The COVID-19 pandemic: reflections for the field of sleep medicine

Citation:

Ramar K. The COVID-19 pandemic: reflections for the field of sleep medicine. J Clin Sleep Med. 2020;16(7):993–996.

INTRODUCTION

The rapid, worldwide spread of the novel coronavirus (COVID-19) has been alarming, and the breadth of its impact is unmatched by any pandemic in recent history. However, COVID-19 was preceded by several outbreaks of varying scale over the past two decades. These include the global outbreak of severe acute respiratory syndrome in 2003; the novel influenza A pandemic, which was detected first in the United States in 2009; the spread of the Middle East Respiratory Syndrome Coronavirus in the Republic of Korea in 2015; and repeated outbreaks of the Ebola virus in West Africa.

Data suggest that global outbreaks of emerging infectious diseases in the human population are increasing with time, driven largely by globalization and urbanization, although improvements in prevention, early detection, control, and treatment are helping to reduce the number of people infected.¹ Such data led the World Economic Forum to declare in January 2019 that “a new era of the risk of epidemics has begun.”²

These crises have an enormous impact on the world economy. The current pandemic has triggered what is expected to be the deepest global recession since World War II.³ In the United States alone, more than 26 million Americans—about 1 in 6 U.S. workers—filed for unemployment in the first 5 weeks of the COVID-19 crisis, and up to 57 million U.S. jobs are now vulnerable to permanent layoffs, temporary furloughs, or reductions in hours and pay.⁴ As a result, millions of workers (and their family members) are likely to lose their health insurance because of the pandemic.⁵

What does this mean for the field of sleep medicine? This economic strain, fear of COVID-19, and uncertainty about the future are likely causing many people to experience stress along with symptoms of depression and anxiety, which may be exacerbated by social distancing and home confinement.⁶ Difficulties with sleep such as insomnia because of this turmoil, in turn, can impact an individual’s resilience and daytime emotional functioning.⁷

Looking ahead, instead of anticipating the end of the COVID-19 crisis, we should adopt a public health perspective, which considers the phases of a pandemic to be a continuum.⁸ These phases overlap with the stages of pandemic risk assessment beginning with preparedness, proceeding to response and recovery, and then returning to preparedness (Figure 1).

Figure 1. The continuum of pandemic phases.

This continuum is according to a global average of cases, over time, based on continued risk assessment and consistent with the broader emergency risk management continuum. Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases.

With lessons from the COVID-19 pandemic, we will be more prepared when another outbreak occurs, including a potential resurgence of COVID-19 later this year or next.⁹ We will also be better equipped to carry out the American Academy of Sleep Medicine (AASM) mission of “advancing sleep care and enhancing sleep health to improve lives” amid the setting of a pandemic.¹⁰ As we continue to address the current crisis, in this editorial, I present reflections on several areas of impact to improve our preparedness as sleep medicine providers. These are areas in which we as a field should innovate and formulate strategies to strengthen and advance sleep medicine for the future.

AREAS OF IMPACT

Local connection

The COVID-19 crisis has provided a timely reminder that the more than the 2,600 AASM-accredited sleep facilities across the United States must be tightly connected with their local community, because the needs of their communities are diverse. COVID-19 quickly ravaged large urban centers such as Seattle and New York City and spread more slowly to other areas. Although the AASM has worked hard to provide COVID-19 guidance applicable to all our accredited facilities, the reality is that our members have had to observe state directives and executive orders based on local conditions. Our provision of sleep care must be agile enough to meet the needs of the local community.

Public health

As we rely on guidance from national and local public health officials, the field of sleep medicine finds itself more closely aligned with the field of public health.^11,12 This integration undergirds the AASM vision, “Sleep is recognized as essential to health.” To help achieve this vision, the AASM continues to fund public awareness efforts. We recently added a new position in our national office for a public health program manager who will develop and oversee the implementation of a comprehensive and multifaceted public health plan. This effort will build on the recent work of the National Healthy Sleep Awareness Project, which was a Centers for Disease Control and Prevention–funded collaboration from 2013 to 2018, involving the AASM, Sleep Research Society, and other partners.¹³

Health disparities

The COVID-19 pandemic has shined a light on existing health disparities in our country.^14,15 These disparities are worsening during the pandemic, as more people face unemployment, food insecurity, and a lack of health insurance in the future. The virus has also been a threat to vulnerable populations, including those in nursing homes and assisted-living facilities, homeless shelters, and correctional facilities.^16–18 It is critical for sleep medicine professionals to recognize that these disparities have a sleep-related dimension, because sleep deficiencies are more common among populations that experience health disparities in the United States.¹⁹ The sleep field needs to address existing sleep health disparities and provide better sleep and circadian guidance to promote sleep health in institutional settings. We as a sleep community must recognize the importance of taking the lead to respond to this challenge, working together to formulate strategies to address this foreseeable gap.

Infection control

Although infection control within a sleep facility has always been addressed by the AASM standards for accreditation,²⁰ its importance has been emphasized dramatically by COVID-19. An analysis found that the virus that causes COVID-19 was detectable in aerosols for up to 3 hours and up to 2–3 days on plastic and stainless steel,²¹ raising concerns about the potential aerosolization of the virus by positive airway pressure (PAP) therapy,²² as well as the possible contamination of PAP, polysomnography, and home sleep apnea test devices. If it is true that we are in a new era of epidemics, then infection control will be more important than ever for sleep facilities, and sleep clinicians will need better and clearer guidance for equipment cleaning and disinfection, especially from device manufacturers. These infection control measures will need to be enhanced further at each facility based on local needs and state/local directives. The AASM will continue to offer guidance and lessons learned from different facilities through various delivery platforms.

Technology innovation

The initial surge of COVID-19 infections sparked innovation nationwide, as both health systems and health care providers had to overcome shortages of vital medical supplies and devices such as personal protective equipment and ventilators. COVID-19 also has revealed the need for similar inventiveness in the sleep field. To address concerns that PAP therapy could aerosolize a virus, we need innovative PAP mask interfaces and virus filtration systems — for use at home, in sleep facilities, and in hospitals — so that PAP devices can be used safely during an outbreak. Although sleep clinicians are already developing inventive, short-term approaches and designs to address these challenges,²³ sustained long-term solutions are needed from leading PAP manufacturers. Furthermore, before COVID-19, disposable home sleep apnea test components and devices may have been considered a convenience more than a necessity. Now, we can see how the sleep field would benefit from having more disposable sleep technology options available to mitigate the potential spread of infection from surface contamination on sleep devices during an outbreak.

Telemedicine services

For years, the AASM has recognized the value of telemedicine as a method of care delivery that can improve patient access to convenient care.²⁴ The AASM also developed AASM SleepTM, a state-of-the-art telemedicine system designed specifically for the field of sleep medicine.²⁵ Adoption of telemedicine has been slow, however, in large part because of disjointed and restrictive policies and regulations at the state and federal levels. COVID-19 suddenly changed the rules of the game, as it became a safer option to provide and receive care from home when possible. The Centers for Medicare & Medicaid Services (CMS) responded by dramatically expanding coverage for telemedicine services and increasing payment rates for virtual visits during the COVID-19 public health emergency.²⁶ As the president-elect of the AASM, I have formed an AASM Telemedicine Presidential Committee that will develop resources for members and answer member inquiries so they can provide remote patient care more effectively. I will also be charging our newly created Advocacy Committee to formulate strategies to advocate for sustained and further enhanced policy changes in the post–COVID-19 environment so we can continue to use these important services to provide care for our patients.

CMS policies

CMS also temporarily relaxed numerous other policies in response to the COVID-19 crisis.²⁷ The sweeping changes included waiving requirements for face-to-face or in-person encounters and covering PAP devices based on the clinician’s assessment of the patient, essentially allowing empiric treatment without a diagnostic sleep study or home sleep apnea test. It will be important for us to carefully track quality measures and outcomes to determine whether these changes are broadly beneficial, to prevent any unintended consequences to patients, and to identify subsets of patients who are affected the most.

Big data

Before COVID-19, sleep and circadian researchers already were exploring how big data could be used to identify differences in sleep architecture, pinpoint sleep-related biomarkers that could have clinical relevance, and promote precision medicine in the management of sleep disorders.²⁸ A global phenomenon such as COVID-19 raises new and intriguing questions about the potential of big sleep data. Can consumer sleep technology devices detect measurable changes in sleep behavior across subpopulations during the life cycle of a COVID-19 infection? More broadly, can these devices identify societal changes in sleep behavior during large-scale home confinement? Perhaps most intriguing: Could we identify signatures of COVID-19 infection in asymptomatic people by leveraging artificial intelligence and machine learning algorithms to analyze PAP adherence data or data from wearable sleep trackers? These are just a few of the questions that sleep and circadian scientists may be able to tackle in the months ahead.

CONCLUSIONS

AASM leaders have anticipated that disruption is coming in sleep medicine,²⁹ although COVID-19 certainly was not the disruptor that we were expecting. Its surprising arrival and blunt force have taken an enormous toll on population health and the world economy. As we respond to and recover from this pandemic, it is important that we also cultivate a mindset of preparedness, hope, and flexibility. The future will bring more unexpected challenges, so the lessons we learn today will be crucial in equipping us to better serve our mission and improve lives by advancing sleep care and enhancing sleep health.

DISCLOSURE STATEMENT

Upon completion in June 2020 of his term as the 2019–2020 American Academy of Sleep Medicine president-elect, Dr. Ramar will become the 2020–2021 president.