Despite the challenges of working in humanitarian settings, several agencies have produced guidelines for the identification and management of HTN. The WHO’s Interagency Emergency Health Kit has included a supplementary module with antihypertensive medications since 2017, but it is unclear how widely these are being used (90, 91). According to a personal communication from a physician who treated HTN in Syrian refugees, the treatment was variable, and dependent on whatever drug samples were available in the clinic. They had limited choices, including atenolol, lisinopril, and verapamil. Treatment was tailored to the patient’s history. For example, patients with a history of coronary artery disease received atenolol and lisinopril, patients with diabetes received lisinopril, and patients with migraine received verapamil. Assessment of HTN and appropriate resourcing to treat it should be a priority for agencies providing emergency and longer-term care for patients after or during humanitarian crises to prevent significant mortality and morbidity. Further studies are needed to accurately estimate prevalence of HTN in crisisaffected populations throughout the world and to evaluate the best treatment approach for this population. Humanitarian crises and disaster settings (natural or humanmade) can affect health care and services in many different ways. A list of potential barriers that can affect the management of individuals with hypertension is as follows: [ significant decline of living standards [ loss/destruction of health care facilities [ flight of medical personnel causing shortage of medical care providers [ severe shortage of medicines [ lack or absence of essential supplies, equipment and materials [ compromise of the provision of primary and secondary health care [ interruption of water, food and electricity [ lack of morbidity and mortality data due to destruction of information systems and data collection [ high psychological stress burden on both general population and health care personnel. SPECIAL SETTINGS 21 GUIDELINE FOR THE PHARMACOLOGICAL TREATMENT OF HYPERTENSION IN ADULTS 4.2 COVID-19 and hypertension Almost all available evidence suggests that hypertension increases the risk of severe COVID-19, defined as admission to intensive care, clinically defined severity or a combination of these; or mortality. It was sometimes unclear, however, whether this risk was independent of other risk factors (92). Initial reports have identified higher rates of HTN among severely ill, hospitalized COVID-19 patients, with overall HTN rates of 50–56% (93, 94). It had been unclear if this relationship was causal or confounded by age and other comorbidities associated with HTN, including obesity, diabetes and chronic kidney disease. Concerns regarding use of angiotensin-converting enzyme inhibitors (ACEis) in these patients were raised due to identification of angiotensin-converting enzyme 2 (ACE2), the monocarboxypeptidase that inactivates angiotensin II and thereby counters the activation of the classic renin–angiotensin– aldosterone system (RAAS), as the functional receptor for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (95, 96). The WHO conducted a rapid review of evidence related to the use ACEis or ARBs in COVID patients which identified 11 observational studies. No studies were found that were designed to directly assess whether ACEis or ARBs increase the risk of acquiring COVID-19. After adjustment for confounders, history of ACEi or ARB use was not found to be associated with increased severity of COVID-19 illness. There were no studies that addressed the potential benefits and harms of initiating ACEis or ARBs as treatment for patients with COVID-19 (97). Accordingly, discontinuation of ACEis or ARBs may yield worse outcomes than continuation of their use in patients with a diagnosis of COVID-19. In contrast to the uncertainty about the potential benefit of initiating RAAS blocker use in patients with COVID-19, there is a clear potential for harm in withdrawing these agents in high-risk COVID-19 patients with established myocardial injury, HTN or heart failure (96). Most of the world’s professional societies either recommend or strongly encourage continuing ACEis/ARBs in COVID-19- infected patients (98). Further research that will address key unanswered questions about the role of the RAAS in the pathogenesis and possible treatment of COVID-19 and other coronavirus-based diseases is urgently needed. Prospective studies – in particular, ongoing randomized, placebo-controlled trials such as the Ramipril for the Treatment of COVID-19 (RAMIC) trial (ClinicalTrials.gov number, NCT04366050) may provide clearer insight regarding the effect of ACEis or ARBs in patients with COVID-19. 4.3 Pregnancy and hypertension Hypertension, including chronic HTN, gestational HTN, pre-eclampsia, and eclampsia, is a very common medical condition in pregnancy (99). Due to the adverse consequences of increased morbidity and mortality to both the women and fetus, HTN in pregnancy must be diagnosed, treated (when appropriate), and followed up diligently. It is important to note that up to 10% of pregnancy-related deaths are attributed to HTN, and its presence in pregnancy leads to long-term adverse cardiovascular consequences.