Underlying Conditions and the Higher Risk for Severe COVID-19

What you need to know

This webpage provides an evidence-based resource for healthcare professionals caring for patients with underlying medical conditions who are at higher risk of experiencing severe outcomes of COVID-19. Severe outcomes of COVID-19 are defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, or death.

This page summarizes data from published reports, scientific articles in press, unreviewed pre-prints, and internal data that were included in literature reviews conducted by subject matter experts. Evidence used to inform the list of underlying conditions was determined by CDC reviewers based on available literature about COVID-19 at time of review. The information reflects evidence regarding underlying medical conditions and is intended to help healthcare professionals make informed decisions about patient care and to increase the awareness of risk among their patients.

The methods used to assess the conditions have changed during the pandemic as the amount of literature and types of studies increased. For instance, preliminary versions of this list focused on providing the latest information based on descriptive data. As the literature grew, CDC investigators categorized the literature by study design.

Since May 2021, the process has been updated to include a CDC-led review process that uses rigorous systematic review methods. To learn more about the process of CDC’s systematic reviews, see CDC systematic review process.

Background

Age is the strongest risk factor for severe COVID-19 outcomes. Patients with one or multiple certain underlying medical conditions are also at higher risk.^(1-3)

Additionally, being unvaccinated or not being up to date on COVID-19 vaccinations also increases the risk of severe COVID-19 outcomes.

Providers should consider the patient's age, presence of underlying medical conditions and other risk factors, and vaccination status in determining the risk of severe COVID-19-associated outcomes for any patient.

Demographic Factors

Studies have shown that COVID-19 does not affect all population groups equally. Three important factors are age, race, and ethnicity.

Age

Age remains the strongest risk factor for severe COVID-19 outcomes, with risk of severe outcomes increasing markedly with increasing age. Based on data from the National Vital Statistics System (NVSS) at NCHS (Risk for COVID-19 Infection, Hospitalization, and Death By Age Group), compared with ages 18–29 years, the risk of death is 25 times higher in those ages 50–64 years, 60 times higher in those ages 65–74 years, 140 times higher in those ages 75–84 years, and 340 times higher in those ages 85+ years. Notably, these data include all deaths in the United States that occurred throughout the pandemic, from February 2020 to July 1, 2022, including deaths among unvaccinated individuals.

Risk of severe outcomes is increased in people of all ages with certain underlying medical conditions and in people who are 50 years and older, with risk increasing substantially at ages >65 years.^4,5 Residents of long-term care facilities are also at increased risk, making up less than 1% of the U.S. population but accounting for more than 35% of all COVID-19 deaths.^6-10

Race and Ethnicity

The COVID-19 pandemic has highlighted racial, ethnic, and socioeconomic disparities in COVID-19 illnesses, hospitalizations, and deaths.^11-13 Some racial and ethnic minority groups are also more likely to face multiple barriers to accessing health care including lack of insurance, transportation, child care, or ability to take time off from work.

Studies have identified racial and ethnic differences in at-home COVID-19 test use, vaccination coverage, and access to outpatient therapeutics.^14-16 Data has shown that compared to non-Hispanic White people, people from racial and ethnic minority groups are more likely to be infected with SARS-CoV-2 (the virus that causes COVID-19). Once infected, people from racial and ethnic minority groups are more likely to be hospitalized, be admitted to the ICU, and die from COVID-19 at younger ages.¹⁷

We are still learning about how the environments where people live, learn, and work can influence the risk for infection and severe COVID-19 outcomes.

Summary of Conditions with Evidence

Evidence used to inform the list of underlying medical conditions that increase a person's risk of severe illness from COVID-19 is presented in alphabetical order by study design section. Conditions are categorized as higher risk, suggestive higher risk, and mixed evidence.

Higher Risk (conclusive)

Higher risk is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or underwent the CDC systematic review process. The meta-analysis or systematic review demonstrates a conclusive increase in risk for at least one severe COVID-19 outcome.

Complete List of Disabilities from CDC’s Systematic Review Process

• Attention-deficit/hyperactivity disorder (ADHD)
• Autism
• Cerebral palsy
• Charcot foot
• Chromosomal disorders
• Chromosome 17 and 19 deletion
• Chromosome 18q deletion
• Cognitive impairment
• Congenital hydrocephalus
• Congenital malformations
• Deafness/hearing loss
• Disability indicated by Barthel Index
• Down syndrome
• Fahr's syndrome
• Fragile X syndrome
• Gaucher disease
• Hand and foot disorders
• Learning disabilities
• Leber's hereditary optic neuropathy (LHON) or Autosomal dominant optic atrophy (ADOA)
• Leigh syndrome
• Limitations with self-care or activities of daily living
• Maternal inherited diabetes and deafness (MIDD)
• Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) and risk markers
• Mobility disability
• Movement disorders
• Multiple disability (referred to in research papers as "bedridden disability")
• Multisystem disease
• Myoclonic epilepsy with ragged red fibers (MERRF)
• Myotonic dystrophy
• Neurodevelopmental disorders
• Neuromuscular disorders
• Neuromyelitis optica spectrum disorder (NMOSD)
• Neuropathy, ataxia, and retinitis pigmentosa (NARP)
• Perinatal spastic hemiparesis
• Primary mitochondrial myopathy (PMM)
• Progressive supranuclear palsy
• Senior-Loken syndrome
• Severe and complex disability (referred to in research papers as "polyhandicap disability")
• Spina bifida and other nervous system anomalies
• Spinal cord injury
• Tourette syndrome
• Traumatic brain injury
• Visual impairment/blindness
• Wheelchair use

Suggestive Higher Risk

Suggestive higher risk is defined as an underlying medical condition or risk factor that did not have a published meta-analysis or systematic review or did not undergo 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 (inconclusive: no conclusions can be drawn from the evidence)

Mixed evidence is defined as an underlying medical condition or risk factor that has a published meta-analysis or systematic review or underwent the CDC systematic review process. The meta-analysis or systematic review is inconclusive, either because the aggregated data on the association between an underlying condition and severe COVID-19 outcomes are inconsistent in direction or there are insufficient (or limited) data on the association between an underlying condition and severe COVID-19 outcomes.

• Limited: The evidence consists of one study, or several small studies with no comparison group, limiting the conclusions that can be drawn.
• Inconsistent: The evidence suggests no clear direction of association, meaning no firm conclusions can be drawn.

Actions Healthcare Professionals Can Take

• Recommend vaccination with approved and authorized COVID-19 vaccines (updated 2023-2024 COVID-19 vaccine), which are safe and effective. Check out the Interim Clinical Considerations for Use of COVID-19 Vaccines as well as Stay Up to Date with Your Vaccines and locations for COVID-19 vaccination for patients for more information.
• Prescribe antivirals, which have been shown to significantly decrease the risk of hospitalization and death when treating patients with mild or moderate illness and risk factors for severe illness. Outcomes are improved if therapeutics are started within the first 5-7 days of symptom onset.
• Consider pemivibart (Pemgarda™), a monoclonal antibody for COVID-19 pre-exposure prophylaxis in people who are moderately or severely immunocompromised and unlikely to mount an adequate immune response to COVID-19 vaccination and who meet the FDA-authorized conditions for use. Pemivibart may provide another layer of protection against COVID-19 in addition to vaccination and can be given at least 2 weeks after receiving a COVID-19 vaccine. For more information, please see the FDA Fact Sheet for Providers.
• Remind older patients and those with underlying medical conditions that wearing a mask is an additional prevention strategy they can choose to further protect themselves.
• Encourage patients to keep appointments for routine care and adhere to treatment regimens for their medical conditions.
• Consider use of telehealth when appropriate.
• Check out additional information for your patients.

Considerations for Patients Within Racial and Ethnic Minority Groups

• Ask patients about their concerns about vaccines and therapy. Consider using an evidence-based and culturally sensitive approach, such as motivational interviewing. Try to provide trusted sources of information and other resources.
• Encourage testing, as well as early treatment, for patients who are eligible.
• Facilitate access to culturally and linguistically appropriate resources.
• Reduce barriers to accessing current outpatient treatments.

CDC strongly encourages healthcare professionals, patients and their advocates, and health system administrators to regularly consult the Infectious Diseases Society of America (IDSA) COVID-19 Treatment Guidelines.

Key Findings from One Large Cross-Sectional Study

Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021

This study used data from the Premier Healthcare Database, which represents approximately 20% of all inpatient admissions in the United States since 2000. This cross-sectional study of 540,667 adults hospitalized with COVID-19 included both inpatients and hospital-based outpatients with laboratory-diagnosed COVID-19 from March 1, 2020, through March 31, 2021. The database included reports from 592 acute care hospitals in the United States. The study was designed to examine risk factors associated with severe outcomes of COVID-19 including admission to an ICU or stepdown unit, invasive mechanical ventilation, and death.

Main Findings:

• Certain underlying medical conditions were associated with an increased risk for severe COVID-19 illness in adults.
• Having multiple conditions was also associated with severe COVID-19 illness.
• Obesity, diabetes with complications, and anxiety and fear-related disorders had the strongest association with death.
• The number of frequent underlying medical conditions (present in ≥10.0% of patients) increased with age.²⁰⁷

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Adapted from Sources:

• Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm
• Pennington AF, Kompaniyets L, Summers AD, Danielson ML, Goodman AB, Chevinsky JR, Preston LE, Schieber LZ, Namulanda G, Courtney J, Strosnider HM, Boehmer TB, Mac Kenzie WR, Baggs J, Gundlapalli AV, Risk of Clinical Severity by Age and Race/Ethnicity Among Adults Hospitalized for COVID-19—United States, March–September 2020, Open Forum Infectious Diseases, Volume 8, Issue 2, February 2021. To learn more, visit: https://doi.org/10.1093/ofid/ofaa638

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Source: Kompaniyets L, Pennington AF, Goodman AB, Rosenblum HG, Belay B, Ko JY, et al. Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020–March 2021. To learn more, visit the Preventing Chronic Disease article: https://www.cdc.gov/pcd/issues/2021/21_0123.htm

More Information

• Methods for the Underlying Conditions ICD-10 List [PDF, 2 pages, 112K]
• COVID-19 Therapeutics
• Clinical Presentation
• COVID-19 Treatment in Outpatients
• COVID-19 Cases, Deaths, and Laboratory Testing (NAATs) by State, Territory, and Jurisdiction
• Demographic Trends of COVID-19 Deaths in the US Reported to NVSS
• Health Equity: Promoting Fair Access to Health
• How Do I Find a COVID-19 Vaccine
• COVID-19 Vaccination Clinical & Professional Resources

References

See CDC Systematic Review References

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3. So CN, Ryerson AB, Yeargin-Allsopp M, Kristie EN et al. Brief Summary of Findings on the Association Between Disabilities and Severe COVID-19 Outcomes. [1984K, 165 pages]CDC COVID-19 Scientific Brief.
4. Okasako-Schmucker DL, Weissman D, Mazurek J et al. Brief Summary of Findings on the Association Between Interstitial Lung Diseases and Severe COVID-19 Outcomes. [print only, 837K, 67 pages]CDC COVID-19 Scientific Brief. October 2021.
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7. Wassef M, Weissman D, Mazurek J et al. Brief Summary of Findings on the Association Between a History of Pulmonary Embolism or Pulmonary Hypertension and Severe COVID-19 Outcomes. [print only, 506K, 16 pages]CDC COVID-19 Scientific Brief. October 2021.
8. Kumasaka JK, Jereb JA, Stone E et al. Brief Summary of Findings on the Association Between Tuberculosis and Severe COVID-19 Outcomes. [print only, 443K, 17 pages]CDC COVID-19 Scientific Brief. October 2021.
9. Morford M, Weissman, D, Mazurek J, et al. Brief Summary of Findings on the Association Between Alpha-1 Antitrypsin Deficiency and Severe COVID-19 Outcomes. [print only, 533K, 27 pages]CDC COVID-19 Scientific Brief. October 2021.
10. Henry MC, Weissman D, Mazurek J, et al.Brief Summary of Findings on the Association Between Underlying Bronchopulmonary Dysplasia (BPD) and Severe COVID-19 Outcomes. [print only, 375K, 12 pages]CDC COVID-19 Scientific Brief. October 2021.
11. Okasako-Schmucker DL, Cornwell C, Mirabelli M, et al. Brief Summary of Findings on the Association Between Asthma and Severe COVID-19 Outcomes. [print only, 2,000KB, 142 pages] CDC COVID-19 Scientific Brief. June 2022.
12. Kumasaka JK, Weissman D, Mazurek J, et al. Brief Summary of Findings on the Association Between COPD and Severe COVID-19 Outcomes. [print only, 2,000KB, 176 pages]CDC COVID-19 Scientific Brief. June 2022.
13. So CN, Green RF, Drzymalia E, et al. Brief Summary of Findings on the Association Between Cystic Fibrosis and Severe COVID-19 Outcomes. [print only, 788K, 54 pages] CDC COVID-19 Scientific Brief. June 2022.
14. Hill AL, Payne AB, Schieve LA, et al. Brief Summary of Findings on the Association Between Thalassemia and Severe COVID-19 Outcomes. [print only, 619 KB, 26 pages] CDC COVID-19 Scientific Brief. June 2022.
15. Morford M, Brief Summary of Findings on the Association Between Hematologic Malignancy and Hematopoietic Stem Cell Transplant/Hematopoietic Cell Transplant and Severe COVID-19 Outcomes [886KB – 78 pages] CDC COVID-19 Clinical Care. January 2023.
16. Supplement: Morford M, Koumans E, Giovanni J, et al. Brief Summary of Findings on the Association Between Secondary Immunosuppression from B-Cell-Depleting Therapy and Severe COVID-19 Outcomes [482 KB – 28 pages] CDC COVID-19 Clinical Care. January 2023.

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