Since SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19),
was first detected in December 2019 (
1
), approximately 1.3 million cases have been reported worldwide (
2
), including approximately 330,000 in the United States (
3
). To conduct population-based surveillance for laboratory-confirmed COVID-19–associated
hospitalizations in the United States, the COVID-19–Associated Hospitalization Surveillance
Network (COVID-NET) was created using the existing infrastructure of the Influenza
Hospitalization Surveillance Network (FluSurv-NET) (
4
) and the Respiratory Syncytial Virus Hospitalization Surveillance Network (RSV-NET).
This report presents age-stratified COVID-19–associated hospitalization rates for
patients admitted during March 1–28, 2020, and clinical data on patients admitted
during March 1–30, 2020, the first month of U.S. surveillance. Among 1,482 patients
hospitalized with COVID-19, 74.5% were aged ≥50 years, and 54.4% were male. The hospitalization
rate among patients identified through COVID-NET during this 4-week period was 4.6
per 100,000 population. Rates were highest (13.8) among adults aged ≥65 years. Among
178 (12%) adult patients with data on underlying conditions as of March 30, 2020,
89.3% had one or more underlying conditions; the most common were hypertension (49.7%),
obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular
disease (27.8%). These findings suggest that older adults have elevated rates of COVID-19–associated
hospitalization and the majority of persons hospitalized with COVID-19 have underlying
medical conditions. These findings underscore the importance of preventive measures
(e.g., social distancing, respiratory hygiene, and wearing face coverings in public
settings where social distancing measures are difficult to maintain)
†
to protect older adults and persons with underlying medical conditions, as well as
the general public. In addition, older adults and persons with serious underlying
medical conditions should avoid contact with persons who are ill and immediately contact
their health care provider(s) if they have symptoms consistent with COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)
(
5
). Ongoing monitoring of hospitalization rates, clinical characteristics, and outcomes
of hospitalized patients will be important to better understand the evolving epidemiology
of COVID-19 in the United States and the clinical spectrum of disease, and to help
guide planning and prioritization of health care system resources.
COVID-NET conducts population-based surveillance for laboratory-confirmed COVID-19–associated
hospitalizations among persons of all ages in 99 counties in 14 states (California,
Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New
York, Ohio, Oregon, Tennessee, and Utah), distributed across all 10 U.S Department
of Health and Human Services regions.
§
The catchment area represents approximately 10% of the U.S. population. Patients must
be residents of a designated COVID-NET catchment area and hospitalized within 14 days
of a positive SARS-CoV-2 test to meet the surveillance case definition. Testing is
requested at the discretion of treating health care providers. Laboratory-confirmed
SARS-CoV-2 is defined as a positive result by any test that has received Emergency
Use Authorization for SARS-CoV-2 testing.
¶
COVID-NET surveillance officers in each state identify cases through active review
of notifiable disease and laboratory databases and hospital admission and infection
control practitioner logs. Weekly age-stratified hospitalization rates are estimated
using the number of catchment area residents hospitalized with laboratory-confirmed
COVID-19 as the numerator and National Center for Health Statistics vintage 2018 bridged-race
postcensal population estimates for the denominator.** As of April 3, 2020, COVID-NET
hospitalization rates are being published each week at https://gis.cdc.gov/grasp/covidnet/COVID19_3.html.
For each case, trained surveillance officers conduct medical chart abstractions using
a standard case report form to collect data on patient characteristics, underlying
medical conditions, clinical course, and outcomes. Chart reviews are finalized once
patients have a discharge disposition. COVID-NET surveillance was initiated on March
23, 2020, with retrospective case identification of patients admitted during March
1–22, 2020, and prospective case identification during March 23–30, 2020. Clinical
data on underlying conditions and symptoms at admission are presented through March
30; hospitalization rates are updated weekly and, therefore, are presented through
March 28 (epidemiologic week 13).
The COVID-19–associated hospitalization rate among patients identified through COVID-NET
for the 4-week period ending March 28, 2020, was 4.6 per 100,000 population (Figure
1). Hospitalization rates increased with age, with a rate of 0.3 in persons aged 0–4
years, 0.1 in those aged 5–17 years, 2.5 in those aged 18–49 years, 7.4 in those aged
50–64 years, and 13.8 in those aged ≥65 years. Rates were highest among persons aged
≥65 years, ranging from 12.2 in those aged 65–74 years to 17.2 in those aged ≥85 years.
More than half (805; 54.4%) of hospitalizations occurred among men; COVID-19-associated
hospitalization rates were higher among males than among females (5.1 versus 4.1 per
100,000 population). Among the 1,482 laboratory-confirmed COVID-19–associated hospitalizations
reported through COVID-NET, six (0.4%) each were patients aged 0–4 years and 5–17
years, 366 (24.7%) were aged 18–49 years, 461 (31.1%) were aged 50–64 years, and 643
(43.4%) were aged ≥65 years. Among patients with race/ethnicity data (580), 261 (45.0%)
were non-Hispanic white (white), 192 (33.1%) were non-Hispanic black (black), 47 (8.1%)
were Hispanic, 32 (5.5%) were Asian, two (0.3%) were American Indian/Alaskan Native,
and 46 (7.9%) were of other or unknown race. Rates varied widely by COVID-NET surveillance
site (Figure 2).
FIGURE 1
Laboratory-confirmed coronavirus disease 2019 (COVID-19)–associated hospitalization
rates,* by age group — COVID-NET, 14 states,
†
March 1–28, 2020
Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance
Network.
* Number of patients hospitalized with COVID-19 per 100,000 population.
† Counties included in COVID-NET surveillance: California (Alameda, Contra Costa,
and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson
counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb,
DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county
represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert,
Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard,
Kent, Montgomery, Prince George’s, Queen Anne’s, St. Mary’s, Somerset, Talbot, Washington,
Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and
Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and
Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan,
and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe,
Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne,
and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison,
Morrow, Perry, Pickaway and Union counties); Oregon (Clackamas, Multnomah, and Washington
counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner,
Williamson, and Wilson counties); and Utah (Salt Lake County).
The figure is a bar chart showing laboratory-confirmed COVID-19–associated hospitalization
rates, by age group, in 14 states during March 1–28, 2020 according to the Coronavirus
Disease 2019–Associated Hospitalization Surveillance Network.
FIGURE 2
Laboratory-confirmed coronavirus disease 2019 (COVID-19)–associated hospitalization
rates,* by surveillance site
†
— COVID-NET, 14 states, March 1–28, 2020
Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance
Network.
* Number of patients hospitalized with COVID-19 per 100,000 population.
† Counties included in COVID-NET surveillance: California (Alameda, Contra Costa,
and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson
counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb,
DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county
represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert,
Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard,
Kent, Montgomery, Prince George’s, Queen Anne’s, St. Mary’s, Somerset, Talbot, Washington,
Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and
Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and
Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan,
and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe,
Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne,
and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison,
Morrow, Perry, Pickaway and Union counties); Oregon (Clackamas, Multnomah, and Washington
counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner,
Williamson, and Wilson counties); and Utah (Salt Lake County).
The figure is a bar chart showing laboratory-confirmed COVID-19–associated hospitalization
rates, by surveillance site, in 14 states during March 1–28, 2020 according to the
Coronavirus Disease 2019–Associated Hospitalization Surveillance Network.
During March 1–30, underlying medical conditions and symptoms at admission were reported
through COVID-NET for approximately 180 (12.1%) hospitalized adults (Table); 89.3%
had one or more underlying conditions. The most commonly reported were hypertension
(49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%),
and cardiovascular disease (27.8%). Among patients aged 18–49 years, obesity was the
most prevalent underlying condition, followed by chronic lung disease (primarily asthma)
and diabetes mellitus. Among patients aged 50–64 years, obesity was most prevalent,
followed by hypertension and diabetes mellitus; and among those aged ≥65 years, hypertension
was most prevalent, followed by cardiovascular disease and diabetes mellitus. Among
33 females aged 15–49 years hospitalized with COVID-19, three (9.1%) were pregnant.
Among 167 patients with available data, the median interval from symptom onset to
admission was 7 days (interquartile range [IQR] = 3–9 days). The most common signs
and symptoms at admission included cough (86.1%), fever or chills (85.0%), and shortness
of breath (80.0%). Gastrointestinal symptoms were also common; 26.7% had diarrhea,
and 24.4% had nausea or vomiting.
TABLE
Underlying conditions and symptoms among adults aged ≥18 years with coronavirus disease
2019 (COVID-19)–associated hospitalizations — COVID-NET, 14 states,* March 1–30, 2020†
Underlying condition
Age group (yrs), no./total no. (%)
Overall
18–49
50–64
≥65 years
Any underlying condition
159/178 (89.3)
41/48 (85.4)
51/59 (86.4)
67/71 (94.4)
Hypertension
79/159 (49.7)
7/40 (17.5)
27/57 (47.4)
45/62 (72.6)
Obesity§
73/151 (48.3)
23/39 (59.0)
25/51 (49.0)
25/61 (41.0)
Chronic metabolic disease¶
60/166 (36.1)
10/46 (21.7)
21/56 (37.5)
29/64 (45.3)
Diabetes mellitus
47/166 (28.3)
9/46 (19.6)
18/56 (32.1)
20/64 (31.3)
Chronic lung disease
55/159 (34.6)
16/44 (36.4)
15/53 (28.3)
24/62 (38.7)
Asthma
27/159 (17.0)
12/44 (27.3)
7/53 (13.2)
8/62 (12.9)
Chronic obstructive pulmonary disease
17/159 (10.7)
0/44 (0.0)
3/53 (5.7)
14/62 (22.6)
Cardiovascular disease**
45/162 (27.8)
2/43 (4.7)
11/56 (19.6)
32/63 (50.8)
Coronary artery disease
23/162 (14.2)
0/43 (0.0)
7/56 (12.5)
16/63 (25.4)
Congestive heart failure
11/162 (6.8)
2/43 (4.7)
3/56 (5.4)
6/63 (9.5)
Neurologic disease
22/157 (14.0)
4/42 (9.5)
4/55 (7.3)
14/60 (23.3)
Renal disease
20/153 (13.1)
3/41 (7.3)
2/53 (3.8)
15/59 (25.4)
Immunosuppressive condition
15/156 (9.6)
5/43 (11.6)
4/54 (7.4)
6/59 (10.2)
Gastrointestinal/Liver disease
10/152 (6.6)
4/42 (9.5)
0/54 (0.0)
6/56 (10.7)
Blood disorder
9/156 (5.8)
1/43 (2.3)
1/55 (1.8)
7/58 (12.1)
Rheumatologic/Autoimmune disease
3/154 (1.9)
1/42 (2.4)
0/54 (0.0)
2/58 (3.4)
Pregnancy††
3/33 (9.1)
3/33 (9.1)
N/A
N/A
Symptom
§§
Cough
155/180 (86.1)
43/47 (91.5)
54/60 (90.0)
58/73 (79.5)
Fever/Chills
153/180 (85.0)
38/47 (80.9)
53/60 (88.3)
62/73 (84.9)
Shortness of breath
144/180 (80.0)
40/47 (85.1)
50/60 (83.3)
54/73 (74.0)
Myalgia
62/180 (34.4)
20/47 (42.6)
23/60 (38.3)
19/73 (26.0)
Diarrhea
48/180 (26.7)
10/47 (21.3)
17/60 (28.3)
21/73 (28.8)
Nausea/Vomiting
44/180 (24.4)
12/47 (25.5)
17/60 (28.3)
15/73 (20.5)
Sore throat
32/180 (17.8)
8/47 (17.0)
13/60 (21.7)
11/73 (15.1)
Headache
29/180 (16.1)
10/47 (21.3)
12/60 (20.0)
7/73 (9.6)
Nasal congestion/Rhinorrhea
29/180 (16.1)
8/47 (17.0)
13/60 (21.7)
8/73 (11.0)
Chest pain
27/180 (15.0)
9/47 (19.1)
13/60 (21.7)
5/73 (6.8)
Abdominal pain
15/180 (8.3)
6/47 (12.8)
6/60 (10.0)
3/73 (4.1)
Wheezing
12/180 (6.7)
3/47 (6.4)
2/60 (3.3)
7/73 (9.6)
Altered mental status/Confusion
11/180 (6.1)
3/47 (6.4)
2/60 (3.3)
6/73 (8.2)
Abbreviations: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance
Network; N/A = not applicable.
* Counties included in COVID-NET surveillance: California (Alameda, Contra Costa,
and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson
counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb,
DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county
represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert,
Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard,
Kent, Montgomery, Prince George’s, Queen Anne’s, St. Mary’s, Somerset, Talbot, Washington,
Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and
Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and
Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan,
and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe,
Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne,
and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison,
Morrow, Perry, Pickaway and Union counties); Oregon (Clackamas, Multnomah, and Washington
counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner,
Williamson, and Wilson counties); and Utah (Salt Lake County).
† COVID-NET included data for one child aged 5–17 years with underlying medical conditions
and symptoms at admission; data for this child are not included in this table. This
child was reported to have chronic lung disease (asthma). Symptoms included fever,
cough, gastrointestinal symptoms, shortness of breath, chest pain, and a sore throat
on admission.
§ Obesity is defined as calculated body mass index (BMI) ≥30 kg/m2, and if BMI is
missing, by International Classification of Diseases discharge diagnosis codes. Among
73 patients with obesity, 51 (69.9%) had obesity defined as BMI 30–<40 kg/m2, and
22 (30.1%) had severe obesity defined as BMI ≥40 kg/m2.
¶ Among the 60 patients with chronic metabolic disease, 45 had diabetes mellitus only,
13 had thyroid dysfunction only, and two had diabetes mellitus and thyroid dysfunction.
** Cardiovascular disease excludes hypertension.
†† Restricted to women aged 15–49 years.
§§ Symptoms were collected through review of admission history and physical exam notes
in the medical record and might be determined by subjective or objective findings.
In addition to the symptoms in the table, the following less commonly reported symptoms
were also noted for adults with information on symptoms (180): hemoptysis/bloody sputum
(2.2%), rash (1.1%), conjunctivitis (0.6%), and seizure (0.6%).
Discussion
During March 1–28, 2020, the overall laboratory-confirmed COVID-19–associated hospitalization
rate was 4.6 per 100,000 population; rates increased with age, with the highest rates
among adults aged ≥65 years. Approximately 90% of hospitalized patients identified
through COVID-NET had one or more underlying conditions, the most common being obesity,
hypertension, chronic lung disease, diabetes mellitus, and cardiovascular disease.
Using the existing infrastructure of two respiratory virus surveillance platforms,
COVID-NET was implemented to produce robust, weekly, age-stratified hospitalization
rates using standardized data collection methods. These data are being used, along
with data from other surveillance platforms (https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview.html),
to monitor COVID-19 disease activity and severity in the United States. During the
first month of surveillance, COVID-NET hospitalization rates ranged from 0.1 per 100,000
population in persons aged 5–17 years to 17.2 per 100,000 population in adults aged
≥85 years, whereas cumulative influenza hospitalization rates during the first 4 weeks
of each influenza season (epidemiologic weeks 40–43) over the past 5 seasons have
ranged from 0.1 in persons aged 5–17 years to 2.2–5.4 in adults aged ≥85 years (
6
). COVID-NET rates during this first 4-week period of surveillance are preliminary
and should be interpreted with caution; given the rapidly evolving nature of the COVID-19
pandemic, rates are expected to increase as additional cases are identified and as
SARS-CoV-2 testing capacity in the United States increases.
In the COVID-NET catchment population, approximately 49% of residents are male and
51% of residents are female, whereas 54% of COVID-19-associated hospitalizations occurred
in males and 46% occurred in females. These data suggest that males may be disproportionately
affected by COVID-19 compared with females. Similarly, in the COVID-NET catchment
population, approximately 59% of residents are white, 18% are black, and 14% are Hispanic;
however, among 580 hospitalized COVID-19 patients with race/ethnicity data, approximately
45% were white, 33% were black, and 8% were Hispanic, suggesting that black populations
might be disproportionately affected by COVID-19. These findings, including the potential
impact of both sex and race on COVID-19-associated hospitalization rates, need to
be confirmed with additional data.
Most of the hospitalized patients had underlying conditions, some of which are recognized
to be associated with severe COVID-19 disease, including chronic lung disease, cardiovascular
disease, diabetes mellitus (
5
). COVID-NET does not collect data on nonhospitalized patients; thus, it was not possible
to compare the prevalence of underlying conditions in hospitalized versus nonhospitalized
patients. Many of the documented underlying conditions among hospitalized COVID-19
patients are highly prevalent in the United States. According to data from the National
Health and Nutrition Examination Survey, hypertension prevalence among U.S. adults
is 29% overall, ranging from 7.5%–63% across age groups (
7
), and age-adjusted obesity prevalence is 42% (range across age groups = 40%–43%)
(
8
). Among hospitalized COVID-19 patients, hypertension prevalence was 50% (range across
age groups = 18%–73%), and obesity prevalence was 48% (range across age groups = 41%–59%).
In addition, the prevalences of several underlying conditions identified through COVID-NET
were similar to those for hospitalized influenza patients identified through FluSurv-NET
during influenza seasons 2014–15 through 2018–19: 41%–51% of patients had cardiovascular
disease (excluding hypertension), 39%–45% had chronic metabolic disease, 33%–40% had
obesity, and 29%–31% had chronic lung disease (
6
). Data on hypertension are not collected by FluSurv-NET. Among women aged 15–49 years
hospitalized with COVID-19 and identified through COVID-NET, 9% were pregnant, which
is similar to an estimated 9.9% of the general population of women aged 15–44 years
who are pregnant at any given time based on 2010 data.
††
Similar to other reports from the United States (
9
) and China (
1
), these findings indicate that a high proportion of U.S. patients hospitalized with
COVID-19 are older and have underlying medical conditions.
The findings in this report are subject to at least three limitations. First, hospitalization
rates by age and COVID-NET site are preliminary and might change as additional cases
are identified from this surveillance period. Second, whereas minimum case data to
produce weekly age-stratified hospitalization rates are usually available within 7
days of case identification, availability of detailed clinical data are delayed because
of the need for medical chart abstractions. As of March 30, chart abstractions had
been conducted for approximately 200 COVID-19 patients; the frequency and distribution
of underlying conditions during this time might change as additional data become available.
Clinical course and outcomes will be presented once the number of cases with complete
medical chart abstractions are sufficient; many patients are still hospitalized at
the time of this report. Finally, testing for SARS-CoV-2 among patients identified
through COVID-NET is performed at the discretion of treating health care providers,
and testing practices and capabilities might vary widely across providers and facilities.
As a result, underascertainment of cases in COVID-NET is likely. Additional data on
testing practices related to SARS-CoV-2 will be collected in the future to account
for underascertainment using described methods (
10
).
Early data from COVID-NET suggest that COVID-19–associated hospitalizations in the
United States are highest among older adults, and nearly 90% of persons hospitalized
have one or more underlying medical conditions. These findings underscore the importance
of preventive measures (e.g., social distancing, respiratory hygiene, and wearing
face coverings in public settings where social distancing measures are difficult to
maintain) to protect older adults and persons with underlying medical conditions.
Ongoing monitoring of hospitalization rates, clinical characteristics, and outcomes
of hospitalized patients will be important to better understand the evolving epidemiology
of COVID-19 in the United States and the clinical spectrum of disease, and to help
guide planning and prioritization of health care system resources.
Summary
What is already known about this topic?
Population-based rates of laboratory-confirmed coronavirus disease 2019 (COVID-19)–associated
hospitalizations are lacking in the United States.
What is added by this report?
COVID-NET was implemented to produce robust, weekly, age-stratified COVID-19–associated
hospitalization rates. Hospitalization rates increase with age and are highest among
older adults; the majority of hospitalized patients have underlying conditions.
What are the implications for public health practice?
Strategies to prevent COVID-19, including social distancing, respiratory hygiene,
and face coverings in public settings where social distancing measures are difficult
to maintain, are particularly important to protect older adults and those with underlying
conditions. Ongoing monitoring of hospitalization rates is critical to understanding
the evolving epidemiology of COVID-19 in the United States and to guide planning and
prioritization of health care resources.