Note: This is the thirteenth of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.

Clinical Context

The world continues to respond to the pandemic respiratory disease COVID-19. As the number of cases grows around the globe, both through increased detection and viral spread, it is essential to develop strategies to protect persons who are most vulnerable to have severe illness from SARS-CoV-19 infection. The World Health Organization (WHO) has stated that most who are infected will be asymptomatic, have only mild symptoms, or recover spontaneously without special treatment.^[1]

Nonetheless, the Centers for Disease Control and Prevention (CDC) has issued specific guidance for persons at greater risk for serious morbidity and mortality from COVID-19.^[2] It states that "older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness" with COVID-19. These include persons older than age 65 years, persons who live in nursing homes or long-term care facilities, and persons with high-risk conditions. such as heart disease, diabetes, lung disease, cancer, and hypertension. Recent evidence suggests that infants and young children may also be at high risk. Individuals who are immunocompromised (ie, persons undergoing cancer treatment or bone marrow/organ transplantation, persons with immune deficiencies or poorly controlled HIV or AIDS, or persons who take medications that weaken the immune system) are at risk as well. The WHO, CDC, and other organizations have also issued guidelines for special populations such as persons in nursing homes, migrant camps, or prisons.

Synopsis and Perspective

More than 100 million Americans are at higher risk for serious illness if they contract COVID-19, according to a new Kaiser Family Foundation (KFF) report.^[3]

Wyatt Koma, BS, a researcher with the KFF Program on Medicare Policy, and colleagues calculated that 105.5 million people in the United States are at high risk for serious illness if infected, which includes 29.2 million adults younger than age 60 because of an underlying medical condition and 76.3 million adults age 60 years and older.

One group particularly at risk is the 1.3 million people living in nursing homes in the United States, Priya Chidambaram, MS, pointed out in a data report published March 13 on the KFF website.^[4]

Mr Koma told Medscape Medical News, "I hope this analysis really helps the public understand the potential reach and impact of coronavirus."

He added, "With 4 out of every 10 people in the US at higher risk of serious illness if they are infected with coronavirus, these estimates confirm the need to take unprecedented efforts to minimize the spread."

Overall, Most Infected Will Recover Quickly

According to the World Health Organization,^[1] most people who become infected will not develop symptoms or will recover quickly without needing treatment, but 41% (105.5 million/258 million in 2018) of US adults fall into the groups at higher risk for serious illness if they are infected by the novel coronavirus.^[3]

Mr Koma and colleagues used data from the nationally representative 2018 Behavioral Risk Factor Surveillance System and calculated the numbers at risk by state and nationwide.

The researchers defined "high-risk," using the latest information from the CDC, as adults ages 60 and older and younger adults between ages 18 and 59 with cancer, heart disease, chronic obstructive pulmonary disease (COPD), or diabetes. The authors acknowledged they could not factor in hypertension because that variable was not tracked by the survey.

According to the American Heart Association,^[5] about 1 in 3 US adults have high blood pressure.

"If we had included hypertension, it is likely the number of younger adults at higher risk of illness if they're infected with coronavirus would have increased," Mr Koma said.

"Also, with this data source, we were unable to account for people living in institutional settings, such as nursing homes, assisted living facilities or prisons," he said. "Had we been able to incorporate the institutional population, the number of under-60 individuals at risk of serious illness, if infected, would have also been higher."

The risk by state, according to the KFF report,^[3] varies widely from 31% in Washington, DC to 51% in West Virginia.

"In Washington [s]tate, California, and New York, some of the states hardest hit by COVID-19 thus far, the share of adults at high risk is 40[%], 37[%] and 40[%], respectively," the authors wrote.

Mr Koma explained that West Virginia's risk is high mainly because of the larger share of the younger adult population who have a serious health condition. Conversely, Washington state has a relatively lower overall rate of adults at risk for serious illness if they get infected because there is a relatively smaller share of adults younger than age 60 years at higher risk.

Highlights

Common questions on high risk and special populations affected by COVID-19

Q: How many people are at high risk for serious illness from COVID-19 because of age or comorbidity?

A: In the United States and possibly in other developed countries, 41% of the total population are at high risk for serious illness. Of 105.5 million people in the United States at high risk, 76.3 million are age ≥ 60 years, and 29.2 million are younger but with underlying comorbidities.^[3] Risk by state varies widely: 31% in Washington, DC; 37% in California; 40% in Washington state and New York; and 51% in West Virginia.

Q. What is the risk level for infants and young children who become infected with SARS-CoV-2?

A. Children with COVID-19 usually have mild symptoms but are more likely than adults to have underlying coinfection (40% in a small series),^[6] warranting evaluation with early chest computed tomography (CT) and pathogen detection. Of note, 40% of children had no fever, and the highest attack rates were in children younger than age 1 year. Children with underlying conditions may be more vulnerable, as 35% in this series had a previously diagnosed congenital or acquired disease; however, 18 of 20 children were cured, and 2 remained under observation for positive swab with negative chest CT.

In a larger series of 2143 children (median age, 7 years) with COVID-19 in China,^[7] more than 90% were asymptomatic, mild, or moderate cases; however, infants were particularly vulnerable to severe and critical cases, which occurred in 10.6% of children age < 1 year, 7.3% at 1 to 5 years, 4.2% at 6 to 10 years, 4.1% at 11 to 15 years, and 3% at age ≥ 16 years.

Q. What is the risk level for pregnant women?

A. Pregnancy is a risk factor for severe viral illness; however, data are currently limited pertaining to COVID-19. The CDC recommends that pregnant women should be monitored for now. Pregnant healthcare personnel who are exposed to patients with suspected or confirmed COVID-19 should follow risk assessment and infection control guidelines provided by CDC for healthcare personnel.^[8]

Q. What is the risk level for animals and pets?

A. Previous coronavirus outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) are known to have originated in animals and spread to people; however, the source for the COVID-19 is unverified to be of animal origin, considering the current human-to-human spread.^[9] Currently, the WHO and CDC do not have evidence to suggest that animals and pets pose a risk of getting or spreading the virus.^[1,9] Neither do they have evidence to suggest risk for spread from imported animals or animal products.

Q. What can persons at high risk do to protect themselves from infection?

A. The CDC recommends social distancing, staying at home as much as possible, frequent handwashing, cleaning and disinfecting the home, having essential supplies on hand, and avoiding crowds and travel.^[10] Persons who develop cough and fever should call their doctor, and persons with difficulty breathing, chest pain, cyanosis, or altered mental state should seek immediate medical attention.

Q. How will nursing homes be affected?

A. Nursing facilities provide care to high-risk patients in close contact with one another. In 2017, 15,483 nursing facilities in the United States provided care for ~ 1.3 million residents, of whom 16% received respiratory treatment (> 30% in some states [eg, Colorado and Utah]), and could therefore be at greater risk for severe complications from respiratory infection^[4]; yet in 2017, nearly 40% of facilities had 1 or more infection control deficiency. Higher resident density could increase risk for faster COVID-19 transmission, and 80% of nursing facility beds were filled in 2017, with some states such as New York and Washington DC reporting > 90% occupancy. Interim guidance from the CDC recommends that during this pandemic, nursing homes should cancel group activities and communal dining to reduce risk for SARS-CoV-2 infection to residents. In addition, they should restrict all visitation, volunteers, and nonessential healthcare personnel except in certain compassionate care situations ^[14]. These changes may negatively affect residents’ mental health, especially among the almost 40% who already have depressive symptoms.

Q. How should homeless shelters prepare?

A. The CDC has suggested strategies to help homeless service providers plan, prepare, and respond to COVID-19.^[11] These include establishing ongoing communication with local public health departments and government emergency planning groups; identifying healthcare facilities that will provide for the homeless; encouraging everyday preventive actions; providing COVID-19 prevention supplies; planning for staff and volunteer absences; reporting cases of suspected COVID-19 to the local health department; transporting persons with severe illness to medical facilities; designating space to accommodate and isolate clients with mild respiratory symptoms; planning for higher shelter usage during an outbreak; minimizing the number of staff members who interact face to face with clients with respiratory symptoms; keeping beds/mats ≥ 6 feet apart in general sleeping areas; and providing a surgical mask to any client with respiratory symptoms.

Q. What is the COVID-19 action plan for the federal Bureau of Prisons (BOP)?

A. The high population density in prisons creates a risk for infection and transmission for inmates and staff. After coordination with the US Department of Justice and the White House, the BOP is implementing phase 2 of their COVID-19 response and is currently deploying national measures.^[12] For 30 days, social, volunteer, and general legal visits; inmate facility transfers; and staff travel and training will be suspended. Enhanced staff screening includes self-reporting and temperature checks. All newly arriving BOP inmates are being screened for COVID-19 exposure risk factors and symptoms; asymptomatic inmates with exposure risk factors are quarantined; and symptomatic inmates with exposure risk factors are isolated and tested for COVID-19 following local health authority protocols. For 30 days, nationwide modified operations will maximize social distancing and limit group gatherings.

Q. What are global COVID-19 outbreak readiness and response operations in migrant camps and camp-like settings?

A. The International Federation of Red Cross and Red Crescent Societies (IFRC), International Organization for Migration (IOM), United Nations High Commissioner for Refugees (UNHCR), and WHO have jointly developed guidelines for refugee camps.^[13] Health risks for people living in collective sites are those associated with movement/displacement, overcrowding, increased climatic exposure from substandard shelter, and poor nutritional and health status. Minimizing COVID-19 spread in such settings requires maximizing site planning for better distancing, crowd management, adhering to infection prevention and control standards, strong risk communication and community engagement, and good surveillance to identify initial cases early. For persons infected with SARS-CoV-2, appropriate case management can lower mortality.

Clinical Implications

• In the United States and possibly in other developed countries, 41% of the total population are at high risk for serious illness from COVID-19 because of age ≥ 60 years or underlying comorbidities; infants age < 1 year are also at risk and may have coinfection.
• Guidance exists to minimize COVID-19 transmission in high-risk settings, including nursing homes, homeless shelters, prisons, and migrant camps.
• Implications for the Healthcare Team: To protect persons at high risk for serious illness from COVID-19, the CDC recommends social distancing, staying at home as much as possible, frequent handwashing, cleaning and disinfecting the home, having essential supplies on hand, and avoiding crowds and travel. The healthcare team should continue to educate the public and colleagues.

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