Underlying Medical Conditions Associated with Higher Risk for Severe COVID-19: Information for Healthcare Professionals

Purpose

This webpage provides an evidence-based resource for healthcare professionals caring for patients with underlying medical conditions who are at higher risk of developing severe outcomes of COVID-19. Severe outcomes of COVID-19 are defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, or death.

This page summarizes data from published reports, scientific articles in press, unreviewed pre-prints, and internal data that were included in a literature review conducted by subject matter experts as of October 2021. The information reflects current evidence regarding underlying medical conditions and is intended to help healthcare professionals make informed decisions about patient care and increasing the awareness of risk among their patients.

Background

We continue to learn more about the risk factors for severe COVID-19 outcomes. Although age is the strongest risk factor for severe COVID-19 outcomes, patients with certain underlying medical conditions are also at higher risk. The more underlying conditions a person has, the higher the risk for severe COVID-19 outcomes.^(9–11)

In addition, studies have shown that COVID-19 does not affect all population groups equally. Two important factors are age and race and ethnicity.

Age

Age remains the strongest risk factor for severe COVID-19 outcomes. Approximately 54.1 million people aged 65 years or older reside in the United States; in 2020, this age group accounted for 81% of U.S. COVID-19 related deaths. As of May 23, 2022 (CDC COVID Data Tracker), the proportion of deaths in this group was more than 42 times than those aged 30-39 years.^(1, 2) In 2020, residents of long-term care facilities made up less than 1% of the U.S. population but accounted for more than 35% of all COVID-19 deaths.^(3-7)

Race & Ethnicity

The COVID-19 pandemic has highlighted racial, ethnic, and socioeconomic disparities in COVID-19 illnesses, hospitalizations, and deaths. ^(22-24) Some racial and ethnic minority groups are also more likely to face multiple barriers to accessing health care including lack of insurance, transportation, child care, or ability to take time off from work.

Estimates of COVID-19 deaths in the U.S. show that people from racial and ethnic minority groups are dying from COVID-19 disproportionately, and studies have identified racial and ethnic differences in at-home COVID-19 test use, vaccination coverage, and access to outpatient therapeutics.^(25-27) Data have shown that compared to non-Hispanic White people, people from racial and ethnic minority groups are more likely to be infected with SARS-CoV-2 (the virus that causes COVID-19). Once infected, people from racial and ethnic minority groups are more likely to be hospitalized, be admitted to the ICU, and die from COVID-19 at younger ages.⁽¹⁸⁾

We are still learning about how the environments where people live, learn, and work can influence the risk for infection and severe COVID-19 outcomes.

Summary of Conditions with Evidence

1. Higher risk for severe COVID-19 outcomes is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or complete the CDC systematic review process. The meta-analysis or systematic review demonstrates good or strong evidence, (depending on the quality of the studies in the review or meta-analysis) for an increase in risk for at least one severe COVID-19 outcome.
   • Asthma
   • Cancer
   • Cerebrovascular disease
   • Chronic kidney disease*
   • Chronic lung diseases limited to:
     • Interstitial lung disease
     • Pulmonary embolism
     • Pulmonary hypertension
     • Bronchiectasis
     • COPD (chronic obstructive pulmonary disease)
   • Chronic liver diseases limited to:
     • Cirrhosis
     • Non-alcoholic fatty liver disease
     • Alcoholic liver disease
     • Autoimmune hepatitis
   • Cystic fibrosis
   • Diabetes mellitus, type 1 and type 2*‡
   • Disabilities‡
     • Attention-Deficit/Hyperactivity Disorder (ADHD)
     • Cerebral Palsy
     • Congenital Malformations (Birth Defects)
     • Limitations with self-care or activities of daily living
     • Intellectual and Developmental Disabilities
     • Learning Disabilities
     • Spinal Cord Injuries
     • (For the list of all conditions that were part of the review, see the module below)
   • Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
   • HIV (human immunodeficiency virus)
   • Mental health disorders limited to:
     • Mood disorders, including depression
     • Schizophrenia spectrum disorders
   • Neurologic conditions limited to dementia‡
   • Obesity (BMI ≥30 kg/m² or ≥95th percentile in children)*‡
   • Primary Immunodeficiencies
   • Pregnancy and recent pregnancy
   • Physical inactivity
   • Smoking, current and former
   • Solid organ or hematopoietic cell transplantation
   • Tuberculosis
   • Use of corticosteroids or other immunosuppressive medications

2. Suggestive higher risk for severe COVID-19 outcomes is defined as an underlying medical condition or risk factor that neither has a published meta-analysis or systematic review nor completed the CDC systematic review process. The evidence is supported by mostly cohort, case-control, or cross-sectional studies. (Systematic reviews are available for some conditions for children with underlying conditions.)
   • Overweight (BMI ≥25 kg/m², but <30 kg/m²)
   • Sickle cell disease
   • Substance use disorders
   • Thalassemia
3. Mixed evidence is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or completing the CDC systematic review process. The meta-analysis or systematic review is inconclusive, either because the aggregated data on the association between an underlying condition and severe COVID-19 outcomes are inconsistent in direction or there are insufficient data (or limited) on the association between an underlying conditions and severe COVID-19 outcomes.
   • Alpha 1 antitrypsin deficiency
   • Bronchopulmonary dysplasia
   • Hepatitis B
   • Hepatitis C
   • Hypertension*

Footnotes:

* indicates underlying conditions for which there is evidence for pregnant and non-pregnant people

‡ underlying conditions for which there is evidence in pediatric patients.

Actions Healthcare Professionals Can Take

• Support approved and authorized COVID-19 vaccines (primary series and all boosters) which are safe and effective. Check out Interim Clinical Considerations for Use of COVID-19 Vaccines as well as Stay Up to Date with your Vaccines and locations for COVID-19 vaccination for patients.
• Consider therapies, such as antivirals and monoclonal antibodies, when treating patients with worsening symptoms or with mild to moderate illness and risk factors for severe illness. These therapeutics have been shown to significantly decrease the risk of hospitalization and death, and outcomes are improved if therapeutics are started within the first days of illness.
• Encourage patients to keep appointments for routine care and adhere to treatment regimens.
• Consider use of telehealth in coordination with community-based organizations, family members, or other providers, when appropriate, although some patients may not have knowledge of or access to appropriate technology or internet service.
• Encourage patients with underlying medical conditions, who are able to, to continue practicing preventive measures such as wearing a high quality mask, and to avoid infection with the virus that causes COVID-19. This becomes even more important with increasing age and number and severity of underlying conditions.
• Check out additional information for your patients.

Considerations For Patients Within Racial and Ethnical Minority Groups

• Ask patients about their concerns about vaccines and therapy. Consider using an evidence-based and culturally sensitive approach, such as motivational interviewing. Try to provide trusted sources of information and other resources.
• Encourage testing, as well as early therapeutics, for patients who are eligible.
• Facilitate access to culturally and linguistically appropriate resources.
• Reduce barriers to accessing current and emerging outpatient treatments.

Key Findings from One Large Cross-Sectional Study

Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021

This study used data from the Premier Healthcare Database, which represents approximately 20% of all inpatient admissions in the United States since 2000. This cross-sectional study of 540,667 adults hospitalized with COVID-19 included both inpatients and hospital-based outpatients with laboratory-diagnosed COVID-19 from March 1, 2020, through March 31, 2021. The database included reports from 592 acute care hospitals in the United States. The study was designed to examine risk factors associated with severe outcomes of COVID-19 including admission to an ICU or stepdown unit, invasive mechanical ventilation, and death.

Main Findings:

• Certain underlying medical conditions increased risk for severe COVID-19 illness in adults.
• Having multiple conditions was also associated with severe COVID-19 illness.
• Obesity, diabetes with complications, and anxiety and fear-related disorders had the strongest association with death.
• The number of frequent underlying medical conditions increased with age.⁽²¹⁾

Adapted from Sources:

• Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm
• Pennington AF, Kompaniyets L, Summers AD, Danielson ML, Goodman AB, Chevinsky JR, Preston LE, Schieber LZ, Namulanda G, Courtney J, Strosnider HM, Boehmer TB, Mac Kenzie WR, Baggs J, Gundlapalli AV, Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19—United States, March–September 2020, Open Forum Infectious Diseases, Volume 8, Issue 2, February 2021. To learn more, visit: https://doi.org/10.1093/ofid/ofaa638

Source: Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm

References