Introduction
Coronavirus disease-19 (COVID-19) emerged abruptly with the report of first cases in Wuhan, China in December 2019. The increasing number of cases have been notified across the world in a short time due to its ability of rapid spreading. This quick global transmission urged the World Health Organization (WHO) to declare a pandemic on March 11, 2020 (1).
From its start, COVID-19 displayed peaks and decreases in incidence resulting in COVID waves. The first wave of the pandemic caught most of the countries unprepared to this highly demanding situation. The first wave was noted between March 2020 July/August 2020 with the ancestral variant (2-4). Until May 2020, the pandemic exerted a high negative impact on health and after that, negative effects declined from June 2020 onwards. The second wave of the pandemic begun at the end of August 2020. As a result of the rapid spread, there had been nearly 25 million confirmed cases and nearly 800,000 deaths as of 30 August 2020 (5).
Advanced age itself and underlying medical comorbidities such as morbid obesity, hypertension and cardiovascular disease are independent risk factors for severe COVID-19 (6-8). In many countries older adults were the most severely affected by the pandemic and every country developed its own strategy to fight it according to their socio-demographic characteristics, healthcare systems and resources.
From the beginning of the pandemic, EuGMS has tried to provide advice and instructions regarding adequate protection and medical care for older patients. The e-congress in 2020 has been thematically dedicated to COVID-19 and contributed to better awareness of many aspects of this disease. In this congress, a specific session was dedicated to identification of different approaches during the first wave of the pandemic (between March 2020-August 2020) (2) among Global European Initiative (GEI) countries that include active members of the EuGMS coming from Eastern Europe, South-Eastern Europe, the Balkans and Mediterranean countries (Hungary, Lebanon, Russian Federation, Slovenia, Tunisia and Turkey). The session named “Prevention and treatment - COVID-19 patients from community to hospitalization across the GEI countries” aimed to present the experiences and approaches in different countries. This comparison could provide an overview of different approaches and enable individual countries to analyse their own approaches. This might provide different perspectives to the countries and might help to reduce the adverse impact of the disease in older adults. Our objective in this paper was to outline these approaches across six GEI countries -Hungary, Lebanon, Russian Federation, Slovenia, Tunisia and Turkey- that were involved in the session.
Methods
During the EuGMS e-congress GEI-COVID meeting, a session was organized with the participation of GEI countries from various regions around the globe, including Eastern Europe, South-Eastern Europe, the Balkans, and the Mediterranean. The aim of this session was to address inquiries and provide insights in four specific areas related to COVID-19 (i) The diagnosis protocol of COVID-19 for older adults, (ii) The hospitalization protocol for older adults with COVID-19, (iii) The governmental and social coping strategies against the pandemic and geriatricians’ roles, (iv) Protection for the nursing home residents.
In this comparative observational study, six GEI countries (i.e., Hungary, Lebanon, Russian Federation, Slovenia, Tunisia and Turkey) actively participated in the 2020 EuGMS e-congress with a shared eagerness to address inquiries and contribute to a deeper comprehension of pandemic hotspots, particularly with a focus on older adults.
To This End, the Following Four Questions Were Formulated:
Question 1. Which protocol was followed from the beginning of the pandemic to diagnose COVID-19 for older adults? Did this protocol differ from the one applied in younger adults?
Question 2. Which protocol was followed from the beginning of pandemic to hospitalize older adults with COVID-19? Did this protocol differ from the one applied in younger adults?
Question 3. What is the situation in your country for older adults now? What are governmental and social strategies to cope with the pandemic (the trend of the incidence, lock-down, screening.. etc.)?
Question 4. What are general governmental regulations applied to protect nursing home residents? How effective or not effective was the protection taken of older adults living in nursing homes?
Each question has been divided into specified sub-sections (Appendix 1). First, the answers of Turkey were outlined and sent to each country representative as a model, aiming to obtain a standardized way of answering to analyse similarities and differences across the involved countries. Following collection of responses to the standardized questions, table were created to present comparisons between countries. The reviewed answers were sent to the countries for their perusal and careful consideration.
The presenting members were informed to answer these questions regarding the time between March-August 2020 which represented the period of the first wave of COVID-19 pandemic (4).
While answering the questions, countries took the declarations of the Ministry of Health, Ministry of Family and Social Services, World Health Organization, Disaster Management Centers and various official social welfare centers as references.
Results
The country representatives were asked to answer the standardized questions at the beginning of October 2020 and the answers were collected until the end of November 2020.
As a general overview, the diagnostic protocols were same in many aspects. Of note, atypical symptoms suggestive COVID-19 were considered on management of older adults in all countries. While the hospitalization protocols and intensive unit care transfer criteria for older adults did not differ from those for young adults, age itself was considered as a criteria for hospitalization in most of the countries. In general terms, governmental and social coping strategies for older ages against ongoing pandemic aimed to limit their social contact. The basic suggestion was “stay at home” warning. The lock-down was applied only for some local areas or specific age groups by few countries. In a word, nursing homes restrictions and precautions stepped up to ensure residents are protected from pandemic.
The answers to the questions are outlined in Table 1, Table 2, Table 3a, Table 3b, Table 4a and Table 4b.
Discussion
We provided comparative overview of the actions against COVID-19 pandemic which were applied by six of the GEI. The six participated countries initially followed the general WHO recommendations. The rapid spread ability of the virus has increased the importance of early governmental measures in order to help to reduce the spread of the disease and negative consequences. Therefore, it is very understandable that these six countries rapidly have implemented their own protocols. They were asked 4 main questions and lots of sub questions about the precautions and steps they took against the virus especially regarding the older adults. Generally, the answers to many of the questions were similar, however, it differed in some points depending on national health system, social-economic conditions and governmental planning.
Applied diagnostic protocol and indications for COVID-19 testing: The diagnostic algorithm for detection of acute COVID-19 based on clinical experiences and laboratories was provided by the WHO (9). This algorithm has been updated from the beginning of the pandemic periodically. Symptoms of COVID-19 infection got a strong focus in diagnosis (fever, dry cough, anosmia and dysgeusia) and consideration of physical examination (bronchitis, pneumonia) had an important place. Hungary, Lebanon and Tunisia have followed very similar paths WHO’s diagnostic flow diagram for detection of acute severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection in the patients with clinical suspicion for COVID-19. The diagnostic flow diagrams were created by all countries and had very similarities (Appendix 2).
There are number of factors brought about differences between these six countries. First, differences between these countries’ strategies might depended on inadequate knowledge about the virus at the beginning, including incubation period, obscurity of the asymptomatic cases. Second, the social-economic condition and the health care systems of the governments.
There were no significant differences in diagnostic protocols between older adults and younger patients between participated GEI countries. Although COVID-19 is a new virus, researches have shown that the severe outcomes of the virus are mostly presented in the older adults (Appendix 3) (6,10). Studies demonstrated that atypical presentation is common in older adults which may also result in worse outcomes such as organ damages requiring earlier management and special treatment (11,12). Development of special COVID-19 diagnostic indications for the older adults is an urgent need. Moreover, it has been emphasized by the British Geriatrics Society that an index or criterion of suspicion for atypical presentation of COVID-19 in older adults is needed. There were some warnings regarding diagnosis of older adults in diagnostic protocols applied by the GEI countries involved. In Tunisia, the unusual presentation such as falling, delirium, sudden loss of autonomy and hypothermia were also considered when assessing the necessity of real time-polymerase chain reaction (PCR) in older adults.
It would be greatly beneficial to establish guidelines on specific diagnostic criteria for the evaluation of older adults. This approach could aid in early identification of COVID-19 at the old age and providing closer follow-up for them, taking isolation measures and potentially decrease the adverse outcomes of the disease and the degree of socio-economic burden.
Protocol following hospitalization for older adults with COVID-19: At the beginning, the rapid spread and unknowledges of the virus put a major pressure on the healthcare system. Not every country in the world was adequately prepared to handle the crisis. Each country continued to develop protocols for hospitalization in addition to the WHO for the detection and follow-up of COVID-19 patients who had to be hospitalized to prevent health system collapse.
The hospital admission management in six GEI countries involved in the study was based on the point to protect health care system and there could be differences in the proper procedure of the diagnostic chain because of the differences of the structure of their systems. Hospital admission for the patient with COVID-19 was mainly focused on vital signs abnormalities, comorbidities, organ failures and low O2 saturation in all involved countries (Appendix 4). Common criteria were the low oxygen saturation with different limits for the all-participant countries. Slovenia declared that there were no written admission criteria. Pneumonia and infiltrates were accepted as admission criteria in Hungary, Lebanon and Turkey. Lebanon, Tunisia and Turkey regarded comorbidities as admission point. Laboratory findings (lymphocyte <800/mm3, CRP> 40 mg/L, ferritin >500 u/mL, D-dimer >1.000 ng/mL) which were supporting COVID-19 were applied as criterion in Lebanon and Turkey. Additionally, unlike all participant countries, delirium was accepted as criteria in Tunisia. In Tunisia, frailty screening and social assessment was routinely preformed (SEGAm) in this age group for the decision taking for admission to the hospital. It was updated by the end of the 1st wave of the pandemic and no longer were considered.
Malnutrition and impairment of oral food intake were considered at the hospitalization of patient in Turkey. Only Turkey declared changes on the hospitalization protocol by August 2020 in order to ensure the sustainability of the health care system.
It is known that age itself is a greater risk factor for negative outcomes during illnesses. As it was recognised as criteria for admission in Lebanon (>50 age), Tunisia (>65 age), Turkey (>50 age). There was no additional protocol specified for the older adults in any countries.
As a course of COVID nature, it can cause severe symptoms which require intensive care unit (ICU) admission or palliative care. The ratio may vary according to population, culture and local ICU admission criteria. ICU admission has been recorded in a wide range between 5 and 90 percent as per different countries (8,13,14). The admission to the palliative care due to severe COVID-19 was not the first option among the participating countries. Generally, all critically ill patients and those who met the ICU admission criteria regardless age were admitted to the ICU. While direction of older adults with serious disease for palliative care transfer rather than ICU was not considered in all countries. Despite that, Slovenia declared if locale admission criteria have not been met it was an option for the older adults.
Assessing age-related factors and atypical infection symptoms such as confusion, lethargy, delirium, impaired oral food intake, and deterioration in older adult could prove advantageous as part of hospitalization criteria. Action taken by these countries, along with the global publications will shape the criteria for the future pandemic situation.
Governmental and social coping strategies: Globally increasing cases of COVID-19 has forced governments to take strict prevention in order to minimize the public health effects. The timing and severity of the measures taken against pandemic might had created differences in incidence between the countries. As Russian Federation had the higher incidence between March and August, Hungary had the lowest at the same time among the participant countries (Table 3a). Each country has determined the fundamental coping strategies, according to social and economic background of the country. Some of the coping strategies were provided by the government, while some were supported by the social organizations. As the course of the COVID-19 has revealed its most devastating effects on the older people. Incidence of the affected older adults was non-available in most countries while Slovenia reported as 22%. Research has shown that age was the most important factor for exposure to the virus (6), thus the governments measures were more directed towards older adults. Most important imposed governmental precaution was lock-down. At the duration of March 2020-April 2020 general lock-down was applied in most countries (Hungary, Lebanon, Russian Federation, Slovenia, Tunisia) while Turkey had applied lock down only for over 65 years of age in all week days and for the younger just at weekends. In the period of June 2020-August 2020, lock-down was lifted in most countries. At this time mostly age specific lock down was continued in some countries (some region in Russian Federation and for older with frailty and chronic diseases in Tunisia between May and June).
Most of the countries have formed coping strategies that prevent the spread of the new coronavirus. Various COVID related coping strategies such as TV spots, leaflets, telemedicine consultation, food delivery, bill payment assistance, supplemental payment, safe medication purchase, prevention of accumulation above certain numbers, interregional movement restriction were implemented by participating countries (Appendix 5). An increasing number of countries had made wearing face masks mandatory or strong recommendation in public areas all around the world despite WHO’s early advices regarding use of masks published on 6 April (15). Although it was mandatory only in closed public areas in Hungary, there was masks requirement in outdoor and indoor areas in other five countries.
There were curfews in Hungary, Lebanon, Slovenia and Turkey. In Turkey, there was an age specific curfew for those over 65 age and for under 18 ages. Generally, in order to protect older adults, a state-controlled timespan determined for the people above the age of 65 as they only were allowed to go in shops, markets, supermarkets and pharmacies. In Russian Federation, staying at home was a recommendation for older adults. In Lebanon and Slovenia, there was no age specific restriction in this field. Some countries allowed citizens to leave homes only for work or to food stores/markets, pharmacy, sport activity (alone), or dog walking. As priority was given to serving older people at supermarkets and food stores in Russian Federation.
The guideline and booklet were published in Lebanon, Tunisia and Turkey by the geriatricians or psychogeriatricians, specifically targeting to help older people cope with the stressful situation and to clarify the questions about COVID-19. The Alzheimer Association of Lebanon helped dementia patients and their relatives in online way. Besides that, Tunisia was the only country that geriatricians issued a guideline concerning the management of patients of old age with COVID-19.
Differences and similarities between coping strategies among these six countries have drawn attention. A common approach observed among the countries was implementation of government-imposed curfews and lock-down measures to ensure that older individuals remained at home and minimized their social interactions. The variations mostly were depended on the social construction within each country. Commentary regarding the advantages and disadvantages of all coping strategies is early at this stage. In addition to the positive effect of reducing the impact of the pandemic, older adults may also experience certain physiological and psychological effects.
Regulations regarding nursing homes: Seniors living in nursing homes were more vulnerable with a higher risk for infection and adverse outcomes because of living close by each other and having more comorbidities (16). Hence, the governments of the most countries published guidelines or booklets regarding the provision of the nursing homes’ seniors care during the pandemic. As stated in guideline published by WHO’s for- long-term care facilities (17), nursing home measures in several countries were also based on recognition, personal protection, isolation and source control.
It is known that infections are the very common cause of acute hospitalization among nursing home residents (18), the most important one is pneumonia (19). The compliance with hygiene rule, such as hand washing or following infection control measures, are also less than optimal in nursing homes (20). Daily activities of nursing home residents are carried out in groups. Considering all these factors, the control of the pandemic was difficult in nursing homes. After the emergence of the COVID-19, the governments of several countries took strict measures in order to protect vulnerable home care residents. The most important implemented step of the six countries was making restriction of external visits. Additionally, new admissions were postponed in all countries, while Lebanon required PCR and Russian Federation set 1-week quarantine rule in separate part of the building for new admission to the nursing homes. Many different precautions were implemented to protect nursing homes in six GEI countries (Appendix 6). Additionally, Hungary, Russian Federation, Tunisia and Turkey created staff specific transport services. A 14-day shift system imposed for the staff in nursing homes in Turkey is a different remarkable measure in comparison with the other countries. Regular PCR tests were performed in Hungary, Lebanon (in some nursing homes), Russian Federation and Turkey, while Tunisia performed PCR in case of the suspected COVID cases and Slovenia declared no regular PCR testing in nursing homes. All countries referred the residents to hospital when necessary and those who just need isolation was isolated in hospital. For those who do not need to be isolated, isolation rooms were prepared only in Tunisia. The lack of knowledge made countries to appoint coordinators in nursing homes to adopt close management, such that persons were nominated in participating countries except Lebanon. The most effective measurements to protect nursing homes were denial of visitors and increased disinfection regulations.
Hungary declared that the management strategies were effective and the Hungary’ protection policy was one of the most successful in Europe. Lebanon stated the measures were not effective due to the lack of obligatory regulations in their country. Russian Federation announced not any cases spreading in nursing homes. Slovenia expressed that the precautions were not effective enough to prevent cases spreading in all nursing homes. These might show the importance of regular PCR and keeping staff away from outside contact. Strict measures were told as effective however with some negative socio-psychological effects in Tunisia and Turkey.
Conclusion
The whole world was unprepared for a pandemic like COVID-19. All countries have created their own measures against pandemic in order to protect people and their health care system. However, COVID-19 have had significant impact on human life. Since the older adults are the most vulnerable in society, they were affected deeply. According to the answers of the involved countries we can understand that some special precautions were taken for older adults among different countries. In summary, the responses from all participating countries regarding the management of COVID-19 in older adults exhibited a remarkable level of similarity in multiple aspects, with only minor variations observed among different countries. The global impact of COVID-19 and the preventative measures taken by different countries will serve as a guiding framework for future planning in the event of such a disaster. The valuable steps taken by different countries and interpreting their impact against the pandemic will contribute to enhancing global preparedness.
Acknowledgements
The authors would like to express gratitude towards Dr. Gülistan Bahat, Dr Athanase Benetos and Dr Mirko Petrovic and Dr. Serdar Özkök for their invaluable contribution in editing of the manuscript.
Ethics
Peer-review: Externally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: Ş.G., Concept: Ş.G., A.L., Design: Ş.G., Data Collection or Processing: Ş.G., A.L., A.A., S.B., K.E., R.G., M.S.H., I.K., G.V., Analysis or Interpretation: Ş.G., A.L., Literature Search: Ş.G., A.L., A.A., S.B., K.E., R.G., M.S.H., I.K., G.V., Writing: Ş.G.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.