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Understanding the increased Covid-19 risk in men and BAME communities



The new virus known as SARs?CoV-2, or Covid-19, is one of a family of viruses termed coronaviruses. These viruses were first identified in around the mid-1960s and are named after the characteristic shape of their outer surface, resembling a halo or crown.

The new virus known as SARs–CoV-2, or Covid-19, is one of a family of viruses termed coronaviruses. These viruses were first identified in around the mid-1960s and are named after the characteristic shape of their outer surface, resembling a halo or crown. 

The first Severe Acute Respiratory Syndrome (SARs) coronavirus (SARs-Cov-1) emerged in 2003, while another coronavirus causing significant disease, the Middle East Respiratory Syndrome (MERS) coronavirus, was first identified in 2012.

As of 11 May, official figures show there have been 219,183 confirmed cases of Covid-19 and 31,855 related deaths across the UK.1 The virus is primarily spread through droplets from the nose or mouth when a person with Covid-19 coughs, sneezes or speaks.2

The World Health Organisation (WHO) and governments are promoting measures, such as social distancing and regular handwashing, to help reduce transmission in the community. 

While the majority of infections are relatively mild, the WHO estimates almost 40% of people affected require hospitalisation and around one in 20 people require ICU treatment.3
It is widely understood that elderly people are most susceptible to severe illness from Covid-19, and that people with underlying conditions, such as diabetes and respiratory diseases, are also particularly vulnerable.

There are also stark disparities in the severity of disease between men and women, and among different ethnic groups.

It is important that healthcare professionals and other keyworkers understand and are aware of these disparities in risk, when assessing and advising patients. 

These factors should be considered to help sensitive discussions with patients and colleagues about prevention measures, as well as in assessing risk of severe disease and complications. Knowledge and policies are changing daily, so as healthcare professionals we need to keep well informed with current advice.
 
How is Covid-19 affecting men more than women?
 
Various reports have shown that men are at greater risk from Covid-19 than women. A recent study from the Office of National Statistics (ONS) showed that among people of working age, death rates due to Covid-19 were nearly twice as high in men, with 9.9 deaths per 100,000 in men compared with 5.5 per 100,000 in women.4

A number of theories are emerging as to why men may be more at risk from the virus. The disparity may be at least partly down to basic biology. For example, evidence indicates men have more angiotensin converting enzyme (ACE)-2 receptors – which allow Covid-19 to enter cells – in lungs and other tissues than women. 5,6

Genetic differences may also affect sex-specific outcomes to Covid-19 infection. The sex hormone testosterone, more highly expressed in men than women, is known to suppress the immune system.7

In addition, certain X chromosome-linked immune factors are more highly expressed in women than men. This includes the Toll–like receptors (TLRs) and in particular TLR7 that may be important in the anti-viral immune response.8,9

Other factors thought to contribute to the disparity between men and women include lifestyle behaviours, such as frequency of hand washing, smoking and diet.10

Body shape may also be important – men typically being more ‘apple-shaped’ with a higher waste to hip ratio than women, who are more typically ‘pear-shaped’. This means more fat is distributed on the torso among men, which can increase pressure on respiratory muscles.
 
How are BAME groups at increased risk from Covid-19?

Mounting evidence indicates that Black, Asian and Minority Ethnic (BAME) people are disproportionately affected by Covid-19. 

A recent ONS analysis showed that, taking into account age differences, black men and women were four times as likely to die from the virus when compared with white people. Those of Bangladeshi and Pakistani origin were over three times at risk and Indians were at twice the risk.11

The UK Government has now set up a scientific review looking at how ethnicity, along with other factors, may be linked to an increased risk of morbidity and mortality compared with white people, and there have been calls for a wider inquiry.12,13  

A number of factors have been put forward as potential contributors to an increased risk in BAME populations. One is that BAME people are more likely to live crowded conditions and experience more poverty, which contributes to poorer health generally and can make it harder for people to adhere to physical distancing and isolation measures. 

BAME groups also have a higher incidence of certain illnesses including heart disease, diabetes and high blood pressure, underlying health conditions that may put them at increased risk of severe illness due to Covid-19.14   

However, a recent Oxford University study found that BAME people were still at twice the risk of dying from Covid-19 compared with white people, even after adjusting for underlying conditions and deprivation.15

The study authors suggest other possible explanations for the increased risk among BAME groups may ‘relate to higher infection risk, including over-representation in “front-line” professions with higher exposure to infection, or higher household density’.

Other experts have also noted that the over-representation of BAME groups in higher risk occupations such as health and care work, the transport sector and shop work may be a key contributory factor.16
 
Role of nurses in educating people and taking history

Nurses can play an important role in educating patients and the public about prevention generally but also the increased risks faced by certain groups, and offering targeted advice.  

Those in high risk groups should be provided with the relevant information and health promotion material should be adapted according to target groups.  Be mindful that different minority groups may use specific media rather than mainstream channels. There may also be language and communication problems. 

Patients should be advised about the importance of minimising risk in crowded conditions, for example not sharing eating utensils and spacing living arrangements as far as is practically possible.

During general consultations healthcare professionals can highlight health promotion messages – for example, the importance of hand washing and maintaining a physical distance.  It is also important to offer advice about healthy eating and taking exercise to prevent weight gain during this period of physical distancing, as well as to promote mental health and wellbeing.  A structured routine may help patients to undertake daily exercise regimes and help to normalise daily living under distancing and isolation measures.

There are a range of resources available online – patients can be directed to resources listed at the end of this article. The Royal College of Nursing (RCN) has also produced guidance for healthcare providers from the BAME community.
 
How to keep updated

There are still many uncertainties about the Covid-19 pandemic. For example, experts are unsure yet whether robust immunity is gained after exposure to SARs-CoV-2 and for how long any possible immunity lasts.

Make sure you are aware of the latest official guidance from the Government, NHS England and Public Health England. In keeping yourself informed more widely, be aware that some media channels can be unhelpful, providing potentially inaccurate or politically biased information.

These are not normal times, when we can use NICE guidelines as the foundation for our decision making.  NICE have, however, published rapid guidelines for different specific conditions.

New theories about Covid-19 infection control strategies and treatments are being debated daily so while it is important to be aware of developments, it is also important to be mindful that most new research findings are not yet published in peer-reviewed journals.
 
Key messages

  • Keep well informed, so that you are equipped to give timely advice and support
  • Maintain a sense of optimism and promote the importance of self-care
  • Consider the risk factors of each individual patient and tailor your care and support appropriately
  • Practice should be in line with the best available evidence
  • Work within your competence
  • Practice what you preach – others will take note.

 

References

1. The European Centre for Disease prevention and Control. COVID-19 situation update for the EU/EEA and the UK, as of 11 May 2020

2. The World Health Organisation (WHO). Q&A on coronaviruses (COVID-19). 17 April 2020

3. WHO press statement April 2020

4.  Office for National Statistics. Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020 

5. R&D Systems. ACE-2: The Receptor for SARS-CoV-2  

6. Sama I, Ravera A, Santema B et al. Circulating plasma concentrations of angiotensin-converting enzyme 2 in men and women with heart failure and effects of renin–angiotensin–aldosterone inhibitors. Eur Heart J. Early online publication: 10 May 2020

7. Taneja V. Sex hormones determine immune response. Front Immunol 2018; 9: 1931   

8. Conti P and Younes A. Coronavirus COV-19/SARS-CoV-2 affects women less than men: clinical response to viral infection. J Biol Regul Homeost Agents 2020; 34 (2)  

9. Mihm S. Letter to the Editor. COVID-19: Possible impact of the genetic background in IFNL genes on disease outcomes. J Innate Immun. 28 April 2020 

10. Rieker P and Bird C. Rethinking Gender Differences in Health: Why We Need to Integrate Social and Biological Perspectives. The Journals of Gerontology: Series B, Volume 60, Issue Special_Issue_2, 1 October 2005, Pages S40–S47

11. Office for National Statistics. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020. Last updated: 7 May 2020

12. UK Government website. News story. Review into factors impacting health outcomes from COVID-19  

13. Caulfield C. PM urged to launch investigation into BAME coronavirus deaths. Metro. 10 May 2020

14. British Heart Foundation – News. Why are so many black and ethnic minority people dying from coronavirus – and what does it have to do with heart disease?  Updated 11 May 2020 

15. The OpenSAFELY Collaborative, Williamson E, Walker A et al. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv preprint posted 7 May 2020

16. Chaturvedi N (as told to Devlin H). Why are people from BAME groups dying disproportionately of COVID-19? The Guardian. 22 April 2020

Further resources 

Centers for Disease Control and Prevention. CDC. 2019 

NHS England (2020) Coronavirus guidance for clinicians and NHS Managers. 

Public Health England (2020) Coronavirus (COVID – 19) What you need to do.  

British Nutrition Foundation (BNF) March 2020.  BNF busts the myths on nutrition and COVID-19. 

Future Learn (23 March, 2020).  COVID-19. Tackling the Novel Coronavirus.

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