COVID-19-related perceptions, context and attitudes of adults with chronic conditions: Results from a cross-sectional survey nested in the ComPaRe e-cohort.

BACKGROUND: To avoid a surge of demand on the healthcare system due to the COVID-19 pandemic, we must reduce transmission to individuals with chronic conditions who are at risk of severe illness with COVID-19. We aimed at understanding the perceptions, context and attitudes of individuals with chronic conditions during the COVID-19 pandemic to clarify their potential risk of infection.
METHODS: A cross-sectional survey was nested in ComPaRe, an e-cohort of adults with chronic conditions, in France. It assessed participants' perception of their risk of severe illness with COVID-19; their context (i.e., work, household, contacts with external people); and their attitudes in situations involving frequent or occasional contacts with symptomatic or asymptomatic people. Data were collected from March 23 to April 2, 2020, during the lockdown in France. Analyses were weighted to represent the demographic characteristics of French patients with chronic conditions. The subgroup of participants at high risk according to the recommendations of the French High Council for Public Health was examined.
RESULTS: Among the 7169 recruited participants, 63% patients felt at risk because of severe illness. About one quarter (23.7%) were at risk of infection because they worked outside home, had a household member working outside home or had regular visits from external contacts. Less than 20% participants refused contact with symptomatic people and <20% used masks when in contact with asymptomatic people. Among patients considered at high risk according to the recommendations of the French High Council for Public Health, 20% did not feel at risk, which led to incautious attitudes.
CONCLUSION: Individuals with chronic conditions have distorted perceptions of their risk of severe illness with COVID-19. In addition, they are exposed to COVID-19 due to their context or attitudes.

Introduction

The novel coronavirus disease 2019 (COVID-19) pandemic threatens to saturate healthcare systems all around the world [1]. On April 7th of July 2020, 6,416,828 cases were confirmed in 213 countries, with 382,867 deaths [2]. In France, 152,444 cases were confirmed, with 29,065 deaths [3]. Severe acute respiratory distress develops in about 16% to 26% of patients hospitalized with COVID-19, thus requiring oxygen supplementation and/or intensive care [4]. As the number of cases grows worldwide, in order to avoid a surge of demand on the healthcare system and shortages of equipment such as ventilators needed to care for critically ill patients [5-7], many countries have imposed quarantine and recommended physical distancing to reduce transmission to people likely to have a severe illness (i.e., older patients and those with chronic comorbidities). Those individuals with chronic comorbidities should also, in return, avoid contacts and/or use appropriate measures to prevent potential infection. Yet, in France and around the world, specific advice for individuals with chronic conditions and their households is scarce with most information is intended for the general public. For example, information from the European Centre for Disease Prevention and Control refer to only “people with chronic diseases” without specifying specific groups of individuals. This was confirmed by a recent study showing that adults with comorbid conditions lacked critical knowledge about COVID-19 [8].

In this study, we aimed to understand the perceptions, context and attitudes toward COVID-19 of individuals with chronic conditions in order to clarify their potential risk of infection.

Material and methods

This study was a cross-sectional survey nested in ComPaRe, a nationwide e-cohort of patients with chronic conditions in France [9].

Participants

Participants were adults with chronic conditions recruited from the Community of Patients for Research (ComPaRe, http://compare.aphp.fr), a nationwide e-cohort of patients with chronic conditions in France. Participants of ComPaRe are adults (>18 years old) who reported having at least one chronic condition (defined as a condition requiring healthcare for at least 6 months) and who joined the project to donate time to accelerate research of their conditions by answering regular patient-reported outcomes and experience measures online [9]. All participants provide electronic informed consent before participating in the e-cohort. ComPaRe was approved by the Comité de Protection des Personnes Ile de France 1 (IRB: 0008367). All methods were performed in accordance with the relevant guidelines and regulations.

Context and settings

Data from this study were collected between March 23 and April 2, 2020 at the peak of the French epidemic. During that time, 27 475 new cases of COVID-19 were confirmed, with a total of 56 261 cases on April 2, 2020. This time period includes the maximum number of daily cases in France (April 1, 2020) [10]. Since March 17, France had been under lockdown (movement restrictions and closure of non-essential businesses), and people with chronic conditions were encouraged to stay at home [11]. During this time, knowledge of COVID-19 was still limited and information for the public was imprecise. For example, information available on the website of the French ministry of health referred to “people at risk”, mixing older people and patients with chronic conditions [12]. Of note, at the time of the study, benefits of using face masks were debated in France and in Europe.

Data collected

Participants’ demographic and clinical data were collected as part of their participation in the ComPaRe e-cohort. All variables are updated yearly. Conditions and medications are self-reported by patients by using the International Classification of Primary Care-Version 2 [13] and the Thesorimed database of medications (French database of medications developed by the national health insurance) [14].

In addition, participants answered a dedicated survey designed by VTT and PR by use of the literature and their own expertise [8]. It was then face-validated by two other researchers (IP and CR) with expertise in questionnaire development before dissemination. The questionnaire was not tested with patients; however, the first respondents provided comments in a dedicated open-ended question at the end of the questionnaire, which led to minor reformulations. Final survey questions are available in S1 and S2 Data. This survey covered 3 topics.

For perception of risk of severe illness with COVID-19, we asked participants whether they felt at high risk of severe illness with COVID-19 with the question: “Do you feel at increased risk of severe illness with COVID-19 as compared to people of the same age as you but without chronic disease?” (yes/no).

For their context. participants described their activity (e.g., whether they continued working outside of the home); their household (i.e., whether any member of their household worked outside of the home and were in contact with the public); and their recent physical visits to healthcare professionals.

For their attitudes to prevent infection, participants were presented four theoretical situations involving different types of contacts: frequent (e.g., family member frequently visiting, child care, etc.) or occasional (e.g., during shopping) and discerning whether these contacts showed symptoms or not. In each situation, participants reported whether they would refuse contact, enact physical distancing or wear personal protective equipment (mask, gloves, etc.).

Analysis

Results of the survey were described globally and for the subgroup of patients considered at high risk of a severe illness according to the French High Council for Public Health (Box 1). These patients were those with a severe cardiac or vascular disease (high blood pressure with complications, history of stroke or ischemic heart disease, cardiac surgery, heart failure), insulin-dependent diabetes, chronic lung disease or lung disease likely to be exacerbated by a viral infection, chronic kidney disease under dialysis, cancer under treatment, immunodeficiency (due to a drug [cancer chemotherapy, immunosuppressive medications, biotherapy and/or corticosteroids], an uncontrolled HIV infection, transplantation, or cancer), liver cirrhosis, or severe obesity (body mass index [BMI] >40 kg/m2), or pregnant in the third trimester [15]. To operationalize these criteria with the data available in ComPaRe, one physician (VTT) matched the conditions and treatments reported by patients in ComPaRe with the list of high-risk conditions and treatments presented above. Cancer chemotherapy immunosuppressive medications, biotherapy and corticosteroids were those classified as such in manufacturers' prescribing information, by using the Vidal dictionary (https://www.vidal.fr/classifications/vidal/).

Box 1. Patients at high risk of severe COVID-19 according to the French High Council for Public Health [15].

According to the literature:

Age ≥ 70 years

History of cardiovascular disease: complicated hypertension, history of stroke or coronary artery disease, heart surgery, heart failure (New York Heart Association class III or IV)

Insulin-dependent diabetes or with diabetic microangiopathy or macroangiopathy

Chronic respiratory disease likely to result in decompensation during a viral infection

Chronic renal failure on dialysis

Cancer under treatment

Despite the lack of data in the literature, the following patients are also considered at high risk based on available data on other respiratory infections:

Cancer chemotherapy, immunosuppressive therapy, biotherapy and/or immunosuppressive dose corticosteroid therapy (= high-risk treatment in this article)

Uncontrolled HIV infection or CD4 count <200/mm3, solid organ or hematopoietic stem cell transplant, or blood cancer under treatment

Cirrhosis at least stage B of the Child-Pugh classification

Morbid obesity (body mass index > 40 kg/m2) by analogy with influenza A (H1N1)09

Third trimester of pregnancy

Descriptive statistics (mean with SD and frequency with percentage) were calculated for all patient characteristics and survey responses. Associations between participant characteristics and responses to the survey items were then examined in bivariate analyses by chi-square or t test, as appropriate. In addition, we fitted two logistic regressions aimed at exploring the association between participants’ characteristics and 1) their perception of their risk for severe infection and 2) their attitudes to prevent infection with occasional contacts with asymptomatic people. Variables included in the model were sex, age (as a continuous variable), household with > 1 person (including the patient), low educational level, smoking status (current smoker vs. others), treatment considered at risk according to the French High Council for Public Health, BMI ≥40 kg/m2, high blood pressure, diabetes (under insulin treatment or not), history of stroke or cardiac ischemic disease, heart failure (any New York Heart Association stage), asthma, chronic obstructive pulmonary disease, thyroid disease, chronic kidney failure (under dialysis or not), cancer (under treatment or not) and osteoarthritis. Analyses were performed on complete cases only. P < 0.05 was considered statistically significant. No corrections for multiple testing were performed.

Analyses involved using a weighted dataset obtained by calibration on margins with weights for age categories (<24, 25–34, 35–44, 45–54, 55–64, 65–74, >75 years), sex and educational level (low, middle school or equivalent, high school or equivalent, associate’s degree, higher education). Weights were derived from national census data describing the French population reporting chronic conditions [16, 17].

Analyses involved use of R v3.6.1 (http://www.R-project.org, the R Foundation for Statistical Computing, Vienna, Austria).

Results

Between March 23 and April 2, 2020, we invited 18,651 patients from ComPaRe to complete our survey and 7169 (38.4%) answered (S1 Fig). Participants were mostly female (5616 [78.3%]) with mean (SD) age 46.1 (14.7) years. In the non-weighted data, diseases most frequently reported were high blood pressure (11.6%), diabetes (7.1%), asthma (6.2%) and cancer (5.2%); 3684 (51.4%) participants reported ≥2 chronic conditions. Differences between respondents and non-respondents are shown in S1 Table. In the weighted sample, 39.4% were at high risk for a severe illness according to the French recommendations: 33.0% because of their conditions, 8.8% because of their treatments, 1.9% with BMI > 40 kg/m2, and 0.5% in their third trimester of pregnancy. Patients’ characteristics before and after weighting are presented in Table 1.

Table 1

Participant characteristics (n = 7169).

Characteristic	Raw dataset (n = 7169)	Weighted dataset1 (n = 7169)
Age, mean (SD)–yr	46.1 (14.7)	55.1 (17.0)
Female sex—no (%)	5616 (78.3)	3788 (52.8)
Educational level—no (%)
Low	386 (5.4)	699 (9.8)
Middle school or equivalent	1164 (16.2)	4039 (56.3)
High school or equivalent	533 (7.4)	991 (13.8)
Associate’s degree	1510 (21.1)	629 (8.8)
Higher education	3576 (49.9)	811 (11.3)
Smoking status
Never smoker	2319 (46.3)	2554 (35.6)
Former smoker	1671 (33.3)	3371 (47)
Current smoker (occasional)	290 (5.8)	309 (4.3)
Current smoker (frequent)	732 (14.6)	926 (12.9)
Missing	2 (0.03)	9 (0.1)
Multimorbid—no (%)	3684 (51.4)	4065 (56.7)
Number of diseases, mean (SD)	2.3 (2.2)	2.5 (2.4)
Conditions2—no (%)
High blood pressure	834 (11.6)	1486 (20.7)
Diabetes	506 (7.1)	819 (11.4)
Stroke or cardiac ischemic disease	70 (1.0)	109 (1.5)
Heart failure (other than ischemic diseases)	79 (1.1)	91 (1.3)
Asthma	448 (6.2)	390 (5.4)
COPD	124 (1.7)	260 (3.6)
Thyroid disease	362 (5.0)	294 (4.1)
Chronic kidney failure	142 (2.0)	276 (3.8)
Cancer	373 (5.2)	515 (7.2)
Osteoarthritis	319 (4.4)	388 (5.4)
Inflammatory rheumatic diseases	407 (5.7)	432 (6.0)
High-risk situation according to the French High Council for Public Health—no (%)	2152 (30.0)	2828 (39.4)
High-risk conditions3	1683 (23.5)	2367 (33.0)
High-risk treatments3	513 (7.2)	628 (8.8)
Third trimester of pregnancy	81 (1.1)	33 (0.5)
BMI ≥ 40 kg/m2	124 (1.7)	139 (1.9)

COPD, chronic obstructive pulmonary disease; BMI, body mass index

1 Weighted data were obtained after calibration on margins for sex, age categories and educational level by using data from a national census describing the French population self-reporting at least one chronic condition.

2 A patient may have multiple chronic conditions.

3 High-risk conditions and treatment are according to the French High Council for Public Health

Perception of the risk of severe illness with COVID-19

In the weighted sample, 63% of participants felt at risk of severe illness with COVID-19, of whom 51% (32% of the whole sample) reported a high-risk situation according to the French High Council for Public Health. Conversely, 37% participants did not feel at risk of severe COVID-19, of whom 20% (7.4% of the whole sample) reported a high-risk situation according to the French High Council for Public Health (Fig 1). Patients’ characteristics associated with a perceived risk of severe COVID-19 identified in the logistic regressions are presented in Table 2.

Fig 1

Participants’ perception of the risk of severe illness with COVID-19 depending on their actual risk of severe illness according to recommendations from the French High Council for Public Health (n = 7169).

Surface is proportional to the number of patients in each category in the weighted analysis (calibration on margins for sex, age categories and educational level by using data from a national census describing the French population self-reporting at least one chronic condition).

Table 2

Association between participant characteristics and their perceived risk of severe COVID-19.

Results of logistic regression analysis of complete cases, accounting for weights obtained after calibration on margins for sex, age categories and educational level by using data from a national census describing the French population self-reporting at least one chronic condition.

Characteristic	Odds ratio (95% confidence interval)
Female sex	1.33 (1.04–1.71)*
Age	1.01 (1–1.02)*
Current smoker	1.21 (0.9–1.62)
Household > 1 person	1.12 (0.83–1.52)
Low educational level	1.1 (0.76–1.59)
High risk treatments	14.08 (6.16–32.18)*
BMI ≥ 40 kg/m2	1.77 (0.81–3.87)
High blood pressure	1.13 (0.75–1.69)
Diabetes	3.02 (1.83–4.98)*
Stroke or cardiac ischemic disease	9.16 (2.26–37.19)*
Heart failure	2.4 (0.67–8.63)
Asthma	4.64 (2.22–9.68)*
COPD	6.32 (2.14–18.73)*
Thyroid disease	1.05 (0.55–1.97)
Chronic kidney disease	2.64 (1.01–6.89)*
Cancer	1.93 (0.99–3.73)
Osteoarthritis	0.98 (0.59–1.62)

* P < 0.05

BMI, body mass index; COPD, chronic obstructive pulmonary disease

Potential risk of infection due to context

In total, 7041 (98%) participants answered the survey section regarding their risk of infection due to their context. Risk of infection involved working outside of the home (8.8% of participants, of whom 29% were care professionals), visits to health facilities for a consultation or test (54.7% of participants) or to a pharmacy (82% of participants); their household (74.9% of participants lived with at least on other person, of whom 18% worked outside of the home and 13% were children < 15 years old), or regular contacts with people outside of their home (e.g., family, friends, housekeeping, child care, etc.) (5% of participants). In all, 23.7% were exposed to some risks because of their work, their household members working outside of the home, or regular visits from external contacts.

Among patients at high risk of a severe illness according to the French High Council for Public Health, 5% continued working, 15% had a household member working outside of the home and 7% reported regular contacts with people outside of their home. In all, 21.1% were exposed to some risks because of their work, their household members working outside of the home, or regular visits from external contacts.

Potential risk of infection due to attitudes

In total, 6940 (97%) participants answered the survey section regarding their attitudes to prevent infections. Independent of the type of contact, participants reported that they would enact physical distancing under all situations presented to them. About one quarter of patients would refuse any contact with symptomatic people (17.8% and 23.4% for occasional and frequent contacts, respectively). Concerning the use of personal protective equipment, use of masks ranged from 19% (for occasional contacts with asymptomatic people) to 65% (for frequent contacts with symptomatic people). Similarly, use of gloves ranged from 19% (for occasional contacts with asymptomatic people) to 50% (for frequent contacts with symptomatic people) (Fig 2).

Fig 2

Participant-reported attitudes to prevent infection in situations involving frequent or occasional contacts with symptomatic or asymptomatic people (n = 6940).

We found similar results in the subgroup of patients at high risk of a severe illness according to the French High Council for Public Health. Only 18.2% and 23.2% patients would refuse contact with symptomatic people for occasional and frequent contacts, respectively. Concerning the use of personal protective equipment, use of masks ranged from 30% (for occasional contacts with asymptomatic people) to 63% (for frequent contacts with symptomatic people). Similarly, use of gloves ranged from 21% (for occasional contacts with asymptomatic people) to 44% (for frequent contacts with symptomatic people).

Patients’ characteristics associated with a perceived risk of severe illness with COVID-19 identified on logistic regression are presented in Table 3. The only variable found associated with use of face masks with asymptomatic people (or refusal to see these people) was patients’ perception of high risk of severe infection by COVID-19 (odds ratio 1.93, 95% confidence interval 1.53–2.43).

Table 3

Association between participant characteristics and the use of face masks for occasional contacts with asymptomatic people (or the refusal to see these people).

Results of logistic regression analysis of complete cases, accounting for weights obtained after calibration on margins for sex, age categories and educational level by using data from a national census describing the French population self-reporting at least one chronic condition.

Characteristic	Odds ratio (95% confidence interval)
Female sex	1.18 (0.92–1.5)
Age	1 (0.99–1.01)
Current smoker	0.94 (0.69–1.28)
Household > 1 person	1.2 (0.93–1.56)
Low educational level	0.95 (0.67–1.34)
High-risk treatments	1 (0.65–1.53)
BMI ≥ 40 kg/m2	1.31 (0.73–2.35)
High blood pressure	0.73 (0.52–1.03)
Diabetes	1.06 (0.72–1.55)
Stroke or cardiac ischemic disease	1.04 (0.44–2.48)
Heart failure	2.36 (0.9–6.23)
Asthma	0.85 (0.59–1.23)
COPD	0.89 (0.42–1.87)
Thyroid disease	1.25 (0.79–1.97)
Chronic kidney disease	0.83 (0.4–1.73)
Cancer	0.66 (0.43–1.03)
Osteoarthritis	1.42 (0.91–2.23)
Feeling at risk of severe COVID-19	1.93 (1.53–2.44)

* P < 0.05

Discussion

We involved 7169 individuals with chronic conditions in a nationwide survey nested in an existing cohort and described their perception of risk of severe COVID-19 and their potential risk of infection due to context and attitudes.

First, our study highlighted that patients with chronic conditions have distorted perceptions of their risk of severe COVID-19. Among patients with criteria for high risk of severe COVID-19 by the French High Council for Public Health (40% of our sample), about 20% did not feel at risk and could therefore adopt incautious attitudes. This figure may even be conservative in light of recent works suggesting that all patients with hypertension, diabetes, cardiovascular disease, or chronic lung disease are at risk, not just those with complicated diseases [18-20]. Data from the he Chinese Center for Disease Control and Prevention showed increased case fatality rate among patients with preexisting comorbid conditions—10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer [20]. Especially, our findings highlight that patients with a BMI ≥ 40 kg/m2 or who smoked did not feel at risk nor took extra precautions when in contact with other people despite these two factors being associated with risk of severe complications and mortality from COVID-19 [21, 22].

These results are of importance because of the confluence of two elements. First, preventing infection for people at risk of severe disease is difficult. In our study, 21.2% of patients at high risk of a severe illness according to French recommendations were in frequent contact with “the outside world” during the quarantine because of their work, their household members working outside of the home, or regular visits from external contacts. Second, feeling at risk seems to be the major factor for using face masks with asymptomatic people. At the time of the study, it was still unknown that 40% to 80% of transmission events could occur from people who are presymptomatic or asymptomatic [23]. Therefore, specific communication clearly identifying patients at risk for severe illness by COVID-19 is mandatory. Communication should also target the household of these patients because the rate of secondary transmission among household contacts of patients with SARS-CoV-2 infection was estimated at 30% [24].

Our results are important given the cumulative amount of evidence showing that patients with chronic conditions, about 20 million individuals in France, are at increased risk of severe COVID and death. In a small case series conducted at the beginning of the epidemic in China, among 102 patients hospitalized for COVID-19, those with comorbidities (especially hypertension, diabetes, cardiovascular and respiratory diseases) were more likely to be hospitalized in Intensive care units [25, 26]. Similar findings were observed in Europe. In a large case series of 4000 patients hospitalized in ICUs in Italy, the highest risk of death was for patients with chronic obstructive pulmonary disease (adjusted HR [aHR] 1.68, 95% CI 1.28–2.19) and type 2 diabetes (aHR 1.18, 95% CI 1.01–1.39) [27]. Reasons underlying these findings are still unclear, with hypotheses related to meta-inflammation or use of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in these populations, despite recent controversial findings about this latter point [28, 29].

Our study complements the literature on the awareness and attitudes of patients with chronic conditions related to COVID-19. To date, most works have focused on the general public [30, 31]. Knowledge and attitudes of patients with chronic conditions is unknown, apart from a study of 600 patients with chronic conditions in the United States that showed gaps in awareness and knowledge of COVID-19 among patients with chronic conditions [8]. Our findings confirm these results and provide details on individuals’ risks associated with their context and their attitudes to prevent infection.

This study has several limitations. First, all data were self-reported, with risk of desirability bias regarding their attitudes. Second, individuals at high risk of severe illness with COVID-19 are not yet well known; recommendations from the French High Council for Public Health are mostly based on case reports in China and precaution measures [15]. Third, the response rate was relatively low (38%) owing to the short duration of data collection (10 days) and the sole use of e-mails for the invitation and reminders. Yet, such response rate is consistent with the literature of online surveys for the general public [32, 33]. Non-respondents were younger, less multimorbid and had fewer conditions considered at high risk according to recommendations than respondents. Despite statistical weighting, results should be generalized with caution.

In conclusion, we found that individuals with chronic conditions may have distorted perceptions of their risk of severe illness with COVID-19. Targeted communication may increase the use of personal protective equipment and prevent infection, which is fundamental because 20% of these individuals are exposed to infection because of their work, their household or regular visits from external contacts, despite quarantine.

Questionnaire for participants (French).

(DOCX)

Click here for additional data file.

Questionnaire for participants (English).

(DOCX)

Click here for additional data file.

Flow chart of participants’ answers to the survey.

(DOCX)

Click here for additional data file.

Demographic characteristics of respondents and non-respondents to the survey (raw data).

(DOCX)

Click here for additional data file.

29 May 2020

PONE-D-20-14011

Potential risk of COVID-19 in adults with chronic conditions because of their perceptions and attitudes: results from a cross-sectional survey nested in the ComPaRe e-cohort

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Reviewer #1: This is peer-review of paper by Viet-Thi Tran et al, which determined Potential risk of COVID-19 in adults with chronic conditions because of their perceptions and attitudes in France. They found that those with chronic medical illnesses have skewed views about their likelihood about severe disease with COVID-19.

The strengths of this study are the large sample size.

Major Comments:

1. The survey design was omitted for us as evaluators, who designed it? How? Is it validated? Elaborate more to this. It should be presented in the appendix.

2. The response rate was very low, what was the reason? How did you distribute it?

3. The analysis was mainly descriptive with no interesting associations came out from this survey. Make it more interesting for the readers and researchers.

4. The definition of the high risk of severe illness is not clear and misleading.

5. Why did you divide Perception of risk of severe illness with COVID-19 to four categories? Explain further and make a valid point.

6. Your survey was looking for perception of people but attitude of people was presented and analysed, please be specific about your objectives and don’t confuse the readers.

7. Very limited discussion was presented; no scientific discussion has been done which very important papers were not discussed concerning prevalence, severity and mortality of chronic respiratory conditions, cardiac, renal, and other comorbidities.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

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26 Jun 2020

Dear Editor,

Thank you very much for giving us the possibility to answer the main concerns raised by the two reviewers of our manuscript entitled “COVID-19–related perceptions, context and attitudes of adults with chronic conditions: results from a cross-sectional survey nested in the ComPaRe e-cohort” (PONE-D-20-14011). You'll find attached the detailed point by point answers to reviewer and editor comments.

Submitted filename: Response.docx

Click here for additional data file.

6 Jul 2020

PONE-D-20-14011R1

COVID-19–related perceptions, context and attitudes of adults with chronic conditions: results from a cross-sectional survey nested in the ComPaRe e-cohort

PLOS ONE

Dear Dr. Tran,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the authors for addressing all the comments except ONE, which is number (7. A very limited discussion was presented; no scientific discussion has been done which very important papers were not discussed concerning prevalence, severity and mortality of chronic respiratory conditions, cardiac, renal, and other comorbidities). They need to cite systematic reviews and meta-analysis about the above comorbidities and link that with the current prevalence and severity reported in France. The other important point here is about Attitude, I can not see anything about smoking habits and the risk of getting an infection with those vulnerable group of patients. A recent meta-analysis published by Plos One highlighted the prevalence and severity associated with former, never and current smokers and COVID-19. Please discuss this in your discussion and make a comparison with your results as this definitely ATTITUDE.

Good luck

Reviewer #2: The authors studied the perceptions, context and attitudes of individuals with chronic conditions during the COVID-19 pandemic to clarify their potential risk of infection,the result was that 63% patients felt at risk because of severe illness, about 23.7% were at risk of infection, at the end they concluded that individuals with chronic conditions have distorted perceptions of their risk of severe illness with COVID-19.So I will give some comments as followings.

In this study, the investigation time period was selected from 3.23-4.2. I want to konw the reason for choosing this study time? Why not choosing a longer period of time or another time period?

In this study, how to define a serious disease state? What types of diseases are included? Whether different disease types will affect the conclusions of this investigation

In the face of the COVID-19 epidemic, what are the current policy measures adopted by the French government?

The following references should be discussed in the revision text.

Cao JL, Hu XR, Tu WJ., & Liu Q. (2020). Clinical Features and Short-term Outcomes of 18 Patients with Corona Virus Disease 2019 in Intensive Care Unit. Intensive Care Medicine, DOI: 10.1007/s00134-020- 05987-7.

Cao JL, Tu WJ, Hu XR, & Liu Q. (2020). Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan,China. Clinical Infectious Diseases,DOI: 10.1093/cid/ciaa243/ 5814897.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

22 Jul 2020

Dear Editor,

Thank you for giving us the possibility to answer the main concerns raised by the two reviewers of our manuscript entitled “COVID-19–related perceptions, context and attitudes of adults with chronic conditions: results from a cross-sectional survey nested in the ComPaRe e-cohort” (PONE-D-20-14011R1).

Reviewers mainly asked for changes in the discussion to detail the link between COVID-19 infection and chronic conditions (e.g. discussing the prevalence, severity and mortality of chronic respiratory conditions, cardiac, renal, and other comorbidities in France). These are, of course, topics of critical importance but we are not sure that they are within the scope of the paper, which was to explore patients’ perceptions and attitudes toward the risk of COVID-19. As requested by the reviewers, we added more details in the discussion to provide a basis for reflection, but we believe that expanding this section too much may lead readers astray.

Reviewer #1: Thank you for the authors for addressing all the comments except ONE, which is number (7. A very limited discussion was presented; no scientific discussion has been done which very important papers were not discussed concerning prevalence, severity and mortality of chronic respiratory conditions, cardiac, renal, and other comorbidities). They need to cite systematic reviews and meta-analysis about the above comorbidities and link that with the current prevalence and severity reported in France.

We added some details to discuss the importance of understanding the perceptions of patients with chronic conditions toward COVID-19.

Our results are important given the cumulative amount of evidence showing that patients with chronic conditions, about 20 million individuals in France, are at increased risk of severe COVID and death. In a small case series conducted at the beginning of the epidemic in China, among 102 patients hospitalized for COVID-19, those with comorbidities (especially hypertension, diabetes, cardiovascular and respiratory diseases) were more likely to be hospitalized in Intensive care units. Similar findings were observed in Europe. In a large case series of 4000 patients hospitalized in ICUs in Italy, the highest risk of death was for patients with chronic obstructive pulmonary disease (adjusted HR [aHR] 1.68, 95% CI 1.28-2.19) and type 2 diabetes (aHR 1.18, 95% CI 1.01-1.39). Reasons underlying these findings are still unclear, with hypotheses related to meta-inflammation or use of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in these populations, despite recent controversial findings about this latter point.

The other important point here is about Attitude, I cannot see anything about smoking habits and the risk of getting an infection with those vulnerable group of patients. A recent meta-analysis published by Plos One highlighted the prevalence and severity associated with former, never and current smokers and COVID-19. Please discuss this in your discussion and make a comparison with your results as this definitely ATTITUDE.

Our objective was to assess patients’ perceptions regarding COVID-19 and their attitudes regarding protection measures. We did not collect whether patients stopped smoking because of the fear of severe COVID.

However, we added details about patients’ current smoking status and their perception of risk for severe COVID-19. Especially, we now describe in table 1 patients’ smoking status and we added patients’ smoking status in the two models, which did not change the results. Finally, we discussed the fact that patients with BMI ≥ 40 kg/m2 or who smoked did not feel at risk and did not take specific measures to protect themselves despite these two factors being associated with risk of severe complications and mortality from COVID-19.

Especially, our findings highlight that patients with a BMI ≥ 40 kg/m² or who smoked did not feel at risk nor took extra precautions when in contact with other people despite these two factors being associated with risk of severe complications and mortality from COVID-19

Reviewer #2: The authors studied the perceptions, context and attitudes of individuals with chronic conditions during the COVID-19 pandemic to clarify their potential risk of infection, the result was that 63% patients felt at risk because of severe illness, about 23.7% were at risk of infection, at the end they concluded that individuals with chronic conditions have distorted perceptions of their risk of severe illness with COVID-19.So I will give some comments as followings.

In this study, the investigation time period was selected from 3.23-4.2. I want to know the reason for choosing this study time? Why not choosing a longer period of time or another time period?

The study was conducted at the peak of the epidemic in France and our results were intended to provide a quick insight into the perceptions and attitudes of chronic patients toward the risk for severe infection.

We now report in the settings section, the number of confirmed cases at the time of the study.

Data from this study were collected between March 23 and April 2, 2020 at the peak of the French epidemic. During that time, 27 475 new cases of COVID-19 were confirmed, with a total of 56 261 cases on April 2, 2020. This time period includes the maximum number of daily cases in France (April 1, 2020).

Because patients are recruited from an existing cohort, so a longer response period would have, at best, increased the survey response rate. We already describe the difference between respondents and non-respondents and discuss the response rate in comparison to other surveys conducted at the same time.

In this study, how to define a serious disease state? What types of diseases are included?

Any participant with a chronic condition can participate in ComPaRe. Patients self-report their chronic conditions by using a list of 217 diseases, inspired from the International Classification of Primary Care-Version 2.

Details on the ComPaRe e-cohort have been published elsewhere (Tran VT, J Clin Epidemiol 2020). The full protocol of the ComPaRe cohort is available on the cohort website www.compare.aphp.fr.

Whether different disease types will affect the conclusions of this investigation

Associations identified in this study were independent of the presence of several conditions (high blood pressure, diabetes, stroke, ischemic heart failure, asthma, COPD, thyroid disease, chronic kidney disease, cancer and osteoarthritis). Indeed, these diseases were included as predictors in the non-parsimonious logistic regression analysis exploring the association between patient characteristics, their perception of their risk for severe infection (Table 2) and their use of face masks for occasional contacts with asymptomatic people (Table 3).

In the face of the COVID-19 epidemic, what are the current policy measures adopted by the French government?

At the time of the study, France had been under lockdown (movement restrictions and closure of non-essential businesses) and people with chronic conditions were encouraged to stay at home. Yet public communication for people with chronic conditions was imprecise. In particular, there was no consensus on the use of face-masks.

Since March 17, France had been under lockdown (movement restrictions and closure of non-essential businesses), and people with chronic conditions were encouraged to stay at home. During this time, knowledge of COVID-19 was still limited and information for the public was imprecise. For example, information available on the website of the French ministry of health referred to “people at risk”, mixing older people and patients with chronic conditions.

The following references should be discussed in the revision text.

Cao JL, Hu XR, Tu WJ., & Liu Q. (2020). Clinical Features and Short-term Outcomes of 18 Patients with Corona Virus Disease 2019 in Intensive Care Unit. Intensive Care Medicine, DOI: 10.1007/s00134-020- 05987-7.

Cao JL, Tu WJ, Hu XR, & Liu Q. (2020). Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan,China. Clinical Infectious Diseases,DOI: 10.1093/cid/ciaa243/ 5814897.

We discuss the aforementioned references in the added paragraph in the discussion.

Our results are important given the cumulative amount of evidence showing that patients with chronic conditions, about 20 million individuals in France, are at increased risk of severe COVID and death. In a small case series conducted at the beginning of the epidemic in China, among 102 patients hospitalized for COVID-19, those with comorbidities (especially hypertension, diabetes, cardiovascular and respiratory diseases) were more likely to be hospitalized in Intensive care units. Similar findings were observed in Europe. In a large case series of 4000 patients hospitalized in ICUs in Italy, the highest risk of death was for patients with chronic obstructive pulmonary disease (adjusted HR [aHR] 1.68, 95% CI 1.28-2.19) and type 2 diabetes (aHR 1.18, 95% CI 1.01-1.39). Reasons underlying these findings are still unclear, with hypotheses related to meta-inflammation or use of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in these populations, despite recent controversial findings about this latter point.

Submitted filename: Response3.docx

Click here for additional data file.

24 Jul 2020

COVID-19–related perceptions, context and attitudes of adults with chronic conditions: results from a cross-sectional survey nested in the ComPaRe e-cohort

PONE-D-20-14011R2

Dear Dr. Tran,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

29 Jul 2020

PONE-D-20-14011R2

COVID-19–related perceptions, context and attitudes of adults with chronic conditions: results from a cross-sectional survey nested in the ComPaRe e-cohort

Dear Dr. Tran:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Wen-Jun Tu

Academic Editor

PLOS ONE