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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 143-146

COVID-19 pandemic: Non-pharmaceutical interventions and addressing polypharmacy for better clinical outcome


1 Department of Pathology, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
2 Department of Physiology, Lake Erie College of Osteopathic Medicine, Erie, PA, USA

Date of Submission03-Oct-2020
Date of Decision10-Mar-2021
Date of Acceptance19-Mar-2021
Date of Web Publication14-May-2021

Correspondence Address:
Mohammed S Razzaque
Department of Pathology, Lake Erie College of Osteopathic Medicine, 2000 West Grandview Boulevard, Erie, PA 16509
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_36_21

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How to cite this article:
Oh J, Abukabda AB, Razzaque MS. COVID-19 pandemic: Non-pharmaceutical interventions and addressing polypharmacy for better clinical outcome. Adv Hum Biol 2021;11:143-6

How to cite this URL:
Oh J, Abukabda AB, Razzaque MS. COVID-19 pandemic: Non-pharmaceutical interventions and addressing polypharmacy for better clinical outcome. Adv Hum Biol [serial online] 2021 [cited 2021 Sep 25];11:143-6. Available from: https://www.aihbonline.com/text.asp?2021/11/2/143/315954





Non-pharmaceutical interventions have been implemented worldwide to control the coronavirus disease (COVID-19) in the absence of specific treatment. These interventions, including mass use of face masks, isolation and quarantine, social distancing and frequent handwashing, are useful measures to reduce disease spread. Even after vaccination for COVID-19, these non-pharmaceutical interventions will be needed for sustained periods of time to avoid disease transmission. There are three main categories of non-pharmaceutical interventions:

  • Individual level: Maintaining hand hygiene, respiratory hygiene and adequate nutrition
  • Environmental level: Adequate cleaning and proper ventilation of indoor spaces
  • Population based: Promoting social distancing, limiting gatherings, restricting movement and using face masks.


Maintaining hand and respiratory hygiene is a familiar measure, and the compliance rate is traditionally high.[1] However, adherence to nonpharmaceutical interventions, such as lockdown or stay-at-home measures, has been poor. Reports describe higher associations with stress and demotivation to follow recommended protective measures, termed pandemic fatigue.[2] The uncertainty of the duration of the current lockdown and the potential loss of income due to restrictions aggravate these already stressful situations.[3] Moreover, a partial relaxation of lockdown restrictions during the pandemic in various countries has created confusion among people which has adversely affected compliance levels. In addition to non-pharmaceutical interventions, pharmaceutical interventions are needed to slow down the spread of the infection. The unavailability of specific drugs, amalgamated with polypharmacy, however is negatively impacting the management of COVID-19 patients. Another growing health concern is the increasing, overuse or misuse of non-specific medications to treat patients with COVID-19. Adherence to non-pharmacological interventions to diminish pandemic-associated health hazards is therefore a pressing need. Of relevance, exacerbation of antimicrobial resistance due to the needless use of antimicrobial drugs seems to be another casualty of the COVID-19 pandemic.[4] Instigating antimicrobial stewardship to minimise unnecessary use of antibiotics and reduce drug-resistance development in this pandemic should be a medical priority.[5],[6],[7]


  Non-Pharmacological Interventions and COVID-19 Top


The rapid spread of COVID-19 infection in the absence of effective therapy has led to the reliance on non-pharmaceutical interventions to reduce disease spread. An enhanced understanding and implementation of non-pharmaceutical interventions are crucial to minimise disease burden.[8] The effectiveness of non-pharmaceutical interventions on the transmission of COVID-19, by using a mandatory face mask in public venues, isolation or quarantine, social distancing, and traffic restriction (to curtail peoples' mobility), has been shown to significantly contain the spread of COVID-19. Among these interventions, social distancing was the single most effective measure compared to other non-pharmaceutical interventions.[9] In a similar line that used European Centre of Disease Control data, non-pharmaceutical interventions (particularly lockdowns) were found to reduce COVID-19 transmission significantly.[3] Data from 175 countries, after adjusting for various confounding factors and lockdown policies, including public and private gatherings restrictions, revealed that non-pharmaceutical interventions, markedly reduced the spread of COVID-19 infections.[10] Since COVID-19 is mostly spread by (1) direct or indirect contact transmission, (2) respiratory droplet transmission and (3) aerosol transmission, the use of non-pharmaceutical interventions, such as facial masks, lockdown, isolation and social distancing, resulted in confinement of the disease, further emphasizing its significance. Without the implementation of non-pharmaceutical interventions it has been estimated that, the COVID-19 outbreak would have been 67-fold greater.[11] In another estimation, non-pharmaceutical interventions in 11 different European countries may have prevented more than 3 million deaths from COVID-19.[12] Analysis of respiratory syncytial virus (RSV) laboratory surveillance data, showed an estimated 20% decline of RSV transmission in the U.S. as a result of non-pharmaceutical interventions for COVID-19.[13] Although susceptibility is predicted to increase during the non-pharmaceutical intervention period, it may cause RSV outbreaks in the future.[13] The effects of non-pharmaceutical interventions (mostly social distancing) on COVID-19 transmission in 41 countries (from January to the end of May 2020) showed a reduced spread (mean percentage reduction) of COVID-19.[14]

Other commonly practiced non-pharmaceutical interventions, such as maintaining hand hygiene with regular physical activity and consuming adequate nutrition, are also believed to provide individual-level protection [Figure 1].[8],[15],[16],[17],[18],[19],[20],[21] The centers for Disease Control and Prevention have recommended frequent handwashing to reduce disease transmission. Similarly, studies have shown that rubbing hands with the World Health Organisation-recommended formulations of alcohol can efficiently inactivate SARS-CoV-2 and minimise viral transmission.[22] In a study conducted on 507 adults, reduced physical activity due to COVID-19-related lockdown resulted in an apparent weight gain and risk of obesity.[23] A similar line of study on children in the U.S. (n = 211; ages 5–13 years) found that children were involved in less physical activity and engaged in more sedentary behavior during the COVID-19 period as compared to the pre-COVID-19 period. The potential consequences of being restricted to home, threaten the health of children, who are predicted to have a higher risk of developing diabetes, obesity and cardiovascular disease.[24] Consequently, the sedentary behaviors linked to social lockdown have long-term health implications among all age groups of otherwise healthy individuals. Food and nutrition insecurity related to the COVID-19 pandemic resulted in imbalanced nutrient consumption around the globe. Since balanced nutrition is essential for the maintenance of a healthy immune system and to provide a shield against the ongoing viral pandemic, COVID-19-related disease burden is likely to be intensified in the absence of nutritional support, amalgamated with less physical activities.[20] Since COVID-19 predominantly affects elderly individuals who are at risk for malnutrition, adequate nutritional support is necessary to reduce morbidity and mortality.
Figure 1: Non-pharmaceutical interventions for COVID-19.

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  Polypharmacy and COVID-19 Top


Polypharmacy usually refers to five or more medicines prescribed per day, although this can range from two to as high as ten or more medicines per day.[25] The prevalence of polypharmacy is higher among the elderly population.[26],[27] The benefits of polypharmacy are a debatable issue, but polypharmacy may be necessary to sustain the quality of life of elderly patients. In contrast, unnecessary polypharmacy by prescribing inappropriate medications may be associated with adverse effects that may increase the disease burden of the elderly.[28],[29] Moreover, with the increasing number of drug prescriptions, the prescription error rate is also enhanced.[30] The impact of polypharmacy is further complicated by the higher incidence of patient-reported consumption errors.[31] Through drug interactions and drug-mediated complications, polypharmacy can reduce the systemic organ function, including the renal and musculoskeletal systems, compromising overall quality of life.[32],[33],[34],[35],[36],[37],[38] Of particular clinical concern, the prevalence of inappropriate polypharmacy in elderly patients ranges from 11.5% to 62.5%.[39] Potentially inappropriate prescription is not only causing harmful health effects to recipients but is also increasing healthcare costs, estimated to be as high as US$ 18 billion per year.[27],[40]

The ongoing COVID-19 pandemic disproportionately affects elderly individuals. The associated comorbidities present in the elderly patients make this population more vulnerable to polypharmacy-associated complications.[41] Existing information suggests that the COVID-19 pandemic, amalgamated with polypharmacy, can increase the disease burden of the geriatric population. Respiratory and heart diseases, hypertension and diabetes have been identified as comorbid conditions for COVID-19 infection, particularly in elderly patients.[42],[43],[44],[45],[56],[47],[48] Some commonly used drugs including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers were reported to increase the severity of COVID-infection.[44] However, separate studies claimed that these drugs have neither harmful nor beneficial effects on the course of COVID-19 infection;[49],[50] carefully designed clinical studies will be needed to clarify any association between commonly used antihypertensive drugs and COVID-19 progression.[51] A study conducted on severe COVID-19 patients (n = 4,272), with age and sex-matched controls (n = 36,948) found that severe COVID-19 cases were associated with polypharmacy; multivariable regression analysis showed that the strongest independent associations were with proton-pump inhibitors, antipsychotic drugs, antihistamines and opioid analgesics.[52] Even though the causality is not conclusive from these association studies, reducing drug prescription and limiting inappropriate polypharmacy are likely to minimise the disease burden related to COVID-19. In additon, prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) has been reported to increase ACE2 expression,[53] raising concern about the use of ibuprofen and other NSAIDs with COVID-19 patients.[54] In a similar line of observation, prolonged use of corticosteroids in COVID-19 patients has been shown to enhance viral replication with increased risk of acute respiratory distress syndrome.[55] Ensuring medication safety in polypharmacy should always be a clinical priority, but its clinical significance has increased immensely during the ongoing COVID-19 pandemic.


  Conclusion Top


The prevalence of polypharmacy has increased greatly in the elderly population. Identifying and discontinuing unnecessarily-prescribed drugs may reduce the risks associated with polypharmacy and will likely improve clinical outcomes, irrespective of COVID-19 infection. The guiding principle of deprescribing drugs is primarily focused on safely eliminating one or more drugs that is needlessly prescribed or wrongfully prescribed for a particular clinical need. Of relevance, there are established guidelines for identifying inappropriate polypharmacy among the elderly community.[56],[57],[58] Studies have found that polypharmacy is common in nursing homes and is associated with adverse health consequences.[40],[59],[60],[61] This is of great concern as, the COVID-19 outbreak is particularly severe in nursing homes.[62],[63],[64],[65],[66] Additional studies will be of crucial importance to whether polypharmacy contributes to higher morbidity and mortality in nursing homes during the COVID-19 pandemic. In the absence of specific therapy for COVID-19, non-pharmacological interventions have been effectively employed to control the spread of infection. Community compliance with the non-pharmaceutical interventions is critical to achieve the desired goals of reducing COVID-19 transmission. Therefore, an increase in community awareness and education regarding the practice of non-pharmaceutical interventions should be encouraged.[67] It appears likely that non-pharmaceutical interventions along with deprescribing polypharmacy will yield a better clinical outcome, particularly for elderly patients with COVID-19.

Acknowledgement

The authors would like to thank Dr. Arafat Tannum, Ms. Peace Uwambaye and Mr. M. Muhit Razzaque for carefully reading the manuscript and providing useful suggestions.



 
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