As a result of pneumonia cases of unknown origin being reported to the World Health Organization (WHO), a new virus from the coronavirus family was detected at the beginning of 2020. Cases of those infected with this virus were seen on many continents. WHO declared the COVID-19 outbreak on March 11, 2020.1 As of December 31, 2020, 81,477,457 cases had been detected worldwide, with 1,798,120 people having died as a result of COVID-19.2 From the beginning of the process, WHO has been advising countries on how to manage the pandemic. Non-pharmacological interventions (i.e., drugs, non-vaccine methods) have been used at the community level to bring the pandemic under control. In addition, countries have implemented various policies for contact tracing, patient treatment, and early case detection. Countries that have adopted intensive testing and quarantine policies are observed to have been able to keep the number of cases at a relatively low level.3, 4
Turkey has also enacted many measures in order to control the pandemic. Measures such as travel restrictions, school closures, stay-at-home orders for those under 20 and over 65 years old, and general curfews have been applied at the national level. Quarantine, isolation, surveillance, and filiation studies have been conducted at the provincial and district levels.5 As of December 31, 2020, up to 16,000 filiation teams were working in the field with a total of 24,504,567 tests being conducted and 2,208,652 cases being detected.6
COVID-19 Effects on Primary Health Care Services
Access to healthcare is a fundamental human right. However, the COVID-19 pandemic has impacted many people’s access to basic healthcare and exerted pressure on countries’ healthcare capacities. WHO has recommended that healthcare providers primarily focus on containing the pandemic.7 For this reason, many countries have placed limitations on providing preventative and curative health services in other areas. Additionally, there has been a decrease in the delivery of basic health services as a result of curfew restrictions and fewer visits to health institutions. WHO conducted a study that reported 90% of countries to have had disruptions in basic health services.8 This situation has further deepened health inequalities.
Vaccination Services and COVID-19
The fight against vaccine-preventable diseases has been fought for decades. Loosening up on these struggles could cause new outbreaks of viruses more aggressive than the coronavirus. Since the start of the pandemic, organizations such as WHO and Centers for Disease Control and Prevention (CDC) have drawn attention to the disruptions that can occur in routine vaccination services due to the pandemic. Many guides have been published in order to prevent these impediments.9 In the report published on March 26, 2020, WHO additionally recommended that mass vaccination programs be temporarily postponed on the grounds that they may pose a risk by spreading COVID-19.7
Following these recommendations, WHO announced in their report published April 14, 2020, that measles vaccination campaigns had been postponed in 24 countries and polio vaccination campaigns in 37 countries. This means the immunization of more than 117 million children may have been disrupted.10 Newborns who were not able to receive their vaccinations due to the effects COVID-19 had on vaccination services are not included in this number. Children less than 12 months old are known to have a higher risk of dying from measles.11
According to the WHO report published on May 22, 2020, over half of 129 countries had reported their routine vaccination services being disrupted between March and April 2020. At least 80 million children under the age of one are estimated to be at risk in these countries.12 The results from the Indonesia Demographic and Primary Health Survey also support WHO’s results. The study reported the percentage of children between the ages of 12-13 months who’d been fully vaccinated as 58%. 13 According to the latest survey conducted by WHO, 70% of the vaccination services of participating countries were reported to have been disrupted.8
Different causes have been observed for the disruptions in vaccination services. Some parents have not visited health centers due to lack of information, others are afraid of being infected with COVID-19, and others are unable to go outside due to restrictions. Reasons such as travel restrictions and borders being closed have led to difficulties in supplying vaccines and personal protective equipment in countries with low income levels. The fact that many healthcare professionals have been assigned to this field to combat COVID-19 has also been able to cause service disruptions in other health-related areas.12
Progress in controlling vaccine-preventable diseases in all countries threatens to decline due to the measures taken to control the COVID-19 pandemic.14 In light of recent information, WHO has recommended vaccination campaigns to continue wherever vaccine-preventable epidemics are active. All countries have additionally been advised to continue their routine immunization service.7, 15 The official website of the Ministry of Health in Turkey has shared that the required planning has been made for avoiding disruptions in routine vaccination services.16 Apart from this, the triage system has been adopted within the scope of the COVID-19 pandemic measures in family health centers that mainly carry out vaccination services, with the necessary personal protection equipment and disinfectants being provided to healthcare workers.5 Turkey’s rate of routine vaccinations during the pandemic as of December was at 98%.17 Additionally, studies on developing COVID-19 vaccines are ongoing in our country. While 17 different domestic vaccine studies for COVID-19 are going on, the inactivated vaccine candidate in the human trial phase is about to begin Phase II of human trials. Three inactivated domestic vaccines are in Phase I of human trials.18
COVID-19’s Impact on Certain Public Health Issues
According to a WHO report dated August 31, 2020, the diagnosis and treatment of non-contagious diseases during the COVID-19 pandemic are the second most frequently interrupted primary healthcare service. Countries have been determined to have a 69% decrease in the services provided for noncommunicable diseases. Primary healthcare services for pregnancy follow-ups, cancer screenings, and diseases such as diabetes, hypertension, and ischemic heart diseases are reported to have been disrupted.19 According to one study, the 15% decrease experienced over 6 months in pregnancy follow-ups in low- and mid-income countries may result in an additional 12.000 maternal deaths.20 More studies are needed on the long-term effects of the delay on follow-ups for chronic diseases.19
Cancelled appointments are among the main reasons for disruptions in primary healthcare services. According to one survey conducted in the United States, 40% of participants said they had canceled appointments made for routine check-ups for chronic diseases during the pandemic. According to the report published on September 4, 2020, by the research company McKinsey & Company, the cost of deferred health services is estimated to constitute 20% of the additional costs brought to the US healthcare system by the COVID-19 pandemic.21
Disrupted cancer-screening activities are another issue due to COVID-19. WHO published a report stating cancer-screening and treatment services to have been disrupted in more than half of the countries.8 In particular, healthcare disruptions are even more pronounced in low-income countries. However, the report discussed the long-term effects of the disruptions rather than the short-term effects. The formation of hospital capacities’ operational overload is predicted, especially when screening services return to normal.22 Screening activities have been maintained during the pandemic in Turkey, with approximately 3 million cancer screening being carried out in the first 9 months.23
The COVID-19 pandemic has also impacted emergency services. Non-COVID-19 emergency room admissions decreased inversely with increases in the number of COVID cases.24,25 With the situation that emerged in China being identified as a worldwide pandemic in particular, a significant decrease in emergency services was observed in non-COVID-19 admissions.26 One study showed a 40% reduction in applications due to cardiovascular emergencies.27 During the pandemic, elderly people with chronic diseases are identified as especially being at risk, and possible delays in their treatment are predicted. This situation increases the dimensions of the “secondary damages” caused by the epidemic.28
Precaution taken at the social and individual levels during the COVID-19 pandemic in particular have affected the course of respiratory infections. Many respiratory tract infections such as influenza, rhinovirus, and SARS have been reported to be seen less than the previous year as a result of the precautions taken.29, 30 The positivity rate for influenza was 1% between the 40th-52nd weeks of 2020 in Turkey. Children are the main source of certain respiratory viruses spreading in the community. The long-term closure of schools in particular has prevented the spread of these viruses in society. A decrease has been observed in the number of outpatient and inpatient treatments of pediatric asthma cases along with the decrease in the frequency of respiratory tract infections.31, 32
The COVID-19 pandemic has affected public health all over the world with its direct and indirect effects. Alongside most healthcare personnel being assigned to combat the pandemic, deficiencies in medications and devices have also been able to cause disruptions in services. Strengthening and supporting the health workforce in both struggling with the pandemic and maintaining health services is important in this sense.
Responses to the COVID-19 Pandemic
WHO has made many recommendations to ensure that health services are not disrupted. Supporting telehealth services is at the top of these recommendations. Proactively calling all high-risk patients who have no scheduled appointments is important in this context. This can be achieved by increasing the capacity of distance health services.33 According to the WHO report, telehealth practices are only used in 42% of low-income countries. An increase in the use of remote healthcare services has occurred during the pandemic in high-income countries, but their use remains limited.34
Some hospitals, municipalities, and private health institutions in Turkey provide telehealth services. The Ministry of Health has additionally developed telehealth applications in order to meet the healthcare needs of COVID-19 patients during the quarantine process. Turkey has 8,015 family health centers and 26,594 medical units in operation. Employees of family health centers providing primary care perform both follow-ups to COVID-19 cases as well as routine follow-ups to pregnant women and people with chronic diseases by phone. People with needs such as examination requests or vaccinations apply to family health centers. Service delivery is maintained at family health centers by applying precautions in accordance with COVID-19 measures. The rapid adaptation to the pandemic of employees in primary care services has played a critical role in the course of this process. Also, the ability of people with health reports to take their medication without a prescription has prevented the victimization of patients.35
Turkey has taken significant steps affecting the capacity of health services since the beginning of the COVID-19 process. As of December, Turkey’s daily test capacity has increased to 300,000, the number of adult intensive care beds to 20,428, a 69% increase to 40.3 beds per 100,000 people compared to before the pandemic. Regardless of health insurance, COVID-19 diagnostic tests are performed, medications are distributed, and provision of treatment services is provided all free of charge.23 The respirators required by intensive care units are also able to be produced in Turkey. Turkey has achieved serious increases in the number of respiratory devices during this period. The number of adult ventilators, which had been at 9,138 at the beginning of the pandemic, reached 14,700, a 61% increase, by the end of the year.
Psychosocial support services for both the community and healthcare professionals were quickly planned and presented in the 81 provinces. Good examples of public and civil society cooperation emerged in these processes.
Turkey has responded to requests from many countries since the beginning of the pandemic. Supplies, including personal protective equipment, have been sent to many countries in the scope of the struggle with COVID-19. In this context, requests for assistance and cooperation have been received from 179 countries and 20 international organizations as of December 31, 2020, through instructions from the Presidential Office, Turkey’s Ministry of Foreign Affairs, and the relevant countries’ embassies. The request of 144 countries and seven international organizations have been met. In-kind aid has been provided to 126 countries through the Ministry of Health, Ministry of National Defense, Turkish Cooperation and Coordination Agency, Red Crescent, Ministry of Foreign Affairs, and Ministry of the Interior. Expert permit requests from 74 countries and 5 international organizations (NATO, WHO, UNICEF, Islamic Development Bank, and World Bank) have also been met. Both grants and export permits were given to 56 countries. Turkish citizens affected by COVID-19 abroad were additionally provided with the opportunity to return to Turkey, and these citizens were brought home by ambulance planes and other means.36
Conclusion
2020 began with the COVID-19 pandemic being announced, one of the most significant events in human history. The pandemic has brought about many problems on economic, environmental, and social issues. While the pandemic had directly affected over 80 million people by the end of the year, the indirect effects and what it has affected will only become clear in the long term. The versatility of the decision’s countries make can enable all areas of this global crisis to be managed. WHO has shown appreciation for the steps Turkey has taken in this sense. Thanks to the multi-faceted measures that have been taken, disruptions in Turkey’s basic health services were lower than in many countries. Also, the rapid increase in health service capacity has shown its effects in the struggle with the pandemic, and no significant disruption was observed even during the periods when the epidemic had reached the most intense number of patients. Remote healthcare services such as improving telehealth services as well as family health centers and district health directorates following up on patients by phone have been implemented. Turkey has additionally sent materials such as personal protective equipment in response to many countries’ requests during this time. In addition to these materials, important steps have been taken to ensure the production of respiratory devices in Turkey. While continuing to implement the measures required for bringing the pandemic under control, efforts have also been ongoing for producing a domestic vaccine in 2021.
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