Dear Editor
More than a billion people suffer from different disabilities and require special healthcare due to their special condition compared to others; however, they usually receive less healthcare and face difficulties accessing health and medical services which, in return, can result in adverse health consequences for them [1]. Hence, the emergence of diseases such as COVID-19 can exacerbate the problems of people with disabilities and expose them to extreme health risks due to their disabilities, and weak immune systems. Epidemiological evidence suggests that the COVID-19 is exceptionally contagious and can quickly spread. The transmission speed of COVID-19 is so rapid such that, after the first case detected in Wuhan, China in December 2019 [2], the virus rapidly spread across the world and 223 countries reported 185, 291, 530 verified cases by July 9th, 2021 [3]. The covid-19 pandemic can also cause mental disorders in people, especially vulnerable groups including people with disabilities. Therefore, providing psychological services to these people is not only an ethical duty but also a public health obligation [4]. Another factor that can exacerbate the consequences of COVID-19 pandemic is the lack of regulations for emergency situations for those who suffer from disabilities [5]. Given that 80% of people with disabilities live in low- or middle-income countries with limited capacities to respond COVID-19 pandemic, this disease can increase the mortality rate [6].
In Iran, the first verified case of COVID-19 was reported by the Ministry of Health and Medical Education on February 19, 2020; after two weeks, almost all cities had been affected by the virus [7]. After the official announcement, in order to control the spread of the virus, public and crowded places were closed. For breaking the chain of transmission, people were strongly advised to stay at home and come out only in case of emergencies, pay attention to personal hygiene, and practice social distancing outside. These measures, especially during the peaks of pandemic, are still recommended. These preventive measures resulted in unpleasant experiences in the people with disabilities, particularly due to their physical conditions and dependency on others for performing daily activities. These experiences varied in these people based on the severity of disabilities and the degree of independence. Extreme feelings of anxiety and fear of being infected, the weaknesses in the immune system and the pre-existing diseases, can increase the probability of being infected for a longer period. Furthermore, it can cause various problems for the families, and aggravate the unpleasant experiences. One example of such experiences for people with movement disability who are unable to leave the house is keeping in a separated room by their family for their own health conditions, which can in turn minimize their social interactions. This can result in feelings of loneliness, isolation, depression, and rejection. Given the inability of these people for providing necessities by themselves, they can become anxious and feel worry about their health for transmission of disease from those who go to their house to meet their needs. Accordingly, this can aggravate their unpleasant experiences and increase their risk of infection.
Meanwhile, practicing preventive measures by the employed people (including those with physical and visual disability) can cause different experiences. For this group, staying at home can result in losing their jobs and economic, social, physical problems (e.g., muscle weakness due to immobility), and mental problems such as depression. On the other hand, leaving the house can expose this group to the risk of infection, given that they use assistive devices (such as canes, elbow crutches and wheelchairs), touch surfaces for detecting objects and navigation (in people with visual disability), use public transportation, and receive support from others. In addition, due to special physical and visual limitations, continually washing hands and using disinfectants are difficult for these people. 
On the other hand, in families with intellectual disability and autism spectrum disorder, teaching personal hygiene practices to children and immunizing them from the disease double the difficulty of the situation, and confront families to numerous problems. Aditionally for all disabled groups, The issue of buying personal protective equipment such as masks, gloves and disinfectants is also important especially when it is hard to find these equipment. These situations can bring about bad experiences and intensify their need for support.
Overall, people with disabilities have enough motivation to follow preventive strategies whereas such measures develop specifically by taking into account their unique characteristics in each group and be taught to them and their family members. The support from all responsible organizations for these people and their families in terms of financial support, accessibility to vaccines, providing medical and psychological services tailored to meet their specific needs based on the intensity and type of their disabilities, and preparing personal protective equipment can be effective in helping them which should be considered by policymakers. 
It is recommended that the special needs of people with disabilities be considered in the emergency response plan during the COVID-19 pandemic. Moreover, while supporting the families, it is necessary to consider their psychological problems (such as loneliness, isolation, depression and sadness) in ttheir educations. In the case of children with intellectual disability and autism spectrum disorder, in addition to parents, experts should also intervene in teaching them about confronting the disease. 


References

1. Kuper H, Heydt P. The missing billion: Access to health services for 1 billion people with disabilities. London: London School of Hygiene & Tropical Medicine; 2019. [Link]
2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. The Lancet. 2020; 395(10223):507-13. [DOI:10.1016/S0140-6736(20)30211-7]
3. World Health Organization (WHO). Coronavirus disease (COVID-19) Pandemic. Geneva: World Health Organization; 2019. [Link]
4. Starace F, Ferrara M. COVID-19 disease emergency operational instructions for mental health departments issued by the Italian society of epidemiological psychiatry. Epidemiology and Psychiatric Sciences. 2020; 29:e116. [DOI:10.1017/S2045796020000372] [PMID] [PMCID]
5. Qi F, Hu L. Including people with disability in the COVID-19 outbreak emergency preparedness and response in China. Disability & Society. 2020; 35(5):848-53. [DOI:10.1080/09687599.2020.1752622]
6. Armitage R, Nellums LB. The COVID-19 response must be disability inclusive. The Lancet Public Health. 2020; 5(5):e257. [DOI:10.1016/S2468-2667(20)30076-1]
7. Minisry of Health & Medical Education (MOHME). [Coronavirus epidemic in Iran (Persian)] [Internet]. 2020 [Updated 2020 February 19]. Availble from: [Link]