# The effect of the COVID-19 pandemic on epistaxis and anaemia in patients with hereditary haemorrhagic telangiectasia (HHT) in central South Africa

## TL;DR

This study examines how the COVID-19 pandemic affected nosebleeds and anemia in people with HHT in central South Africa, finding some clinically significant changes.

## Contribution

The study provides specific insights into managing HHT during a pandemic, highlighting the impact of nasal swab testing and other pandemic-related factors.

## Key findings

- Nasal swab testing for SARS-CoV-2 caused nosebleeds in 75% of HHT patients.
- Some patients experienced clinically significant changes in nosebleed severity and anemia during the pandemic.
- The overall changes in nosebleed severity and hemoglobin levels were not statistically significant for the study population.

## Abstract

Recurrent epistaxis, which frequently results in iron deficiency anaemia and impaired quality of life, is the most frequent complication of hereditary haemorrhagic telangiectasia (HHT). Specific data to guide rare disease management during a pandemic such as COVID-19 are lacking.

To better define the impact of the COVID-19 pandemic on HHT, we conducted a retrospective and prospective observational descriptive review of HHT patients in central South Africa. Epistaxis severity scores (ESSs) and haemoglobin (Hb) levels before and after the start of the pandemic were compared. Variables that may have influenced epistaxis severity and anaemia were investigated, viz. (i) mask use, (ii) nasal versus oral swabs to test for SARS-CoV-2, (iii) COVID-19 disease and (iv) its management, (v) COVID-19 vaccines, and (vi) the social impact of the pandemic.

Twenty-four patients with confirmed HHT were included in the study. Subset analyses revealed a clinically significant change in ESSs (≥ 0.71 minimal important difference) and Hb levels (> 2.7% biologic variation) in 6/11 (54.6%) and 12/15 (80%) patients. While the median ESS improved in 2/11 (18.2%) patients, it worsened in 4/11 (36.4%) patients during the pandemic. However, the changes in the median ESS (2.25 pre-pandemic versus 2.5 during the pandemic; p = 0.38) and Hb level (9.5 g/dL pre-pandemic versus 10 g/dL during the pandemic; p = 0.38) for the study population were not statistically significant. Clinical and social variables that may influence epistaxis severity and anaemia were identified. Nasal swab testing for SARS-CoV-2 induced epistaxis in 9/12 (75%) cases and was noted as an important factor.

The COVID-19 pandemic has had a clinically significant impact on epistaxis severity and anaemia in some individuals with HHT in central South Africa. Specific strategies are needed to optimise the management of HHT during the COVID-19 and future respiratory pandemics.