Impact of COVID-19 on the clinical care of Ethiopian PD patients: A glimpse into the burden

Dear editor,

At the beginning of the pandemic, most experts warned COVID 19 will hit Africa hard, citing the universal lack of health care facility capable of coping with a pandemic of such magnitude. Now, the prophecy seems to be realizing. As of this writing, Africa reported more than one million COVID 19 cases and a total of 22,066 deaths. Likewise, Ethiopia also reported 20, 900 COVID-19 cases and 365 deaths, where the majority of the cases and deaths were reported from the capital Addis Ababa [1]. Currently, Parkinson Patient Support Organization-Ethiopia (PPSO-E), a non-profitable patient support organization located in Addis Ababa that has 600 registered Parkinson's disease (PD) patients as members. Almost all of these patients are from Addis Ababa and surrounding cities, making them much more vulnerable to the fast-spreading virus. Neurological care in Ethiopia is significantly inadequate⸻a few trained neurologists, lack of movement disorder specialists, inadequate neurological investigations such as NCS, EMG, MRI, and unavailability of basic antiparkinsonian medications [2].

Before COVID19, PPSO-E has supported these PD patients socially, economically, and by clinical care, in collaboration with volunteering neurologists from department of Neurology, School of Medicine Addis Ababa University. However, because of COVID 19, the organization routine activities have been immensely affected. One of the most important activities affected by the pandemic was the regular physical training for the PD patients. The program was led by a trained physiotherapist three times per week. However, following COVID 19 the program was completely put on hold (100%) until the pandemic is under control. This will further limit the benefit our patients get from such a program. Similarly, most of non-COVID neurological disorder clinical care was interrupted at most health care facilities in the country. For example, the movement disorder clinic at Tikur Anbessa Specialized Hospital (TASH) which runs on a weekly basis used to see on average 15 to 20 PD patients per week before the pandemic. However, since the pandemic, the numbers of patients were significantly reduced up to 80–85%.

The main reason behind service interruption at PPSO-E and most of the public health facilities including TASH were multifactorial. However, the most important reason was related to countries' infection containment measures strategies, including 5 month-long state of emergency, closure of schools and public service sectors including transport service, which was eased later. Likewise, in order to reduce COVID 19 transmission in the public health facilities and to reserve beds and mechanical ventilators for COVID 19 patients, most facilities adopted a policy of reducing non-COVID clinical services including outpatients and inpatients, sparing emergency services. This trend resulted in a significant reduction of non-COVID neurological patient's visit to our hospital. In order to continue clinical care for non-COVID neurological patients, teleneurology service was introduced and patients were followed via phone clinics, which worked from Monday to Friday. In addition, we tried to interview few PD patients and their caretakers by phone to understand why they don't want to visit hospitals to continue their pre-COVID 19 care; most responded that they feared they might acquire the virus by visiting the health facilities, even if the facility was non-COVID, like TASH.

Before the pandemic, most of Ethiopian PD patients had been suffering from poor access to clinical care, delayed diagnosis, costly medications in short supply, social stigma, and economic disadvantages, which even got worse by the global measures to contain the COVID-19 outbreak. Most of these PD patients have been struggling to get their medications on a timely basis, even before the COVID-19 pandemic mainly because of financial constraints and unavailability of even the basic antiparkinsonian drugs such as Levodopa. In addition, the PPSO-E also provides a regular financial and food support for more than 30 bedridden advanced stage PD patients in Addis Ababa through a house-to-house visit. Before COVID-19, most of PD patients had received their antiparkinsonian drugs for free from the public Hospitals or PPSO-E. Availability of Levodopa lacks consistency in most public Hospitals in Addis Ababa.

Thus far, our movement disorders clinic at TASH is mostly working as a phone clinic and few PD patients came in person to be evaluated. It is vital to keep the clinical care for these vulnerable PD patients to help them pass this pandemic. So far, our hospital (TASH) is a non-COVID hospital, means we will refer COVID patients to COVID dedicated hospitals in Addis Ababa. Therefore, we can slowly start resuming the pre-COVID neurological services, including electrophysiological tests. In the meantime, it's critical to keep the teleneurology services to our PD patients. This includes telephone consultations and ordering prescription so that the patient's attendant can pick it up from the hospital pharmacy. This will reduce inappropriately exposing elderly PD patients to hospital visits. Furthermore, encouraging home visits by a volunteered neurologist to evaluate bed ridden PD patients in Addis Ababa will be another way of keeping the neurological care amid COVID 19.

Considering the recent alarming number of COVID 19 cases in Ethiopia, no doubt that, our PD patients are expected to continue suffering from lack of proper clinical care, immobility due to potential future lockdowns, social isolation, and economic constrains, as most of the patients are elderly, poor, and lack caretakers. Therefore, a holistic approach to address the physical and mental wellbeing of PD patients is essential during such global public health crisis. These can be implemented by creating smooth coordination between patients' support organizations such as PPSO-E, professional organizations such as Association of Ethiopian Neurologists (AEN), funders such as World Parkinson Program (WPP), and health authorities. The support may include continuation of the clinical care via teleneurology or by home visits, organization of antiparkinsonian drug donation for the patients, and mobilization of personal protective equipment (PPE), hygienic materials, and financial support for the patients. It's important to support PD patients in Ethiopia during this timing before the full force of the pandemic unfolds.