Coronavirus disease 2019 (COVID‐19): not one epidemic but four

At this crucial time, it is correct to focus on controlling the COVID‐19 epidemic using the meagre tools we have available – social distancing, hand washing, protection of healthcare workers as critical infrastructure and expansion of testing as much as possible combined with quarantine to prevent community spread. However, we are faced with at least three other contemporaneous epidemics that we also need to manage: more morbidity and mortality from non‐COVID‐19‐related acute disease, increased harm due to diminished support for patients with chronic disease and a mental health epidemic across society but likely to be concentrated in front line workers. Understanding the risks related to these additional epidemics occurring in close proximity – worse outcomes for acute and chronic non‐COVID‐19 illnesses and an increase in mental health disorders related to trauma, especially in first responders – may help us to reduce them.

First, with new non‐COVID‐19 illness, there are undoubtedly contributing factors on the patient side; patients are currently avoiding medical care if they can because other patients are seen as sources of risk and potentially leaving investigation and management of new symptoms until later. If they come to hospital, and their symptoms may be COVID‐19 related, their care is diverted until COVID‐19 is ruled out, which is not always easy. Many diagnostic tests are much harder to get as a consequence of perceived infection control risks as a result of the recommendations of specialist groups, including, for example, transoesophageal echocardiography and ear, nose and throat specialist examinations. As a consequence, empirical treatments and more clinical, less solid diagnoses are likely. In addition, personal protective equipment may be required before resuscitation, which is likely to slow first responders and decrease their effectiveness, which is dependent upon the time to action. In many ways, these problems are insoluble, but it is important at least to recognise them and to develop better and faster ways of testing for COVID‐19 so that patients can be treated and triaged faster, as well as encouraging people to present to care early if they have a problem.

Second, those with chronic illness are already being harmed. Initially, there are some higher‐profile cases, including the inability to get matched stem cells into Australia for transplantation, the decision of some groups to stop transplants and the reduction in outpatient reviews only partly compensated for by an increase in use of telehealth. This is particularly true of hard‐to‐reach populations, including homeless people with blood‐borne viruses, where it may be increasingly difficult to keep them linked in because volunteer drivers and others may no longer operate. Undoubtedly, changes that have been made to protect front‐line workers are necessary, but they are likely to come at a cost to the chronically ill and disadvantaged. Our only ways of mitigating this are related to keeping care as usual as much as possible – regular testing, regular review and keeping contact with our patients if possible, so they do not fall out of care.

The third epidemic is likely to come a bit later but is again something communicated from our colleagues overseas and, indeed, our knowledge of previous epidemics and loss. If the experience overseas is followed here, there is likely to be loss of mental well‐being broadly across society, partly due to the decreased ability to follow up those with chronic mental disease but also due to mass trauma. Seeing many people die, including family members, friends and colleagues in the health system, is something we all fear, here and now, and is already leading to a feeling of pre‐traumatic stress syndrome or anticipatory loss. Many groups are already supplying information on mindfulness, ways of escaping the ubiquitous coronavirus news and direct psychological support in preparation; however, some increased post‐traumatic stress disorder can be anticipated, especially among first responders, who are tired, stressed and notoriously not good at looking after ourselves.

We are in a war with COVID‐19, and winning that war has the highest priority, but minimising the risks related to these three shadow epidemics, and recognising their existence, is a critical step in avoiding further morbidity and mortality, both now and after COVID‐19 is beaten.