Dr Devi Nair, Health Economist, Goa Institute of Management, Sanqulim, Goa and Dr Krishnanunni Raveendran highlight the vulnerabilities of people with existing health conditions and how COVID-19 would impact them
In December, 2019, a series of pneumonia cases reported in the city of Wuhan, Hubei province, China, with clinical symptoms similar to common viral pneumonia with unknown origin. After a few days of confusion regarding the origin and spread, Chinese health authorities confirmed that, this was associated with a severe acute respiratory syndrome corona virus outbreak [1]. The (WHO) named this as COVID-19 and recognised the outbreak to be a Public Health Emergency of International Concern on January 30, 2020 and declared it as a pandemic on March 11, 2020 [2]. So far(until April 17th), 213 countries and 2074,529 people affected with COVID- 19 and 139,378 deaths reported.
COVID-19 is a new virus observed among human beings, so nobody has prior exposure or immunity to it, means the entire human population is at risk to infection. Based on the available evidence, the infection primarily spreads through contact with an infected person and through respiratory droplets when people cough or sneeze. It shows the initial symptoms similar to viral pneumonia such as fever, cough, myalgia, fatigue and shortness of breath. In serious cases complications like, acute respiratory distress syndrome and cardiac failure. The incubation period is typically around five days but range from 2-14 days. COVID-19 is usually a mild disease and majority of cases (>80 per cent) are showing only common viral fever (flu) like symptoms. But about 5 per cent can develop serious stages of pulmonary distress syndrome and can lead to death [3]. WHO report on NCDS and COIVD-19 say, the new coronavirus can affect people in all age groups, but the risk is high in older age group and people with pre-existing noncommunicable diseases (NCDs). These NCDs include: cardiovascular diseases, chronic respiratory disease (COPD), diabetes and cancer. Evidence from China and European countries show that people who already have a history of noncommunicable diseases are seriously affected with COVID-19 [4]. According to WHO (2018) in particular four major noncommunicable diseases, cardiac diseases, diabetes, cancer and chronic pulmonary diseases are the “leading killers” and “slow motion disaster” account for 71 per cent (77million) deaths globally. Global Health Estimates (2018) also reported, out of total deaths about 85 per cent of the NCD deaths occurs in European region. Japan (82 per cent), US (88 per cent) and UK (89 per cent) deaths were due to NCDs only. In reality the emergence of COIVD-19 will worsen the situations of these countries. Old age and pre-existing NCD conditions can reduce the immunity level and will lead to worse outcomes. The global statistics on COVID-19 also shows that the death rate is 21.9 per cent in the age group of above 80 years, 8 per cent in the age group between 70-79 years and further 3.6 per cent in the age group of 60–69 years of age group [5]. New York University Hospital say that, out of 400 COVID patients admitted,90 per cent were from >45 years and 60 per cent reported as >65 age group.
The most common co-morbidity observed in COVID-19 patients who was admitted in the critical care units in most countries, was due to hypertension, diabetes and chronic respiratory problems. Available data show that, percentage of deaths observed in COVID-19 patients at global level with pre-existing conditions such as cardiovascular disease (13.2 per cent) diabetes (9.2 per cent), chronic respiratory disease (8 per cent), hypertension (8.4 per cent), and cancer (7.6 per cent) compare to patients without co-existing conditions (.9 per cent) [6]. A study in China reported that out of 1590 COVID patients, at least one co-morbidity seen among (25.1 per cent), whereas 16.9 per cent had history of hypertension and 8.2 per cent were diabetics [7].
Another study among 1099 patients with COVID-19, of whom 173 had severe disease with co-morbidities of hypertension (23.7 per cent), diabetes mellitus (16.2 per cent), coronary heart diseases (5.8 per cent), and cerebrovascular disease (2.3 per cent) [8]. It is notable that, the most frequent co-morbidities reported in the above-mentioned studies of patients with COVID-19 are hypertension, coronary diseases, cerebro-vascular diseases and diabetes.
In addition to acute respiratory distress symptoms, many COVID-19 patients are also developing cardiac problems—and dying of heart failure. Based on the data coming in from China, Italy, and the US, now cardiologists believe that, COVID-19 virus can infect the heart muscle. An initial study published in Scientific American say, one in five patients, shows cardiac damage leading to heart failure and death even with out signs of respiratory distress. A recent report from New York University Hospital was stunting. They said, on April 6 itself within 40 minutes six COVID-19 affected patients had heart failure, of which four died.
The largest cohort study on hospitalised patients with COVID-19 in China showed that mortality was higher in patients with diabetes or coronary heart disease, and an increased high-sensitivity cardiac troponin I (an excellent predictor of heart failure in acute coronary syndrome) during hospitalisation was found in more than half of those who died.
When it comes to diabetes and COVID-19, The American Diabetes Association explains, “In China, where most cases have occurred so far, people with diabetes had much higher rates of serious complications and death than people without diabetes.” Chronic diabetic conditions may cause dysfunction of immune system and making diabetics more susceptible to infections and people with diabetics are in high risk categories if they affected with COVID-19 virus.
People with chronic obstructive pulmonary disease (COPD) are the most vulnerable groups among four major NCDs to COVID-19 infections. They are more likely to develop severe disease or to be admitted to intensive care units (ICU) than those with cardiac problems or diabetes. Researchers at the University College London (UCL) conducted a meta-analysis of seven published studies from China, COPD was not the most common disease — being present in only 4.5 per cent of those with severe cases, and in 9.7 per cent of all in the ICU — but it increased by 17.8 times the likelihood of being admitted to an ICU. People with COPD were also 6.4 times more likely to develop severe disease. For those with cardiovascular disease, the likelihood for severe disease was 2.7 times higher, and for ICU admissions 4.4 times more likely. High blood pressure increased these chances by two-fold (for severe disease) and 3.7 fold (for ICU admission). Diabetes had no association with either severe disease or admission to an ICU. The researchers wrote. “Despite being uncommon in our study population, COPD was by far the strongest risk factor for COVID-19 severity, followed by cardiovascular disease and hypertension.” [9]
COVID-19 pandemic is creating challenges to cancer patients also. The standard therapies in oncology such as chemotherapy and radiotherapy can reduce the immune responses in human body. American Society of Clinical Oncology (ASCO) say, “The blood cancers often directly compromise the immune system, so those patients are probably most at risk, whereas cancers such as colon cancer, breast cancer, and lung cancer do not typically cause immune suppression that is not treatment-related.” But NHS England warned that certain groups of cancer patients are more vulnerable to serious illness if they become infected with severe acute respiratory syndrome coronavirus. These groups include individuals who are undergoing active chemotherapy or radical radiotherapy for lung cancer, and patients with cancers of the blood or bone marrow. Based on the available data and above given evidences, it is worth noting the complications of COVID-19 on noncommunicable disease patients and their needs to be addressed in a comprehensive way for better treatment outcomes.
References:
1.World Health Organization. Novel coronavirus – China. Available from: http://www.who.int/csr/zxcvXDdon/12 -january-2020-novel-coronavirus-china/en/, accessed on March 31, 2020.
2. World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus2019/technical-guidance/naming-the-coronavirus-disease- (covid -2019)-and -the-virus-that-causes-it, accessed on March 31, 2020.
3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497-506.
4.World health organization (WHO), COVID 19 and NCDs, https://www.who.int/emergencies/ diseases/novel-coronavirus-2019
5.Leung C. Clinical features of deaths in the novel coronavirus epidemic in China. Rev Med Virol 2020; e2103
6.China Medical Treatment Expert Group for COVID-19. Comorbidity and its impact on 1,590 patients with COVID-19 in China: A Nationwide Analysis; 2020.
7. 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. Lancet 2020; 395:507-13.
8. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020; published online Feb 24. https://doi.org/10.1016/S22132600(20)30079-5.
9. Guan W, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; published online Feb 28. DOI:10.1056/NEJMoa2002032.