Coronavirus disease 2019 ([COVID-19](https://nabtahealth.com/covid-19/)) has affected large parts of the world and has now reached pandemic status. As of the 22nd of May, the SARS-CoV-2 virus had spread to 188 countries with over 5 million cases and more than 300,000 deaths worldwide. This disease is caused by a respiratory virus called severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). More data is emerging on the variability of outcomes caused by COVID-19. The infection affects populations and individuals in different ways, and this seems to be dependent on a combination of biological, [socioeconomic](https://nabtahealth.com/glossary/socioeconomic/) or [sociodemographic](https://nabtahealth.com/glossary/sociodemographic/) factors, which may or may not be linked to underlying health conditions. Some individuals may be infected with the virus and not experience any symptoms, whilst the same infection in others may cause severe respiratory disease, multi-organ failure and death. The available data surrounding the signs and risks of infection by SARS CoV-2, as well as the outcomes and treatments of COVID-19, is continuously evolving. Provision of updated, evidence-based, information using the most recent clinical research and data will help mitigate the spread of the infection, and protect those who are more vulnerable around us. Watching out for the most common signs of the infection such as a fever, cough and shortness of breath, even if the symptoms are mild, is paramount to protecting yourself and others. Staying at home, and maintaining self-isolation and distancing measures if you have any symptoms of COVID-19 reduces the risk of infecting others . If you are living with others and know that you have been infected, wear a mask in their presence to limit their exposure and ask them to do the same. If possible, stay at least 2 metres away from others at home, limit contamination of surfaces and other communal facilities, and avoid sharing household items. These measures are particularly important for those who are at increased risk of severe disease once infected with the virus. This article provides an outline of the different risk factors that make individuals more vulnerable to the acquisition of severe or critical symptoms following infection with SARS CoV-2, based on the most current reports and research. #### **Demographics** Characteristics such as gender, age, and weight have been shown to contribute to the way that a person responds once exposed to, or infected with, SARS CoV-2. Case-fatality rates, defined as the rate of death from COVID-19 from the total number of diagnosed cases, vary worldwide. Data gathered to date by Johns Hopkins University show that case-fatality rates range from 0-16% by country, suggesting that there are ethnic and [socioeconomic](https://nabtahealth.com/glossary/socioeconomic/) factors that contribute to the risk of dying from COVID-19. As more data emerges, and with further research, the clinical and scientific community will begin to understand the role that genetic, social, and cultural factors play in controlling the rates and outcomes of infection. To date, three main demographic factors present disproportionate risks as summarised below. #### **Gender** COVID-19 appears to adversely affect the male population more than the female. Men are at increased risk of developing moderate to severe symptoms once infected with the SARS CoV-2 virus. As a result, data published to date is showing that men are, on average, twice as likely to be critically hospitalised or die once infected by the virus. More research is required to understand how females are more protected from SARS CoV-2 than men, but it is possible to extrapolate this based on the fact that the X chromosome carries a number of important genes that have an important role in the regulation of the immune system. Therefore, the reduced susceptibility of females to the acquisition of symptoms associated with viral infection can be attributed to the X chromosome. In males, the presence of a single X chromosome, compared to the two copies that females carry, means that they can be more immuno-compromised under certain conditions. There are also lifestyle and cultural aspects which can put men in a higher risk category than women such as [smoking](#smoking) and alcohol. #### **Age** Individuals of any age can contract SARS CoV-2, with or without becoming symptomatic. To date, COVID-19 has affected significantly more individuals in the 65 and over age bracket, and less of the younger population. Studies have shown that advanced age puts individuals at a higher risk of experiencing severe symptoms once infected with SARS CoV-2; meaning that this age group is more likely to require hospitalisation. Age also correlates with the acquisition of non-communicable disorders such as [hypertension](https://nabtahealth.com/glossary/hypertension/), chronic renal disease and diabetes. In the context of COVID-19, over 70% of those who have been hospitalised with the infection over the age of 65 have at least one underlying health condition. In general, the ability of our bodies to regenerate slows down with age, and this applies to all organs, including the skin, gastrointestinal tract, liver and immune system. As a result, the older you are, the less likely your body is able to effectively or rapidly clear infections. Maintaining a balanced diet and partaking in regular exercise gives you a better chance of maintaining a healthy body to fight infections. This is particularly important if you are in the older population group. However, despite the clear correlation between age and disease severity, certain young adults and children can also experience critical symptoms following infection with SARS CoV-2 for reasons that are not yet well understood. Caution, protection and healthy lifestyle choices must be adopted by all. #### **Body Mass Index** Your body weight can be used as an indicator to determine how at risk you are of developing severe or critical COVID-19 symptoms. An optimal [Body Mass Index](https://nabtahealth.com/what-is-body-mass-index-bmi/) ([BMI](https://nabtahealth.com/glossary/bmi/)) is 18.5-24.9 kg/m2 and if you lie within this range, you are considered to have a healthy weight. People in this category have enough body fat to function effectively. Body fat, or adipose tissue, is an essential component of every organ and cell in our body; it has multiple roles, including insulation, energy storage, and the maintenance of hormones. Fat cells are also a source of [stem cells](https://nabtahealth.com/glossary/stem-cells/) which can differentiate into other cell types, such as bone and nerve cells, as required. These [stem cells](https://nabtahealth.com/glossary/stem-cells/) therefore, have regenerative capabilities which are able to replace damaged or otherwise compromised tissues in our body as needed. Overweight individuals with a [BMI](https://nabtahealth.com/glossary/bmi/) above 25 kg/m2 and obese individuals with a [BMI](https://nabtahealth.com/glossary/bmi/) above 30 kg/m2 are at higher risk of developing multiple health disorders, such as cardiovascular disease, stroke, and cancer. They are also more likely to be severely or chronically symptomatic if infected by SARS CoV-2. Having an excess of body fat means you are likely to be in a chronic state of low-grade [inflammation](https://nabtahealth.com/glossary/inflammation/), which can impair your immune system’s response to infection. If infected, the obese are more likely to be hospitalised because their bodies are unable to fight the infection effectively, either as a direct correlation of excess body fat, or as an indirect correlation with the other health disorders that accompany obesity and which put individuals at a higher risk. If you have a [BMI](https://nabtahealth.com/glossary/bmi/) below 18.5 kg/m2 you are classed as being underweight, meaning that your body is not storing enough body fat, giving you less overall protection. Being underweight weakens your immune system and puts you at increased risk of developing severe COVID-19 symptoms. Individuals who are underweight may be malnourished, and as a result may lack some of the essential nutrients, vitamins and minerals necessary for their cells and organs to function properly. This makes them more vulnerable to any external challenges or insults, such as complications arising from infection with a virus. Obese, overweight and underweight individuals should consider contacting a local healthcare provider and a nutritionist who can help them make a healthy and monitored weight loss or gain plan. #### **Underlying health conditions** COVID-19 has shown selectivity towards vulnerable individuals with underlying non-communicable disorders (NCDs). Some of the most prevalent NCDs include type 2 diabetes, [hypertension](https://nabtahealth.com/glossary/hypertension/), cardiovascular disease, chronic lung conditions, chronic kidney disease, chronic liver disease and cancer. This trend is consistent world-wide, as more statistics on patients emerge from the clinical and scientific community at large. Here, we outline a number of NCDs which have been shown to impact responses to the infection, and explore why individuals with these conditions are at risk of more severe COVID-19 symptoms. #### **Diabetes mellitus** If you have diabetes, you are unable to properly regulate blood glucose levels due to insufficient insulin production or reduced insulin sensitivity. Lack of insulin, or the inability of cells to respond to insulin, results in high blood glucose levels which puts you in a hyperglycaemic state. Under normal conditions, one of insulin’s functions (it has many others) is to signal your body to activate white blood cells, which are the main cells in our blood and lymph nodes that fight infections. Therefore, when the body is unable to produce sufficient amounts of insulin, a dysfunction of the immune system may occur, putting the individual at risk. A compromised immune system will be less able to control the spread of, and manage the symptoms associated with, invading pathogens such as SARS CoV-2. Being in a hyperglycemic state puts pressure on one’s body, which can result in damage to multiple organs such as the heart, kidney and nervous system . Individuals with either type 1 or type 2 diabetes are, therefore, at higher risks of developing health complications such as the acquisition of [cardiovascular disease](#CVdisease), [renal disease](#kidney) and peripheral nerve damage which also in turn put them at a higher risk of being negatively affected by infections and other external pressures. If you are diabetic, it is important to keep taking your medications as required. Those who are on insulin replacement therapy should monitor their body’s sensitivity to insulin which may determine the appropriate dose of insulin to take in order to avoid being in either a hyper- or hypo-glycaemic state. This is particularly important if you have been infected with SARS CoV-2. #### **Cardiovascular disease** The highest numbers of patients who have been hospitalised with severe or chronic COVID-19 have had [hypertension](https://nabtahealth.com/glossary/hypertension/) or another type of cardiovascular disease (CVD). Autopsy results from patients who have died with or from the disease show evidence of [myocarditis](https://nabtahealth.com/glossary/myocarditis/), defined by the presence of unusual inflammatory cells in the heart. Individuals hospitalised due to the infection also show markers of cardiac injury in their blood and this is seen in patients with and without a pre-existing history of CVD, suggesting that the virus puts pressure on the heart muscles, even in those with no known prior heart issues. Heart failure can occur when your heart muscle doesn’t pump blood as efficiently as it normally does. When combined with [arrhythmia](https://nabtahealth.com/glossary/arrhythmia/), which is a common feature seen in vulnerable individuals infected with SARS CoV-2, it puts pressure on the heart and affects how well it functions. There are recent findings that suggest that blood clotting events which are a characteristic of COVID-19 disease progression, are also responsible for some of the cardiovascular events observed in individuals who have died from the infection. This is supported by evidence suggesting that individuals who are on blood thinning medication have significantly improved survival rates compared to those who are not on medication. It is well established that [inflammation](https://nabtahealth.com/glossary/inflammation/) contributes to cardiovascular disease progression. Perpetual [inflammation](https://nabtahealth.com/glossary/inflammation/) can also damage the heart muscle and exhaust the immune system. Having a compromised heart and a dysfunctional immune system are likely to be the main contributory factors leading to cardiac failure in COVID-19 patients. #### **Chronic Lung Conditions** Having long-term conditions that result in recurrent [inflammation](https://nabtahealth.com/glossary/inflammation/) in the lungs such as asthma, Chronic Obstructive Pulmonary Disorder (COPD), and [cystic fibrosis](https://nabtahealth.com/glossary/cystic-fibrosis/) (CF) make individuals more susceptible to respiratory lung infections. The lungs are home to specialised white blood cells which help to protect them from inhaled pathogens and toxins under normal circumstances. However, individuals who have compromised lungs, either due to perpetual [inflammation](https://nabtahealth.com/glossary/inflammation/) or abnormal function of the epithelium in the lungs, may result in a state of immune and tissue exhaustion and damage; making the lungs more vulnerable to infection or challenge. In addition, controlling lung [inflammation](https://nabtahealth.com/glossary/inflammation/) in individuals with chronic or acute asthma may require the individual to use [immunosuppressive medications](#immunosuppressive) such as steroids, which will dampen the immune response and make them more vulnerable to infection. In general, the more chronic the condition, the more likely that a person is compromised, either due to long term medication use or as a result of the pressure the disease poses on lung tissue. Individuals with CF are at a high risk of developing other lung complications because the disease is caused by a genetic dysfunction which affects the level of salt in cells. This leads to water imbalance which can clog up highly vascular organs such as the lungs and digestive tract. In the lungs, this affects the air flow in and out of the lungs, resulting in respiratory distress. As COVID-19 is predominantly a respiratory disease, not having the necessary protection mechanisms in place within the lungs puts individuals at a higher risk of developing severe respiratory disease if infected with SARS CoV-2. You should continue to take your medications but take extra care to protect yourself. If you are a smoker, it is highly recommended you stop smoking to give your lungs a better chance to control and recover from the infection (see [smoking](#smoking) section). #### **Cancer** Blood cancer is caused by a dysfunction in white or red blood cell production from the bone marrow or lymph nodes. Leukaemia, lymphoma and myeloma are white blood cell cancers. The white blood cells normally fight infections, and if they are dysfunctional, your body is less able to fight infections efficiently. Polycemia vera is a rare cancer and a type of red blood cell cancer. The red blood cells help to carry oxygen to the rest of your body. Having any cancer of the blood puts you at a higher risk of experiencing severe symptoms once infected with SARS CoV-2. Cancers that affect other major organs, such as the lungs, kidneys or liver also place individuals at a higher risk, as those organs are unable to function properly if malignant. The fact that COVID-19 is a respiratory disease means that those with compromised lungs, either due to cancer or other conditions, are likely to be severely affected if infected. See the [lung](#lung), [liver](#liver) and [kidney](#kidney) sections of this report. In general, people who have cancer are immunosuppressed either due to the cancer itself or the treatment they are undergoing. Individuals with stable disease may wish to discuss the option of delaying [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/) or elective therapy with their oncologist until the threat of COVID-19 is reduced. Individuals with progressive, aggressive or metastatic disease requiring treatment should take extra caution to protect themselves and self-isolate. See [immunosuppressive treatment](#immunosuppressive) section for further information. #### **Liver Disease** Having chronic liver disease may put you at risk of experiencing severe symptoms once infected with SARS CoV-2. Compromised blood liver functions are a common feature in individuals who are critically hospitalised with COVID-19. The liver is an essential [detoxifying](https://nabtahealth.com/glossary/detoxifying/) organ. Its primary function is to filter blood from the digestive tract and the rest of the body. The liver also stores and releases glucose as needed, makes [cholesterol](https://nabtahealth.com/glossary/cholesterol/), and stores [iron](https://nabtahealth.com/glossary/iron/). The liver holds certain types of white blood cells, and supports immune function by clearing infections. Liver disease involves a process of progressive destruction and regeneration of the liver, often leading to scarring and permanent damage. This progressive liver damage often causes a dysfunction in [metabolism](https://nabtahealth.com/glossary/metabolism/), leading to [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or impaired insulin production (see [diabetes](#diabetes) section). This in turn affects the immune system and the ability of the body to clear infection, thus hindering the way the body responds to infectious pathogens such as SARS CoV-2. #### **Kidney Disease** As more data emerges on the clinical characteristics of individuals who have been hospitalised or who have died from COVID-19, it is becoming apparent that the most affected organs, after the lungs, are the kidneys. Kidney disease occurs when the kidneys are unable to filter out water and waste from the blood effectively. The filtration of waste products is a natural part of the metabolic process; therefore, factors such as medication, environmental pollution and infection that add to waste generation, also add to the pressure on the kidneys to work efficiently and effectively. Kidneys have historically been thought of as organs that are unable to regenerate, but new research shows that they do have regenerative capabilities, but this process is likely to be slow. As cellular turnover slows down naturally with age, and because age is directly associated with acquisition of kidney disease (see [age](#age) section), recent reports from the USA show that most of the COVID-19-related deaths to date in individuals over 65 have concurrent kidney failure as the main cause of mortality. If compromised kidney function means that the body is not able to effectively filter invading pathogens and toxins, infection with SARS CoV-2 will put additional pressure on the kidneys, potentially leading to kidney damage and toxic shock which will require immediate hospitalisation. Individuals with NCDs such as kidney disease should take their conditions very seriously and talk to a designated healthcare provider about putting appropriate measures in place to protect themselves. Maintaining good hydration and a healthy lifestyle is key. ### **Other factors** #### **[HIV](https://nabtahealth.com/glossary/hiv/)/ AIDS** Testing positive for Human Immunodeficiency Virus ([HIV](https://nabtahealth.com/glossary/hiv/)) does not make you more susceptible to developing severe COVID-19 symptoms, provided you are on effective [antiretroviral](https://nabtahealth.com/glossary/antiretroviral/) treatment. However, if you are not on appropriate treatment, the [HIV](https://nabtahealth.com/glossary/hiv/) virus is free to attack your immune system, putting you at a higher risk of developing AIDS. AIDS stands for Acquired Immuno-Deficiency Syndrome. As the name indicates, this is a progressive condition that results in destruction of the immune system. Without a functioning immune system, you will become immunocompromised, meaning that it will be more difficult for your body to fight an infection. This increases the likelihood of you experiencing more severe symptoms, should you become infected with SARS CoV-19, of. If you have [HIV](https://nabtahealth.com/glossary/hiv/) you should already be under care of an appropriate healthcare provider who can properly monitor your condition. #### Smoking Tobacco smoke exposure increases susceptibility to respiratory tract infections such as COVID-19. Smoking is known to damage the lungs and airways which causes a range of severe respiratory problems (see [chronic lung conditions](#lung)), it also puts you at a high risk of developing lung cancer and [cardiovascular disease](#CVdisease), the latter is the risk factor most frequently seen in those individuals who have died from COVID-19. Smoking does not only directly affect you, it also puts those around you who are exposed to secondhand smoke at risk. In light of the current pandemic, there has never been a more important time to stop smoking, not only for your own health, but also to protect those around you. If you are using e-cigarettes or other ‘vaping’ devices, recent clinical and scientific evidence has suggested that these pose a similar threat to the health of your lungs and heart. E-cigarettes contain chemicals that are not present in traditional cigarettes, but which have additional health implications associated with them. E-cigarettes also carry an additional hygiene risk due to reuse of mouth pieces, which means you are more likely to expose yourself to pathogens, such as SARS-CoV-2, which can survive on a variety of surfaces. #### **Immunosuppressive medication or treatment** There are many medications, treatments and medical procedures that can temporarily reduce the ability of your immune system to fight infection. In this section, we will provide a few examples; however, if you are on any medication or have undergone a medical procedure recently which makes you immune compromised, you should be in regular contact with your healthcare provider. They will be able to determine how vulnerable you are to acquiring severe or critical COVID-19 symptoms and advise you which steps to take to reduce your chances of catching this, or any, infection. * **Immunosuppressants** Drugs that suppress the immune system such as certain biologics (recombinant proteins) and glucocorticoids (steroids), inhibit white blood cells activity or function. These cells are the main fighters of infection in the body and, therefore, taking drugs that stop them from working effectively or reduce their numbers, affects the ability of the immune system to fight infection. This makes you more susceptible to severe symptoms following infection with SARS CoV-2. * **[Chemotherapy](https://nabtahealth.com/glossary/chemotherapy/)** One of the most widely used treatments for cancer is [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/). The mechanism of chemotherapeutic agents is to destroy rapidly growing cells by damaging DNA and other factors involved in cell division. Because of its mechanism of action, [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/) also attacks the highly dividing and healthy cells of the body such as the [stem cells](https://nabtahealth.com/glossary/stem-cells/) of the bone marrow. These [stem cells](https://nabtahealth.com/glossary/stem-cells/) are responsible for providing a continuous supply of the disease fighting, white blood cells. During and immediately after [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/) your body is less able to defend itself against infection. Individuals who have certain types of [cancer](#cancer) may already be at an increased risk of experiencing severe COVID-19 symptoms; and if the same individual is also undergoing [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/), extra protection and caution should be considered. * **Bone marrow transplantation** is a procedure that aims to replace otherwise damaged or destroyed bone marrow with healthy bone marrow. The first step involves [radiotherapy](https://nabtahealth.com/glossary/radiotherapy/) to partially or completely eliminate faulty [stem cells](https://nabtahealth.com/glossary/stem-cells/). The aim is to reintroduce healthier bone marrow via a transplant. As described above, the bone marrow is an essential source of infection-fighting white blood cells. The period between bone marrow elimination and transplant acceptance (i.e. the body adjusting to its new, healthier bone marrow) is around 6 weeks, and this can vary from person to person. During this critical time, a transplant recipient is at extremely high risk of acquiring infections. This includes infection with SARS CoV-2. #### **Living in a care facility or nursing home** Nursing home populations are at the highest risk of being affected by COVID-19 compared to the general population because they have a high proportion of [older](#age) adults who are often living with underlying chronic medical conditions which puts them at risk of experiencing severe or chronic symptoms if infected with SARS-CoV-2. To protect all who live and work in nursing homes and care facilities, regular cleaning and disinfection of common areas, appropriate [social distancing](https://nabtahealth.com/what-is-social-distancing/), and self-isolation measures where required, should be implemented. It is important that carers, who may carry the virus but may not be at risk themselves, also take the necessary steps to protect those residents who are considered high risk. This includes social distancing as much as possible and wearing appropriate Personal Protective Equipment (PPE). #### **Working in a healthcare environment** Being a doctor, nurse or an individual working in a hospital or clinic means that you may have regular exposure to patients who may have tested positive for SARS CoV-2 and, therefore, there is a risk of them passing the infection on to you. Take sensible precautions when handling infected patients; use PPE when at work, such as masks, a clinical coat/suit and gloves, and ensure that it is changed on a regular basis. Outside of work, take steps to protect yourself and those around you who may be vulnerable to infection. Use best practice for maintaining hygiene, including removal of potentially contaminated clothing whilst still at work, washing hands with soap and water, and disinfecting any other materials that may come in contact with others outside the hospital setting. #### **Contact with an infected or exposed individual / environment** Being in close contact with someone who has COVID-19, or someone who has been exposed to the SARS CoV-2 virus, puts you at high risk of infection, which is increased if you have other confounding factors, such as those mentioned in this article. Because the majority of individuals who are exposed to the virus do not display obvious symptoms, extra care to protect yourself should be taken if you are in a high risk category. Based on current data surrounding the length of time the virus remains in our bodies (the incubation period), you should self-isolate for at least 14 days from the time of potential exposure (Day 0) to minimise passing the infection to others. ### **Conclusion** As this article shows, many of the factors that result in an individual becoming ‘high risk’ occur as a result of underlying health conditions. Therefore, it is important to ensure that your current health status is under control and that medication, where required, is taken appropriately. Being aware of the signs of infection such as a fever, cough, shortness of breath, is key. Call ahead before visiting a health care provider or emergency department to alert them to the fact that you have been exposed to the virus. If you are in a country which has implemented tools to alert or monitor infected or potentially infected individuals, you may wish to adopt some of those tools to protect those around you and reduce the chance of cross contamination. The general recommendation is to limit hospital visits and contact with healthcare facilities where ever possible. If you have a chronic condition and require ongoing medical care or monitoring, provided your doctor is okay with it, consider using telehealth, electronic consultations and remote care, as appropriate. If you are considered high risk and require medications or a pharmacy visit, think about asking others who are less vulnerable to pick up what is needed. It is important to keep taking your medications as recommended. Nabta Health is committed to providing you with the most up to date, peer-reviewed, clinically- and scientifically-validated information on COVID-19 and other conditions. If you are not sure what your, or your loved ones’, risk factors are, Nabta Health has built a risk assessment questionnaire, which can be accessed from our Application. The Nabta App can be downloaded from our website ([www.nabtahealth.com](http://www.nabtahealth.com)). **References:** * [https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html) * Madjid, M., _et al_. Potential Effects of Coronaviruses on the Cardiovascular System: A Review. _JAMA Cardiol._ Published online March 27, 2020. * Ruparelia, N., _et al._ Inflammatory processes in cardiovascular disease: a route to targeted therapies. _Nat Rev Cardiol_ 14**,** 133–144 (2017) * Libert, C.,_et al_. The X chromosome in immune functions: when a chromosome makes the difference. _Nat Rev Immunol_ 10, 594–604 (2010) * ue Tsai, Xavier Clemente-Casares, Angela C. Zhou, Helena Lei, Jennifer J. Ahn, Yi Tao Chan, O.C., et al. Insulin Receptor-Mediated Stimulation Boosts T Cell Immunity during [Inflammation](https://nabtahealth.com/glossary/inflammation/) and Infection. _Cell [Metabolism](https://nabtahealth.com/glossary/metabolism/)_ 28 (6), 922-934 (2018) * Muniyappa, R. and Gubbi, S. COVID-19 pandemic, coronaviruses, and diabetes mellitus. _Am j physiol. Endocrinology and [metabolism](https://nabtahealth.com/glossary/metabolism/)_ 318(5), E736-E741. (2020) * Hanna, T. P. _et al_. “Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. _Nature rev clin oncol_ 17(5) 268-270. (2020) * [https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf](https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf) * Jafar, N., _et al_. The Effect of Short-Term Hyperglycemia on the Innate Immune System. _Am J of Med Sci_, 351 (2), 201-211 (2016) * Cheng, Y., _et al_. Kidney disease is associated with in-hospital death of patients with COVID-19. _Kidney int._ vol. 97 (5), 829-838 (2020) * Parohan, M., et al. Liver injury is associated with severe Coronavirus disease 2019 (COVID‐19) infection: a systematic review and meta‐analysis of retrospective studies. _Hepatol Res_. (2020) * [https://coronavirus.jhu.edu/map.html](https://coronavirus.jhu.edu/map.html) * Ishan, P., _et al_. Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19. J Am College Cardiol. (in press) (2020).
It is quite astounding to think that five months ago barely anyone outside of China had heard of Coronavirus disease 2019 (COVID-19). As bells tolled and fireworks exploded to mark the end of 2019 and the start of 2020, a little known Chinese province called Wuhan was on its way to global recognition, for all the wrong reasons. As we moved into a new year and a new decade, little did many of us know quite how tumultuous the start of 2020 would be. Move forward to April and it is hard to imagine anyone not knowing what COVID-19 is. Social media and the sensationalist press have made us all experts. The headlines scream out worse case scenarios, schools are closed, events are cancelled, face masks, sanitiser and (somewhat bizarrely) toilet roll sales have escalated exponentially. Rumours and conspiracy theories are rife; opinion pieces are cited as fact and a simple scroll through social media, reveals post after post on the topic. I write articles for a women’s health platform; I spend my days researching topics that I think will be of interest to our target audience. I have written about fertility issues, cancer, pregnancy and postnatal depression; I have even penned a more personal piece on our experience of [absence seizures](https://nabtahealth.com/absence-seizures-in-childhood-a-parents-perspective/). I have researched areas that I thought I had no personal interest in and topics that are unlikely to ever impact me directly. I have always learnt from it and I have never approached a topic with quite as much trepidation as I approach COVID-19. Why is this the case? COVID-19 is impacting my day to day life; my children are currently unable to attend school and nursery and my daughter will spend the remainder of the school year completing ‘at home learning’ whereby her teacher sends work home for her to complete with our help and support. Mid way through March 2020, all cinemas, gyms, soft play areas, community parks and swimming pools in our region closed and there is no sign of them reopening in the coming weeks. In April, in Dubai, we underwent a period of complete lockdown, where only one member of a family could leave the house, with a police permit, every three days. Children were prohibited from leaving at all. Most people are probably well acquainted with the phrases ‘[social distancing](https://nabtahealth.com/what-is-social-distancing/)’ and ‘flattening the curve’ by now. As an expatriate living in Dubai, I have always been confident that I could get ‘home’ with minimal notice. Now, however, at a time when flights to and from various destinations are being cancelled and government policies and guidelines are changing daily, I can no longer be certain of this. Suddenly, home seems to be awfully far away. I have my personal feelings on the virus, the spread of information, the steps that are being taken in an attempt to contain it. I read things I agree with and things I definitely do not agree with, but one thing I knew was that I did not want to add to the wealth of opinion pieces on the topic. So I postponed writing about COVID-19. However, I believe it would be amiss of Nabta, as a healthcare platform, not to provide information; so I looked on the websites of trusted organisations, the WHO, the CDC and the NHS and I wrote based on the advice they were giving. No rumours, no opinions, no conspiracies, just the facts, as of today. Of course this is an evolving situation and the statistics and the guidelines are changing constantly, but what do we know today? **1)** **As of March 11th 2020, the COVID-19 outbreak has been declared a pandemic by the WHO.** Pandemic: The worldwide spread of a new disease. Of course with reported cases growing and the numbers (of people and countries) affected increasing daily, it was probably only a matter of time before this call was made. It does not mean that the virus has suddenly become more deadly or more infectious, but it is becoming more widespread. **2) What is COVID-19?** The Coronaviruses are a large family of viruses, known to cause respiratory distress. COVID-19 is the most recently discovered. It is related to the SARS (severe acute respiratory system) virus, but not the same. SARS is more deadly, but less infectious than COVID-19. **3) How is COVID-19 spread?** It is thought that the main mode of transmission is via respiratory droplets passing from one person to another. This means that when a person who is infected coughs or exhales, they are potentially spreading the virus to those in close proximity. Acquiring the disease in this manner is less likely if you maintain a distance of 1.5 metres or more and try to avoid touching your mouth, nose and eyes. There is a risk of infection by touching an infected surface and then touching your eyes, nose or mouth. This is not, however, thought to be the main mode of spread. It is not yet known how long the virus can survive on surfaces, but cleaning with a simple disinfectant should be sufficient to kill it. People can have the disease, but remain symptom-free for up to 14 days. This is known as the incubation period and represents a high-risk time for transmission of the condition. The exact duration of the incubation period is an estimate based on the longest incubation period seen with other, similar, coronaviruses. **4) What are the symptoms of COVID-19?** The main symptoms of COVID-19 are fever, tiredness and a dry cough. Other recognised symptoms include the loss of a person’s sense of smell or taste. In severe cases an infected person can develop pneumonia. Approximately 80% of people will recover without needing specialised, medical treatment and some people will remain [asymptomatic](https://nabtahealth.com/glossary/asymptomatic/). Unfortunately one of the biggest challenges in reducing the spread is that those who have no symptoms, or only mild symptoms, can still pass the disease on to others. To date, it seems as though young people and children are likely to get a mild version of COVID-19. Those at most risk of developing a serious illness are the elderly and those with underlying health issues, such as high blood pressure, diabetes and heart disease. **5) Is there a cure for COVID-19?** There is currently no cure for COVID-19 and healthcare efforts need to go into managing the symptoms. Antibiotics are not an option as they do not cure viruses. Researchers are working on developing a vaccine, but this will take time. **6) Finally, be careful of what you read and what information you pass on to others.** Whilst easy to believe the headlines, be aware that not everything that is published on the World Wide Web is scientifically sound. The WHO guidelines to date have remained simple and concise: * **Clean hands** regularly and thoroughly. The virus can be killed by soap and water or an alcohol-based hand wash. * Practice **good respiratory hygiene**; cover your mouth when coughing or sneezing and immediately discard used tissues. * If you have symptoms of COVID-19 and/or have recently visited a country where COVID-19 is spreading, adopt **self quarantine for 14 days** to reduce the risk of spread. * Follow the guidelines of your local health authority. These will differ depending on where in the world you are. Countries with mass outbreaks are likely to have more stringent measures in place. In China the outbreak has been contained and transmission slowed. This shows the value in **following government advice and adhering to local policies** and restrictions. * Wear a face mask and gloves if recommended to do so by your local health authority. The WHO releases a [situation report](https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/) everyday, summarising the latest developments. I have been reading these over the last few days, whilst constructing this article. At a time when there are so many unknowns and so many unanswered questions, relying on trustworthy sources for any new information is key. There is a lot of talk across social media about the responsibility we all have to implement ‘social distancing’, but I believe we also have a responsibility to consider carefully the stories we spread. Over time the COVID-19 outbreak will teach us a lot; the statistics and figures will prove invaluable for epidemiologists, scientists will increase their knowledge of infectious diseases and, particularly, the family of coronaviruses. We will, for the first time, be able to look at the impact of social media on a pandemic. In the meantime, these are worrying times, stay safe, follow health authority guidelines and maintain good personal hygiene. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#037a626f6f62436d626177626b66626f776b2d606c6e) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * “About Coronavirus Disease 2019 (COVID-19).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 24 Feb. 2020, [www.cdc.gov/coronavirus/2019-ncov/about/index.html](https://www.cdc.gov/coronavirus/2019-ncov/about/index.html). * “Coronavirus (COVID-19).” NHS Choices, NHS, [www.nhs.uk/conditions/coronavirus-covid-19/](http://www.nhs.uk/conditions/coronavirus-covid-19/). * “Novel Coronavirus (2019-NCoV) Situation Reports.” World Health Organization, World Health Organization, [www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/](http://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). * “Q&A On Coronaviruses (COVID-19).” World Health Organization, World Health Organization, [www.who.int/news-room/q-a-detail/q-a-coronaviruses](http://www.who.int/news-room/q-a-detail/q-a-coronaviruses).
There are certain factors that put particular groups of people at higher risk of experiencing severe disease if infected by SARS CoV-2. Click [here](https://nabtahealth.com/covid-19-risk-factors-an-overview/) for an overview. Characteristics such as [gender](https://nabtahealth.com/covid-19-risk-factors-demographics-gender/), age, and [weight](https://nabtahealth.com/covid-19-risk-factors-demographics-weight/) are collectively known as demographics. These factors play a key role in determining how a person responds following infection with SARS CoV-2. This article explores age in more detail: #### **The effect of age** Individuals of any age can contract SARS CoV-2, with or without becoming symptomatic. To date, COVID-19 has affected **significantly more individuals in the 65 and over age bracket**, and less of the younger population. Studies have shown that advanced age puts individuals at a higher risk of experiencing severe symptoms once infected with SARS CoV-2; meaning that this age group is more likely to require hospitalisation. In the US, eight out of ten deaths from COVID-19 have been in those aged 65 and over. The main reasons why older adults seem to suffer more from COVID-19 are: * **Underlying health conditions**. Age correlates with the acquisition of non-communicable disorders such as [hypertension](https://nabtahealth.com/glossary/hypertension/), [chronic renal disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-kidney-disease/), and [diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/). In the context of COVID-19, over 70% of those who have been hospitalised with the infection over the age of 65 have at least one underlying health condition. * **Slower regeneration**. In general, the ability of our bodies to regenerate slows down with age, and this applies to all organs, including the skin, gastrointestinal tract, liver, and immune system. The immune system loses resiliency and becomes more susceptible to infections. As a result, the older you are, the less likely your body is able to effectively or rapidly clear infections. The older generation are also more susceptible to other respiratory viruses, including the seasonal flu. Consuming a [balanced diet](https://nabtahealth.com/the-good-dietary-fat/) and partaking in regular exercise will contribute to good overall health. Good health and a stronger immune system will both enhance your body’s ability to fight infections. This is particularly important for those in the older population group. However, despite the clear correlation between age and disease severity, there are cases of young adults and children experiencing critical symptoms following infection with SARS CoV-2. The reasons for this remain unknown, but the underlying message is clear: caution, protection, and healthy lifestyle choices should be adopted by all. [ COVID-19 Risk Factors – Demographics: Gender ](https://nabtahealth.com/covid-19-risk-factors-demographics-gender/) [ COVID-19 Risk Factors – Demographics: Weight ](https://nabtahealth.com/covid-19-risk-factors-demographics-weight/) **Sources:** * Adler, Sarah Elizabeth. “Coronavirus Most Serious for People Age 65+.” _AARP_, [www.aarp.org/health/conditions-treatments/info-2020/coronavirus-severe-seniors.html](http://www.aarp.org/health/conditions-treatments/info-2020/coronavirus-severe-seniors.html). * “People Who Are at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, 14 May 2020, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html). * Richardson, Safiya, et al. “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.” _Jama_, vol. 323, no. 20, 22 Apr. 2020, pp. 2052–2059., doi:10.1001/jama.2020.6775.
Prior to January 2020, it is likely that very few of us would have heard the phrase ‘social distancing’. Now, as many as 3 billion people globally not only know what social distancing is, but are being asked to implement it in their everyday lives. These are unprecedented times. With [COVID-19](https://nabtahealth.com/covid-19/) infections continuing to rise, up to 70 countries and territories across the world are requesting that their citizens adopt some form of social distancing. Some are even implementing a complete mandatory lockdown, prohibiting any residents from leaving their homes. This includes India, which is about to embark on a 21 day total lockdown, affecting 1.3 billion people. What does social distancing mean? --------------------------------- The World Health Organisation ([WHO](https://www.who.int/)) says that socially distancing means maintaining a distance of at least 1 metre between people. This reduces the risk of breathing in infected respiratory droplets, which is considered to be the predominant way in which the virus spreads. Through the implementation of social distancing techniques, governments and health authorities across the world are hoping that we can limit the kind of mixing that allows an infection to spread throughout a population. Whilst the specific guidelines may vary between countries, the overall aim is essentially the same; limit social contact and avoid crowded places. Some suggestions for how to socially distance are: * Avoid contact with anyone displaying symptoms of COVID-19; particularly if they have a high fever or a cough. * Avoid non-essential use of public transport. * Work from home where possible. * Avoid large and small gatherings in public places (bars, restaurants, leisure centres). * Avoid gatherings with friends and family. * Only visit a doctor or hospital in an emergency. Attempt to communicate via phone or online services first. These are taken from guidelines given to UK citizens ([gov.UK](https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults)), but are relevant to all who are being asked to limit their social contact with others. Who is most at risk? -------------------- In order for social distancing to work, i.e. for it to reduce the spread of infection, the vast majority of the population need to abide by it. This might seem frustrating when reports suggest that even if we were to become infected, many of us would only experience mild symptoms. However, [some people are at risk of serious illness](https://nabtahealth.com/covid-19-risk-factors-an-overview/). Successful social distancing can reduce the likelihood of those who are most vulnerable from falling ill and it can lessen the burden on health care systems around the world that might otherwise struggle to cope. Some of the people most at risk of experiencing severe symptoms are: * Those who are aged over 70. * Those with chronic respiratory disease (asthma, chronic obstructive pulmonary disease, bronchitis). * Those with chronic heart, liver or kidney disease. * Those with a weakened immune system, such as patients undergoing [chemotherapy](https://nabtahealth.com/glossary/chemotherapy/). * Those with diabetes. * Those who are overweight ([](https://nabtahealth.com/what-is-body-mass-index-bmi/)[BMI](https://nabtahealth.com/glossary/bmi/) >40). * Possibly [pregnant women](https://nabtahealth.com/i-am-pregnant-should-i-be-worried-about-the-recent-covid-19-outbreak/), although the data on this is inconclusive to date. If you fall into one or more of these categories it is particularly important for you to observe stringent social distancing. Will social distancing eliminate COVID-19? ------------------------------------------ The WHO believes that social distancing is a way of buying time; time that can then be spent researching and finding ways to attack the virus. Restricting the movement and social interaction of populations is the best option we have for keeping case numbers at a manageable level. The question of how sustainable this approach is remains to be answered; certainly, the emotional impact of protracted periods of self isolation needs to be considered. Fortunately, we live in a world that is technologically advanced with messaging apps and online video calls helping all of us to maintain contact with family and friends during these challenging times. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#255c44494944654b444751444d404449514d0b464a48) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * “Coronavirus Disease (COVID-19) Advice for the Public.” World Health Organization, World Health Organization, [www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public](http://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public). * “Coronavirus, Social Distancing and Self-Quarantine.” Johns Hopkins Medicine, [www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine](http://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine). * “Guidance on Social Distancing for Everyone in the UK.” GOV.UK, [www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults](https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults).
There are certain factors that put particular groups of people at higher risk of experiencing severe disease if infected by SARS CoV-2. Click [here](https://nabtahealth.com/covid-19-risk-factors-an-overview/) for an overview. The association between non-communicable disorders (NCDs) and more severe COVID-19 symptoms is consistent worldwide; those with underlying NCDs are more vulnerable to experiencing severe complications following infection with SARS CoV-2. Some of the most prevalent NCDs include type 2 diabetes, [hypertension](https://nabtahealth.com/glossary/hypertension/), [cardiovascular disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/), [chronic lung conditions](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/), [chronic kidney disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-kidney-disease/), [chronic liver disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/), and [cancer](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cancer/). This article covers diabetes. #### **What is Diabetes Mellitus (DM)?** Patients with diabetes are unable to properly regulate their blood glucose levels due to insufficient insulin production or reduced insulin sensitivity. Lack of insulin, or the inability of cells to respond to insulin, results in high blood glucose levels, known as [hyperglycaemia](https://nabtahealth.com/glossary/hyperglycaemia/). Under normal conditions, one of insulin’s many functions is to signal your body to activate white blood cells, which are the main cells in our blood and lymph nodes that fight infections. Therefore, when the body is unable to produce sufficient amounts of insulin, the immune system may be compromised as a result, putting the individual at risk of infection. A compromised immune system will be less able to control the spread of, and manage the symptoms associated with, invading pathogens such as SARS CoV-2. #### **Why does diabetes increase the risk of COVID-19 complications?** * **Efficient viral entry into cells**. The ACE2 receptor is the [enzyme](https://nabtahealth.com/glossary/enzyme/) that is allowing SARS CoV-2 to infect the cells of the body. Increased expression of ACE2 correlates with increased viral uptake by the cells of the body. Preliminary data suggests that patients with diabetes might have an increased expression of ACE2 in the lungs; however further work is required to validate this. * **An inability to efficiently clear the virus**. Patients with diabetes seem to be less able to clear the virus once it enters their body. * **Compromised immune response**. The body’s immune system relies on its ability to metabolise glucose as a form of energy. The inability of diabetics to regulate glucose, results in perpetual activation of the immune system, which causes a state of immune exhaustion. This can, in turn, compromise the extent to which an individual is able to fight infections * **Increased susceptibility to hyperinflammation**. A further consequence of having a compromised immune system means that people with diabetes may be more susceptible to an intense inflammatory response upon exposure to SARS CoV-2. Normally the immune system is composed of cells that function to dampen an acute inflammatory response. These cells are also dysfunctional in diabetics, therefore, it is more difficult to maintain immune [homeostasis](https://nabtahealth.com/glossary/homeostasis/), resulting in an increase in inflammatory mediators (known as cytokines). The physiological consequence of this is a ‘cytokine storm’, which can, in severe cases, [lead](https://nabtahealth.com/glossary/lead/) to multiorgan failure. * **Comorbidities**. The prevalence of [obesity](https://nabtahealth.com/covid-19-risk-factors-demographics-weight/), [cardiovascular disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/) and [hypertension](https://nabtahealth.com/glossary/hypertension/) is high in patients with diabetes. Furthermore, being in a hyperglycemic state puts pressure on the body’s organs, including the heart, kidneys, and nervous system, which become susceptible to damage. Individuals with type 1 or type 2 diabetes are, therefore, at increased risk of developing additional health complications, such as cardiovascular disease, renal disease, and peripheral nerve damage. This, in turn, makes them more susceptible to experiencing an adverse response to infections and other external pressures. Patients with well controlled diabetes are at lower risk of experiencing diabetes-related complications following SARS CoV-2 infection. #### **I have diabetes, what should I do?** If you are diabetic, it is important to keep taking your medications. To date, there have been no supply-related issues. Those who are on insulin replacement therapy should monitor their body’s sensitivity to insulin which will determine the appropriate dose of insulin to take in order to avoid entering a hyper- or [hypoglycaemic](https://nabtahealth.com/glossary/hypoglycaemic/) state. In addition to this, make sure that your overall health is as good as possible; your diet should be well-balanced and nutritious, and you should stay active, partaking in [regular exercise](https://nabtahealth.com/ive-been-diagnosed-with-diabetes-how-can-exercise-help-improve-my-condition/). [COVID-19 Risk Factors - Demographics: Weight](https://nabtahealth.com/covid-19-risk-factors-demographics-weight/) [COVID-19 Risk Factors - Underlying Health Conditions: Cardiovascular Disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/) **Sources:** * “How COVID-19 Impacts People with Diabetes.” _American Diabetes Association_, [www.diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-diabetes](http://www.diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-diabetes). * Muniyappa, Ranganath, and Sriram Gubbi. “COVID-19 Pandemic, Coronaviruses, and Diabetes Mellitus.” _American Journal of Physiology-Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/)_, vol. 318, no. 5, 26 Apr. 2020, doi:10.1152/ajpendo.00124.2020 * “People Who Are at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, 14 May 2020, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html). * Yang, Jing, et al. “Prevalence of Comorbidities and Its Effects in Patients Infected with SARS-CoV-2: a Systematic Review and Meta-Analysis.” _International Journal of Infectious Diseases_, vol. 94, 12 Mar. 2020, pp. 91–95., doi:10.1016/j.ijid.2020.03.017.
There are certain factors that put particular groups of people at higher risk of experiencing severe disease if infected by SARS CoV-2. Click [here](https://nabtahealth.com/covid-19-risk-factors-an-overview/) for an overview. The association between non-communicable disorders (NCDs) and more severe COVID-19 symptoms is consistent worldwide; those with underlying NCDs are more vulnerable to experiencing severe complications following infection with SARS CoV-2. Some of the most prevalent NCDs include [type 2 diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/), [hypertension](https://nabtahealth.com/glossary/hypertension/), cardiovascular disease, [chronic lung conditions](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/), [chronic kidney disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-kidney-disease/), [chronic liver disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/), and [cancer](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cancer/). This article covers cardiovascular disease. #### **Cardiovascular disease: cause or consequence of COVID-19?** Many patients who have been hospitalised with severe or chronic COVID-19 have had [hypertension](https://nabtahealth.com/glossary/hypertension/) or another type of cardiovascular disease (CVD). CVD is associated with chronic low-grade [inflammation](https://nabtahealth.com/glossary/inflammation/). Long-term [inflammation](https://nabtahealth.com/glossary/inflammation/) can [lead](https://nabtahealth.com/glossary/lead/) to an exhausted immune state, which is less able to respond to, or fight, any new challenges, such as exposure to a novel infectious agent. Autopsy results from patients who have died with or from the disease show evidence of [myocarditis](https://nabtahealth.com/glossary/myocarditis/), confirmed by the presence of unusual inflammatory cells in the heart. It is thought that the extent of myocardial injury might serve as a useful prognostic tool, with more pronounced [myocarditis](https://nabtahealth.com/glossary/myocarditis/) indicative of a worse prognosis. Furthermore, individuals hospitalised with COVID-19 often show biomarkers of cardiac injury in their blood. However, it is important to note that even those who have no pre-existing history of CVD are testing positive for circulating cardiac inflammatory markers; suggesting that SARS CoV-2 is also putting pressure on the heart muscles of those with no known heart issues. #### **Why would a respiratory infection trigger CVD?** Respiratory infections, including COVID-19 are triggers for CVD because they make it harder for the heart to work. * COVID-19 causes **systemic [inflammation](https://nabtahealth.com/glossary/inflammation/)**, which is more robust in patients with severe or critical disease. It is well established that [inflammation](https://nabtahealth.com/glossary/inflammation/) can [lead](https://nabtahealth.com/glossary/lead/) to the development or exacerbation of heart conditions; for example, perpetual [inflammation](https://nabtahealth.com/glossary/inflammation/) can damage the heart muscle and exhaust the immune system. Therefore, the main contributory factors leading to cardiac failure in COVID-19 patients are thought to be a compromised heart and a dysfunctional immune system, caused by virus-induced inflammatory events. * **Heart failure** can occur when your heart muscle doesn’t pump blood as efficiently as normal. When combined with **[arrhythmia](https://nabtahealth.com/glossary/arrhythmia/)**, which is commonly seen in vulnerable individuals infected with SARS CoV-2, it puts pressure on the heart and affects how well it functions. * There are recent findings that suggest that **blood clotting events** which are a characteristic of COVID-19 disease progression, are also responsible for some of the cardiovascular events observed in individuals who have died from the infection. This is supported by evidence suggesting that individuals who are on blood-thinning medication have significantly improved survival rates compared to those who are not on medication. #### **Unanswered questions and treatment options** The novel status of COVID-19 means that a lot of questions remain unanswered. Including, but not limited to, the association between the virus and CVD. Currently there is no cure for COVID-19; treatment focuses on managing the complications that arise as a result of infection. This means that those who present with symptoms of CVD may be treated with medications such as statins, beta blockers and anti-platelet agents. The heavy involvement of inflammatory events suggests that there may be a role for anti-inflammatory therapies in the management of COVID-19. #### **I have CVD, what should I do?** Make sure you continue to take any prescribed medications and ensure you have a good supply. One of the most important things you can do to lower the risk of serious complications is to manage your overall health, making it as good as possible. Exercise regularly and stay active. Ensure that your [diet is balanced and healthy](https://nabtahealth.com/the-good-dietary-fat/); eat a diet rich in unsaturated fats, such as fish, olives, avocados, nuts and seeds, to lower [cholesterol](https://nabtahealth.com/glossary/cholesterol/) levels. Having a pre-existing heart condition does make you higher risk for COVID-19-related complications. Therefore, it is imperative that you take the necessary [social distancing](https://nabtahealth.com/what-is-social-distancing/) steps to minimise your exposure to the virus. [COVID-19 Risk Factors - Underlying Health Conditions: Diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/) [COVID-19 Risk Factors - Underlying Health Conditions: Chronic Lung Conditions](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/) **Sources:** * Fogarty, Helen, et al. “COVID19 Coagulopathy in Caucasian Patients.” _British Journal of Haematology_, vol. 189, no. 6, 24 Apr. 2020, pp. 1044–1049., doi:10.1111/bjh.16749. * Klok, F.a., et al. “Incidence of Thrombotic Complications in Critically Ill ICU Patients with COVID-19.” _Thrombosis Research_, vol. 191, 10 Apr. 2020, pp. 145–147., doi:10.1016/j.thromres.2020.04.013. * Madjid, Mohammad, et al. “Potential Effects of Coronaviruses on the Cardiovascular System.” _JAMA Cardiology_, 27 Mar. 2020, doi:10.1001/jamacardio.2020.1286. * “People Who Are at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, 14 May 2020, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html). * Ruparelia, Neil, et al. “Inflammatory Processes in Cardiovascular Disease: a Route to Targeted Therapies.” _Nature Reviews Cardiology_, vol. 14, no. 3, 1 Dec. 2016, pp. 133–144., doi:10.1038/nrcardio.2016.185. * Wang, Lun, et al. “Cardiovascular Impairment in COVID-19: Learning From Current Options for Cardiovascular Anti-Inflammatory Therapy.” _Frontiers in Cardiovascular Medicine_, vol. 7, 30 Apr. 2020, p. 78., doi:10.3389/fcvm.2020.00078.
The main religion of the Middle East and North Africa (MENA) is Islam. Ramadan is a time of reflection, prayer and fasting for Muslims. COVID-19 is going to affect the way that Muslims mark the Holy Month. A time that is traditionally steeped in cultural traditions and communities coming together to pray and socialise, Ramadan in 2020 is going to be a very different experience. What changes can you expect to see and how can you ensure that your Ramadan maintains the core principles of prayer, reflection and fasting whilst staying safe and adhering to government guidelines? 2020 will go down in history as the year of [COVID-19](https://nabtahealth.com/covid-19/). Starting in China, the virus has swept across the planet, leaving barely a country or territory unaffected. Our day-to-day routines have been altered beyond recognition, with many countries implementing some form of [social distancing](https://nabtahealth.com/what-is-social-distancing/). Of course this has taken time to adjust to; changing our behaviours, habits and norms for what, for many, remains an invisible enemy, has been challenging. ##### Prayer Usually Ramadan is a time when mosque attendance increases. Unfortunately this year, in many locations, mosques have been closed in an attempt to reduce the spread of the virus. People are encouraged, where possible, to complete their prayers at home. All normal prayers in the day, and the more special prayers associated with Ramadan such as the late evening prayers (Taraweeh) and Eid al Fitr prayers, can be performed at home without a sermon. Families who live together can pray together, but larger congregations are not allowed. Of course, prayer and mosque attendance are both of spiritual importance, particularly during the Holy Month; but it should also be considered that for many, the act of coming together in prayer is a social activity. Maintaining contact with friends, family and loved ones is as important now as ever, even if that contact has to be via video calls. ##### Community On the topic of socialising, Ramadan has long been a time for family and friends to come together; to reflect and to pray, but also to break their fast together in the evening. With strict social distancing and active nightly curfews in some parts of the MENA region, the gatherings observed in previous years are not going to happen. It is traditional in some parts of the Gulf region for children to participate in Garge’aan on the fifteenth night of Ramadan. Dressed in traditional dress, they visit their neighbours, and sing local songs in return for sweets and nuts. Depending on their age, some children may struggle to deal with the disappointment of not getting to partake in this ritual. Even for adults, it is another sign that times are different this year and can be difficult to accept from an emotional perspective. ##### Health One of the biggest problems with COVID-19 to date is how little we really know about it. Scientists and doctors are working continuously to better understand the virus and to determine why some people are affected so much more severely than others. Currently, there are people considered to be at higher risk, including the elderly, those with a history of respiratory disease and those with non-communicable diseases, such as diabetes type 2 and obesity. However, amongst the many unknowns with regards to this virus, is the impact of diet on susceptibility and prognosis; certainly, consuming a diet rich in vitamin C (found in many fruit and vegetables, including oranges, papaya, guava, bell peppers and broccoli) and [vitamin D](https://nabtahealth.com/glossary/vitamin-d/) (found in oily fish, mushrooms and eggs) seems to exert some protective effects. However, fasting is a major part of the observation of Ramadan; and it remains to be seen whether varying food intake over a sustained time period is going to put people at higher risk due to reduced nutrient and fluid intake. There are steps that can be taken to try and ensure a healthier fast, particularly during these uncertain times: * **Regular exercise**. Fasting can cause a lack of energy and, over time, muscle weakness. Try to exercise indoors after breaking your fast (or outside if local policy allows it). This will not only help to maintain physical fitness, but also improve your emotional wellbeing. * Those who are under a strict curfew may not be able to spend time outdoors. The sun is an excellent source of **[vitamin D](https://nabtahealth.com/glossary/vitamin-d/)** and those who are spending significant amounts of time indoors are at greater risk of [vitamin D](https://nabtahealth.com/glossary/vitamin-d/) deficiencies. If fasting, try to ensure that your main meal is rich in [vitamin D](https://nabtahealth.com/glossary/vitamin-d/) containing foods. * During the month of Ramadan it is normal for regular sleep patterns and routines to be disrupted. Later meals and evening prayers can disturb the normal circadian rhythm, which can have a negative effect on the **immune system**. Maintaining a strong immune system is essential in the fight against COVID-19. Eat well when you can and try to ensure you still get sufficient sleep to maximise the health of your immune system, even during periods of fasting. * Look after your **mental health**. This article has already alluded to it, but an inability to do what you would normally do during the weeks ahead; such as partake in rituals, share food with neighbours, play games and break your fast with close friends and family; can all be highly detrimental to your state of mind. Adhering to strict social distancing rules is difficult and is a particularly big ask during the month of Ramadan. Seek help and support if you need it during these weeks. Video calls may not be the same as being with people, but they are a compromise and might be the start of new traditions and routines in years to come. In practical terms, not all Muslims are able to fast. Consideration is always given to those who are pregnant, or have underlying health issues. This year, frontline medical workers are also exempt from fasting if it is considered that they will weaken their immune system, or compromise their ability to treat patients. Those who have tested positive for SARS CoV-2, the virus responsible for COVID-19, are also exempt if their symptoms would make it difficult to fast. Ramadan in 2020 is going to be a restrained affair; a time of quiet contemplation and modest iftars, rather than extravagant socialising. Whilst change is always challenging and deviating from long-help practices and traditions is hard, the fundamental principles of Ramadan still remain. Those observing the Holy Month can use the time to reflect, to give thanks for all that they have and offer up Zakat for those in need. Nabta wishes all our readers a blessed, healthy Holy Month. Ramadan Mubarak.
As far as the new [COVID-19](https://nabtahealth.com/covid-19/) virus is concerned, at present we have a lot more questions than answers. Hardly surprising given that at the start of the year barely anybody had heard of the virus. Whilst researchers and healthcare professionals work tirelessly to better understand a condition that has caused global chaos and uncertainty, all we can really do is follow current guidelines and make the best decisions for our families and loved ones. The [benefits of breastfeeding](https://nabtahealth.com/benefits-of-breastfeeding/) cannot be denied. The United Nations International Children’s Emergency Fund (UNICEF) and World Health Organisation (WHO) categorically state that exclusive breastfeeding for the first six months gives your child the best possible start. But what about if you are ill yourself? The predictions suggest that many of us will, over time, be diagnosed with COVID-19 and this will include [those who are pregnant](https://nabtahealth.com/i-am-pregnant-should-i-be-worried-about-the-recent-covid-19-outbreak/) or breastfeeding. #### I have recently been diagnosed with COVID-19, should I stop breastfeeding? First the good news, there is currently no clinical evidence that the virus passes into breast milk. Next, the caveat……this virus is new, studies to date have been preliminary and whilst analyses performed thus far have found no transmission via breast milk, case numbers have been small. This is probably why guidance from organisations such as WHO and the Centers for Disease Control and Prevention (CDC) with regards to breastfeeding following a COVID-19 diagnosis, is only just becoming available. The main mode of virus spread is via respiratory droplets. These are the particles we release when we cough or exhale. Thus, it would seem that the biggest risk to your breastfed baby will probably come from the close contact and sharing of airborne droplets that comes with breastfeeding and not from the milk they are drinking. Advice from the WHO states that: “The numerous benefits of skin-to-skin contact and breastfeeding substantially outweigh the potential risks of transmission and illness associated with COVID-19”. [WHO, April 2020.](https://www.who.int/docs/default-source/maternal-health/faqs-breastfeeding-and-covid-19.pdf?sfvrsn=d839e6c0_1) #### What precautionary steps can I take to minimise the risk of passing the virus to my child? Talk to your family and health care professionals about the benefits and risks of breastfeeding. Be aware that as time passes, our knowledge will develop and, as such, the advice from WHO and CDC may change. To date, the advice is: * If you feel well enough, breastfeed your infant. If not, consider expressing milk. * Wash your hands thoroughly (for at least 20 seconds) before feeding your baby or touching any bottles or breast pumps. * If you have access to a medical mask, wear it whilst feeding your baby. Consult [WHO guidelines](https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks) for how to safely wear and discard your mask. * Try to avoid coughing or sneezing whilst feeding your baby. If you do cough or sneeze, use a tissue to catch any particles, discard it immediately and wash your hands again before continuing the feed. * If you do express milk, ask someone who is well to feed your baby. Make sure all equipment is thoroughly cleaned and sterilised before and after use. Additionally: * You do not need to wash your breast before every feed. However, if you cough or sneeze directly onto your chest, wash it promptly with soap and water for at least 20 seconds. * There is no defined period of time to wait before breastfeeding after COVID-19 infection. If you are well enough, you should continue to breastfeed throughout. If you are not well enough, you can start as soon as you feel better. If [lactation](https://nabtahealth.com/glossary/lactation/) is difficult, consult a specialist for help and support. #### Why are these guidelines different to those given to the general population? On first appearances, these guidelines appear to directly contradict most of the advice we are being given elsewhere. [Social distancing](https://nabtahealth.com/what-is-social-distancing/) is a concept many of us are now implementing. Adults and older children are strongly recommended to avoid crowded places and maintain a distance of at least 1.5 metres from other people. This is considered to be the best approach for minimising transmission of the virus. In contrast, mothers are recommended to continue breastfeeding, even if they are COVID-19 positive, and ensure as much skin-to-skin contact as possible with their infant. On the basis of the evidence available to date, the reasons for this are twofold: 1. The benefits of breastfeeding far outweigh the risk of transmission. Breastfeeding reduces the risk of [neonatal](https://nabtahealth.com/glossary/neonatal/) mortality and has additional [health benefits for the nursing mother](https://nabtahealth.com/benefits-of-breastfeeding-for-the-mother/). 2. To date, children are at low risk of COVID-19 infection. The majority that get it, experience only mild symptoms, or are [asymptomatic](https://nabtahealth.com/glossary/asymptomatic/) #### Staying positive Breastfeeding can be difficult at the best of times; add a global pandemic to the mix and things really get tough. Remember that nothing needs to come between the bond you have with your child. There is no need for you to completely socially isolate yourself from your baby. In the early days of the virus, some new mothers in China were advised to separate from their babies for 14 days (the predicted incubation period). This was rapidly found to be far more detrimental than beneficial in terms of bonding and initiating feeding. Babies and young children have, to date, not been severely affected by COVID-19. Of course you do not want your child to fall ill, but maintain good personal hygiene and you will reduce the chances of this happening. Allow yourself time to recover. Even if your symptoms seem mild, this new virus is a big deal. There is a lot that remains unknown and until it is better understood, erring on the side of caution is wise. Ask family and friends for help. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#ff869e93939ebf919e9d8b9e979a9e938b97d19c9092) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Chen, Huijun, et al. “Clinical Characteristics and Intrauterine Vertical Transmission Potential of COVID-19 Infection in Nine Pregnant Women: a Retrospective Review of Medical Records.” The Lancet, vol. 395, no. 10226, 7 Mar. 2020, pp. 809–815., doi:10.1016/s0140-6736(20)30360-3. * “Coronavirus Infection and Pregnancy.” Royal College of Obstetricians & Gynaecologists, [www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/](http://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/). * “FREQUENTLY ASKED QUESTIONS: Breastfeeding and COVID-19 For health care workers”. World Health Organization, [https://www.who.int/docs/default-source/maternal-health/faqs-breastfeeding-and-covid-19.pdf?sfvrsn=d839e6c0\_1](https://www.who.int/docs/default-source/maternal-health/faqs-breastfeeding-and-covid-19.pdf?sfvrsn=d839e6c0_1). * “Pregnancy & Breastfeeding.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Mar. 2020, [www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html](https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html). * Rasmussen, Sonja A., et al. “Coronavirus Disease 2019 (COVID-19) and Pregnancy: What Obstetricians Need to Know.” American Journal of Obstetrics and Gynecology, 24 Feb. 2020, doi:10.1016/j.ajog.2020.02.017. * “When and How to Use Masks.” World Health Organization, World Health Organization, [www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks](http://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks).
Whilst being pregnant can be a time of eager anticipation and excitement, it can also be a time of increased anxiety and worry. Certainly, in the months leading up to delivery there is a lot to consider, from keeping yourself and your developing baby fit and healthy, to all the practical aspects that come with welcoming a newborn into your home. Needless to say, a global health pandemic, such as the [coronavirus 2019](https://nabtahealth.com/covid-19/) (COVID-19) outbreak, is probably the last thing in the world you want to have to consider right now. So, how worried should you be? Does being pregnant make you more likely to catch COVID-19, or more susceptible to developing serious complications? What are the risks to your unborn baby? What should you do if you develop symptoms of COVID-19 whilst pregnant? #### Am I more likely to catch COVID-19? The short answer to this, and in fact to many of the questions involving pregnancy and COVID-19, is that we simply do not know. Consider that this is a virus that has only been in existence since the very end of 2019; whilst the number of reported cases has grown exponentially over a remarkably short time; there is still not enough data available from existing cases to enable researchers to perform detailed risk analyses. At the moment, what we do know is that with the rapid, progressive spread of COVID-19 globally, pregnant women are, and will continue to be, affected. Pregnancy can alter the body’s immune system and consequently the way in which it responds to viral infections. This means that pregnant women occasionally experience more severe symptoms. However, guidelines released by the UK-based Royal College of Obstetricians and Gynaecologists (RCOG), state that pregnant women are no more likely to contract COVID-19 than the general public. #### Will my symptoms be more serious if I am pregnant? The RCOG states that the majority of pregnant women who develop COVID-19 will experience mild or moderate cold or flu symptoms. They suggest that most pregnant women will not become severely unwell. Furthermore, the World Health Organisation (WHO) does not mention pregnant women as a high risk group: “……evidence to date suggests that two groups of people are at a higher risk of getting severe COVID-19 disease. These are older people; and those with underlying medical conditions”. [WHO Situation Report 51](https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf), 11th March 2020. Despite this, on 16th March 2020, pregnant women in the UK were placed in the category of ‘vulnerable people’, meaning that they should adopt stringent social distancing practices to reduce their risk of infection. There is no data from the current outbreak, but other related coronavirus infections, such as severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV), did cause serious illness in some pregnant women. Adding pregnant women to the category of vulnerable people is a precautionary, preventative step aimed at reducing the risk of severe infection, on the basis of the limited data we have thus far. It is imperative, therefore, that pregnant women take all necessary steps to avoid infection: * Wash hands regularly and thoroughly. * Adopt stringent personal respiratory hygiene approaches. Cover your mouth when you cough or sneeze. Avoid touching your eyes, mouth or nose. * Avoid coming into contact with those who are unwell, particularly if they have tested positive for COVID-19. #### I have been diagnosed with COVID-19, am I more likely to experience complications in my pregnancy? This is another question that is very difficult to answer with the limited data we currently have available to us. However, data on other viral respiratory illnesses has suggested that pregnant women are at higher risk of obstetric complications, than their non-infected counterparts. Infection with SARS-CoV or MERS-CoV during pregnancy did increase the possibility of complications; for example, SARS has been shown to restrict foetal growth and MERS has been implicated in cases of placental abruption. There is no evidence that COVID-19 increases the risk of [](https://nabtahealth.com/miscarriage-101/)[miscarriage](https://nabtahealth.com/glossary/miscarriage/), and data on the other coronaviruses has been inconclusive in terms of identifying a direct link. However, COVID-19 might increase your risk of premature delivery. This is evident in the preliminary data to come out of China, but it is not yet clear whether these were induced deliveries, performed to enable better management of the expectant mother’s symptoms. #### What are the risks to my unborn child if I develop COVID-19? Vertical transmission is the name given to an infection that passes from the mother to the child whilst the child is in the womb (in utero). There are very few reported cases of newborns testing positive for COVID-19. A recent case made it into the UK press of a newborn and his mother both testing positive, and there are reports of a similar case in China, earlier on in the outbreak. It is not yet known whether either baby developed the condition in utero, or whether the hospital environment, or exposure to the mother’s coughing at birth, resulted in viral transmission. Regarding the UK case, it is also not known whether the infant went on to develop any COVID-19 symptoms; in general, children appear to experience only mild symptoms. There have been a limited number of studies looking at mothers who were infected with the virus during the third trimester of pregnancy and went on to deliver healthy, non-infected babies. Naturally, to date, these studies only involve a very small number of cases and further work is definitely required. However, the take home message should be that whilst it is impossible to say that vertical transmission does not happen, the evidence to date suggests it is not inevitable and mothers who have the virus are not guaranteed to pass it on to their child. The RCOG do not recommend [](https://nabtahealth.com/is-caesarean-considered-a-better-choice/)[Caesarean](https://nabtahealth.com/glossary/caesarean/) section (C-section) as standard for patients with COVID-19; a vaginal birth may still be possible, depending on the severity of the mother’s symptoms. If she is experiencing pronounced respiratory difficulties, a natural birth is likely to exacerbate things and her doctor will probably recommend a C-section. Birthing pools are not recommended for women who have tested positive for COVID-19. #### What should I do if I start to develop COVID-19 symptoms during pregnancy? First and most importantly, don’t panic. You will need to follow the guidelines stipulated by the country you live in. At this moment in time, different countries have different policies and recommendations in place. Maintain contact with your doctor or midwife; provided your pregnancy is otherwise low risk and not at a critical stage, they will probably want to postpone any scheduled antenatal appointments. As time passes, an increasing number of doctors and midwives are likely to conduct appointments via video conferencing, even for those who do not have any COVID-19 symptoms. This will enable all patients to limit social contact. If symptoms do become severe, you will likely be hospitalised and placed in isolation. Your baby will be closely monitored and a multidisciplinary team of specialists will construct an individualised management strategy, to ensure the best outcome for you and your baby. #### Final note These are unusual times and we still have much to learn and discover about COVID-19. Even the most simple questions cannot yet be definitively answered and rumours and speculation are rife. We have used the most trusted sources and evidence to bring you this information and will commit to updating regularly, as our knowledge and understanding grows. At Nabta Health, we will present the facts as they stand today; we can attempt to offer reassurance and will stress the importance of continuing to look after not only your physical health, but also your mental health. Take care. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#bcc5ddd0d0ddfcd2dddec8ddd4d9ddd0c8d492dfd3d1) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Chen, Yan, et al. “Infants Born to Mothers With a New Coronavirus (COVID-19).” Frontiers in Pediatrics, vol. 8, 16 Mar. 2020, doi:10.3389/fped.2020.00104. * “COVID-19 Virus Infection and Pregnancy.” Royal College of Obstetricians & Gynaecologists, [www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/](http://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/). Based on: [https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-21-covid19-pregnancy-guidance-2118.pdf](https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-21-covid19-pregnancy-guidance-2118.pdf). * Favre, Guillaume, et al. “2019-NCoV Epidemic: What about Pregnancies?” The Lancet, vol. 395, no. 10224, 22 Feb. 2020, doi:10.1016/s0140-6736(20)30311-1. * Mullins, E., et al. “Coronavirus in Pregnancy and Delivery: Rapid Review.” Ultrasound in Obstetrics & Gynecology, 2020, doi:10.1002/uog.22014. * “Novel Coronavirus (2019-NCoV) Situation Reports.” World Health Organization, World Health Organization, [www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/](http://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). * “Pregnancy & Breastfeeding.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 14 Mar. 2020, [www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC\_AA\_refVal=https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html](https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC_AA_refVal=https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html). * Rasmussen, Sonja A., et al. “Coronavirus Disease 2019 (COVID-19) and Pregnancy: What Obstetricians Need to Know.” American Journal of Obstetrics and Gynecology, 24 Feb. 2020, doi:10.1016/j.ajog.2020.02.017. * Schwartz, David A., and Ashley L. Graham. “Potential Maternal and Infant Outcomes from Coronavirus 2019-NCoV (SARS-CoV-2) Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections.” Viruses, vol. 12, no. 2, 10 Feb. 2020, p. 194., doi:10.3390/v12020194. * Wang, Xiaotong, et al. “A Case of 2019 Novel Coronavirus in a Pregnant Woman with Preterm Delivery.” Clinical Infectious Diseases, 28 Feb. 2020, doi:10.1093/cid/ciaa200.
Coronavirus disease 2019 (COVID-19) has affected large parts of the world and has now reached pandemic status. As of June 29th 2020, the virus had spread to 188 countries with more than 10 million cases and over 500,000 deaths worldwide. The disease is caused by a **novel** respiratory virus called **S**evere **A**cute **R**espiratory **S**yndrome **Co**rona**v**irus **2** (SARS CoV-2). The fact that it is novel means that most individuals who encounter the virus have no immunological memory of it. Immunological memory is an innate programming mechanism that has been key to our survival as a species for centuries; it occurs when we are exposed to a pathogen that we have already encountered or been vaccinated against. The memory of this previous immune response enhances the ability of the immune system to fight the virus when it is exposed to it again. This is seen with pathogens such as the influenza virus. Being exposed to a pathogen earlier in life gives one the best chance of acquiring the immunological memory to effectively fight it again later in life. This is because the immune system is in its most malleable, healthy and responsive state in young individuals. Antibodies are a fundamental part of the immune system; they are the body’s soldiers, armed with information and secret codes that enable them to combat enemies effectively. The novelty of SARS CoV-2 puts certain individuals at a high risk because their soldiers, for this particular enemy, have not been trained at all. More data is emerging on the variability of outcomes caused by COVID-19. The infection affects populations and individuals in different ways, and this seems to be dependent on a combination of biological, [socioeconomic](https://nabtahealth.com/glossary/socioeconomic/), or [sociodemographic](https://nabtahealth.com/glossary/sociodemographic/) factors, which may or may not be linked to underlying health conditions. Some individuals may be infected with the virus and not experience any symptoms, whilst the same infection in others may cause severe respiratory disease, multi-organ failure, and death. **Case-fatality rates: the COVID-19 death rate as a proportion of the total number of diagnosed cases.** Case-fatality rates vary worldwide; data gathered by Johns Hopkins University to date shows rates ranging from 0–23% across different countries. This suggests that there are **ethnic and [socioeconomic](https://nabtahealth.com/glossary/socioeconomic/) factors** that contribute to the risk of dying from COVID-19. As more data emerges, and with further research, the clinical and scientific community will begin to understand the role that genetic, social, and cultural factors play in controlling the rates and outcomes of infection. Provision of updated, evidence-based information using the most recent clinical research and data will help mitigate the spread of the infection, and protect those who are more vulnerable around us. Nabta has produced a set of articles that explore the different risk factors that make individuals more vulnerable to the acquisition of severe or critical symptoms following infection with SARS CoV-2, based on the most current reports and research: * [COVID-19 Risk Factors – Demographics: Gender](https://nabtahealth.com/covid-19-risk-factors-demographics-gender/). * [COVID-19 Risk Factors – Demographics: Age](https://nabtahealth.com/covid-19-risk-factors-demographics-age/). * [COVID-19 Risk Factors – Demographics: Weight](https://nabtahealth.com/covid-19-risk-factors-demographics-weight/). * [COVID-19 Risk Factors – Underlying Health Conditions: Diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/). * [COVID-19 Risk Factors – Underlying Health Conditions: Cardiovascular Disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/). * [COVID-19 Risk Factors – Underlying Health Conditions: Chronic lung conditions](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/). * [COVID-19 Risk Factors – Underlying Health Conditions: Cancer](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cancer/). * [COVID-19 Risk Factors – Underlying Health Conditions: Liver Disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/). * [COVID-19 Risk Factors – Underlying Health Conditions: Kidney Disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-kidney-disease/). * [COVID-19 Risk Factors – Others:](https://nabtahealth.com/covid-19-risk-factors-others-hiv-aids/) [HIV](https://nabtahealth.com/glossary/hiv/)/AIDS. * [COVID-19 Risk Factors – Others: Smoking](https://nabtahealth.com/covid-19-risk-factors-others-smoking/). * [COVID-19 Risk Factors – Others: Immunosuppressed Individuals](https://nabtahealth.com/covid-19-risk-factors-others-immunosuppressed-individuals/). * [COVID-19 Risk Factors – Others: Environment](https://nabtahealth.com/covid-19-risk-factors-others-environment/). Whilst there is a huge amount of active research by international bodies into better understanding and tackling this invisible but powerful enemy, significantly more work is required. The scientific and clinical community have a need to decipher those additional factors that place seemingly healthy individuals at risk. More importantly, because of the variability in response to SARS CoV-2, understanding what and how molecular and genetic mechanisms govern and drive COVID-19 pathogenesis is key. Unfortunately, a significant number of reports and efforts to date are driven by the need to publish work and acquire additional funding. What we need is accurate and careful experimental design that offers evidence-based solutions, treatments, and results that are safe and efficacious for those who are vulnerable and at the highest risk. For now, if you are considered high risk, ensure that your current health status is as good as possible and that medication, where required, is taken appropriately. If you have been exposed to the virus and need to visit a health care facility, call ahead to alert them to the fact that you may be infectious. They will advise you on the correct precautionary steps to take to safeguard your health and that of others. If you are in a country that has implemented tools to alert or monitor infected or potentially infected individuals, you may wish to adopt some of those tools to protect those around you and reduce the chance of cross-contamination. It is worthwhile to note that not all individuals in a high risk category will experience severe symptoms, even if they are exposed to SARS CoV-2. However, minimising your risk of infection is certainly advisable. Take steps such as following good respiratory hygiene, maintaining distance between yourself and others when in public and washing your hands regularly. The [World Health Organisation](https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public) provides thorough information on protection during this pandemic, and this guidance should be more strictly implemented if you are in a high risk category. In general, anyone in this category should take general measures to maintain a healthy lifestyle by partaking in regular exercise and maintaining a healthy diet. The general recommendation is to limit hospital visits and contact with healthcare facilities when possible. If you have a chronic condition and require ongoing medical care or monitoring, consider using telephone or electronic consultations if this facility is available to you, after discussion with your healthcare provider or doctor. Remote or home-based care is possible in some cases. If you are considered high risk and require medications or a pharmacy visit, consider asking others who are less vulnerable to pick up what is needed. It is important to keep taking your medications as recommended. Nabta Health is committed to providing you with the most up to date, peer-reviewed, clinically- and scientifically-validated information on COVID-19 and other conditions. If you are not sure what your, or your loved ones’, risk factors are, Nabta Health has built an electronic risk assessment questionnaire, which can be accessed from our Application. The Nabta App can be downloaded from our website ([www.nabtahealth.com](http://www.nabtahealth.com/)). [COVID-19 Risk Factors - Demographics: Gender](https://nabtahealth.com/covid-19-risk-factors-demographics-gender/) **Sources:** * “COVID-19 Map.” _Johns Hopkins Coronavirus Resource Center_, [coronavirus.jhu.edu/map.html](https://coronavirus.jhu.edu/map.html). * “Groups at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html). * “Q&A On Coronaviruses (COVID-19).” _World Health Organization_, World Health Organization, [www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses](http://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses).
There are certain factors like weight that put particular groups of people at higher risk of experiencing severe disease if infected by SARS CoV-2. Click [here](https://nabtahealth.com/covid-19-risk-factors-an-overview/) for an overview. Characteristics such as [gender](https://nabtahealth.com/covid-19-risk-factors-demographics-gender/), [age](https://nabtahealth.com/covid-19-risk-factors-demographics-age/), and weight are collectively known as demographics. These factors play a key role in determining how a person responds following infection with SARS CoV-2. This article explores weight in more detail: #### **The effect of weight** Your body weight can be used as an indicator to determine how at risk you are of developing severe or critical COVID-19 symptoms. An optimal [Body Mass Index](https://nabtahealth.com/what-is-body-mass-index-bmi/) ([BMI](https://nabtahealth.com/glossary/bmi/)) is 18.5–24.9 kg/m² and if you lie within this range, your weight is considered to be healthy. People with a healthy [BMI](https://nabtahealth.com/glossary/bmi/) have enough body fat to function effectively. Body fat, or adipose tissue, is an essential component of every organ and cell in our body; it has multiple roles, including insulation, energy storage, and the maintenance of hormones. Fat cells are also a source of [stem cells](https://nabtahealth.com/glossary/stem-cells/) that can differentiate into other cell types, such as bone and nerve cells, as required. These [stem cells](https://nabtahealth.com/glossary/stem-cells/), therefore, have regenerative capabilities that are able to replace damaged or otherwise compromised tissues in our body as needed. This means that a certain amount of adipose tissue is required for optimal health. #### **High [BMI](https://nabtahealth.com/glossary/bmi/)** Individuals with a [BMI](https://nabtahealth.com/glossary/bmi/) above 25 kg/m² are termed overweight, and those with a [BMI](https://nabtahealth.com/glossary/bmi/) above 30 kg/m² are termed obese. Overweight and obese people are at higher risk of developing multiple health disorders, such as [cardiovascular disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/), stroke, and [cancer](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cancer/). They are also more likely to be severely or chronically symptomatic if infected by SARS CoV-2: * **Low grade [inflammation](https://nabtahealth.com/glossary/inflammation/)**. Having an excess of body fat means you are likely to be in a chronic state of low-grade [inflammation](https://nabtahealth.com/glossary/inflammation/), which can impair your immune system’s response to infection. Following SARS CoV-2 infection, the obese are more likely to be hospitalised because their bodies are unable to fight the infection effectively. * **Co-existing health conditions**. The other health disorders listed above that often accompany obesity, also put individuals at a higher risk of severe disease. Those who are severely obese ([BMI](https://nabtahealth.com/glossary/bmi/) > 40 kg/m²) are at increased risk of suffering from acute respiratory distress syndrome, which is a major complication of COVID-19 and can hinder a doctor’s ability to treat an affected patient. #### **Low [BMI](https://nabtahealth.com/glossary/bmi/)** A [BMI](https://nabtahealth.com/glossary/bmi/) below 18.5 kg/m² means that a person is medically underweight. Their body is storing insufficient fat, resulting in less overall protection. Being underweight weakens the immune system, putting a person at increased risk of developing severe COVID-19 symptoms. Individuals who are underweight may be malnourished, and as a result may lack some of the essential nutrients, vitamins and minerals necessary for their cells and organs to function properly. This makes them more vulnerable to any external challenges or insults, such as complications arising from an infection with a virus. Obese, overweight, and underweight individuals should consider contacting their local healthcare provider, and/or a nutritionist, with a view to establishing a healthy plan for losing or gaining weight sensibly. [COVID-19 Risk Factors - Demographics: Age](https://nabtahealth.com/covid-19-risk-factors-demographics-age/) [COVID-19 Risk Factors - Underlying Health Conditions: Diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/) **Sources:** * “COVID-19 Map.” _Johns Hopkins Coronavirus Resource Center_, [coronavirus.jhu.edu/map.html](https://coronavirus.jhu.edu/map.html). * “People Who Are at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, 14 May 2020, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html).
There are certain factors that put particular groups of people at higher risk of experiencing severe disease if infected by SARS CoV-2. Click [here](https://nabtahealth.com/covid-19-risk-factors-an-overview/) for an overview. The association between non-communicable disorders (NCDs) and more severe COVID-19 symptoms is consistent worldwide; those with underlying NCDs are more vulnerable to experiencing severe complications following infection with SARS CoV-2. Some of the most prevalent NCDs include [type 2 diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/), [hypertension](https://nabtahealth.com/glossary/hypertension/), [cardiovascular disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/), [chronic lung conditions](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/), chronic kidney disease, [chronic liver disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/), and [cancer](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cancer/). This article covers kidney disease. #### **What is kidney disease?** Kidney disease occurs when the kidneys are unable to filter out water and waste from the blood effectively. The filtration of waste products is a natural part of the metabolic process; therefore, factors such as medication, environmental pollution and infection that add to waste generation, also add to the pressure on the kidneys to work efficiently and effectively. Kidneys have historically been thought of as organs that are unable to regenerate, but new research shows that they do have regenerative capabilities; however the rate of cellular turnover slows down with age. This means that the elderly are more susceptible to kidney disease. #### **The kidneys: a key target for SARS CoV-2?** As more data emerges on the clinical characteristics of individuals who have been hospitalised or who have died from COVID-19, it is becoming apparent that the most affected organs, after the lungs, are the kidneys. Recent reports from the USA show that most individuals over 65 who have died with or from COVID-19, have had concurrent kidney failure. It is important to remember that [advancing age](https://nabtahealth.com/covid-19-risk-factors-demographics-age/) is an additional risk factor for severe disease. It is becoming apparent that kidney disease is not only a risk factor for serious illness, but can also be a lasting complication of SARS CoV-2 infection. For this reason, there are two populations of patients to consider here: * Those with pre-existing kidney disease. * Those who recover from COVID-19, but are left with damage to their kidneys. #### **Pre-existing disease** [Dialysis](https://nabtahealth.com/glossary/dialysis/) patients are more prone to acquiring infections because they have a weakened immune system. They often have co-existing conditions, such as [hypertension](https://nabtahealth.com/glossary/hypertension/) or [diabetes](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-diabetes/), which also make them high risk for severe disease following infection with SARS CoV-2. Compromised kidney function means that the body is not able to effectively filter invading pathogens and toxins. Infection with SARS CoV-2 will put additional pressure on the kidneys, potentially leading to kidney damage and toxic shock which will require immediate hospitalisation. #### **Lasting damage to the kidneys** All patients who are hospitalised with COVID-19 should be monitored for signs of kidney damage. It is thought that more than 15% hospitalised patients (and > 20% of those who end up in intensive care) will experience an acute kidney infection (AKI). AKIs cause an abrupt loss of kidney function and require early detection and treatment to reduce the risk of chronic kidney disease. #### **Why are the kidneys vulnerable to infection with SARS CoV-2?** Further work is required to establish exactly why the kidneys are so vulnerable to infection. However, there are some possible explanations: * Following infection SARS CoV-2 enters the cells of the body through a receptor called ACE2. Preliminary work suggests that this receptor might be expressed in organs throughout the body, meaning that COVID-19 has the capacity to become a **systemic disease**, targeting multiple organs, including the [heart](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-cardiovascular-disease/), [liver](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/), kidneys and [lungs](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-chronic-lung-conditions/). In fact, RNA sequencing data revealed that ACE2 RNA expression is 100 times higher in the kidneys than it is in the lungs. Further work is required to establish whether or not this is of functional consequence. * Severe **inflammatory response**, leading to a systemic immune response and the destruction of healthy tissue. * A consequence of COVID-19 is **increased blood clotting**, which may clog the kidneys and reduce their ability to filter waste products. * **Low oxygen levels** in the blood, due to respiratory failure, results in hypoxia. This can affect other organs such as the kidneys, leading to cell death and tissue damage #### **I have kidney disease, what should I do?** Individuals with pre-existing kidney disease should be aware that their risk of serious complications from COVID-19 is higher than the general population. If already undergoing [dialysis](https://nabtahealth.com/glossary/dialysis/), this will probably continue, with strict hygiene measures in place to protect you and your healthcare providers. You should also put the necessary measures in place to protect yourself, such as [social distancing](https://nabtahealth.com/what-is-social-distancing/), maintaining good personal hygiene, staying hydrated and attempting to live a healthy lifestyle. [COVID-19 Risk Factors - Underlying Health Conditions: Liver disease](https://nabtahealth.com/covid-19-risk-factors-underlying-health-conditions-liver-disease/) [COVID-19 Risk Factors - Others:](https://nabtahealth.com/covid-19-risk-factors-others-hiv-aids/) [HIV](https://nabtahealth.com/glossary/hiv/)/AIDS **Sources:** * Cheng, Yichun, et al. “Kidney Disease Is Associated with in-Hospital Death of Patients with COVID-19.” _Kidney International_, vol. 97, no. 5, May 2020, pp. 829–838., doi:10.1016/j.kint.2020.03.005. * “Coronavirus: Kidney Damage Caused by COVID-19.” _Johns Hopkins Medicine_, [www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-kidney-damage-caused-by-covid19](http://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-kidney-damage-caused-by-covid19). * “COVID-19: Kidney Disease.” _National Kidney Foundation_, 3 June 2020, [www.kidney.org/coronavirus/kidney-disease-covid-19](http://www.kidney.org/coronavirus/kidney-disease-covid-19). * “People Who Are at Higher Risk for Severe Illness.” _Centers for Disease Control and Prevention_, Centers for Disease Control and Prevention, 14 May 2020, [www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html](https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html). * Post, Adrian, et al. “Sodium Status and Kidney Involvement during COVID-19 Infection.” _Virus Research_, vol. 286, 21 May 2020, p. 198034., doi:10.1016/j.virusres.2020.198034.
