|Year : 2020 | Volume
| Issue : 2 | Page : 90-95
Hypertension and COVID-19: A public health perspective
Alka Aggarwal Singh1, Asha Shah2, Jai Prakash Narain3
1 Independent Public Health Consultant, Gurugram; Former India Lead, Resolve to Save Lives, and Country Director, Vital Strategies, Ahmedabad, India; Former Senior Specialist, Monitoring and Evaluation, The Global Fund, Geneva
2 Professor of Medicine, GCS Medical College; Former Professor and HOD Medicine, BJ Medical college & Civil Hospital, Ahmedabad, India
3 Senior Visiting Fellow, University of New South Wales, Sydney Kensington, Australia; Former Director of Communicable Diseases, World Health Organization, SEA Regional Office, New Delhi, India
|Date of Submission||02-Jun-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Alka Aggarwal Singh
Source of Support: None, Conflict of Interest: None
As the count for COVID-19 infection and deaths climb around the world, it is pertinent to look at the other pandemic of cardiovascular disease (CVD) and hypertension (HT). These conditions have been found to be the most common underlying conditions around the world. Unlike CVD, HT is not considered an independent risk factor for COVID-19. However, it is a risk factor for CVD and hence needs attention. Globally, HT affects approximately 900 million people and kills an estimated 9 million annually (11% of all deaths). It causes end-organ damage to cardiac, cerebral, and renal systems as well as eyes. However, <15% of those with HT have it under control. The COVID-19 pandemic has affected the HT situation by its psychogenic effects which are known to exacerbate HT, questioned the use of certain antihypertensives, decreased access to health services, and diverted resources from already stretched health systems. Despite these challenges, some lessons from the earlier outbreaks of infectious diseases are indicative. Primary health services can still support patients of HT with some adaptation of the traditional system, as well as by the adoption of new technologies. Patients can be encouraged for self-care. HT needs attention as a serious medical condition that can be controlled with concerted efforts from the global community. In the pandemic situation, there needs to be an advocacy for the continuity of services for HT as well as for other noncommunicable diseases and other health services. The treatment protocols for HT need to be simplified keeping prolonged social isolation in mind. Serious efforts are being made to protect healthcare workers from infection. These should be complemented with attention to HT and other underlying conditions that increase morbidity and mortality among the infected. Countries should adopt a policy of data sharing to learn from each other and to keep the public informed. Finally, countries should reserve health funds for disasters and pandemic situations and build a reserve force of healthcare workers to prevent a massive disruption of regular health services.
Keywords: COVID-19, hypertension, policy, public health
|How to cite this article:|
Singh AA, Shah A, Narain JP. Hypertension and COVID-19: A public health perspective. Int J Non-Commun Dis 2020;5:90-5
| Introduction|| |
At the time of writing this article, COVID-19 has infected close to 5.7 million and claimed more than 358,000 lives. There is still much to learn about the pathology and long-term sequelae of the disease and the diversion of healthcare workers on the morbidity and mortality of non-COVID diseases. Social distancing and economic recession have set a new normal, and there is, yet, little understanding of how the situation will evolve further and how it will impact society and lifestyle diseases.
Cardiovascular disease (CVD) and hypertension (HT) are documented as common conditions associated with COVID-19. Before the SARS-CoV2 pandemic, CVD was the leading noncommunicable disease (NCD) pandemic responsible for majority of deaths around the world, and HT was its major risk factor. In 2015, an estimated 874 million adults had systolic blood pressure (SBP) of 140 mmHg or higher. This paper briefly reviews the association between the COVID-19 pandemic and HT before going on to suggest measures for the control of HT in the context of the pandemic.
| COVID-19 and Hypertension|| |
Hypertension, the most common underlying condition
The elderly population bears disproportionate morbidity and mortality due to COVID-19. That is due to an increased prevalence of underlying comorbidities among them.
In China, the overall case-fatality rate (CFR) was 2.3% (1023 deaths among 44,672 confirmed cases). However, in those aged 70–79 years, the CFR was 8.0% which increased to almost 15% in those aged 80 years or more. No deaths were reported in children aged 9 years or less. The CFR was high among those with preexisting conditions – 10.5% with CVD, 7.3% with diabetes, 6.3% with chronic respiratory disease, 6.0% with HT, and 5.6% with cancer. In a cohort study of 416 hospitalized patients with COVID-19, about 20% of the patients had cardiac injury. Compared to patients without cardiac injury, they were older and had a higher chance of HT (59.8% vs. 23.4%; P < 0.001). In a multicenter study from Wuhan with definite outcomes, HT was the most common comorbidity (30%), followed by coronary heart disease (8%). In a meta-analysis of 1527 laboratory-confirmed cases, patients with HT were more likely to develop severe/intensive care unit (ICU) cases after COVID-19 infection.
In Italy, the clinical picture was similar. The median age of the people infected with SARS-CoV2 who died in Italy was 81 years, and the median age of the patients diagnosed was 62 years. COVID-19 morbidity and mortality were seen to be strongly dependent on the presence of concomitant serious diseases. Among those who died, only 3.8% were without any comorbidity. Most common comorbidities observed in a sample of 2351 patients who died were ischemic heart disease (28.2%), atrial fibrillation (22%), heart failure (16.4%), stroke (10.8%), HT (69.2%), diabetes (31.8%), chronic renal failure (21%), and others to a varying degree.
In the US, among the patients hospitalized for COVID-19 in March 2020, HT was seen in 50% of the patients and CVD in 27.8%. In another study from New York, of the 5700 hospitalized patients, HT was seen in 56.6%, coronary artery disease in 11.1%, and congestive heart failure in 6.9%.
Most patients with COVID-19 predominantly have a respiratory tract infection, but a proportion of patients progress to a more severe and systemic disease. Acute respiratory distress syndrome, shock, multiple organ dysfunction, and coagulation abnormalities with increased D-dimer are the conditions in a proportion of patients that are associated with substantial mortality.
Effect of medication for COVID-19 on hypertension
A reverse association is also noted between COVID-19 and HT. Some of the drugs being used or considered for the management of COVID-19 are immunomodulators such as tocilizumab, bevacizumab, eculizumab, and fingolimod, as well as immunosuppressants such as methylprednisolone. HT is one of their adverse effects.,
| Is Hypertension a Risk Factor for COVID-19?|| |
It is possible that the reported association between HT and COVID-19 infection is confounded by age and comorbidities. A few studies have shown a lack of sound evidence for HT as an independent risk factor for COVID-19.,, An old Finnish study of pneumonia in the elderly too indicated that age, lifestyle factors, e.g., high alcohol intake, and comorbidities including heart disease and diabetes, but not HT, were independently associated with increased risk of pneumonia. Nonetheless, since HT is a risk factor for CVD, which is in turn a risk factor for COVID-19, it becomes an important consideration for reducing the disease burden.
| Global Epidemiology of Hypertension|| |
Hypertension is a silent killer
HT kills an estimated 9.4 million people annually worldwide (10.8% of all deaths) – about as many as all infectious diseases combined – and is responsible for 7% disability-adjusted life years (DALYs). Largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million), followed by hemorrhagic stroke (2 million) and ischemic stroke (1.5 million). It is the leading remediable risk factor for CVD  and a risk factor for end-stage kidney disease. In addition, the end-organ damage by HT further extends to hypertensive retinopathy.
An estimated 874 million people have HT (SPB of 140 mmHg or more). With 30% prevalence in adults, India alone is estimated to have more than 200 million people with HT. Globally, less than half of those affected are aware that they have HT and it is adequately controlled in only about 13% of the people. High blood pressure (BP) ranks first as a cause of DALYs worldwide, accounting for 212 million DALYs. This is true for both men and women (122.2 million and 89.9 million DALYs, respectively). From 1990 to 2015, the DALYs accounted for by high blood pressure have increased by 28%. About 10% of the world's overall health expenditure was considered to be due to HT, increasing to 25% in some countries. It is, therefore, evident that HT exerts both a physical and an economic toll on humanity.
Treatment of hypertension is possible at the primary healthcare level
Treatment of HT at primary healthcare level in developing countries is possible by using standard treatment protocols that are affordable, by task shifting, and by ensuring uninterrupted drug supply combined with a simple monitoring system.,, This is embodied in the WHO's HEARTS technical package. Antihypertensive therapy that targets a SBP of 120 mmHg is known to be beneficial. Each 20-mmHg increment of SBP or 10-mmHg increment of diastolic BP is associated with doubling of the risk of a fatal cardiovascular event.
| Challenges Posed by the Pandemic on Hypertension Control|| |
Psychogenic effects of COVID-19
The general population is experiencing unprecedented stress, anger, grief, anxiety, depression, insomnia, and hostility as a result of the pandemic and the accompanying social isolation. The relationship of these to HT is well known.,, Lockdown has imposed decreased physical activity for millions of people, making them susceptible to weight gain. All this is true for healthcare professionals as well as for those who are experiencing unprecedented stress both at a personal and at a professional level. They are forced into a situation of having to make impossible decisions for allocating scant resources to equally needy patients. They are likely to experience shame, guilt or disgust, and develop depression, posttraumatic disorder, and even suicidal ideation.,,
COVID-19 and antihypertensives
Angiotensin-converting enzyme inhibitors and angiotensin II type-I receptor blockers (ARBs) are the leading choice of antihypertensives as they provide an additional 10% greater reduction in coronary heart disease risk, compared to the other antihypertensives. However, there is now a concern about their use as SARS-CoV2 binds to ACE2 receptors widely distributed in the body. ACE2 is significantly increased in patients with diabetes and HT who are treated with ACE inhibitors or ARBs. Theoretically, ACE2 could promote the proliferation of COVID-19 and enhance its capability for infection and severe life-threatening complications. Loss of ACE2 in the tubular epithelium of the kidney could contribute to altered sodium transport, leading to an increase in blood volume and BP, as well as both acute and chronic effects on kidney injury. Loss of ACE in the brainstem could result in increased autonomic activity and increased BP. Loss of ACE2 in vasculature and pulmonary tissue could also result in HT. However, some studies have also shown association with less severe disease, lower level of interleukin-6, and improved clinical outcomes in COVID patients with their use., Studies are unadjusted for confounders such as age, sex, race, ethnicity, socioeconomic status indicators, and comorbidities such as diabetes, chronic kidney disease, and heart failure, and as yet, there is no conclusion regarding the association of COVID-19 with renin angiotensin system inhibitors.
| Impact of COVID-19 on the Health System|| |
SARS-CoV2 pandemic is affecting the way all health services are delivered. As was seen with the Ebola outbreak, 0.3%–5% of the healthcare professionals have lost their lives because of infection at work or outside.,, There is a distinct fear of catching the infection because of a lack of adequate number or poor-quality PPE, N95 respirators, and masks. With shrinking revenues, there is fear of contractual workforce being laid off. Morale is expected to be low because of fear of violence, low resources, low salaries, and high workload. All the emotional stress and exacerbation of existing staff deficiency have an adverse effect on the functioning of health facilities.
Second, the economic depression and loss in revenue will result in less spending by the governments on health. This will not only have a deleterious effect on the health system of developing countries but also increase the already high out-of-pocket expenditure. Private-owned health facilities, too, are facing a severe loss of revenue and prospects of bankruptcy because the revenue-generating non-COVID services have been suspended. The pandemic has challenged even the high performing health systems, to support service delivery and financing, maintain coordination of services, access to adequate medical supplies and equipment, adequate risk communication, and trust of the public and health workforce.
| Ensuring Continuity of Health Services during the Pandemic|| |
Disruption of services with the pandemic and lessons from earlier outbreaks
There are fears and actual evidence that resources for essential services are diverted from already stretched health systems toward the COVID-19 response, resulting in a decrease in utilization of services.,, However, during the Ebola outbreak, it was seen that at the peripheral health units, the patients with HT continued to seek care in the same numbers as before the outbreak. Nonphysician health workers can manage HT by screening of individuals, referral to physicians for diagnosis and management, patient education for lifestyle improvement, and conducting follow-up and reminders for medication adherence and appointments.,
Modification of the existing mode of care
Support to health workers, robust information and referral systems, and reliable medicine supply chains should be continued. To decongest health facilities and minimize the risk of COVID-19 infection, alternative sources of medications should be thought of for patients whose BP is under control and only need to refill the prescription. Community pharmacies, private pharmacies, and e-pharmacies are some of the options.
NCD clinics or cardiovascular clinics will have to modify their operations, depending on the type of patients they see, the availability of resources such as electronic health records, availability of PPE for protection of staff, and the number of available staff. Use of simple phones and smartphones will be useful. For instance, smartphone apps for monitoring of arrhythmias are a viable option.
Access to tele-medicine will be important for both emergency and nonemergency visits during the pandemic period., There is a surge in the use of tele-medicine, in general, and many expect this high usage to continue and not revert to the pre-COVID era. Thus, both medium- and long-term measures should be considered for upgrading the system. In the era of social distancing, self-care will play an important role in the prevention and management of CVDs. Patients should have access to online tools and resources for self-care-diet, exercise, adherence to medication, smoking cessation, and reduced exposure to smoke. Home measurement of BP should be promoted, and where possible, self-adjustment or tele-medicine-based stepping up of antihypertensive medication should be encouraged. Health providers should continue online and traditional efforts to prevent long-term morbidity and mortality by continuing programs for smoking cessation, healthy lifestyle, and control of cardiovascular risks such as blood sugar and BP.
| Policy Issues to Address COVID-19 and Hypertension|| |
HT is a risk factor for CVD which is responsible for almost half of all deaths globally. Unlike smoking and obesity, it has failed to achieve a concerted effort from the global community. There needs to be increased advocacy for HT as a serious medical condition and its control. HT being the most common underlying condition of COVID-19 gives the opportunity to do so.
Second, there also needs to be advocacy for continuity of services for HT, and in general, for other diseases – NCDs, maternal and child health services, and infectious diseases. NCDs are a barrier to achieving SDG 1, SDG 2, SDG 4, SDG 5, and SDG 10. NCDs offer a high return on investments for countries at all income levels, contributing to economic growth.,
Third, treatment protocols need to be adapted for a pandemic situation. For this, one recommendation is to not change the medication of patients who have maintained their BP. The other recommendation is to use calcium channel blockers. The latter option might be particularly useful as it does not require checking of renal function every 3–6 months, which is difficult in prolonged lockdown and limited mobility.
Fourth, HCWs on clinical duty should be screened to ensure that their BP is within the normal range, and like the general population, they, too, should be regularly encouraged for self-care and decompression time.
Fifth, there is a need for strengthening the policy for data sharing. While most information is available from developed countries, which are known for high median age, high prevalence of obesity, and better control of HT, there are less data from developing countries on the pandemic situation, clinical presentation, and outcomes. Not sharing available data are a compromise of ethics.
Finally, an important question is how to ensure that there is enough financial muscle to support the continuity of healthcare services for causes other than COVID-19. It would be important to reserve health funds for disaster or pandemic situations. Similarly, a reserve force of healthcare workers comprising clinicians and nonclinicians will be useful. These arrangements would prevent massive disruption of regular health services.
| Conclusion|| |
Globally, approximately 900 million people have HT (SPB of 140 mmHg or more). It kills an estimated 9.4 million people annually (10.8% of all deaths). However, <15% of those with HT have it under control. Among COVID-19 patients, HT is documented to be the most common underlying condition, and among the severe cases, those with HT are more likely to be admitted to ICU. The resources for essential services are diverted from the already stretched health systems toward the COVID-19 response, resulting in a decrease in utilization of all health services including those that support the care and control of HT. To address these issues, this paper recommends: (1) increased advocacy for HT as a serious condition and for its control; (2) increased advocacy for continuity of services for HT and other NCDs, (3) regular screening and care for HT and CVDs among the healthcare workers, (4) adaptation of treatment protocols, (5) data sharing, and (6) reserve funds and human resources for surge capacity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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