Infectious Respiratory Conditions After SCI

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Author: Sharon Jang | Reviewers: Phillip Popovich, Katherine Mifflin | Published: 2 September 2020 | Updated: 29 February 2024

The adverse effects of a spinal cord injury (SCI) on the respiratory and immune systems can increase the risk of getting an infectious respiratory condition. This page reviews the relationship between SCI and infectious respiratory conditions.

Key Points

  • Many respiratory changes occur after SCI, including a weakened ability or a loss of breathing and/or coughing function.
  • Individuals with acute SCI are more susceptible to infectious respiratory conditions due to a weakened immune system and a potentially lessened ability to cough or clear secretions.
  • As individuals with SCI transition from the acute to chronic, they are less likely to catch infectious respiratory conditions. However, if they do, the condition may present more severely.
  • The best thing to do is to try to prevent these conditions! Strategies such as vaccinations and good hand washing practice can help.

The upper respiratory system (red) and lower respiratory system (blue).1

The respiratory system involves the lungs, and is responsible for breathing, coughing, and speaking. It consists of the upper respiratory tract (nose, mouth, and the throat (pharynx)), and the lower respiratory tract (voice box (larynx), airways (windpipe or trachea), and lungs). Breathing and coughing both depend on various muscles in the chest and neck. Changes to respiratory function after SCI depend on the level of injury and completeness of the injury. After SCI, especially high cervical level injury, some muscles required for breathing may be affected. These include:

  • The diaphragm, which is the main muscle that pulls air into the lungs,
  • The abdominal muscles, which helps to expel air from the lungs and produce a forceful cough, and
  • The muscles in between your ribs (intercostal muscles), which help squeeze air out of the lungs.

The muscles used to breathe are mostly controlled by the upper parts of the spine.2

As a result, sustaining a higher-level injury may result in impaired respiratory function. Some of these changes include:

  • A reduction in the amount of air you are able to breathe,
  • A stiffer lung, making it difficult to take a full, deep breath,
  • A weak or ineffective cough,
  • An increased amount of mucus, and
  • Difficulties with swallowing.

Despite these changes, many technologies and techniques are available that can assist with breathing and coughing. Moreover, the greatest amount of air you are able to blow out after taking your biggest breath in increases over time from injury.

For more information, refer to our article on Respiratory Changes After SCI.

The immune system is responsible for fighting infections and preventing illness. To keep our bodies healthy, the immune system does three main things:

  1. Recognizes harmful germs, such as bacteria and viruses, when they enter the body,
  2. Kills germs and removes them from the body, and
  3. Fights changes in the body that may cause illness (e.g., cancer cells)

Who are the key players in the immune system?

The immune system is comprised of two main parts: the innate immune system and the adaptive (or acquired) immune system. The innate immune system refers to a non-specific line of defence (i.e., it acts against all germs in the same manner) that you are born with. It is often the first line of defense, which is made up of parts of your body that prevent germs from entering. This includes:

  • The outer layer of the skin, which acts as a physical barrier to germs,
  • Mucus and hair, which traps germs,
  • Saliva, which rinses out germs from the mouth,
  • Bodily fluids, such as stomach acid, which kills bacteria, and
  • Urination and defecation, which excretes germs from the body.

Many organs throughout the body contribute to producing cells required to keep you healthy.3

If germs manage to invade the body, the innate immune system is the first system to recognize them. The innate immune system will then trigger a general attack, such as inflammation and fever. This attack affects the entire body, and does not directly target the germ. Innate immune cells then enlist the help of the adaptive immune system.

The second line of defense involves the adaptive immune system, which initiates specific defences for each germ that enters your body. For example, the body will react differently to a virus that causes influenza versus one that causes measles. The main players in the second line of defense are various types of white blood cells. This includes: natural killer cells, which kill any cell that is not recognized as part of the body, lymphocytes, which help the body remember the invaders for the future and destroy them, and phagocytes, which help “eat” and break up invading organisms.

The cells that contribute to the first and second line of defence are produced in organs all over the body, including the bone marrow, spleen, lymph nodes, adrenal glands, tonsils, and thymus.

Spinal Cord Injury Immune Depression Syndrome (SCI-IDS) is a condition that weakens the immune system after SCI. Weak evidence suggests that SCI-IDS commonly occurs among those with acute SCI. That said, there is also early evidence that SCI-IDS can persist and be present in those with chronic (>1 year) SCI. Although researchers are unsure why the immune system is weakened after SCI, hypotheses have been made:

  • SCI-IDS may be a self-defence mechanism that lowers the body’s immunity to prevent the body from attacking itself after the damage that has occurred in the spinal cord.
  • Many of the organs associated with the immune system, such as the spleen, thymus, and lymph nodes, are controlled by the sympathetic nervous system. These nerves are impaired when an individual sustains an injury at T6 or above. As a result, the immune system may not be as active.

A natural killer cell. The number of these cells is decreased after SCI.4

Weak evidence suggests that immune system changes may occur regardless of level of injury. For example, the amount of natural killer cells are reduced in adults with SCI, regardless of level of injury, in comparison to an able-bodied population. This reduces the body’s ability to fight off germs, which may cause infections, disease, and illnesses. Moreover, early animal research suggests that individuals with SCI may be more susceptible to viruses, such as the flu due to impairments in the body’s immunity. However, it is important to note that these findings have not yet been replicated in humans.

Although the immune system recovers after acute SCI, some (weak) evidence suggests that lowered immunity may extend into the chronic stage of SCI. One study investigated the genes responsible for programming and developing immune cells. The authors found that the genes that normally create natural killer cells are reduced, resulting in lower amounts of these germ-fighting cells throughout the body. A second study supported these findings, as individuals with SCI were found to have lower amounts of natural killer cells in their blood compared to an able-bodied population.

Having an SCI in combination with a weakened immune system has many implications for secondary complications. For example, after SCI many individuals may have difficulties with or be unable to effectively void urine, which encourages the growth of bacteria. This, in combination with a weakened immune system, may explain why urinary tract infections (UTIs) are a common secondary complication of SCI. Although SCI complications and a weakened immune system may contribute to many other secondary complications (e.g., UTI, pressure sores), this article will focus on infectious respiratory conditions that are common with SCI.

For more information, refer to our articles on UTIs and Pressure Injuries!

Respiratory infections can occur in anyone, but people with SCI are at a higher risk for the following reasons:

  • Weakened immune system: After SCI, individuals may have a weakened immune system, some researchers believe that this may make them more prone to infections.
  • Reduced/absent respiratory functioning: As people with SCI may have an inability/weakened ability to cough, mucus begins to build up in the airways and the lung. This accumulation of mucus creates a breeding ground for bacteria and viruses.
  • Inhaling your food, drinks, or saliva (aspiration) is common after SCI. This results in these substances collecting in your lung, which may result in pneumonia.
  • Use of mechanical respiratory devices: The use of mechanical ventilation can cause ventilator-assisted pneumonia, especially in hospital environments. If parts of the ventilation system (e.g., tubing) are not cleaned properly, bacteria can grow

The heart (in the center) and lungs are complexly interconnected. The lungs help oxygenate the blood, which is pumped by the heart.7

Infectious respiratory diseases can target either the upper respiratory tract (i.e., the nose, mouth, and throat), or the lower respiratory tract (i.e., the voice box, windpipe, airways into the lungs, and the lungs). Oxygen is required for each organ to function properly. When a part of your respiratory system becomes infected, the amount of air you breathe in may be reduced. This reduces the amount of oxygen available for the body, and may quickly affect the function of the brain and other organs. Moreover, these infections can spread all over the body (sepsis). Once it spreads, it becomes more difficult to treat.

As an SCI can negatively affect respiratory and immune function, the rates of respiratory diseases, such as bacterial pneumonia and influenza, among individuals with SCI is high. In fact, respiratory diseases account for just over 80% of all deaths after SCI. In addition, respiratory conditions often present more severely in SCI. This was shown in a (weak evidence) study, where people with SCI who contracted influenza or pneumonia were 37 times more likely to die from the infection compared to an able-bodied population. Two of the most common respiratory infections in people with SCI are pneumonia and the flu. These conditions are particularly infectious, and are caught through tiny droplets of fluid in the air that may be released as a cough or a sneeze. These droplets may fall on surfaces, and can spread if someone touches the surface, then touches their mouth or eyes.

Some (weak evidence) research done to predict who is more likely to experience respiratory illness after SCI indicated that those with a complete injury and those with tetraplegia are at an increased risk of dying from a respiratory related infection. Another study found that during acute care, those with a complete injury were at a greater risk of getting pneumonia. This is related to the lack of/weakened ability to cough and clear mucus from the airways. Secondary complications that may predispose people with SCI to respiratory illnesses include: obesity, heart disease, asthma, chronic obstructive pulmonary disease (COPD), chronic coughing, chronic existence of phlegm, wheezing, and the use of pulmonary medications.

Pneumonia and SCI

Pneumonia is an infection caused by a bacteria or virus, which leads to an infection of the small air sacs in the lungs. It is one of the most common infections in acute SCI with about 30% of individuals with acute SCI experiencing pneumonia (weak evidence), dropping to about 3.5% in the chronic stages of SCI (i.e., 1-20 years post injury). Although the chance of getting pneumonia decreases after acute SCI, it is important to remember that pneumonia manifests more severely in people with SCI. That is to say, while your chances of getting pneumonia may be reduced at longer times after SCI, if you do get it, it is more severe.

Influenza and SCI

Influenza, or the flu, is a respiratory condition caused by a virus. There are multiple types and sub-types of influenza, although type A and B are the strains that most often cause the flu season. The flu virus affects the nose, throat, and sometimes the lungs, and can lead to secondary conditions such as pneumonia. Flu vaccines are recommended, especially for people with SCI as they are a vulnerable population. There is weak evidence that supports the use of flu vaccines for people with SCI, as their immune system responds similarly to the vaccine compared to able-bodied individuals. That said, those with tetraplegia may have a reduced response to the vaccine. Animal studies suggest that vaccines may be less effective with higher levels of SCI. More research is required to determine the response to influenza vaccines after SCI.

Other infectious respiratory conditions and SCI

There are many other infectious respiratory conditions that exist, such as the common cold, tuberculosis, and coronaviruses. However, little to no research has been done on the impact of these conditions in the SCI population. Although the available research is limited, it is important to note that individuals with SCI are still at an increased risk of contracting these conditions. The following section describes various respiratory infections in the able-bodied population unless otherwise noted.

Common Cold

The common cold (or simply, the cold) is a general term for a mild upper respiratory tract condition affecting the nose and throat. Common symptoms include stuffy nose, sneezing, sore throat, and cough. Unlike other conditions, there are multiple types of viruses that can cause a cold. Rhinoviruses, coronaviruses, and influenza viruses account for the majority of cases. The cold occurs most frequently in the fall, and decreases upon the arrival of spring. On average, a person will catch the cold once a year, but it is likely that this rate is underestimated.


A coronavirus (above), which gets its name from the spikes on the outside that resemble a crown, which is “corona” in Latin.10

Coronaviruses are responsible for many health conditions including the common cold, Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS), and novel coronavirus disease 2019 (COVID-19). These are the four strains of coronavirus now known to affect humans, and they are responsible for 10-30% of upper respiratory tract infections. Although these viruses are genetically related, they cause very different conditions. The severity of the conditions they may cause varies from mild (such as the common cold, described above), to severe (such as MERS, SARS, and COVID-19). Though MERS, SARS, and COVID-19 can all lead to pneumonia, each condition affects the body differently: MERS has a greater impact on the digestive system and kidneys, while SARS and COVID-19 most heavily impact the respiratory system, clotting function, and heart activity.

The 2019 Novel Coronavirus (COVID-19)

The COVID-19 outbreak began in 2019 in Wuhan, China, and has since spread around the world in 2020. Currently, little is known about the virus and the infection it causes, though research is on-going. The virus appears to attack the respiratory system, resulting in symptoms such as cough, shortness of breath, and pneumonia, in addition to fever and kidney failure. The extent of the symptoms ranges from mild to severe, and it is possible for someone to be infected without symptoms. This virus has caused a sense of unease among the SCI community. In a survey conducted by a group of researchers, some of the most common concern included increased vulnerability to infection, decreased availability of caretakers, inability to obtain medical supplies, the inability to be appropriately tested, an inability to travel to medical appointments, and an inability to self-quarantine.

To date, few weak evidence studies on COVID-19 and SCI have been completed. This biggest take away is that the typical symptoms of COVID-19 as reported by the World Health Organization (i.e., cough, fever, and shortness of breath) are not necessarily applicable to people with spinal cord injuries. As coughing is often impaired with SCI, it can be absent in reported cases of COVID-19 in people with SCI.

Instead, common symptoms of COVID-19 in people with SCI include a fever and feeling weaker than normal. Other symptoms that have been reported include shortness of breath, body aches/worsening pain, sweating, chest pain, and increased spasticity, a worsened ability to clear secretions, and abnormally fast breathing. Although people with SCI may have fewer of the typical COVID-19 symptoms, one study has found that they are more likely to experience COVID-19 more severely compared to able-bodied individuals.


Tuberculosis is an infection of the lungs that can be caused by Mycobacterium tuberculosis bacteria. The presence of tuberculosis is higher in developing countries in comparison to developed countries. This is related to factors such as lower rates of vaccination and higher rates of HIV (an immune compromising condition) in developing countries. Treating tuberculosis is particularly difficult, as many strains of the virus/bacteria are resistant to drugs.

Upper respiratory tract infections

Upper respiratory tract infections are a group of conditions that affect the nose and throat. Some conditions include pharyngitis (sore throat) and laryngitis (inflammation of the voice box; when you lose your voice). These infections are of particular note to those using ventilators, as over 90% of pneumonia and hospitalizations start with an upper respiratory tract infection.

In order to avoid getting infectious respiratory conditions, prevention is key, especially in the community. Here is what you can do to stay healthy:

  • Wash your hands with warm water and soap for 20-30 seconds
  • Get vaccinated for pneumonia and the flu. Vaccinations are especially important, as weak evidence suggest that rates of vaccination are still low.
  • Stay hydrated! Drinking water can help loosen up the mucus in your lungs.
  • Clean surfaces that may have been in contact with a sick person. This includes parts of your wheelchair, including the joystick, pushrims, etc.
  • Avoid smoking. Smoking can damage the lung’s ability to fight infections, which can compound issues with an already weak immune system.
  • Practice good health habits, such as exercising and having a healthy diet.
  • Stay home if you are sick.
  • Let the people around you know you are feeling unwell. This way they can check up on you and know to avoid close contact.

After an SCI, respiratory functions (i.e., breathing and coughing) and the immune system are compromised. Researchers are still unsure about why the immune system is suppressed. While there is some weak evidence for why the immune system changes after SCI, more clinical trials are required to determine the specific effects of SCI on the immune system.

Given the changes to respiratory and immune functioning after SCI, there is a higher risk of getting an infectious respiratory disease. The best thing to do is to work at prevention, which can be done through a variety of ways such as getting vaccinated and staying hydrated. Discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

SCIRE Community. “Respiratory Changes After SCI”. Available from:

SCIRE Community. “COVID-19 & SCI Infographic”. Available from:

Parts of this page has been adapted from SCIRE Professional “Respiratory Management Following Spinal Cord Injury” Module:

Sheel AW, Welch JF, Townson AF (2018). Respiratory Management Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. Vancouver: p. 1-72.
Available from: 

Evidence for “What is the immune system” is based on:

Tortora, G.J., and Derrickson .B.(2013).The Lymphatic System and Immunity. In Roesch, B. (Eds.), Principles of Anatomy and Physiology (pp. 366-447). Biologtical Science Textbooks

Evidence for “What happens to the immune system after SCI” is based on:

Allison, D. J., & Ditor, D. S. (2015). Immune dysfunction and chronic inflammation following spinal cord injury. Spinal Cord, 53(1), 14–18.

Campagnolo, D. I., Dixon, D., Schwartz, J., Bartlett, J. A., & Keller, S. E. (2008). Altered innate immunity following spinal cord injury. Spinal Cord, 46(7), 477–481.

Popovich, P., & McTigue, D. (2009). Beware the immune system in spinal cord injury. Nature Medicine, 15(7), 736–737.

Schwab, J. M., Zhang, Y., Kopp, M. A., Brommer, B., & Popovich, P. G. (2014). The paradox of chronic neuroinflammation, systemic immune suppression, autoimmunity after traumatic chronic spinal cord injury. Experimental Neurology, 258, 121–129.

Riegger, T., Conrad, S., Schluesener, H. J., Kaps, H. P., Badke, A., Baron, C., … Schwab, J. M. (2009). Immune depression syndrome following human spinal cord injury (SCI): A pilot study. Neuroscience, 158(3), 1194–1199.

Herman, P., Stein, A., Gibbs, K., Korsunsky, I., Gregersen, P., & Bloom, O. (2018). Persons with Chronic Spinal Cord Injury Have Decreased Natural Killer Cell and Increased Toll-Like Receptor/Inflammatory Gene Expression. Journal of Neurotrauma, 35(15), 1819–1829.

Evidence for “Why are people with SCI at higher risk for respiratory infections” is based on:

Brommer, B., Engel, O., Kopp, M. A., Watzlawick, R., Müller, S., Prüss, H., … Schwab, J. M. (2016). Spinal cord injury-induced immune deficiency syndrome enhances infection susceptibility dependent on lesion level. Brain, 139(3), 692–707.

Burns, S. P. (2007). Acute Respiratory Infections in Persons with Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America, 18(2), 203–216.

Evidence for “What infectious respiratory conditions should I be aware of?” is based on:

Northwest Regional Spinal Cord Injury System. (2004, October 12). Common respiratory problems in SCI – What you need to know.

DeVivo, M. J., Black, K. J., & Stover, S. L. (1993). Causes of death during the first 12 years after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 74(3), 248–254.

Stolzmann, K. L., Gagnon, D. R., Brown, R., Tun, C. G., & Garshick, E. (2010). Risk factors for chest illness in chronic spinal cord injury: a prospective study. American Journal of Physical Medicine & Rehabilitation, 89(7), 576–583.

Berlly, M., & Shem, K. (2007). Respiratory management during the first five days after spinal cord injury. Journal of Spinal Cord Medicine, 30(4), 309–318.

McKinley, W. O., Jackson, A. B., Cardenas, D. D., & DeVivo, M. J. (1999). Long-term medical complications after traumatic spinal cord injury: A Regional Model Systems Analysis. Archives of Physical Medicine and Rehabilitation, 80(11), 1402–1410.

Trautner, B. W., Atmar, R. L., Hulstrom, A., & Daroiuche, R. O. (2004). Inactivated Influenza Vaccination for People With Spinal Cord Injury. Arch Phys Med Rehabil, 85(11), 1886–1889.

Centers for Disease Control and Prevention. (2020a). Understanding influenza viruses.

Centers for Disease Control and Prevention. (2020b). Prevent seasonal flu.

Burns, S. P. (2007). Acute Respiratory Infections in Persons with Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America, 18(2), 203–216.

Rao, N. M. (2015). Swine flu the pandemic disease – preventive measures to take. Journal of Medical Science and Technology, 4(1), 1–2.

Heikkinen, T., & Järvinen, A. (2003). The common cold. Lancet, 361(9351), 51–59.

Paules, Catharine, I., Marston, H. D., & Fauci, A. S. (2020). Coronavirus Infections – More than Just the Common Cold. Journal of the American Medical Association, 323(8), 707–708.

Stillman, M. D., Capron, M., Alexander, M., Di Giusto, M. L., & Scivoletto, G. (2020). COVID-19 and spinal cord injury and disease: results of an international survey. Spinal Cord Series and Cases, 6(1), 21.

Rodriguez-Cola, M., Jimenez-Velasco, I., Henares-Gutierrez, F., Lopez-Dolado, E., Gambarrutta-Malfatti, C., Vargas-Baquero, E., & Gil-Agudo, A. (2020). Clinical features of coronavirus disease 2019 (COVID-19) in a cohort of patients with disability due to spinal cord injury.

Righi, G., Del, G., & Popolo, G. Del. (2020). COVID-19 tsunami : the first case of a spinal cord injury patient in Italy. Spinal Cord Series and Cases, 3–7.

Mayo Clinic (2020). Tuberculosis.

World Health Organization. (2020). Tuberculosis.

Evidence for “What can you do to prevent infectious respiratory conditions” is based on:

LaVela, S. L., Smith, B., & Weaver, F. M. (2007). Perceived Risk for Influenza in Veterans With Spinal Cord Injuries and Disorders. Rehabilitation Psychology, 52(4), 458–462.

Ronca, E., Miller, M., Brinkhof, M. W. G., Jordan, X., Léger, B., Baumberger, M., … Fekete, C. (2020). Poor adherence to influenza vaccination guidelines in spinal cord injury: results from a community-based survey in Switzerland. Spinal Cord, 58(1), 18–24.

Weaver, F. M., Smith, B., LaVela, S., Wallace, C., Evans, C. T., Hammond, M., & Goldstein, B. (2007). Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders. Journal of Spinal Cord Medicine, 30(1), 10–19.

Image credits
  1. Modified from 2301 Major Respiratory Organs ©Anatomy and Physiology, Betts et al., CC BY 3.0
  2. Modified from Neck muscles, lateral view ©Olek Remesz, CC-BY-SA 2.5; A cutout of the thoracic wall showing the three layers of intercostal muscle – from the left wall ©CFCF, CC BY-SA 4.0; Pectoralis Major ©Anatomy and Physiology, Betts et al., CC BY 3.0; Respiratory system ©Theresa knott, CC BY-SA 3.0
  3. Modified from: Outlines ©Servier Medical Art, CC BY 3.0; Lymph Node ©Servier Medical Art, CC BY 3.0; Thymus ©Servier Medical Art; Spleen ©Servier Medical Art; Colon ©Servier Medical Art; File 603: Anatomy of long bone ©Anatomy and Physiology, Betts et al., CC BY 3.0
  4. Human Natural Killer Cell ©NIH NIAID, CC BY 2.0
  5. DNA ©Servier Medical Art, CC BY 3.0
  6. Coronavirus infographic symptoms and prevention©Freepik, Freepik License
  7. Modified from Heart ©Servier Medical Art CC BY 3.0; Pulmonary circulation ©Servier Medical Art, CC BY 3.0
  8. Lobar pneumonia illustrated ©NIH
  9. Sneezing ©Andrei Yushchenko, CC BY 3.0
  10. 3D medical animation coronavirus ©Scientific Animations
  11. Infographic with details about coronavirus with illustrated sick man ©Freepik, Freepik License
  12. Syringe shot medicine bottle medical needle ©qimono, Pixabay License


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

COVID-19 Factsheet: Guidance for SCI Caregivers

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Author: The SCIRE Professional Team | Reviewers: Cynthia Morin, Andrea Townson | Published: 5 August 2020 | Updated: ~

People living with spinal cord injuries (SCI) have a greater risk of developing more serious symptoms of COVID-19. It is critical for caregivers and attendant services to take the necessary precautions and preventive actions outlined in this document in order to minimize the risk of transmission.

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Wash hands often

  • Use soap and water to wash hands for 30 seconds before and after contact with your client.
  • Use a hand sanitizer (with at least 70% alcohol) if soap/water are not available.

Clean and disinfect

  • Clean frequently touched surfaces in client’s home (e.g. doorknobs, light switches, counters, cabinets, phones, remote controls, handles on toilets and faucets) once every few days using soapy water to wipe away debris/dirt.
  • After cleaning, use only disinfectants (e.g., Clorox, Lysol, Microban) that have a Drug Identification Number (DIN) and have been approved by Health Canada for use against COVID-19 in Canada/your country’s standards.
  • For clients who use mobility aids or other equipment, regularly clean the: wheelchair joystick, armrest, wheel rims, mechanical lift controller and other frequently used surfaces.
  • If approved disinfectants are not available, a diluted bleach solution can be prepared for household disinfection in accordance with the instructions on the label, or follow instructions for proper handling of household (chlorine) bleach.
  • Place contaminated laundry (including non-medical cloth masks), into a container with plastic liner.
    • wash using regular laundry detergent and hot water (60-90°C)
    • wear gloves when handling laundry
    • clean hands with soap and water for 30 seconds immediately after removing gloves

Protective equipment

  • If your caregiving role requires the need to be within 2 metres (6 feet) to assist with daily tasks (ex. Bathing, brushing teeth, dressing) wear personal protective equipment such as: a medical mask, disposable gloves, and eye protection.
  • Do not re-use medical masks or gloves. However, under extreme supply limitations, masks may be re-used if not visibly damaged, contaminated, or wet.
    • If a mask is re-used, prevent contamination by storing it in a clean paper/plastic bag, or cleanable container with a lid (discard bags after each use)
    • Healthcare practitioners have been instructed to use 1 mask/day (put on when entering facility/home and removed when eating or leaving facility/home at end of shift)
  • Place used medical masks, gloves, and other contaminated items in a lined container, secure the contents and dispose of them with other household waste.
    • Take gloves off first, wash hands, then remove mask
    • Clean your hands again with soap/water/hand sanitizer before touching your face/other surfaces

Caregivers should create a back-up care plan for clients

  • Decide who can step in if you are unable to provide care for your client.
  • Consider the specialized tasks you manage for people with SCI and expand your circle of care to include a person with SCI’s family members or friends who may be able to help if necessary.
  • Use video platforms (Facetime, Skype, Zoom) to review the plan with your circle and recipient to ensure they are comfortable with the backup-plan.

The care plan should include the following:

  • Contact information for: doctors, clinics, pharmacy, family, friends, neighbours, home and community care case managers, and food delivery.
  • Information regarding the client’s condition (medical history, allergies, specific needs etc.).
  • A schedule of what your typical tasks look like with enough detail for someone to follow and take over if need be.
  • A list of names and doses of medications and when they are given to the recipient.
  • A list of important supplies that need to be purchased regularly (e.g., toilet paper, cleaning supplies, hygiene products).
  • Information about their likes and dislikes, self-care routines, and food preferences.
  • Additional non-perishable food items to ensure your client has continued access to healthy meals.
  • A list of essential items your client needs if they need to leave their home or require hospitalization.

A podcast created by caregivers of BC who share their experiences, “highlighting the joys, trials, and self-discoveries that come along with this rewarding and taxing position”: Caregiving Out Loud Podcast

Advice provided from the Government of Canada for Caregivers in caring for a person with COVID-19 at home

Tip sheet created by the Ontario Caregiver Organization. Provides resources/education on improving caregiver mental health during COVID-19.: Tips for Caregivers Mental Health During COVID-19

The Family Caregivers of BC provide multiple tips and resources for caregivers to practice self-care.: Self-Care Tips During Uncertain Times

Coronavirus Disease 2019 (COVID-19) Fact Sheet. (2020, March 4). Retrieved from: (

Public Health Ontario (2020, February 14). Coronavirus Disease 2019 (COVID-19) Self-isolation: Guide for caregivers, household members and close contacts. Retrieved from:

Public Health Agency of Canada (2020, May 1). How to care for a person with COVID-19 at home: Advice for caregivers. Retrieved from:

Public Health Ontario (2020, April 10). Coronavirus Disease 2019 (COVID-19) When and How to Wear a Mask Recommendations for the General Public. Retrieved from:

The Ontario Caregiver Foundation (2020, March 31). COVID-19 – Do you have a plan? Retrieved from:

Family Caregivers of British Columbia (2020, March 11). COVID-19. Retrieved from:

Image credits

  1. Hand Washing ©AnnaliseArt, Pixabay
  2. Cleaning Supplies ©MarCuesBo, Pixabay
  3. Protective Equipment ©artpolka Pixabay
  4. Checklist©OpenClipart-Vectors, Pixabay


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Mental Health Support and SCI

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Author: SCIRE Professional Team | Reviewer: Rachael Neal | Published: 5 August 2020 | Updated: ~

Living during the COVID-19 pandemic can be stressful, and it is common to feel worried, sad, or anxious from time to time. This sheet contains information about some resources, techniques, and tips to help support your mental health in the time of COVID-19.

Key Points

  • The COVID-19 pandemic may cause increased mental health concerns in people who have already experienced sweeping changes in life due to spinal cord injury (SCI).
  • Feelings of worry and anxiety in times of global uncertainty are common, and it is important to know that you are not alone.
  • Learning to recognize and acknowledge your anxiety and to engage in concrete, meaningful actions and activities can help you manage your worries.
  • Refer only to reliable sources of news about COVID-19. Limiting yourself to appropriate information consumption can reduce the likelihood of feeling overwhelmed or in danger.

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How can I organize and structure my day to benefit my wellbeing?

Our normal daily routines and activities are changing with the current pandemic situation, which can feel unsettling. You may find that some things you usually did to look after your wellbeing have become difficult to carry on. Though you may not have control over those changes, you can focus on what choices and coping strategies you have that are within your control.

Maintain balance

Try organizing your days to include a variety of activities that you know will improve your general mood. You can strive for a routine that is a balance of activities that give you feelings of pleasure, achievement, and closeness.

You will get a sense of accomplishment when you, for instance, choose to finish a work task, complete an exercise routine, or learn to cook a new recipe. A pleasure activity may be reading a book or watching a favourite comedy show. Schedule a video call with a friend or family to feel connected.

If you feel overwhelmed or unmotivated, break tasks down to pieces that you can work on, or set a goal to work for a small chunk of time rather than having the goal to finish something all at once.

What can I do to deal with this time of uncertainity to help me to stay in a healthier place?

As someone with a SCI, you have likely already experienced uncertainty. It is the ‘not knowing’ how things are going to turn out that can be difficult to cope with. The coronavirus uncertainty and isolation can be particularly worrying when you have additional health care needs.

There are different levels of worry and anxiety. Anxiety is a natural emotion and worrying is common during change. Remind yourself that you will not feel this way forever and that there are things you can do to cope. Use the diagram on the left to see if you are in the ‘fear zone’ and identify specific steps you will try to move towards learning and growth zones.


Why do I worry even when nothing seems wrong, and how do I stop it?

It is common during times of uncertainty, like the COVID-19 pandemic, that you may notice more worry thoughts, some even leading to worst-case scenarios. The graphic below illustrates how worries can quickly escalate even from something relatively minor that you would not have recognized as being a worry trigger before.

To reduce this type of worry, the first step is to practice noticing when your thoughts are reaching a later, more catastrophic point. For instance, if you first notice a feeling of anxiety, ask yourself, “What was I just thinking?”. Step back to the event that began your worries, and ask yourself if you have reasonable evidence to believe that the initial event is likely to lead to the worst-case scenario, or whether there may be other explanations you can consider. Are you are assuming a negative outcome when the situation is actually an unknown?

Think of a strategy that may have helped you with a similar problem in the past. Make a list of things that generally help you relax and choose one that is possible to do now.

Which category does your worry fall into?

Worry becomes a problem when it stops you from living the life you want to live, or if it leaves you feeling helpless or exhausted.

Assess the impact of your worries on your life. Seek professional help if you are noticing that you are not able to carry out important roles or activities in your life because of interference from worry.

Worry Time

Another effective strategy is designating a specific Worry Time – schedule a time for later in the day when you allow yourself to worry as much as you feel the need to. This can be helpful in two ways:

  1. It can prevent worry from interfering with your important daily activities, and
  2. Postponing worry can sometimes circumvent the worry from happening at all (at the scheduled time, you may not even feel like worrying, in other words, it was an ‘in the moment’ worry).

Worry Time may be particularly effective if your worry is hypothetical or in the future (and action is not possible). The worry should be put aside, and your attention focused on a technique or activity that will distract you from your worry thoughts (re-focus on something that is in the present).

The current pandemic has brought many changes to the lives of people with SCI, and you may notice yourself having new or different concerns for your well-being. Awareness and reminders of active, positive coping strategies are especially important.

Even though there is much about the COVID-19 situation that you cannot control, you can shift your focus to what you can influence and have power over:

  • Choose your routine. Plan how you spend your time and what you focus on during the day.
  • Choose your distractions. Have a list of small, practical, or creative tasks that you can easily accomplish.
  • Choose your information. Limit how much news you watch and when you take in new information.

“With awareness and active steps, we can exercise the positive power of being able to recognize our fear and patterns of survival” (Vicki Enns, Clinical Director, Crisis & Trauma Resource Institute)

Duff, J. (2000). Coping Effectiveness Training reduces depression and anxiety following traumatic spinal cord injury. Proceedings of the British Psychological Society, 8(1): 17.

Whalley, M. & Kaur, H. (2020, March 19). Free Guide To Living With Worry And Anxiety Amidst Global Uncertainty. Retrieved from

Enns, V. (2020, May). How to Cope with Post-Traumatic Stress During COVID-19. Retrieved from:

Wilkinson, A., Meares, K., Freestones, M. (2011). CBT for worry & generalised anxiety disorder. London: Sage.

Image credits

  1. Learning Zone model by Tom Senninger. Creative Commons BY-NC-SA 4.0
  2. Escalator clip art © DLPNG Creative Commons
  3. Afraid © Stephanie Heendrickxen Creative Commons
  4. Man © corpus delicti Creative Commons
  5. Stop Light Icon #432967 © Free Icons Library Creative Commons
  6. Woman © Crello Creative Commons
  7. Clock © Crello Creative Commons
  8. Thought bubble © Crello Creative Commons
  9. Man on computer © user:cth103_t Creative Commons


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Spinal Cord Injury Specifics

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Author: SCIRE Professional Team | Reviewers: Cynthia Morin, Andrea Townson | Published: 4 August 2020 | Updated: ~

Key Questions

  • Are you at a higher risk for COVID-19 because of your SCI?
  • What are the precautions you can take to prevent exposure to the virus?
  • How can you keep your assistive devices/equipment clean and virus-free?
  • How can you keep your assistive devices/equipment clean and virus-free?
  • What can you do to ensure your interactions with others are safe?
  • When should you seek medical attention, and what do your healthcare providers need to know?

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What we know about the risks for people with spinal cord injury (SCI) is based on how SCI and COVID-19 both affect the body.

Respiratory function

Everyone with SCI has some level of impairment in respiratory function given how SCI weakens breathing muscles, however people with cervical and upper thoracic levels of injury may have greater impairments than those with lower thoracic levels of injury. Still, all levels of SCI above T12 have a reduced ability to both inspire air maximally and to forcefully expel air through coughing. With an impaired cough, individuals are less able to manage respiratory secretions.

Other risk factors

  • Some complications (common secondary health issues of SCI), such as cardiovascular disease or higher body mass index (BMI), may increase the risks of a more serious case of COVID-19.

People with SCI may also have a greater risk of exposure to COVID-19, as those who require assistance cannot avoid contact with caregivers.

Given that there is no current treatment for COVID-19 other than supportive care, it is best to take precautions to avoid exposure to the virus whenever possible.

  • Practice physical distancing (6 feet), avoid large groups and stay home when possible.
  • Clean all surfaces regularly with soap and warm water or antibacterial solution.
  • Wash your face and hands after being in public or having in-person conversations.
  • Wash clothes after each wear and if possible separate indoor and outdoor clothes.
  • Learn about home delivery options from grocery stores, pharmacies, and other institutions providing essential services.
  • Keep 30 days of medications and medical supplies on hand (i.e., catheters, wound dressings, disposable gloves).
  • If you require the assistance of caregivers, ensure that they use PPE and follow protocols re: minimizing the transmission of COVID-19.
  • Learn how you can connect with your local SCI organization (e.g., SCI-BC).

Maintaining a clear respiratory tract

• Stay hydrated to keep lung secretions thin.
• Change positions frequently, and use gravity to help clear your lungs.
• Practice deep breathing and coughing exercises to strengthen respiratory muscles.
• Eat healthy, well-balanced meals to boost your immune system.

Wheelchair users

As a wheelchair user, it is especially important to keep at least 6 feet from another person. Because your head is lower than people who are standing you may be more vulnerable to respiratory droplets. You may consider wearing eye protection when you are not able to maintain physical distancing.

Manual wheelchairs
  • If possible, avoid making contact between your hands and your tires when pushing (and launder your pushing gloves frequently).
  • Remove your pushing gloves and/or put on disposable gloves before touching or cleaning your chair.
  • Use antibacterial solution to clean wheels, brakes, and push rims.
  • Wash your hands then avoid touching your tires if possible (use paper towels or cloth to cover when transferring).
Power wheelchairs
  • Use antibacterial solution on a cloth to clean the joystick (and any other controls), armrests, tray, and headrest (have someone help you if needed).
  • Get assistance to help wash or sanitize your hands if unable to do so independently.

Things to note about assistive devices

  • Regularly clean assistive devices with antibacterial products (i.e., splints, cuffs, braces, “reachers”, canes, crutches, handgrips and brakes, storage compartments).
  • Refresh your memory about best practices for using your devices safely.
  • Complete a maintenance check.
Ventilators and respirators
  • Wash hands before and after working with the ventilator.
  • Ensure caregivers wear a mask or eye shield when suctioning secretions.
  • Clean and disinfect medical equipment according to manufacturing descriptions.
  • Change filters according to manufacturing descriptions.

Avoid using your mouth: Ask for help, especially if others are in contact with the materials.

On the following list, check off which guidelines you already practice. Determine where you can make improvements to ensure your own safety, and the safety of those around you.

Ensure someone is available to address any of your urgent needs

Wear a mask, and request that those around you also wear a mask

Have others wash their hands when they arrive and each time interacting with you

Avoid having others directly touch your face, or their own

Ask others to stay home if they are unwell (temperature >38° or 100.4°F), if they are exhibiting any symptoms of COVID-19, or if they have possibly been exposed to an unwell person

Plan backup caregivers, and prepare others who may be needed to support you in an emergency

Let sick employees who are sent home know that there is an EI sickness benefit for those forced to quarantine due to COVID-19

Read through the SCIRE Caregiver Fact-sheet

Medical appointments

Confirm that you provider is still seeing patients, or if an online virtual health service is available. In deciding whether to attend regular medical appointments, discuss the urgency of appointments with your doctor/care provider. Some appointments if delayed can lead to serious health risks, but others can be safely postponed (especially given additional COVID exposure risks).

When to seek medical care if you think you have COVID-19:

  • If you think you are infected with COVID-19, read what to do from a reputable diagnostic source (e.g., the BC CDC website).
  • If you are at a greater risk of developing severe symptoms (i.e., upper thoracic and cervical levels of SCI), visit the hospital when experiencing any shortness of breath.
  • If it becomes harder to breathe, you are unable to swallow, or you feel much worse than when you got tested, seek immediate medical care at an urgent care clinic or Emergency department.

When interacting with emergency services be sure to:

  • Inform medical providers/emergency responders about your SCI and how it affects your respiratory system.
  • Provide breathing equipment, assistive devices, and/or a personal directive.

Evidence for “COVID and SCI Specifics” is based on:

FAQs About COVID-19 and SCI/D with Mount Sinai’s Dr. Bryce (2020, March 30). Retrieved from:

Information for people with paraplegia about the corona virus. (2020, March 26) Retrieved from:

COVID-19 Guidance for People Living with Spinal Cord Injury. (2020, March 12). Retrieved from:

Public Safety Canada and Emergency Management Ontario. (2010). Emergency Preparedness Guide for People with Disabilities/Special Needs. Retrieved from:

Vetkasov, A. & Hoskova, B. (2014). Special Breathing Exercises in Persons with SCI and Evaluate their Effectiveness by Using X-ray of Lungs and Other Tests. Athens Journal of Sports. 1. 217-223.

Health and Safety in the Time of COVID-19. (2020, May 1). Retrieved from:

COVID-19 Guidance for the SCI Community. (2020, March 19). Retrieved from:

Spinal Injuries Association on SCI and Coronavirus. (2020, March 6). Retrieved from:

Maffin, J (2020, May 25) SCI and COVID-19 Frequently Asked Questions (FAQ). Retrieved from:

ACI-NSW Agency for Clinical Innovation (2020, March 19). Information on Coronavirus (COVID-19) for people with Spinal Cord Injury. Retrieved from:

Image credits

  1. Virus © Freepik, Flaticon licence
  2. Spine © Freepik, Flaticon licence
  3. Washing Hands © Freepik, Flaticon licence
  4. Groceries © Freepik, Flaticon licence
  5. Infected Lungs © Freepik, Flaticon licence
  6. Wheelchair © Freepik, Flaticon licence
  7. Controller © Freepik, Flaticon licence
  8. Walker © Freepik, Flaticon licence
  9. Broken Arm © Freepik, Flaticon licence




Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Social Isolation and SCI

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Author: SCIRE Professional Team | Reviewer: Rachael Neal | Published: 23 July 2020 | Updated: ~

In the time of COVID-19, physically distancing is necessary to limit virus transmission and to keep everyone as safe as we possibly can. However, social isolation can have serious effects on mental health for everyone, including those with spinal cord injury (SCI).

Key Points

  • Social isolation is the absence of relationships and interactions with one another and is linked to mental health issues like depression and anxiety.
  • People with SCI may be at increased risk for the negative effects of social isolation.
  • Consider seeking help if you experience symptoms such as marked changes in personality, difficulty coping with daily activities, prolonged sadness, or excessive worry.
  • Strategies to maintain good health while physically distancing include daily structure, reaching out to others, good diet/hydration, and regular exercise.

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What is social isolation?

Social isolation is described as the absence of relationships, often due to physical separation from others. This differs from loneliness, which is a state of distress caused by feeling alone or separated.

Social isolation has been linked to various mental health issues, such as higher fatigue and depression rates. People who are socially isolated often report more difficulties with access and fewer close relationships.

Am I at increased risk for these potential effects if I have an SCI?

People with SCI are not necessarily more vulnerable to the effects of social isolation. However, research shows a higher proportion of depression and anxiety in people with SCI compared to the general population. The COVID-19 pandemic may limit access to caregivers or peer support networks that people with SCI depend on which can worsen symptoms of depression and anxiety.

You may want to reach out to a professional if you experience any of the following symptoms to the extent that it is concerning to you or close others:

  • Marked changes in mood, eating or sleeping patterns
  • Excessive anxiety
  • Prolonged sadness, depression, or apathy (disinterest)
  • Thoughts or statements about hurting yourself, harming others, or suicide
  • Increased substance use or using substances in ways that could be harmful
  • Excessive anger, irritability, hostility, or violent behavior

Look after your general health

There are direct links between mental health and physiological health. So, it is especially important at a time like this to take care of your general health. Stay mentally and physically active, have proper nutrition, hydrate well, and get enough sleep. Maintaining physical health can help serve as a buffer for emotional stress as we are more likely to feel that we have the resources to cope with stress when we are rested and eating well versus when we are tired and hungry.

Manage your worry

Some degree of worrying at a time like this is normal, but it is important to note if your worry is excessive, or if worry thoughts are interfering with your ability to do other things.
Strategies you can employ if you are feeling worried include:
• Noticing and limiting your exposure to things that trigger your worry,
• Practice postponing your worry to a later time, and
• Relying on reputable news sources to ensure your information regarding the pandemic is up-to-date and accurate.

Set a routine

Setting a routine can help you maintain a sense of normalcy during the pandemic. Stick to the usual structure of your day as best as you can by eating, exercising, and sleeping at the same times that you normally would. By setting a routine, many people find that they feel have a sense of purpose and predictability that is comforting. Using structure can also encourage us to work on tasks, which can bring feelings of accomplishment, and that feeling of accomplishment is naturally rewarding.

Stay connected

In the digital age, there are many ways to stay connected virtually to your loved ones. Videochatting, calling, and messaging is possible through many different platforms. ForaHealthyMe SCIO: Home is an example of a virtual platform established for connecting people with SCI.
As restrictions to physical distancing are slowly relaxing, it is possible to physically meet some of your loved ones in small numbers and at a safe distance from each other (it is still important be cautious and maintain physical distancing).

Be knowledgeable and take appropriate precautionary measures

A study has shown that being up-to-date with accurate health information (e.g., treatment, local outbreak situation) and taking particular precautionary measures (e.g., hand hygiene, wearing a mask) was associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression. Taking recommended steps to protect your health (e.g., washing your hands, mask use) can also remind you of the strategies that are currently within your control, which can also increase your self-confidence in coping with uncertainty over time.

Reach out for help if needed

Most of us are currently facing challenges that we have never faced before. It is natural and encouraged that you seek help if you require assistance in any aspect of your life. Seeking help when you need it is a sign of strength and good judgment!
There are many resources you can currently access that provide information, emotional support, and advice to people with SCI. Below are a few examples of such resources.

Resources to access

BC Government COVID-19 mental health support: Virtual Mental Health Supports During COVID-19 – Province of British Columbia

BC Mental Health Hotline: dial 310-6789, and do not add 604, 778 or 250 before the number. It’s free and available 24 hours a day.

We also recommend:, BounceBack and a “FACE COVID” e-book that can be found at

For good plain language information on COVID in multiple languages, visit and for reliable data on COVID cases worldwide, visit

You can also check out the other resources listed on our site:

Physical distancing is a necessary precaution that needs to be taken during the COVID-19 pandemic, but it can have adverse mental health effects if you do not take steps to stay socially connected. To maintain good mental health when isolation is inevitable, we recommend maintaining good physical health, managing your worry, setting a routine, staying connected with family and friends, and staying knowledgeable about the current situation.

Frank, M., Heinemann, A. and Wong, A., 2016. An Empirical Investigation of a Biopsychosocial Model of Social Isolation in Persons with Neurological Disorders. Archives of Physical Medicine and Rehabilitation, 97(10), p.e20.

Brooks, S., Webster, R., Smith, L., Woodland, L., Wessely, S., Greenberg, N. and Rubin, G., 2020. The Psychological Impact of Quarantine and How to Reduce It: Rapid Review of the Evidence. SSRN Electronic Journal, 395(10227).

Migliorini C, Tonge B, Taleporos G. Spinal cord injury and mental health. Aust N Z J Psychiatry. 2008;42(4):309‐314. doi:10.1080/00048670801886080 2020. Mental Health: What’s Normal, What’s Not – Mayo Clinic. [online] Available at: <> [Accessed 10 June 2020].

Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med. 2017;195:42-49. doi:10.1016/j.socscimed.2017.11.008

Wang C, Pan R, Wan X, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 2020;17(5):1729. Published 2020 Mar 6. doi:10.3390/ijerph17051729

Image credits

  1. Woman in House © Mohamed Hassan, CC0 1.0
  2. Image by SCIRE Team
  3. Doctor © CO. Department of Health Care Policy and Financing, CC0 1.0
  4. Image by SCIRE Team
  5. Notebook © Gentaur CC0 1.0
  6. Image by SCIRE Team
  7. Man on computer © user:cth103_t CC0 1.0
Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.