Indirect acute effects of the COVID-19 pandemic on physical and psychological morbidity in the UK

Date of ISAC Approval: 
31/07/2020
Lay Summary: 
The COVID-19 pandemic is an unprecedented public health crisis associated with very significant morbidity and mortality. Much of the clinical and research focus across the UK is understandably targeting pandemic management. As healthcare resources are reallocated to the COVID-19 response, there will inevitably be decreased resources for non-COVID-19 related healthcare, including activities designed to prevent people becoming ill, such as monitoring of chronic disease, potentially creating or worsening physical and mental health of patients. Mental health is also likely to be impacted by fears around the COVID-19 pandemic, as well as control measures such as mass social distancing, closures of social spaces and self-isolation. Understanding of these indirect effects will help public health planning and policy over the following months, particularly when/if the COVID-19 pandemic is under control. The outcomes will occur in several phases. This initial body of work focuses on acute presentations in the early stages of the pandemic. Our group is also planning a further large study focused on extending this to later outcomes related to the COVID-19 pandemic.
Technical Summary: 
The COVID-19 pandemic is an unprecedented public health crisis associated with very significant morbidity and mortality. Much of the clinical and research focus across the UK is understandably targeting pandemic management. As healthcare resources are reallocated to the COVID-19 response and modifications made to methods of care delivery due to social distancing requirements, there will inevitably be an impact on non-COVID-19 related healthcare provision, including activities designed to prevent people becoming ill, such as monitoring of chronic disease, potentially creating or worsening physical and mental health of patients. We plan to analyse changes in disease incidence, routine monitoring and health outcomes, during and following the COVID-19 pandemic. The initial approach will be a descriptive before and after analysis. This will be followed by an interrupted time series analysis. This initial body of work focuses on acute presentations in the early stages of the pandemic. Our group is also planning a further large study focused on extending this to later outcomes related to the COVID-19 pandemic.
Health Outcomes to be Measured: 
Our programme of research focuses on a range of outcomes resulting from the diversion of resources and social distancing. This study focuses on acute manifestations of chronic comorbidities that we anticipate may be increased due to decreased resources for management of disease, including reduced availability of face-to-face consultations, and difficulty accessing medications and healthcare whilst in self-isolation. Although we will focus on some incident conditions, we are also interested in outcomes affecting people with existing morbidity, e.g. diabetic emergencies and prescribing patterns for selected conditions. We plan to undertake this study in several phases. 1. The first phase is the focus of this proposal. We will focus on acute adverse outcomes- the impact of resource restriction on non-COVID conditions (see Figure 1), for example diabetic emergencies. 2. The later phases will be detailed in a subsequent ISAC and will focus on intermediate outcomes (interrupted care for chronic conditions and delayed outcomes, e.g. resulting from delayed presentations and burnout from prolonged psychological trauma and economic hardship). Although there is potentially a huge range of diagnoses that could present with acute presentations related to the COVID-19 pandemic, we have focused on a number of specific outcomes in this initial proposal which plausibly could be adversely affected acutely. We have specifically selected diabetic emergencies and respiratory outcomes as these individuals are likely to be included on vulnerable and extremely vulnerable lists, making it very difficult for them to access healthcare resources. Psychological health is also likely to be impacted by fears around the COVID-19 pandemic, as well as control measures such as mass social distancing, closures of social spaces and self-isolation. Furthermore, existing mental illness may be affected by difficulty accessing medications and talking therapies whilst in self-isolation. Detailed outcomes are listed below. By ICD Chapter ICD Chapter IV Endocrine. Diabetic emergencies (diabetic ketoacidosis and diabetic comas). ICD Chapter V Mental. Mental illness: obsessive compulsive disorder (OCD), depression and adjustment disorders with depressed mood, anxiety and adjustment disorders with anxious mood, severe mental illness (SMI), self-harm, attempted suicide, substance abuse and sleep disorders. ICD Chapter X Respiratory. Acute severe asthma including exacerbations and status asthmaticus, COPD exacerbations To understand changes in the outcomes detailed above, we will also capture activity related to chronic disease monitoring, consultations and prescribing for the specific diseases of interest- diabetes, respiratory disease and mental health.
Collaborators: 

Sinead Langan - Chief Investigator - London School of Hygiene & Tropical Medicine (LSHTM)
Amy Mulick - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Charlotte Warren-Gash - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Harriet Forbes - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Helen Strongman - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Helena Carreira - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
John Tazare - Collaborator - GSK
Kate (Kathryn) Mansfield - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Kevin Wing - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Liam Smeeth - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Patrick Bidulka - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Rohini Mathur - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Sharon Cadogan - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)
Sinead Langan - Corresponding Applicant - London School of Hygiene & Tropical Medicine (LSHTM)
Yun “Angel” Wong - Collaborator - London School of Hygiene & Tropical Medicine (LSHTM)

Linkages: 
2011 Rural-Urban (Non-standard) LSOA;HES Admitted;Mother Baby Link;ONS;Practice Level Carstairs Index