The issue that has come to define the present doctor–patient relationships at most
levels of chronic health care, beside the scale of public health issues that has emanated
from it, is the coronavirus disease of 2019 (COVID-19) pandemic. While this has the
potential to effect everyone worldwide, its impact on persons with chronic health
conditions is being increasingly recognized in terms of challenges in consistency
of not only health care delivery but also managing emergent concerns. Persons with
epilepsy as well as their families/caregivers and the health care providers face further
consequences of the pandemic. Thier risk of contracting the virus compounds with emergency
room (ER) visits or hospital admissions. COVID-19 is thus proving to be the scourge
of persons with chronic health care conditions.
The numbers of cases of COVID-19 are being increasingly reported from many resource-limited
countries, with India and the subcontinent as a whole emerging as a hotspot of infection
after making a reasonable start in terms of initial control of the infectivity rate
of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). “Unlocking” seems
to have exponentially increased the rate of transmission of the virus, with the lockdown
expected to have a preemptive role in preventing a burden on intensive and clinic-based
or indoor health care service providers. Our current health care systems are likely
to encounter tremendous stress with the massive rise in the number of infected cases
despite the attempts to improve the available health care infrastructure by the Centre
and States. Telemedicine services have emerged as an important tool, which, however,
remains inaccessible to patients of the lower socioeconomic strata. Medication online
delivery systems are still to be in regular use in towns and villages with logistic
challenges in prescription acquisition and purchase to compound the stigma already
attached to epilepsy in addition to compliance issues with regard to treatment. Maintaining
a regular supply of antiepileptic drugs (AEDs) is a paramount concern given the hesitation
on the part of many pharmacies to issue AED based on prior prescriptions and mandating
updated prescriptions for the same.
These issues pose considerable yet surmountable challenges to epilepsy care providers
who may also be redeputed to shoring up pandemic services especially in public health
setups. One has to anticipate the long-term effects of the pandemic on epilepsy care
in terms of delays into investigation and referral, as well as management of chronic
epilepsy, especially the drug-resistant forms, which may be medically managed by timely
appropriate AED dose adjustments or be surgically remediable. This is likely to widen
the treatment gap, thereby making it paramount that general physicians and regional
neurologists take over the onus of investigating, managing, and initiating prompt
referral through telemedicine or online networking with tertiary or quaternary referral
centers. In India, up to 30 to 40% of epilepsy cases in children and adults may be
due to the consequence of perinatal insults, parasitic, and other infections, with
COVID-19 also associated with a potential of meningoencephalitis, including acute
necrotizing hemorrhagic encephalitis and hypoxic encephalopathy, with resultant presentation
as acute symptomatic seizures.[1] In the elderly with the potential neglect of noncommunicable diseases such as cerebrovascular
disorders, diabetes, coronary artery disease, chronic renal, and hepatic dysfunction,
presentation of patients with encephalopathy and acute symptomatic seizures are also
likely to compound and neurological services will have to be geared up for this eventuality.
Immunizations against infections may also be delayed, which can lead to a rise in
bacterial/viral infections among children compounding the risk of central nervous
system complications. This is a result of the fact that preventive measures are likely
to fall behind during this pandemic due to the lack of resources as well as fear in
the community with regard to travel for access to health care. The high prevalence
of communicable diseases such as HIV (human immunodeficiency virus) infection, tuberculosis,
malaria, dengue, and cysticercosis will also provide another element to the strife
especially among the lower socioeconomic strata who are already crippled by restrictions
imposed in afflicted cities and towns, unemployment, and substance abuse. Although
most of these patients do not have epilepsy, they have a higher risk of delayed presentation
and consequent morbidity and mortality, as well as drug resistance, and health care
providers will have to brace for a surge in neurological sequelae as well as presentations
of epilepsy in this group of patients with communicable disorders. Active surveillance
by the existing public health machinery for these disorders is paramount to prevent
a systematic neglect as well as an explosion of these cases during and after the pandemic.
Recent recommendations of a multinational group of experts involved in epilepsy care
are very pragmatic.[2] Emphasis ought to be placed on delivery of epilepsy care to the doorstep using internet-based
or telecom-based telemedicine or smartphone-based hospital-sourced services as much
as possible to mitigate the risk of exposure both ways, which is likely during visits
to consulting chambers, outpatient clinics, and ERs. It would be desirable for each
patient to have an individualized emergency rescue plan (e.g., midazolam through buccal/nasal
routes, rectal diazepam, or oral clobazam). The technique for administration as well
as helplines for ambulances or paramedical care in the event of lack of cessation
of seizures within 5 minutes should be accessible. Viral polymerase chain reaction (PCR)-based
testing facilities should be readily available in centers catering to care of children
with fever-provoked seizure exacerbations, febrile status epilepticus, and Dravet
syndrome as the child and guardian will have to be tested during ER visits as well
as prior to indoor care in regions where community transmission is apparent. Concerns
of asymptomatic carrier rates of SARS-CoV-2 mandate sentinel surveillance strategies
of health care workers as well as testing of persons planned for prolonged indoor
management including epilepsy surgery. Other aspects with regard to when ER visits
should be sought including situations of prolonged encephalopathy or intolerable AED-related
side effects such as idiosyncratic reactions or drug toxicity should be counselled
beforehand. Emergent airway and respiratory support measures in children/adults with
underlying disabilities or on polypharmacy in view of drug-resistant epilepsy, who
are at a risk of respiratory depression (with an inherent SUDEP [sudden unexpected
death in epilepsy] risk) after repetitive or prolonged seizures, have to be taught.
A regular supply of AED should be made the rule, and repeat prescriptions should be
readily downloadable or medications be supplied for a longer duration than usual,
although needless stockpiling is to be avoided. Patients who access free supply of
medications from health centers need to be either granted an extended supply or seek
door-to-door access through ASHA (Accredited Social Health Activist) workers and other
panchayat support staff. Amidst all the panic, the importance of compliance is to
be reiterated. Unless compelled by situations such as West syndrome, drop attacks,
recurrent admissions for repetitive seizure clusters, status epilepticus, progressive
encephalopathy as in Rasmussen’s encephalitis or epileptic encephalopathy as a consequence
of a potentially surgically remediable syndrome, dynamic interventions that are curative
or palliative can be postponed (e.g., epilepsy surgery). Neuroimaging should also
be delayed unless there are urgent diagnostic or therapeutic decisions to be taken,
for example, new-onset epilepsy unclassified, appearance of neurological deficits,
suspected increase in size of a causative tumor, bleed, traumatic injury, or infective
etiologies. In parallel, diagnostic electroencephalogram (EEG) can be delayed unless
nonconvulsive status epilepticus or epileptic encephalopathies such as West syndrome
and epileptic aphasia spectrum disorders such as continuous spike-wave discharges
of sleep are suspected. At the same time, attempts at AED reduction/cessation ought
to be postponed or reversed till regular monitoring or rescue access is possible.
With psychosocial stress emerging as a key after-effect of the pandemic, the importance
of lifestyle is to be emphasized including avoidance of sleep deprivation, substance
abuse, and promotion of digital hygiene (especially in patients with reflex epilepsy
such as photosensitivity), as well as home-based recreation and relaxation techniques.
This would enable the physician to address comorbidities such as depression, bipolar
disorder, and psychosis.
Telemedicine-based contact, as mentioned previously, will help in addressing anxiety
and management issues of patients and caregivers and instill confidence for further
follow-up. For new evaluations of persons with epilepsy, careful history and smartphone
or home-camera based record of events will be of immense value. Didactic “teleneurology”
services, although requiring a paradigm shift in the attitude of physicians and patients/carers
to enable wider acceptance, should enable reliable assessment of mentation, cognition,
focal deficits, eye movements, gait, and overall disability. Hospitals should frame
policies to reduce exposure of health care workers as well through staff rotas including
that of neurologists and technologists, which will also facilitate contact tracing
and ensure a reserve pool of health care workers. Critical care unit management of
epilepsy emergencies such as status epilepticus has its own share of risks in terms
of airborne spread of infection, and dedicated COVID-19 isolation units distinct from
neurocritical care units are advisable to reduce direct exposure of health care professionals.
Besides social distancing and disinfection policies, establishing boundaries of contact,
promulgating hygiene, and observance of barriers through an effective public and protocol-driven
health care worker education program will be crucial. Establishing predesignated staff
and clinic spaces will facilitate tracing of contacts and minimize disruption should
individual health professionals become infected. In managing status epilepticus, additional
precautions should be undertaken to prevent airborne spread from secretions, as well
as timely decision-making to stepdown units and early but planned discharge to home
care. Despite the constraint of resources, through a concerted effort supported by
state policy, shoring up infrastructure, cooperation between public and private health
care providers, and educating and empowering persons with epilepsy as well as their
carers should enable all stakeholders to circumvent the odds.
In most epidemics, postmortems have contributed greatly toward the elucidation of
the underlying pathophysiology of disease. Similarly, in the COVID pandemic too, despite
the hazards imposed, thanks to a courageous group of pathologists, there is a rapidly
growing body of literature from Italy, United States, Germany, United Kingdom, China,
and so on, demonstrating that the basic pathology is endothelial damage activating
both coagulation and inflammatory cascade, producing microthrombotic pathology and
acute respiratory distress syndrome pathology in the lungs and other viscera. The
ACE2 (angiotensin-converting enzyme 2) that is now known to be the target receptor
for SARS-CoV-2 is expressed in glial cells and neurons in the brain, making it a potential
target of COVID-19. Entry into the brain can occur either through hematogenous spread
or through the transcririform route. Anosmia, hypogeusia, and respiratory failure
have been attributed to the direct involvement of olfactory tracts and brain stem.
Other complications including acute stroke and Guillain–Barre’s syndrome have been
attributed to parainfectious, postinfectious immune-mediated pathology, and hypercoagulable
states. While few report presence of the virus in cerebrospinal fluid, not many have
been able to conclusively demonstrate the presence of the virus in the brain tissues
examined. The relative contribution of virus versus host response in disease causation
remains to be elucidated, and the final answers would need more postmortem studies,
but the emerging understanding of molecular biological and immunological perturbations
has provided insights into the pathophysiology of COVID-19, thereby directing treatment
strategies.
To conclude, the real impact of this ongoing pandemic on people living with epilepsy
will only be known in future. But the nonmedical issues such as those occurring due
to loss of jobs, nonavailability of medications or lack of proper medical consultations
due to lockdown, suboptimal care, poor access to telemedicine for majority of the
cases, postponement of tests or interventions in selected cases, and mental health
issues among others will definitive have a negative effect including widening of treatment
gap for some time.
