The declaration of the COVID-19 as a global pandemic by the WHO on March 11, 2020, has dramatically affected the public interest and access to medical services (Timeline of WHO’s response to COVID-19 2020). The attention of the general population rapidly shifted as national lockdown orders were imposed, COVID-19 vaccines distributed, and seasonal variations in case numbers endured. This study set out to analyze internet search trends of specific gastroenterological diseases, symptoms, and procedures throughout the pandemic compared to pre-pandemic levels to determine how this event may influence public health and safety measures in the future.
Our study observed a reduction in the relative search volume of 10 of 15 gastrointestinal disease search terms during the early pandemic compared to previous years’ data. Following this downtrend was a relative rebound to baseline during Fall 2020 with reductions in 5 of 15 search terms and only 3 terms by Spring 2021. The issuance of “stay at home” orders in the United States may explain the reductions in RSV when the public focus shifted away from gastroenterological health maintenance to the severe respiratory infection caused by COVID-19 infection (Coronavirus Guidelines for America 2020; KFF 2020). However, the lockdown measures proved necessary to reduce the transmission of COVID-19 by avoiding unnecessary patient traffic in hospitals and from hospitals to the community (Brindle 2020; COVID-surg Collaborative 2020).
Recent literature has cited similar trends in RSV across various medical specialties when comparing the initial phase of the pandemic to later seasons. For example, Esen-Salman et al. conducted a Google Trends analysis of public interest in dermatologic symptoms, conditions, treatments, and procedure search terms throughout the COVID-19 pandemic. Comparable to this study’s findings, there was initially a marked decrease in the public interest, followed by a shift in RSV to levels prior to the pandemic (2021).
Of the 7 search terms related to gastrointestinal symptoms, the phrases “nausea,” “diarrhea,” and “constipation” displayed significant increases in search volume throughout the total study period. Certain gastrointestinal symptoms such as nausea and diarrhea appear prior to presentation with COVID-19 infection, which may explain this finding (Cholankeril 2020). Elucidation of COVID-19 symptomatology through Google Trends may be a valuable indication to screen for possible infection.
The Centers for Medicare and Medicaid Services imposed a temporary measure to “[delay] all elective surgeries, non-essential medical, surgical, and dental procedures” in response to the growing pandemic (Trump 2020; Centers for Medicare and Medicaid Services 2020; Goldman 2020). The postponement was an essential step to reduce the transmission of COVID-19 and ensure both patient and medical personnel safety (KFF 2020; Brindle 2020). Of note, in the Spring of 2020, procedural search terms in 4 of 7 key terms representing sigmoidoscopy, colonoscopy, capsule endoscopy, endoscopy decreased in internet search traffic compared to previous years. Although the reduction in procedures in many hospitals nationwide aided efforts to limit the viral spread, many hospitals and medical practices began operating under maximal capacity (Dhanda 2020).
The COVID-19 pandemic established severe barriers to access adequate care for many patients nationwide. In addition, the growing public fear of entering hospitals and healthcare facilities may have led to delayed diagnosis, progression of specific medical conditions, and decreased overall quality of life (ACS 2020). Khan et al. reported that COVID-19 patients with a pre-existing diagnosis of GI cancers had a significantly higher risk of hospitalization (RR 2.37, 95% CI 2.19-2.55), mechanical ventilation (RR 2.16, 95% CI 1.69-2.75), and mortality (RR 3.81, 95% 3.14-4.63) compared to the control group (2021). Clinicians should take extra caution when delaying treatment and prioritize those with high-risk conditions to prevent worse outcomes in COVID-19 patients with pre-existing GI cancer and delayed access to care.
Mandeep S. Sawhney observed deferral of many gastrointestinal procedures in the early stages of the COVID-19 pandemic to a later period upon formalizing guidelines with more significant safety measures (Sawhney 2020). Many healthcare institutions adapted to the pandemic by implementing new visitation policies, regular COVID testing, proper allocation PPE, along with social distancing to limit the spread of the virus per national recommendations (Francescani 2020). During the Fall 2020 and Spring 2021, COVID-19 cases were at their lowest due to the lifting of lockdown measures and vaccine rollouts available to the healthcare workers and the public. These events led to progressive increases in elective surgeries to meet the growing demand for those treated earlier in the pandemic (Moletta 2020). With the drop in case numbers, there was a significant rebound of two RSV terms, colonoscopy and procedure RSV to near baseline nearly all terms rose above pre-pandemic levels.
Due to the backlog of procedures, multiple medical specialties observed increased workload upon lifting lockdown restrictions and returning to pre-pandemic life. Bhambavani et al. observed a rebound of procedural capacity in May 2021 among all urological procedure categories except male infertility (2020). Similar reports indicate a growing interest in non-essential cosmetic facial plastic surgery in the face of the ongoing pandemic (Dhanda 2020). A single-center prospective cohort study conducted by Dawod et al. indicated that endoscopy procedures with appropriate PPE and preoperative testing are associated with a low risk of periprocedural COVID-19 infection for outpatients and endoscopy unit staff (2021). Proper implementation of infection prevention measures, and increased vaccination efforts, may pave the way for the regular utility of healthcare services.
The COVID-19 pandemic decreased the outreach physicians have in education and guidance for their patients, which may have resulted in decreased RSV compared to previous years. In the field of otolaryngology, there was roughly an 80% reduction in the number of completed appointments from mid-March 2020 to mid-April 2020 compared with the corresponding period in 2019 (Kasle 2020). Furthermore, emergency department consultations for ENT related concerns were reduced by nearly 80% over the course of the pandemic (Shipchandler 2020). To combat the lack of access to medical services, healthcare providers have responded by providing care through telemedicine (Rodriguez 2021). Outpatient visits in GI clinics via telemedicine may serve to reduce exposure to COVID-19 and remove barriers to care for many patients (Keesara 2020).
The COVID-19 pandemic has severely impacted the lifestyle and health of the US population at large. Opportunities for physical activity were limited during the lockdown upon the closure of many gyms, workplaces, and public spaces. During the COVID-19 pandemic, the overall step counts rapidly decreased worldwide (Keesara 2020). As a result, sedentary lifestyles and unhealthy dietary habits became routine for many. An inability to work or exercise, replaced by increased sugar and alcohol intake, may escalate stress and anxiety levels and worsen existing mental health issues (World Health Organization 2020; Foulds 2015; Tison 2020; Mattioli 2020). Nielsen reported a 54% increase in national sales of alcohol for the week ending March 21, 2020, compared with one year before (The Nielsen Company 2020). Furthermore, increased alcohol use is linked to many gastrointestinal conditions such as esophageal squamous cell cancer, gastric cancer, hepatocellular carcinoma, and colorectal cancer (Scherübl 2020). Increased alcohol intake and exaggerated stress response may worsen several functional GI disorders via pathways of the gut-brain axis (Gubatan 2021). It is imperative that physicians take into account lifestyle disturbances caused by COVID-19 to optimize the delivery of high-quality health care.
Although this study has shown a decrease in Google Trends search interest in gastrointestinal topics with subsequent elevations in later periods, there is no evidence to suggest that this could directly impact health outcomes. Another limitation is that internet searches were analyzed via English, whereas many internet searches may have been in a different language. Additionally, only one search engine was used. However, the Google search engine has approximately 90% of the internet market share (StatCounter Global Stats), so it likely represents all internet searches. This study was further limited by the geographical variance in the institution of local lockdown measures and vaccination distribution efforts.