What’s next now that the WHO has declared a COVID-19 pandemic?

Lauren Vogel

doi:10.1503/cmaj.1095855

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Delirium in Hospitalized Older Adults during the COVID19 Pandemic
Maanit Kohli [MD]

Posted on: 12 April 2020
Hookah smoking and COVID-19: Call for Action
Skand Shekhar [MD] and Fady Hannah-Shmouni [MD]

Posted on: 06 April 2020

Posted on: (12 April 2020)
Page navigation anchor for Delirium in Hospitalized Older Adults during the COVID19 Pandemic
Delirium in Hospitalized Older Adults during the COVID19 Pandemic
Maanit Kohli [MD], Internal Medicine Physician / Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai
Delirium is an acute confusional state characterized by an alteration of consciousness with deficits in attention and is associated with poor outcomes1,2. Older age, dementia, and functional disabilities are predisposing factors, whereas acute illness, drugs, and acute exacerbation of chronic illness are common precipitating factors2. Multicomponent, nonpharmacologic interventions are regularly used to mitigate its risk factors, examples being various re-orientation protocols, cognitive stimulation, early mobilization, amongst others.

With the ongoing Covid19 Pandemic, recent epidemiological studies indicate that middle-aged and older adults are most commonly affected, with older adults being more likely to have severe disease3.

Essential knowledge regarding the treatment of COVID19 is being gained nearly daily. Though the management of the underlying disease remains paramount, older patients remain incredibly vulnerable to develop delirium and its complications. They may require longer hospitalizations, more prolonged ICU stays, while also being kept in isolation. These circumstances make the use of the above-mentioned interventions challenging. Physicians being unable to utilize non-pharmacological alternatives often have to rely on medications like antipsychotics and sedative agents.

Recognition of this potential dilemma is crucial for its prevention. The development of protocols and sharing of knowledge regarding measures used in different inpati...
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Delirium is an acute confusional state characterized by an alteration of consciousness with deficits in attention and is associated with poor outcomes1,2. Older age, dementia, and functional disabilities are predisposing factors, whereas acute illness, drugs, and acute exacerbation of chronic illness are common precipitating factors2. Multicomponent, nonpharmacologic interventions are regularly used to mitigate its risk factors, examples being various re-orientation protocols, cognitive stimulation, early mobilization, amongst others.

With the ongoing Covid19 Pandemic, recent epidemiological studies indicate that middle-aged and older adults are most commonly affected, with older adults being more likely to have severe disease3.

Essential knowledge regarding the treatment of COVID19 is being gained nearly daily. Though the management of the underlying disease remains paramount, older patients remain incredibly vulnerable to develop delirium and its complications. They may require longer hospitalizations, more prolonged ICU stays, while also being kept in isolation. These circumstances make the use of the above-mentioned interventions challenging. Physicians being unable to utilize non-pharmacological alternatives often have to rely on medications like antipsychotics and sedative agents.

Recognition of this potential dilemma is crucial for its prevention. The development of protocols and sharing of knowledge regarding measures used in different inpatient settings may help tackle this obstacle.
Show Less
Competing Interests: None declared.
References
Lauren Vogel. What’s next now that the WHO has declared a COVID-19 pandemic?. CMAJ 2020;192:E349-E350.
1.Joseph Francis Jr M, MPH. 2020. In: Michael J Aminoff M, DSc, Kenneth E Schmader M, eds. Delirium and acute confusional states: Prevention, treatment, and prognosis. UpToDate.
2.Marcantonio ER. Delirium in Hospitalized Older Adults. New England Journal of Medicine. 2017;377(15):1456-1466.
3.Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239-1242.
Posted on: (6 April 2020)
Page navigation anchor for Hookah smoking and COVID-19: Call for Action
Hookah smoking and COVID-19: Call for Action
Skand Shekhar [MD], Section on Endocrinology & Genetics (SEGEN), National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland
Other Contributors:
Fady Hannah-Shmouni, Section on Endocrinology & Genetics (SEGEN)
A hookah (shisha or waterpipe) is a single or multi- stemmed instrument used for smoking various flavored substances such as cannabis, tobacco and opium for centuries and is popular in the Indian subcontinent, the Arabian peninsula, Kenya, South Africa, Turkey, United States and Canada. Across the United States, 2.6 million people smoke hookah with a recent mushrooming of ‘hookah bars’ with 100 million hookah-ers globally.^1,2 Comparably, in Canada its high prevalence particularly among young adults is a matter of growing concern.³

Smoking has emerged as an independent risk not only for transmission but also COVID-19 severity.⁴ Similarly hookahs are an ideal mode for transmission and may exacerbate the risk for severe COVID-19 through shared use. They have difficult-to-clean, long pipes and a cold water reservoir, ideal for coronavirus transmission. Further, hookah smoke contains several hazardous chemicals in addition to tobacco that injure the respiratory lining predisposing the smoker to viral infections, tuberculosis and other infectious diseases and the coronavirus is not exception. Though not formally reported, hookah smoking (like e-cigarettes) poses a threat of disproportionately increasing COVID-19 in the youth. Furthermore, MERS-CoV, another coronavirus infection, was also thought to be transmitted by waterpipe smoking.

Several countries have already placed restrictions on hookah use gi...
Show More

A hookah (shisha or waterpipe) is a single or multi- stemmed instrument used for smoking various flavored substances such as cannabis, tobacco and opium for centuries and is popular in the Indian subcontinent, the Arabian peninsula, Kenya, South Africa, Turkey, United States and Canada. Across the United States, 2.6 million people smoke hookah with a recent mushrooming of ‘hookah bars’ with 100 million hookah-ers globally.^1,2 Comparably, in Canada its high prevalence particularly among young adults is a matter of growing concern.³

Smoking has emerged as an independent risk not only for transmission but also COVID-19 severity.⁴ Similarly hookahs are an ideal mode for transmission and may exacerbate the risk for severe COVID-19 through shared use. They have difficult-to-clean, long pipes and a cold water reservoir, ideal for coronavirus transmission. Further, hookah smoke contains several hazardous chemicals in addition to tobacco that injure the respiratory lining predisposing the smoker to viral infections, tuberculosis and other infectious diseases and the coronavirus is not exception. Though not formally reported, hookah smoking (like e-cigarettes) poses a threat of disproportionately increasing COVID-19 in the youth. Furthermore, MERS-CoV, another coronavirus infection, was also thought to be transmitted by waterpipe smoking.

Several countries have already placed restrictions on hookah use given the public health risks of COVID-19 transmission it poses. In Cario, Egypt a recent ban on hookahs was imposed with the cities of Abu-Dhabi and Dubai in UAE, also banning hookah use. In Canada, the legality of hookah varies by province - it is illegal in Ottawa and parts of Alberta but it remains legal in other provinces.

Noting the recent WHO advice⁵ on COVID-19 and hookah use, we suggest that hookah or waterpipe smoking should be regulated to ensure restriction of COVID-19 transmission through hookah smoking.
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Competing Interests: None declared.
References
1. Prevention CfDCa. Tobacco Product Use Among Adults — United States. November 9, 2018 2017.
2. Akl EA, Gunukula SK, Aleem S, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health. 2011;11(1):244.
3. Minaker LM, Shuh A, Burkhalter RJ, Manske SR. Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey. Cancer Causes Control. 2015;26(6):831-838.
4. Liu W, Tao Z-W, Lei W, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J. 9000;Publish Ahead of Print.
5. Mediterranean WHOROftE. Tobacco and waterpipe use increases the risk of suffering from COVID-19. Tobacco Free initiative. 2020. http://www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html. Acc