Clinical Epidemiology of Hospitalized Patients With Coronavirus Disease 2019 (COVID-19) in Japan: Report of the COVID-19 Registry Japan

Association between mortality and age among mechanically ventilated COVID-19 patients: a Japanese nationwide COVID-19 database study

Background

Only a few studies have reported the association between age and mortality in COVID-19 patients who require invasive mechanical ventilation (IMV). We aimed to evaluate the effect of age on COVID-19-related mortality among patients undergoing IMV therapy.

Methods

This cohort study was conducted using the COVID-19 Registry Japan database, a nationwide multi-centre study of hospitalized patients with laboratory-confirmed COVID-19. Of all 33,808 cases registered between 1 January 2020 to 28 February 2021, we analysed 1555 patients who had undergone IMV. We evaluated mortality rates between age groups using multivariable regression analysis after adjusting for known potential components, such as within-hospital clustering, comorbidities, steroid use, medication for COVID-19, and vital signs on admission, using generalized estimation equation.

Results

By age group, the mortality rates in the IMV group were 8.6%, 20.7%, 34.9%, 49.7% and 83.3% for patients in their 50s, 60s, 70s, 80s, and 90s, respectively. Multivariable analysis showed that compared with those for patients aged < 60 years, the odds ratios (95% confidence interval) of death were 2.6 (1.6–4.1), 6.9 (4.2–11.3), 13.2 (7.2–24.1), 92.6 (16.7–515.0) for patients in their 60s, 70s, 80s, and 90s, respectively.

Conclusions

In this cohort study, age had a great effect on mortality in COVID-19 patients undergoing IMV, after adjusting for variables independently associated with mortality. This study suggested that age was associated with higher mortality and that preventing progression to severe COVID-19 in elderly patients may be a great public health issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00959-6.

The burden of isolation to the individual: a comparison between isolation for COVID-19 and for other influenza-like illnesses in Japan

At present, there is scarce evidence about the burden associated with the isolation of COVID-19 patients. We aimed to assess the differences between COVID-19 and other influenza-like illnesses (ILIs) in disease burden brought by isolation. We conducted an online survey of 302 respondents who had COVID-19 or other ILIs and compared the burden of isolation due to sickness with one-to-one propensity score matching. The primary outcomes are the duration and productivity losses associated with isolation, the secondary outcome is the health-related quality of life (HRQoL) valuation on the day of the survey. Acute symptoms of outpatient COVID-19 and other ILIs lasted 17 (interquartile range (IQR) 9-32) and 7 (IQR 4-10) days, respectively. The length of isolation due to COVID-19 was 18 (IQR 10-33) days and that due to other ILIs was 7 (IQR 4-11) days, respectively. The monetary productivity loss of isolation due to COVID-19 was 1424.3 (IQR 825.6-2545.5) USD and that due to other ILIs was 606.1 (IQR 297.0-1090.9) USD, respectively. HRQoL at the time of the survey was lower in the COVID-19 group than in the 'other ILIs' group (0.89 and 0.96, P = 0.001). COVID-19 infection imposes a substantial disease burden, even in patients with non-severe disease. This burden is larger for COVID-19 than other ILIs, mainly because the required isolation period is longer.

Rehabilitation in acute COVID-19 patients: A Japanese retrospective, observational, multi-institutional survey

OBJECTIVE

To investigate the changes in activities of daily living (ADLs) and the conditions of rehabilitation for acute COVID-19 patients in Japan.

DESIGN

Retrospective, observational survey.

SETTING

Four tertiary hospitals with intensive care units and one secondary hospital in Japan.

PATIENTS

COVID-19 patients (N=478) admitted to five hospitals INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES

Walking ability and swallowing status were assessed using the Functional Independence Measure (FIM) locomotion item and Food Intake Scale (FILS) at admission and discharge. The physiatrists of each hospital were also surveyed regarding the factors that influenced decisions to provide rehabilitation.

RESULTS

Excluding patients who died, the proportion of critical patients who could walk independently at discharge was 63%, and the proportion of those who were able to take three meals orally at discharge was 90%. Rehabilitation was provided to 13.4% of all patients, in particular to 58.3% of patients with critical symptoms.

CONCLUSIONS

After COVID-19 treatment, patients, especially those with critical symptoms, still have functional disabilities related to walking and swallowing. During the period studied, it is possible that sufficient rehabilitation could not be provided.

Status of online diet management program users in Japan during the 2020 Coronavirus disease 2019 pandemic

The spread of coronavirus disease 2019 (COVID-19) has led to drastic changes in people’s lifestyles, including teleworking and restrictions on socializing. In the context of observing social distancing for preventing infection, the need to maintain fitness and health has attracted particular attention. We aimed to determine the relationship between the increase in the number of active users of online diet management applications and COVID-19 infection rates in Japan. A total of 1.5 million rows of log data was analyzed. The active number of users of online diet management applications increased with increase in the number of COVID-19 infections. The active user number in Kanagawa Prefecture, where the first cases of COVID-19 were reported in Japan, was particularly high. Moreover, there was a significant increase in the user number in prefectures under a state of emergency when compared to that in prefectures not under a state of emergency. The social anxiety caused by COVID-19 is expected to increase the demand for online health management applications further. The use of such programs can aid in achieving social distancing while enabling users to maintain healthy lifestyles.

Modeling the onset of symptoms of COVID-19: Effects of SARS-CoV-2 variant

Identifying order of symptom onset of infectious diseases might aid in differentiating symptomatic infections earlier in a population thereby enabling non-pharmaceutical interventions and reducing disease spread. Previously, we developed a mathematical model predicting the order of symptoms based on data from the initial outbreak of SARS-CoV-2 in China using symptom occurrence at diagnosis and found that the order of COVID-19 symptoms differed from that of other infectious diseases including influenza. Whether this order of COVID-19 symptoms holds in the USA under changing conditions is unclear. Here, we use modeling to predict the order of symptoms using data from both the initial outbreaks in China and in the USA. Whereas patients in China were more likely to have fever before cough and then nausea/vomiting before diarrhea, patients in the USA were more likely to have cough before fever and then diarrhea before nausea/vomiting. Given that the D614G SARS-CoV-2 variant that rapidly spread from Europe to predominate in the USA during the first wave of the outbreak was not present in the initial China outbreak, we hypothesized that this mutation might affect symptom order. Supporting this notion, we found that as SARS-CoV-2 in Japan shifted from the original Wuhan reference strain to the D614G variant, symptom order shifted to the USA pattern. Google Trends analyses supported these findings, while weather, age, and comorbidities did not affect our model's predictions of symptom order. These findings indicate that symptom order can change with mutation in viral disease and raise the possibility that D614G variant is more transmissible because infected people are more likely to cough in public before being incapacitated with fever.

Genomic Epidemiology Reveals Multiple Introductions of Severe Acute Respiratory Syndrome Coronavirus 2 in Niigata City, Japan, Between February and May 2020

The coronavirus disease 2019 (COVID-19) has caused a serious disease burden and poses a tremendous public health challenge worldwide. Here, we report a comprehensive epidemiological and genomic analysis of SARS-CoV-2 from 63 patients in Niigata City, a medium-sized Japanese city, during the early phase of the pandemic, between February and May 2020. Among the 63 patients, 32 (51%) were female, with a mean (±standard deviation) age of 47.9 ± 22.3 years. Fever (65%, 41/63), malaise (51%, 32/63), and cough (35%, 22/63) were the most common clinical symptoms. The median C_t value after the onset of symptoms lowered within 9 days at 20.9 cycles (interquartile range, 17–26 cycles), but after 10 days, the median C_t value exceeded 30 cycles (p < 0.001). Of the 63 cases, 27 were distributed in the first epidemic wave and 33 in the second, and between the two waves, three cases from abroad were identified. The first wave was epidemiologically characterized by a single cluster related to indoor sports activity spread in closed settings, which included mixing indoors with families, relatives, and colleagues. The second wave showed more epidemiologically diversified events, with most index cases not related to each other. Almost all secondary cases were infected by droplets or aerosols from closed indoor settings, but at least two cases in the first wave were suspected to be contact infections. Results of the genomic analysis identified two possible clusters in Niigata City, the first of which was attributed to clade S (19B by Nexstrain clade) with a monophyletic group derived from the Wuhan prototype strain but that of the second wave was polyphyletic suggesting multiple introductions, and the clade was changed to GR (20B), which mainly spread in Europe in early 2020. These findings depict characteristics of SARS-CoV-2 transmission in the early stages in local community settings during February to May 2020 in Japan, and this integrated approach of epidemiological and genomic analysis may provide valuable information for public health policy decision-making for successful containment of chains of infection.

Indications for SARS-CoV-2 nucleic acid amplification test for areas with low endemicity

INTRODUCTION

The optimal indication for the nucleic acid amplification test (NAAT) in areas with low endemicity for coronavirus disease 2019 (COVID-19) is unclear. This study aimed to identify patients who should undergo the NAAT for COVID-19 diagnosis.

METHODS

We retrospectively analyzed the clinical data of patients with suspected COVID-19 who underwent NAAT between October 5, 2020, and May 31, 2021 in our institution.

RESULTS

A total of 1238 patients were enrolled and NAAT positive results were observed in 40 patients (3.2%). The NAAT positivity rate was 34.3% (23/67) in patients with a history of close contact and 1.5% (17/1171) in patients without a history of close contact. Olfactory/gustatory dysfunction and a history of stay in other prefectures were independent risk factors of COVID-19 in patients without a history of close contact. On the other hand, the NAAT positivity rate was only 0.7% (8/1073) in patients without olfactory/gustatory dysfunction and a history of stay in other prefectures. Among them, the group without respiratory symptoms/sign had only one NAAT-positive case (0.1%: 1/1073).

CONCLUSIONS

This study revealed that a history of close contact, olfactory/gustatory dysfunction, and a history of stay in other prefectures are key eligibility criteria for NAAT in areas with relatively few patients with COVID-19. On the other hand, NAAT may not be necessary in cases without all of these factors and respiratory symptoms/sign.

Association between physical activity status and severity of COVID-19 in older adults

The risk factors specific to the elderly population for severe coronavirus disease 2019 (COVID-19) caused by the Omicron variant of concern (VOC) are not yet clear. We performed an exploratory analysis using logistic regression to identify risk factors for severe COVID-19 illness among 4,868 older adults with a positive severe acute respiratory coronavirus 2 (SARS-CoV-2) test result who were admitted to a healthcare facility between 1 January 2022 and 16 May 2022. We then conducted one-to-one propensity score (PS) matching for three factors - dementia, admission from a long-term care facility and poor physical activity status - and used Fisher's exact test to compare the proportion of severe COVID-19 cases in the matched data. We also estimated the average treatment effect on treated (ATT) in each PS matching analysis. Of the 4,868 cases analysed, 1,380 were severe. Logistic regression analysis showed that age, male sex, cardiovascular disease, cerebrovascular disease, chronic lung disease, renal failure and/or dialysis, physician-diagnosed obesity, admission from a long-term care facility and poor physical activity status were risk factors for severe disease. Vaccination and dementia were identified as factors associated with non-severe illness. The ATT for dementia, admission from a long-term care facility and poor physical activity status was -0.04 (95% confidence interval -0.07 to -0.01), 0.09 (0.06 to 0.12) and 0.17 (0.14 to 0.19), respectively. Our results suggest that poor physical activity status and living in a long-term care facility have a substantial association with the risk of severe COVID-19 caused by the Omicron VOC, while dementia may be associated with non-severe illness.

Longer Prehospitalization and Preintubation Periods in Intubated Non-survivors and ECMO Patients With COVID-19: A Systematic Review and Meta-Analysis

Purpose: There is no clear consensus on the clinical course of critical COVID-19 patients. We examined the clinical course among intubated survivors, non-survivors, and extracorporeal membrane oxygenation (ECMO) patients to reveal the standard clinical course and the difference among critical COVID-19 patients.

Methods: In this systematic review and meta-analysis, we searched PubMed, Web of Science, and Scopus for original studies published until December 11, 2020, including case accumulation and clinical course reporting. Pregnant patients and children were excluded. We followed PRISMA guidelines and registered them with PROSPERO (CRD42021235534).

Results: Of the 11,716 studies identified, 94 met the selection criteria, and 2,549 cases were included in this meta-analysis. The times from intubation to extubation and death were 12.07 days (95% confidence interval 9.80–14.33 days) and 10.14 days (8.18–12.10 days), respectively, and the ECMO duration was 14.72 days (10.57–18.87 days). The time from symptom onset to hospitalization (prehospitalization period) of intubated survivors, non-survivors, and ECMO patients was 6.15 (4.61–7.69 days), 6.45 (4.55–8.34 days), and 7.15 days (6.48–7.81 days), and that from symptom onset to intubation (preintubation period) was 8.58 (7.36–9.80 days), 9.14 (7.26–11.01 days), and 10.54 days (9.18–11.90 days), respectively. Sensitivity analysis showed that the time from intubation to extubation and death was longer in the US and Europe than in East Asia.

Conclusion: For COVID-19, we hypothesize that prehospitalization and preintubation periods are longer in intubated non-survivors and ECMO patients than in intubated survivors. These periods may serve as a predictor of disease severity or death and support therapeutic strategy determination.

Clinical characteristics and prognosis of immunosuppressed inpatients with COVID-19 in Japan

Introduction

We aimed to analyze the clinical characteristics and outcomes of immunosuppressed inpatients with coronavirus disease 2019 (COVID-19).

Methods

In this observational study, we utilized a large nationwide registry of hospitalized patients with COVID-19 in Japan. Patients’ baseline characteristics and outcomes were compared according to the immunosuppressed states of the patients. The impact of different therapeutic agents on the clinical courses of the patients was evaluated.

Results

Data of 14,760 patients were included, and 887 (5.9%) were immunosuppressed. The immunosuppressed state of the patient resulted from solid tumor (43.3%, n = 384), chemotherapy within 3 months (15.6%, n = 138), collagen disease (16.9%, n = 150), use of immunosuppressive agents (16.0%, n = 142), and metastatic solid tumor (13.5%, n = 120). Immunosuppressed patients were older and had a higher severity of illness at admission and during hospitalization than non-immunosuppressed patients. The mortality rates for major diseases causing immunosuppression were as follows: solid tumor, 12.5% (48/384; P < 0.001; relative risk [RR], 3.41); metastatic solid tumor, 31.7% (38/120; P < 0.001; RR, 8.43); leukemia, 23.1% (9/39; P < 0.001; RR, 5.87); lymphoma, 33.3% (20/60; P < 0.001; RR, 8.63); and collagen disease, 15.3% (23/150; P < 0.001; RR 3.97). Underlying diseases with high mortality rates were not necessarily associated with high rates of invasive supportive care.

Conclusions

The prognosis of immunosuppressed COVID-19 inpatients varied according to the different immunosuppressed states. Multiple factors, including the severity of the underlying diseases, might have affected their invasive supportive care indications.

Multiple Cardiovascular Diseases or Risk Factors Increase the Severity of Coronavirus Disease 2019

BACKGROUND

This study aimed to determine whether disease severity varied according to whether coronavirus disease 2019 (COVID-19) patients had multiple or single cardiovascular diseases and risk factors (CVDRFs).Methods and Results:COVID-19 patients with single (n=281) or multiple (n=412) CVDRFs were included retrospectively. Multivariable logistic regression showed no significant difference in the risk of in-hospital death between groups, but patients with multiple CVDRFs had a significantly higher risk of acute respiratory distress syndrome (odds ratio: 1.75, 95% confidence interval: 1.09-2.81).

CONCLUSIONS

COVID-19 patients with multiple CVDRFs have a higher risk of complications than those with a single CDVRF.

The evaluation of factors affecting antibody response after administration of the BNT162b2 vaccine: a prospective study in Japan

The aim of this study was to evaluate the antibody reaction after administration of the BNT162b2 vaccine, and to reveal the factors that affect antibody production. This prospective study was carried out in the Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital, in Tokyo, Japan, from April 15, 2021 to June 09, 2021. All our hospital's workers who were administered the BNT162b2 vaccine as part of a routine program were included in this study. We calculated the anti-SARS-CoV-2 spike-specific antibody titter (1) before vaccination, (2) 7 to 20 days after the first vaccination, and (3) A total of 7 to 20 days after the second vaccination. The low-antibody titer group (LABG) was defined as the group having less than 25 percentiles of antibody titer. Univariate and Multivariate logistic regression analysis were performed to ascertain the effects of factors on the likelihood of LABG. A total of 374 participants were eventually included in our study, and they were divided into 94 LABG and 280 non-LABG. All samples showed significant antibody elevation in the second antibody test, with a mean value of 3,476 U/mL. When comparing the LABG and non-LABG groups, the median age, blood sugar, and HbA1c were significantly higher in the LABG group. The rates of participants with low BMI (<18.5) and high BMI (>30) were significantly higher in the LABG group. The proportion of chronic lung disease, hypertension, diabetes, dyslipidemia, autoimmune disease, and cancer were significantly higher in the LABG group. Although there was no significant difference confirmed with respect to the exercise hours per day, the proportion of participants that did not perform outdoor exercises was significantly higher in the LABG group. The time interval between the second vaccination and the second antibody test, and between the first and the second vaccination was significantly longer in the non-LABG group. In the multivariate logistic regression analysis, older than 60 years, the past history of hypertension, HbA1c higher than 6.5%, and lack of outdoor exercises were significant suppressors of antibody responses, whereas the length of days from the first to the second vaccination longer than 25 days promoted a significant antibody response. Again, our single-center study demonstrates that older than 60 years, hypertension, HbA1c higher than 6.5%, and lack of outdoor exercises were significant suppressors of antibody responses, whereas the length of days from the first to the second vaccination longer than 25 days promoted a significant antibody response. Evidence from multi-center studies is needed to develop further vaccination strategies.

Lung squamous cell carcinoma with hemoptysis after vaccination with tozinameran (BNT162b2, Pfizer-BioNTech)

A 66-year-old man with squamous cell carcinoma had been receiving chemoradiation therapy after stereotactic radiotherapy for brain metastases. Atezolizumab was initiated as second-line therapy, after which the patient became progression- and recurrence-free. Four days after his second dose of tozinameran (BNT162b2, Pfizer-BioNTech), the patient developed persistent hemoptysis. The patient had no thrombocytopenia or coagulation abnormalities. Bronchoscopy revealed active bleeding from the left lingual tracheal branch. The patient was intubated and admitted to the intensive care unit because of increased bleeding. Subsequently, left bronchial artery embolization was performed using a Serescue. Hemostasis was achieved after the procedure, and the patient was discharged 7 days after the onset of hemoptysis. Vaccination against coronavirus disease has been reported to be associated with thrombosis and cerebral hemorrhage, and the hemoptysis in this case was suspected to be induced by vaccination. In summary, the benefits of vaccination exceeded the risks of adverse events in a patient with cancer. However, in conditions such as after chemoradiation, especially in patients with radiation pneumonitis wherein the vasculature is vulnerable, patients should be carefully monitored for hemorrhagic events after vaccination.

Impact of body mass index on the outcome of Japanese patients with cardiovascular diseases and/or risk factors hospitalized with COVID-19 infection

BACKGROUND

Obesity is reported to be a predictor of adverse clinical events in coronavirus disease 2019 (COVID-19) in Western countries. However, there are limited data reported regarding the prognostic impact of obesity in Asian patients. We investigated the relationship between body mass index (BMI) and in-hospital outcomes in 580 Japanese patients with cardiovascular disease and/or risk factors and who were admitted for COVID-19 infection using data from 49 hospitals in Japan.

METHODS

We analyzed data from the Clinical Outcomes of COVID-19 Infection in Hospitalized Patients with Cardiovascular Disease and/or Risk Factors (CLAVIS-COVID) registry. BMI was classified into four groups accordance with the definition of the Japan Society for the Study of Obesity, as follows: underweight, <18.5 kg/m²; normal range, 18.5 to <25 kg/m²; pre-obese, 25 to 30 kg/m²; and obese, ≥30 kg/m².

RESULTS

In-hospital death occurred in 15.0% (n=87) of the patients and intubation was performed for 139 (24.0%) patients. In a multivariate analysis, we found a significant association between higher BMI and in-hospital mortality [underweight: hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.23-0.97; p=0.041; pre-obese: HR 1.46, 95%CI 0.84-2.55; p=0.18; and obese: HR 3.28, 95%CI 1.34-8.02; p=0.009 vs. normal range]. In contrast, the association between BMI and the intubation rate was not statistically significant.

CONCLUSIONS

Obesity was associated with a stepwise increase in the risk of in-hospital mortality in Japanese patients with COVID-19 infection. The threshold BMI for the increased risk of a worse outcome was 30, which was much lower in comparison to Western countries.

Cardiovascular implications of the COVID-19 pandemic

The COVID-19 pandemic has rapidly emerged as one of the biggest public health concerns of the 21st century. Although it was initially reported as a cluster of pneumonia cases, it quickly became apparent that COVID-19 is not merely a respiratory tract infection. Its clinical course is often complicated by cardiovascular manifestations including venous and arterial thrombosis, electrical disturbances, and myocardial damage. In addition, the cardiovascular system is involved not only during infection but also preceding the contraction of the virus; having cardiovascular comorbidities indicates significant vulnerability to the pathogen. As longer-term data continue to accumulate, we now have concerns over its lasting cardiovascular effects after recovery. Moreover, there have been substantial collateral effects on the epidemiology of cardiovascular diseases. Reports of adverse cardiovascular events from vaccination have emerged as new hurdles to our efforts to bring an end to the pandemic. As such, the association between COVID-19 and the cardiovascular system and cardiovascular practice in general is expansive. In this review, we provide an overview of the knowledge and considerations in this field, based on the evidence available at the time of this writing.

Evaluation of the efficacy of anticoagulation therapy in reducing mortality in a nationwide cohort of hospitalized patients with coronavirus disease in Japan

Objectives

To determine whether anticoagulation therapy improves outcomes in patients with coronavirus disease 2019 (COVID-19) in Japan given their lower risk of thrombosis compared with Western cohorts.

Methods

The efficacy of anticoagulation therapy in hospitalized patients with COVID-19 was evaluated using a nationwide registry: the COVID-19 Registry Japan. The inverse probability of weight treatment method was used to adjust for baseline confounders in the anticoagulation and non-anticoagulation groups.

Results

Of the 1748 patients included, anticoagulants were used in 367 patients (treatment group). The patients in the anticoagulant group were older, predominantly male, and often presented with obesity, hyperlipidaemia, hypertension, diabetes and elevated D-dimer levels. Twenty-nine-day mortality was 7.6% in the whole cohort (treatment group, 11.2%; no treatment group, 6.6%), 6% in patients who were not treated with steroids (treatment group, 12.3%; no treatment group, 5.2%), and 11.2% in patients treated with steroids (treatment group, 10.5%; no treatment group, 11.8%). Mortality in the whole cohort was similar between the treatment and no treatment groups (P=0.99), and an insignificant decreasing trend in mortality was observed in patients treated with steroids (P=0.075).

Conclusions

Anticoagulants may be beneficial in Asians, in whom comorbidities and risk of thrombosis may differ from other ethnic groups.

Clinical Characteristics of Hospitalized COVID-19 in Children: Report From the COVID-19 Registry in Japan

A total of 1038 pediatric patients with COVID-19 were identified. Among these, 308 (30%) had asymptomatic COVID-19. The overall outcome was good, and no patients died. A significant rate of patients aged <24 months and ≥13 years were found in the symptomatic group.

Evaluation of Biomarkers of Severity in Patients with COVID-19 Infection

OBJECT

Although many Japanese patients infected with coronavirus disease 2019 (COVID-19) only experience mild symptoms, in some cases a patient's condition deteriorates, resulting in a poor outcome. This study examines the behavior of biomarkers in patients with mild to severe COVID-19.

METHODS

The disease severity of 152 COVID-19 patients was classified into mild, moderate I, moderate II, and severe, and the behavior of laboratory biomarkers was examined across these four disease stages.

RESULTS

The median age and male/female ratio increased with severity. The mortality rate was 12.5% in both moderate II and severe stages. Underlying diseases, which were not observed in 45% of mild stage patients, increased with severity. An ROC analysis showed that C-reactive protein (CRP), ferritin, procalcitonin (PCT), hemoglobin (Hb) A1c, albumin, and lactate dehydrogenase (LDH) levels were significantly useful for the differential diagnosis of mild/moderate I stage and moderate II/severe stage. In the severe stage, Hb levels, coagulation time, total protein, and albumin were significantly different on the day of worsening from those observed on the day of admission. The frequency of hemostatic biomarker abnormalities was high in the severe disease stage.

CONCLUSION

The evaluation of severity is valuable, as the mortality rate was high in the moderate II and severe stages. The levels of CRP, ferritin, PCT, albumin, and LDH were useful markers of severity, and hemostatic abnormalities were frequently observed in patients in the severe disease stage.

A single-center comparative analysis of outpatients with and without COVID-19 in Sapporo, Japan

This study aimed to investigate the demographic, clinical, and epidemiological statistics of Japanese patients attending a designated outpatient clinic for COVID‐19 in Sapporo, Japan, and contrast the clinical and epidemiological features between those with and without mild COVID‐19. A total of 27 (8.6%) of 315 patients were diagnosed with COVID‐19. They had higher proportions of myalgia, direct contact with a confirmed COVID‐19 patient, and attendance of social gatherings in close confines. We believe that our study makes a significant contribution to the literature because it provides a clinical picture of mild COVID‐19 in the Japanese population, which has not been studied extensively. It can also assist in optimizing the local preventive measures to reduce the transmission of COVID‐19.

The profile of patients hospitalized with COVID-19 under the Quarantine Act in a designated hospital near an international airport in Japan

The Japanese Government has implemented quarantine measures in response to the COVID-19 pandemic. Individuals testing positive at the airport's quarantine office were lodged either in a designated hotel or hospital under the Quarantine Act. The aim of this study is to describe the management of patients with COVID-19 admitted under the Quarantine Act and to evaluate its impact on medical resources. Data were retrospectively collected, including demographics, comorbidities, status at admission, clinical condition, treatment, outcomes, status at discharge, duration of hospitalization, and the cost of hospitalization for all patients hospitalized with COVID-19 at this facility under the Quarantine Act between January 2020 and April 2021. A total of 48 patients (39 males, 9 females; median age: 38.5 years) with COVID-19, half (52.1%) of which were Japanese, were hospitalized under the Quarantine Act. The majority (87.5%) of the patients lived or planned to stay outside of Chiba Prefecture. The most frequent time of admission was 9 PM-1 AM. Hypoxia on admission was observed in 10 (20.8%) patients and oxygen therapy was provided to 8 (16.7%). One patient died due to respiratory failure. The median duration of hospitalization was 11 days. The total cost of hospitalization was 82,705,289 yen (approximately $760,000), which was covered by public funds. Patients hospitalized with COVID-19 under the Quarantine Act were younger and less severely ill than inpatients with COVID-19 from among the general population in Japan (according to a COVID-19 registry), but consumed a significant amount of medical resources at this hospital. An efficient system to manage patients with COVID-19 in designated hotels should be created and indications for hospitalization should be determined.

Risk factors for severity on admission and the disease progression during hospitalisation in a large cohort of patients with COVID-19 in Japan

OBJECTIVES

To investigate the risk factors contributing to severity on admission. Additionally, risk factors of worst severity and fatality were studied. Moreover, factors were compared based on three points: early severity, worst severity and fatality.

DESIGN

An observational cohort study using data entered in a Japan nationwide COVID-19 inpatient registry, COVIREGI-JP.

SETTING

As of 28 September 2020, 10480 cases from 802 facilities have been registered. Participating facilities cover a wide range of hospitals where patients with COVID-19 are admitted in Japan.

PARTICIPANTS

Participants who had a positive test result on any applicable SARS-CoV-2 diagnostic tests were admitted to participating healthcare facilities. A total of 3829 cases were identified from 16 January to 31 May 2020, of which 3376 cases were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was severe or nonsevere on admission, determined by the requirement of mechanical ventilation or oxygen therapy, SpO2 or respiratory rate. Secondary outcome was the worst severity during hospitalisation, judged by the requirement of oxygen and/orinvasive mechanical ventilation/extracorporeal membrane oxygenation.

RESULTS

Risk factors for severity on admission were older age, men, cardiovascular disease, chronic respiratory disease, diabetes, obesity and hypertension. Cerebrovascular disease, liver disease, renal disease or dialysis, solid tumour and hyperlipidaemia did not influence severity on admission; however, it influenced worst severity. Fatality rates for obesity, hypertension and hyperlipidaemia were relatively lower.

CONCLUSIONS

This study segregated the comorbidities influencing severity and death. It is possible that risk factors for severity on admission, worst severity and fatality are not consistent and may be propelled by different factors. Specifically, while hypertension, hyperlipidaemia and obesity had major effect on worst severity, their impact was mild on fatality in the Japanese population. Some studies contradict our results; therefore, detailed analyses, considering in-hospital treatments, are needed for validation.

TRIAL REGISTRATION NUMBER

UMIN000039873. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000045453.

Usefulness of Respiratory Mechanics and Laboratory Parameter Trends as Markers of Early Treatment Success in Mechanically Ventilated Severe Coronavirus Disease: A Single-Center Pilot Study

Whether a patient with severe coronavirus disease (COVID-19) will be successfully liberated from mechanical ventilation (MV) early is important in the COVID-19 pandemic. This study aimed to characterize the time course of parameters and outcomes of severe COVID-19 in relation to the timing of liberation from MV. This retrospective, single-center, observational study was performed using data from mechanically ventilated COVID-19 patients admitted to the ICU between 1 March 2020 and 15 December 2020. Early liberation from ventilation (EL group) was defined as successful extubation within 10 days of MV. The trends of respiratory mechanics and laboratory data were visualized and compared between the EL and prolonged MV (PMV) groups using smoothing spline and linear mixed effect models. Of 52 admitted patients, 31 mechanically ventilated COVID-19 patients were included (EL group, 20 (69%); PMV group, 11 (31%)). The patients’ median age was 71 years. While in-hospital mortality was low (6%), activities of daily living (ADL) at the time of hospital discharge were significantly impaired in the PMV group compared to the EL group (mean Barthel index (range): 30 (7.5–95) versus 2.5 (0–22.5), p = 0.048). The trends in respiratory compliance were different between patients in the EL and PMV groups. An increasing trend in the ventilatory ratio during MV until approximately 2 weeks was observed in both groups. The interaction between daily change and earlier liberation was significant in the trajectory of the thrombin–antithrombin complex, antithrombin 3, fibrinogen, C-reactive protein, lymphocyte, and positive end-expiratory pressure (PEEP) values. The indicator of physiological dead space increases during MV. The trajectory of markers of the hypercoagulation status, inflammation, and PEEP were significantly different depending on the timing of liberation from MV. These findings may provide insight into the pathophysiology of COVID-19 during treatment in the critical care setting.

Feasibility of sit training for patients with severe COVID-19 pneumonia during deep sedation: A case report

RATIONALE

There have been a few reports on the early rehabilitation of patients with coronavirus disease (COVID-19), and none on the effectiveness and adverse events of early mobilization for mechanical ventilation patients (other than COVID-19) during deep sedation. This report indicates that sitting without adverse events is possible in patients with severe COVID-19 pneumonia during deep sedation with muscle relaxation.

PATIENT CONCERNS

A 65-year-old man with a history of diabetes mellitus, lacunar infarction, and Parkinson's disease was admitted to a local hospital for pneumonia due to COVID-19. After admission, the patient was managed on a ventilator under deep sedation with muscle relaxants and sedatives. Twelve days after admission, the patient was transferred to our hospital due to his worsening respiratory status.

DIAGNOSIS

Pneumonia due to COVID-19 was diagnosed using a polymerase chain reaction-dependent method.

INTERVENTIONS

The day following transfer, a physical therapist started passive range of motion training and sitting.

OUTCOMES

The period spanning his initial rehabilitation to muscle relaxant medication interruption was 9 days, and he underwent 7 rehabilitation sessions. The patient was unable to sit during only one of the 7 sessions due to pre-rehabilitation hypoxemia. In 5 of the 6 sitting sessions, PaO2/FiO2 transiently decreased but recovered by the time of subsequent blood sampling. The patient's PaCO2 decreased during all sessions. His blood pressure did not drastically decrease in any sitting session, except the first. Sputum excretion via sputum suction increased during sitting, and peak inspiratory pressure did not change.

LESSONS

The patient eventually died of pneumonia due to COVID-19. However, sitting during deep sedation with muscle relaxants did not cause any serious adverse events nor did it appear to cause obvious negative respiratory effects.

Characteristics and Survival of Intensive Care Unit Patients with Coronavirus Disease in Osaka, Japan: A Retrospective Observational Study

The epidemiological and clinical characteristics, treatments, and outcomes of patients with coronavirus disease 2019 (COVID-19) who are admitted to the intensive care unit (ICU) have not been adequately evaluated in Japan. We analyzed the registry data of 205 patients with COVID-19 admitted to the ICU between February and November 2020, in Osaka Prefecture, Japan. A Cox proportional hazards model was used to assess the association between epidemiological factors and mortality among ICU patients. Of the 205 ICU patients, 161 (78.5%) were men and 149 (72.7%) were older than 60 years. A total of 117 patients (57.1%) had comorbidities. The most common symptoms at diagnosis were mild (n = 131, 63.9%). A total of 187 patients (91.2%) received mechanical ventilation, and 32 patients (15.6%) required extracorporeal membrane oxygenation. Patients were followed up for a median of 25 days after ICU admission. A total of 147 patients (71.7%) were alive at discharge, and 58 patients (28.3%) died. The hazard ratio for mortality among patients aged >80 years was 6.02 (95% confidence interval: 2.10−17.25) in the multivariable model, which was higher than that among those aged ≤59 years. These results are useful for recognizing the clinical course of this infection in ICU patients.

Clinical characteristics and outcomes of patients hospitalized with COVID-19 in Brazil: Results from the Brazilian COVID-19 registry

OBJECTIVES

To describe the clinical characteristics, laboratory results, imaging findings, and in-hospital outcomes of COVID-19 patients admitted to Brazilian hospitals.

METHODS

A cohort study of laboratory-confirmed COVID-19 patients who were hospitalized from March 2020 to September 2020 in 25 hospitals. Data were collected from medical records using Research Electronic Data Capture (REDCap) tools. A multivariate Poisson regression model was used to assess the risk factors for in-hospital mortality.

RESULTS

For a total of 2,054 patients (52.6% male; median age of 58 years), the in-hospital mortality was 22.0%; this rose to 47.6% for those treated in the intensive care unit (ICU). Hypertension (52.9%), diabetes (29.2%), and obesity (17.2%) were the most prevalent comorbidities. Overall, 32.5% required invasive mechanical ventilation, and 12.1% required kidney replacement therapy. Septic shock was observed in 15.0%, nosocomial infection in 13.1%, thromboembolism in 4.1%, and acute heart failure in 3.6%. Age >= 65 years, chronic kidney disease, hypertension, C-reactive protein ≥ 100mg/dL, platelet count < 100×109/L, oxygen saturation < 90%, the need for supplemental oxygen, and invasive mechanical ventilation at admission were independently associated with a higher risk of in-hospital mortality. The overall use of antimicrobials was 87.9%.

CONCLUSIONS

This study reveals the characteristics and in-hospital outcomes of hospitalized patients with confirmed COVID-19 in Brazil. Certain easily assessed parameters at hospital admission were independently associated with a higher risk of death. The high frequency of antibiotic use points to an over-use of antimicrobials in COVID-19 patients.

Characteristics, outcomes and global trends of respiratory support in patients hospitalized with COVID-19 pneumonia: a scoping review

INTRODUCTION

To date, a shared international consensus on treatment of Coronavirus Disease 2019 (COVID-19) with invasive or non-invasive respiratory support is lacking. Patients' management and outcomes, especially in severe and critical cases, can vary depending on regional standard operating procedures and local guidance.

EVIDENCE ACQUISITION

Rapid review methodology was applied to include all the studies published on PubMed and Embase between December 15th 2019 and February 28th 2021, reporting in-hospital and respiratory support-related mortality in adult patients hospitalized with COVID-19 that underwent either continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV). Only English language studies with ≥100 patients and reporting data on respiratory failure were included. Data on comorbidities, ventilatory parameters and hospital-related complications were registered.

EVIDENCE SYNTHESIS

Fifty-two studies (287359 patients - 57.5% males, mean age 64 years (range 24-98)) from 17 different countries were included in the final analysis. 33.3% of patients were hospitalized in intensive care units. 44.2% had hypertension, 26.1% had diabetes, and 7.1% a chronic respiratory disease. 55% of patients underwent respiratory support (36% IMV, 62% NIV and 2% CPAP). Without considering a study with the highest number of patients treated with NIV (n=96729), prevalence of NIV and CPAP use was 12.5% and 13.5% respectively. Globally, invasive and non-invasive approaches were heterogeneously applied. In-hospital mortality was 33.7%, and IMV-related mortality was 72.6% (range: 4.3%-99%). Specific mortality in patients treated with CPAP or NIV was available for 53% of studies, and was 29% (range: 7.2%-100%). The median length of hospital stay was 13 days (range: 6-63). The most frequent hospital-related complication was acute kidney injury being reported in up to 55.7% of enrolled patients.

CONCLUSIONS

Global employment of respiratory supports and related outcomes are very heterogeneous. The most frequent respiratory support in patients with COVID-19 pneumonia is IMV, while NIV and CPAP are less frequently and equally applied, the latter especially in Europe, while data on NIV/CPAP-related mortality is often under-reported. Integrated and comprehensive reporting is desirable and needed to construct evidence-based recommendations.

Sustained Neutralizing Antibodies 6 Months Following Infection in 376 Japanese COVID-19 Survivors

Objective: There is scarce evidence regarding the long-term persistence of neutralizing antibodies among coronavirus disease 2019 (COVID-19) survivors. This study determined neutralizing antibody titers (NT50) and antibodies against spike protein (SP) or nucleocapsid protein (NP) antigens approximately 6 months after the diagnosis of COVID-19. Methods: COVID-19 survivors in Japan were recruited. Serum samples and data related to patients' characteristics and COVID-19 history were collected. NT50 and titers of antibodies against NP and SP antigens were measured at 20-32 weeks after the first positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results. Factors associated with NT50 were identified using the multivariable linear regression and the correlations among NT50 and titers of immunoglobulin G (IgG) and total immunoglobulins (Igs) against NP and SP were assessed by Spearman's correlation. Results: Among 376 participants (median [range] days after testing positive for SARS-CoV-2, 180 (147-224); median [range] years of age, 50 (20-78); 188 [50%] male), most tested positive for NT50 (n = 367, 98%), SP-IgG (n = 344, 91%), SP-total Ig (n = 369, 98%), NP-IgG (n = 314, 84%), and NP-total Ig (n = 365, 97%). Regression analysis indicated that higher BMI, fever, and the requirement of mechanical ventilation or extracorporeal membrane oxygenation were significantly associated with higher NT50. Anti-SP antibodies correlated moderately with NT50 (Spearman's correlation: 0.63 for SP IgG; 0.57 for SP-total Ig), while the correlation was weak for anti-NP antibodies (0.37 for NP IgG; 0.32 for NP-total Ig). Conclusions: Most COVID-19 survivors had sustained neutralizing antibodies and tested positive for SP-total Ig and NP-total Ig approximately 6 months after infection.

Japanese WHO Collaborating Centres (WHO CCs) fight against COVID-19

WHO Regional Office for the Western Pacific (WPRO) organized an online meeting connecting WHO Collaborating Centres (WHO CCs) in the region on 25 August 2020, to share experiences and promote networking on COVID-19 response. The meeting shared regional update on situation and responses, and COVID-19 related experiences of selected WHO CCs, followed by discussions on opportunities for enhancing collaboration between WPRO and WHO CCs. Priorities of WPROs support to countries included a health systems approach rather than single intervention. On behalf of WHO CCs in Japan, the National Center for Global Health and Medicine (NCGM) delivered a presentation on the results of a survey about COVID-19 related activities of these WHO CCs. These activities were categorized into collaboration with WHO, research and development, public health responses, and clinical services. Collaboration with WHO included sending consultants through the scheme of GOARN, strengthening of COVID-19 testing, and contribution to development of WPRO guidelines. Research and development involved establishment of a nationwide registry of COVID-19 clinical data. Following the meeting, NCGM further enhanced its activities as WHO CC. Since WHO CCs in the country have a wide range of expertise that could contribute to health system strengthening, it is worthwhile for the WHO CCs to consider amending existing work plans for supporting countries in the region to incorporate a health systems approach as part of COVID-19 response strategies.

Clinical and Biomarker Profiles and Prognosis of Elderly Patients With Coronavirus Disease 2019 (COVID-19) With Cardiovascular Diseases and/or Risk Factors

BACKGROUND

This study investigated the effects of age on the outcomes of coronavirus disease 2019 (COVID-19) and on cardiac biomarker profiles, especially in patients with cardiovascular diseases and/or risk factors (CVDRF).Methods and Results:A nationwide multicenter retrospective study included 1,518 patients with COVID-19. Of these patients, 693 with underlying CVDRF were analyzed; patients were divided into age groups (<55, 55-64, 65-79, and ≥80 years) and in-hospital mortality and age-specific clinical and cardiac biomarker profiles on admission evaluated. Overall, the mean age of patients was 68 years, 449 (64.8%) were male, and 693 (45.7%) had underlying CVDRF. Elderly (≥80 years) patients had a significantly higher risk of in-hospital mortality regardless of concomitant CVDRF than younger patients (P<0.001). Typical characteristics related to COVID-19, including symptoms and abnormal findings on baseline chest X-ray and computed tomography scans, were significantly less prevalent in the elderly group than in the younger groups. However, a significantly (P<0.001) higher proportion of elderly patients were positive for cardiac troponin (cTn), and B-type natriuretic peptide (BNP) and N-terminal pro BNP (NT-proBNP) levels on admission were significantly higher among elderly than younger patients (P<0.001 and P=0.001, respectively).

CONCLUSIONS

Elderly patients with COVID-19 had a higher risk of mortality during the hospital course, regardless of their history of CVDRF, were more likely to be cTn positive, and had significantly higher BNP/NT-proBNP levels than younger patients.

Coronavirus Disease 2019 and Nasal Conditions: A Review of Current Evidence

The nasal epithelium expressing enriched angiotensin-converting enzyme II (ACE2), the key cell entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), could serve as the first barrier to protect the airway from viral infection. Recent studies have demonstrated that higher viral loads were detected in the nasal cavity than the pharynx in coronavirus disease 2019 (COVID-19) patients, and otolaryngologists should carefully consider infection prevention in clinical practice for the treatment of nasal conditions. Moreover, several studies have indicated that anosmia is one of the clinical characteristics of COVID-19, but the precise prevalence and mechanism remain unclear. Thus far, comorbidity of allergic rhinitis and chronic rhinosinusitis do not seem to be a major risk factor for severe COVID-19. However, we should develop strategies in clinical practice for treatment of nasal diseases during the pandemic. In this article, we reviewed current evidence of the relationship between COVID-19 and nasal conditions, such as COVID-19-related olfactory dysfunction, allergic rhinitis, and chronic rhinosinusitis.

Clinical Manifestations of Coronavirus Disease 2019

Coronavirus disease 2019 is an infection caused by severe acute respiratory syndrome coronavirus 2. Many symptomatic patients have influenza-like symptoms such as fever, respiratory symptoms (cough, sore throat, and nasal discharge), headache, and malaise. In some cases, oxygen is required within a week of onset, and in more severe cases, the patient is admitted to the intensive care unit after around 10 days of onset. In the COVIREGI-JP registry of hospitalized patients with coronavirus disease 2019, patients with renal dysfunction, liver disease, obesity, hyperlipidemia, hypertension, and diabetes tended to be more severely ill after hospitalization than patients without comorbidities. It has also become clear that symptoms can persist even after the acute phase has passed.

Hypertension, diabetes mellitus, and cerebrovascular disease predispose to a more severe outcome of COVID-19

INTRODUCTION

The world is currently facing the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The total number of cases of coronavirus disease 2019 (COVID-19) is rising daily and no vaccine has yet been approved. While the pathophysiology behind the virus is still being studied, many possible several risk factors using small sample sizes have been found.

MATERIAL AND METHODS

We conducted a pooled analysis using several databases such as Medline, Scopus, Wangfang, Web of Science, Research Square, medrxiv, and Google Scholar to identify studies reporting severe and non-severe groups of COVID-19 patients. The odds ratios as well as the 95% confidence intervals for hypertension, diabetes, and cerebrovascular disease leading to severe COVID-19 were calculated using R-software.

RESULTS

Fifty-three articles were used for our analysis and they involved 30,935 confirmed cases of COVID-19 from several countries across the world. The odds ratio for severe COVID-19 in hypertensive patients, diabetics, and patients with a history of cerebrovascular disease was 2.58 (95% confidence interval (CI): 2.16-3.08, from 53 studies), 2.17 (95% CI: 1.72-2.74, from 44 studies), and 2.63 (95% CI: 1.80-3.85, from 25 studies), respectively.

CONCLUSIONS

Our analysis confirms that patients with hypertension, diabetes, or cerebrovascular disease are at a higher risk of a severe outcome of COVID-19. It is thus vital for physicians to identify the main risk factors for a severe outcome of this disease.

Clinical characteristics and mortality associated with COVID-19 in Jakarta, Indonesia: A hospital-based retrospective cohort study

Background

Data on COVID-19-related mortality and associated factors from low-resource settings are scarce. This study examined clinical characteristics and factors associated with in-hospital mortality of COVID-19 patients in Jakarta, Indonesia, from March 2 to July 31, 2020.

Methods

This retrospective cohort included all hospitalised patients with PCR-confirmed COVID-19 in 55 hospitals. We extracted demographic and clinical data, including hospital outcomes (discharge or death). We used logistic regression to examine factors associated with mortality.

Findings

Of 4265 patients with a definitive outcome by July 31, 3768 (88%) were discharged and 497 (12%) died. The median age was 46 years (IQR 32-57), 5% were children, and 31% had >1 comorbidity. Age-specific mortalities were 11% (7/61) for <5 years; 4% (1/23) for 5-9; 2% (3/133) for 10-19; 2% (8/638) for 20-29; 3% (26/755) for 30-39; 7% (61/819) for 40-49; 17% (155/941) for 50-59; 22% (132/611) for 60-69; and 34% (96/284) for ≥70. Risk of death was associated with higher age, male sex; pre-existing hypertension, diabetes, or chronic kidney disease; clinical diagnosis of pneumonia; multiple (>3) symptoms; immediate ICU admission, or intubation. Across all ages, risk of death was higher for patients with >1 comorbidity compared to those without; notably the risk was six-fold increased among patients <50 years (adjusted odds ratio 5.87, 95%CI 3.28-10.52; 27% vs 3% mortality).

Interpretation

Overall in-hospital mortality was lower than reported in high-income countries, probably due to younger age distribution and fewer comorbidities. Deaths occurred across all ages, with >10% mortality among children <5 years and adults >50 years.

Topical lignocaine anaesthesia for oropharyngeal sampling for COVID-19

OBJECTIVES

To ascertain if topical lignocaine application in oropharynx prior to swab sampling to test for COVID-19 improves a patient's comfort and to assess its effect on the swab sample taken to conduct the RT-PCR.

METHODS

Adult patients testing positive on the RT-PCR COVID-19 test were sampled again within 48 h after administering topical oropharyngeal anaesthesia. Patients were asked to rate their discomfort on a visual analog scale (VAS) for both sample A and B. A qualitative real-time RT-PCR for detection of SARS-CoV-2 RNA, was performed, and the cycle threshold value (Ct), used as a surrogate marker for the viral load, was measured for the sample taken without lignocaine (sample A) and the sample taken post-lignocaine application (sample B). The difference in Ct values of both the groups was checked for any statistical significance using paired t-test. Wilcoxon signed rank test was used on VAS scores to determine any significant decrease in discomfort.

RESULTS

Forty patients were included in the study. Twenty-nine patients (72.5%) reported the procedure to be more comfortable post-lignocaine application. Median (IQR) discomfort on VAS decreased from 7 (1) to 5 (2) after lignocaine use, which was statistically significant (p < 0.05). Mean Ct value for sample A was 17.21 ± 5.25 and for sample B was 18.44 ± 4.8 (p > 0.05), indicating a non-significant effect of lignocaine on SARS-CoV-2 concentration in the sample.

CONCLUSION

Topical lignocaine, while improving the comfort of the procedure of oropharyngeal sampling for patient did not alter the SARS-CoV-2 viral load that was detected in nasal and oropharyngeal samples taken together.