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      Risk factors for hospitalisation and death from COVID-19: a prospective cohort study in South Sudan and Eastern Democratic Republic of the Congo

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      Author(s): 1 , 2 , , 2 , 1 , 3 , 4 , 5 , The IMC-CDC COVID-19 Research Team, 5
      Other contributor(s): (Collab), (Collab), (Collab), (Collab), (Collab), (Collab)
      Publication date (Electronic):
      Journal: BMJ Open
      Publisher: BMJ Publishing Group
      Keywords: COVID-19, Epidemiology, Public health

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          Abstract

          Objectives

          Our study described demographic characteristics, exposures and symptoms, and comorbidities to evaluate risk factors of hospitalisation and mortality among cases in Juba, South Sudan (SSD) and North and South Kivu in eastern Democratic Republic of the Congo (DRC).

          Design

          Prospective observational cohort of COVID-19 cases.

          Methods

          Individuals presenting for care at one of five study facilities in SSD (n=1) or DRC (n=4) or referred from home-based care by mobile medical teams between December 2020 and June 2021 were eligible for enrolment. Demographic characteristics, COVID-19 exposures, symptoms at presentation, as well as acute and chronic comorbidities, were evaluated using a standard questionnaire at enrolment. Disease progression was characterised by location of care using mixed-effects regression models.

          Results

          751 individuals were eligible for enrolment. Among cases followed to discharge or death (n=519), 375 were enrolled outpatients (75.7%). A similar number of cases were enrolled in DRC (n=262) and SSD (n=257). Overall mortality was 4.8% (95% CI: 3.2% to 6.9%); there were no outpatient deaths. Patients presenting with any symptoms had higher odds of hospitalisation (adjusted OR (AOR) 2.78, 95% CI 1.47 to 5.27) and all deaths occurred among symptomatic individuals. Odds of both hospitalisation and mortality were greatest among cases with respiratory symptoms; presence of low oxygen levels on enrolment was strongly associated with both hospitalisation (AOR 7.77, 95% CI 4.22 to 14.29) and mortality (AOR 25.29, 95% CI 6.42 to 99.54). Presence of more than one chronic comorbidity was associated with 4.96 (95% CI 1.51 to 16.31) times greater odds of death; neither infectious comorbidities evaluated, nor malnutrition, were significantly associated with increased mortality.

          Conclusions

          Consistent with prior literature, older age, low oxygen level, other respiratory symptoms and chronic comorbidities were all risk factors for mortality. Patients presenting with these characteristics were more likely to be hospitalised, providing evidence of effective triage and referral.

          Trial registration number

          NCT04568499.

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          Most cited references24

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Fei Zhou, Ting Yu, Ronghui Du … (2020)
          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            Demographic risk factors for COVID-19 infection, severity, ICU admission and death: a meta-analysis of 59 studies

            Bart Pijls, Shahab Jolani, Anique E.N. Atherley … (2021)
            Objective We aimed to describe the associations of age and sex with the risk of COVID-19 in different severity stages ranging from infection to death. Design Systematic review and meta-analysis. Data sources PubMed and Embase through 4 May 2020. Study selection We considered cohort and case–control studies that evaluated differences in age and sex on the risk of COVID-19 infection, disease severity, intensive care unit (ICU) admission and death. Data extraction and synthesis We screened and included studies using standardised electronic data extraction forms and we pooled data from published studies and data acquired by contacting authors using random effects meta-analysis. We assessed the risk of bias using the Newcastle-Ottawa Scale. Results We screened 11.550 titles and included 59 studies comprising 36.470 patients in the analyses. The methodological quality of the included papers was high (8.2 out of 9). Men had a higher risk for infection with COVID-19 than women (relative risk (RR) 1.08, 95% CI 1.03 to 1.12). When infected, they also had a higher risk for severe COVID-19 disease (RR 1.18, 95% CI 1.10 to 1.27), a higher need for intensive care (RR 1.38, 95% CI 1.09 to 1.74) and a higher risk of death (RR 1.50, 95% CI 1.18 to 1.91). The analyses also showed that patients aged 70 years and above have a higher infection risk (RR 1.65, 95% CI 1.50 to 1.81), a higher risk for severe COVID-19 disease (RR 2.05, 95% CI 1.27 to 3.32), a higher need for intensive care (RR 2.70, 95% CI 1.59 to 4.60) and a higher risk of death once infected (RR 3.61, 95% CI 2.70 to 4.84) compared with patients younger than 70 years. Conclusions Meta-analyses on 59 studies comprising 36.470 patients showed that men and patients aged 70 and above have a higher risk for COVID-19 infection, severe disease, ICU admission and death. PROSPERO registration number CRD42020180085.
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              Association of Obesity with Disease Severity among Patients with COVID‐19

              Markos Kalligeros, Fadi Shehadeh, Evangelia Mylona … (2020)
              Abstract Objective To explore the potential association of obesity and other chronic diseases with severe outcomes, such as intensive care unit (ICU) admission and invasive mechanical ventilation (IMV), in patients hospitalized with COVID‐19. Methods Retrospective cohort of 103 patients hospitalized with COVID‐19. Demographic data, past medical history and hospital course were collected and analyzed. A multivariate logistic regression analysis was implemented to examine associations. Results From February 17th to April 5th, 103 consecutive patients were hospitalized with COVID‐19. Among them, 41 patients (39.8%) were admitted to the ICU and 29 (70.7%) required (IMV). The prevalence of obesity was 47.5% (49/103). In a multivariate analysis, severe obesity (BMI ≥35 kg/m2) was associated with ICU admission (aOR 5.39; 95% CI:1.13‐25.64). Moreover, patients who required IMV, were more likely to have had heart disease (aOR 3.41; 95% CI:1.05‐11.06), obesity (BMI=30‐34.9 kg/m2) (aOR 6.85; 95% CI: 1.05‐44.82) or severe obesity (BMI≥35 kg/m2) (aOR 9.99; 95% CI:1.39‐71.69). Conclusion In our analysis, severe obesity (BMI ≥35 kg/m2) was associated with ICU admission, while history of heart disease and obesity (BMI ≥30 kg/m2) were independently associated with the use of IMV. Increased vigilance and aggressive treatment of patients with obesity and COVID‐19 are warranted.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2022
                Publication date (Electronic): 18 May 2022
                Publication date PMC-release: 18 May 2022
                Volume: 12
                Issue: 5
                Electronic Location Identifier: e060639
                Affiliations
                [1 ]departmentDivision of Global Health Protection , Centers for Disease Control and Prevention , Atlanta, Georgia, USA
                [2 ]departmentInternational Health , Johns Hopkins University Bloomberg School of Public Health , Baltimore, Maryland, USA
                [3 ]International Medical Corps , Juba, South Sudan
                [4 ]International Medical Corps , Kinshasa, The Democratic Republic of the Congo
                [5 ]International Medical Corps , Santa Monica, California, USA
                Author notes
                [Correspondence to ] Eva Leidman; eleidman@ 123456cdc.gov
                Author information
                http://orcid.org/0000-0002-4191-5931
                Article
                Publisher ID: bmjopen-2021-060639
                DOI: 10.1136/bmjopen-2021-060639
                PMC ID: 9118359
                PubMed ID: 35584876
                SO-VID: c25889ab-17b1-4e38-b41c-33cd7db2d5a4
                Copyright © © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 05 January 2022
                Date accepted : 11 April 2022
                Categories
                Subject: Epidemiology
                Subject: 1506
                Subject: 2474
                Subject: 1692
                Series title: Original research
                Custom metadata
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                access-type free

                ScienceOpen disciplines: Medicine
                Keywords: covid-19,epidemiology,public health
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: covid-19, epidemiology, public health

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