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We thank Brennan et al, for sharing their experiences. In contrast to our observed reduction of more than 50% in AECOPD hospital admissions over a 6-month period, Brennan and colleagues observed a reduction of only 18% over a 4-month period. In addition, while we saw a significant and sustained decrease, Brennan et al. observed a decrease only in the first month following lockdown. At the fundamental level, respiratory viruses can spread either via contact, droplet or aerosols and thus in theory mask wearing, social distancing and increased personal respiratory etiquette and community hygiene would reduce transmission and contribute to reduced incidence of AECOPD. The use of masks has been shown to reduce exposure to acute respiratory viruses by 46%.
We hypothesise that these differences could potentially be due to variations in the degree of adherence to mask wearing/social distancing, as well as nuances in public health measures introduced in various countries during the COVID-19 pandemic.
For instance, Singapore had mandated face-mask wearing in April 2020. The observations reported by Brennan et al terminated in June 2020 while Ireland only mandated face-mask wearing in August 2020. and hence may not have captured the impact of compulsory mask wearing. The difference in timing of implementation and enforcement of government policies during the COVID-19 pandemic possibly contributed to a different experience in Ireland.
Aside from early impleme...
Aside from early implementation and mandatory public health measures, efforts from the government are also needed to maximise adoption of these public health measures. Egan et al conducted a study to evaluate the effect of infographics on public recall, sentiment and willingness to use face-masks during COVID-19. The study showed that recall of the salient steps of effective mask wearing was significantly higher in participants who viewed the Singaporean Ministry of Health infographic. In addition, acknowledging the impact of pandemic public health measures on personal lives of the public, health messaging in Singapore has encouraged and emphasised social responsibility. These came in the form of financial aids to businesses and citizens and also fines for failure to comply to health policies. Thus, while various countries may be implementing the same public health measures, enforcement and adherence by the public may differ. Further efforts by the government are essential to maximise adoption and these can vary between countries due to differences in political systems.
In Singapore, a recent survey showed that as of January 3 2021, 91% of Singaporean respondents stated compliance to face mask wearing in public places during the COVID-19 outbreak, up from 24% on Feb 21, 2020. In fact, by end April 2020, compliance rate was already 90%. In Hong Kong, the compliance of face mask usage by HKSAR general public was 96.6% (range: 95.7% to 97.2%). Comparatively, in a large community survey conducted in Ireland, when self-reported compliance with health guidance (including hand hygiene, social distancing, mask wearing and other public health measures) was assessed on an 11-point score, the average score was only 7.44 (S.D 2.48).
In conclusion, the different experience by Brennan and colleagues are interesting yet not unexpected. Enforcement and adherence to public health measures during a pandemic will vary from country to country. These are affected by the country’s organizational system as well as at an individual level – the public’s attitudes and socioeconomic behaviour during a pandemic which translate to adherence to strict public health measures.
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We read with interest the recent study by our colleagues Tan et al (1) which reported the introduction of public health measures during the pandemic, such as social distancing and universal mask wearing, were observed to coincide with a marked reduction in transmission of other circulating respiratory viral infections. They reported a reduction in hospital admissions with acute exacerbation of COPD (AECOPD) by over 50% during the six month period of the pandemic from February to June 2020. They supported this observation with microbiological data showing a significant reduction in PCR-positive respiratory viral infections compared to the pre-pandemic era.
Ireland has the highest rate of hospitalisations for AECOPD in all OECD Countries (2). The first case of COVID-19 in the Republic of Ireland was reported on 29/02/2020 and stringent public health measures were introduced in mid-March to combat the spread (3).
We wish to describe our experiences of hospital admission with AECOPD during the first wave of the pandemic in a tertiary referral hospital in the West of Ireland. In our clinical practice, we noticed a reduction in patients admitted with COPD exacerbations at the beginning of the pandemic. We aimed to evaluate the impact of these infection control measures on our COPD population.
We conducted a retrospective cohort study of electronic health care records of patients who were hospitalised with a primary diagnosis of AECOPD over the four-month per...
We conducted a retrospective cohort study of electronic health care records of patients who were hospitalised with a primary diagnosis of AECOPD over the four-month period of 01/03/2020 to 30/06/2020 which corresponded to the period where the strictest public health guidelines were in place. We compared this period to the same four-month period in the previous year as a control group. The primary outcome was the number of admissions with a primary diagnosis of AECOPD. The secondary outcomes we assessed were: a) the severity of AECOPD as determined by DECAF score (3) b) length of stay c) acute in-hospital mortality.
Overall, there were 123 hospitalisations with AECOPD in the 2020 cohort compared with 150 hospitalisations the previous year. This corresponds to a 18% reduction in hospital admissions. Table 1 and Table 2 below display the results. However, when subgroup analysis by month was performed, this reduction was primarily driven by a significant reduction in admissions during March 2020 (20 vs 42, p=0.02). There was no significant difference between the following three months between the pandemic and control period. Male patients accounted for just over 50% in both groups. Those in the pandemic group were significantly older, median 76 years (IQR 70-84) compared with 73.5 years (IQR 67-80), p<0.01.
We calculated DECAF scores (4) as a measure of the severity of exacerbations and allow an objective comparison between groups. There was no statistical or clinical difference in the mean DECAF scores between groups, 1.94 (+/- 1.34) and 1.73 (+/-1.25) nor the proportion of patients presenting with a DECAF of > 3 indicating a severe exacerbation. In the pandemic group 5.7% (n=7) died in hospital compared with 4.7% (n=7) in the control group. This was not significant and in-hospital mortality was slightly lower than other published studies on mortality in AECOPD (5,6) although there are many factors that can influence in-hospital mortality. There was no difference in median length of stay of those discharged, which was approximately 7 days in both groups. Interestingly, on subgroup analysis, more patients died during May 2020 than the previous May 2019 (10% (n=2) versus 0% (n=0), p <0.04) although the absolute numbers are very small.
Our experience with AECOPD during the pandemic period contrasts with the experiences of Tan et al, and indeed of a previous Hong Kong study which noted a 44% reduction in AECOPD during the pandemic period (7). While there was a reduction of 18% overall this is of smaller magnitude than the above studies of similar duration. Furthermore, the reduction is accounted for almost entirely by a dramatic reduction in admissions during the month of March alone which was the beginning of the lockdown period in Ireland, followed by a restoration of admissions to levels comparable to the previous year.
Although there were no detectable differences in DECAF scores of patients admitted, the overall trend of admissions along with the proportional increase in mortality during March suggests that hospital avoidance may account for the temporary but dramatic reduction in admissions. There have been well-publicised concerns regarding patients delaying seeking hospital care for emergencies such as myocardial infarctions and strokes, due to fears of contracting COVID-19 (8). Thus, it is plausible that patients with COPD who had mild to moderate exacerbations may have sought assistance from primary care facilities in the first instance resulting in a smaller but sicker cohort of patients presenting to hospital with a corresponding mortality bias.
We agree that reduced viral transmission is certainly an important factor in reducing AECOPD and the reports on reduction in influenza rates support Tan et al’s viral PCR studies (1,9). Anti-viral therapies merit an increased research focus to target therapeutic options. However, if viral reduction accounted in part for the reduction in AECOPD in our patient population, it appears to have been a transient phenomenon at most. Conversely and fortuitously, our patients appeared to have benefited from the extremely low levels of COVID-19 during the first wave of the pandemic in our predominantly rural catchment area. Only one patient tested positive for SARS-COV-2 during the study period and recovered fully.
In summary, we feel that our contrasting results to Tan et al are of interest and merit discussion. Our findings are plausible explained by differences in public support and adherence to universal mask wearing during the first wave of the pandemic and public attitudes to the risk of nosocomial transmission of COVID-19.
1. Tan JY, Conceicao EP, Wee LE, Sim XY, Venkatachalam I. COVID-19 public health measures: a reduction in hospital admissions for COPD exacerbations. Thorax. 2020 Dec 3.
2. National Clinical Effectiveness Committee. National Clinical Guideline: Management of Chronic Obstructive Pulmonary Disease (COPD) Version 5.0. Department of Health. July 2020
3. Department of Health. Statement from National Public Health Emergency Team- 29 February 2020. February 2020. Available at gov.ie - Statement from the National Public Health Emergency Team - Saturday 29 February (www.gov.ie)
4. Steer J, Gibson J, Bourke SC. The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax. 2012 Nov 1;67(11):970-6.
5. Connors Jr AF, Dawson NV, Thomas C, Harrell Jr FE, Desbiens N, Fulkerson WJ, Kussin P, Bellamy P, Goldman L, Knaus WA. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). American journal of respiratory and critical care medicine. 1996 Oct;154(4):959-67.
6. Gunen H, Hacievliyagil SS, Kosar F, Mutlu LC, Gulbas G, Pehlivan E, Sahin I, Kizkin O. Factors affecting survival of hospitalised patients with COPD. European Respiratory Journal. 2005 Aug 1;26(2):234-41.
7. Chan KP, Ma TF, Kwok WC et al. Significant reduction in hospital admissions for acute exacerbation of chronic obstructive pulmonary disease in Hong Kong during coronavirus disease 2019 pandemic. Respiratory Medicine. 2020 Jul 12:106085.
8. Lange SJ, Ritchey MD, Goodman AB et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions—United States, January–May 2020. MMWR Morb Mortal Wkly Rep 2020 Jun 26;69(25):795.
9. Soo RJ, Chiew CJ, Ma S et al. Decreased influenza incidence under COVID-19 control measures, Singapore. Emerg Infect Dis. 2020 Aug;26(8):1933.
2020 2019 P value
No of AECOPD 123 150
Male-N (%) 66 (53.7%) 77 (51.3%) P=0.383
Age- Median 76 (70-84) 73.5 (67-80) P <0.01
March (N) 20 42 0.02
April (N) 38 40 0.44
May (N) 33 32 0.29
June (N) 32 36 0.70
Table 2. Clinical Presentation -DECAF score of patients
2020 (n=123) 2019 (n=150) P value
Mean ±SD 1.94 (+/- 1.34) 1.73 (+/- 1.25) 0.182
DECAF ≥3: N (%) 32 (26%) 41 (27.3%) 0.81
Clinical Parameters of DECAF score N (%)
Dyspnoea mMRC 5a/5b 70 82 0.711
Dyspnoea mMRC 5a 46 68 0.187
Dyspnoea mMRC 5b 24 14 0.015
Eosinopenia 54 63 0.749
Consolidation 38 52 0.509
Atrial fibrillation 40 34 0.069
Acidaemia 13 16 0.97
LOS (days) Median 6.5 (4-11) 7 (4-11) 0.98
Deaths 7 (5.7%) 7 (4.7%) 0.704
Deaths March 2 (10%) 0 (0%) 0.037
Deaths April 1 (2.6%) 1 (2.5%) 0.97
Deaths May 2 (6%) 3 (9.4%) 0.62
Deaths June 2 (6.3%) 3 (8.3%) 0.74