Covid-19 Tanısı ile Hacettepe Üniversitesi Erişkin Hastanesinde İzlenen Hastaların Hastalık ile İlgili Risk Algıları ve Yaşam Tarzı Değişikliği Planlarının Değerlendirilmesi

Abstract

ABSTRACT Zarnishanov Kamil. Evaluation of Disease-Related Risk Perceptions and Lifestyle Change Plans of Patients Followed Up at Hacettepe University Adult Hospital with the Diagnosis of COVID-19. Hacettepe University School of Medicine. Thesis in Internal Medicine Department, Ankara, 2021 Introduction: Coronaviruses are a family of viruses known to cause both respiratory and intestinal diseases in various animal species and humans. It is known that these viruses can cause mild infections, as well as extremely severe infections such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) (1). On December 31 2019, the World Health Organization (WHO) China Country Office reported cases of pneumonia of unknown cause In Wuhan city of Hubei province. On 7 January 2020, it was determined that a new coronavirus, which was not detected in humans before, caused the disease. It was found that there is a close similarity between this new virus and SARS CoV which made an epidemic in 2002, and due to this similarity, the originally named 2019-nCoV was changed to SARS-CoV-2. The disease caused by SARS-CoV-2 has been defined as Coronavirus Disease 2019 (COVID-19) (1). Despite global precaution and quarantine efforts, the incidence of the virus has gradually increased and was declared as a pandemic by WHO on March 11, 2020 (2). Initial data showed that all age groups are at risk for SARS-CoV-2, with COVID-19 being generally reported to be more likely to occur in people with advanced age and / or comorbidities. (3) In the study where descriptive and cross-sectional analysis of all cases diagnosed in China in the initial period of the pandemic was made, it was seen that the case fatality rate could change dramatically with age and accompanying comorbidities. In the study including 72,314 patients, it was stated that there were 889 asymptomatic patients and the case-fatality rate was found to be 2.3%. While the case fatality rate was less than 0.5% up to the age of 50, the case fatality rate was 1.3% between the ages of 50-59, 3.6% between the ages of 60-69, 8% between the ages of 70-79 and 14.8% between the ages of 80 and over. While the highest case-fatality rate is observed in patients with cardiovascular disease (10.5%), the case-fatality rates are significantly higher in the presence of diabetes (7.3%), chronic respiratory disease (6.3%), hypertension (6.0%) and cancer (5.6%), respectively. (4) Obesity and smoking were also associated with increased risk in subsequent studies. (5) Chronic diseases; They are diseases that progress slowly, last for 3 months or longer, are caused by more than one risk factor, usually have a complicated course and affect the quality of life of the person. These diseases, which are risk factors that increase the case fatality rates in the COVID-19 pandemic, have been the leading cause of death in all developed or developing countries all over the world. (6) In fact, chronic diseases have created a silent global pandemic, paving the way for increasing the effects of the pandemic with the COVID-19 pandemic. Alcohol and cigarette consumption, physical inactivity and unhealthy nutrition have been identified as modifiable risk factors that need to be urgently tackled to prevent premature deaths due to chronic diseases. (7) Another issue that affects the clinical course and is emphasized a lot is the differences between male and female genders. Mortality rates in the male gender were reported higher in the Chinese and Italian studies. Since chronic diseases are diseases that have a high economic and social burden on the individual and society, there is a need for health policies and effective interventions for the control of these diseases. If the existing scientific knowledge and experience on chronic diseases and risk factors are combined with the opportunities of countries and put into practice, the burden of diseases on society can be reduced significantly. When we look at the clinic of the disease, besides asymptomatic cases, it can be seen in a spectrum ranging from respiratory failure requiring mechanical ventilation to sepsis, septic shock, and multiorgan failure. The severity of the clinical picture is variable in symptomatic cases. Patients may present with mild symptoms or with a rather severe clinical picture such as multiple organ failure. In an article in which approximately 72 thousand cases from China were reported, the clinical picture was mild in 80% of the cases, severe in 15%, and respiratory failure, shock, and multi-organ failure in 5%, with a very high risk of mortality, severe It has been stated that there is a clinical picture Patients who were still hospitalized at Hacettepe University Medical Faculty Hospital with the diagnosis of COVID-19 and those who were previously hospitalized with the diagnosis of COVID-19 in Hacettepe University Medical Faculty Hospital, were discharged and applied to the COVID-19 Monitoring Polyclinic of Hacettepe University Faculty of Medicine Hospital for control purposes were included in this study. After obtaining written consent from the patients that they agreed to participate in the study, the changes they planned to make in the general health status and lifestyle of those who had COVID-19 were questioned using a questionnaire method. With this study, we have produced hypotheses about the impact of COVID-19 disease on general health assessment and the changes it will make in their future lives. The main purpose of the study is to evaluate whether hospitalization due to COVID-19 will lead to behavioral change decisions such as quitting smoking, limiting alcohol consumption, regular dieting, regular exercise, and regular follow-up of chronic diseases to eliminate these risk factors which they are modifiable risk factors associated with both premature death and poor endpoints of COVID 19. Patients and Methods: The research was conducted between February 10, 2021 and May 10, 2021, after the ethics committee approval was obtained. It is planned to collect the data of the patients within the first 2 months (February 10, 2021 - April 10, 2021), and it is planned to analyze and write the data obtained within 1 month after the data collection process (April 10, 2021 - May 10, 2021). Patients who aged 18 and over were still hospitalized at Hacettepe University Medical Faculty Hospital with the diagnosis of COVID-19 and those who were previously hospitalized with the diagnosis of COVID-19 in Hacettepe University Medical Faculty Hospital, were discharged and applied to the COVID-19 Monitoring Polyclinic of Hacettepe University Faculty of Medicine Hospital for control purposes were included in this study. Patients who could not be contacted, could not answer questions, or did not consent to participate in the study were excluded. Among the patients included in the study, those who had positive results of RT-PCR and serological tests such as ELISA or rapid antibody tests, those whose RT-PCR result was negative and whose CT result was typical for COVID-19 or COVID-19 could not be ruled out, were diagnosed with COVID-19. COVID-19 diagnosis was excluded in patients whose RT-PCR results were negative and CT results were reported to be incompatible with COVID 19 or as no sign of pneumonia. The research was planned as a cross-sectional questionnaire study under the main title of observational research. In the first part of the questionnaire, sociodemographic information of the patients such as age, gender, height, weight, marital status, number of children, educational status, job/occupation, chronic diseases, cohabitants over 65 years old and/or having a chronic disease, whether they had pneumonia and influenza (seasonal flu) vaccine and if they were not vaccinated, the reasons were questioned. In the second part, in order to evaluate the risk perception of the patients, their thoughts about why they got COVID 19 disease and their risk factors were questioned. (For example; such as smoking, using alcohol, being overweight, having a chronic disease, not getting vaccinated.) According to the perception of these risk factors, the patients were asked about the changes they want to make in their future lives (such as quitting smoking, limiting alcohol consumption, regular sports and exercise, regular vaccination) and the methods (such as smoking cessation clinics, family medicine) they will apply to make these changes. In the third part of the questionnaire, the smoking history of the patients was asked. In order to determine how the awareness and smoking behaviors of patients diagnosed with COVID-19 will change, the patients were asked about the duration and amount of smoking, the date they last smoked, other tobacco products they regularly use, the presence of a smoker at home, and previous attempts to quit smoking. The Fagerström Test for Nicotine Dependence was planned to determine nicotine addiction in patients with active smokers. The test was first proposed by Fagerström in 1978, what the Fagerström Tolerance Test was, and this test was reconsidered by Heatherton et al. in 1991 and FBNT emerged. Turkish validity of the test Uysal et al.[11] and it was found moderately reliable, and attention was drawn to the questions that needed attention. FBNT consists of six questions and each question is given a different score. The purpose of the test was accepted as determining the nicotine addiction levels of the patients and observing the effect on their smoking cessation behaviors. The purpose of the Fagerström Nicotine Dependence Test was to evaluate the smoking addiction of people who decided to quit smoking after the COVID-19 disease before being referred to the Smoking Cessation Polyclinics. In addition to lifestyle changes, it was also aimed to conduct a General Health Questionnaire (GHQ), which was developed by the patient and adapted to many languages and cultures, especially in primary care, in order to distinguish mental illness in those who had COVID-19 disease. SPSS 23 program was used for statistical analysis. In this study, no additional examinations were made except for the examinations that should be done about the disease of the patients. No additional blood tests were taken, no additional imaging tests were performed. No treatment was undertaken in addition to the standard treatments they were receiving. There was no additional cost for patients. Discussion and Results: The COVID-19 pandemic has emerged suddenly and has affected people of all genders, races and countries indiscriminately. Unfortunately, the prognosis can be poor in individuals with chronic diseases. (3) In fact, chronic diseases have created a silent global pandemic, paving the way for increasing the effects of the pandemic with the COVID 19 pandemic. Alcohol and cigarette consumption, physical inactivity and unhealthy nutrition have been identified as modifiable risk factors that need to be urgently tackled to prevent premature deaths due to chronic diseases. (7) 212 Patients who aged 18 and over were still hospitalized at Hacettepe University Medical Faculty Hospital with the diagnosis of COVID-19 and those who were previously hospitalized with the diagnosis of COVID-19 in Hacettepe University Medical Faculty Hospital, were discharged and applied to the COVID-19 Monitoring Polyclinic of Hacettepe University Faculty of Medicine Hospital for control purposes were included in this study. Patients who could not be contacted, could not answer questions, or did not consent to participate in the study were excluded. Later, 12 patients who did not give their consent, did not accept the study and could not communicate, were excluded, and 200 patients were descended. The patients were classified according to their demographic data, then their thoughts about why they got COVID-19 disease and risk factors were asked with the questionnaire method, and the level of awareness created by the disease was ensured to be understood. In addition, the general health questionnaire was evaluated, as well as the lifestyle changes. When the demographic characteristics of the patients participating in the study were examined, the mean age in our study was 45.61±16.82 while the median age was 37.2 in Turkey. (8) The reason for choosing a higher age population in our study was to see more clearly the effect of chronic diseases that increase in parallel with increasing age, and especially the impact of COVID 19 on the risk perception and general health assessment of patients. As a matter of fact, 72% of the patients participating in our study had 1 or more chronic diseases and 63% were using at least 1 drug. Considering the distribution of chronic diseases of the patients who participated in our study, it was seen that the prevalence of chronic diseases seen worldwide was higher. Although coronary artery disease was present in 168 patients in our study, it was the first among diseases with 41.17%. According to TEKHARF 1990 study; In our country, the prevalence of CAD in adults aged 20 and over is 3.8%, the reason why the prevalence of CAD is higher in our study is that COVID-19 disease is more prevalent in chronic diseases, and patients diagnosed with COVID-19 and have chronic diseases, were followed up in our hospital rather than outpatient follow-up. (9) Thus, patients with chronic diseases were hospitalized and followed up in our hospital and thus included in the study. The same situation was also present in type 2 DM. However, the percentage of patients who stated that they had a diagnosis of HT among the patients participating in the study was seen to be 11.2%, meaning it was lower than the world. This has been attributed to the low awareness of hypertension in the population. Considering previous studies, the prevalence of obesity was high and the prevalence of overweight was similar in our study. However, we were able to say that our patient group was not chosen and we thought to be an example that represents the society and that we are not in a bad place in terms of obesity prevalence. A low percentage of patients diagnosed with COVID-19 with high body mass index are aware of obesity, and statistically a small proportion will only lose weight, diet and exercise after discharge. A significant majority of 146 patients with chronic diseases (81.5%) thought that their chronic diseases caused COVID-19. Although the majority of the patients had chronic diseases and many of them obey the COVID-19 preventive rules such as masks and personal hygiene, it was concluded that they were the general health levels that they thought of due to their chronic diseases in the first place, causing COVID-19 disease. In the interviews with the patients, 63% of the patients stated that they would follow up their chronic diseases more regularly from now on, while 19% stated that they would not continue their follow-up. When the reason for refusal of the patients who refused to follow-up was questioned, it was noticed that there were thoughts that, should stay away from hospitals and healthcare workers, could be described as "Corona phobia" even in the literature. (10) In the second part of the study, it was seen that the majority of patients did not receive pneumococcal and seasonal influenza vaccines before being diagnosed with COVID-19. It has been observed that failure to administer pneumococcal and seasonal influenza vaccines, especially by patients over 65 years of age and with chronic diseases, is thought to cause COVID-19 disease. It was observed that the main reason why the patients were not vaccinated was that they had problems in obtaining the vaccine, especially in the pneumococcal vaccine. This problem can be solved by improving health policies. In the second place of patients not being vaccinated, almost one-fourth – one-fifth (21.77% and 23.61%) of patients do not know that they should be vaccinated. The solution to this social unawareness is especially through the physicians in the primary health care institutions. Among the third and fourth most common causes of the patients who did not receive the vaccine in both vaccine groups, there is not knowing whether the patients are in the risk group or not, and thinking that the vaccine does not work. The fifth most common reason is the possible side effects of the vaccine, which is similar in both groups (4.83% - 4.86%). However, in the latest guidelines, vaccines are considered to be protective because the side effects of vaccines are maximum 2%, including the mildest and most common side effects (11). Again, as it will be seen in the second part of our study, it was seen that the majority of the patients (78% flu, 83% pneumococcal) would get their vaccinations after they were diagnosed with COVID 19 and discharged. The reason that increased this awareness and willingness to be vaccinated was the fact that the vaccine is currently seen by patients as a concrete pharmacological/immunological protection method and solution, apart from masks, social distance and hygiene. In addition, knowing that the side effects of the vaccine are lower than the side effects of other treatments whose effectiveness has not been proven (favipravir, glucocorticoid ..) were also seen to affect the decision of the patients to have the vaccine. The percentage of patients who are hesitant to get vaccinated is 11% for the pneumococcal vaccine and 18% for the seasonal flu vaccine. The percentage of those who absolutely refused the vaccine was still around 6% in the pneumococcal vaccine and 4% in the seasonal flu vaccine. In this study, it was pleasing to see the positive effect of interviewing patients, especially on undecided patients. They stated that although 54% of the patients had COVID 19, they would have the COVID 19 vaccine. From the first days of the pandemic, it was understood from the answers to the questions asked about mask and hygiene, which are two of the 3 main components of protection from COVID 19, that the majority of patients pay attention to these two protection measures. However, although the vast majority of patients follow the rules, they do not see that non-compliance with these rules causes them to get COVID-19 disease. When we look at the data, 12% of the patients think that the reason for not complying with the hand washing and hygiene rules, 84% of the patients think that this is not the factor that causes them to catch the disease, despite complying with the hand washing and hygiene rules. Despite these data, the fact that the majority of the patients stated that they would comply with the hygiene and mask-related measures was found interesting at first, but the information that the COVID 19 disease, which currently does not have a definite specific treatment, can be prevented by following the mask and hygiene rules, which is considered as the absolute primary protection method, by the physicians and during the hospitalization. It was thought that this awareness was created by telling the patients through mass media and media after discharge. It has been observed that there will be a significant increase in the percentage of personal hygiene and mask wearing after discharge, and the disease process has a great impact on patients in this regard. According to the data, 98% of the patients stated that they would/will start to obey the hand washing and hygiene rules more. In addition, 76% of the patients stated that they wear or will continue to wear masks. Although it was thought that the majority of the patients were forced to enter crowded environments and their profession could cause the COVID-19 disease, the prediction that only a small number of them could change their profession, but the majority would not enter crowded environments, except for compulsory situations, due to socioeconomic level and the concern of not being able to find another job was confirmed. It was observed that the disease process had a great impact on patients in this regard. When the smoking status, which is the third subject of our study, was questioned, it was seen that 31.51% of the smoking patients (n=76 patients) strongly thought that getting COVID-19 disease was related to smoking, and 57.85% of the patients partially accepted or disagreed with this issue. The fact that 38% of the patients were smokers and 63.14% of the patients, especially those with one or more chronic diseases, stated that they would quit smoking, showing that the effect of smoking on COVID-19 disease was understood by the society, as in other respiratory diseases. The smoking rate of the patients participating in the study was above the Turkey average (23.8%) (12). This confirmed the hypothesis that smokers are more likely to have COVID-19 disease. It was observed that the relationship between alcohol and COVID-19 in the society is less known than cigarettes, just like cigarettes, and indecisive ideas are more prominent. However, it was thought that 13,79% of patients who still consume alcohol, unlike cigarettes, said that they would quit alcohol, and that the relationship between COVID-19 and alcohol did not create a significant awareness in patients. In addition to lifestyle changes, a General Health Questionnaire (GHQ) was also conducted in those who had COVID-19. It was observed that GSA scores increased with the age of the patients. It was observed that the incidence of mental problems was higher after COVID-19, especially in individuals aged 65 and over. In addition, a similar correlation was found with the number and severity of chronic diseases. The relationship between the state and trait anxiety scores of the individuals participating in the study and their marital status and education level was found to be statistically significant. It was observed that the level of anxiety increased after COVID-19, especially in widowed, divorced, illiterate or primary school graduates, and in patients who did not have individuals or children over the age of 65 at home. Similarly, in the literature, we confirmed our hypothesis about the effect of COVID-19 disease on general health assessment and the changes it will make in their future lives with this study. Combining data with different centers will provide more valuable information on COVID-19 disease and general health activity. References: 1. Study claiming new coronavirus can be transmitted by people without symptoms was flawed. 2020. Availab- le from: https://www.sciencemag.org/news/2020/02/ paper non-symptomatic-patient-transmitting-coronavi- rus-wrong. 2. Coronavirus disease 2019 (COVİD-19) Situation Report – 51 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311- sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10 3. Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol. 2020;92(4):441‐447. doi:10.1002/jmv.25689 4. Surveillances, Vital. "The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020." China CDC Weekly 2.8 (2020): 113-122. 5. Wang D, Hu B, Hu C, etal . Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus–Infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9. 10.1001/jama.2020.1585 32031570 6. Global Health Observatory (GHO) data Premature NCD deaths. Situation and trends. https://www.who.int/gho/ncd/mortality_morbidity/ncd_premature_text/en/ 7. Noncommunicable Disease ande their risk factors. Time to deliver: report of the WHO İndependent High Level commission on Noncommunicable Disease https://www.who.int/ncds/management/time-to-deliver/en/ 8. Adrese Dayalı Nüfus Kayıt Sistemi Sonuçları, 2020 – TÜİK https://data.tuik.gov.tr/Bulten/Index?p=Adrese-Dayal%C4%B1-N%C3%BCfus Kay%C4%B1t-Sistemi-Sonu%C3%A7lar%C4%B1-2020-37210&dil=1 9. Türk Erişkinlerinde Kalp Hastalığı ve Risk Faktörleri (TEKHARF) 2017 ONAT - TEKHARF-2017.pdf (tkd.org.tr) 10. Psychiatric Aspects of Coronavirus (2019-nCoV) Infection - Psychiatric Aspects of Coronavirus (2019-nCoV) Infection | Iranian Journal of Psychiatry and Behavioral Sciences | Full Text (kowsarpub.com) Keywords: COVİD-19, Chronic Disease, Cigarette General Health Questionnaire