Demographic risk factors for COVID-19 infection, severity, ICU admission and death: a meta-analysis of 59 studies

Programmed Cell Death-1/Programmed Cell Death-1 Ligand as Prognostic Markers of Coronavirus Disease 2019 Severity

Current research proves that immune dysregulation is a common feature of coronavirus disease 2019 (COVID-19), and immune exhaustion is associated with increased disease mortality. Immune checkpoint molecules, including the programmed cell death-1 (PD-1)/PD-1 ligand (PD-L1) axis, may serve as markers of disease severity. Accordingly, in this study, we evaluated the expression of PD-1/PD-L1 in patients with COVID-19. Blood immunophenotypes of hospitalized patients with moderate (n = 17, requiring oxygen support) and severe (n = 35, requiring mechanical ventilation in the intensive care setting) COVID-19 were compared and associated with clinical, laboratory, and survival data. The associations between severity and lymphocyte profiles were analysed at baseline and after 7 and 14 days of in-hospital treatment. Forty patients without COVID-19 infection were used as controls. For PD-1-positive T and B lymphocyte subsets, notable increases were observed between controls and patients with moderate or severe COVID-19 for CD4+PD-1+ T cells, CD8+PD-1+ T and CD19+PD-1+ B cells. Similar trends were observed for PD-L1-positive lymphocytes, namely, CD4+PD-L1+ T cells, CD8+PD-L1+ T cells and CD19+PD-L1+ B cells. Importantly, all markers associated with PD-1 and PD-L1 were stable over time for the analysed time points in the moderate and severe COVID-19 groups. Increased abundances of PD-1+ and PD-L1+ lymphocytes were associated with disease severity and mortality and were stable over time in patients with moderate to severe COVID-19. These immune exhaustion parameters may be attractive biomarkers of COVID-19 severity.

Sex-adjusted approach to baseline variables demonstrated some improved predictive capabilities for disease severity and survival in patients with Coronavirus Disease 19

INTRODUCTION

The study was focused on comparing crude and sex-adjusted hazard ratio calculated by the baseline variables which may have contributed to the severity of the disease course and fatal outcomes in Coronavirus Disease-19 (COVID-19) patients.

METHOD

The study enrolled 150 eligible adult patients with confirmed SARS-CoV-2 infection. There were 61 (40.7%) male patients, and 89 (59.3%) female patients. Baseline information of patients was collected from patient medical records and surveys that the patients had completed on admission to the hospital.

RESULTS

Considerable number of baseline variables stratified according to disease severity and outcomes showed different optimal cut-points (OCP) in men and women. Sex-adjusted baseline data categories such as age; BMI; systolic and diastolic blood pressure; peripheral RBC and platelet counts; haematocrit; percentage of neutrophils, lymphocytes, monocytes, and their ratio; percentage of eosinophils; titre of plasma IL-6, IL-8, IL-10, and IL-17; and CXCL10; and ratio of pro- and anti-inflammatory cytokines demonstrated significant impacts on the development of the severe stage and fatal outcomes by the mean hazard ratio in the Kaplan-Meier and Cox regression models.

CONCLUSION

This study confirmed some improved predictive capabilities of the sex-adjusted approach in the analysis of the baseline predictive variables for severity and outcome of the COVID-19.

Poor oral health status and adverse COVID-19 outcomes: A preliminary study in hospitalized patients

BACKGROUND

Most of the common risk factors for severe outcomes of coronavirus disease 2019 (COVID-19) are correlated with poor oral health, tooth loss, and periodontitis. This has pointed to a possible relationship between oral and systemic health in COVID-19 patients. Hence, this study aimed to assess the dental and periodontal status of hospitalized COVID-19 patients and their associations with the incidence of adverse COVID-19 outcomes.

METHODS

We included 128 hospital patients aged between 20 and 97 years and with diagnoses of COVID-19 in this prospective observational study. Dental and periodontal status was assessed using in-hospital clinical examinations, including the Decayed, Missing, and Filled Teeth index, periodontal status, and tooth loss patterns (Eichner index). Associations between oral health measures, the severity of COVID-19 symptoms, and hospitalization endpoints were tested using chi-square test and incidence rate ratio (IRR) estimation using a generalized linear model with log-Poisson regression. The regression models used a block-wise selection of predictors for oral health-related variables, comorbidities, and patients' ages.

RESULTS

Overall, poor oral health conditions were highly prevalent and associated with critical COVID-19 symptoms, higher risk for admission in the intensive care unit (ICU), and death. Periodontitis was significantly associated with ICU admission (IRR = 1.44; 95% confidence interval [95%CI] = 1.07-1.95; P = 0.017), critical symptoms (IRR = 2.56; 95%CI = 1.44-4.55; P = 0.001), and risk of death (IRR = 2.05; 95%CI = 1.12-3.76; P = 0.020) when adjusted for age and comorbidities. The Eichner index (classes B and C) was associated with ICU admission.

CONCLUSION

There was a positive association between deleterious oral health-related conditions, especially periodontitis, and severe COVID-19 outcomes in hospitalized COVID-19 patients.

Neutralizing antibody and T cell responses against SARS-CoV-2 variants of concern following ChAdOx-1 or BNT162b2 boosting in the elderly previously immunized with CoronaVac vaccine

Background

The existence of SARS-CoV-2 variants of concern (VOCs) in association with evidence of breakthrough infections despite vaccination resulted in the need for vaccine boosting. In elderly individuals, information on the immunogenicity of booster vaccinations is limited. In countries where the CoronaVac inactivated vaccine is the primary vaccine, the appropriate boosting regimen is not clear. Immunologic studies of the effects of booster vaccination against VOCs, particularly Delta and Omicron, following CoronaVac in elderly individuals are helpful for policy makers. In this study, we determined the immune responses against VOCs following ChAdOx-1 or BNT162b2 boosting in elderly individuals previously immunized with CoronaVac.

Results

Before boosting, the median % inhibition of neutralizing antibodies (NAbs) against the wild-type (WT), Alpha, Beta, Delta and Omicron variants in the ChAdOx-1 and BNT162b2 groups was 52.8% vs. 53.4, 36.6% vs. 39.9, 5.2% vs. 13.7, 34.3% vs. 44.9, and 20.8% vs. 18.8%, respectively. After boosting with ChAdOx-1 or BNT162b2, the % inhibition of NAbs were increased to 97.3% vs. 97.4, 94.3% vs. 97.3%, 79.9 vs. 93.7, 95.5% vs. 97.5, and 26.9% vs. 31.9% for WT, Alpha, Beta, Delta and Omicron variants, respectively. Boosting with BNT162b2 induced significantly higher NAb levels than boosting with ChAdOx-1 against the Alpha, Beta and Delta variants but not the WT and Omicron variants. NAb levels against Omicron variant were not significantly different before and after boosting with ChAdOx-1 or BNT162b2. To evaluate T-cell responses, S peptides of the WT, Alpha, Beta and Delta variants were used to stimulate T cells. Upon stimulation, the expression of IL-17A in CD8 T cells was higher in the BNT162b2 group than in the ChAdOx-1 boosting group. However, IFN-γ production in CD4 and CD8 T cells did not significantly differ under all vaccination regimens. The expression of FasL in CD4 T cells, but not CD8 T cells, was higher in the BNT162b2-boosted group.

Conclusion

Boosting with either ChAdOx-1 or BNT162b2 in CoronaVac-primed healthy elderly individuals induced high NAb production against all examined VOCs except Omicron. BNT162b2 stimulated higher NAb and some T-cell responses than ChAdOx-1. Vaccine boosting is, therefore, recommended for elderly individuals previously immunized with CoronaVac.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12979-022-00279-8.

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

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.

UKB.COVID19: an R package for UK Biobank COVID-19 data processing and analysis

COVID-19 caused by SARS-CoV-2 has resulted in a global pandemic with a rapidly developing global health and economic crisis. Variations in the disease have been observed and have been associated with the genomic sequence of either the human host or the pathogen. Worldwide scientists scrambled initially to recruit patient cohorts to try and identify risk factors. A resource that presented itself early on was the UK Biobank (UKBB), which is investigating the respective contributions of genetic predisposition and environmental exposure to the development of disease. To enable COVID-19 studies, UKBB is now receiving COVID-19 test data for their participants every two weeks. In addition, UKBB is delivering more frequent updates of death and hospital inpatient data (including critical care admissions) on the UKBB Data Portal. This frequently changing dataset requires a tool that can rapidly process and analyse up-to-date data. We developed an R package specifically for the UKBB COVID-19 data, which summarises COVID-19 test results, performs association tests between COVID-19 susceptibility/severity and potential risk factors such as age, sex, blood type, comorbidities and generates input files for genome-wide association studies (GWAS). By applying the R package to data released in April 2021, we found that age, body mass index, socioeconomic status and smoking are positively associated with COVID-19 susceptibility, severity, and mortality. Males are at a higher risk of COVID-19 infection than females. People staying in aged care homes have a higher chance of being exposed to SARS-CoV-2. By performing GWAS, we replicated the 3p21.31 genetic finding for COVID-19 susceptibility and severity. The ability to iteratively perform such analyses is highly relevant since the UKBB data is updated frequently. As a caveat, users must arrange their own access to the UKBB data to use the R package.

Mucosal immune responses to infection and vaccination in the respiratory tract

The lungs are constantly exposed to inhaled debris, allergens, pollutants, commensal or pathogenic microorganisms, and respiratory viruses. As a result, innate and adaptive immune responses in the respiratory tract are tightly regulated and are in continual flux between states of enhanced pathogen clearance, immune-modulation, and tissue repair. New single-cell-sequencing techniques are expanding our knowledge of airway cellular complexity and the nuanced connections between structural and immune cell compartments. Understanding these varied interactions is critical in treatment of human pulmonary disease and infections and in next-generation vaccine design. Here, we review the innate and adaptive immune responses in the lung and airways following infection and vaccination, with particular focus on influenza virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The ongoing SARS-CoV-2 pandemic has put pulmonary research firmly into the global spotlight, challenging previously held notions of respiratory immunity and helping identify new populations at high risk for respiratory distress.

Risk Factors of Symptomatic COVID-19 in Samtse District, Bhutan

Introduction

All Coronavirus disease 2019 (COVID-19) positive cases in Samtse District, Bhutan were isolated in the isolation facilities managed by the government hospitals. This study aimed to identify the socio-demographic risk factors for developing COVID-19 symptoms amongst these patients.

Methods and Materials

A secondary data of the COVID-19 positive cases from isolation facilities of Samtse District from 5 May to 7 September 2021 was used for this study. Survival analysis was carried out to estimate the cumulative probability of symptom onset time by each risk factor. Kaplan–Meier curves were used to estimate the probabilities for the onset of symptoms at different time points and a log-rank test was employed to assess the differences between covariates.

Results

A total of 449 patients were included, of which 55.2% were males and 73.3% (328) were aged >18 years. The mean age was 42 years with a range of 3 months to 83 years. Forty-seven percent (213) reported at least one symptom. Common symptoms were fever (32.3%, 145), headache (31.6%, 142), and cough (30.1%, 135), respectively. Males were 64% less likely to be symptomatic than females [adjusted hazard ratio (aHR) = 0.36, 95% confidence interval (CI) 0.183–0.917]. Farmers (aHR = 3.17, 95% CI 1.119–8.953), and drivers and loaders (aHR = 3.18, 95% CI 1.029–9.834) were 3 times more likely to be symptomatic compared to housewives. Residents of Samtse sub-districts were 5 times more likely to be symptomatic than those living in other sub-districts (aHR = 5.16, 95% CI 2.362–11.254).

Conclusion

The risk of developing COVID-19 symptoms was being fe male, farmers, drivers and loaders, and residents of the Samtse sub-district. These high-risk groups should be provided additional care when in isolation facilities.

Identification of Risk Factors for COVID-19 Hospitalization in Patients With Anti-Rheumatic Drugs: Results From a Multicenter Nested Case Control Study

Patients with inflammatory rheumatic diseases (IRDs) do not have an increased risk for coronavirus disease 2019 (COVID-19) compared with the general population. However, it remains uncertain whether subgroups of patients with IRD using different immunosuppressive antirheumatic drugs carry a higher risk for severe COVID-19 compared with other patients with IRD. The aim of this study is to identify risk factors for severe COVID-19, requiring hospitalization in patients with IRD. This is a multicenter nested case control study conducted in the Netherlands. Cases are hospital known patients with IRD requiring hospitalization for COVID-19 between March 1, 2020, and May 31, 2020. Controls are hospital known patients with IRD not requiring hospitalization for COVID-19 in this period, included at a 4:1 ratio. Patient, disease, and treatment characteristics were extracted from electronic medical records and a questionnaire. Potential risk factors were analyzed using unconditional logistic regression, corrected for confounders and multiple testing. Eighty-one cases and 396 controls were included. General risk factors of older age and obesity apply to patients with IRD as well (odds ratio (OR) for age ≥ 75 3.5, 95% confidence interval (CI) 1.9-6.3, OR for body mass index ≥ 40 4.5, 95% CI 1.5-14). No significantly increased ORs for COVID-19 hospitalization were found for any antirheumatic agent or IRD. A protective effect was found for use of methotrexate (OR 0.53, 95% CI 0.31-0.92). In conclusion, similar to the general population, elderly and obese patients with IRD have a higher risk for hospitalization for COVID-19. We did not identify a specific antirheumatic agent or IRD to increase the risk of COVID-19 hospitalization in patients with IRD, except for a possible protective effect of methotrexate.

Lung function before and after COVID-19 in young adults: A population-based study

Background

There is limited evidence on the long-term impact of mild-to-moderate coronavirus disease 2019 (COVID-19) on lung function among young adults.

Objectives

We aimed to assess whether COVID-19 has a negative impact on lung function in young adults and whether asthma, allergic sensitization, or use of inhaled corticosteroids (ICSs) modifies a potential association.

Methods

Participants from the population-based BAMSE (Barn, Allergi, Miljö, Stockholm, Epidemiologi) cohort with spirometry assessed before (2016-2019) and after onset of the COVID-19 pandemic (2020-2021) were included. Serum levels of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain-specific IgG, IgM, and/or IgA (determined with ELISA) defined seropositivity. Mean change in lung function (ie, change in FEV₁, forced vital capacity [FVC], and FEV₁/FVC ratio expressed as percent of predicted [pp]) from before to after onset of the pandemic were compared between the seronegative and seropositive participants. In seropositive participants, change in lung function was assessed in relation to allergic sensitization and self-reported ICS use.

Results

Of the 853 included participants, 29% (n = 243) were seropositive. There were no differences in change in lung function between the seronegative and seropositive participants (for mean change in FEV₁ pp [SD], seropositivity = 0.87% [4.79%] and seronegativity = 1.03% (4.76%) [P = .66] for difference using a t test; FVC pp (SD), seropositivity = 1.34% (4.44%) and seronegativity = 1.29% (4.27%) [P = .87]; and for FEV₁/FVC pp (SD), seropositivity = -0.25% (3.13%) and seronegativity = -0.13% (3.15%) [P = .61]). Similar results were observed among participants with asthma (n = 147 [17%]). Among seropositive participants, allergic sensitization or ICS use did not influence lung function.

Conclusion

We found no evidence of mild-to-moderate COVID-19 affecting lung function long term in a population-based cohort of young adults. Moreover, neither asthma nor allergic sensitization nor ICS use affected the results.

Coronavirus disease 2019 in Saudi Arabia: A nationwide real-world characterization study

Background

On March 11th, 2020, The World Health Organization (WHO) declared that the COVID-19 is a pandemic due to its worldwide spread. The COVID-19 pandemic has extended its impact to Saudi Arabia. By mid-February 2021, The Kingdom of Saudi Arabia has reported more than 373,000 COVID-19 cases impacting different population categories (i.e., male, female, different age groups, comorbidities status). The objective of this nationwide study was to describe and explore the characteristics of hospitalized patients diagnosed with COVID-19 in Saudi Arabia.

Methods

This study was an observational epidemiological study based on collected clinical data from ten health institutions across all regions in Saudi Arabia. The study was conducted during the period from March 2nd, 2020, to January 31st, 2021. The data were collected included demographics, medical information, medications, and laboratory and diagnostic. More detailed information on usually missing factors such as smoking status, comorbidities, length of hospital stay were also collected. Both descriptive and inferential analyses were conducted using the statistical analysis software "SAS®" version 9.4.

Results

During the study period, 5286 patients were included in this study. Of these, (79.15%) were male. Of all 5286 patients, quite a high number of the studied population 2010 (38.02%) were smokers. The majority of the patients 3436 (65%) were reported to have comorbidities, with hypertension being the most common disease 1725 (32.6%), followed by diabetes 1641(31.04%). A high proportion of the patients, 2220 patients (41.99%), were admitted to the intensive care unit; of these, (33.52%) were on mechanical ventilation. Most patients received anticoagulant prophylaxis medications (n = 4414, 83.5%). All patients were given more than one antibiotic prophylaxis. Overall, the median hospital stay was 5.5 days, and the median length in the intensive care unit was 4.26 days. Around (89.14%) of patients were discharged from the hospital, and (10.8%) died.

Conclusion

In this real-world study utilizing a large sample size, this study provides confirmatory results on the COVID-19 patients characteristics that are similar to other populations. Healthcare professionals need to give COVID-19 patients with specific characteristics including smoking, diabetes mellitus and cardiac disease more care to avoid losing these patients.

Clinical Characteristics, Risk Factors for Severity and Pharmacotherapy in Hospitalized COVID-19 Patients in the United Arab Emirates

Data on the clinical characteristics, severity and management of COVID-19 from the Middle East region, especially the United Arab Emirates (UAE), is very limited. We studied the clinical characteristics, laboratory biomarkers, risk factors for severity and pharmacotherapy of hospitalized COVID-19 patients in this single-center, analytical cross-sectional study conducted in a secondary care hospital of the UAE. A total of 585 patients were included in the study (median age, 49 years (IQR, 39−59); 66% male). Age > 45 years (OR = 2.07, 95% CI: 1.04−4.14, p = 0.040), male gender (OR = 3.15, 95% CI: 1.52−6.51, p = 0.002), presentation symptoms such as fever (OR = 3.68, 95% CI:1.34−10.11, p = 0.011) and shortness of breath/dyspnea (OR = 5.36, 95% CI: 2.69−10.67, p < 0.001), Hb < 13 g/dL (OR = 3.17, 95% CI: 1.51−6.65, p = 0.002), neutrophils > 7 × 103/mcL (OR = 4.89, 95% CI: 1.66−14.37, p=0.004), lymphocytes < 1 × 103/mcL (OR = 7.78, 95% CI: 1.01−60.19, p = 0.049), sodium < 135 mmol/L (OR = 5.42, 95% CI: 1.05−27.95, p = 0.044), potassium < 3.6 mmol/L (OR = 3.36, 95% CI: 1.03−11.01, p = 0.045), urea > 6.5 mmol/L (OR = 3.37, 95% CI: 1.69−6.73, p = 0.001) and LDH > 227 IU/L (OR = 6.26, 95% CI: 1.61−24.32, p = 0.008) were independent predictors of the severity of COVID-19. Antivirals (524, 89.6%) and corticosteroids (358, 61.2%) were prescribed for the management of COVID-19. In conclusion, older age, male gender, presentation symptoms such as fever and dyspnea, low hemoglobin, neutrophilia, lymphopenia, hyponatremia, hypokalemia, elevated levels of urea and lactate dehydrogenase were found to be independent risk factors for severe COVID-19. The pharmacotherapy of COVID-19 patients in our study was diverse, and the medications were prescribed based on the clinical condition of the patients.

Burden of COVID-19: a preliminary analysis in the population of Saudi Arabia

Background

Coronavirus infection (COVID-19) has resulted in an unprecedented number of human deaths and economic losses. Analyzing the role of disease in different groups of people is useful for determining the burden of disease. As a result, the purpose of this study was to investigate the influence of COVID-19 on the Saudi Arabian population's quality of life, with a particular emphasis on the likely fall in their life expectancy.

Methods

A cross-sectional and retrospective analysis of 2,988 patients' databases was performed to assess COVID-19-induced mortality and complications in the community. The data was gathered from official websites that track the disease's impact daily between July and October 2021. On the acquired data, disability-adjusted life years (DALYs) and relative risk analysis were performed. The data was statistically analyzed using SPSS IBM 25. The Pearson's correlation test was used to examine the relationship between age and disease impact. The significance of the findings was determined by using a P value of less than 0.05.

Results

The data from the study indicated that the positive test rate, infection rate, and mortality rate in the population were 1.84% [+0.11/-0.39 of 95% confidence interval (CI)], 1.54% (+0.38/-0.52 of CI), and 1.59% (+0.4/-0.7 of CI), respectively. Highest percentage of mortality was observed in Riyadh (17%), followed by Jeddah (8.7%) and Makkah (7.5%). The DALYs/100,000 inhabitants increased progressively as the age of the population increased, and the highest value was found for those over 70 years old (25.73 ± 2.09). Similarly, the risk outcome (55%) increased significantly (p = 0.037) from 40 years onwards, and the maximum was observed at above 70 years (184%, p = 0.006). The correlation analysis indicated a significant association (p = 0.032) between age and COVID-19 induced mortality from the 40-year-old population onwards.

Conclusion

The current study found that the COVID-19 load in Saudi Arabia was comparable to that in nations that were said to have performed well during the pandemic. DALYs increased from 40 years to 60 years, although people over 60 years had a lower life expectancy and were more susceptible to infection. After 60 years, the occurrence of numerous co-morbid illnesses may have added to the population's burden of COVID-19. Further research in this area may yield a more precise estimate of the COVID-19-induced burden on the entire population.

Systematic on-site testing for SARS-CoV-2 infection among asymptomatic essential workers in Montréal, Canada: a prospective observational and cost-assessment study

BACKGROUND

Essential workers are at increased risk for SARS-CoV-2 infection. We aimed to estimate the yield, acceptability and cost of systematic workplace-based testing of asymptomatic essential workers for SARS-CoV-2 infection.

METHODS

From Jan. 27 to Mar. 12, 2021, we prospectively recruited non-health care essential businesses in Montréal, Canada, through email or telephone contact. Two trained mobile teams, each composed of 2 non-health care professionals, visited businesses. Consenting asymptomatic employees provided saline gargle samples under supervision. Samples were analyzed by means of reverse transcription polymerase chain reaction (RT-PCR). At businesses with outbreaks (≥ 2 participants with a positive result), we retested all participants with a negative result on initial testing. Our primary outcomes were yield (proportion of test results that were positive), acceptability (proportion of participants estimated to be present at the business who agreed to participate) and costs (including training, sample collection and analysis, and communicating results). Our secondary outcome was identification of factors associated with a positive test result on multivariable logistic regression.

RESULTS

Of the 366 businesses contacted, 69 (18.8%) agreed to participate. Nineteen businesses (28%) were manufacturers or suppliers, 12 (17%) were in auto sales or repair, and 11 (16%) were in childcare; the corresponding number of employees was 1225, 242 and 113. The median number of participants per business was 13 (interquartile range [IQR] 8-22). Of an estimated 2348 employees on site, 2128 (90.6%) participated (808 [38.0%] female, median age 48 [IQR 37-57] yr). Of the 2626 tests performed, 53 (2.0%) gave a positive result. Self-reported nonwhite ethnicity (adjusted odds ratio [OR] 3.7, 95% confidence interval [CI] 1.4-9.9) and a negative SARS-CoV-2 test result before the study (adjusted OR 0.4, 95% CI 0.2-0.8) were associated with a positive test result. Five businesses were experiencing an outbreak; at these businesses, 40/917 participants (4.4%) had a positive result on the initial test. We repeated testing for employees with initially negative results at 3 of these businesses over 2-3 weeks: 8/350 participants (2.3%) had a positive result on the second test, and none had a positive result on the third and fourth tests; no employer reported new positive results after our final visit (up to Mar. 26, 2021). At the remaining 64 businesses, 1211 participants were tested once, of whom 5 (0.4%) had a positive result. The per-person RT-PCR cost was $34, and all other costs, $8.67.

INTERPRETATION

On-site saline gargle sampling of essential workers for SARS-CoV-2 testing was acceptable and of modest cost, and appears most useful in the context of outbreaks. This sampling strategy should be evaluated further as a component of efforts to prevent SARS-CoV-2 transmission. PREPRINT: medRxiv - doi:10.1101/2021.05.12.21256956.

The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective

INTRODUCTION

COVID-19 infection is expected to be associated with an increased likelihood of erectile dysfunction (ED). Considering the high transmissibility of COVID-19, ED may be a concerning consequence for a large segment of the population.

AIMS

To (1) summarize existing published evidence for the impact of COVID-19 on the prevalence, severity, treatment, and management of ED; and (2) identify health-related trends in the emerging literature and identify gaps in the existing research literature and make recommendations for future research needs in the area.

METHODS

A scoping literature search was conducted on April 27, 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR) checklist was followed. The literature search was performed in PubMed using the terms: COVID-19, erectile, sexual, and dysfunction. A total of 693 publications were screened for relevance. Studies were appraised for their level of evidence based on study design and the rigor of methodology.

RESULTS

The evidence that COVID-19 infection causes or impacts ED is compelling. Four topics emerged regarding the nature of the association between COVID-19 and ED: (1) the biological impact of COVID-19 infection on ED; (2) the mental health impact of COVID-19 on ED; (3) the impact of COVID-19 on the management of ED and access to ED treatment; and (4) health disparities and the impact of COVID-19 on ED. Long-term and well-designed studies are needed to clarify the extent of the impact of COVID-19 on ED. The pandemic exposed several vulnerabilities within worldwide healthcare and social systems.

CONCLUSION

COVID-19 has a uniquely harmful impact on men's health and erectile function through biological, mental health, and healthcare access mechanisms. As the pandemic wanes, strategies to identify long-term effects and additional health care support may be needed to adequately mitigate the impact of COVID-19 on men's health. Hsieh T-C, Edwards NC, Bhattacharyya SK, et al.The Epidemic of COVID-19-Related Erectile Dysfunction: A Scoping Review and Health Care Perspective. Sex Med Rev 2022;10:286-310.

Postoperative, But not Preoperative COVID-19 is Associated With an Increased Rate of Medical Adverse Events Following Arthroscopic Procedures

Purpose

To characterize how severe acute respiratory syndrome coronavirus 2 infection in the perioperative period affects the medical adverse event (MAE) rates in arthroscopic sports medicine procedures.

Methods

The Mariner coronavirus disease 2019 (COVID-19) database was queried for all shoulder, hip, or knee arthroscopies, 2010 to 2020. Patients with COVID-19 in the 3 months before to 3 months after their surgery were matched by age, sex, and Charlson Comorbidity Index to patients with an arthroscopy but no perioperative COVID-19 infection, or a COVID-19 infection but no arthroscopic procedure. MAEs in the 3 months after surgery or illness were compared between groups.

Results

The final cohort consisted of 1,299 matched patients in 3 groups: COVID-19 alone, arthroscopy and perioperative COVID-19, and arthroscopy alone. There were 265 MAEs if a patient had COVID-19 alone (20.4%), 200 MAEs if a patient had arthroscopy with COVID-19 (15.4%), and 71 (5.5%) MAEs if a patient had arthroscopy alone (P < .01). If a patient had an arthroscopy, having COVID-19 was associated with 3.1-fold elevated odds (95% confidence interval [CI] 2.9-3.4, P < .01) of MAE. Among patients with an arthroscopy, MAEs were more common if a patient acquired COVID-19 in the 3 months after their surgery (pooled odds ratio 7.39, 95% CI 5.49-9.95, P < .01) but not if a patient had preoperative COVID-19 (pooled odds ratio 0.66, 95% CI 0.42-1.03, P = .07).

Conclusions

Having COVID-19 during the postoperative period appears to confer a 7-fold elevated risk of MAEs after shoulder, hip, and knee arthroscopy compared with matched patients with arthroscopy and no perioperative COVID-19 but equivalent to that of patients with COVID-19 and no arthroscopy. However, there was no increase in postoperative MAEs if a patient had COVID-19 during the 3 months preceding surgery. Therefore, it appears safe to conduct an arthroscopic procedure shortly after recovery from COVID-19 without an increase in acute medical complication rates.

Level of evidence

Level III, retrospective cohort study.

The impact of pre-existing hypertension and its treatment on outcomes in patients admitted to hospital with COVID-19

The impact of pre-existing hypertension on outcomes in patients with the novel corona virus (SARS-CoV-2) remains controversial. To address this, we examined the impact of pre-existing hypertension and its treatment on in-hospital mortality in patients admitted to hospital with Covid-19. Using the CAPACITY-COVID patient registry we examined the impact of pre-existing hypertension and guideline-recommended treatments for hypertension on in-hospital mortality in unadjusted and multi-variate-adjusted analyses using logistic regression. Data from 9197 hospitalised patients with Covid-19 (median age 69 [IQR 57–78] years, 60.6% male, n = 5573) was analysed. Of these, 48.3% (n = 4443) had documented pre-existing hypertension. Patients with pre-existing hypertension were older (73 vs. 62 years, p < 0.001) and had twice the occurrence of any cardiac disease (49.3 vs. 21.8%; p < 0.001) when compared to patients without hypertension. The most documented class of anti-hypertensive drugs were angiotensin receptor blockers (ARB) or angiotensin converting enzyme inhibitors (ACEi) (n = 2499, 27.2%). In-hospital mortality occurred in (n = 2020, 22.0%), with more deaths occurring in those with pre-existing hypertension (26.0 vs. 18.2%, p < 0.001). Pre-existing hypertension was associated with in-hospital mortality in unadjusted analyses (OR 1.57, 95% CI 1.42,1.74), no significant association was found following multivariable adjustment for age and other hypertension-related covariates (OR 0.97, 95% CI 0.87,1.10). Use of ACEi or ARB tended to have a protective effect for in-hospital mortality in fully adjusted models (OR 0.88, 95% CI 0.78,0.99). After appropriate adjustment for confounding, pre-existing hypertension, or treatment for hypertension, does not independently confer an increased risk of in-hospital mortality patients hospitalized with Covid-19.

Comparative effectiveness of the BNT162b2 and ChAdOx1 vaccines against Covid-19 in people over 50

Although pivotal trials with varying populations and study methods suggest higher efficacy for mRNA than adenoviral Covid-19 vaccines, not many studies have directly compared vaccine effectiveness in the population. Here, we conduct a head-to-head comparison of BNT162b2 versus ChAdOx1 against Covid-19. We analyse 235,181 UK Biobank participants aged 50 years or older and vaccinated with one or two doses of BNT162b2 or ChAdOx1. People are followed from the vaccination date until 18/10/2021. Inverse probability weighting is used to minimise confounding and the Cox models to derive hazard ratio. We find that, compared with one dose of ChAdOx1, vaccination with BNT162b2 is associated with a 28% (95% CI, 12-42) decreased risk of SARS-CoV-2 infection. Also, two doses of BNT162b2 vs ChAdOx1 confers 30% (95% CI, 25-35) and 29% (95% CI, 10-45) lower risks of both infection and hospitalisation during the study period when the Delta variant is dominant. Furthermore, the comparative protection against the infection persists for at least six months among the fully vaccinated, suggesting no differential waning between the two vaccines. These findings can inform evidence-based Covid-19 vaccination campaigns and booster strategies.

Sex Differences in Use of Low Tidal Volume Ventilation in COVID-19-Insights From the PRoVENT-COVID Study

The purpose of this study was to compare and understand differences in the use of low tidal volume ventilation (LTVV) between females and males with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). This is a post-hoc analysis of an observational study in invasively ventilated patients with ARDS related to COVID-19 in 22 ICUs in the Netherlands. The primary endpoint was the use of LTVV, defined as having received a median tidal volume (V_T) ≤6 ml/kg predicted body weight (PBW) during controlled ventilation. A mediation analysis was used to investigate the impact of anthropometric factors, next to the impact of sex per se. The analysis included 934 patients, 251 females and 683 males. All the patients had ARDS, and there were no differences in ARDS severity between the sexes. On the first day of ventilation, females received ventilation with a higher median V_T compared with males [6.8 (interquartile range (IQR) 6.0–7.6 vs. 6.3 (IQR 5.8–6.9) ml/kg PBW; p < 0.001]. Consequently, females received LTVV less often than males (23 vs. 34%; p = 0.003). The difference in the use of LTVV became smaller but persisted over the next days (27 vs. 36%; p = 0.046 at day 2 and 28 vs. 38%; p = 0.030 at day 3). The difference in the use LTVV was significantly mediated by sex per se [average direct effect of the female sex, 7.5% (95% CI, 1.7–13.3%); p = 0.011] and by differences in the body height [average causal mediation effect, −17.5% (−21.5 to −13.5%); p < 0.001], but not by the differences in actual body weight [average causal mediation effect, 0.2% (−0.8 to 1.2%); p = 0.715]. In conclusion, in this cohort of patients with ARDS related to COVID-19, females received LTVV less often than males in the first days of invasive ventilation. The difference in the use of LTVV was mainly driven by an anthropometric factor, namely, body height. Use of LTVV may improve by paying attention to correct titration of V_T, which should be based on PBW, which is a function of body height.

Clinicodemographic profile, intensive care unit utilization and mortality rate among COVID-19 patients admitted during the second wave in Bangladesh

INTRODUCTION

The second wave of COVID-19 arrived in Bangladesh in March 2021. This pilot research from a tertiary care COVID-dedicated hospital observed the clinicodemographic profile, intensive care unit (ICU) utilization, and mortality rate among COVID-19 patients admitted during the second wave.

METHODS

Reverse transcription-polymerase chain reaction or chest high-resolution computed tomography confirmed 972 COVID-19 cases included in this cross-sectional study from 24 March to 23 June 2021, recruited using convenience sampling. Data regarding clinicodemographic profile, ICU utilization and mortality rate were analyzed.

RESULTS

The mean study cohort age was 54.47±12.73 years, with most patients (48.3%) aged 41-60; 64.1% were men. Fever (77.9%) and cough (75.9%) were the most common symptoms, and hypertension (43.6%) and diabetes (42.15%) the most common comorbidities. Nearly half of patients had total lung involvement of 26%-50%, and 23.8% required ICU. Overall mortality was 16.5%, whereas the mortality rate among ICU admitted patients was 56.1%. The most important predictors of mortality were older age, chronic renal illness, the proportion of lung involvement and ICU requirement.

CONCLUSIONS

We found higher mortality and ICU utilization rate and greater total lung involvement during the second wave. The mortality rate among the elderly and ICU patients was also higher than earlier.

The General Public's Perceptions of How the COVID-19 Pandemic Has Impacted the Elderly and Individuals with Intellectual Disabilities

This study examined the general public's perceptions of how the COVID-19 pandemic has impacted the elderly and people with intellectual disabilities as well how these perceptions relate to people's level of familiarity and contact quality with these groups. A cross-sectional survey was administered to a sample of the Dutch population (n = 1458 and n = 1761, comprising questions related to the elderly and people with intellectual disabilities, respectively). The general public was found to be generally aware of the deleterious impact of the pandemic upon the elderly and people with intellectual disabilities. Specifically, the respondents reported that both groups' quality of life, physical and mental health, and quality and frequency of social contact was lower than it was prior to COVID-19, in addition to perceiving them as lonelier and less self-reliant. Notably, the impact on the elderly was considered to be greater than that on people with intellectual disabilities. Furthermore, those who had no familiarity with people with intellectual disabilities in real life perceived the impact to be lower than those who had a greater degree of familiarity. These findings have important implications, both for increasing awareness of the pandemic's negative impact on these vulnerable groups and in terms of sufficiently addressing their specific needs and concerns. The findings also underscore that, particularly during the COVID-19 pandemic, it is important to increase the visibility of groups who already relied more on help and support from others in society prior to the pandemic, such as the elderly and people with intellectual disabilities, via, among other things, self-advocacy, education, and enhanced intergroup contact, in order to be able to sufficiently address their needs during these challenging times.

COVID-19-Associated Endothelial Dysfunction and Microvascular Injury: From Pathophysiology to Clinical Manifestations

Coronavirus-19 disease (COVID-19) affects more people than previous coronavirus infections and has a higher mortality. Higher incidence and mortality can probably be explained by COVID-19 causative agent's greater affinity (about 10-20 times) for angiotensin-converting enzyme 2 (ACE2) receptor compared with other coronaviruses. Here, the authors first summarize clinical manifestations, then present symptoms of COVID-19 and the pathophysiological mechanisms underlying specific organ/system disease. The worse clinical outcome observed in COVID-19 patients with diabetes may be in part related to the increased ADAM17 activity and its unbalanced interplay with ACE2. Therefore, strategies aimed to inhibit ADAM17 activity may be explored to develop new effective therapeutic approaches.

A simple risk score for mortality including the PCR Ct value upon admission in patients hospitalized due to COVID-19

Purpose

To develop a simple score for the outcomes from COVID-19 that integrates information obtained at the time of admission including the Ct value (cycle threshold) for SARS-CoV-2.

Methods

Patients with COVID-19 hospitalized from February 1st to May 31st 2021 in RoMed hospitals, Germany, were included. Clinical and laboratory parameters upon admission were recorded and patients followed until discharge or death. Logistic regression analysis was used to determine predictors of outcomes. Regression coefficients were used to develop a risk score for death.

Results

Of 289 patients (46% female, median age 66 years), 29% underwent high-flow nasal oxygen (HFNO) therapy, 28% were admitted to the Intensive Care Unit (ICU, 51% put on invasive ventilation, IV), and 15% died. Age > 70 years, oxygen saturation ≤ 90%, oxygen supply upon admission, eGFR ≤ 60 ml/min and Ct value ≤ 26 were significant (p < 0.05 each) predictors for death, to which 2, 2, 1, 1 and 2 score points, respectively, could be attributed. Sum scores of ≥ 4 or ≥ 5 points were associated with a sensitivity of 95.0% or 82.5%, and a specificity of 72.5% or 81.7% regarding death. The high predictive value of the score was confirmed using data obtained between December 15th 2020 and January 31st 2021 (n = 215).

Conclusion

In COVID-19 patients, a simple scoring system based on data available shortly after hospital admission including the Ct value had a high predictive value for death. The score may also be useful to estimate the likelihood for required interventions at an early stage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01783-1.

Estimating local outbreak risks and the effects of non-pharmaceutical interventions in age-structured populations: SARS-CoV-2 as a case study

During the COVID-19 pandemic, non-pharmaceutical interventions (NPIs) including school closures, workplace closures and social distancing policies have been employed worldwide to reduce transmission and prevent local outbreaks. However, transmission and the effectiveness of NPIs depend strongly on age-related factors including heterogeneities in contact patterns and pathophysiology. Here, using SARS-CoV-2 as a case study, we develop a branching process model for assessing the risk that an infectious case arriving in a new location will initiate a local outbreak, accounting for the age distribution of the host population. We show that the risk of a local outbreak depends on the age of the index case, and we explore the effects of NPIs targeting individuals of different ages. Social distancing policies that reduce contacts outside of schools and workplaces and target individuals of all ages are predicted to reduce local outbreak risks substantially, whereas school closures have a more limited impact. In the scenarios considered here, when different NPIs are used in combination the risk of local outbreaks can be eliminated. We also show that heightened surveillance of infectious individuals reduces the level of NPIs required to prevent local outbreaks, particularly if enhanced surveillance of symptomatic cases is combined with efforts to find and isolate nonsymptomatic infected individuals. Our results reflect real-world experience of the COVID-19 pandemic, during which combinations of intense NPIs have reduced transmission and the risk of local outbreaks. The general modelling framework that we present can be used to estimate local outbreak risks during future epidemics of a range of pathogens, accounting fully for age-related factors.

Using a Systems Approach to Explore the Mechanisms of Interaction Between Severe Covid-19 and Its Coronary Heart Disease Complications

Frontiers requested research on how a systems approach can explore the mechanisms of cardiovascular complications in Covid-19. The focus of this paper will thus be on these detailed mechanisms. It will elucidate the integrated pathogenic pathways based on an extensive review of literature. Many severe Covid-19 cases and deaths occur in patients with chronic cardiovascular comorbidities. To help understand all the mechanisms of this interaction, Covid-19 complications were integrated into a pre-existing systems-based coronary heart disease (CHD) model. Such a complete model could not be found in literature. A fully integrative view could be valuable in identifying new pharmaceutical interventions, help understand how health factors influence Covid-19 severity and give a fully integrated explanation for the Covid-19 death spiral phenomenon seen in some patients. Covid-19 data showed that CHD hallmarks namely, Hypercoagulability, Hypercholesterolemia, Hyperglycemia/Hyperinsulinemia, Inflammation and Hypertension have an important effect on disease severity. The pathogenic pathways that Covid-19 activate in CHD were integrated into the CHD model. This fully integrated model presents a visual explanation of the mechanism of interaction between CHD and Covid-19 complications. This includes a detailed integrated explanation of the death spiral as a result of interactions between Inflammation, endothelial cell injury, Hypercoagulability and hypoxia. Additionally, the model presents the aggravation of this death spiral through the other CHD hallmarks namely, Hyperglycemia/Hyperinsulinemia, Hypercholesterolemia, and/or Hypertension. The resulting model further suggests systematically how the pathogenesis of nine health factors (stress, exercise, smoking, etc.) and seven pharmaceutical interventions (statins, salicylates, thrombin inhibitors, etc.) may either aggravate or suppress Covid-19 severity. A strong association between CHD and Covid-19 for all the investigated health factors and pharmaceutical interventions, except for β-blockers, was found. It is further discussed how the proposed model can be extended in future to do computational analysis to help assess the risk of Covid-19 in cardiovascular disease. With insight gained from this study, recommendations are made for future research in potential new pharmacotherapeutics. These recommendations could also be beneficial for cardiovascular disease, which killed five times more people in the past year than Covid-19.

Low Serum Levels of Interferon Alpha in COVID-19 Patients Are Associated with Older Age

Innate immune response, especially type 1 interferon (IFN) response is considered to play a substantial role in the outcome of SARS-CoV-2 infection. A reduced and delayed IFN response has been associated with progression to severe COVID-19. In this study, we investigated levels of circulating IFNα and serum neutralizing activity in COVID-19 patients admitted to the intensive care unit. We found a significant association of levels of IFNα with age (p = 0.007). This association has also been observed in a cohort of COVID-19 outpatients with mild infection (p = 0.02). The impact of senescence on IFN response can explain the higher susceptibility of the elderly to severe COVID-19.

SARS-CoV-2 antibodies protect against reinfection for at least 6 months in a multicentre seroepidemiological workplace cohort

Identifying the potential for SARS-CoV-2 reinfection is crucial for understanding possible long-term epidemic dynamics. We analysed longitudinal PCR and serological testing data from a prospective cohort of 4,411 United States employees in 4 states between April 2020 and February 2021. We conducted a multivariable logistic regression investigating the association between baseline serological status and subsequent PCR test result in order to calculate an odds ratio for reinfection. We estimated an odds ratio for reinfection ranging from 0.14 (95% CI: 0.019 to 0.63) to 0.28 (95% CI: 0.05 to 1.1), implying that the presence of SARS-CoV-2 antibodies at baseline is associated with around 72% to 86% reduced odds of a subsequent PCR positive test based on our point estimates. This suggests that primary infection with SARS-CoV-2 provides protection against reinfection in the majority of individuals, at least over a 6-month time period. We also highlight 2 major sources of bias and uncertainty to be considered when estimating the relative risk of reinfection, confounders and the choice of baseline time point, and show how to account for both in reinfection analysis.

Identifying the potential for SARS-CoV-2 reinfection is crucial for understanding possible long-term epidemic dynamics. Analysis of a seroepidemiological cohort suggests that primary infection with SARS-CoV-2 protects against reinfection in the majority of individuals, at least over a six month period.

Silent Hypoxia in COVID-19 Pneumonia: State of Knowledge, Pathophysiology, Mechanisms, and Management

Patients with COVID-19 often present with life-threatening hypoxemia without dyspnea or signs of respiratory distress. Termed silent or happy hypoxia, it has puzzled clinicians and challenged and defied our understanding of normal respiratory physiology. A range of host- and pathogen-related factors appears to contribute to its development, including SARS-CoV-2's ability to produce different COVID-19 phenotypes; induce endothelial damage and elicit a vascular distress response; invade cells of the central nervous system and disrupt normal interoception and response; and modulate transcription factors involved in hypoxic responses. Because hypoxemia in COVID-19 is associated with increased mortality risk and poorer survival, early detection and prompt treatment is essential to prevent potential complications. Interventions to prevent hypoxemia and improve oxygen delivery to the blood and the tissues include home pulse-oximetry monitoring, optimization of patient positioning, judicious use of supplemental oxygen, breathing control exercises, and timely and appropriate use of ventilatory modalities and adjuncts.

Risk factors for nosocomial SARS-CoV-2 infections in patients: results from a retrospective matched case-control study in a tertiary care university center

BACKGROUND

Factors contributing to the spread of SARS-CoV-2 outside the acute care hospital setting have been described in detail. However, data concerning risk factors for nosocomial SARS-CoV-2 infections in hospitalized patients remain scarce. To close this research gap and inform targeted measures for the prevention of nosocomial SARS-CoV-2 infections, we analyzed nosocomial SARS-CoV-2 cases in our hospital during a defined time period.

METHODS

Data on nosocomial SARS-CoV-2 infections in hospitalized patients that occurred between May 2020 and January 2021 at Charité university hospital in Berlin, Germany, were retrospectively gathered. A SARS-CoV-2 infection was considered nosocomial if the patient was admitted with a negative SARS-CoV-2 reverse transcription polymerase chain reaction test and subsequently tested positive on day five or later. As the incubation period of SARS-CoV-2 can be longer than five days, we defined a subgroup of "definite" nosocomial SARS-CoV-2 cases, with a negative test on admission and a positive test after day 10, for which we conducted a matched case-control study with a one to one ratio of cases and controls. We employed a multivariable logistic regression model to identify factors significantly increasing the likelihood of nosocomial SARS-CoV-2 infections.

RESULTS

A total of 170 patients with a nosocomial SARS-CoV-2 infection were identified. The majority of nosocomial SARS-CoV-2 patients (n = 157, 92%) had been treated at wards that reported an outbreak of nosocomial SARS-CoV-2 cases during their stay or up to 14 days later. For 76 patients with definite nosocomial SARS-CoV-2 infections, controls for the case-control study were matched. For this subgroup, the multivariable logistic regression analysis revealed documented contact to SARS-CoV-2 cases (odds ratio: 23.4 (95% confidence interval: 4.6-117.7)) and presence at a ward that experienced a SARS-CoV-2 outbreak (odds ratio: 15.9 (95% confidence interval: 2.5-100.8)) to be the principal risk factors for nosocomial SARS-CoV-2 infection.

CONCLUSIONS

With known contact to SARS-CoV-2 cases and outbreak association revealed as the primary risk factors, our findings confirm known causes of SARS-CoV-2 infections and demonstrate that these also apply to the acute care hospital setting. This underscores the importance of rapidly identifying exposed patients and taking adequate preventive measures.

COVID-19-Related Mortality Risk in People With Severe Mental Illness: A Systematic and Critical Review

Background: Increasing clinical evidence suggests that people with severe mental illness (SMI), including schizophrenia spectrum disorders, bipolar disorder (BD), and major depressive disorder (MDD), are at higher risk of dying from COVID-19. Several systematic reviews examining the association between psychiatric disorders and COVID-19-related mortality have recently been published. Although these reviews have been conducted thoroughly, certain methodological limitations may hinder the accuracy of their research findings. Methods: A systematic literature search, using the PubMed, Embase, Web of Science, and Scopus databases (from inception to July 23, 2021), was conducted for observational studies assessing the risk of death associated with COVID-19 infection in adult patients with pre-existing schizophrenia spectrum disorders, BD, or MDD. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). Results: Of 1,446 records screened, 13 articles investigating the rates of death in patients with pre-existing SMI were included in this systematic review. Quality assessment scores of the included studies ranged from moderate to high. Most results seem to indicate that patients with SMI, particularly patients with schizophrenia spectrum disorders, are at significantly higher risk of COVID-19-related mortality, as compared to patients without SMI. However, the extent of the variation in COVID-19-related mortality rates between studies including people with schizophrenia spectrum disorders was large because of a low level of precision of the estimated mortality outcome(s) in certain studies. Most studies on MDD and BD did not include specific information on the mood state or disease severity of patients. Due to a lack of data, it remains unknown to what extent patients with BD are at increased risk of COVID-19-related mortality. A variety of factors are likely to contribute to the increased mortality risk of COVID-19 in these patients. These include male sex, older age, somatic comorbidities (particularly cardiovascular diseases), as well as disease-specific characteristics. Conclusion: Methodological limitations hamper the accuracy of COVID-19-related mortality estimates for the main categories of SMIs. Nevertheless, evidence suggests that SMI is associated with excess COVID-19 mortality. Policy makers therefore must consider these vulnerable individuals as a high-risk group that should be given particular attention. This means that targeted interventions to maximize vaccination uptake among these patients are required to address the higher burden of COVID-19 infection in this already disadvantaged group.

Temporal trends of sex differences for COVID-19 infection, hospitalisation, severe disease, intensive care unit (ICU) admission and death: a meta-analysis of 229 studies covering over 10M patients

Background: This review aims to investigate the association of sex with the risk of multiple COVID-19 health outcomes, ranging from infection to death. Methods: Pubmed and Embase were searched through September 2020. We considered studies reporting sex and coronavirus disease 2019 (COVID-19) outcomes. Qualitative and quantitative data were extracted using standardised electronic data extraction forms with the assessment of Newcastle Ottawa Scale for risk of bias. Pooled trends in infection, hospitalization, severity, intensive care unit (ICU) admission and death rate were calculated separately for men and women and subsequently random-effects meta-analyses on relative risks (RR) for sex was performed. Results: Of 10,160 titles, 229 studies comprising 10,417,452 patients were included in the analyses. Methodological quality of the included studies was high (6.9 out of 9). Men had a higher risk for infection with COVID-19 than women (RR = 1.14, 95%CI: 1.07 to 1.21). When infected, they also had a higher risk for hospitalization (RR = 1.33, 95%CI: 1.27 to 1.41), higher risk for severe COVID-19 (RR = 1.22, 95%CI: 1.17 to 1.27), higher need for Intensive Care (RR = 1.41, 95%CI: 1.28 to 1.55), and higher risk of death (RR = 1.35, 95%CI: 1.28 to 1.43). Within the period studied, the RR for infection and severity increased for men compared to women, while the RR for mortality decreased for men compared to women. Conclusions: Meta-analyses on 229 studies comprising over 10 million patients showed that men have a higher risk for COVID-19 infection, hospitalization, disease severity, ICU admission and death. The relative risks of infection, disease severity and death for men versus women showed temporal trends with lower relative risks for infection and severity of disease and higher relative risk for death at the beginning of the pandemic compared to the end of our inclusion period. PROSPERO registration: CRD42020180085 (20/04/2020).

Pre-Existing Lymphopenia Increases the Risk of Hospitalization and Death after SARS-CoV-2 Infection

There is limited information regarding the severity of COVID-19 in immunocompromized patients. We conducted a retrospective cohort study considering the period from 1 March 2020 to 31 December 2020 to determine whether previously existing lymphopenia increases the risk of hospitalization and death after SARS-CoV-2 infection in the general population. The laboratory and hospital discharge databases of the Azienda Sanitaria Universitaria Friuli Centrale were used, and 5415 subjects infected with SARS-CoV-2 and with at least one recent absolute lymphocyte count determination before SARS-CoV-2 positivity were included. In total, 817 (15.1%) patients had severe COVID-19. Patients developing severe COVID-19 were more frequently males (44.9% of the severe COVID-19 group vs. 41.5% in the non-severe COVID-19 group; p < 0.0001) and were older (73.2 ± 13.8 vs. 58.4 ± 20.3 years; p < 0.0001). Furthermore, 29.9% of the lymphopenic patients developed severe COVID-19 vs. 14.5% of the non-lymphopenic patients (p < 0.0001). In a logistic regression model, female sex remained a protective factor (OR = 0.514, 95%CI 0.438–0.602, p < 0.0001), while age and lymphopenia remained risk factors for severe COVID-19 (OR = 1.047, 95%CI 1.042–1.053, p < 0.0001 for each additional year of age; OR = 1.715, 95%CI 1.239–2.347, p = 0.0011 for lymphopenia). This provides further information to stratify the risk of COVID-19 severity, which may be an important element in the management of immunosuppressive therapies.

Determinants of COVID-19-Related Length of Hospital Stays and Long COVID in Ghana: A Cross-Sectional Analysis

OBJECTIVES

There is paucity of data on determinants of length of COVID-19 admissions and long COVID, an emerging long-term sequel of COVID-19, in Ghana. Therefore, this study identified these determinants and discussed their policy implications.

METHOD

Data of 2334 patients seen at the main COVID-19 treatment centre in Ghana were analysed in this study. Their characteristics, such as age, education level and comorbidities, were examined as explanatory variables. The dependent variables were length of COVID-19 hospitalisations and long COVID. Negative binomial and binary logistic regressions were fitted to investigate the determinants.

RESULT

The regression analyses showed that, on average, COVID-19 patients with hypertension and diabetes mellitus spent almost 2 days longer in hospital (p = 0.00, 95% CI = 1.42-2.33) and had 4 times the odds of long COVID (95% CI = 1.61-10.85, p = 0.003) compared to those with no comorbidities. In addition, the odds of long COVID decreased with increasing patient's education level (primary OR = 0.73, p = 0.02; secondary/vocational OR = 0.26, p = 0.02; tertiary education OR = 0.23, p = 0.12).

CONCLUSION

The presence of hypertension and diabetes mellitus determined both length of hospitalisation and long COVID among patients with COVID-19 in Ghana. COVID-19 prevention and management policies should therefore consider these factors.

Using data from a private provider of telemedicine to assess the severity of the early 2021 Covid-19 wave in Brazil

In early 2021, Brazil saw a dramatic recurrence in Covid-19 cases associated to the spread of a novel variant of the SARS-CoV-2 virus, the P1 variant. In light of previous reports showing that this variant is more transmissible and more likely to infect people who had recovered from previous infection, a retrospective analysis was conducted to assess if the early 2021 Covid-19 wave in Brazil was associated with an increase in the number of individuals presenting with a more severe clinical course. Fifty-one thousand and fourteen individuals who underwent telemedicine consultations were divided into two groups: patients seen on or before January 31, 2021, and on or after February 1, 2021. These dates were chosen based on the spread of the P1 variant in Brazil. Referral to the emergency department (ED) was used as a marker of a more severe course of the disease. No differences were seen in the proportion of patients referred to the ED in each group nor in the odds ratio of being referred to the ED from the 1st of February 2021 (OR=0.909; 95%CI: 0.81-1.01). Considering the entire cohort, age had an impact on the odds of being referred to the ED, with individuals older than 59 years showing twice the risk of the remaining population and those less than 19 years showing a lower risk.

Covid-19 and mucormycosis superinfection: prospective, obsevational study in a single center

Background:

Mucormycosis (MCR) has been increasingly described in patients with coronavirus disease 2019 (COVID-19), but the epidemiological factors, neurological presentation, and outcome of such patients are not well described.

Aims:

To study the patient demographics, presenting symptoms and signs, the role of co-morbidities, medications used to treat COVID-19, and the outcomes of management and to study the spectrum of neuraxis involvement and its outcome.

Methods:

It was a prospective, observational, cross-sectional hospital-based single center cohort study. Confirmed MCR cases with and without COVID-19 were collected. The study was carried out over a period of 3 months from May to July 2021, followed by 3-month follow-up. Information on epidemiological factors, neurological findings, treatment (including medical and surgical treatment), and outcome was recorded.

Results:

A total of 141 patients were diagnosed with MCR, out of which 98 were COVID-associated MCR (CAM). The CAM incidence was 0.39% among COVID-19-positive patients. The MCR case fatality rate at 90 days was 43.9% but was higher for CAM than for non-CAM patients. Older ages (>50 years), diabetes mellitus, multiple risk factors, diabetic ketoacidosis on admission, brain involvement, and history of COVID-19 pneumonitis were associated with a higher risk for death.

Conclusions:

Possibly because of improper usage of corticosteroids, zinc, oxygen, and tocilizumab, there was sudden surge of cases of MCR in the COVID-19 pandemic. Therefore, treating physicians should use the COVID-19 pneumonia regimen judiciously. Neurological involvement itself is a poor prognostic sign, but combined surgical and medical management exhibited better outcome.

Longitudinally monitored immune biomarkers predict the timing of COVID-19 outcomes

The clinical outcome of SARS-CoV-2 infection varies widely between individuals. Machine learning models can support decision making in healthcare by assessing fatality risk in patients that do not yet show severe signs of COVID-19. Most predictive models rely on static demographic features and clinical values obtained upon hospitalization. However, time-dependent biomarkers associated with COVID-19 severity, such as antibody titers, can substantially contribute to the development of more accurate outcome models. Here we show that models trained on immune biomarkers, longitudinally monitored throughout hospitalization, predicted mortality and were more accurate than models based on demographic and clinical data upon hospital admission. Our best-performing predictive models were based on the temporal analysis of anti-SARS-CoV-2 Spike IgG titers, white blood cell (WBC), neutrophil and lymphocyte counts. These biomarkers, together with C-reactive protein and blood urea nitrogen levels, were found to correlate with severity of disease and mortality in a time-dependent manner. Shapley additive explanations of our model revealed the higher predictive value of day post-symptom onset (PSO) as hospitalization progresses and showed how immune biomarkers contribute to predict mortality. In sum, we demonstrate that the kinetics of immune biomarkers can inform clinical models to serve as a powerful monitoring tool for predicting fatality risk in hospitalized COVID-19 patients, underscoring the importance of contextualizing clinical parameters according to their time post-symptom onset.

Clostridioides difficile infection (CDI) during the COVID-19 pandemic

The ongoing coronavirus disease (COVID-19) pandemic has dramatically tested healthcare systems around the world, with serious repercussions on the measures of prevention and control of hospital-acquired infections (HAIs). Among HAIs, Clostridioides difficile infection (CDI) represents one of the most important global public health threats. Although the full impact of the COVID-19 pandemic on CDI remains undetermined, depending on the development of the pandemic in the coming months, in this review literature studies of the last three years have been considered in order to depict the current situation, and make some considerations about possible future developments. If on the one hand, a general reduction in CDI incidence has been reported in several settings, mainly due to the extraordinary reinforcement of infection prevention measures, on the other hand, the critical circumstances experienced in many hospitals have limited the effectiveness of these measures, particularly in the intensive care units (ICUs), increasing the possibility of the occurrence of hospital-acquired CDI (HA-CDI). New concerns have arisen from the decrease in C. difficile testing and the increased use of broad-spectrum antibiotics reported during the pandemic. In particular, overuse of antibiotics and disinfectants may lead to a selection of resistant C. difficile strains not only in hospitals but also in the community. Furthermore, patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and patients that have survived COVID-19 may represent a new group of frail patients potentially at a higher risk of CDI, a group that could potentially increase in size due to SARS-CoV-2 evolution. In the dramatic COVID-19 era, the multifactorial nature of CDI has emerged more clearly than before, highlighting the necessity of a strong refocus on efforts to improve prevention strategies and to integrate CDI surveillance in a One Health prospective in order to curtail the public health threat posed by this infection in the next future.

Retrospection of heatwave and heat index

The frequency and intensity of extreme events especially heat waves (HW) are growing all around the world which ultimately poses a serious threat to the health of individuals. To quantify the effects of extreme temperature, appropriate information, and the importance of HW and heat index (HI) are carefully discussed for different parts of the world. Varied definitions of the HW and HI formula proposed and used by different countries are carried out systematically continent-wise. Different studies highlighted the number of definitions of HW; however, mostly used Steadman's formulae, which was developed in the late 1970s, for the calculation of HI that uses surface air temperature and relative humidity as climatic fields. Since then, dramatic changes in climatic conditions have been observed as evident from the ERA5 datasets which need to be addressed; likewise, the definition of HW, which is modified by the researchers as per the geographic conditions. It is evident from the ERA5 data that the temperature has increased by 1-2 °C as compared to the 1980s. There is a threefold increase in the number of heatwave days over most of the continents in the last 40 years. This study will help the researcher community to understand the importance of HW and HI. Furthermore, it opens the scope to develop an equation based on the present scenario keeping in mind the basics of an index as considered by Steadman.

Is the Endothelium the Missing Link in the Pathophysiology and Treatment of COVID-19 Complications?

Patients with COVID-19 present a wide spectrum of disease severity, from asymptomatic cases in the majority to serious disease leading to critical care and even death. Clinically, four different scenarios occur within the typical disease timeline: first, an incubation and asymptomatic period; second, a stage with mild symptoms due mainly to the virus itself; third, in up to 20% of the patients, a stage with severe symptoms where a hyperinflammatory response with a cytokine storm driven by host immunity induces acute respiratory distress syndrome; and finally, a post-acute sequelae (PASC) phase, which present symptoms that can range from mild or annoying to actually quite incapacitating. Although the most common manifestation is acute respiratory failure of the lungs, other organs are also frequently involved. The clinical manifestations of the COVID-19 infection support a key role for endothelial dysfunction in the pathobiology of this condition. The virus enters into the organism via its interaction with angiotensin-converting enzyme 2-receptor that is present prominently in the alveoli, but also in endothelial cells, which can be directly infected by the virus. Cytokine release syndrome can also drive endothelial damage independently. Consequently, a distinctive feature of SARS-CoV-2 infection is vascular harm, with severe endothelial injury, widespread thrombosis, microangiopathy, and neo-angiogenesis in response to endothelial damage. Therefore, endothelial dysfunction seems to be the pathophysiological substrate for severe COVID-19 complications. Biomarkers of endothelial injury could constitute strong indicators of disease progression and severity. In addition, the endothelium could represent a very attractive target to both prevent and treat these complications. To establish an adequate therapy, the underlying pathophysiology and corresponding clinical stage should be clearly identified. In this review, the clinical features of COVID-19, the central role of the endothelium in COVID-19 and in other pathologies, and the potential of specific therapies aimed at protecting the endothelium in COVID-19 patients are addressed.

Hospital admission and emergency care attendance risk for SARS-CoV-2 delta (B.1.617.2) compared with alpha (B.1.1.7) variants of concern: a cohort study

BACKGROUND

The SARS-CoV-2 delta (B.1.617.2) variant was first detected in England in March, 2021. It has since rapidly become the predominant lineage, owing to high transmissibility. It is suspected that the delta variant is associated with more severe disease than the previously dominant alpha (B.1.1.7) variant. We aimed to characterise the severity of the delta variant compared with the alpha variant by determining the relative risk of hospital attendance outcomes.

METHODS

This cohort study was done among all patients with COVID-19 in England between March 29 and May 23, 2021, who were identified as being infected with either the alpha or delta SARS-CoV-2 variant through whole-genome sequencing. Individual-level data on these patients were linked to routine health-care datasets on vaccination, emergency care attendance, hospital admission, and mortality (data from Public Health England's Second Generation Surveillance System and COVID-19-associated deaths dataset; the National Immunisation Management System; and NHS Digital Secondary Uses Services and Emergency Care Data Set). The risk for hospital admission and emergency care attendance were compared between patients with sequencing-confirmed delta and alpha variants for the whole cohort and by vaccination status subgroups. Stratified Cox regression was used to adjust for age, sex, ethnicity, deprivation, recent international travel, area of residence, calendar week, and vaccination status.

FINDINGS

Individual-level data on 43 338 COVID-19-positive patients (8682 with the delta variant, 34 656 with the alpha variant; median age 31 years [IQR 17-43]) were included in our analysis. 196 (2·3%) patients with the delta variant versus 764 (2·2%) patients with the alpha variant were admitted to hospital within 14 days after the specimen was taken (adjusted hazard ratio [HR] 2·26 [95% CI 1·32-3·89]). 498 (5·7%) patients with the delta variant versus 1448 (4·2%) patients with the alpha variant were admitted to hospital or attended emergency care within 14 days (adjusted HR 1·45 [1·08-1·95]). Most patients were unvaccinated (32 078 [74·0%] across both groups). The HRs for vaccinated patients with the delta variant versus the alpha variant (adjusted HR for hospital admission 1·94 [95% CI 0·47-8·05] and for hospital admission or emergency care attendance 1·58 [0·69-3·61]) were similar to the HRs for unvaccinated patients (2·32 [1·29-4·16] and 1·43 [1·04-1·97]; p=0·82 for both) but the precision for the vaccinated subgroup was low.

INTERPRETATION

This large national study found a higher hospital admission or emergency care attendance risk for patients with COVID-19 infected with the delta variant compared with the alpha variant. Results suggest that outbreaks of the delta variant in unvaccinated populations might lead to a greater burden on health-care services than the alpha variant.

FUNDING

Medical Research Council; UK Research and Innovation; Department of Health and Social Care; and National Institute for Health Research.

Death analysis of COVID-19 patients admitted in dedicated COVID hospital in Mumbai

Introduction:

COVID-19 poses a great threat globally and also a huge burden on developing countries due to its expensive, less effective, and toxic treatment. India is one of the countries with large number of confirmed cases. This study is done to assess the death due to COVID-19 on various parameters so that necessary action can be taken to reduce the disease burden of COVID-19.

Aim and Objective:

I) To find sociodemographic and other factors associated with mortality. II) To study various comorbidities related to the death due to COVID-19 infection. III) Recommendation for reducing mortality in COVID-19 patients.

Material and Method:

Data related to COVID-19 death was taken from MRD (Medical Record Department) & e-Health records from HMIS and was analyzed by Bivariate analysis in SPSS.

Results:

Results showed that people with 1--2 comorbidity have 62% death. Mortality was found to be more in elderly, that is, >60 years age group with 67.5% of total mortality. And in males (68.6%) as compared to female.

Conclusion:

People with comorbidities have significant association. Also, it showed that death was more common in male and elderly age group as compared to female and youngsters.

Clinical prediction system of complications among patients with COVID-19: A development and validation retrospective multicentre study during first wave of the pandemic

Clinical evidence suggests that some patients diagnosed with coronavirus disease 2019 (COVID-19) experience a variety of complications associated with significant morbidity, especially in severe cases during the initial spread of the pandemic. To support early interventions, we propose a machine learning system that predicts the risk of developing multiple complications. We processed data collected from 3,352 patient encounters admitted to 18 facilities between April 1 and April 30, 2020, in Abu Dhabi (AD), United Arab Emirates. Using data collected during the first 24 h of admission, we trained machine learning models to predict the risk of developing any of three complications after 24 h of admission. The complications include Secondary Bacterial Infection (SBI), Acute Kidney Injury (AKI), and Acute Respiratory Distress Syndrome (ARDS). The hospitals were grouped based on geographical proximity to assess the proposed system's learning generalizability, AD Middle region and AD Western & Eastern regions, A and B, respectively. The overall system includes a data filtering criterion, hyperparameter tuning, and model selection. In test set A, consisting of 587 patient encounters (mean age: 45.5), the system achieved a good area under the receiver operating curve (AUROC) for the prediction of SBI (0.902 AUROC), AKI (0.906 AUROC), and ARDS (0.854 AUROC). Similarly, in test set B, consisting of 225 patient encounters (mean age: 42.7), the system performed well for the prediction of SBI (0.859 AUROC), AKI (0.891 AUROC), and ARDS (0.827 AUROC). The performance results and feature importance analysis highlight the system's generalizability and interpretability. The findings illustrate how machine learning models can achieve a strong performance even when using a limited set of routine input variables. Since our proposed system is data-driven, we believe it can be easily repurposed for different outcomes considering the changes in COVID-19 variants over time.

The Upsurge of Diarrhea Amid COVID-19 Pandemic Makes Matter Worse in Bangladesh: A Call to Action

We have seen an alarming increase in diarrhea prevalence amid Coronavirus Disease-2019 (COVID-19) in Bangladesh. Healthcare professionals might face difficulty in diagnosis as these two infectious diseases have some common symptoms. Though there are confirmatory diagnostic tests for individual cases, there are chances of misdiagnosis as co-infections occur. Here we presented distinct clinical features of diarrhea and COVID-19 for differential diagnosis. We demonstrated the common overlapping symptoms of these two infectious diseases to facilitate fast diagnosis of patients. Also, we have discussed possible reasons for this upsurge of diarrheal infections in Bangladesh. Finally, we have made some recommendations based on our findings for managing this upsurge of diarrheal disease during the COVID-19 pandemic in Bangladesh. The healthcare authorities should take immediate measures before the tremendous twin effects of these two infectious diseases.