In March, the Centers for Disease Control and Prevention (CDC) urged people to stay away from overcrowded emergency rooms and conduct elections, including cardiac procedures, to reduce the potential for coronavirus exposure. As early as April, doctors worried that people experiencing life-threatening emergencies were avoiding hospitals. Those fears have been proven.
In Boston, March Israel Deaconess Medical Center data in March / April showed heart attack hospitals drop 33 percent, stroke hospitals drop 58 percent, and referrals for breast cancers and blood dropped more than 60 percent from two months before. Even those who have experienced a heart attack or stroke avoid hospitals; one study showed a 38 percent fall in patients treated for ST-Elevation Myocardial Infarction, a life-threatening narrowing of an important cardiac artery.
By June, 41percent of Americans reported avoiding some care for fear of Covid. The CDC found that emergency visits across the U.S. declined 23 percent for heart attacks from March to May and 20 percent for strokes. Although the World Health Organization (WHO) still urges people to avoid regular visits to dental care and health, following that guidance can lead to unexpected, long-term consequences.
In diseases such as cardiovascular disease, delayed treatment can lead to preventable death or permanent disability. Researchers at Virginia Commonwealth University and Yale University looked at obesity – the number of deaths expected based on recent years – in March and April. They decided that in general. 56,246 (65 percent) of 87,001 deaths in the U.S. within two months were attributed to COVID-19.
However, in 14 states, including populous California and Texas, more than 50 percent of deaths are attributed to other causes, most commonly heart disease, the leading cause of death in America. A person whose primary cause of death is cardiovascular or pulmonary may also have had COVID 19. The five states with the highest COVID-19 deaths also experienced significant proportional increase in mortality due to pre-existing malignancies conditions: diabetes (96 percent), heart disease (89 percent), Alzheimer’s disease (64 percent), and cerebrovascular disease (35 percent). New York City experienced the largest increase, notably the causes of heart disease (398 percent) and diabetes (356 percent).
But in diseases such as cancers, delayed treatment and delayed diagnoses cause side effects that are not immediately noticeable. Delays are rising. A national study of U.S. patients receiving tests from Quest Diagnostics between January and April found the average weekly number of new diagnoses for six common cancers dropped 46 percent, with those diagnosis of breast cancer in March and April falling the most (52 percent), compared to two months before. Data from 20 U.S. health care institutions found breast cancer screening to drop by 89 percent and colorectal cancer to be diagnosed by 85 percent in the first four months of 2020, compared to the same period last year years.
These delays are likely to result in higher mortality. A Lancet study using data from the UK estimated that diagnostic delays in four major tumor types (breast, colorectal, lung, and esophageal) from March to June could result in 3,291 to 3,621 preventable deaths and an additional 59,204 to 63,229 years of life lost In addition, a systematic review of Nature shows that delays in radiotherapy more than eight weeks after surgery have doubled the local risk of recurrence in patients breast cancer. In June, the National Cancer Institute, modeling the potential effects of a delayed diagnosis (assuming a 75 percent reduction in mammography and colorectal screening) and delayed treatment (assuming one-third of those diagnosed patients who delayed treatment to six months) for six months, predicted a one-percent increase (an additional 10,000 deaths) in the United States from breast and colorectal cancers only over the next decade.
Whether we are at risk for cancer or heart disease, dental care is a place where delays mean problems, now and in the future, for each of us. Reluctance to visit the dentist has spread due to the suspected risk of delivery from an infected patient spreading COVID-19 to dental staff or to the next patient. Despite these potential risks, no COVID-19 cases have been reported transferred to a U.S. dental office so far, according to the CDC. The American Dental Association (ADA) “respectfully but still does not completely agree” with the WHO recommendation to delay “regular” dental care, which could have a cascading effect on other aspects of your health, because gum disease is associated with an increased risk of dementia, heart disease, and rheumatoid arthritis, among other conditions.
Dentists and the ADA have become a model of how to approach safety with COVID-19 promptly. In mid-May, in sync with the ADA, the CDC released a guide for dental practices, which is constantly updated, calling for the highest level of PPE available – masks, goggles color and face shields. The ADA’s temporary guidelines call for the use of rubber dams and high-speed suction as much as possible, and hand-scaling when brushing teeth rather than ultrasound scaling to reduce potential droplets. COVID-19 from being aerosolized.
At this point, should you delay the operation or other procedures called “elective?” Critically talk to your physician and review information on reported COVID-19 cases associated with the hospital or surgical center where you will have the procedure; It is important to check that the facility strictly implements a comprehensive set of safety protocols:
- Screening of patients, workers and visitors on admission for COVID-19 symptoms and risk factors
- Testing of all admitted patients
- Requires universal masking and appropriate care equipment / PPE
- Thorough cleaning and disinfection facilities for a range of organisms and viruses
- Decreases the number of people in the facilities while requiring physical evacuation
And when should you go to the emergency room? Johns Hopkins recommends that you visit the ER if you have:
- Chest pain or pressure, palpitations, shortness of breath, or other symptoms of heart attack other heart problems
- Sudden numbness, weakness, confusion, loss of vision, speech or balance problems, or other symptoms of stroke
- Unexplained or worsened shortness of breath, or other breathing problems
- High fever
- Severe or inexplicable pain
- Serious injury or trauma, including deep, large, or severe reduction
- Possible broken bones
- And any other problems you consider as an emergency
Many have neglected care for too long, and it is time for federal and local health authorities to change their guidelines regarding the avoidance of so-called elective procedures. Public health officials and agencies should remind people not to avoid the ER if they have an emergency and return to the schedule for evidence-based evaluation and necessary treatment and surgery. Finally, and most importantly, public health authorities should remind everyone to consult their providers to determine which procedures, treatments and screenings should not be delayed.
Jonathan Fielding MD, who heads public health for Massachusetts and Los Angeles County, is a professor of Health Policy and Management at UCLA.