Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa

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Abstract

Background

Risk factors for COVID-19 death in sub-Saharan Africa and the effects of HIV and tuberculosis on COVID-19 outcomes are unknown.

Methods

We conducted a population cohort study using linked data from adults attending public sector health facilities in the Western Cape, South Africa. We used Cox-proportional hazards models adjusted for age, sex, location and comorbidities to examine the association between HIV, tuberculosis and COVID-19 death from 1 March-9 June 2020 among (i) public sector “active patients” (≥1 visit in the 3 years before March 2020), (ii) laboratory-diagnosed COVID-19 cases and (iii) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19 comparing HIV positive vs. negative adults using modelled population estimates.

Results

Among 3,460,932 patients (16% HIV positive), 22,308 were diagnosed with COVID-19, of whom 625 died. COVID-19 death was associated with male sex, increasing age, diabetes, hypertension and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR] 2.14; 95% confidence interval [CI] 1.70-2.70), with similar risks across strata of viral load and immunosuppression. Current and previous tuberculosis were associated with COVID-19 death (aHR [95%CI] 2.70 [1.81-4.04] and 1.51 [1.18-1.93] respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95%CI 1.96-2.86); population attributable fraction 8.5% (95%CI 6.1-11.1).

Conclusion

While our findings may over-estimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both HIV and current tuberculosis were independently associated with increased COVID-19 mortality. The associations between age, sex and other comorbidities and COVID-19 mortality were similar to other settings.

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Author and article information

Journal

Journal ID (nlm-ta): Clin Infect Dis

Journal ID (iso-abbrev): Clin. Infect. Dis

Journal ID (publisher-id): cid

Title: Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America

Publisher: Oxford University Press (US )

ISSN (Print): 1058-4838

ISSN (Electronic): 1537-6591

Publication date (Electronic): 29 August 2020

Electronic Location Identifier: ciaa1198

Affiliations

[1 ] Health Impact Assessment, Western Cape Government: Health

[2 ] Centre for Infectious Disease Epidemiology and Research , School of Public Health and Family Medicine, University of Cape Town

[3 ] School of Public Health and Family Medicine, University of Cape Town

[4 ] Division of Health Systems and Public Health , Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University

[5 ] Metro Health Services, Western Cape Government: Health

[6 ] Rural Health Services, Western Cape Government: Health

[7 ] Communicable Disease Sub-Directorate, Western Cape Government: Health

[8 ] National Institute for Communicable Diseases , National Health Laboratory Service, South Africa

[9 ] Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town

[10 ] Division of Computational Biology, University of Cape Town

[11 ] Health Programmes Directorate , Western Cape Government: Health

[12 ] Faculty of Health Sciences, North West University

[13 ] George Hospital, Western Cape Government: Health

[14 ] Groote Schuur Hospital, Western Cape Government: Health

[15 ] Department of Medicine, University of Cape Town

[16 ] Department of Surgery, University of Cape Town

[17 ] Department of Radiology, University of Cape Town

[18 ] Karl Bremer Hospital, Western Cape Government: Health

[19 ] Khayelitsha District Hospital, Western Cape Government: Health

[20 ] Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health

[21 ] Tygerberg Hospital, Western Cape Government: Health

[22 ] Department of Medicine, Stellenbosch University

[23 ] Department of Obstetrics and Gyneacology, Stellenbosch University

[24 ] Emergency Medical Services, Western Cape Government

[25 ] Western Cape Government : Health

[26 ] City Health , Community Services and Health, City of Cape Town

[27 ] South African Medical Research Council Burden of Disease Research Unit

[28 ] School of Public Health, University of the Western Cape

[29 ] School of Pathology , University of the Witwatersrand and School of Pathology , University of Cape Town

[30 ] National Health Laboratory Service and Division of Virology , School of Pathology , University of Cape Town

[31 ] Division of Emergency Medicine, University of Cape Town

[32 ] Division of Immunology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town

[33 ] University of Pretoria

[34 ] School of Public Health, University of Witwatersrand

[35 ] University of Witwatersrand, South African Medical Research Council Antibody Immunity Research Unit and the Centre for the AIDS Programme in South Africa (CAPRISA)

Author notes

Corresponding author: Mary-Ann Davies, Affiliation: Health Impact Assessment Directorate, Western Cape Government: Health and Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa. Email: mary-ann.davies@ 123456uct.ac.za , Telephone: +27 21 4066051, Address: University of Cape Town, Faculty of Health Sciences, Anzio Road, Observatory, 7925, CAPE TOWN, SOUTH AFRICA

Article

Publisher ID: ciaa1198

DOI: 10.1093/cid/ciaa1198

PMC ID: 7499501

PubMed ID: 32860699

SO-VID: bda3e378-1564-451d-8004-77ad832f52bd

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.