First Published: March 17, 2020
Last Update: March 23, 2020
The novel coronavirus, SARS-CoV-2, which causes COVID-19, has spread swiftly from person-to-person resulting in respiratory illness in thousands of individuals around the world. Now a global pandemic, COVID-19 is here in the U.S. and life as we know it has come to a grinding halt. Major league sports teams have ceased or delayed the start of their seasons, concerts and large entertainment events have been canceled, schools are closing across the country, bars and restaurants have shut their doors, and travel from Europe has been suspended for 30 days. The Centers for Disease Control and Prevention (CDC) and the federal government recommend no gatherings of ten or more people and to limit nonessential travel. The mayor of San Francisco was the first to issue a citywide “shelter in place” order for all residents in the six Bay Area counties, asking all residents to stay in their homes and limit contact with others for three weeks. These extraordinary efforts that encourage “social distancing”
are an attempt to “flatten the curve,” mitigate the effects this immensely infectious disease will have on the healthcare system and prevent the potential lethal impact it could have on our highest risk populations.
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Because SARS-CoV-2 is a newly identified virus, humans do not have a pre-existing immunity and therefore everyone is susceptible. According to the World Health Organization (WHO, 2020a), most people (about 80%) will recover from the disease without requiring special treatment. However, approximately one out of every six people who contract COVID-19 will become very sick and develop breathing difficulties (WHO, 2020). Who are these individuals that are at greater risk for developing a serious illness from COVID-19?
Who is at Greatest Risk?
There are specific segments of our population that are most vulnerable to severe acute respiratory infection (SARI) secondary to COVID-19. These include the following:
- Older adults – over the age of 60 years
- As we age, our immune systems’ ability to fight infection declines (Azar, 2018) and therefore makes us more susceptible to infection.
- Fewer immune cells results in a longer response to foreign microbes.
- Fewer white blood cells may cause a delay in healing.
- Other factors that make older adults more vulnerable include malnutrition, comorbid conditions (i.e. diabetes, chronic obstructive pulmonary disease), decreased mucosal barriers, and a decreased cough reflex (Azar, 2018).
- Individuals with underlying medical conditions:
- Cardiac conditions – such as coronary artery disease, heart failure, and hypertension
- While the specific effects of COVID-19 on the cardiovascular system are not fully understood, there have been reports of acute cardiac injury, arrhythmias, hypotension, and tachycardia. Based on experience with influenza and other acute viral infections, short term effects on the cardiac system may include (Beck, 2020) :
- Increased risk of acute coronary syndromes associated with severe inflammatory response to the infection.
- Myocardial depression leading to heart failure.
- Under-recognized risk of arrhythmias related to acute inflammation.
- Lung disease – chronic obstructive pulmonary disease (COPD), asthma, pulmonary fibrosis, and cystic fibrosis
- Individuals with chronic lung diseases suffer from limited airflow due to a variety of conditions including inflammation, constricted or obstructed airways, alveolar abnormalities and other structural issues.
- Viral illnesses exasperate underlying lung disease and may cause respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic shock.
- Diabetes: Individuals with diabetes mellitus have an increased risk of infection due to several factors (Weintrob, 2020):
- Hyperglycemia or poor control of blood glucose impairs the immune system.
- Vascular insufficiency could hinder the local inflammatory response and absorption of antibiotics.
- Immunocompromised or immunosuppressed individuals – those receiving chemotherapy and other cancer treatments, therapies for autoimmune diseases (i.e. rheumatoid arthritis, lupus, multiple sclerosis, and inflammatory bowel disease), human immunodeficiency virus (HIV) and organ or bone-marrow transplant patients
- As described above, compromised immune systems diminish an individual’s ability to fight off infection and heal.
- Pregnancy – At the time of this writing, there is limited evidence on risk and transmission in pregnancy and breastfeeding. Please refer to the CDC’s Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.
A report published by the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) on February 20, 2020, outlined the crude fatality rate (CFR) for each of these high-risk groups based on 55,924 laboratory confirmed COVID-19 cases (WHO, 2020b).
|WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) Report
February 16-24, 2020
|High Risk Factors
||Crude Fatality Rate (CFR)
|Elderly – over 80 years of age
|Chronic lung disease
Based on current information, the CDC
has outlined several important steps that all high risk individual should take to reduce the possibility of contracting COVID-19 in addition to actions to take if you do get sick (CDC, 2020a). The recent deaths at the Life Care Center in Washington state is a tragic reminder that long term care facilities, skilled nursing facilities and nursing homes need to follow specific CDC recommendations to prevent the spread of COVID-19
such as restricting visitors except during end of life situations, restricting all volunteers and nonessential healthcare personnel, canceling group activities and communal dining, and actively screening residents for fever and respiratory symptoms (CDC, 2020b).
A Note on Healthcare Workers
Clinicians working on the front lines of this disease put aside their own well-being to care for patients with COVID-19 and undoubtedly put themselves at increased risk for contracting the virus. As we have witnessed in other countries, the pandemic has and will continue to overburden our healthcare system. Long hours and stressful environments can take a toll on practitioners, decreasing their immune systems, making them more vulnerable to severe illness. Lack of appropriate personal protective equipment (PPE)
such as N95 masks, gowns and gloves or poor compliance with infection prevention and control practices
may also contribute to placing providers at heightened risk. Health care administrators should ensure proper staffing, appropriate infection prevention supplies are available and reinforce education and training on the importance of adhering to infection control guidelines.
We all have a responsibility to prevent the spread of this contagion regardless of our own personal risk. For more resources on COVID-19, please view our Resources for Nurses
and Tools for Frontline Clinicans and Medical Researchers.
Addendum (March 23,2020)
This article was first published on March 17, 2020 based on the most current data. A new report by the CDC (2020c) analyzed 4,226 COVID-19 cases in the United States that occurred between February 12 and March 16, 2020. They found “31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths associated with COVID-19 were among adults aged ≥ 65 years with the highest percentage of severe outcomes among persons aged ≥85 years”. These findings are similar to data analyzed in the WHO-China Joint Mission Report. However, among the 2,449 cases with known age, while 31% were greater than 65 years of age, 18% were aged 45-64 years and 29% were between 20-44 years. Of the 508 cases that required hospitalization, 35% were age 45-64 and 20% were age 20-44 years. Of the 121 patients admitted to the intensive care unit, 36% were age 45-64 years and 12% were age 20-44 years. This new data indicates that adults of any age are at risk of developing severe illness which can lead to hospitalization, ICU admission and potentially death (CDC, 2020c). It is important to note that data on other risk factors, including underlying health conditions, were not available at the time of this analysis.