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DOCTOR'S NOTE
Features|Coronavirus pandemic
Comorbidities and COVID: A much higher risk of death
Dr Khan examines the underlying health conditions that cause severe illness in COVID patients.
[Illustration by Jawahir Al-Naimi/Al Jazeera]
By Dr Amir Khan
24 May 2021
While some countries are vaccinating their way out of the COVID-19 pandemic and are starting to see an easing of restrictions, other countries in South Asia are experiencing a new wave of infections that are causing devastation to their populations and healthcare systems.
Those most at risk of developing severe complications – and even of dying – as a result of the virus remain the most vulnerable members of our societies.
Age remains the biggest risk factor for becoming seriously ill with COVID-19, with more than 80 percent of COVID deaths occurring in people over the age of 65. As we get older, our muscles become weaker and the anatomy of our lungs changes. This causes them to become less efficient when it comes to moving air and mucus out of the body, resulting in a lowering of the defence system that our lungs and immune systems can provide.
It is thought the immune system of older people – those over 65 – is slower to respond to the virus, leading to a longer period of infection and inflammation as a result of the disease. This prolonged period also allows the virus to replicate and overwhelm the immune system and internal organs, resulting in poorer outcomes.
But certain underlying health conditions, known as “comorbidities”, also increase your risk of becoming seriously ill as a result of catching COVID-19. Serious illness could mean a person will need hospitalisation, intensive care or a ventilator to help them breathe, or they may even die.
When looking at which illnesses increase a person’s risk of severe disease from COVID-19, it is important to remember that people with underlying health conditions also tend to be older so age as well as their health plays a part.
Heart disease
Studies show that high blood pressure and cardiovascular disease are high up on the list of underlying health conditions that can make a COVID-19 infection worse. About 10 percent of patients with pre-existing heart disease – otherwise known as cardiovascular disease (CVD) – who contract COVID-19 will die, compared with only 1 percent of patients who are otherwise healthy.
Severe viral illness puts increased demands on the heart. When the virus causes inflammation and infection in the lungs, they are not as efficient at doing their job of gas exchange as before the infection. This leads to blood oxygen levels dropping. When this happens, the heart must work harder to pump what oxygen there is in the blood around the body to meet the demands of the rest of the organs. This can tire and weaken the heart and, if a pre-existing heart condition exists, this will only serve to worsen the problem.
COVID-19 can also cause inflammation of the heart muscle, a condition known as myocarditis and this, in turn, can lead to dangerous heart rhythms.
There is no special protocol for people with heart conditions to protect themselves from COVID-19, but following local guidance on social distancing is recommended, as well as keeping up to date with flu and pneumonia vaccines to help you keep as healthy as possible.
Diabetes
Diabetes describes a spectrum of conditions that result in insulin levels falling too low or rising too high. Insulin is a hormone needed to control blood sugars at an optimal level for the body to function. Everyone with diabetes, regardless of which type, is more vulnerable to developing a severe illness or even dying if they do get COVID-19, but the way it affects a person will vary from individual to individual. If blood sugars rise too high or fall too low, problems can develop. Simultaneously, if insulin levels become too high, this can also adversely affect the body’s ability to fight off infections.
The reasons that having diabetes increases the risk of death from COVID-19 are varied and complex. Often, those who have had poorly controlled diabetes for many years have seen their high blood sugars cause damage to nerves and blood vessels around their body. This results in widespread inflammation; blood vessels become fragile and do not ferry blood and nutrients around the body as well as they should.
All of this affects the overall health of the immune system, meaning it is unable to react to infections as well as in those without diabetes. This is why people with diabetes are often referred to as being “immunocompromised” (having a weaker immune system).
People with type 2 diabetes have a higher chance of being overweight or obese. This usually means their heart and lungs are less healthy and less able to help the body fight off infection. Having a high level of fat in the body can also cause inflammation, which affects the immune system’s ability to work at an optimal level.
If you have diabetes, contracting any infection can adversely affect your body’s ability to control blood sugars. A coronavirus infection can cause blood sugars to become dangerously high as insulin levels become erratic; these high blood sugars can trigger dangerous “events” in the body including the blood becoming acidotic (when fluids contain too much acid) and damage to the kidneys. This will further compromise the immune system, leading to a higher chance of complications from the coronavirus infection.
The better controlled your diabetes is, the better your chances of coming through COVID-19 without developing dangerous complications. Being on the right treatment, alongside a healthy diet and good levels of exercise in order to keep weight at an optimal level are key.
Lung disease
Having a chronic lung condition is another risk factor for becoming seriously unwell with COVID-19. Lung conditions that increase this risk include: asthma, if it’s moderate to severe; chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis; damaged or scarred lung tissue such as interstitial lung disease – including idiopathic pulmonary fibrosis; cystic fibrosis, with or without lung or other solid organ transplant; and pulmonary hypertension – high blood pressure in the lungs.
In general terms, the more severe the lung condition, the higher the risk of serious illness from COVID-19, which is primarily a disease of the lungs. COVID-19 can cause a condition known as Acute Respiratory Distress Syndrome (ARDS), which occurs when an infection causes fluid to build up in the lungs, affecting the exchange of oxygen and carbon dioxide, this can cause people to become short of breath and for their blood oxygen levels to drop to dangerously low levels.
If the lungs are already underperforming because of a previous or underlying lung condition then they are likely to become overwhelmed and ARDS can set in sooner. There are studies to suggest those with the common lung condition, chronic pulmonary airway disease – usually caused by damage due to smoking tobacco – have an increased number of ACE2 receptors in parts of their airways. These are the receptors that the coronavirus spike protein binds to in order to enter human cells and cause an infection. The more of these receptors, the higher the risk of infection.
The best advice to anyone, regardless of whether they have an underlying lung condition or not, is to stop smoking. This is the kindest thing you can do for your lungs. Many of the lung conditions listed are not caused by smoking, in which case sticking to social distancing measures and making sure you are on the right treatment in order to manage your lung condition is key.
There are many other comorbidities that increase the risk of developing serious illness from COVID-19, including certain cancers, immune system disorders and kidney disease. Whatever the risk, as always reducing your risk through mask-wearing, social distancing and going for the vaccine when called is absolutely key.
[Illustration by Jawahir Al-Naimi/Al Jazeera]
Progress report: COVID cases surge in Nepal
Over the last few weeks India has dominated the headlines as frantic scenes of people queueing outside hospitals and desperately searching for oxygen were streamed across the world, but now it appears the epicentre of the pandemic has moved to neighbouring Nepal.
The landlocked country has an already fragile healthcare system and, with many Nepalese workers forced to return from India where lockdowns meant a lack of work, the variant first discovered in India, B1.617 – which is thought to be more transmissible – is a real concern. Nepal and India share a 1,800km open border, over which people from both countries are allowed to travel and work visa-free.
In Nepal, there are just eight doctors for every 10,000 people, much fewer than in India. Nepal is also behind on vaccines when compared with its neighbour. The country has recorded more than 6,000 deaths since the pandemic began with more than half occurring in the weeks between March 4 and May 21.
“The situations are worsening day by day and it may go out of control in future,” Dr Samir Adhikari, a spokesperson for Nepal’s Ministry of Health and Population, said on May 3. Since then, cases have risen and deaths continue to stack up. Doctors say the country was ill-prepared for the rise in COVID cases. At a meeting of doctors organised by Kathmandu Metropolitan City on May 11, Dr Chandra Mani Adhikari, executive director of Shahid Gangalal Heart Centre, said: “No one is going to say this, but I [will] say it: our health system has collapsed.”
The country has a population of 30 million and, already, families are struggling to find ICU beds for loved ones and have been scrambling for oxygen amid supply shortages.
It is felt that Nepal was caught off guard as cases suddenly rose in India. Having largely escaped the pandemic up until now, Nepal had been lulled into a false sense of security. As the threat from India loomed, shops remained open and large weddings and festivals were allowed to continue.
The Nepalese vaccination programme got off to a good start in January, with the country obtaining doses of the Covishield vaccine from India. Healthcare workers and the elderly were prioritised. But as India’s crisis worsened, supplies for Nepal ran out, meaning much of the population remains at risk. Countries such as Switzerland and Australia have pledged aid to help the country battle the virus, but as cases continue to rise and hospitals become overwhelmed, it may be too little too late.
In the Doctor’s Surgery: Vaccinating younger people
Despite the high death toll in the UK and many blunders by the government in controlling the spread of coronavirus, it has had an extremely successful vaccination programme. This is mainly due to the National Health Service (NHS) and those who work within it.
I have been helping at our vaccination centre, and the cohort we are vaccinating now are aged between 32 and 35. It has been interesting to see the shift in opinions and concerns as we have moved down the age groups of those receiving the vaccines.
When I was vaccinating elderly groups, the mood was that of elation; they were overcome with joy to receive their doses of the vaccine – but then they were the group most at risk of becoming seriously unwell should they have contracted the virus. The mood has changed now with younger people. While the vast majority are still happy to receive the vaccine, their reasons are different. They know that they are less likely to become sick should they get COVID-19 but also know there are other benefits to getting the vaccine.
“I’m only getting this so I can go on holiday,” one lady told me as I gave her the jab. “Some countries won’t let you in unless you have been vaccinated.” It is true, there are some countries which insist on travellers having had both vaccines before they can enter, and this lady was clearly desperate for a holiday.
“My grandma has got heart disease, I’m getting my vaccine so I can visit her,” another patient said. There is now increasing evidence that the vaccines help prevent the spread of the virus so this made perfect sense.
Then there were those who still had reservations and wanted to seek some reassurance.
“You are absolutely sure this will not affect my future chances of having a baby?” one 33-year-old woman asked me. This is a common question and a myth about the vaccines that simply will not go away.
“There is no evidence the vaccines affect fertility in any way,” I replied. She seemed to be satisfied with that robust answer and consented to the vaccine.
I imagine as we move to younger and younger age groups, the questions and reasons for having the vaccine will continue to change, but one thing is for sure: the vaccines are the key to returning to as normal a life as possible and I am happy to play my part in giving them out.
And now some good news: Vaccines do work against the Indian variant
The variant first identified in India, known as B1.617, has caused concern across the world. It is thought to be more transmissible than the original strain of the coronavirus and even the variant first found in the UK. There has also been some concern that due to one of the mutations in B1.617, it may be able to evade the immune response triggered by the vaccines.
An American study, which is yet to be peer-reviewed, took blood containing COVID antibodies from people who had had either the Pfizer or Moderna vaccines and observed the effects on the B1.617 variant. The results show that the antibodies were able to neutralise the B1.617 variant to some extent, though less effectively than they did the original variant of the virus that was circulating at the start of the pandemic. The authors state more research is needed, but this is a promising start.
[Illustration by Jawahir Al-Naimi/Al Jazeera]
Reader’s Question: Can I hug my friends and family if I’ve had the vaccine?
Most of us have been deprived to some extent of our usual levels of human contact since the pandemic began. Whereas pre-pandemic, hugging our friends and family was commonplace, it now comes with some risk. None of us wants to unknowingly spread the virus through close contact if we can avoid it. But, according to the Centres for Disease Prevention and Control (CDC) in the US, if two people have had both doses of the COVID-19 vaccines and waited for two weeks after their second dose to allow antibodies to build up, they can visit each other indoors without social distancing, including being able to give each other a hug. The chance of them becoming seriously sick from COVID-19 is almost zero. Precaution is still advised when visiting those who have not yet been vaccinated, and outdoors is still the safest place to be. Other countries, such as the UK, have allowed indoor mixing to resume within guidelines and that includes giving hugs for many people.
SOURCE: AL JAZEERA
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