Severe COVID-19: What Roles Do Age and Chronic Health Conditions Play?

Takeaways

• The risk for severe COVID-19 infection increases with age and in the presence of a chronic health condition, like diabetes, high blood pressure, and heart disease.

• Some possible reasons for the link between severe infections and advanced age include a weakened immune system, lowered physiological reserves, and more intense inflammation compared to younger individuals.

• Underlying health conditions are believed to weaken the immune system and increase stress on already compromised organs, potentially increasing the risk of severe COVID-19 infection.

• Individuals advanced in age or with chronic health conditions could lower their risk of severe COVID-19 infection by managing their medical condition, staying healthy, and practicing good personal hygiene.

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As the COVID-19 pandemic continues, new challenges arise each day. You may have heard that COVID-19 causes infections that are more severe in those who are older or have chronic health conditions. What does it mean if you or your loved ones fall into one of these categories? Is there anything you can and should be doing? 

What are the risk factors for severe COVID-19 infection?

While severe illness and death can occur in otherwise healthy individuals of any age, it predominantly occurs in adults with advanced age or a chronic health condition.

Age¹⁻⁶

Case fatality rates increase from 2.3% when averaged across all age groups (i.e. 23 deaths per 1000 thousand persons infected with COVID-19) to 8-12% amongst those aged 70-79 years, and 15-20% amongst those aged 80 and above.

Death rate by age group

Age Group	Death Rate
All Age Group	2.3%
70 - 79	8 - 12%
80 and above	15 - 20%

8 out of 10 deaths in the U.S. have been in adults aged 65 years and above⁷. 

While 65 years old has been commonly used as the cut off age for increased risk, there is no “magic age” where the risk of death increases suddenly. 

Some possible reasons for severe infections in those with advanced age include:

• Old age is associated with chronic health conditions

• The immune system weakens with increased age, making it more difficult to fight off infections

• Inflammation in older persons can be more intense causing organ damage

• Physiological reserves in older persons are lower, hence they may find it more difficult to recover after an infection

However, there have also been significant numbers of young adults with severe COVID-19 infection, so everyone needs to take precautions.

Chronic Health Conditions¹⁻⁶

Underlying chronic health conditions that have been associated with severe illness and mortality include:

1. Diabetes 

2. High blood pressure

3. Heart disease

4. Chronic lung disease (such as asthma)

5. Cancer 

6. Chronic kidney disease

7. Obesity

8. HIV

While reasons for the increased risk are not entirely clear, there have been some hypotheses:

• An immune system weakened by a chronic health condition is unable to fight off the virus, leading to a more severe infection.

• The stress of a viral infection can increase demand on already compromised organs (such as the heart, lungs or kidneys).

There have also been theories that a family of medicines called ACE inhibitors (angiotensin-converting enzyme inhibitors) allows more viral organisms to enter cells, increasing the risk of infection in patients taking such medication. However, there is no clear evidence that these medications increase the severity of infection or risk of contracting COVID-19. ACE inhibitors are commonly taken by people with diabetes and hypertension and major professional bodies have recommended individuals continue these medications unless specifically advised otherwise by their doctor⁸⁻⁹.

What can you or your loved ones do to lower your risk?¹⁰⁻¹¹

In short, you and your loved ones should pay attention to managing your medical condition well, staying healthy and keeping safe. If you are unsure of what to do, check in with your healthcare provider.  You should:

Manage your medical condition well:

• Continue your medication. Do not change or discontinue your medication or treatment plan without talking to your doctor. 

• Have at least a 1 month supply of medications you require. Speak to your doctor early to refill your medications if needed - there may be delays in getting medications delivered during this period and you should not miss your medications. 

• Stay in touch with your doctor. If you have a scheduled follow-up appointment but are worried about going to a clinic or hospital, check if there are other options such as teleconsultation that allow you to be reviewed from the safety of your home.

• Do not delay getting emergency care for your underlying condition because of COVID-19. Emergency departments have contingency infection prevention plans to protect you from getting COVID-19 if you need care for your underlying condition.

Stay healthy:

• Eat well, keep moving. Just like you would otherwise, make sure you eat healthily, stay hydrated and get in some exercise whenever possible. Take this opportunity to prepare your meals at home. Use the commute time you save to squeeze in a home workout. Keeping up a healthy lifestyle will help you keep your chronic health condition under control.

• Stay connected with your loved ones. While you might be physically apart from your loved ones, make sure you keep in touch with them, whether by phone, text or video. This is important so you don’t feel isolated and lonely.

• Talk to your doctor about whether your vaccinations are up-to-date. If you are older than 65 years, or if you have underlying conditions (e.g. diabetes) or other immunocompromised states, you should consider obtaining vaccinations against influenza and pneumococcal disease.

Keep Safe:

• Frequent hand-washing and avoiding contact with your face

• Social distancing - avoiding contact with people you do not live with if possible, and keeping a safe distance of 1-2m away from anyone else if not

• Staying home as much as possible 

• Wearing a mask if you have to go out

• Avoiding contact with anyone who you know is sick

Summary

While it may be frightening to learn that you or your loved ones are at an increased risk of a severe infection during the pandemic, you can turn this fear on its head! 

Take this opportunity to make the lifestyle change you have always wanted to and improve your health. Use the extra time that you may have at home to prepare your own meals - you will learn so much more about the food you consume (for example, you will know how much sugar goes into that cake if you bake it yourself). Get started on that new exercise routine or that weight loss goal. 

A positive attitude can make all the difference, and that’s the best thing we can do now. 

References

1. Guan WY, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020.

2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497.

3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054.

4. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020.

5. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020.

6. Ruan Q, Yang K, Wang W, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020.

7. Cite Chow, Nancy, et al. "Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019—United States, February 12–March 28, 2020." (2020).

8. Patel, Ankit B., and Ashish Verma. "COVID-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: what is the evidence?." Jama (2020).

9. Vaduganathan, Muthiah, et al. "Renin–angiotensin–aldosterone system inhibitors in patients with Covid-19." New England Journal of Medicine 382.17 (2020): 1653-1659.

10. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html

11. https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/