ACEP COVID-19 Field Guide

Author: Sandra Schneider, MD, FACEP, Senior Vice President for Clinical Affairs, American College of Emergency Physicians; Adjunct Professor of Emergency Medicine, University of Pittsburgh

• Vaccination reduces the risk of severe COVID-19 or death by 90% in all age groups.
• Vaccine effectiveness decreases by about half in 120 days but returns to baseline after a booster.
• Age is the strongest risk factor for severe COVID-19 outcomes.
• Approximately 54.1 million people aged ≥65 years reside in the United States; in 2020, this age group accounted for 81% of US COVID-19–related deaths.
• As of February 7, 2022 (CDC COVID-19 data tracker), the number of deaths in this group was more than 97 times the number of deaths in the age group 18 to 29 years.
• The risk of dying if infected is 360 times greater for people aged 85 years than those aged 25 years.
• In 2020, residents of long-term care facilities made up less than 1% of the US population but accounted for more than 35% of all COVID-19–related deaths.
• Additionally, people aged ≥18 years with certain underlying medical conditions are at an increased risk of severe illness from COVID-19.
• Studies have shown that some people with disabilities are more likely to get COVID-19 and have worse outcomes.
• Data have also shown that compared with non-Hispanic White people, people from racial and ethnic minority groups are more likely to die from COVID-19 at younger ages.
• In 2020, the largest percentage increases in death occurred among adults aged 25 to 44 years and among Hispanic people.

Risk categories

• Higher risk of severe COVID-19 outcomes:
  • An underlying medical condition or risk factor that has a published meta-analysis or systematic review or has completed the CDC systematic review process.
  • The meta-analysis or systematic review demonstrates good or strong evidence for an increased risk of at least one severe COVID-19 outcome.
• Suggestive higher risk of severe COVID-19 outcomes:
  • An underlying medical condition or risk factor that neither has a published meta-analysis nor systematic review nor has 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.)
• Mixed evidence:
  • An underlying medical condition or risk factor that has a published meta-analysis or systematic review or is completing the CDC systematic review process.
  • The meta-analysis or systematic review is inconclusive because either the aggregated data on the association between an underlying condition and severe COVID-19 outcomes are inconsistent in direction or the data are insufficient (or limited) on the association between an underlying condition and severe COVID-19 outcomes.

Higher risk of severe COVID-19 outcomes

• Cancer
• Cerebrovascular disease
• Chronic kidney disease*
• Chronic lung diseases limited to:
  • Interstitial lung disease
  • Pulmonary embolism
  • Pulmonary hypertension
  • Bronchiectasis
  • COPD
• Chronic liver diseases limited to:
  • Cirrhosis
  • Nonalcoholic fatty liver disease
  • Alcoholic liver disease
  • Autoimmune hepatitis
• Cystic fibrosis
• Type 1 or type 2 diabetes*
• Disabilities
  • Attention deficit hyperactivity disorder
  • Cerebral palsy
  • Congenital malformations (birth defects)
  • Limitations with self-care or activities of daily living
  • Intellectual and developmental disabilities
  • Learning disabilities
  • Spinal cord injuries
• Heart conditions (eg, heart failure, coronary artery disease, cardiomyopathies)
• HIV
• Mental health disorders limited to:
  • Mood disorders, including depression
  • Schizophrenia spectrum disorders
• Neurologic conditions limited to dementia
• Obesity (body mass index [BMI] ≥30 kg/m²)*
• Primary immunodeficiencies
• Pregnancy or recent pregnancy
• Physical inactivity
• Smoking (current and former)
• Solid organ or hematopoietic stem cell transplantation
• Tuberculosis
• Use of corticosteroids or other immunosuppressive medications

Suggestive higher risk of severe COVID-19 outcomes

• Children with certain underlying conditions
• Overweight (BMI ≥25 kg/m² but <30 kg/m²)
• Sickle cell disease
• Substance use disorders
• Thalassemia

Mixed evidence

• Alpha-1 antitrypsin deficiency
• Asthma
• Bronchopulmonary dysplasia
• Hepatitis B
• Hepatitis C
• Hypertension*

* Indicates underlying conditions for which there is evidence for pregnant and nonpregnant people

For additional information, see the CDC’s guidance on “Underlying Conditions and the Higher Risk for Severe COVID-19.”