• Users Online: 3956
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Browse Articles Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2022  |  Volume : 13  |  Issue : 1  |  Page : 109

SARS-CoV-2: Review of conditions associated with severe disease and mortality

School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada

Date of Submission23-Oct-2020
Date of Acceptance08-Mar-2021
Date of Web Publication08-Aug-2022

Correspondence Address:
Joshua Eyitemi
Representative of the Alumni Group, University of Saskatchewan, School of Public Health, 104 Clinic Place, Saskatoon, SK S7N 2Z4
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpvm.IJPVM_640_20

Rights and Permissions

The 2019 Coronavirus Virus Disease (COVID-19) represents a global public health challenge in the twenty-first century. As of June 2020, the virus had spread across 216 countries across the globe. This paper aims to analyze and identify those existing comorbidities among COVID-19 patients that represent potential risk factors for COVID-19 complications, severe illness, and death. Multiple database resources were searched. The resources include the University of Saskatchewan library USearch, Google Scholar, PubMed, Medline, and the Google search engine. Thirty-seven articles, which included 15 different types of chronic diseases, were selected. Among the reviewed diseases and conditions, cancer, diabetes, lymphopenia, hypertension, kidney disease, smoking, chronic obstructive pulmonary disease (COPD), and organ transplant were found to represent potential risk factors for COVID-19 complications, severe illness, and death. Other conditions that require further research as to whether they predispose subjects to severe illness and death include coronary artery disease, cerebrovascular disease, valvular heart disease, gastrointestinal diseases, HIV/AIDS, asthma, and liver disease. In conclusion, this article explains the association between diseases mentioned above and the severity of COVID-19 and clearly shows the population at risk. This paper will help government bodies and decision-makers prioritize resources for these populations to reduce mortality rates and overall quality of life.

Keywords: Chronic, COVID-19, mortality

How to cite this article:
Eyitemi J, Thomas B, Ramos Y, Feng X, Ezekwesili C. SARS-CoV-2: Review of conditions associated with severe disease and mortality. Int J Prev Med 2022;13:109

How to cite this URL:
Eyitemi J, Thomas B, Ramos Y, Feng X, Ezekwesili C. SARS-CoV-2: Review of conditions associated with severe disease and mortality. Int J Prev Med [serial online] 2022 [cited 2023 Sep 21];13:109. Available from: https://www.ijpvmjournal.net/text.asp?2022/13/1/109/353572

  Introduction Top

In December 2019, the city of Wuhan in the province of China became the epicenter for a respiratory illness outbreak of unknown etiology. It was later identified as a novel coronavirus (2019 Coronavirus Virus Disease [COVID-19]) disease.[1] Since then, the disease has rapidly spread across the world, affecting approximately 216 countries and territories, with some countries having a higher number of cases and higher mortality rates than others.[2]

The severity and mortality among COVID-19 patients have been associated with potential risk factors and comorbidities.[3] This rapid review's objective is to analyze and identify those existing comorbidities among COVID-19 patients that represent potential risk factors for COVID-19 complications, severe illness, and death.

  Methods Top

A literature review was conducted to explore the potential association between existing comorbidities in patients infected with COVID-19 and the severity and complications of the disease. Multiple database resources including the University of Saskatchewan library USearch, Google Scholar, PubMed, Medline, and the Google search engine were utilized. In the end, 37 articles were retrieved, which included 15 types of diseases.

  Association of Diseases with Severity of Covid-19 Top

Cancer and COVID-19

As compared to other strains of Coronavirus, more COVID-19 deaths were reported to have resulted from multiple organ dysfunction syndromes rather than respiratory failure.[4] This may be attributed to the widespread distribution of angiotensin-converting enzyme,[4] which is the functional receptor for SARS-CoV-2 in multiple organs.[5],[6] Cancer patients are more susceptible to infection than cancer-free patients because of their systemic immunosuppressive state caused by malignancy and anticancer therapy, such as chemotherapy and surgery.[7],[8],[9],[10] Thus, these patients may be at an increased risk for serious COVID-19 illness and have a poorer prognosis. To illustrate, a cohort study with 1590 cases from 575 hospitals in China found that the proportion of cancer patients in COVID-19 cases is much higher than the incidence of cancer in the overall Chinese population.[11] Most notably, cancer patients were found to have a higher risk for severe events such as admission into the intensive care unit, invasive ventilation, and death, compared to cancer-free patients.[11]

Furthermore, another literature report came to a similar conclusion that the immunosuppressive status of cancer patients caused cancer patients to be at a higher risk of COVID-19 infection than the general population.[12] The same study also claimed that the immunosuppressive condition caused by malignant tumors and anti-cancer therapies such as chemotherapy or surgery significantly increased cancer patients' susceptibility to severe complications of COVID-19.[12] It was found that cancer patients are 3.5 times more likely to develop COVID-19 severe infections than patients without cancer.[12] Moreover, having cancer history brings the highest risk for severe complications, and it is associated with COVID-19 poor prognosis.[12]

Based on the above findings, the researchers provided strategies for how cancer patients respond to the COVOID-19 crisis. Firstly, a deliberate delay of adjuvant chemotherapy or elective surgery to treat stable cancer in endemic areas should be considered.[11] Secondly, patients with cancer or cancer survivors should be given better health security provisions.[11] Thirdly, when cancer patients are infected with SARS-CoV-2, more intensive surveillance or treatment should be considered, especially in older patients or those with other comorbidities.[11]

Kidney disease and COVID-19

In a large prospective cohort study in Wuhan, China, researchers found a high prevalence of kidney disease in COVID-19 hospitalized patients.[13] A potential reason for the high incidence of kidney disease at admission to the hospital is that some COVID-19 patients had a previous history of chronic kidney disease.[13]

Such patients with functional deficiencies in populations of innate and adaptive immune cells are known to have a higher risk for pneumonia and upper respiratory tract infection.[14],[15] Furthermore, after the lungs get infected with COVID-19, the virus can penetrate the blood, accumulate in the kidney, and cause sustained damage of organ's resident cells.[13] The study also suggests that kidney disease is associated with higher hospital mortality.[13] One possible reason for this is that COVID-19 patients with existing kidney disease have a higher risk of developing acute kidney injury (AKI) during hospitalization, which can lead to poorer prognosis and significant mortality.[13]

Similarly, in Arentz's research in Washington State, it showed that out of 21 critically ill COVID-19 patients, 18 of them had confirmed comorbidities. The most common was chronic kidney disease (48%).[16] Hence, these findings indicate that early identification of those with kidney disease, interventions to provide adequate care, and nephrotoxin avoidance may help improve the prognosis of COVID-19 patients.[13]

Smoking and COVID-19

The main invasion route of the COVID-19 virus is through mucosal tissues: nose, mouth, and upper respiratory tract.[17] Exposure to cigarette smoke triggers inflammatory processes in the lung, heightened mucosal inflammation, expression of inflammatory cytokines and tumor necrosis factor α, increased permeability in epithelial cells, mucus overproduction, and impaired mucociliary clearance.[18] A recent systematic study from Vardavas and Nikitara reported that “smoking is likely associated with negative development and adverse effects of COVID-19”.[19] The research has shown that differences in COVID-19 disease prevalence and severity are associated with the higher expression of ACE2 among smoking people.[20] Conversely, Lippi, and Henry's brief meta-analysis recorded no correlation between smoking status and COVID-19 severity.[21] However, we cannot ignore the fact that tobacco smoke exposure is the leading risk factor for lung disease.[18] Also, smoking is a significant risk factor for bacterial and viral infections.[22] Moreover, other suggested risk factors for severe COVID-19 illness (lung and cardiovascular diseases, diabetes, etc.) are common among smokers.[17]

According to another report, the poor prognosis of COVID-19 patients with a history of smoking is significantly higher than that of patients without a history of smoking.[19] Smokers were 1.4 times more likely to have severe COVID-19 symptoms and approximately 2.4 times more likely to be admitted to an ICU, need mechanical ventilation, or die than non-smokers.[19]

Chronic obstructive pulmonary disease and COVID-19

Chronic obstructive pulmonary disease (COPD) is associated with a high risk of morbidity and mortality in community-acquired pneumonia (CAP). At the same time, COVID-19 is relatable as it is a systemic respiratory illness that may progress to severe hypoxemia.[23]

According to a meta-analysis conducted to analyze the association between COPD and increased odds of severe COVID-19 infection, it was advised that clinicians should always monitor COPD patients with suspected infection.[23] The results from the study showed that the odds of increased severity of COVID-19 infection are five times higher in COPD patients (OR = 5.69; 95% CI: 2.49–13.00; 12 = 0.0%; Cochran's Q, P = 0.95).[23] Therefore, to reduce COVID-19 exposure or severity, patients with COPD should practice protective measures against contact with suspected or confirmed cases of COVID-19.[23]

Bone marrow/organ transplantation and COVID-19

As the management of COVID-19 in the transplant population remains unclear and complicated, bone marrow/organ transplantation patients require utmost care and attention. Posttransplant patients are usually under immunosuppressive therapy; the immunosuppressive agents they take, including cyclosporin-A and mycophenolate mofetil, have been reported to increase the risk of opportunistic infection, including viral infection.[24]

According to reports among the transplant population, comorbidities increase the risk of severe pneumonia in the COVID-19 infected population.[25] However, in the history of transplantation, immunosuppressive agents have never been reported as a risk factor to increase the chances of COVID-19. Haung et al.[25] dispute the claim that the discontinuation of immunosuppressants and steroid treatment might help faster recovery from COVID-19 pneumonia among the posttransplant population due to the fact that patients in their study developed a nosocomial bacterial infection during hospitalization, which warrants more careful use of steroids in COVID-19 disease.[25]

Cerebrovascular disease and COVID-19

According to a retrospective, observational case series, neurological manifestations fell into three categories: central nervous system manifestations (dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system manifestations (taste impairment, smell impairment, vision impairment, and nerve pain), and skeletal muscle injury manifestations.[26] Most neurologic manifestations among patients in this case series occurred early in the illness (with a median time to hospital admission being 1–2 days).

The patients with severe infection had little or no COVID-19 symptoms and more underlying disorders like hypertension.[26],[27] In addition, they were older and more likely to develop neurologic manifestations, especially acute cerebrovascular disease, conscious disturbance, and skeletal muscle injury. In the United States, cerebrovascular diseases are regularly associated with high morbidity, mortality, and a financial burden.[27]

Although more extensive studies are needed, these studies explain that for those with severe COVID-19, rapid clinical deterioration, or worsening could be associated with neurological events such as stroke, which would contribute to its high mortality rate.[26] However, clinicians must consider the state of the present COVID-19 epidemic during the diagnosis of neurological manifestations. Also, coupled with the current COVID-19 pandemic, understanding cerebrovascular disease patients who are at high risk for COVID-19 will place priority in resource allocation.[27]

Lymphopenia and COVID-19

COVID-19 patients with lymphocytopenia have demonstrated more severe disease than patients with normal lymphocytes level.[28] Lymphocytopenia alone is a prominent feature among patients severely affected with SARS-CoV,[29] which is explained by the necrosis or apoptosis of lymphocyte when there is invasion of viral particles.[28] It is suggested that the severity of the disease is determined by lymphopenia in patients with COVID-19.[30] A study by Zhang et al.,[30] analyzing the absolute number of different subsets of lymphocytes among Intensive Care Unit (ICU) patients, showed that there was a dramatic decrease in the total number of T-cells, CD4+ T cells, CD8+ T cells, total B cells, and natural killer cells among severely ill patients.

Lymphocytopenia in COVID-19 patients with severe disease may be caused by T-cell exhaustion, and a state of T-cell dysfunction resorts from the using up of T cell during many chronic infections and cancer.[31] The expression of inhibitory receptors characterizes it, and IL-10, an inhibitory cytokine, not only prevents T-cell proliferation but also can induce T-cell exhaustion.[31] It is characterized by the expression of inhibitory receptors, and IL-10, an inhibitory cytokine, not only prevents T-cell proliferation but also can induce T-cell exhaustion.[31] A study by Diao et al.[31] demonstrated that COVID-19 patients have very high levels of serum IL-10 following SARS-CoV-2 infection, which may be responsible for the apoptosis of T cells in these subjects.

Lastly, lymphocytopenia in COVID-19 patients with high levels of circulating cytokines can be explained by pre-existing chronic diseases and reveals a connection between the existence of these chronic diseases and the development of severe disease after infection.[31]

Coronary artery disease and COVID-19

There is often poor prognosis in patients with the acute coronary syndrome who are infected with the SARS-CoV-2.[32] This phenomenon is because, in acute coronary syndrome (ACS), there can be a reduction in cardiac functional reserve resulting from myocardial ischemia or necrosis.[32] Therefore, when an individual with ACS is infected with SARS-CoV-2, there may be resulting cardiac insufficiency, which can lead to a sudden worsening of these patients' conditions.[33]

A study by Zheng et al.,[32] in Wuhan, China, reported that some patients with COVID-19, who had previous ACS, showed that there was an association between history of ACS and severe illness and high mortality after SARS-CoV-2 infection. In patients with underlying coronary artery disease and cardiac insufficiency, SARS-CoV-2 infection might act as a precipitating factor to deteriorate the condition and lead to death.[6]

It remains unclear whether cardiomyopathy in some aged patients was pre-existing or resulted from the impact of SARS-CoV-2 infection.[16] There is a need to conduct more research on the correlation between the pre-existing coronary artery disease, cardiomyopathy, and the development of severe illness after SARS-CoV-2 infection.

Valvular heart disease and COVID-19

Patients with pre-existing structural and valvular cardiac diseases tend to have a more severe illness from SARS-CoV-2[34]; this may result from the effects of dysfunctional valves on the pulmonary system.[35] For example, a patient with prolonged mitral stenosis may experience lodging blood in the left atrium, causing atrial hypertension. This hypertension can find its way up to the lungs, leading to pulmonary hypertension.[36]

As the current literature has limited information on the impact of COVID-19 in patients with structural heart disease (SHD), it is imperative to extrapolate that these patients are at high risk for poor prognosis based on their old age and several comorbidities.[37] Further research still needs to be conducted to provide specific descriptions on the impact of pre-existing structural heart disease on the outcome of SARS-CoV-2 infection in patients.

Diabetes and COVID-19

Diabetes has become a suspected risk factor associated with severe COVID-19 illness and death. A reason for this may be the abnormalities in the immune system associated with high blood glucose.[38] The irregularities in innate cellular immunity play a role in the pathogenesis of increased infections in diabetic patients.[39] Moreover, diabetic cells become more adherent to microorganisms, which later become more virulent in a high glucose environment.[39]

In a recent study analyzing the impact of diabetes and hyperglycemia among laboratory-confirmed COVID-19 patients, it was found that patients with diabetes and/or uncontrolled hyperglycemia had a longer length of stay in the hospital when compared with patients without diabetes and/or hyperglycemia.[40] The same study concluded that the mortality rate was considerably higher among patients with diabetes and/or uncontrolled hyperglycemia than among patients without diabetes and/or hyperglycemia.[40] Furthermore, the study found that COVID-19 patients with uncontrolled hyperglycemia had a high mortality rate.[40]

Similarly, another study analyzing the risk for ICU admission and mortality in COVID-19 patients with diabetes concluded that diabetes represents a high risk for ICU admission and mortality among COVID-19 patients.[41] This study found a significant increased risk for ICU admission among diabetic patients (OR: 2.79, 95% CI: 1.85–4.22, P < 0.0001, I2 = 46%).[41] The study also analyzed patients for secondary outcomes, finding diabetic patients to be at a higher risk for mortality (OR: 3.21, 95% CI: 1.82–5.64, P < 0.0001, I2 = 16%).[41]

Since research has shown that COVID-19 patients with diabetes and/or uncontrolled hyperglycemia are at higher risk for severe illness and death compared with patients without diabetes and/or uncontrolled hyperglycemia. Clinicians must pay particular attention to COVID-19 patients with diabetes and/or uncontrolled hyperglycemia to ensure adequate treatment for diabetes and hyperglycemia.

Hypertension and COVID-19

Hypertension has been identified as a potential risk factor for severe COVID-19 illness and death. A study that analyzed the clinical characteristics of patients who died of coronavirus associated complications in China found that among patients who died of COVID-19-induced pneumonia, hypertension was the most common chronic comorbidity.[3] Similarly, in a case series, it was reported that the rate of hypertension was higher among COVID-19 patients admitted to ICU than among COVID-19 patients that were not admitted to ICU.[35]

Furthermore, another recent case series analyzing the characteristics, comorbidities, and outcomes of hospitalized COVID-19 patients in New York reported that hypertension was one of the most common comorbidities among COVID-19 hospitalized patients.[42] Relatedly, a study evaluating the outcome in hypertensive patients with COVID-19 and its association with the use of renin-angiotensin system blockers (RASB) concluded that hypertension is one of the comorbidities that represents an increased risk for in-hospital death among COVID-19 patients.[43] Lastly, a retrospective cohort study exploring clinical course and risk factors for mortality of adult inpatients in China found hypertension as the most common comorbidity in COVID-19 adult patients.[6]

As hypertension has been identified as one of the comorbidities associated with severe COVID-19 illness and death, special attention must be paid to COVID-19 patients with existing hypertension.[43]

Gastrointestinal disease and COVID-19

There is limited information about gastrointestinal disease patients and the potential risk for COVID-19 complications. A recent review has reported that irritable bowel disease (IBD) patients could be at higher risk for COVID-19 complications.[44] A possible reason for this may be the chronic condition itself and the use of immunosuppressant as a treatment.[44]

Although more research is needed to evaluate the potential risk of COVID-19 complications among patients with gastrointestinal disease, health authorities in developing countries must pay special attention due to the lack of basic sanitation in part of the population.[44]


Research dedicated to understanding the impact of COVID-19 on the health and well-being of individuals living with HIV is a new area being explored. According to a recent article, a weakened immune system from AIDS was not associated with the development of COVID-19.[45] These findings may be because some AIDS patients use protease inhibitors, which may impact the development of COVID-19.[46],[47],[48]

On the other hand, in a case study conducted in 2020, an AIDS patient diagnosed with COVID-19 presented with fever and chest lesions symptoms upon admission to the hospital.[45] The progression of the patient's symptoms was reported to be similar to that of a moderate COVID-19 patient.[49],[50] A possible reason for this may be that the presence of a weakened immune system decreases the body's immune response to COVID-19, which could increase the damage to the respiratory system of AIDS patients.[51] Additionally, the presence of a weakened immune system was thought to be associated with the delayed clearing of the SARS-CoV-2.[49] However, this was not the outcome for the AIDS patient within the case study; these findings may be due to the use of LPV/r and arbidol.[45]

Health impacts of COVID-19 and HIV were also explored in a case series based on five HIV patients. In this study, none of the five patients died from COVID-19; however, they were reported to have experienced health challenges, which included lung infections, viral pneumonia, admissions to intensive care, and noninvasive assistance for breathing.[48] Other studies have suggested that individuals aged 18–49 living with HIV are at risk for COVID-19.[52] The risk of dying from complications associated with COVID-19 might be higher for younger individuals living with HIV.[53]

However, more information is needed to understand the full extent of the health impact that COVID-19 can have on patients living with HIV or AIDS.[45] This is supported by findings that suggest that factors that influence personal behaviors might also contribute to an increased susceptibility of contracting COVID-19. For example, the severity of patients' symptoms was reported to affect their use of personal protective equipment (PPE).[54] More specifically, individuals with mild to moderate AIDS symptoms may not be as likely to wear PPE as those with severe symptoms.[54]

Asthma and COVID-19

According to the current research, asthma patients may be disproportionately represented among adult patients hospitalized for COVID-19.[55],[56] These findings might be associated with hospitalization due to asthma exacerbations, which can be brought on by the presence of SARS-CoV-2.[55] Concern over the impact of COVID-19 on the health and wellness of individuals living with asthma has increased due to finding substantial commonalities in the clinical presentation of asthma exacerbation and COVID-19.[57],[58] In light of this, children experiencing difficulties with breathing or intensified coughing episodes were recommended to be tested for COVID-19,[57],[58] especially since asthmatic children infected with SAR-CoV-2 could develop pneumonia or acute respiratory disease due to the presence of their existing condition.[59]

Attention to the potential risk associated with COVID-19 and asthma was confirmed when the CDC placed moderate and severe asthma as a condition associated with higher susceptibility for contracting COVID-19.[59] Unfortunately, the literature is currently unclear about the extent of the risk for COVID-19 that is faced by children living with asthma.[55] This is because most of the research associated with risk determinants is based on data from the adult population.[57],[60],[61] More research must be gathered within the younger asthmatic population, especially since adult data regarding asthma and COVID-19 suggest that asthma is a risk factor for adverse health outcomes.[55]

Liver disease/cirrhosis and COVID-19

Presently, the impact of COVID-19 on the health and the well-being of patients living with liver disease is not fully understood.[62] Due to this lack of clarity surrounding the potential impact of COVID-19 on impaired liver conditions, liver disease has not been listed as a risk factor for severe disease outcomes associated with COVID-19.[62]

Findings from a 2020 study suggest that liver disease is not related to the worsening of COVID-19 disease progression or death.[62] However, studies with larger sample sizes are needed to better understand the possible health impact that COVID-19 could have on patients with pre-existing chronic liver diseases.[62] With this being said, because COVID-19 is a relatively new public health concern, many questions remain regarding liver disease and COVID-19.[63] For instance, it is unknown whether individuals living with pre-existing cirrhosis who have contracted COVID-19 are at a higher risk for deterioration in liver functioning or developing acute-on-chronic liver failure.[63]

Overall, more information is needed to better understand the full impact that COVID-19 may have on the disease progression and overall health outcomes of individuals impacted by COVID-19 and living with liver disease.

  Discussion Top

Our review suggests that COVID-19 is both a suspected and a confirmed risk factor influenced by various pre-existing health conditions. The CDC[64] supports these findings by suggesting that preventive actions against COVID-19 are necessary and essential for patients with an existing health condition. Some of these health conditions included asthma, chronic kidney disease, chronic lung disease, diabetes, severe heart conditions, and liver disease.[64] Similarly, the Government of Canada[65] reports that health disease, hypertension, lung disease, diabetes, and cancer are health conditions that are associated with a high risk for severe illness form COVID-19. Nonetheless, individuals with or without a pre-existing health condition need to be cautious and practice healthful behaviors such as social distancing, washing hands, and travelling with hand sanitizers.[65]

Somewhat surprisingly, one study suggested that a weakened immune system in AIDS patients was not associated with the development of COVID-19. Interestingly, these findings were reported to be linked to the use of drugs related to treatment. This suggests that the type of therapy utilized to treat the pre-existing health condition could reduce the severity of COVID-19 progression. Thus, clinicians need to pay special attention to the quality of care provided to patients with health conditions and COVID-19. Nevertheless, individuals with HIV and COVID-19 were found to suffer health challenges, and the risk of death might be higher in specific populations. Notably, more research is required to document how COVID-19 impacts health conditions. According to the World Health Organization,[66] for instance, there is currently no peer-reviewed literature that evaluates the risk of COVID-19 and smoking.[66] This is troubling because, in 2015, more than 1.1 billion individuals were reported to smoke tobacco.[67]

Nevertheless, the WHO[68] asserts that because COVID-19 mainly attacks the lungs and smoking makes it more difficult for individuals' respiratory function, smoking will make it more challenging for the human body to withstand COVID-19. The impact of COVID-19 on health conditions is complex amongst cancer patients, and care should be modified to address the patient's unique challenges. For instance, recent research suggests that COVID-19 exposure in cancer patients can be dangerous and even lethal.[69] Researchers suggest that the approach for cancer patients needs to be adaptive and tailored to the needs of the patient, the available health resources, and the expertise of the health professionals.[69]

This report provides insights into health conditions that may be a high risk for severe illness for COVID-19 outcomes. Presently, there is a gap in the literature, and consequently, there is a need for more research to fully understand the extent to which COVID-19 impacts different health conditions. For example, researchers report the need for further research to understand how gastrointestinal symptoms are associated with COVID-19 and possible fecal-oral transmission.[70]

Notably, a limitation of this study was the limited access to research regarding COVID-19 and health conditions. The limited research is because COVID-19 is a novel disease, and research is gradually building over time. Further work is needed to understand the severity of COVID-19 illness amongst patients with various existing comorbidities and the impact that treatments and preventative measures have on disease progression.

  Conclusions Top

The general population's safety is essential and some may argue that everyone should be included, but the thing is that nobody is excluded; there is only prioritization. The association between existing health conditions and the severity of COVID-19 gleans by focusing on which populations are at risk. Considering the weak economy and tight budgets that has resulted due to the COVID-19 pandemic, policymakers will need to focus their country's resources on these populations while other ways of preventing COVID-19 are being sought. When this group of people are selected, the funds can be directed to test the populations at higher risk for severe COVID-19 illness to reduce mortality rates and improve the overall quality of life.

Finally, at this time, simple testing kits should be made available to the public, in a similar way that test kits are available for HIV/AIDS, ovulation, or pregnancy. This is because as we wait for vaccines or other effective treatments, we need to control the spread to the barest minimum, and the only way to do that is to have everyone test for the disease.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle. J Med Virol 2020;92:401-2.  Back to cited text no. 1
World Health Organization.Coronavirus disease 2019 (COVID-19) Situation Report – 51. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10.  Back to cited text no. 2
Xie J, Tong Z, Guan X, Du B, Qiu H. Clinical Characteristics of Patients Who Died of Coronavirus Disease 2019 in China. JAMA Netw Open 2020;3:e205619.  Back to cited text no. 3
Wang C, Horby P, Hayden F, Gao G. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.  Back to cited text no. 4
Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol 2004;203:631-7.  Back to cited text no. 5
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 6
Li JY, Duan XF, Wang LP, Xu YJ, Huang L, Zhang TF, et al. Selective depletion of regulatory T cell subsets by docetaxel treatment in patients with nonsmall cell lung cancer. J Immunol Res 2014;2014:286170. doi: 10.1155/2014/286170.  Back to cited text no. 7
Kamboj M, Sepkowitz K. Nosocomial infections in patients with cancer. Lancet Oncol 2009;10:589-97.  Back to cited text no. 8
Longbottom ER, Torrance HD, Owen HC, Fragkou PC, Hinds CJ, Pearse RM, et al. Features of postoperative immune suppression are reversible with interferon gamma and independent of interleukin-6 pathways. Ann Surg 2016;264:370-7.  Back to cited text no. 9
Sica A, Massarotti M. Myeloid suppressor cells in cancer and autoimmunity. J Autoimmun 2017;85:117-25.  Back to cited text no. 10
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 2020;21:335-7.  Back to cited text no. 11
Al-Quteimat OM, Amer AM. The impact of the COVID-19 pandemic on cancer patients. Am J Clin Oncol 2020;43:452-5.  Back to cited text no. 12
Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int 2020;97:829-38.  Back to cited text no. 13
Betjes MG. Immune cell dysfunction and inflammation in end-stage renal disease. Nat Rev Nephrol 2013;9:255-65.  Back to cited text no. 14
Cohen-Hagai K, Rozenberg I, Korzets Z, Zitman-Gal T, Einbinder Y, Benchetrit S. Upper respiratory tract infection among dialysis patients. Isr Med Assoc J 2016;18:557-60.  Back to cited text no. 15
Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 critically Ill patients with COVID-19 in Washington State. JAMA 2020;323:1612-4.  Back to cited text no. 16
Berlin I, Thomas D, Le Faou AL, Cornuz J. COVID-19 and smoking. Nicotine Tob Res 2020;22:1650-2.  Back to cited text no. 17
Strzelak A, Ratajczak A, Adamiec A, Feleszko W. Tobacco smoke induces and alters immune responses in the lung triggering inflammation, allergy, asthma and other lung diseases: A mechanistic review. Int J Environ Res Public Health 2018;15:1033. doi: 10.3390/ijerph 15051033.  Back to cited text no. 18
Vardavas CI, Nikitara K. COVID-19 and smoking: A systematic review of the evidence. Tob Induc Dis 2020;18:20.  Back to cited text no. 19
Cai H. Sex difference and smoking predisposition in patients with COVID-19. Lancet Respir Med 2020;8:e20.  Back to cited text no. 20
Lippi G, Henry BM. Active smoking is not associated with severity of coronavirus disease 2019 (COVID-19). Eur J Intern Med 2020;75:107-8.  Back to cited text no. 21
Arcavi L, Benowitz N. Cigarette smoking and infection. Arch Intern Med 2004;164:2206-16.  Back to cited text no. 22
Lippi G, Henry BM. Chronic obstructive pulmonary disease is associated with severe coronavirus disease 2019 (COVID-19). Respir Med 2020;167:105941. doi: 10.1016/j.rmed. 2020.105941.  Back to cited text no. 23
Sahu KK, Jindal V, Siddiqui AD, Cerny J. Facing COVID-19 in the hematopoietic cell transplant setting: A new challenge for transplantation physicians. Blood Cells Mol Dis 2020;83:102439. doi: 10.1016/j.bcmd. 2020.102439.  Back to cited text no. 24
Huang J, Lin H, Wu Y, Fang Y, Kumar R, Chen G, et al. COVID-19 in posttransplant patients-report of 2 cases. Am J Transplant 2020;20:1879-81.  Back to cited text no. 25
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:683-90.  Back to cited text no. 26
Aggarwal G, Lippi G, Michael Henry B. Cerebrovascular disease is associated with an increased disease severity in patients with Coronavirus Disease 2019 (COVID-19): A pooled analysis of published literature. Int J Stroke 2020;15:385-9.  Back to cited text no. 27
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 28
Chu H, Zhou J, Wong BH, Li C, Chan JF, Cheng ZS, et al. Middle East respiratory syndrome coronavirus efficiently infects human primary T lymphocytes and activates the extrinsic and intrinsic apoptosis pathways. J Infect Dis 2016;213:904-14.  Back to cited text no. 29
Zhang G, Hu C, Luo L, Fang F, Chen Y, Li J, et al. Clinical features and short-term outcomes of 221 patients with COVID-19 in Wuhan, China. J Clin Virol 2020;127:104364. doi: 10.1016/j.jcv. 2020.104364.  Back to cited text no. 30
Diao B, Wang C, Tan Y, Chen X, Liu Y, Ning L, et al. reduction and functional exhaustion of T cells in patients with coronavirus disease 2019 (COVID-19). Front Immunol 2020;11:827. doi: 10.3389/fimmu. 2020.00827.  Back to cited text no. 31
Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020;17:259-60.  Back to cited text no. 32
Guo J, Huang Z, Lin L, Lv J. Coronavirus disease 2019 (COVID-19) and cardiovascular disease: A viewpoint on the potential influence of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on onset and severity of severe acute respiratory syndrome coronavirus 2 infection. J Am Heart Assoc 2020;9:e016219.  Back to cited text no. 33
Tan W, Aboulhosn J. The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease. Int J Cardiol 2020;309:70-7.  Back to cited text no. 34
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 35
Demaria AN. Structural heart disease during a pandemic. Struct Heart 2020;4:150-1.  Back to cited text no. 36
Wang B, Zhang L, Zhang D, Yuan H, Wu C, Zhang Y, et al. Bedside ultrasound in assessment of 510 severe and critical patients with COVID-19 pneumonia in Wuhan, China. Adv Ultrasound Diagn Ther 2020;4:60-6.  Back to cited text no. 37
Ilyas R, Wallis R, Soilleux EJ, Townsend P, Zehnder D, Tan BK, et al. High glucose disrupts oligosaccharide recognition function via competitive inhibition: A potential mechanism for immune dysregulation in diabetes mellitus. Immunobiology 2011;216:126-31.  Back to cited text no. 38
Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 1999;26:259-65.  Back to cited text no. 39
Bode B, Garrett V, Messler J, McFarland R, Crowe J, Booth R, et al. Glycemic characteristics and clinical outcomes of COVID-19 patients hospitalized in the United States. J Diabetes Sci Technol 2020;14:813-82.  Back to cited text no. 40
Roncon L, Zuin M, Rigatelli G, Zuliani G. Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome. J Clin Virol 2020;127:104354. doi: 10.1016/j.jcv. 2020.104354.  Back to cited text no. 41
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020;323:2052-9.  Back to cited text no. 42
Singh AK, Gupta R, Misra A. Comorbidities in COVID-19: Outcomes in hypertensive cohort and controversies with renin angiotensin system blockers. Diabetes Metab Syndr 2020;14:283-7.  Back to cited text no. 43
Queiroz NSF, Barros LL, Azevedo MFC, Oba J, Sobrado CW, Carlos AS, et al. Management of inflammatory bowel disease patients in the COVID-19 pandemic era: A Brazilian tertiary referral center guidance. Clinics (Sao Paulo) 2020;75:e1909.  Back to cited text no. 44
Su J, Shen X, Ni Q, Zhao H, Cai J, Zhu B, et al. Infection of severe acute respiratory syndrome coronavirus 2 in a patient with AIDS. AIDS 2020;34:1575-6.  Back to cited text no. 45
Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19. N Engl J Med 2020;382:1787-99.  Back to cited text no. 46
Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus-A possible reference for coronavirus disease-19 treatment option. J Med Virol 2020;92:556-63.  Back to cited text no. 47
Blanco JL, Ambrosioni J, Garcia F, Martínez E, Soriano A, Mallolas J, et al. COVID-19 in patients with HIV: Clinical case series. Lancet HIV 2020;7:e314-6.  Back to cited text no. 48
Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579:270-3.  Back to cited text no. 49
Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19). Radiology 2020;295:715-21.  Back to cited text no. 50
Channappanavar R, Perlman S. Pathogenic human coronavirus infections: Causes and consequences of cytokine storm and immunopathology. Semin Immunopathol 2017;39:529-39.  Back to cited text no. 51
Bialek S, Boundy E, Bowen V, Chow N, Cohn A, et al. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) - United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:343-6.  Back to cited text no. 52
Shiau S, Krause KD, Valera P, Swaminathan S, Halkitis PN. The burden of COVID-19 in people living with HIV: A syndemic perspective. AIDS Behav 2020;24:2244-9.  Back to cited text no. 53
Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: A series of meta-analyses. BMJ Open 2016;6:e011453.  Back to cited text no. 54
Abrams E, 't Jong G, Yang C. Pediatric asthma and covid-19. 2020. Available from: https://www.cps.ca/en/documents/position/paediatric-asthma-and-covid-19.  Back to cited text no. 55
Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical characteristics of Covid-19 in New York city. N Engl J Med 2020;382:2372-4.  Back to cited text no. 56
Rasmussen SA, Thompson LA. Coronavirus disease 2019 and children: What pediatric health care clinicians need to know. JAMA Pediatr 2020;174:743-4.  Back to cited text no. 57
Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EWY, et al. COVID-19: Pandemic contingency planning for the allergy and immunology clinic. J Allergy Clin Immunol Pract 2020;8:1477-88.e5.  Back to cited text no. 58
CDC. (n.d). Coronavirus disease 2019 (covid-19): People with asthma. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/asthma.html.  Back to cited text no. 59
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 60
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 61
Lippi G, de Oliveira MHS, Henry BM. Chronic liver disease is not associated with severity or mortality in Coronavirus disease 2019 (COVID-19): A pooled analysis. Eur J Gastroenterol Hepatol 2021;33:114-5.  Back to cited text no. 62
Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Rep 2020;2:100113. doi: 10.1016/j.jhepr. 2020.100113.  Back to cited text no. 63
CDC. Coronavirus disease 2019 (COVID-19). 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html.  Back to cited text no. 64
Government of Canada. People who are at high risk for severe illness from covid-19. 2020. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/people-high-risk-for-severe-illness-covid-19.html.  Back to cited text no. 65
WHO. Prevalence of tobacco smoking 2018. Available from: https://www.who.int/gho/tobacco/use/en/. [Last accessed on 2022 Jun 20].  Back to cited text no. 66
World Health Organization. (2020). Tobacco. World Health Organization. from https://www.who.int/news-room/fact-sheets/detail/tobacco. [Last accessed on 2022 Jun 20].  Back to cited text no. 67
WHO. Who statement: Tobacco use and covid-19. 2020. Available from: https://www.who.int/news-room/detail/11-05-2020-who-statement-tobacco-use-and-covid-19.  Back to cited text no. 68
Moujaess E, Kourie HR, Ghosn M. Cancer patients and research during COVID-19 pandemic: A systematic review of current evidence. Crit Rev Oncol Hematol 2020;150:102972. doi: 10.1016/j.critrevonc. 2020.102972.  Back to cited text no. 69
Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal–oral transmission. Gastroenterology 2020;158:1518-9.  Back to cited text no. 70


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Association of D...

 Article Access Statistics
    PDF Downloaded64    
    Comments [Add]    

Recommend this journal