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COVID-19: Death comes for the weakened

Copyright © 2020 Albuquerque Journal

Diabetes, heart disease and lung disease were the most prevalent underlying conditions in New Mexicans who died from COVID-19, according to a Journal analysis of state health records.

Medical professionals say these conditions, among the most common, are a “clear contributor” to the death toll of a virus that has taken the lives of more than 680 across the state.

“Every infectious disease, every pathogen, is more effective in its disease course when the immune response is not working well,” Daniel Sosin, an epidemiologist with the New Mexico Department of Health, told the Journal. “The challenge for us right now is understanding what parts of the immune response and how do we counter that.”

Of the cases he has reviewed, Sosin said there is a clear progression with underlying conditions. They are present in 47% of people who test positive, 79% of hospitalizations and 92% of deaths.

Sosin said conditions connected with our immune function have proven particularly dangerous, such as cancer, kidney disease, lung disease, immunodeficiency disorder, obesity, heart conditions and diabetes.

With three decades of experience working for the Centers for Disease Control and Prevention under his belt, Sosin said the covonavirus that causes COVID-19 is “unique” in its fortitude.

“(It’s) not the most severe virus we’ve had in outbreak form, but the combination of how easily spread it is, how severe it is – is unique,” he said. “Its ability to remain in our communities for as long as it has and keep coming back when we back away is also unique.”

Those most at risk

Records provided to the Journal by the state Health Department paint a picture of those lives the virus has claimed – and those, seemingly, most at risk. The records show known underlying conditions for every documented COVID-19 fatality as of Thursday, a total of 669 cases. The names, ages and sex of the deceased individuals were excluded to protect their privacy. Of the 669 cases, 148 were left blank or listed as unknown.

NMDOH spokesman David Morgan said the case investigation process, as it stands, is “imperfect.”

“It is possible that a question was not asked in an interview or that an interview was not done to capture this information,” he said. “In the case of a fatality, we try to gather information from next of kin, or hospital staff or records, but this is not always possible.”

Excluding the 148 cases where information wasn’t filled out, 521 people died from COVID-19 between March 25 and Aug. 6. Of those, 95% had underlying conditions. Only 24 of the 521, 5%, were listed as having no underlying conditions.

Of the 521 cases, half had cardiovascular disease, 46% had diabetes, and 29% had chronic lung disease. Sosin said those conditions are more common, in general.

Additionally, NMDOH records showed 17% of those who died had renal disease, 8% had liver disease and 7% had an immunodeficiency disorder.

As time has gone on, Morgan said NMDOH has started tracking other preexisting conditions in accordance with CDC guidelines during the “rapidly evolving pandemic.”

“We were capturing information deemed important to public health action and have been adapting as information changes,” he said.

Since July 8, NMDOH began recording severe obesity – a body-mass index of 40 or higher – autoimmune disease and hypertension.

Of the 133 deaths since July 8 where data was available, 61% had hypertension, 12% were severely obese and 3% had an autoimmune disease.

All told, at least 29% of New Mexicans who contracted COVID-19 and died also had neurological disabilities, including dementia, Parkinson’s disease and Alzheimer’s.

However, Sosin said no causal relationship between neurological disability and deaths has been found yet, and the numbers could relate to age.

What is clear, he said, is mortality rates go up as age increases.

“There’s no indication that this virus is going away before (many more people) are infected or immunized,” he said. “It is so critically important that persons with underlying conditions or advanced age are protected by all of us.”

Multiple conditions

The outsized role of preexisting conditions in the deaths of COVID-19 patients is not lost on medical professionals.

Denise Gonzales, a medical director at Presbyterian Hospital, sees it firsthand.

Despite low hospitalizations and a low mortality rate in New Mexico, Gonzales said she is seeing a trend in deaths: Patients with either a weak immune system or a weak body are most vulnerable, especially in instances where patients have more than one underlying condition.

“So somebody with (chronic obstructive pulmonary disease) from years of smoking, plus diabetes, is the most terrible case that you can have because you can’t respond to the stress of an illness and you can’t respond appropriately to fight off the infection either,” Gonzales said.

“With every single additional disease, you have additional risk of not being able to respond appropriately and not being able to survive.”

Many conditions often go hand in hand – like cardiovascular conditions, and obesity, in the presence of diabetes.

The Journal’s analysis of DOH data found that two-thirds of those with preexisting conditions who died had two or more. For instance, one patient was morbidly obese and suffering from renal disease, cardiovascular disease and diabetes.

Like Sosin, Gonzales said she noted patients are at the highest risk of mortality if they have “diabetes, obesity, chronic lung disease, and liver disease like cirrhosis.”

Outside of the underlying conditions currently being tracked by NMDOH, some patients were in their own dire straits that can bring a host of complications; at least 11 had severe alcohol abuse, two had lupus and one was a kidney donor.

“I can tell you that personally, I’ve only cared for one person who seemingly didn’t have any of those risk factors, but this patient was obese and so that is a risk factor,” she said. “But other than that, at least of the patients that I’ve taken care of, they all have at least one of those risk factors: diabetes, liver disease, chronic kidney disease.”

All potentially at risk

During the pandemic, Sosin said, focus is needed on those populations that grapple most with underlying conditions – notably Native American populations hit particularly hard on the Navajo Nation and in northwestern New Mexico.

So far, the Navajo Nation, which includes large swaths of New Mexico, Arizona and Utah, has seen more than 9,000 cases of COVID-19 and more than 450 deaths related to the virus.

Sosin said they are trying to reinforce COVID-safe practices in those populations, take active measures to prevent infections and provide early care “because we know their course of illness can be much more severe, including death.”

According to the U.S. Department of Health and Human Services, Native Americans are nearly three times as likely to be diagnosed with diabetes and 50% more likely to be obese or diagnosed with heart disease than non-Hispanic whites.

Sosin said any treatment for those with underlying conditions would target certain parts of the immune and inflammatory response. But there is still more research to be done.

“It does appear that the immune response and inflammatory response to COVID-19 is particularly intense, and as we understand more how to control that, we may have more effective ways to treat (those with) the conditions,” he said.

Despite the numbers, Sosin said nobody should get complacent as the virus can put anyone – no matter their health – in the hospital, or worse. It is happening all across the country.

Medical professionals stress that even if an individual who contracts COVID-19 doesn’t die, they may have lasting complications, and they may pass the disease to someone who does have preexisting conditions.

“It is an important message that everybody is potentially at risk. This is an easily transmitted virus and it does cause severe disease,” he said. “These are numbers of deaths we haven’t seen from a pandemic for over a hundred years. This is serious and it doesn’t avoid people without underlying conditions.”

Winter is coming

Looking ahead, Sosin said they are concerned by the versatility of COVID-19, as it “doesn’t appear to have seasonality.”

“Early in the course of the pandemic, in late winter and early spring, we were all counting on it going away like most seasonal respiratory viruses until we hit the fall,” he said. “What we see is, whenever we ease up the pressure on these COVID-safe practices, the virus shoots back. It comes back just as strong, or stronger.”

He added, “This virus is really related to the ways that we share the virus, and stopping it has to do with all the practices the governor is calling for.”

Sosin urged people to take those precautions to heart as the state heads toward the uncertainty of winter: wear a mask, practice social distancing and regularly clean surfaces.

He said the approaching fall and winter will create complexity as health care providers have to determine which cases are COVID-19 and which are a common cold, strep throat or seasonal viruses.

Also, the spread of COVID-19 could be amplified by symptoms of those viruses, such as sniffling and coughing.

“The additional burden on the health care system is really what we’re worried about. If we’re not able to bring control – and maintain a low level of infections of COVID-19 – when we have COVID-19 infection on top of other severe respiratory viral infections, we will have trouble maintaining the health care systems and quality of health care that we can currently provide,” he said. “We haven’t experienced it yet but are certainly concerned that, if there are multiple concurrent infections, that we will have more severe outcomes.”

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