COVID-19: One pandemic shading another

Since March 2020, after the World Health Organization (WHO) offi cially declared COVID-19 a pandemic, people worldwide has struggled with what can likely be considered the most severe global health crisis of recent times, comprising of 131,000,000 confi rmed cases and more than 2,800,000 deaths [1]. The fi rst registered case was reported in Wuhan, China, in November, 2019 [2,3] and it took less than three months for the infection to strike Brazil, as the fi rst offi cial COVID-19 Brazilian case was confi rmed, in February 25th 2020 [4]. As in many unexpected critical health issues, COVID-19 has not only directly affected those infected by it. It also reached those who remained free of disease, however greatly impacted by the socioeconomic consequences of the pandemic. One of these consequences concerns to mental health diseases which has been greatly struck by the pandemic outbreak and has been an issue for COVID-19 survivors, their contacts and those who have not yet had contact with the disease [5]. The prevalence of mental health diseases such as anxiety, depression, acute distress disorder and burnout have since then steeply increased and now it represents by itself an additional pandemic [6,7]. Interpersonal contact has greatly been compromised due to the disruption of normal lifestyles and this has been suggested to be a major risk factor for the deterioration of mental health [8,9]. Moreover, evidence has emerged of some strong predictors for the development of mental health disorders during COVID-19 pandemic. For instance, women seem to be at a higher risk than men [7,10-13]. Since the outbreak of COVID-19 and its inevitable impacts on daily routine such as cities lockdowns and home quarantines, families have been forced to a more intense indoor interaction. This environment has promoted a fertile ground for an old, well-known and ominous breach in human rights domestic violence against women which has since then forced the United Nations (UN) to issue a warning on the matter.

Since March 2020, after the World Health Organization (WHO) offi cially declared COVID-19 a pandemic, people worldwide has struggled with what can likely be considered the most severe global health crisis of recent times, comprising of 131,000,000 confi rmed cases and more than 2,800,000 deaths [1]. The fi rst registered case was reported in Wuhan, China, in November, 2019 [2,3] and it took less than three months for the infection to strike Brazil, as the fi rst offi cial COVID- 19 Brazilian case was confi rmed, in February 25 th 2020 [4]. As in many unexpected critical health issues, COVID-19 has not only directly affected those infected by it. It also reached those who remained free of disease, however greatly impacted by the socioeconomic consequences of the pandemic. One of these consequences concerns to mental health diseases which has been greatly struck by the pandemic outbreak and has been an issue for COVID-19 survivors, their contacts and those who have not yet had contact with the disease [5]. The prevalence of mental health diseases such as anxiety, depression, acute distress disorder and burnout have since then steeply increased and now it represents by itself an additional pandemic [6,7]. Interpersonal contact has greatly been compromised due to the disruption of normal lifestyles and this has been suggested to be a major risk factor for the deterioration of mental health [8,9]. Moreover, evidence has emerged of some strong predictors for the development of mental health disorders during COVID-19 pandemic. For instance, women seem to be at a higher risk than men [7,[10][11][12][13]. Since the outbreak of COVID-19 and its inevitable impacts on daily routine such as cities lockdowns and home quarantines, families have been forced to a more intense indoor interaction. This environment has promoted a fertile ground for an old, well-known and ominous breach in human rights -domestic violence against women -which has since then forced the United Nations (UN) to issue a warning on the matter.
There's increasing evidence that male sex is a risk factor for poor outcomes in COVID-19 infection as compared to female sex.
This difference relates both to the susceptibility for contracting COVID-19 infection as well as for the severity of its clinical course. Differences in immune mechanisms, social vulnerability and even confounding factors, such as smoking habit, may all play a role. No defi nite explanations for such differences, however, have so far been confi rmed [14][15][16]. For instance, men infected by SARS-CoV-2 face a higher mortality risk than women as reported from China (2.8%vs 1.7%, n=44000) [17,18].
It's also hypothesized that men are more frequently infected with COVID-19 than women due to differences in following appropriate personal preventive measures, such as wearing a mask and avoiding social gathering. Although both men and women are equally exposed to information and guidelines on such measures, women might be more prone to fully comply with them [19,20]. A study performed in Spain reported that women scored higher on perceived vulnerability than men [21], hence, exposing themselves less to transmission risks and more frequently following COVID-19 preventive protocols [22,23]. This common behavior after a disease threat may be ingrained in mental processes common to women, such as those described by the fi eld of developmental psychology [24].
Actually, being women is currently recognized as a strong predictor for developing anxiety, fear and stress during the ongoing COVID-19 pandemic [25]. For instance, anxiety levels have been shown to be three times higher among women than among men [26]. However great are the direct and indirect impacts of COVID-19 on women's mental health, there's an even more urgent matter that seems to be mentally and physically threatening women's welfare during the pandemic: the rise of domestic violence worldwide [27]. And this is no different in Brazil [28]. The ramping up of lockdown measures exposed the underlying vulnerabilities of women, who are forced to stay at home, work from home and implement social distance while remaining at the same time at close contact with their aggressor [29]. All indirect effects of COVID-19 disturb women happiness, building up distress, depression, anxiety and leading at the very end to impairment in mental health. Figueiredo  Data summarize the alarming scenario we are just living in: as the pandemic intensifi es, reports of domestic violence against women are rapidly spreading worldwide and their partners are taking advantage of physical distancing measures to isolate victims from the appropriate assistance resources [30,31]. In China, the cases of domestic violence were three times greater in February 2020 compared to February 2019 [32]. In Russia, the number of calls to domestic abuse hotlines increased from 6,000 in March 2020 to more than 13,000 in April 2020 [33].

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Some authors have also shown a similar increase in developed countries as USA, United Kingdom, Canada and Australia [34][35][36][37]. It still happens, however, far more often in developing countries [38].
Although these data are concerning, they are not unexpected.
It is well-known that 30% of women experience physical or sexual violence by an intimate partner in their lifetime [39].
During catastrophic situations involving humanitarian crisis, such as war scenarios, natural calamities and the ongoing COVID-19 pandemic, the prevalence of domestic violence tends to escalate [40].
Approaches towards ending domestic violence should ideally consist of a mutual collaboration between governmental and non-governmental organizations, aiming fi rst at those women most vulnerable. These should be integrated in order to prevent the problem, whilst providing shelter, psychological support and education to women, particularly in cases where children are involved. Furthermore, fi ghting domestic violence consists of continually solving domestic problems, not only during the pandemic but thereafter. As mentioned above, this is not a new issue. All efforts must be carefully implemented, weighting aforementioned bad experiences we have previously learned from other humanitarian crisis. In fact, we must bear in mind we are currently facing two distinct pandemic situations and a collective effort is required to stop both.