The UAE has set new benchmarks for the world in the fight against COVID-19. The country’s leadership managed the situation effectively and within a short period, they built large field hospitals. Within weeks, thousands of beds were made available and 13 drive-through test facilities opened. Moreover, the country was proactive and worked towards quickly making private hospitals COVID-19 free. The UAE is also a rare example of where everybody, irrespective of their residency status, has access to almost free or subsidised testing, quarantine and treatment facilities.

Speaking on the second day of the 2020 USCIPP annual meeting was Dr Raza Siddiqui, CEO, Arabian Healthcare Group, who highlighted the UAE’s achievements, at the ‘Impact and challenges of COVID-19: A Local perspective from the UAE on solutions for the future’ session.

He emphasised that the country confronted the challenges presented by COVID-19 head-on: “Within weeks, Abu Dhabi set up manufacturing facilities of masks. Additionally, the Dubai World Trade Centre was converted into a 3,000-bed world-class quarantine facility in just 10 days. Today, the UAE is in the top three countries for testing most of its population. It is a relatively small country, with a population of around 9-10 million, but still more than 50,000 people are tested every day, which is a world record!”

The CEO added that COVID-19 has further accelerated the use of technology, in the areas of telemedicine, homecare, and remote monitoring. For instance, in the UAE, telemedicine became a reality quickly with insurance companies approving teleconsultations and payment gateways being established. The country also took the lead in using robots for disinfection, and for food and medicine delivery thereby minimising human contact.

The COVID-19 impact

This is probably the first time in the history of the world that a healthcare crisis has impacted the entire global economy and the effect has been felt across different industries. For example, the pharma industry has been impacted by 7 per cent, retail by 10 per cent, financial services 12 per cent, technology/media/telecom 17 per cent, manufacturing 21 per cent, and healthcare up to 28-30 per cent, shared Dr Siddiqui.

Due to the sudden onset of the disease, even mature healthcare systems like the U.S. and some countries in Europe, that usually have a strong preparedness for disasters, couldn’t handle the situation well.

The healthcare trends in the GCC and the UAE, in particular, are different as compared to the rest of the world as most of the population here comprises of expats. Also, here the population above 50 years of age hardly makes up 5 per cent.

Dr Siddiqui highlighted: “The impact of COVID-19 has been maximum on outpatient care because the younger population generally uses outpatient and ambulatory care more. The impact has been 70 per cent on outpatient care.

“The revenues dropped significantly – almost eight million fewer patients per week were recorded in the whole of GCC. If we go department wise, the Emergency department visits dropped in the public sector by 50 per cent and private sector by 40 per cent. We have seen cases of cardiac emergencies and neuro emergencies not even coming to the hospital due to the fear of contracting COVID-19. The outpatient business dropped in the public sector by 80 per cent, private sector by 50 per cent, and likewise inpatient business dropped.”

By default, hospitals designed in the region are multi-speciality hospitals. Therefore, the role of senior specialists and consultants in specialities like cardiology and neurosciences, orthopaedics, and other sub-speciality departments, became defunct for more than four months. The revenue dropped and cost went up significantly because of sanitisation and extensive use of PPE. “Hospitals also had to manage the morale of the employees by taking care of them,” he said. “Also, front-liners were exposed to the virus all the time and hospitals had to make sure they remained healthy and infection-free.”

In the case of elective procedures such as hip replacement, and cardiac surgeries, these were not taking place and the departments of cosmetic surgeries were practically closed. Dental care was restricted by the Ministry and regulatory authorities because of close patient contact. He added that hospitals were suffering due to the revenue drop and that primary care was down by 70 per cent, secondary care by 65 per cent, and mental health by 45 per cent. The total impact was over 15 to 20 per cent in revenue to multi-speciality hospitals.

Dr Raza Siddiqui

Will medical tourism bounce back?

When asked about when medical tourism would make a return, Dr Siddiqui stressed that operating from the UAE is a great opportunity, as the country looks at the 360-degree of every business. Moreover, the entire ecosystem in the country is supportive of tourism and medical tourism.

“The UAE is the first country in the world that has been able to open its doors not only for tourists but also medical tourists,” he shared. “Most tourism destinations are closed, and we don’t know for how long. The UAE will be the first country to bounce back when it comes to medical tourism because when a patient is travelling overseas, they are looking for overall recovery, safe airport, local transport, infection-free environment etc. For example, at RAK Hospital, we have already started to receive patients, and just last week we carried out a joint replacement and this patient chose to come all the way from Ethiopia.”

On a parting note, Dr Siddiqui stressed that several trends in medical tourism are going to be corrected. For instance, he said, around 40 per cent of the patients who travel overseas need not travel.

“Technology is going to play a key role here. Going forward I see a more mature and elderly brother role of U.S. health organisations. I think mature healthcare systems should support local healthcare systems slowly to become self-sufficient through technology such as telemedicine, AI and data management. Only extremely unwell patients should travel for care. With all these factors in mind, I see a very positive future for the U.S. and Middle East relationship,” he concluded.

World Heart Day is an initiative of the World Heart Federation (WHF) launched in 2000 to coincide with the Olympic Games in Sydney. Celebrated annually on 29 September, it's today seen as the world's most effective campaign against cardiovascular disease.

The theme for World Heart Day in 2020 is #UseHeart to Beat Cardiovascular Disease. The WHF explains that taking care of one's heart right now is more important than ever in these "unprecedented times".

Through the campaign it is asking individuals, governments and communities to use head, influence and compassion to beat cardiovascular disease.

Cardiovascular disease in numbers

According to the WHO, cardiovascular diseases take the lives of 17.9 million people every year, 31 percent of all global deaths. Triggering these diseases are tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol.

These in turn show up in people as raised blood pressure, elevated blood glucose and overweight and obesity, risks detrimental to good heart health.

Men are more proportionally affected

In a Patient Talk podcast recently on men's health issues including diabetes and heart disease, Dr Ali Razzak revealed that while cardiovascular disease accounts for 30 percent of mortality worldwide, in the UAE it’s around 40 percent.

Within that men are more proportionally affected than women. He attributed this to factors such as rapid modernisation, less physical activity and a less healthy diet.   

Women have unique risk factors

A Cleveland Clinic specialist meanwhile - Leslie Cho, M.D. of Women's Cardiovascular Center - said that women have unique risk factors for heart disease that need to be taken into account in prevention and treatment strategies.

She explained that some conditions specific to women, such as endometriosis, have been found to raise the risk of developing coronary artery disease by 400 percent in women under 40.

Maintaining good heart health through exercise and monitoring

Many studies have linked higher resting heart rates with lower physical fitness, as well as higher blood pressure and body weight.

Increasing aerobic fitness is therefore an essential part of building a healthy heart. The more one exercises, the more they will be able to lower their resting heart rate, helping lungs and heart become stronger while also considerably reducing stress for a better life balance.

Heart rate monitoring should also be important to everyone, regardless of age or physical condition.

Monitoring is a growing trend among heart patients, too. Dr Curtis Rimmerman, cardiologist and Chair of International Operations at Cleveland Clinic, revealed in an interview recently that heart outpatients are now being monitored live and remotely via computer from the comfort of their own surroundings, resulting in less invasive surgery and faster recovery times.

Cardiovascular disease and COVID-19

The WHF has embarked on a global study which aims to better describe cardiovascular outcomes and identify risk factors associated with severe complications and death in hospitalised patients with COVID-19. It is expected to publish preliminary data in late 2020.

Meanwhile, the Cleveland Clinic Journal of Medicine revealed cardiovascular complications of COVID-19 that include acute myocardial injury in 12% to 28%, arrhythmias in 7 percent to 17 percent, and heart failure in about 20 percent, although whether they were caused by or exacerbated by COVID-19 remains unclear. Nevertheless, heart patients with a history of cardiovascular disease are at particularly high risk of adverse outcomes.

A webinar from Roche Diagnostics Middle East FZCO shed light on how cardiac involvement due to acute myocarditis may occur in patients with COVID-19 without respiratory tract signs and symptoms of infection.

Mayo Clinic highlighted that some of the medications being used to treat COVID-19 are known to cause drug-induced prolongation of the QTc in some - an indicator of the health of the heart's electrical recharging system.

Patients with a dangerously prolonged QTc are at increased risk for potentially life-threatening ventricular rhythm abnormalities that can culminate in sudden cardiac death.

On the first day of the 2020 USCIPP annual meeting yesterday, being held virtually due to COVID-19 travel restrictions, the panellists shed light on the impact of the virus on the medical travel industry.

Speaking at the ‘International medical travel trends & industry outlook: a USCIPP analysis’ session, Tricia Johnson, Professor, Department of Health Systems Management, College of Health Sciences, Rush University, and Research Director, USCIPP, shared that before COVID-19, the U.S. received over 63,000 unique patients, with 87 per cent being adults and 13 per cent paediatric patients, and generated approximately US$2.9 billion in gross revenue. The patients were mostly travelling for treatments related to oncology, cardiology, and neurosciences, both adults and paediatric patients, and the majority were travelling from the UAE, Kuwait, Saudi Arabia, Qatar as well as Mexico, and Canada.

She said: “If we go back to 2015-2016, 2016-2017, and 2017-2018, the market had overall remained steady or modestly increased. Prior to COVID-19, the U.S. saw quite a strong and promising market, with new geographic regions emerging and patients travelling in relatively high volumes.”

Road to recovery

It is not a surprise that COVID-19 has impacted all aspects of the travel and tourism industry. Johnson said that one of the first questions USCIPP got from its members was that were there any lessons learnt from 9/11 and the Great Recession (2008-2009).

She explained that post 9/11, there was a moderate decrease and it took nearly 10 years for inbound travel to recover. And while another drop was seen post the Great Recession, travel volumes recovered more quickly after 2008-2009.

One of the challenges, Johnson emphasised, for inbound medical travel would be consumer confidence in the U.S. as a travel destination and visa restrictions that may have a more lasting impact based on medical travel patterns post 9/11, and the fact that different U.S. states don’t have a coordinated response to COVID-19.

She said: “USCIPP spent some time looking at what recovery might look like and took a quantitative approach to look at increases in travel and when these might occur. The key consideration is when are we going to have rapid availability of point-of-care-testing (POCT) that will allow patients to travel easily before a vaccine is available.

In terms of projections, she stressed that there is some increase expected between now and 2023. However, a lot of the slope of the recovery is going to depend on when rapid POCT is available at a low cost and when a vaccine would be available. Although even through 2023, medical travel won’t be at the same point it was a year ago. Some increase in patients travelling in the coming months is also anticipated.

“I believe the economic crisis of COVID-19 will have a lesser effect on inbound medical travel than other factors once regional economies being to recover. The lessons are we learning right now can allow the industry to be more resilient and stronger going forward,” she added.

Opportunities for medical travel

According to Johnson, the growing importance of cultural sensitivity as a business imperative is more important than ever before today. Below she stresses on five growth opportunities for the medical travel industry:

1. Hospitals should strategically grow service lines that differentiate them from the market. Fewer international patients, with more complex needs, would mean higher revenue, as for some patients, risks of travel would outweigh the benefits. Also, hospitals can leverage their unique skills and make it as easy as possible to access them.
2. Target geographic regions with easier travel to hospitals such as where flights are shorter and might not require air travel. For the U.S., it would be the North American market that saw a 30 per cent increase in patients prior to the pandemic.
3. Strengthen non-patient collaborations and relationships: education & training; marketing & consulting; management service agreements and joint ventures.
4. Change the narrative: Public confidence in the U.S. national public health response versus U.S. patient care response to COVID-19, highlight the positives.
5. Leverage expertise and sophistication of telehealth for international patients.

“We are facing challenges we haven’t faced in the past, but there are opportunities to be innovative, provide access to care and improve health globally,” she concluded.

Stem cell treatment and gene therapy could drastically improve the lives of more than 20 million people globally who have the genetic blood disorder sickle cell disease, says a leading expert from a top American paediatric hospital, Cleveland Clinic Children’s, marking Sickle Cell Disease Awareness Month in September.

Gene therapy is an experimental technique that aims to treat genetic diseases by altering a disease-causing gene or introducing a healthy copy of a mutated gene to the body. In a recent trial presented at the virtual American Society of Gene and Cell Therapy Annual Meeting in May, the results of a phase 1/phase 2 trial LentiGlobin gene therapy led to reductions in sickle cell disease-related complications and haemolysis.

New frontiers in sickle cell disease

According to Ravi Talati, a doctor of osteopathic medicine in the Department of Pediatric Hematology and Oncology at Cleveland Clinic Children’s: “Sickle cell disease is entering a new frontier where emerging treatments in stem cells and gene therapy can help people to significantly reduce comorbidities related to sickle cell disease and enable healthier lives for years. Newer treatments include transplanting stem cells from healthy bone marrow that can produce normal red blood cells, in addition to gene therapy, which can remove the abnormal gene or increase the amount of foetal haemoglobin created.”

More than 20 million people worldwide have sickle cell disease, according to the National Heart, Lung, and Blood Institute. In addition, the Sickle Cell Disease Foundation says that more than 250 million people globally have the sickle cell genetic mutation, putting them at risk of passing this mutation to their children. Sickle cell is prevalent in the Middle East, South Asia, Africa, Latin America, and the Mediterranean.

Treatment options

Fortunately, while clinical trials of newer therapies continue, sickle cell disease patients have a wide range of treatments that can help to reduce pain. For example, penicillin can reduce the incidence of infection, hydroxyurea can help to keep red blood cells in a spherical shape, and L-glutamine can help red blood cells to regain their flexibility.

Recently, the U.S. Food and Drug Administration approved two new drugs for sickle cell disease: crizanlizumab-tmca, a monthly infusion that can prevent or reduce pain, and voxeletor, which can help to prevent the red blood cells from turning into a sickle shape.

Recent studies have found that dry eyes could be an indication that Coronavirus is present. The infection spreads through respiratory droplets expelled when someone coughs, sneezes or talks. Therefore, where close contact is required to care for a COVID-19 patient, safety eyewear such as goggles or a face shield is a must for healthcare workers and infection control and prevention staff. These can help in avoiding a viral build-up in the eye and should be used as part of Personal Protective Equipment (PPE).

Face shields are also becoming popular among the general population, as it is a less restrictive covering and keeps foggy glasses and sweat at bay. It also stops people from touching their face with unwashed and potentially contaminated hands. These are now commonly seen on travellers before they board an aircraft and have also started to make their way on fashion sites.

Also, for those with allergies, a face shield, along with a face mask, is recommended before stepping outside. But are face shields the best option when it comes to protecting oneself from the Coronavirus?

What is a face shield?

A face shield is a transparent curved plastic that has an A-frame lid covering the nose and mouth and is attached to a headband that can be worn over the face. It should fit securely so that there is no gap between the band and the forehead. The shield should also extend beyond the chin.

Face shields have become a staple for healthcare personnel taking care of patients infected with COVID-19. These are also being worn during a variety of other medical procedures, where blood or other bodily fluids could get into the eyes, nose and mouth. This coverage is ideal since Coronavirus could enter the body through those points.

The Centers for Disease Control and Prevention (CDC) in the U.S. doesn’t recommend wearing face shields for everyday activities or as a substitute for face masks. However, some people may choose to use a face shield when they know that they’ll be in close contact with others and can wear a mask underneath the face mask to minimise the risk of infection since face shields have openings at the bottom.

Are face shields effective?

According to a 2014 study, a face shield reduced exposure by 96 per cent when tested against an influenza-infused aerosol from a distance of 18 inches away. It also reduced the surface contamination of a respirator by 97 per cent.

The goal of a face shield is to minimise the distance that the aerosol travels. It cannot alone prevent the spread of COVID-19 but can help in reducing transmission and block large particles from getting into the eyes and mouth.

While face masks absorb droplets, face shields don’t. They are typically for single-use, but if being reused, these will need to be cleaned frequently with mild soap and water or a hand sanitizer. Those wearing a face shield should wash their hands before and after removing the face shield and avoid touching their eyes, nose and mouth when removing it.

Face shields are bulkier than masks and might be a little uncomfortable for the wearer. However, wearing a mask may not be feasible in every situation for some people for example, who are deaf or hard of hearing or those who care for or interact with a person whose hearing is impaired.

Although evidence on face shields is limited, the available information suggests that face shields can be an effective additional layer of protection against COVID-19, along with wearing a face mask, practising safe social distancing and washing hands regularly.

Over the years, I’ve learned a few things about cyberattacks in the healthcare industry:

1. The real threat is already in healthcare networks in the form of privileged access misuse.
2. The growth in healthcare IoT devices is overwhelming and dangerous.
3. A majority of attacks occur due to negligence, misuse and a lack of security awareness by insiders.

By default, a lot of people have access to patient medical records. This makes it very easy, and perhaps a bit enticing, for some to take advantage of the situation.

Internal actors are largely responsible for healthcare data loss. I’m talking about employees who access patient data out of curiosity or to commit identity fraud. Apparently, it is the only industry where this occurs at such an alarming rate.

While everyone else worries about cyberattacks from someone they’ve never met, security professionals in healthcare worry most about the people they talk to in the break room.

Even worse, motives seem to be a mix of financial gain – patient records are the most valuable form of digital personal data – and simple curiosity. The curious want to know what’s going on with others and the information is there for the taking.

A love affair with IoT devices

The ongoing proliferation of IoT in the medical industry doesn’t help either. These medical devices produce massive volumes of data about every patient who comes through the door, and most healthcare organisations don’t have a way to track what or where those devices are.

IoT might be the easiest target for attackers. There are lots of them, no one is watching, and security is nonexistent. We’ve seen attacks evolve from authenticating through default admin passwords and using IoT for botnets to the outright destruction of IoT devices by wiping their drives. Granted, wiped devices can be restored, but the impact is far greater if those devices deliver critical care.

Recurring challenges

There is a recurring set of challenges based on the feedback we get from our healthcare customers.

• Lack of security professionals – One person can only do so much in a day. Healthcare security professionals are often tasked to do more than is humanly possible.
• Lack of money – Hiring more people is tough because healthcare organisations have lean budgets. They are tasked with finding operational efficiencies and doing more using what little they have.
• Lack of visibility – Lots of IoT devices, coupled with the free flow of patient data in the network, create massive internal blind spots about what’s happening. The biggest threat is inside the network, where perimeter security is blind.

Reduce the time to discover threats

When you factor in how long it takes to discover a data breach, it suggests that healthcare is losing the battle. It’s not acceptable to find out weeks, months or years after a breach occurs.

I believe the answer lies in 360-degree visibility inside the network – across cloud, data centre, IoT, and enterprise networks – as well as real-time attacker detection and the prioritisation of all detected threats so you know where to start.

However, that answer must address the challenges I mentioned earlier. Here are four ways to get there:

1. Eliminate the manual, time-consuming work of security analysts through automation and prioritisation of detected threats.
2. Lower the skills barrier needed to hunt down cyber threats.
3. Consider that everything is connected, which makes for an easy target and a huge attack surface.
4. Provide visibility inside the network to see attackers – where they are, what they’re doing, and the compromised hosts and workloads they’ve exploited.

This fundamental approach is advocated by a growing number of healthcare security professionals. Many are augmenting their security teams with AI-derived machine learning models to automate the early detection of cyberattackers, speed-up incident response, investigate conclusively and hunt more efficiently for threats.

It’s a battle that has been won by many healthcare organisations and the idea is gaining momentum.

Chris Morales

The following article is available in full, including figures and data, on Cleveland Clinic Journal of Medicine June 2020 as part of its COVID-19 Curbside Consults.

The initial evidence supporting the prone position in non-ventilated awake patients with COVID-19 infection was anecdotal and theoretical. However, several early studies support the potential role of this practice to improve oxygenation, improve clinical outcomes, and reduce the need for intensive care admission.

Although there is not a set amount of time that has been proven to be optimal for awake proning, we recommend sessions of 2 to 3 hours for at least a total 4 to 5 hours a day as tolerated based on the existing data and our anecdotal experience. Despite the low-risk and low-cost nature of proning awake patients, there are still logistical concerns that may prevent adequate proning, the most significant of which is patient comfort and compliance.

Introduction

Prone positioning is a well-established and routine intervention for patients with moderate-to-severe acute respiratory distress syndrome (ARDS) who require mechanical ventilation. As COVID-19 infection spread and evolved into a global pandemic, anecdotal evidence also suggested a role for proning of non-ventilated, awake patients with COVID-19 infection.

Despite rapidly evolving research and novel therapeutics, COVID-19 infection remains associated with significant morbidity and mortality, especially in the setting of critical illness, leading to multi-organ involvement and shock. Moreover, limited hospital resources and restrictions on using noninvasive ventilation due to concerns for aerosolization may limit the ability of health care providers to quickly mechanically ventilate these patients, making low-risk temporizing measures especially attractive.

Proning non-ventilated, awake patients, has been proposed as a potential low-risk intervention that may be associated with improved oxygenation, clinical outcomes, and reduced need for intensive care admission. Several studies since the beginning of the pandemic have addressed the potential role of proning awake patients with COVID-19 infection in optimizing outcomes.

Physiology of proning in acute hyopxemic respiratory failure

Prone positioning may affect the mechanics and physiology of gas exchange to improve oxygenation in both intubated and non-intubated patients, and may be even more effective in the latter. Prone positioning may reduce the difference between ventral and dorsal pleural pressure, or the “ventral-dorsal transpulmonary difference.”

Alveoli that collapse during supine positioning may be recruited over time with prone positioning and improve oxygenation. On the other hand, supine positioning is associated with a higher dorsal than ventral pleural pressure, causing greater ventral alveoli expansion.

Additionally, supine positioning may be associated with compression of the medial posterior lung parenchyma and diaphragm. During positioning, the heart becomes dependent, decreasing posterior medial lung compression. This may shift perfusion toward healthier alveoli in the anterior lungs, allowing for improved ventilation-perfusion matching and reduced intrapulmonary shunting. Lastly, proning may improve secretion management, which can, in turn, prevent atelectasis and improve recruitment of pulmonary parenchyma.

The evidence

Initially, the evidence supporting the prone position in awake patients with COVID-19 infection was anecdotal and theoretical based on principles applied from proning of mechanically ventilated patients and studies of non-COVID patients, but there has since been several early studies supporting the potential role of this practice. These studies are inherently limited, however, by their small size and lack of controls, but larger robust studies are in progress.

Several case reports and small case series initially noted a potential improvement in oxygenation with awake proning in patients with COVID-19 infection. Elharrar et al reported in a single-center study of 24 patients that prone positioning was associated with an increase in PaO2 of more than 20% from baseline. Several of these patients, however, did not tolerate proning or did not have sustained improvement in oxygenation once turned supine.

Sartini et al in a cross-sectional study of 15 awake patients with mild and moderate ARDS noted a sustained improvement in most patients in conjunction with noninvasive ventilation.

Ng et al noted a reduced need for mechanical ventilation and improved outcomes in a series of patients who underwent prone positioning for 1 hour at a time, 5 times a day spaced 3 hours apart. Caputo et al studied early safe proning with up to 120 minutes as tolerated in 50 awake non-intubated patients with refractory hypoxemia (median oxygen saturation of 84%) and noted an immediate increase in median oxygen saturation with only one-third of patients requiring intubation.

Due to limited data on its efficacy, there is not a set amount of time that has been proven to be optimal for awake proning, with each study employing slightly different protocols largely dependent on patient tolerance. For example, some protocols call for patients to rotate positions every 2 hours, starting with left lateral recumbent, right lateral recumbent, sitting upright 60 to 90 degrees, and lastly, lying prone in bed. Others have suggested at least 2 separate 3-hour sessions of proning per day. Based on the existing data and our anecdotal experience, we recommend sessions of 2 to 3 hours for at least a total 4 to 5 hours a day as tolerated.

Thus several studies have suggested a potential benefit of proning awake patients with COVID-19 infection, but these studies are small and limited in their scope. Despite the low-risk and low-cost nature of proning awake patients, there are still logistical concerns that may prevent adequate proning, the most significant of which is patient comfort and compliance.

Read the full article.

The following article is available in full, including figures and data, on Cleveland Clinic Journal of Medicine June 2020 as part of its COVID-19 Curbside Consults.

Gastrointestinal (GI) symptoms are seen in patients with COVID-19. The prevalence could be as high as 50%, but most studies show ranges from 16% to 33%.

Related: Irritable bowel syndrome with diarrhea: Treatment is a work in progress

Presenting with GI symptoms increases the risk of testing positive for SARs-CoV-2. Approximately 50% of patients with COVID-19 have detectable virus in their stool. Having GI symptoms has been associated with more severe disease.

Management of GI symptoms is mainly supportive, given the lack of FDA-approved treatments for COVID-19. Healthcare providers should be aware of the GI manifestations of COVID-19 and perform SARS-CoV-2 testing for patients presenting with digestive changes, especially in those with respiratory symptoms.

Sars-Cov-2 in the gastronintestinal tract

Several studies have shown the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the digestive tract and stools. Approximately 50% of patients with coronavirus disease 2019 (COVID-19) have detectable viral RNA in the stool. SARS-CoV-2 nucleocapsid protein has been found in gastric, duodenal, and rectal glandular epithelial cells. 

Viral RNA also has been found in esophageal, gastric, duodenal, and rectal biopsies but only in patients with severe disease, suggesting that the presence of SARS-CoV-2 in gastrointestinal (GI) tissue is associated with a more severe disease course. Live virus has also been detected in the stool of patients with COVID-19 by electron microscopy. Although these findings raise the possibility of fecal-oral transmission, this mode of transmission has not been confirmed.

The pathophysiology of digestive symptoms associated with COVID-19 remains unclear. SARS-CoV-2 appears to enter host cells by binding to the angiotensin-converting enzyme-2 (ACE2) receptor and using the transmembrane serine protease 2 for spike protein priming. ACE2 is highly expressed in the small bowel and colon.

Data have shown co-expression of ACE2 and transmembrane serine protease 2 in esophageal cells and absorptive enterocytes from both the ileum and colon. Another study reported the infection of enterocytes by SARS-CoV-2 in small intestinal organoids. These findings support the possibility of viral invasion of enterocytes and provide a potential mechanism for SARS-CoV-2–associated GI symptoms.

Infectious SARS-CoV-2 has been isolated from stool samples of COVID-19 patients and shown to infect human intestinal organoids. There is also a clinical study from Austria that showed evidence for intestinal inflammation induced by SARS-CoV-2 in which patients with current or resolved diarrhea had higher concentrations of fecal calprotectin than patients without diarrhea. Interestingly, fecal calprotectin levels significantly correlated with serum interleukin 6.

Although the presence of SARS-CoV-2 RNA in the stool was not initially thought to be associated with digestive symptoms, recent data indicate that patients with GI symptoms may be more likely to have detectable fecal RNA than patients with respiratory symptoms only. In a study out of Wuhan, China, 69% of patients with diarrhea had detectable RNA in the stool as opposed to only 17% of patients without diarrhea.

Interestingly, viral RNA can be detected in stool several weeks after symptom onset. Another study from China found that respiratory samples remained positive for an average of 16.7 days after symptom onset, whereas fecal samples remained positive for about 27.9 days. In addition, patients with diarrhea may have more prolonged fecal shedding than patients without diarrhea. What is unknown is whether these patients are infective and if there is a fecal-oral spread to coronavirus.

GI symptoms: Prevalence

Although initial data found the prevalence of GI symptoms to be 2% to 10% among patients with COVID-19,15,16 subsequent studies have reported higher rates. In a multicenter study of 204 patients with COVID-19 in China, 50.5% reported GI symptoms at presentation to the hospital.

In a meta-analysis including 60 studies and 4,243 patients, the pooled prevalence of all GI symptoms was 16.1% in studies from China and 33.4% from other countries. In another meta-analysis including 47 studies and 10,890 unique patients, GI symptoms were present in less than 10% of patients, but rates were higher in studies outside of China.

Most studies included hospitalized patients, but some included outpatients. More recent studies out of California, New York, and Massachusetts reported a prevalence of GI symptoms of 31.9%19 and 35% (both inpatients and outpatients) and 61.3% (hospitalized patients). Furthermore, a US case-control study found that the presence of digestive symptoms was associated with a 70% increased risk of testing positive for SARS-CoV-2 (adjusted odds ratio 1.7; 95% confidence interval 1.1–2.5).

Of note, patients with COVID-19 may present with GI symptoms without respiratory symptoms. In a retrospective study of 1,141 patients with COVID-19 in China, 16% presented with GI symptoms only. A recent US study reported that 14.2% of patients with COVID-19 had digestive symptoms as their main presenting complaint, regardless of age or underlying comorbidities.

GI symptoms: Characteristics

Among GI manifestations associated with SARS-CoV-2 infection, loss of appetite or anorexia is the most commonly reported symptom. Although rates vary across studies, a meta-analysis of 60 studies found a pooled prevalence of 26.8% in patients with COVID-19. Diarrhea was the second most common symptom with a pooled prevalence of 12.5%.

A pooled analysis of clinical studies that reported diarrhea found a prevalence of 10.4% (range 2% to 50%) in patients with COVID-19. However, recent US data found higher rates ranging from 23.7% to 33.7%. Although some studies have described mild diarrhea, other studies have reported severe diarrhea and acute hemorrhagic colitis associated with COVID-19. The etiology of colitis is not known, but given the thrombotic complications associated with COVID-19, this likely represents ischemia.

Other digestive manifestations include nausea or vomiting and abdominal pain. According to US data, nausea or vomiting were found in 10.3% to 26.4% of patients with COVID-19, whereas abdominal pain was found in 8.8% to 14.5% of patients. Dysgeusia has also been reported, often in conjunction with anosmia, in up to 64% of patients with COVID-19. Interestingly, in a US study, dysgeusia and anosmia were more common among patients with GI symptoms and were independently associated with nausea and anorexia.

Read the full article.

GCC accounts only for 1.2 per cent of the global HC revenue, but it is the region that saw the highest growth rate in the last decade. GCC has opened doors to global suppliers and moved beyond U.S. imports, which is likely to be the game-changer in the 2020s.

Technology and digitisation are in higher demand than ever before because of higher awareness and the shortage of skilled resources. The growth of domestic manufacturing and investment in start-ups will open doors for the competition and make healthcare affordable and available for all. The development of a sustainable supply chain in the 2020s will drive the penetration and adoption of healthcare products in the region.

The region promoted local production of generics in 2019, thereby increasing the pharmaceutical revenue in the region by 5 per cent to 10 per cent annually. This is likely to have been driven by KSA and UAE.

In the IVD market, NGS technology will be the key driver and is likely to see a double-digit growth rate. The UAE, KSA, and Kuwait were key contributors for this growth. AI that enables imaging services has seen high adoption from the last quarter of 2018. It is expected to be the key focus for tertiary hospitals. GCC digital health market is likely to grow significantly to capture 4 per cent to 6 per cent of the global market. Medtech vendors have grown their market by supporting the private sector’s growth in the region, and it is only likely to grow further with a higher double-digit growth rate.

Frost & Sullivan’s ‘Healthcare Industry Outlook for the Gulf Cooperation Council Countries, Forecast to 2020’ has been developed to support investors, healthcare companies, and other GCC organisations to understand the growth potential, opportunities in this rapidly changing industry. The base year for the study is 2018; the forecast is for 2020.

Key issues addressed

• What is the size of the market driven by the 5 key segments: Pharma, IVD, medical devices, medical imaging and digital health in the region?
• What are some of the trends that are shaping up the market and the segments that are likely to have an impact on market growth? 
• What are the strategies that companies have to adopt to meet the future needs of the industry?
• What is the opportunity potential for technology across various healthcare settings?

Download the report here.