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Factors that make people more vulnerable to COVID-19 – Expert Q&A

The Prime Minister Jacinda Ardern has today announced the new guidelines for life at Alert Level 2. 

While various restrictions will be lifted, people considered to be more vulnerable to COVID-19 are still encouraged to take additional precautions.

The SMC asked experts to comment on how COVID-19 affects a range of vulnerable populations:

  1. obesity and diabetes
  2. cardiovascular disease
  3. people taking immunosuppressive medications
  4. mental illness
  5. people living in precarity
  6. Māori communities
  7. Pasifika communities

Dr Caryn Zinn, Senior Lecturer and Dietician, Auckland University of Technology, comments:

Evidence from the US shows 89% of people hospitalised for COVID-19 had at least one underlying condition: high blood pressure, Type 2 diabetes, excess body fat or chronic lung disease. Older adults tend to be at greater risk of poor COVID-19 outcomes due to a higher likelihood of having one or more of these conditions, but this does not mean young people are exempt.

“In New Zealand, a large part of the population is considered unhealthy. Almost two thirds of adults are overweight or obese (that’s around 2,256,000 people), 6.4% have Type 2 diabetes (around 220,000 people), and 16% have high blood pressure (632,000 people).

“Underlying conditions are problematic for several reasons. The metabolic dysregulation that comes with excess body fat can compromise the immune system and increase the risk of respiratory infections and further chronic diseases. Poor blood sugar control can impair the immune response by altering the cellular processes which help to overcome infection.

“As we move into Level 2, people can make positive lifestyle changes to help protect themselves. For people with Type 2 diabetes, maintaining stable blood sugar is crucial. Consuming a high quality whole-food diet, avoiding smoking and excessive alcohol, and doing regular exercise should be a focus, alongside keeping good social distancing, to protect and improve health.”

No conflict of interest.

Professor Mark Richards, Heart Foundation Chair of Cardiovascular Studies in the Christchurch Heart Institute at the University of Otago, and Canterbury District Health Board, comments:

“The reasons underlying differences between people in their vulnerability to COVID-19 are still largely unknown. The background conditions associated with greater risk include asthma, chronic obstructive airways disease, diabetes, high blood pressure and cardiac diseases, increasing age and those with suppressed immune systems.

“Those with cardiovascular abnormalities, such as hypertension and heart disease, pose more of a puzzle. It is becoming clear that blood vessel and heart involvement in COVID-19 complications is quite frequent, and this may reflect the poorer cardiovascular function in those with underlying conditions.

“In New Zealand, over 10% of the total population and over 25% of the 60+ population are living with hypertension. Fortunately, we have done a world-leading job in reducing the presence of the coronavirus in the community. Nevertheless, vulnerable people will need to remain vigilant and maintain all the behaviours proven to be effective in reducing rates of infection, as well as maintaining good care of their background conditions.”

No conflict of interest.

Professor Lisa Stamp, Department of Medicine at the University of Otago, Canterbury District Health Board and President of the New Zealand Rheumatology Association, comments:

“So far we have not seen any evidence in the published medical literature that people with arthritis and other inflammatory rheumatic disease who are receiving immunosuppressive drugs like methotrexate and leflunomide are at increased risk of developing COVID-19, or have poorer outcomes if they are infected. Steroids like prednisone do increase the risk of infection at higher doses, but there is emerging evidence that some of the newer biological agents may actually mitigate the severe impact of COVID-19.

“Untreated inflammation is associated with an increased risk of infection or can require the introduction of steroids which can increase risks. In the current pandemic, the message remains the consistent: it is better to stay on regular medications that control inflammation than to stop taking them.”

No conflict of interest.

Professor Richard Porter, Head of Department, Psychological Medicine at the University of Otago, and Consultant Psychiatrist with Canterbury District Health Board, comments:

“There are multiple aspects of the current situation which are likely to impact on mental health. For people with mental illness, the loss of a regular rhythm, both social and biological (such as sleeping and eating at regular times), is very important.

“All mental health problems tend to be worse during stress. In addition, changes in rhythms, particularly sleep/wake cycle tends to cause relapses in mood disorders. This may be particularly problematic during lockdown and even during Level 3.

“Our experience in Christchurch following the 2011 earthquake was that mental health services received fewer referrals and there were fewer inpatient admissions for a number of months following the earthquake. This may have been because of an increased level of social cohesiveness, which for a period of time buffered the effects of stress. It remains to be seen whether such an effect will be seen during the COVID-19 crisis, since the social distancing measures will tend to prevent such social cohesiveness. There is some evidence that social cohesiveness has been possible via the media and social media though.

“However, we would expect that a return to a greater level of freedom and normality may also see the realisation for many that their situation has changed for the worse, and the cumulative effect of a loss of routine and social rhythm may result in many people requiring mental health care.”

No conflict of interest.

Dr Chris Gale, Consultant Psychiatrist and Senior Lecturer, Dunedin School of Medicine, University of Otago, comments:

“If we were certain that we had eliminated the virus, we could concentrate on minimising the vulnerability of people who were either suffering from a mood disorder prior to the epidemic or have developed one during lockdown. But we are not yet certain of this.

“As a society, we are now facing two groups of people who are vulnerable. Those who are at risk from the virus, and those whose health is at risk as a consequence of the lockdown. We need to be planning how to deal with both groups, and we may not know how successful our policies are until this time is over.

“We can consider actions from other countries or states, and consider what are the ‘least bad’ options moving forward. Involving the population, particularly the vulnerable, in this, in an open and transparent manner may help people deal with some fairly bleak choices, and accept the risks they are taking regarding their individual situation. One size will not fit all, and we need to allow for this.”

No conflict of interest.

Dr Shiloh Groot (Ngāti Uenukukōpako, Ngāti Pikiao), Senior Lecturer in Community Psychology, University of Auckland, comments:

“Homelessness and poverty are not neutral states, but rather intimately interwoven with other experiences of being on the margins of society. Likewise, our ability to alleviate, respond to, and recover from the various psychological, social, cultural, physical, and financial effects produced in a disaster context such as COVID 19 has never been equal.

“Major cities around the world are contending with similar challenges: issues of overcrowding or multi-generational homes and urban displacement, defunding, unaffordable housing, maintaining client, staff and volunteer safety, and racing to fill heightened supply shortages.

“For people living precarious lives, there are the additional burdens such as reduced income and redundancies, insecure employment, an inability to stockpile food, and rent and utility demands which are only exacerbated by a welfare and justice system that disproportionately punishes Māori and Pasifika for the conditions of their lives. Many young people and their families are struggling to ensure they have access to technology for engaging their education. Many older people are struggling with loneliness and access to healthcare. We do not live in an equal society.

“Although Aotearoa New Zealand has proven to be exemplary when it comes to decisive leadership that heeds robust scientific evidence and prioritises compassion for all, do we pat ourselves on the back as we prepare to move from Level 3 to Level 2? Or do we need to think more strategically about the future of our peoples? Is the ‘status quo’ that created so many precarious lives and living situations acceptable in a post-lockdown future?”

No conflict of interest.

Dr Rhys Jones, Senior Lecturer at Te Kupenga Hauora Māori, University of Auckland, comments:

“The prevalence of underlying health conditions such as cardiovascular, respiratory and kidney diseases, diabetes and cancer is much higher in Māori populations than in non-Māori. Māori also tend to get these diseases at younger ages and are more likely to have multiple conditions, which exacerbates the risks posed by COVID-19. This means that Māori are more likely to experience serious outcomes from COVID-19.

“Researchers at Te Pūnaha Matatini have modelled how infection fatality rates for COVID-19 (the risk of dying for those who are infected) may vary by ethnicity. Their findings are alarming. The estimated infection fatality rate for Māori is between 1.5 and 2.5 times as high as the rate for non-Māori. In other words, on average, Māori people who become infected are approximately twice as likely to die as non-Māori people with COVID-19.

“Those numbers almost certainly underestimate the true inequity. The infection fatality rate is probably even higher for Māori due to other factors not captured in the study’s analysis, such as racism in the health and disability system and other inequities. And that’s without even considering the greater risk of being exposed to COVID-19 for Māori (and Pasifika) communities due to crowded housing and higher intergenerational contact rates.

“That’s why many are so concerned about the prospect of COVID-19 transmission becoming established in Māori communities. That’s why whānau, hapū, iwi and Māori communities are taking specific actions in an attempt to keep the virus out. As we move towards Alert Level 2, it is critical that control measures take into account the disproportionate threat of COVID-19 for Māori communities, and in particular for groups in our communities who experience multiple oppressions such as disabled people, those with chronic health conditions, and sexual and gender minorities.”

No conflict of interest.

Dr Maryann Heather, GP and Senior Lecturer in Pacific Health, University of Auckland, comments:

“Pacific communities in New Zealand are facing various challenges in this pandemic. In particular, doctors are expressing serious concern that people have not been seeking medical care during lockdown, and are therefore experiencing far more urgent issues when their condition deteriorates. As we move towards Alert Level 2, there is likely to be a surge in the number of patients seeking care from their GPs, or requiring treatment at hospital, with acute medical concerns. We strongly urge people to seek advice and treatment for any health issues as soon as possible, particularly if a patient has a condition which requires frequent monitoring.

“Alongside these issues, there has also been a hesitancy among some Pacific people to get tested for COVID-19. This is in part due to fear of having the virus, but also a fear of needing to take time off work, and of placing a financial strain on family as a result. This has proven particularly problematic for families living with financial difficulties. The need to report any symptoms of COVID-19, and to be tested as quickly as possible, must continue to be communicated to these communities. In South Auckland, Pacific language-speaking staff have facilitated testing where language remains a barrier.

“For many large family groups, physical distancing has been particularly challenging. Depression, anxiety and isolation are serious issues in these communities, but the importance of protecting our bubbles and maintaining physical boundaries must continue to be emphasised while we remain at Alert Level 3.”

No conflict of interest.