The list of comorbidities approved by the Health Ministry is overly restrictive and complicated. Many conditions, including obesity, have been left out. The focus seems to be on people with severe diseases and combination of comorbidities.
On February 27, the Health Ministry released a list of 20 comorbidities that will make a person in the age group 45-59 years eligible for a COVID-19 vaccine. The list of comorbidities approved by the Ministry has come under severe criticism.
“The list of comorbidities provided by the Health Ministry is overly restrictive and complicated. Many conditions, including obesity, have been left out,” says Dr. Gagandeep Kang, Professor of Microbiology at CMC Vellore.
“The focus seems to be on people with severe diseases and combination of comorbidities,” says Dr. Anant Bhan, a researcher in global health and bioethics based in Bhopal.
Hypertension is one of the common conditions that increases the risk of progressing to severe COVID-19 disease and death. However, people with hypertension alone will not be eligible unless it is accompanied by other diseases such as diabetes or conditions such as angina.
Focus has been on severe forms of a disease
“The initial focus has been on severe forms of a disease or condition. In a month or two we may see less severe forms of diseases included,” says Dr. D. Prabhakaran from the Public Health Foundation of India (PHFI), Delhi and one of the two members who prepared the list for cardiovascular diseases. There were two members for each thematic disease who prepared a list, and the final list was prepared based on suggestions from each group, he says.
Across the world, people with comorbidities have been identified as a high-risk group wherein the person infected with SARS-CoV-2 virus has a greater chance of becoming critically ill and even dying. The risk is higher in older people with comorbidities. That is the reason why in India as part of the second phase of vaccination, people above the age 60 years and those above 45 years with comorbidities are eligible to receive a vaccine from March 1 onwards.
Restrictive even during vaccine abundance
Besides being restrictive, the focus is on people with more than one comorbidity. With each comorbidity increasing the chances of severe disease and death, focussing on people with more than one comorbidity would have been acceptable in case of vaccine shortage. But with millions of doses of both vaccines already available in India, it is not clear why the focus has been on diseases at an advanced stage, says Dr. Giridhara Babu, epidemiologist at PHFI, Bengaluru.
“Large sections of the population don’t even know if they have comorbidities. It would have been better had we followed the U.K example, which has gone with age bands instead of focussing on comorbidities,” Dr. Kang says. “It would have been easier to cover more people at risk with age cut-offs.”
Diabetes is one of the major comorbidities for even death in COVID-19 patients. However, only those with over 10 years of diabetes plus hypertension will be eligible for vaccination. Similarly, only those with end-stage kidney disease and on haemodialysis are included. People with stroke will become eligible for a vaccine only if they also have hypertension or diabetes. However, many suffer from stroke caused by aneurysm or haemorrhage caused by arterial block in the brain even in the absence of hypertension or diabetes.
While asthma and chronic obstructive pulmonary disease (COPD) have not been specified, the list includes those using corticosteroids for a “prolonged period” as being eligible. How long is “prolonged” is not defined.
Dr. Prabhakaran says there is evidence that people with more severe forms of disease are at a greater risk of dying or becoming critically ill with COVID-19 disease and hence the focus has been on vaccinating these people on priority. But Dr. Bhan says that when vaccinating people with severe disease there should be greater vigilance for serious adverse events and safety.
Unlike other diseases, more conditions of cardiovascular disease have been included in the list. “Cardiovascular disease is a spectrum, which may not be the case for other diseases,” says Dr. Prabhakaran.
“They should have ideally included people in institutional care, like people with mental disease, or those accessing healthcare facilities often as these people are at higher risk,” says Dr. Bhan.