Increasingly, COVID-19 has produced statistics on death and post-COVID-19 morbidity. Yet, some of the COVID-19 sequelae are not yet known. Although not a comprehensive list, there are some "secondary statistics" to be alert for: social isolation/loneliness, behavioral sequelae (anxiety, drug overdoses, and suicide), delays in treating preventive care that lead to late-stage diagnoses, and even a resurgence of drug-resistant infections.
Social Isolation/Loneliness
Many of us have sadly watched the elderly, those with dementia, and those who are incredibly lonely traverse this pandemic. Some of the most able adult children were able to pull their loved ones from skilled nursing facilities or long-term care facilities and take them home. I have watched/we watched the love and dedication required, with humility. Those with dementia left alone do not understand what happened in 2020.
The UCLA Loneliness scale is the gold standard for defining loneliness for research purposes and has been around since at least the 1980s. It measures one's subjective feelings of loneliness, as well as feelings of social isolation. Objectively, a genomics researcher, Steve Cole, took samples of white blood cells from lonely men and women and found that nearly every sample showed the donor to be in a state of high alert, with inflammatory markers elevated (Darling, 2019-2020). As health care professionals, we understand the consequences of inflammatory responses on health.
Loneliness is not new to the pandemic and is also not only in the elderly. It has been determined that there is a relationship between psychological loneliness and physical states. One statistic determined that there is a 32% increase in early death for those living alone (sample size 3.4 million people). Closely related to loneliness is the absence of touch and hugs. It has been well known for decades that children who are not touched in their formative years have a dramatic decrease in meaningful childhood milestones. It is not such a stretch that adult humans need the same.
Reduction in Life Expectancy
A study published in early February predicted the pandemic would reduce overall life expectancy by 1.13 years in 2020, with life expectancy for Black and Latino populations three to four times lower than White Americans (Rodriguez, 2021a). In addition to the obvious cause (death from COVID-19 at an earlier age), there are other reasons this statistic is so poignant.
It was not uncommon for people with serious and real health issues to stay away, not just from emergency departments (ED) where COVID-19 was rampant but also from less urgent sites. Postponements of crucial cancer screenings, diagnostics, and treatments left people undiagnosed, undetected, and undertreated. In total, 80,000 patients with cancer had later diagnosis due to the pandemic. According to the Cancer Treatment Centers of America (2020), a recent study suggested that delaying cancer treatment by even 1 month can raise a patient's risk of dying by 6%-13% and that risk keeps rising the longer treatment is delayed.
Anecdotally, I saw patients who delayed care. When they finally sought health care, the surgeries were drastic or the prognosis was grim. Patients with heart failure were found to be in extreme advanced volume overload, where before being leery of COVID-19-infected hospitals earlier treatment would have been achieved. One relatively young woman was found to have a huge renal mass replacing the right kidney with invasion into the liver, psoas muscle, posterior chest wall, inferior vena cava, and renal vein. A complex surgery and a long recovery followed.
Drug-Resistant Infections
Another recent finding is that some drug-resistant infections are on the rise. Although all measures were being taken to reduce the morbidity and mortality of COVID-19, opportunistic bacteria and fungi were thriving. So many factors contribute to the rise of drug resistance that it is difficult to point to only one factor. However, the literature on this outcome is compelling. As we are currently observing, COVID-19 mutations are making early victories less certain. This is the same mechanism that drug-resistant bacteria and fungi use: mutation for its greater survival.
Isolated outbreaks of various drug-resistant infections in Florida, New Jersey, and California, as well as in India, Italy, Peru, and France, have been identified. Overall figures have been hard to track because many nursing homes and hospitals simply stopped screening for the germs as resources were diverted to COVID-19. Look for the spread of Candida auris, carbapenem-resistant Acinetobacter baumannii, or Klebsiella pneumoniae (Richtel, 2021).
Behavioral Health Care Issues
While ED visits were down in 2020, drug overdoses increased during the pandemic. Researchers from the Centers for Disease Control and Prevention studied more than 180 million ED visits from December 30, 2018, to October 10, 2020, and found that weekly counts of all drug overdoses were up to 45% higher in 2020 than in 2019, according to the study published in February 3 in the peer-reviewed JAMA Psychiatry. Opioid overdoses, specifically, increased about 29% compared with before the pandemic (Rodriguez, 2021b).
As this Editorial is being written (March 2021), the pandemic numbers are visibly down, the ability to get vaccinated is rising, skilled nursing facilities and hospitals are allowing a small number of visitors, and "elective" surgeries are back on the schedule ... all good signs. Although we have seen major changes in health care delivery, we are more prepared to move forward ... even if the prediction that the COVID-19 mutations could send us into another surge occur. Our teamwork is enhanced. Our resilience muscles are strengthened. And our compassion is deepened. We have grown as individuals, as case managers, as humans.
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