National Institutes of Health Coronavirus Disease (COVID-19) Treatment Guidelines provide recommendations for treatment of COVID-19 in adults and children with cancer.[91] The recommendations for treating COVID-19 in patients with cancer are the same as for the general population; however, clinicians should be aware of potential drug interactions and overlapping toxicities. A hematologist or oncologist should be consulted before adjusting cancer-directed medications. Molecular diagnostic testing for SARS-CoV-2 is recommended in patients who develop signs and symptoms of COVID-19 and in asymptomatic patients prior to procedures that require anesthesia and before initiating cytotoxic chemotherapy and long-acting biologic therapy.

Guidelines for SARS-CoV-2 vaccination for patients receiving SACT are available.[92][93] A study conducted in Israel prospectively examined the immunogenicity of the BNT162b2 mRNA vaccine in patients with solid organ tumors who were receiving SACT. After the first dose of vaccine, 29% of patients receiving SACT were seropositive for SARS-CoV-2 compared with 84% of controls. After the second dose of vaccine, 86% of patients receiving SACT were seropositive for SARS-CoV-2. The vaccine was not associated with a higher rate of adverse events in people receiving SACT.[94] A prospective cohort study conducted in the UK reported that SACT was not associated with reduced neutralizing antibody titer following SARS-CoV-2 vaccination. Seroconversion of patients with solid organ malignancies was 39% after the first vaccine dose and 85% after the second dose. Seroconversion of patients with hematological malignancies was 29% after the first vaccine dose and 59% after the second dose.[95] A prospective, multicenter, noninferiority study of the mRNA-1273 COVID-19 vaccine found that most patients with cancer who received chemotherapy, immunotherapy, or both for a solid tumor developed an adequate antibody response to vaccination.[96] One population-based, case-control study, conducted in the UK, reported SARS-CoV-2 vaccine effectiveness of 69.8% in the control population and 65.5% in patients with cancer. After 3 to 6 months, vaccine effectiveness was 61.4% in the control population, but had declined to 47.0% in patients with cancer.[97] Vaccinated patients with cancer have lower case-fatality rates, lower risk of complications due to COVID-19, and less requirement for COVID-19-specific therapy and oxygen therapy, compared with unvaccinated patients with cancer.[98]

Patients with cancer may be at increased risk of breakthrough COVID-19 infection after vaccination compared with patients without cancer.[99] International registry data have shown that patients with cancer who develop breakthrough COVID-19 infection after full vaccination continue to be at risk from severe outcomes.[100] Among the patients who had a breakthrough infection, those with hematological malignancies were over-represented.

Considerations for patients receiving radiation therapy

The European Society for Medical Oncology (ESMO) has published guidance on management of cancer patients during the COVID-19 pandemic and recommends that the benefit/risk ratio may need to be reconsidered in some patients. ESMO considers patients receiving extensive radiation therapy to be at risk. ESMO suggests that decisions for starting or continuing cancer therapy are discussed for both patients who do not have COVID-19 infection, and those who do have COVID-19 infection, are asymptomatic or paucisymptomatic, and are still fit and willing to be treated after explanation of the risks and benefits.[89][90]

ESMO suggests the following patient prioritization:[89]

High priority: patient condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g., significant overall survival gain and/or substantial improvement in quality of life [QoL])
Medium priority: patient situation is noncritical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority
Low priority: patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is nonpriority based on the magnitude of benefit (e.g., no survival gain with no change nor reduced QoL).

The International Lymphoma Radiation Oncology Group has published emergency guidelines for radiation therapy in hematologic malignancies, should radiation therapy be necessary. Alternative dose fractionations may be given.[101]

The European Society for Radiotherapy and Oncology (ESTRO) and the American Society for Radiation Oncology (ASTRO) have published guidance on radiation therapy for lung cancer in the current COVID-19 pandemic.[102] They highlight that the prognosis of lung cancer patients should not be compromised by departing from guideline-recommended radiation therapy practice; however, delaying or interrupting treatment is generally recommended for patients with COVID-19. An international group of experts in the management of lung cancer have also published recommendations for optimizing lung cancer radiotherapy during the pandemic.[103]

Further oncology resources are available at:

Considerations for patients with neuromuscular diseases

The World Muscle Society has published advice for management of patients with neuromuscular disease during the COVID-19 pandemic. Patients should continue taking corticosteroids and may require a dose increase if they become unwell. Corticosteroids should not be stopped if a patient becomes ill. Immunosuppressive treatment should not be stopped preemptively unless advised otherwise by a specialist. If a patient taking immunosuppressive medication becomes ill, an individual decision regarding temporary withdrawal or a change of immunosuppressive agent should be made with their neuromuscular specialist. When initiating immunosuppressants, the risk of becoming severely ill with COVID-19 should be balanced against the risk of deferring treatment.[104]

Where possible, treatments for neuromuscular diseases should be given in a non-hospital setting and subcutaneous immune globulin used instead of intravenous immune globulin. Intravenous immune globulin, plasma exchange and complement inhibitor treatment is not expected to affect the risk of COVID-19 infection or of severe disease. Chloroquine and azithromycin should not be given to patients with myasthenia gravis unless ventilatory support is available.[104]

In the UK, people aged 12 years or above with specific underlying health conditions that put them at risk of severe COVID-19 should be offered vaccination; this currently includes those with severe neuro-disability and/or neuromuscular conditions that compromise respiratory function.[28]

Use of ACE inhibitors and angiotensin-II receptor antagonists

People with cardiovascular disease are at higher risk of severe complications and death from COVID-19; however, meta-analyses have found no association between ACE inhibitor or angiotensin-II receptor antagonist use and mortality from COVID-19, need for mechanical ventilation, or adverse cardiac events.[105][106][107] Use of ACE inhibitors or angiotensin-II receptor antagonists has been associated with increased survival in patients with COVID-19.[108][109]

British, European, American, and Asian heart groups advise that patients should continue to take ACE inhibitors and angiotensin-II receptor antagonists as prescribed.[110][111][112][113] Any change in medication should be based on individual patient risk assessment.

Routine immunization

The World Health Organization recognizes immunization as a core health service that should be prioritized and safeguarded during the COVID-19 pandemic, where feasible, to prevent morbidity and mortality from vaccine-preventable non-COVID-19 diseases.[114]

The ability to maintain routine immunization will differ between countries and locations, depending on factors such as health system capacity and the need for physical distancing; local guidelines should be consulted.[114][115] Priority may be given to vulnerable people at higher risk of morbidity and mortality.[116] Globally, there was widespread disruption to routine immunization services in 2020 and 2021.[117][118][119][120][121] Though there has been recovery in some regions, many children are still under-vaccinated or unvaccinated.[117] The World Health Organization and UNICEF report the largest sustained decline in childhood vaccinations in approximately 30 years from 2019 to 2021, with the majority of those missing vaccination living in low- and middle-income countries.[121] Clinicians are encouraged to identify children who have missed well-child visits and/or recommended vaccinations and work with families to bring children up to date as quickly as possible.[122][120]

The US Centers for Disease Control and Prevention recommend influenza vaccination of persons aged ≥6 months for the 2021-2022 influenza season. Influenza vaccine and COVID-19 vaccine may be administered at the same visit. Influenza vaccinations should be deferred for patients with suspected or confirmed COVID-19 until they have recovered from the acute illness and no longer need to isolate.[123]

The UK 2022-2023 influenza immunization program includes all children aged 2-3 on 31 August 2022, all primary school aged children (from reception to Year 6), secondary school-aged children focusing on Years 7, 8 and 9, people ages 6 months to under 50 years in clinical risk groups, pregnant women, people ages 50 years and older, people living in long-stay residential homes, close contacts of immunocompromised people, carers, and frontline health and social care staff.[124][125] Influenza activity levels were very low globally in 2020-2021 and a resurgence in influenza activity to prepandemic levels or higher is expected in winter 2022-2023. Influenza vaccination is important to reduce morbidity and mortality from influenza, and to reduce hospitalizations during a time when there may be co-circulation of influenza, SARS-CoV-2, and other respiratory viruses.[124]

The priority for the UK human papillomavirus vaccine program is delivering the first dose to all eligible children, including those who missed their scheduled first dose due to school closures. The interval between the first and second dose can be extended without compromising protection or the effectiveness of the second dose.[126]

Vaccination guidance during a pandemic (Centers for Disease Control and Prevention). Opens in new window

Considerations for patients who require anticoagulation

The Anticoagulation Forum advises that if a patient is taking warfarin, the indication should be reviewed to establish whether anticoagulation is still necessary. If so, clinicians should consider whether patients can switch to a direct oral anticoagulant (DOAC) or whether the patient could self-monitor their INR. Patients may be switched from warfarin to a DOAC if they are suitable candidates and consent to switching.[127] Warfarin treatment should be stopped before DOACs are started.[128] Stable patients who take warfarin can be offered extended INR testing; an interval of up to 12 weeks is appropriate.[127]

The UK has issued a safety warning regarding anticoagulation patients with mechanical heart valves. Patients with mechanical heart valves require lifelong treatment with a vitamin K antagonist, usually warfarin. They must not be switched to DOACs or low-molecular-weight heparin (LMWH). Cases of valve thrombosis requiring emergency surgery, and a case of severe anemia, have been reported in patients with mechanical heart valves whose anticoagulation was inappropriately switched during the pandemic.[129]

Anticoagulation may need to be switched if the patient is hospitalized for any reason, including a diagnosis of COVID-19. US guidelines recommend that patients who are receiving anticoagulant or antiplatelet therapies for underlying conditions should continue these medications if they receive a diagnosis of COVID-19, unless significant bleeding occurs or other complications are present.[130] Continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists if they have suspected or confirmed COVID-19 infection.[128] Adjustments to usual anticoagulation may be indicated, especially if the patient receives antibiotics or antivirals.[128] An online tool to check potential COVID-19 drug interactions has been developed:

Liverpool Drug Interaction Group: COVID-19 drug interactions Opens in new window

UK guidelines state that patients who are admitted to hospital with COVID-19 and are receiving anticoagulation for another condition should continue their current anticoagulant at the current dose, unless a change in clinical circumstances contraindicates this. If their clinical condition is deteriorating, and the current anticoagulant is not LMWH, clinicians can consider switching to LMWH.[131]

An anticoagulation service in the UK reported a six-fold increase in the odds of having a supratherapeutic INR (>8.0) during the initial period of lockdown in March and April 2020, compared with the same dates in 2019. COVID-19 infection, antibiotic therapy, other interacting drugs, inpatient hospital admission, recent hospital discharge, entering an end-of-life care pathway, and prolonged testing interval were all identified as risk factors for elevated INR.[132]

Patients with atrial fibrillation who receive anticoagulation have a lower risk of death, but higher risk of hospitalization, from COVID-19 compared with patients with atrial fibrillation who are eligible for anticoagulation but are not receiving it.[133]

UK guidance states that the Pfizer-BioNTech COVID-19 vaccine may be given intramuscularly to patients who are taking warfarin, provided they are up-to-date with INR testing and their latest INR is below the upper limit of the therapeutic range. Patients who are stabilized on a DOAC may also receive the Pfizer-BioNTech vaccine. The risk of hematoma formation may be reduced by using a 23-gauge or 25-gauge needle and applying firm pressure to the injection site for 2 minutes, without rubbing.[28]

Considerations for management of patients in community psychiatry services

The US Center for the Study of Traumatic Stress advises that patients with delusions, obsessive-compulsive thoughts and behaviors, a predominance of somatic symptoms, other active or uncontrolled symptoms, or those previously exposed to severe trauma may be particularly vulnerable in the current pandemic, and that frequent clinical contact may help avoid exacerbations and hospitalizations.[134]

Patients should have adequate supplies of prescribed medication to avoid interruptions in treatment. Some treatment programs have been amended in response to this: for example, the Substance Abuse and Mental Health Services Administration in the US has introduced flexibility in the Opioid Treatment Program, depending on stability of the patient.[135]

The Royal College of Psychiatrists in the UK has provided guidance on provision of medication during the current pandemic; clinicians should consider additional factors when prescribing benzodiazepines/rapid tranquillization, lithium, clozapine, and depots/long-acting injectables.[136] Longer intervals between drug monitoring may be appropriate for some patients who have been stable on treatment.[137] Individual patient needs should be carefully reviewed, but it is likely that many patients should remain on their regular medication until face-to-face consultation is possible. Patients taking psychotropic drugs may be at risk of significant drug-drug interactions with experimental treatments for COVID-19.[138] Financial insecurity and job loss caused by the pandemic may exacerbate symptoms of depression, anxiety, and distress, and psychosomatic symptoms.[139] Proactive screening for suicidality is recommended.[137]

Meta-analysis has found that the presence of any mental health disorder is associated with increased risk of hospitalization with COVID-19, and increased COVID-19 mortality.[140][141][142] Severe mental illness is associated with higher risk of mortality.[141][143] The association between COVID-19 mortality and antipsychotic disorders, mood disorders, antipsychotic use, and anxiolytic use persisted after adjustment for age, sex, and other confounders. Further research is suggested to determine the underlying mechanisms.[140]

Patients with mental health conditions should be offered vaccination against COVID-19 unless contraindicated. Use of antipsychotics, anxiolytics, and hypnotics is associated with lower odds of vaccination compared with non-users. Antidepressant use is not associated with lower odds of vaccination.[144]

Considerations for mental health of adults

Studies have consistently shown worsening of mental health of adults during the COVID-19 pandemic.

In April and May 2020, adults in 14 countries reported significant decreases in mental wellbeing during pandemic restrictions.[145] It is estimated that there are an additional 53.2 million cases of major depressive disorder, and an additional 76.2 million cases of anxiety disorders globally, as a consequence of the pandemic.[146]

People at increased risk of mental ill health due to COVID-19 include:[147][148][149][150][151][152][153][154]

Female sex
Minority racial and ethnic groups
Younger adults (age <30 years)
Essential workers
Unpaid carers for adults
Transgender or nonbinary people
Adults with disabilities
Parents of children <18
Lower income households.

Studies of older adults have found significant increases in loneliness, anxiety, and insomnia during the pandemic.[155][156][157]

UK data analysis found that, compared with the general population, people living with mental disorders were already at a higher risk of all-cause mortality before the pandemic and that during the pandemic there was a further steep increase in mortality risk relative to the general population.[158]

One study of suicide rates in 21 countries found that in the early months of the pandemic, numbers of suicides remained unchanged or declined in high-income and upper-middle-income countries compared with expected levels before the pandemic, which may be a result of additional mental health support and financial safety nets provided by these countries.[159]

A study from the US demonstrated a bidirectional relationship between physical activity and mental health during the pandemic. Psychological distress during the pandemic was associated with increased difficulty in maintaining prepandemic physical activity levels. Difficulty maintaining prepandemic physical activity levels was associated with worsening psychological distress.[160]

People who experience COVID-19 infection may also be at increased risk of incident mental health disorders. One cohort study found that compared with control groups, those with COVID-19 had an increased risk of disorders such as anxiety, depressive disorders, stress and adjustment disorders, opioid use disorders, other substance use disorders, neurocognitive decline, and sleep disorders. The risks of mental health disorders were highest in those who were admitted to hospital for COVID-19 but were evident even for those who were not admitted to hospital.[161] Another cohort study reported an increased risk of subsequent neuropsychiatric diagnoses (anxiety or dementia) and of subsequent antidepressant prescription in survivors of COVID-19, compared with the rest of the population.[162]

Mental health of children and adolescents

Most children with pre-existing mental health needs have reported that their mental health has worsened during the pandemic, citing concerns about their family’s health, school closures, loss of routine, loss of social connection and anxiety about the future.[163] Lockdown restrictions and social isolation may cause loneliness and affect the mental health of previously healthy children.[164] One study reviewing changes in mental-health scales before and during lockdown in the UK found that there was an increase in depression symptoms in children during the lockdown.[165] Children and adolescents are probably more likely to experience depression and anxiety during and after enforced isolation. Preventative support and early intervention should be offered where possible.[166] Practical guidance to share with parents and carers, according to the child’s developmental stage, is available.[167]

In England, pandemic-related anxiety has been reported to be higher in girls than boys (aged 11-22 years) and there is a greater prevalence of anxiety in people aged 17-22 compared with those aged 11-16 years.[168] Prescriptions for antidepressants in people aged 0-17 years peaked during the first UK lockdown, with an increase of 8% compared with March 2019, and an increase of 21% compared with March 2016.[169]

In Iceland, adolescents aged 13-18 years reported worse mental wellbeing and increased depressive symptoms compared with peers of the same age before the COVID-19 pandemic. Girls were affected more than boys. Alcohol intoxication, cigarette smoking, and e-cigarette use declined among 15-18 year olds of both sexes.[170]

In the US, the proportion of mental health-related emergency department visits for children increased in April to October 2020 compared with the same time period in 2019. Compared with 2019, the proportion increased approximately 24% for children aged 5-11 years and 31% for those aged 12-17 years.[171] A further US study reported that compared with 2019, among adolescents aged 12-17 years, weekly emergency department visits increased among females for eating and tic disorders in 2020; depression, eating and tic disorders, and OCD in 2021; and anxiety, trauma and stressor-related disorders, eating and tic disorders, and OCD, as well as overall mental-health-related visits, in January 2022.[172] Emergency department visits for suspected suicide attempts in children aged 12-17 years increased by 22.3% during summer 2020 and by 39.1% during winter 2021 compared with corresponding periods in 2019.[173] Most of the suicide attempts were made by females. An evaluation of suicides among adolescents in 14 states in the US found that the proportion of overall suicides among adolescents increased during the pandemic.[174] In another US study, 37% of adolescents experienced poor mental health during the pandemic. Feeling close to persons at school, or staying virtually connected with friends and family, were protective against poor mental health, persistent feelings of sadness and hopelessness, and considering suicide.[175] In 2021, the American Academy of Pediatrics declared a state of emergency regarding child and adolescent mental health.[176]

Schooling changes during the pandemic may also impact children’s mental health and wellbeing. A survey of 1290 parents of children aged 5-12 years in the US found that those receiving virtual instructions only were more likely than parents of those receiving in-person instruction to report worsened mental or emotional health. [177] The psychosocial impact of school-based measures to prevent COVID-19 infection has not been well-studied, but early evidence suggests such measures are associated with increased anxiety and reduced general wellbeing.[178]

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Considerations for the mental health of healthcare workers

Healthcare workers managing novel viral outbreaks are at risk from adverse psychological events.[179] Frontline healthcare workers are at highest risk for developing anxiety, depression, acute stress and insomnia.[148][180][181][182]

Specific advice for healthcare professionals and first responders from the CDC and World Health Organization includes:[183][184][185]

Recognize that it is normal to feel under pressure in this situation, and that caring for their mental health and psychosocial wellbeing is as important as caring for their physical health
Learn the symptoms of secondary traumatic stress, including: excessive worry and fear about something bad happening; being easily startled or feeling "on guard" all of the time; physical signs of stress - for example, heart racing; nightmares or recurrent thoughts about the traumatic situation; and the feeling that other people's trauma is theirs
Learn the symptoms of burnout, including: sadness, depression, or apathy; feeling easily frustrated, irritable, or blaming others; feeling indifferent, isolated, or disconnected from others; poor hygiene; feeling tired, exhausted, or overwhelmed; feeling like a failure, that nothing they can do will help, or that they are not doing their job well; or feeling they need alcohol or drugs to cope
Follow general measures to reduce stress, including: taking breaks from reading, watching, or listening to news stories; taking care of mental and physical health: for example, through meditating, eating well-balanced meals, taking regular exercise, getting plenty of sleep; avoiding alcohol and drugs; ensuring sufficient rest between shifts; spending time doing activities they enjoy; and connecting with family and friends
Keep a journal
Work in teams and limit the amount of time working alone
Develop a "buddy system," where two partners support each other and monitor each other’s stress, workload, and safety
Allow time for themselves and their family to recover from helping with the pandemic
Ask for help if they feel unable to care for family and patients as they did before the pandemic.

Clinicians can help colleagues by being alert to symptoms of burnout or secondary traumatic stress, offering the opportunity to talk (but not forcing them to do so), signposting them to useful resources, being kind and reassuring, encouraging them to maintain good self-care, and escalating concerns if necessary. Healthcare organizations are encouraged to provide proactive, comprehensive mental health support.[180]

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Safeguarding children and young people

The COVID-19 pandemic presents challenges for the safeguarding of children and young people. There is an increased risk of child abuse, owing to increased stress affecting parents and caregivers, loss of social contact with friends, teachers, and extended family, loss of financial or caring support from community resources or schools, increased exposure of children to parents or carers with substance misuse disorders, and decreased access to mental health services.[186]

Experts advise that parents and friends can reduce the risk of child abuse in several ways, including: maintaining virtual contact with friends and extended family; establishing and following a family schedule; and researching the community resources and financial aid available.[186]

The American Academy of Pediatrics (AAP) strongly supports the continued provision of child healthcare during the pandemic, unless community circumstances require necessary adjustments. Well child care should occur in person if possible.[122] The AAP has also published specific guidance for the care of children and youth with special health care needs during the pandemic, as they are more likely to experience disruption to health care, education, and community life, and some are more likely to experience more severe COVID-19 infection.[187] Interim guidance on supporting the emotional and behavioral needs of children and families during the pandemic has also been provided by the AAP.[164]

The International Paediatric Association has published a position statement providing recommendations on children’s healthcare during the pandemic, with guidance on routine care and immunization, prevention of acquiring and transmitting infection, addressing social isolation and disruption of education, and provision of remote care.[188]

The Royal College of Paediatric and Child Health emphasizes that pediatricians should continue to make decisions based on the best interests of the child. The College recognizes that redeployment of staff may reduce pediatricians' ability to contribute to multiagency safeguarding processes and advises that pediatricians should liaise with colleagues in the police and social care to discuss the different levels of support available for vulnerable children, depending on local health resources. Well children and young people should not be admitted to the hospital as a place of safety unless there is no alternative. Contingency plans should be made in case the caregivers of vulnerable children become ill and cannot look after the children in their care or acquire food and medicine.[189]

Further information is available at:

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Use of valproate

Valproate (or its derivatives such as valproic acid, divalproex sodium, valproate semisodium) is harmful if used during pregnancy as it increases the risk of congenital malformations and neurodevelopmental disorders. In the UK it is contraindicated in girls and women of childbearing potential unless conditions of the Pregnancy Prevention Programme are met. The UK Medicines and Healthcare Products Regulatory Agency has published interim guidance stating that initiation of valproate in girls of any age and women of childbearing potential requires face-to-face consultation (with appropriate physical distancing). A remote consultation can be considered based on individual risk assessment.[190]

If a pregnancy test is required and a face-to-face appointment is not possible then a home pregnancy test could be acceptable, but this is at the discretion of the clinician. Minimum criteria for home pregnancy testing need to be met: the test, and at least one spare, should be sent by the clinic to the patient; the test should meet minimum required sensitivity; and the test result should be verified by the prescriber, ideally by the patient sending a photograph of the test.

The annual review of existing patients taking valproate (that is part of the licence terms) should not be delayed. Patients should not stop taking it without consulting their doctor.[190]

Considerations for cardiac investigations

The American College of Cardiology, American Heart Association and Heart Rhythm Society have published joint guidance on the management of arrhythmias during the COVID-19 pandemic.

Nonurgent or elective procedures should be postponed. This requires an individual risk assessment and discussion with the patient. In general, electrophysiological procedures that are unlikely to directly impact clinical care or outcomes over the next several months may be considered for deferral. Emergent, urgent, and semi-urgent procedures include those where there is a risk to the patient's life, risk of permanent dysfunction of an extremity or organ system, or risk of severe or rapidly worsening symptoms if the procedure is not performed. Specific examples from each category are discussed in the guidance.[191]Lakkireddy DR, Chung MK, Gopinathannair R, et al. Guidance for cardiac electrophysiology during the coronavirus (COVID-19) pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Circulation. 2020 May 26;141(21):e823-31.

Considerations for patients with cardiac implantable electronic devices (CIEDs)

Australian and European guidelines recommend that remote monitoring is used wherever possible for patients with CIEDs.[192][193] Patients may require in-person device interrogation if there is new or suspected lead dysfunction, battery depletion (especially in pacemaker-dependent patients), malignant arrhythmia detection, and implantable cardiac defibrillator (ICD) therapy.[193] Wireless technology should be used where possible for in-person checks of CIEDs to allow staff to maintain a safe distance from the patient.[192][193] ICDs cannot be deactivated remotely. If a patient with an ICD is receiving end of life care, the treating clinical team should secure a magnet to the skin over the ICD where possible, rather than using the programmer.[192] Advice is given for device management during magnetic resonance imaging and surgery. Indications for urgent and semi-urgent elective procedures are listed.[192][193]

Considerations for patients with eating disorders

Patients with eating disorders may have atypical responses to infections, for example, malnourished patients may not develop fever. Clinicians should discuss the best way to reduce risk of COVID-19 infection and other physical health complications with patients, taking into account the potential impact of the approach on their mental health and eating disorder.[194]

New symptoms of fatigue or lack of energy should be evaluated, even if temperature and cough are absent. Clinicians should be aware that lockdown measures might exacerbate patients’ eating disorder symptoms for many reasons, including anxiety about the pandemic, changes in food availability, exercise restrictions, loss of social support, financial stresses and worry about job and accommodation security and increased alcohol consumption.[194] In the US, reported emergency department visits for eating disorders increased during the pandemic, compared with 2019, and the proportion of emergency department visits with eating disorders doubled among adolescent females.[172]

Assessment, psychological services and medication reviews should be provided using video consultations if face to face assessment is not possible. Physical examination is an important part of assessment, especially for malnourished patients. Blood tests and ECGs may be performed in primary or secondary care depending on local arrangements and level of risk. An individual care plan for weighing should be developed depending on whether the patient is cooperative or is likely to falsify their weight.[194]

The American Academy of Pediatrics recommends that all patients should be assessed for the onset of obesity during the pandemic. Obesity and related comorbidities should be treated without delay. Clinicians should screen for disordered eating (e.g., binge eating, purging, and restrictive eating) in patients with obesity.[195]

Further online resources:

Considerations for patients with hyperthyroidism

European guidance makes recommendations for the management of patients with hyperthyroidism during the pandemic.[196] Diagnosis should be made based on clinical suspicion supported by biochemistry testing. TSH-receptor antibodies should be checked where possible. Determination of malignancy risk associated with palpable thyroid nodules can usually be postponed, unless there is rapid growth, or highly suspicious features on palpation or imaging. Uncontrolled thyrotoxicosis may be associated with more severe COVID-19. Block-and-replace regimens are preferred for newly diagnosed hyperthyroidism to reduce the number of blood tests required. Recommended regimens are detailed in the guidance. Symptoms of neutropenia induced by antithyroid drugs (sore throat, mouth ulceration, fever, and flu-like illness) may be indistinguishable from symptoms of COVID-19. Antithyroid drugs should be discontinued in patients with symptoms of neutropenia and an urgent full blood count should be performed.[196]

Potential impact of COVID-19 pandemic on diagnosis and management of other conditions

Concerns have been raised that diagnosis and treatment of other medical conditions may be delayed during the COVID-19 pandemic. Emergency department attendance in five US states decreased by between 41.5% and 63.5% in early March 2020.[197] One study reported a 42% reduction in hospital admissions, including significant reductions in the number of admissions for stroke, myocardial infarction, heart failure, COPD, and appendicitis.[198] Compared with 2019, pediatric emergency department visits in the US decreased by 51%, 22%, and 23% during 2020, 2021, and January 2022, respectively.[199] In Denmark, hospital admissions for non-COVID-19 diseases decreased during national lockdowns compared with prepandemic baseline admissions.[200] Mortality rates were higher for patients admitted to hospital with respiratory diseases, cancer, pneumonia, and sepsis.[200] Some elective surgery has been delayed. Increasing use of opioids in patients with osteoarthritis awaiting hip and knee arthroplasty has been reported in the UK.[201]

In primary care studies in the UK, diagnosis of physical and mental health conditions between March and May 2020 decreased substantially compared with previous years.[202][203] Women and people with a chronic illness experienced significantly more cancelled medical or surgical appointments and procedures during the first 2020 lockdown in the UK.[204]

Impact on cardiovascular conditions

An analysis of hospital admissions in England found a 40% reduction in weekly acute coronary syndrome admissions between mid-February 2020 and the end of March 2020, compared with 2019 rates; by the end of May 2020, admission rates for acute coronary syndrome were 16% lower than the baseline average.[205] Percutaneous coronary intervention procedures for ST-elevation myocardial infarction (STEMI) in England decreased by 43% in April 2020, compared with average monthly procedures in 2017 to 2019. Overall symptom-to-hospital time and door-to-balloon time increased after the lockdown, but no significant differences in major adverse cardiac events or in-hospital mortality were observed between the pre- and post-lockdown patient groups.[206] A study of acute cardiovascular deaths in England and Wales found an increase in cardiovascular deaths during the pandemic, with most unrelated to COVID-19 infection, and nearly half occuring in the community.[207] However, there was no significant decrease in hospital admissions with acute myocardial infarction, or acute stroke alerts, in the October 2020 to January 2021 surge.[208]
In the US, cardiovascular deaths increased during the early phase of the COVID-19 pandemic (339,076 heart disease and 76,767 cerebrovascular disease deaths from March to August 2020 compared with 321,218 and 72,190 deaths during the same months in 2019), with Black, Hispanic, and Asian populations experiencing a disproportionate increase compared with the non-Hispanic white population.[209]
In France, admissions for acute myocardial infarction (MI) decreased following the nationwide lockdown.[210]
In Sweden, there was a significant decrease in the number of patients with MI who were referred for coronary angiography, but there was no change in mortality.[211] Similarly, a global literature search and meta-analysis found that there was a significant reduction in hospital admissions for patients with STEMI during the pandemic, but this was not associated with an increase in hospital mortality.[212]
Another study reported a 47% decrease in new cases of atrial fibrillation during the first 3 weeks of lockdown in Denmark compared with the number of cases diagnosed in 2019. The adjusted odds ratio of ischemic stroke or all-cause mortality during lockdown compared with the corresponding weeks in 2019 was 1.41 (95% CI 0.93 to 2.12).[213] In the UK, a systematic review and meta-analysis found that the number of hospital admissions for stroke was reduced in the COVID-19 pandemic compared with corresponding periods prepandemic.[214] The study also found a higher rate of hemorrhagic stroke in the pandemic period.
In low/middle income countries there was a 21% decline in hospitalizations, and a 27% decline in revascularizations, for ST-elevation myocardial infarction (STEMI). In hospital mortality for STEMI increased by 22%.[215]

Impact on diabetes

In Germany, there was a significant increase in the proportion of children and adolescents with newly diagnosed type 1 diabetes who had diabetic ketoacidosis (DKA) during the COVID-19 pandemic compared with the same months in 2018 and 2019.[216] In Italy, there were 23% fewer new diagnoses of type 1 diabetes between 20 February and 14 April 2020, compared with the same period in 2019, and children presenting with DKA had more severe DKA.[217] A region of the UK reported an increase in the number of new cases of type 1 diabetes in children diagnosed during April and May 2020, compared with the previous 5 years, and over half of the children presented with severe DKA.[218]
One study in the UK looking at the indirect effects of the COVID-19 pandemic on type 2 diabetes between March and December 2020 found reductions in diagnosis and monitoring of type 2 diabetes. Those aged 65 years and older, men, and people from deprived areas had the greatest reductions in diagnosis rates.[219] Another study found that rates of non-COVID-19-related mortality in people with diabetes were significantly increased in those not receiving comprehensive routine diabetes care during the pandemic.[220]
Hospital admissions increased by 41% for patients with pre-existing type 2 diabetes and by 57% for patients with newly diagnosed diabetes during the first wave of the pandemic in the UK compared with preceding years. Hospital admissions with DKA were significantly increased in men and people of nonwhite ethnicity.[221]
A cohort study conducted in the US found that, while diabetes outpatient visits and testing was reduced during the pandemic, average prescription fills and HbA1c levels were not significantly affected in patients with type 2 diabetes compared with prepandemic levels.[222]

Impact on infectious diseases

In the US, incidence of croup, bronchiolitis, and influenza in children decreased significantly after the introduction of social distancing measures, and influenza activity overall in the US is reported to be historically low in the 2020-2021 season.[223][224]
In the UK, hospital admissions for common and severe childhood infections reduced following behavioral changes and societal strategies used to reduce transmission of COVID-19.[225] The greatest reductions in admissions were seen for influenza, bronchiolitis, meningitis, and measles.
In the US, rates of central line-associated bloodstream infections increased by 51% during the COVID-19 pandemic compared with the prepandemic period. Infection rates were higher in hospitals where >10% of monthly admissions were patients with COVID-19 compared with hospitals where <5% of monthly admissions were patients with COVID-19. Infections with coagulase negative Staphylococci and candida species increased during the pandemic compared with the prepandemic period.[226]
Twenty-six percent fewer foodborne infections were reported during 2020 compared with the preceding years, likely due to reduced international travel and restaurant closures.[227]
A study of the potential impact of disruptions in health services for major infectious diseases in low-income and middle-income countries suggested that there could be a substantial increase in HIV, tuberculosis, and malaria deaths in settings with high burdens of those diseases.[228] Maintaining core treatment and prevention services are suggested as a priority to minimize the impact of the pandemic.
New HIV diagnoses in the US decreased by 17% from 2019 to 2020.[229] Testing for HIV in health care settings decreased by 43% from 2019 to 2020. Strategies such as self-testing and opt-out screening may be considered to compensate for testing and diagnoses missed during the COVID-19 pandemic.[230]
In March 2021, WHO estimated that 1.4 million fewer people received care for TB in 2020 than in 2019, with low- and middle-income countries most affected.[231] Tuberculosis case detection decreased by 18% in 2020 compared with 2019.

Impact on cancer

Globally, there was a decrease of 46.7% in breast cancer screening, 44.9% in colorectal cancer screening, and 51.8% in cervical cancer screening, during the pandemic.[232]
In England, analysis of data from January 2019 to June 2020 found a decline in urgent referrals and chemotherapy attendances during the pandemic.[233] The number of referrals for suspected colorectal cancer, number of colonoscopies, and number of surgeries for colorectal cancer were significantly reduced during April 2020. There was a decrease in laparoscopic procedures and a greater proportion of stoma-forming procedures relative to 2019.[234]
An international, prospective cohort study found that 15% of patients with cancer experienced a delay to curative surgery during periods of full lockdown. There were no differences in resectability rates observed with longer delays. The long-term effect on outcomes is not yet known.[235]

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