A correspondence in The Lancet describes the growing number of younger patients affected by covid-19 in the United States and an association between obesity and more serious illness. Since the pandemic started, older patients with multiple chronic medical problems have been observed to have had the highest risk for severe and critical covid-19. Is obesity also a risk factor?
The researchers reviewed the existing medical literature, including the largest intensive care unit study to-date, which analyzed 1,591 covid-19 patients in Italy. The average age of these patients was 63 years; only 13 percent of patients were younger than 51 years of age. In that study, as well as reports from China, the most common chronic medical condition among patients with severe/critical covid-19 were high blood pressure, heart disease, type 2 diabetes, and emphysema. However, obesity is much less common in countries that were hit by covid-19 early in the pandemic. In China, the prevalence of obesity is only 6.2 percent. The numbers are somewhat higher in Italy (20 percent) and in Spain (24 percent). In the United States, obesity is present in approximately 40 percent of the nation.
When the researchers assessed 265 patients admitted to ICUs in the United States, they found that younger patients were more likely to be obese. Obesity is hypothesized to contribute to severe or critical covid-19 due in part to the effects of restricted ventilation of the lungs (some have also proposed physiologic reasons related to how the virus may enter fat cells). This is thought to impair the immune system from fighting the SARS-CoV-2 virus. Stress that infections impart on the cardiovascular system may also be magnified in persons with obesity.
Brief19 previously reported on the poor quality of existing coronavirus antibody testing kits. These tests came to market under Emergency Use Authorizations granted by the Food and Drug Administration. As a result, new tests were not required to go through the regulatory processes normally require that manufacturers demonstrate that their products do what they purport to do. Many new tests have failed to produce accurate results. This could have substantial implications as states make decisions based on information garnered from antibody tests about reopening. To combat inaccuracies, yesterday the FDA ordered antibody test manufacturers to provide evidence within ten days that their tests are accurate. Those that fail to do so will be removed from market. If we are to make policy decisions based on epidemiologic information, it is crucial that the information be accurate. This is an important step towards that goal.
A recent CDC Morbidity and Mortality Weekly Report shows that while Black patients accounted for 47 percent of all all-cause hospitalizations in patients in the Atlanta and southern Georgia areas through March 2020, Black patients comprised over 80 percent of the patients hospitalized specifically for covid-19. The median age was not significantly different between Black and non-Black patients. Black patients not more likely to have diabetes, heart disease, or severe obesity, though they were more likely to be Medicaid beneficiaries. With respect to covid-19 care, Black patients were not more likely to require mechanical ventilation or die in the hospital. This information suggests that Black patients did not have increased risk factors for hospitalization in general, but were nevertheless disproportionately represented in patients hospitalized especially for covid-19. While Black persons in Georgia appear to have had more positive tests for SARS-CoV-2 than statistically expected compared to others in the state, that difference appears too small to explain the difference in hospitalization rates described here. However, Blacks are less likely to be tested for the virus, and therefore the reported rates of infection may be artificially lower than the real numbers.
Meanwhile, a group of physicians have floated policy proposals aimed at reducing racial disparities related to covid-19. Ideas include continued pushes for covid-19 racial data to "accurately measure disparities and inform additional testing, medical resources, and ultimately preventative vaccination," nationwide Medicaid expansion to cover the newly uninsured patient population due to covid-19 unemployment, and a reduction in application barriers (known as "sludge") to social services. Finally, experts are advocating for continued investment in community care hubs in an effort to reach minority communities through trusted, local organizations.
A common criterion among plans to re-open, including the President's, is that covid-19 cases be on the decline. Despite this, three states started to re-open yesterday despite an increase in the number of covid-19 related deaths. More concerning, a federal model, not previously available to the public but obtained by the New York Times yesterday, showed a predicted national trend towards more daily covid-19 deaths. Additionally, data shows that Florida and Georgia, two of the earliest states to re-open, have recently decreased the number of covid-19 tests performed daily, despite the fact that ample testing is another criterion for re-opening under President Trump's plan. While the effects of opening remain to be seen, premature openings could cost many lives. New York Times.