COVID-19 disease and co-morbidities – Jamaica Observer

COVID-19 disease continues to spread worldwide and indeed in our island nation, with more than two million cases worldwide and 143 cases here in Jamaica as at Friday, April 17, 2020.

With five reported deaths, Jamaica currently has a case fatality rate of 3.5 per cent. The number of cases in Jamaica has jumped significantly in the past 48 hours, suggesting community spread of the virus. Fifty-two of the reported 143 cases (36 per cent) are attributed to one call centre in Portmore, highlighting the extraordinary virulence of this virus in close quarters and hence the need for social distancing. In response, the Government has imposed a lockdown on St Catherine in attempt to forestall further community spread.

Information about this novel coronavirus continues to evolve at a rapid pace. It has become clear that there is a spectrum of disease, with the majority of patients (80 per cent) having mild or no symptoms. The remainder will have severe disease leading to hospitalisation, with a small percentage requiring ICU care. The chance of dying of COVID-19 disease can be difficult to estimate but this risk has varied from around two to three per cent in China to around 12 per cent in Italy.

As more is known about the disease, it has become clear that there are patient factors which increase the risk of having severe disease or dying. The most important factors appear to be age, sex and co-morbidities. Co-morbidities can be thought of as chronic medical conditions (eg heart disease, hypertension, diabetes, chronic lung disease) that worsen the outcome of COVID-19 disease.

The hospitalisation rate for COVID-19 is 4.6 per 100,000 population, and almost 90 per cent of hospitalised patients have some type of underlying condition, according to the US Centers for Disease Control and Prevention. Hospitalisation and adverse outcomes rise with age and the presence of comorbidities. Individuals older than 65 years of age tend to have more risk of complications and death and are also the ones most likely to have one or more underlying chronic medical condition or co-morbidity. Hypertension, heart disease and obesity appear to be the most common comorbidities among the older individuals, occurring in 73 per cent, 51 per cent and 41 per cent of patients, respectively.

Age and COVID-19 disease

Age plays a significant role in the risk of having severe COVID-19 disease. As age increases, the risk of getting severe symptoms, the risk of hospitalisation, the risk of hospitalisation requiring ICU care, and the risk of death all rise as well. Data from China looking at over 70,000 patients found an overall risk of dying of about two per cent. In patients above the age of 80 years the risk of dying rose to 14.8 per cent in China and 22 per cent in Italy. This compares to a risk of dying of 0.2 to 0.4 per cent (two to four in a 1000) in patients less than 50 years of age. Data from the United States has found that 80 per cent of the deaths that have occurred in patients with COVID-19 disease have been in patients more than 65 years of age. Patients less than 19 years of age in the United States have extremely low need for hospitalisation and are at a low risk of death.

There are many factors which make the elderly population more susceptible to infection in general and which make infection more severe when it does occur. Some of these factors in the patient with COVID-19 disease include reduced effectiveness of the immune system, higher rates of diseases which impact immune function, age-related decreases in heart and lung function etc. It is for these reasons that many countries, including Jamaica, have suggested that the elderly take special care in distancing themselves from the general population, as should they get infected, they are more likely to have severe symptoms, more likely to require health care resources and more likely to die. It also does serve as a warning to the young people in our population to practise social distancing and proper hygiene as well. Being young may make it unlikely for you to have severe disease but if you pass on the disease to your parents or grandparents, they may not be so lucky.

Sex (gender) and COVID-19 disease

It has become clear that the male sex is associated with a higher risk of getting COVID-19 disease and more severe disease when infected. The largest study from China has found that 51.4 per cent of patients are male vs 48.6 per cent of patients being female. In the United States, hospitalisation data from March 2020 has found that, of patients hospitalised, 54.4 per cent of them were male as opposed to 45.6 per cent who were female. When looking at patients who have died from COVID-19 disease from the Chinese data set, the difference is starker, with 63.8 per cent of deaths occurring in males as opposed to 36.2 per cent in females. In Italy, 70.6 per cent of patients who died were male with women representing only 29.4 per cent of deaths. The exact reasons for the male predominance in rates of infection and risk of severe disease are currently unclear but it is important for the male members of our society to be aware of their risk and protect themselves accordingly.

Co-morbidities and COVID-19 disease

Co-morbidity is a medical term that is used to describe medical conditions (usually chronic diseases) that can worsen other diseases when they occur together. Common co-morbidities include diabetes, hypertension, kidney disease, heart disease and chronic lung disease. These co-morbidities can act through many different mechanisms. For example, diabetes is well known to affect immune function, decrease the ability of the body to fight infection and to decrease the healing ability of the body. Patients who have a history of chronic lung disease will do worse with COVID-19 infection in the lung when compared patients who have normal lungs. Patients who have heart disease can have difficulty in increasing the amount of blood flow needed to help fight infection. Patients with a prior history of cholesterol in arteries (atherosclerosis) may have increased risk of heart attack and stroke at the time of infection, given inflammation which can increase the tendency of the blood to clot.

Data from patients with COVID-19 infections have shown quite clearly that patients with co-morbidities do worse than patients without. They are more likely to have severe symptoms requiring hospitalisation, more likely to require care in an intensive care unit, and more likely to die. The data from China suggests that when compared to an overall death rate of 2.3 per cent in all patients with COVID-19 infection, patients who have no co-morbidities have a risk of death of 0.9 per cent. The risk of death for patients with COVID-19 infection and cardiovascular disease was 10.5 per cent, for patients with diabetes 7.3 per cent, patients with chronic lung disease 6.3 per cent, patients with hypertension 6.0 per cent, and patients with cancer 5.6 per cent. Preliminary data from the United States suggests that cerebrovascular disease, chronic kidney disease and obesity may also elevate risk.

There also is quite clear evidence that the more co-morbidities patients have, the higher is the risk of death. One review of the Italian experience noted that patients with three or more co-morbidities constituted 48.6 per cent of the total deaths. Patients with no co-morbidities constitute only 1.2 per cent of total deaths.

Are smokers at higher risk for COVID-19?

Conditions that increase oxygen needs or reduce the ability of the body to use it properly will put patients at higher risk of serious lung infections. Smoking has long been known to cause chronic lung damage and limitation in lung capacity and function. A long history of smoking has long been associated with several lung diseases. Smokers may also already have pre-existing lung disease or reduced lung capacity which would greatly increase risk of serious illness, including COVID-19.

Furthermore, smokers are likely to be more vulnerable to COVID-19 as the act of smoking means that fingers (and possibly contaminated cigarettes) are in repeated contact with lips, which increases the possibility of transmission of virus from hand to mouth.

Smoking products such as water pipes often require the sharing of mouthpieces and hoses, which could facilitate the transmission of COVID-19. The US Food and Drug Administration (FDA) has issued an advisory that smoking leads to worse outcome, with COVID-19 infection. According to the FDA, Cigarette smoking causes heart and lung diseases, suppresses the immune system, and increases the risk of respiratory infections.

Mounting evidence suggests that, compared with non-smokers, people who smoke cigarettes face a higher risk of developing severe complications and dying from COVID-19 infections. A recent study of more than 1,000 patients in China, published in the New England Journal of Medicine found that smokers with COVID-19 were more likely to require intensive medical interventions than those who didn't smoke. In the study, 12.3 per cent of current smokers were admitted to an ICU, were placed on a ventilator or died, as compared with only 4.7 per cent of non-smokers.

Smokers may be prone to severe COVID-19 infections, in part because their lungs contain an abundance of entry points that the virus can exploit.

What does this mean for our population?

Jamaica, unfortunately, has a high prevalence of lifestyle diseases which can serve as significant co-morbidities for patients with COVID-19 infection. According to the last Jamaican Health and Lifestyle Survey (2016-2017), the prevalence of hypertension and diabetes were 33.8 per cent and 12 per cent, respectively. In terms of obesity, 54 per cent of our people are overweight. In addition to this, the elderly constitute a large proportion of our population (241,200 persons/12.6 per cent of total population: Data from 2015 Economic and Social Survey of Jamaica).

Given this data it is clear that the elderly and patients with conditions that put them at increased risk must take precautions to avoid exposure. We must also remember that those of us who are younger and who do not have co-morbidities must play our part to keep our fellow citizens safe.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital

Correspondence to emadu@caribbeanheart.com or call 876-906-2107

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COVID-19 disease and co-morbidities - Jamaica Observer