Impact on Mental Health, Disease Management and Socioeconomic Modifications in Hematological Patients during COVID-19 Pandemia in Italy
Authors: De Muro Marianna , Amadori Sergio , Ardu Nicolina Rita , Cerchiara Elisabetta , De Fabritiis Paolo , Niscola Pasquale , Dante Sabatino , Schittone Valentina , Tesei Cristiano , Trawinska Malgorzata Monika , Abruzzese Elisabetta 
Published: February 2021

The SARS-CoV-2 (COVID-19) outbreak is upending current life and generating much anxiety and uncertainty. The effects of home confinement, social isolation, cancelled schools, closed businesses, and negative economic impacts have had serious consequences. Hematologic patients (HP) are a subset of highly vulnerable population with increased risk of developing severe COVID-19 symptoms due to their immunocompromised status. These risks have been augmented during the COVID outbreak because of deviations from current standards of care, e.g., reduced visits, treatment supply and access to routine exams. This study investigated the impact of the current pandemic on HP assessing demographics, medical information, mental health and caregiver practical management. In collaboration with AIL (Italian Association against Leukemia) and CNR (National Research Council), a survey was generated and distributed to Italian HP. The general population (GP) were used as controls.
The assessment used the DASS-21 questionnaire, a self-reported, 21 item screening instrument that provides independent measures of depression, stress and anxiety with recommended severity thresholds subscales. The survey was self-administered between April and August, 2020. The questionnaires' reliability was verified based on an analysis of its internal consistency using Cronbach's alpha.
As of 30 June 2020, 1113 HP and 1125 GP completed the survey from 20 Italian Regions. The two population groups were homogeneous by age, gender and distribution and included regions at both high (CHP) and low (CLP) prevalence of infections at the time of the survey.
HP and GP median age was 50 years (range: HP 11- 93; GP 13-85). 61% HP and 68% GP were female; the rest were male. The year of diagnosis of hematological disease ranged from 1965 to 2020; 21.9% had chronic myeloid leukemia, followed by Hodgkin (15.7%) and non-Hodgkin (15.9%) lymphomas, chronic myeloproliferative neoplasms (15.9%), multiple myeloma (8.9%), chronic lymphocytic leukemia (4.9%), acute myeloid (5.6%) and lymphoblastic (3.25%) leukemias, other (7%).
1071 HP and 1125 GP responded about their occupation as follows: employed full/part time (38.7% HP , 47.7% GP), retired (19.2% HP,10.8% GP), freelancer (9.2% HP, 12.2% GP), unemployed (6.2% HP, 3.4% GP) , students (4.6% HP, 3.2% GP), company executive (4.1% HP, 4.8% GP), manager (2% HP, 4.7 % GP), cooperative member (0.7% HP , 0.7% GP), housewife (8.5% HP 4.8% GP), other (6.8% HP,7.7% GP). During the pandemic 63.7% HP didn't work and 36.3% did work compared to the GP group (33.8% didn't; 66.2 % did). Where specified, the reasons for not working were: layoffs (10.9% HP, 15.9% GP), lack of work (8.1%HP, 15.6 % GP), vacation/ parental leave (4.4% HP, 3.5% GP), reduced business activity for economic reasons (2.2% HP, 3.3% GP), occasional work (2.1% HP, 5.7% GP), seasonal employment, (0.6% HP,1.1 % GP).
625/1073 HP (58.2%) were in active treatment. Of these, 40.1% were in Day Hospital, 56.4% were outpatient; and 3.5% inpatients. The remaining HP were off therapy (448/1073; 41.8%).
1105 HP and 1127 GP responded to the DASS questionnaire. Extremely severe depression was found in 12.9% HP vs 7% GP; 18.1% HP expressed severe anxiety vs 9.6% GP and extremely severe stress was present in 7.1% HP and 5.3% GP. The Cronbach's alpha coefficient for the internal homogeneity of the questionnaire was 0.95, confirming the cohorts correctness (0.8 or greater, indicates a very good level of reliability).
Providing care to HP during the pandemic has been challenging for both patients and doctors. Restrictions on visits and lab/instrumental exams, reduced equipment supply and a paucity of personal protection equipment (PPEs) for health care providers and patients have penalized normal routine care. As a result, 38.2% HP postponed or did not attend scheduled therapy and &gt;50% had difficulty obtaining PPEs through normal sources; 57% in CHP and 36% in CLP regions had to buy them themselves.
To our knowledge this is the first report of the impact of the pandemic on psychological distress, work consequences and illness management in HP. Most of HP in this study are outpatients in active treatment. Interesting data emerged from job losses, which is more common among HP. The DASS-21 instrument revealed higher anxiety and depression levels in HP. Detailed results including longitudinal analysis and high versus low geographic prevalence of COVID-19 infections will be presented.
Figure 1

Disclosures
Abruzzese: Incyte: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bms: Honoraria.