Obesity, Ethnicity, and Risk of Critical Care, Mechanical Ventilation, and Mortality in Patients Admitted to Hospital with COVID-19: Analysis of the ISARIC CCP-UK Cohort

The association between excess weight and COVID-19 outcomes: An umbrella review

This umbrella review assessed the association between excess weight and COVID-19 outcomes. MEDLINE, PsycINFO, and CINAHL were systematically searched for reviews that assessed the association between excess weight and COVID-19 outcomes. A second-order meta-analysis was conducted on the available data for intensive care unit admission, invasive mechanical ventilation administration, disease severity, hospitalization, and mortality. The quality of included reviews was assessed using the AMSTAR-2 appraisal tool. In total, 52 systematic reviews were included, 49 of which included meta-analyses. The risk of severe outcomes (OR = 1.86; 95% CI: 1.70 to 2.05), intensive care unit admission (OR = 1.58; 95% CI: 1.45 to 1.72), invasive mechanical ventilation administration (OR = 1.70; 95% CI: 1.57 to 1.83), hospitalization (OR = 1.82; 95% CI: 1.61 to 2.05), and mortality (OR = 1.35; 95% CI: 1.24 to 1.48) following COVID-19 infection was significantly higher in individuals living with excess weight compared with those with a healthy weight. There was limited evidence available in the included reviews regarding the influence of moderating factors such as ethnicity, and the majority of included reviews were of poor quality. Obesity appears to represent an important modifiable pre-infection risk factor for severe COVID-19 outcomes, including death.

Obesity differs from diabetes mellitus in antibody and T-cell responses post-COVID-19 recovery

OBJECTIVE

Obesity and type 2 diabetes (DM) are risk factors for severe coronavirus disease 2019 (COVID-19) outcomes, which disproportionately affect South Asian populations. This study aims to investigate the humoral and cellular immune responses to SARS-CoV-2 in adult COVID-19 survivors with overweight/obesity (Ov/Ob, BMI ≥ 23 kg/m2) and DM in Bangladesh.

METHODS

In this cross-sectional study, SARS-CoV-2-specific antibody and T-cell responses were investigated in 63 healthy and 75 PCR-confirmed COVID-19 recovered individuals in Bangladesh, during the pre-vaccination first wave of the COVID-19 pandemic in 2020.

RESULTS

In COVID-19 survivors, SARS-CoV-2 infection induced robust antibody and T-cell responses, which correlated with disease severity. After adjusting for age, sex, DM status, disease severity, and time since onset of symptoms, Ov/Ob was associated with decreased neutralizing antibody titers, and increased SARS-CoV-2 spike-specific IFN-γ response along with increased proliferation and IL-2 production by CD8 + T cells. In contrast, DM was not associated with SARS-CoV-2-specific antibody and T-cell responses after adjustment for obesity and other confounders.

CONCLUSION

Ov/Ob is associated with lower neutralizing antibody levels and higher T-cell responses to SARS-CoV-2 post-COVID-19 recovery, while antibody or T-cell responses remain unaltered in DM.

Adiposity and mortality among intensive care patients with COVID-19 and non-COVID-19 respiratory conditions: a cross-context comparison study in the UK

BACKGROUND

Adiposity shows opposing associations with mortality within COVID-19 versus non-COVID-19 respiratory conditions. We assessed the likely causality of adiposity for mortality among intensive care patients with COVID-19 versus non-COVID-19 by examining the consistency of associations across temporal and geographical contexts where biases vary.

METHODS

We used data from 297 intensive care units (ICUs) in England, Wales, and Northern Ireland (Intensive Care National Audit and Research Centre Case Mix Programme). We examined associations of body mass index (BMI) with 30-day mortality, overall and by date and region of ICU admission, among patients admitted with COVID-19 (N = 34,701; February 2020-August 2021) and non-COVID-19 respiratory conditions (N = 25,205; February 2018-August 2019).

RESULTS

Compared with non-COVID-19 patients, COVID-19 patients were younger, less often of a white ethnic group, and more often with extreme obesity. COVID-19 patients had fewer comorbidities but higher mortality. Socio-demographic and comorbidity factors and their associations with BMI and mortality varied more by date than region of ICU admission. Among COVID-19 patients, higher BMI was associated with excess mortality (hazard ratio (HR) per standard deviation (SD) = 1.05; 95% CI = 1.03-1.07). This was evident only for extreme obesity and only during February-April 2020 (HR = 1.52, 95% CI = 1.30-1.77 vs. recommended weight); this weakened thereafter. Among non-COVID-19 patients, higher BMI was associated with lower mortality (HR per SD = 0.83; 95% CI = 0.81-0.86), seen across all overweight/obesity groups and across dates and regions, albeit with a magnitude that varied over time.

CONCLUSIONS

Obesity is associated with higher mortality among COVID-19 patients, but lower mortality among non-COVID-19 respiratory patients. These associations appear vulnerable to confounding/selection bias in both patient groups, questioning the existence or stability of causal effects.

Prevalence of overweight and obesity and their effect on COVID-19 severity and hospitalization among younger than 50 years versus older than 50 years population: A systematic review and meta-analysis

Cohort studies have shown that both overweight and obesity have their impact by increasing hospitalization with COVID-19. We conducted a systematic literature search in PubMed, Google Scholar, and MedRxiv databases following the PRISMA guidelines. Statistical analyses were performed using STATA software version 16 MP (Stata Corp, College Station, TX, USA) and Med Calc software version 22.009(Med Calc software Ltd, Ostend, Belgium). The primary outcome was to measure the prevalence of overweight and obesity and their impact on the risk of hospitalization among COVID-19 patients under and above 50 years of age. In total, 184 studies involving 2,365,377 patients were included. The prevalence of overweight was highest among those younger than 50 years of age over those older than 50 years of age, (26.33% vs. 30.46%), but there was no difference in obesity (36.30% vs. 36.02%). Overall, the pooled prevalence of overweight and obesity among hospitalized COVID-19 patients was 31.0% and 36.26%, respectively. Compared with normal weight, the odds of hospitalization with overweight (odds ratio [OR] 2.186, 95% confidence interval [CI] [1.19, 3.99], p < 0.01) and obesity (OR 3.069, 95% CI [1.67, 5.61], p < 0.001) in those younger than 50 years and obesity (OR 3.977, 95% CI [2.75, 5.73], p < 0.001) in the older than 50 years age group were significantly high. The increased prevalence of overweight and obesity among the under 50 years age group and obesity among the older than 50 years age group significantly increased the rate of COVID-19 infections, severity and hospitalization.

Hospital Admission Factors Independently Affecting the Risk of Mortality of COVID-19 Patients

INTRODUCTION

COVID-19 is a disease characterized by high in-hospital mortality, which seems to be dependent on many predisposing factors.

OBJECTIVES

The aim of this study was to analyze the clinical symptoms, abnormalities in the results of laboratory tests, and coexisting chronic diseases that independently affected the risk of in-hospital mortality in patients with COVID-19.

PATIENTS AND METHODS

We analyzed the records of patients with COVID-19 who were hospitalized from 6 March 2020 to 30 November 2021.

RESULTS

Out of the entire group of 2138 patients who were analyzed, 12.82% died during hospitalization. In-hospital mortality was independently associated with older age (OR 1.53, 95% CI 1.20-1.97); lower arterial blood oxygen saturation (OR 0.95, 95% CI 0.92-0.99); the presence of a neoplasm (OR 4.45, 95% CI 2.01-9.62), a stomach ulcer (OR 3.35, 95% CI 0.94-11.31), and dementia (OR 3.40, 95% CI 1.36-8.26); a higher score on the SOFA scale (OR 1.73, 95% CI 1.52-1.99); higher lactate dehydrogenase (LDH) (OR 1.08, 95% CI 1.05-1.12); higher N-terminal pro-brain natriuretic peptide (NT pro BNP) (OR 1.06, 95% CI 1.01-1.11); and lower total bilirubin in blood concentration (OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

We found that low oxygen saturation, old age, and the coexistence of cancer, gastric ulcers, and dementia syndrome were variables that independently increased mortality during hospitalization due to COVID-19. Moreover, we found that decreased platelet count and bilirubin concentration and increased levels of LDH and NT-proBNP were laboratory test results that independently indicated a higher risk of mortality. We also confirmed the usefulness of the SOFA scale in predicting treatment results. The ability to identify mortality risk factors on admission to hospital will facilitate both adjusting the intensity of treatment and the monitoring of patients infected with SARS-CoV-2.

Clinical outcomes following COVID-19 infection in ethnic minority groups in the UK: a systematic review and meta-analysis

OBJECTIVES

This study evaluated the differences in clinical outcomes of COVID-19 infection between ethnic minorities and the White ethnic group in the UK.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This study included adult residents in the UK with confirmed COVID-19 infection. The outcomes evaluated in this study were mortality, intensive care unit (ICU) admission and invasive mechanical ventilation (IMV). Outcome data were compared between individuals from ethnic minority groups and individuals from a White ethnic background. MEDLINE, Embase, Cochrane, medRxiv and PROSPERO were searched for articles published between May 2020 and April 2021. The risk of bias was evaluated using the Newcastle-Ottawa Scale checklist.

PROSPERO ID

CRD42021248117.

RESULTS

Fourteen studies (767,177 participants) were included in the current review. In the adjusted analysis, the pooled odds ratio (OR) for mortality following COVID-19 infection was higher for Black (OR 1.83, 95% confidence interval [CI]: 1.21-2.76, number of studies [k] = 6), Asian (OR 1.16, 95% CI: 0.85-1.57, k = 6) and Mixed and Other (MO) ethnic groups (OR 1.12, 95% CI: 1.04-1.20, k = 5) compared with the White ethnic group. The adjusted and unadjusted ORs of ICU admission for many of the ethnic minority groups were more than double the OR values for the White ethnic group (Black ethnic group = OR 2.32, 95% CI: 1.73-3.11, k = 5; Asian ethnic group = OR 2.34, 95% CI: 1.89-2.90, k = 5; and MO ethnic group = OR 2.26, 95% CI: 1.64-3.11, k = 4). In the adjusted analysis for IMV, the ORs were similarly significantly raised in ethnic minority groups compared with the White ethnic group (Black ethic group = OR 2.03, 95% CI: 1.80-2.29, k = 3; Asian ethnic group = OR 1.84, 95% CI: 1.20-2.80, k = 3; and MO ethnic group = OR 2.09, 95% CI: 1.35-3.22, k = 3).

CONCLUSION

This review found that in the UK, Black, Asian and MO ethnic groups experienced increased COVID-19-related disease severity and mortality compared with the White ethnic group majority.

Expert Consensus: Main Risk Factors for Poor Prognosis in COVID-19 and the Implications for Targeted Measures against SARS-CoV-2

The clinical evolution of patients infected with the Severe Acute Respiratory Coronavirus type 2 (SARS-CoV-2) depends on the complex interplay between viral and host factors. The evolution to less aggressive but better-transmitted viral variants, and the presence of immune memory responses in a growing number of vaccinated and/or virus-exposed individuals, has caused the pandemic to slowly wane in virulence. However, there are still patients with risk factors or comorbidities that put them at risk of poor outcomes in the event of having the coronavirus infectious disease 2019 (COVID-19). Among the different treatment options for patients with COVID-19, virus-targeted measures include antiviral drugs or monoclonal antibodies that may be provided in the early days of infection. The present expert consensus is based on a review of all the literature published between 1 July 2021 and 15 February 2022 that was carried out to establish the characteristics of patients, in terms of presence of risk factors or comorbidities, that may make them candidates for receiving any of the virus-targeted measures available in order to prevent a fatal outcome, such as severe disease or death. A total of 119 studies were included from the review of the literature and 159 were from the additional independent review carried out by the panelists a posteriori. Conditions found related to strong recommendation of the use of virus-targeted measures in the first days of COVID-19 were age above 80 years, or above 65 years with another risk factor; antineoplastic chemotherapy or active malignancy; HIV infection with CD4+ cell counts < 200/mm³; and treatment with anti-CD20 immunosuppressive drugs. There is also a strong recommendation against using the studied interventions in HIV-infected patients with a CD4+ nadir <200/mm³ or treatment with other immunosuppressants. Indications of therapies against SARS-CoV-2, regardless of vaccination status or history of infection, may still exist for some populations, even after COVID-19 has been declared to no longer be a global health emergency by the WHO.

Obesity as an independent risk factor for COVID-19 severity and mortality

BACKGROUND

Since December 2019, the world has struggled with the COVID-19 pandemic. Even after the introduction of various vaccines, this disease still takes a considerable toll. In order to improve the optimal allocation of resources and communication of prognosis, healthcare providers and patients need an accurate understanding of factors (such as obesity) that are associated with a higher risk of adverse outcomes from the COVID-19 infection.

OBJECTIVES

To evaluate obesity as an independent prognostic factor for COVID-19 severity and mortality among adult patients in whom infection with the COVID-19 virus is confirmed.

SEARCH METHODS

MEDLINE, Embase, two COVID-19 reference collections, and four Chinese biomedical databases were searched up to April 2021.

SELECTION CRITERIA

We included case-control, case-series, prospective and retrospective cohort studies, and secondary analyses of randomised controlled trials if they evaluated associations between obesity and COVID-19 adverse outcomes including mortality, mechanical ventilation, intensive care unit (ICU) admission, hospitalisation, severe COVID, and COVID pneumonia. Given our interest in ascertaining the independent association between obesity and these outcomes, we selected studies that adjusted for at least one factor other than obesity. Studies were evaluated for inclusion by two independent reviewers working in duplicate.  DATA COLLECTION AND ANALYSIS: Using standardised data extraction forms, we extracted relevant information from the included studies. When appropriate, we pooled the estimates of association across studies with the use of random-effects meta-analyses. The Quality in Prognostic Studies (QUIPS) tool provided the platform for assessing the risk of bias across each included study. In our main comparison, we conducted meta-analyses for each obesity class separately. We also meta-analysed unclassified obesity and obesity as a continuous variable (5 kg/m2 increase in BMI (body mass index)). We used the GRADE framework to rate our certainty in the importance of the association observed between obesity and each outcome. As obesity is closely associated with other comorbidities, we decided to prespecify the minimum adjustment set of variables including age, sex, diabetes, hypertension, and cardiovascular disease for subgroup analysis.  MAIN RESULTS: We identified 171 studies, 149 of which were included in meta-analyses.  As compared to 'normal' BMI (18.5 to 24.9 kg/m2) or patients without obesity, those with obesity classes I (BMI 30 to 35 kg/m2), and II (BMI 35 to 40 kg/m2) were not at increased odds for mortality (Class I: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.94 to 1.16, high certainty (15 studies, 335,209 participants); Class II: OR 1.16, 95% CI 0.99 to 1.36, high certainty (11 studies, 317,925 participants)). However, those with class III obesity (BMI 40 kg/m2 and above) may be at increased odds for mortality (Class III: OR 1.67, 95% CI 1.39 to 2.00, low certainty, (19 studies, 354,967 participants)) compared to normal BMI or patients without obesity. For mechanical ventilation, we observed increasing odds with higher classes of obesity in comparison to normal BMI or patients without obesity (class I: OR 1.38, 95% CI 1.20 to 1.59, 10 studies, 187,895 participants, moderate certainty; class II: OR 1.67, 95% CI 1.42 to 1.96, 6 studies, 171,149 participants, high certainty; class III: OR 2.17, 95% CI 1.59 to 2.97, 12 studies, 174,520 participants, high certainty). However, we did not observe a dose-response relationship across increasing obesity classifications for ICU admission and hospitalisation.

AUTHORS' CONCLUSIONS

Our findings suggest that obesity is an important independent prognostic factor in the setting of COVID-19. Consideration of obesity may inform the optimal management and allocation of limited resources in the care of COVID-19 patients.

Global prevalence and effect of comorbidities and smoking status on severity and mortality of COVID-19 in association with age and gender: a systematic review, meta-analysis and meta-regression

A COVID-19 patient often presents with multiple comorbidities and is associated with adverse outcomes. A comprehensive assessment of the prevalence of comorbidities in patients with COVID-19 is essential. This study aimed to assess the prevalence of comorbidities, severity and mortality with regard to geographic region, age, gender and smoking status in patients with COVID-19. A systematic review and multistage meta-analyses were reported using PRISMA guidelines. PubMed/MEDLINE, SCOPUS, Google Scholar and EMBASE were searched from January 2020 to October 2022. Cross-sectional studies, cohort studies, case series studies, and case-control studies on comorbidities reporting among the COVID-19 populations that were published in English were included. The pooled prevalence of various medical conditions in COVID-19 patients was calculated based on regional population size weights. Stratified analyses were performed to understand the variations in the medical conditions based on age, gender, and geographic region. A total of 190 studies comprising 105 million COVID-19 patients were included. Statistical analyses were performed using STATA software, version 16 MP (StataCorp, College Station, TX). Meta-analysis of proportion was performed to obtain pooled values of the prevalence of medical comorbidities: hypertension (39%, 95% CI 36-42, n = 170 studies), obesity (27%, 95% CI 25-30%, n = 169 studies), diabetes (27%, 95% CI 25-30%, n = 175), and asthma (8%, 95% CI 7-9%, n = 112). Moreover, the prevalence of hospitalization was 35% (95% CI 29-41%, n = 61), intensive care admissions 17% (95% CI 14-21, n = 106), and mortality 18% (95% CI 16-21%, n = 145). The prevalence of hypertension was highest in Europe at 44% (95% CI 39-47%, n = 68), obesity and diabetes at 30% (95% CI, 26-34, n = 79) and 27% (95%CI, 24-30, n = 80) in North America, and asthma in Europe at 9% (95% CI 8-11, n = 41). Obesity was high among the ≥ 50 years (30%, n = 112) age group, diabetes among Men (26%, n = 124) and observational studies reported higher mortality than case-control studies (19% vs. 14%). Random effects meta-regression found a significant association between age and diabetes (p < 0.001), hypertension (p < 0.001), asthma (p < 0.05), ICU admission (p < 0.05) and mortality (p < 0.001). Overall, a higher global prevalence of hypertension (39%) and a lower prevalence of asthma (8%), and 18% of mortality were found in patients with COVID-19. Hence, geographical regions with respective chronic medical comorbidities should accelerate regular booster dose vaccination, preferably to those patients with chronic comorbidities, to prevent and lower the severity and mortality of COVID-19 disease with novel SARS-CoV-2 variants of concern (VOC).

SARS-CoV-2 antibody responses associate with sex, age and disease severity in previously uninfected people admitted to hospital with COVID-19: An ISARIC4C prospective study

The SARS-CoV-2 pandemic enables the analysis of immune responses induced against a novel coronavirus infecting immunologically naïve individuals. This provides an opportunity for analysis of immune responses and associations with age, sex and disease severity. Here we measured an array of solid-phase binding antibody and viral neutralising Ab (nAb) responses in participants (n=337) of the ISARIC4C cohort and characterised their correlation with peak disease severity during acute infection and early convalescence. Overall, the responses in a Double Antigen Binding Assay (DABA) for antibody to the receptor binding domain (anti-RBD) correlated well with IgM as well as IgG responses against viral spike, S1 and nucleocapsid protein (NP) antigens. DABA reactivity also correlated with nAb. As we and others reported previously, there is greater risk of severe disease and death in older men, whilst the sex ratio was found to be equal within each severity grouping in younger people. In older males with severe disease (mean age 68 years), peak antibody levels were found to be delayed by one to two weeks compared with women, and nAb responses were delayed further. Additionally, we demonstrated that solid-phase binding antibody responses reached higher levels in males as measured via DABA and IgM binding against Spike, NP and S1 antigens. In contrast, this was not observed for nAb responses. When measuring SARS-CoV-2 RNA transcripts (as a surrogate for viral shedding) in nasal swabs at recruitment, we saw no significant differences by sex or disease severity status. However, we have shown higher antibody levels associated with low nasal viral RNA indicating a role of antibody responses in controlling viral replication and shedding in the upper airway. In this study, we have shown discernible differences in the humoral immune responses between males and females and these differences associate with age as well as with resultant disease severity.

Association of BMI with general health, working capacity recovered, and post-acute sequelae of COVID-19

OBJECTIVE

The aim of this study was to determine the risk of post-acute sequelae of COVID-19 associated with the continuous spectrum of BMI.

METHODS

Epidemiology of Long COVID (EPILOC) is a population-based study conducted in Baden-Württemberg (Germany), including subjects aged 18 to 65 years who tested positive for SARS-CoV-2 between October 2020 and April 2021. Eligible subjects answered a standardized questionnaire, including sociodemographic characteristics, lifestyle factors, and the presence of specific symptoms. Participants assessed their current general health recovery and working capacity compared with the pre-infection situation and provided their body height and weight. Generalized additive models were used to assess the association of BMI with general health recovered, working capacity recovered, and prevalence of fatigue, cognitive impairment, and chest symptoms.

RESULTS

The analyses included 11,296 individuals (41% male), with a mean age of 44.0 (SD 13.7) years. Best general health recovery was observed at BMI of 22.1 (95% CI: 21.0-27.0) kg/m² in men and BMI of 21.6 (95% CI: 20.3-23.1) kg/m² in women. In addition, we found that increasing BMI was consistently associated with post-COVID fatigue, neurocognitive impairment, and chest symptoms.

CONCLUSIONS

High BMI contributes to impaired recovery after SARS-CoV-2 infection; however, a low BMI is associated with impaired recovery as well.

The effect of diabetes on COVID-19 incidence and mortality: Differences between highly-developed-country and high-migratory-pressure-country populations

The objective of this study was to compare the effect of diabetes and pathologies potentially related to diabetes on the risk of infection and death from COVID-19 among people from Highly-Developed-Country (HDC), including Italians, and immigrants from the High-Migratory-Pressure-Countries (HMPC). Among the population with diabetes, whose prevalence is known to be higher among immigrants, we compared the effect of body mass index among HDC and HMPC populations. A population-based cohort study was conducted, using population registries and routinely collected surveillance data. The population was stratified into HDC and HMPC, according to the place of birth; moreover, a focus was set on the South Asiatic population. Analyses restricted to the population with type-2 diabetes were performed. We reported incidence (IRR) and mortality rate ratios (MRR) and hazard ratios (HR) with 95% confidence interval (CI) to estimate the effect of diabetes on SARS-CoV-2 infection and COVID-19 mortality. Overall, IRR of infection and MRR from COVID-19 comparing HMPC with HDC group were 0.84 (95% CI 0.82-0.87) and 0.67 (95% CI 0.46-0.99), respectively. The effect of diabetes on the risk of infection and death from COVID-19 was slightly higher in the HMPC population than in the HDC population (HRs for infection: 1.37 95% CI 1.22-1.53 vs. 1.20 95% CI 1.14-1.25; HRs for mortality: 3.96 95% CI 1.82-8.60 vs. 1.71 95% CI 1.50-1.95, respectively). No substantial difference in the strength of the association was observed between obesity or other comorbidities and SARS-CoV-2 infection. Similarly for COVID-19 mortality, HRs for obesity (HRs: 18.92 95% CI 4.48-79.87 vs. 3.91 95% CI 2.69-5.69) were larger in HMPC than in the HDC population, but differences could be due to chance. Among the population with diabetes, the HMPC group showed similar incidence (IRR: 0.99 95% CI: 0.88-1.12) and mortality (MRR: 0.89 95% CI: 0.49-1.61) to that of HDC individuals. The effect of obesity on incidence was similar in both HDC and HMPC populations (HRs: 1.73 95% CI 1.41-2.11 among HDC vs. 1.41 95% CI 0.63-3.17 among HMPC), although the estimates were very imprecise. Despite a higher prevalence of diabetes and a stronger effect of diabetes on COVID-19 mortality in HMPC than in the HDC population, our cohort did not show an overall excess risk of COVID-19 mortality in immigrants.

Fewer COVID-19 Neurological Complications with Dexamethasone and Remdesivir

OBJECTIVE

The objective of this study was to assess the impact of treatment with dexamethasone, remdesivir or both on neurological complications in acute coronavirus diease 2019 (COVID-19).

METHODS

We used observational data from the International Severe Acute and emerging Respiratory Infection Consortium World Health Organization (WHO) Clinical Characterization Protocol, United Kingdom. Hospital inpatients aged ≥18 years with laboratory-confirmed severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection admitted between January 31, 2020, and June 29, 2021, were included. Treatment allocation was non-blinded and performed by reporting clinicians. A propensity scoring methodology was used to minimize confounding. Treatment with remdesivir, dexamethasone, or both was assessed against the standard of care. The primary outcome was a neurological complication occurring at the point of death, discharge, or resolution of the COVID-19 clinical episode.

RESULTS

Out of 89,297 hospital inpatients, 64,088 had severe COVID-19 and 25,209 had non-hypoxic COVID-19. Neurological complications developed in 4.8% and 4.5%, respectively. In both groups, neurological complications were associated with increased mortality, intensive care unit (ICU) admission, worse self-care on discharge, and time to recovery. In patients with severe COVID-19, treatment with dexamethasone (n = 21,129), remdesivir (n = 1,428), and both combined (n = 10,846) were associated with a lower frequency of neurological complications: OR = 0.76 (95% confidence interval [CI] = 0.69-0.83), OR = 0.69 (95% CI = 0.51-0.90), and OR = 0.54 (95% CI = 0.47-0.61), respectively. In patients with non-hypoxic COVID-19, dexamethasone (n = 2,580) was associated with less neurological complications (OR = 0.78, 95% CI = 0.62-0.97), whereas the dexamethasone/remdesivir combination (n = 460) showed a similar trend (OR = 0.63, 95% CI = 0.31-1.15).

INTERPRETATION

Treatment with dexamethasone, remdesivir, or both in patients hospitalized with COVID-19 was associated with a lower frequency of neurological complications in an additive manner, such that the greatest benefit was observed in patients who received both drugs together. ANN NEUROL 2023;93:88-102.

Spike-antibody responses to COVID-19 vaccination by demographic and clinical factors in a prospective community cohort study

Vaccination constitutes the best long-term solution against Coronavirus Disease-2019; however, vaccine-derived immunity may not protect all groups equally, and the durability of protective antibodies may be short. We evaluate Spike-antibody responses following BNT162b2 or ChAdOx1-S vaccination amongst SARS-CoV2-naive adults across England and Wales enrolled in a prospective cohort study (Virus Watch). Here we show BNT162b2 recipients achieved higher peak antibody levels after two doses; however, both groups experience substantial antibody waning over time. In 8356 individuals submitting a sample ≥28 days after Dose 2, we observe significantly reduced Spike-antibody levels following two doses amongst individuals reporting conditions and therapies that cause immunosuppression. After adjusting for these, several common chronic conditions also appear to attenuate the antibody response. These findings suggest the need to continue prioritising vulnerable groups, who have been vaccinated earliest and have the most attenuated antibody responses, for future boosters.

COVID-19 Outcomes in Minority Ethnic Groups: Do Obesity and Metabolic Risk Play a Role?

PURPOSE OF REVIEW

Globally, minority ethnic groups have been at higher risk of COVID-19 mortality and morbidity than majority populations. This review outlines factors that may interact to create these inequalities and explores the hypothesis that differing levels of cardio-metabolic risk, according to ethnic group, play a role.

RECENT FINDINGS

Two UK Biobank studies have reported that the body mass index is more strongly associated with an increased risk of COVID-19 infection and mortality in minority ethnic populations than in White populations. A study of UK patients found that the strongest association between obesity and adverse COVID-19 outcomes was in people of Black ethnicity. Differences in the prevalence of obesity and its metabolic sequelae have been shown to partly mediate ethnic inequalities in COVID-19 outcomes, although not always consistently. It is possible that ethnic differences in the consequences of obesity may explain some of the remaining disparity in COVID-19 risk.

Reviving the mutual impact of SARS-COV-2 and obesity on patients: From morbidity to mortality

Obesity-related metabolic dysfunction, endothelium imbalance, chronic inflammation, immune dysregulation, and its comorbidities may all have a role in systemic inflammation, leading to the pulmonary fibrosis and cytokine storm, which leads to failure of lung function, which is a hallmark of severe SARS-CoV-2 infection. Obesity may also disrupt the function of mucociliary escalators and cooperation of epithelial cell's motile cilia in the airway, limiting the clearance of the coronavirus that causes severe acute respiratory syndrome (SARS-CoV-2). Adipose tissues in obese patients have a greater number of proteases and receptors for SARS-CoV-2 admittance, proposing that they could serve as an accelerator and reservoir for this virus, boosting immunological response and systemic inflammation. Lastly, anti-inflammatory cytokines such as anti-IL-6 and the infusion of mesenchymal stem cells could be used as a modulation therapy of immunity to help COVID-19 patients. Obesity, on the other hand, is linked to the progress of COVID-19 through a variety of molecular pathways, and obese people are part of the SARS-CoV-2 susceptible individuals, necessitating more protective measures.

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.

Ethnic Differences in Coronavirus Disease 2019 Hospitalization and Hospital Outcomes in a Multiethnic Population in the Netherlands

Background

Evidence from the United States and United Kingdom suggests that ethnic minority populations are at an increased risk for developing severe coronavirus disease 2019 (COVID-19); however, data from other West-European countries are scarce.

Methods

We analyzed data from 1439 patients admitted between February 2020 and January 2021 to 4 main hospitals in Amsterdam and Almere, the Netherlands. Differences in the risk for hospitalization were assessed by comparing demographics to the general population. Using a population-based cohort as reference, we determined differences in the association between comorbidities and COVID-19 hospitalization. Outcomes after hospitalization were analyzed using Cox regression.

Results

The hospitalization risk was higher in all ethnic minority groups than in those of Dutch origin, with age-adjusted odds ratios ranging from 2.2 (95% confidence interval [CI], 1.7-2.6) in Moroccans to 4.5 (95% CI, 3.2-6.0) in Ghanaians. Hypertension and diabetes were similarly associated with COVID-19 hospitalization. For all other comorbidities, we found differential associations. Intensive care unit admission and mortality during 21-day follow-up after hospitalization was comparable between ethnicities.

Conclusions

The risk of COVID-19 hospitalization was higher in all ethnic minority groups compared to the Dutch, but the risk of adverse outcomes after hospitalization was similar. Our results suggest that these inequalities may in part be attributable to comorbidities that can be prevented by targeted public health prevention measures. More work is needed to gain insight into the role of other potential factors such as social determinants of health, which might have contributed to the ethnic inequalities in COVID-19 hospitalization.

Metabolically unhealthy individuals, either with obesity or not, have a higher risk of critical coronavirus disease 2019 outcomes than metabolically healthy individuals without obesity

BACKGROUND

This study aimed to determine the relative and independent contributions of impaired metabolic health and obesity to critical coronavirus disease 2019 (COVID-19).

METHODS

We analyzed 4069 COVID-19 patients between January and June 2020 in South Korea, classified into four groups according to metabolic health status and body mass index (BMI): metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy obesity (MHO), and metabolically unhealthy obesity (MUO). The primary outcome was a composite of intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), extracorporeal membrane oxygenation (ECMO), and death. Multivariable Cox proportional hazard regression models were used to estimate the hazard ratio (HR) for the outcome.

RESULTS

The incidence rate (per 100 person-months) of critical COVID-19 was the lowest in the MHNW group (0.90), followed by the MHO (1.64), MUNW (3.37), and MUO (3.37) groups. Compared with MHNW, a significantly increased risk of critical COVID-19 was observed in MUNW (HR, 1.41; 95% CI, 1.01-1.98) and MUO (HR, 1.77; 95% CI, 1.39-2.44) but not in MHO (HR, 1.48; 95% CI, 0.98-2.23). The risk of ICU admission or IMV/ECMO was increased only in MUO; however, the risk of death was significantly higher in MUNW and MUO. The risk of critical COVID-19 increased insignificantly by 2% per 1 kg/m² BMI increase but significantly by 13% per 1 metabolically unhealthy component increase, even after mutually adjusting for BMI and metabolic health status.

CONCLUSIONS

Metabolic health is more important to COVID-19 outcomes than obesity itself, suggesting that metabolic health status should be considered for a precise and tailored management of COVID-19 patients.

A population-based cohort study of obesity, ethnicity and COVID-19 mortality in 12.6 million adults in England

Obesity and ethnicity are known risk factors for COVID-19 outcomes, but their combination has not been extensively examined. We investigate the association between body mass index (BMI) and COVID-19 mortality across different ethnic groups using linked national Census, electronic health records and mortality data for adults in England from the start of pandemic (January 2020) to December 2020. There were 30,067 (0.27%), 1,208 (0.29%), 1,831 (0.29%), 845 (0.18%) COVID-19 deaths in white, Black, South Asian and other ethnic minority groups, respectively. Here we show that BMI was more strongly associated with COVID-19 mortality in ethnic minority groups, resulting in an ethnic risk of COVID-19 mortality that was dependant on BMI. The estimated risk of COVID-19 mortality at a BMI of 40 kg/m² in white ethnicities was equivalent to the risk observed at a BMI of 30.1 kg/m², 27.0 kg/m², and 32.2 kg/m² in Black, South Asian and other ethnic minority groups, respectively.

Which children and young people are at higher risk of severe disease and death after hospitalisation with SARS-CoV-2 infection in children and young people: A systematic review and individual patient meta-analysis

BACKGROUND

We aimed to describe pre-existing factors associated with severe disease, primarily admission to critical care, and death secondary to SARS-CoV-2 infection in hospitalised children and young people (CYP), within a systematic review and individual patient meta-analysis.

METHODS

We searched Pubmed, European PMC, Medline and Embase for case series and cohort studies published between 1st January 2020 and 21st May 2021 which included all CYP admitted to hospital with ≥ 30 CYP with SARS-CoV-2 or ≥ 5 CYP with PIMS-TS or MIS-C. Eligible studies contained (1) details of age, sex, ethnicity or co-morbidities, and (2) an outcome which included admission to critical care, mechanical invasive ventilation, cardiovascular support, or death. Studies reporting outcomes in more restricted groupings of co-morbidities were eligible for narrative review. We used random effects meta-analyses for aggregate study-level data and multilevel mixed effect models for IPD data to examine risk factors (age, sex, comorbidities) associated with admission to critical care and death. Data shown are odds ratios and 95% confidence intervals (CI).PROSPERO: CRD42021235338.

FINDINGS

83 studies were included, 57 (21,549 patients) in the meta-analysis (of which 22 provided IPD) and 26 in the narrative synthesis. Most studies had an element of bias in their design or reporting. Sex was not associated with critical care or death. Compared with CYP aged 1-4 years (reference group), infants (aged <1 year) had increased odds of admission to critical care (OR 1.63 (95% CI 1.40-1.90)) and death (OR 2.08 (1.57-2.86)). Odds of death were increased amongst CYP over 10 years (10-14 years OR 2.15 (1.54-2.98); >14 years OR 2.15 (1.61-2.88)).The number of comorbid conditions was associated with increased odds of admission to critical care and death for COVID-19 in a step-wise fashion. Compared with CYP without comorbidity, odds ratios for critical care admission were: 1.49 (1.45-1.53) for 1 comorbidity; 2.58 (2.41-2.75) for 2 comorbidities; 2.97 (2.04-4.32) for ≥3 comorbidities. Corresponding odds ratios for death were: 2.15 (1.98-2.34) for 1 comorbidity; 4.63 (4.54-4.74) for 2 comorbidities and 4.98 (3.78-6.65) for ≥3 comorbidities. Odds of admission to critical care were increased for all co-morbidities apart from asthma (0.92 (0.91-0.94)) and malignancy (0.85 (0.17-4.21)) with an increased odds of death in all co-morbidities considered apart from asthma. Neurological and cardiac comorbidities were associated with the greatest increase in odds of severe disease or death. Obesity increased the odds of severe disease and death independently of other comorbidities. IPD analysis demonstrated that, compared to children without co-morbidity, the risk difference of admission to critical care was increased in those with 1 comorbidity by 3.61% (1.87-5.36); 2 comorbidities by 9.26% (4.87-13.65); ≥3 comorbidities 10.83% (4.39-17.28), and for death: 1 comorbidity 1.50% (0.00-3.10); 2 comorbidities 4.40% (-0.10-8.80) and ≥3 co-morbidities 4.70 (0.50-8.90).

INTERPRETATION

Hospitalised CYP at greatest vulnerability of severe disease or death with SARS-CoV-2 infection are infants, teenagers, those with cardiac or neurological conditions, or 2 or more comorbid conditions, and those who are obese. These groups should be considered higher priority for vaccination and for protective shielding when appropriate. Whilst odds ratios were high, the absolute increase in risk for most comorbidities was small compared to children without underlying conditions.

FUNDING

RH is in receipt of a fellowship from Kidney Research UK (grant no. TF_010_20171124). JW is in receipt of a Medical Research Council Fellowship (Grant No. MR/R00160X/1). LF is in receipt of funding from Martin House Children's Hospice (there is no specific grant number for this). RV is in receipt of a grant from the National Institute of Health Research to support this work (grant no NIHR202322). Funders had no role in study design, data collection, analysis, decision to publish or preparation of the manuscript.

Mechanisms contributing to adverse outcomes of COVID-19 in obesity

A growing amount of epidemiological data from multiple countries indicate an increased prevalence of obesity, more importantly central obesity, among hospitalized subjects with COVID-19. This suggests that obesity is a major factor contributing to adverse outcome of the disease. As it is a metabolic disorder with dysregulated immune and endocrine function, it is logical that dysfunctional metabolism contributes to the mechanisms behind obesity being a risk factor for adverse outcome in COVID-19. Emerging data suggest that in obese subjects, (a) the molecular mechanisms of viral entry and spread mediated through ACE2 receptor, a multifunctional host cell protein which links to cellular homeostasis mechanisms, are affected. This includes perturbation of the physiological renin-angiotensin system pathway causing pro-inflammatory and pro-thrombotic challenges (b) existent metabolic overload and ER stress-induced UPR pathway make obese subjects vulnerable to severe COVID-19, (c) host cell response is altered involving reprogramming of metabolism and epigenetic mechanisms involving microRNAs in line with changes in obesity, and (d) adiposopathy with altered endocrine, adipokine, and cytokine profile contributes to altered immune cell metabolism, systemic inflammation, and vascular endothelial dysfunction, exacerbating COVID-19 pathology. In this review, we have examined the available literature on the underlying mechanisms contributing to obesity being a risk for adverse outcome in COVID-19.

Risk factors for PICU admission and death among children and young people hospitalized with COVID-19 and PIMS-TS in England during the first pandemic year

Identifying which children and young people (CYP) are most vulnerable to serious infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is important to guide protective interventions. To address this question, we used data for all hospitalizations in England among 0-17 year olds from 1 February 2019 to 31 January 2021. We examined how sociodemographic factors and comorbidities might be risk factors for pediatric intensive care unit (PICU) admission among hospitalizations due to the following causes: Coronavirus Disease 2019 (COVID-19) and pediatric inflammatory multi-system syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the first pandemic year (2020-2021); hospitalizations due to all other non-traumatic causes in 2020-2021; hospitalizations due to all non-traumatic causes in 2019-2020; and hospitalizations due to influenza in 2019-2020. Risk of PICU admission and death from COVID-19 or PIMS-TS in CYP was very low. We identified 6,338 hospitalizations with COVID-19, of which 259 were admitted to a PICU and eight CYP died. We identified 712 hospitalizations with PIMS-TS, of which 312 were admitted to a PICU and fewer than five CYP died. Hospitalizations with COVID-19 and PIMS-TS were more common among males, older CYP, those from socioeconomically deprived neighborhoods and those who were of non-White ethnicity (Black, Asian, Mixed or Other). The odds of PICU admission were increased in CYP younger than 1 month old and decreased among 15-17 year olds compared to 1-4 year olds with COVID-19; increased in older CYP and females with PIMS-TS; and increased for Black compared to White ethnicity in patients with COVID-19 and PIMS-TS. Odds of PICU admission in COVID-19 were increased for CYP with comorbidities and highest for CYP with multiple medical problems. Increases in odds of PICU admission associated with different comorbidities in COVID-19 showed a similar pattern to other causes of hospitalization examined and, thus, likely reflect background vulnerabilities. These findings identify distinct risk factors associated with PICU admission among CYP with COVID-19 or PIMS-TS that might aid treatment and prevention strategies.

The vicious cycle: a history of obesity and COVID-19

Recently, we face a surge in the fast-forward Coronavirus Disease 2019 (COVID-19) pandemic with nearly 170 million confirmed cases and almost 3.5 million confirmed deaths at the end of May 2021. Obesity, also known as the pandemic of the 21st century, has been evolving as an adverse prognostic marker. Obesity is associated with a higher risk of being SARS-CoV-2-positive (46%), as well as hospitalization (113%) and death (48%) due to COVID-19. It is especially true for subjects with morbid obesity. Also, observational studies suggest that in the case of COVID-19, no favorable “obesity paradox” is observed. Therefore, it is postulated to introduce a new entity, i.e., coronavirus disease-related cardiometabolic syndrome (CIRCS). In theory, it applies to all stages of COVID-19, i.e., prevention, acute proceedings (from COVID-19 diagnosis to resolution or three months), and long-term outcomes. Consequently, lifestyle changes, glycemic control, and regulation of the renin-angiotensin-aldosterone pathway have crucial implications for preventing and managing subjects with COVID-19. Finally, it is crucial to use cardioprotective drugs such as angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and statins. Nevertheless, there is the need to conduct prospective studies and registries better to evaluate the issue of obesity in COVID-19 patients.

Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries

OBJECTIVE

To estimate the direct and indirect effects of the covid-19 pandemic on mortality in 2020 in 29 high income countries with reliable and complete age and sex disaggregated mortality data.

DESIGN

Time series study of high income countries.

SETTING

Austria, Belgium, Czech Republic, Denmark, England and Wales, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, Latvia, Lithuania, the Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Scotland, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, and United States.

PARTICIPANTS

Mortality data from the Short-term Mortality Fluctuations data series of the Human Mortality Database for 2016-20, harmonised and disaggregated by age and sex.

INTERVENTIONS

Covid-19 pandemic and associated policy measures.

MAIN OUTCOME MEASURES

Weekly excess deaths (observed deaths versus expected deaths predicted by model) in 2020, by sex and age (0-14, 15-64, 65-74, 75-84, and ≥85 years), estimated using an over-dispersed Poisson regression model that accounts for temporal trends and seasonal variability in mortality.

RESULTS

An estimated 979 000 (95% confidence interval 954 000 to 1 001 000) excess deaths occurred in 2020 in the 29 high income countries analysed. All countries had excess deaths in 2020, except New Zealand, Norway, and Denmark. The five countries with the highest absolute number of excess deaths were the US (458 000, 454 000 to 461 000), Italy (89 100, 87 500 to 90 700), England and Wales (85 400, 83 900 to 86 800), Spain (84 100, 82 800 to 85 300), and Poland (60 100, 58 800 to 61 300). New Zealand had lower overall mortality than expected (-2500, -2900 to -2100). In many countries, the estimated number of excess deaths substantially exceeded the number of reported deaths from covid-19. The highest excess death rates (per 100 000) in men were in Lithuania (285, 259 to 311), Poland (191, 184 to 197), Spain (179, 174 to 184), Hungary (174, 161 to 188), and Italy (168, 163 to 173); the highest rates in women were in Lithuania (210, 185 to 234), Spain (180, 175 to 185), Hungary (169, 156 to 182), Slovenia (158, 132 to 184), and Belgium (151, 141 to 162). Little evidence was found of subsequent compensatory reductions following excess mortality.

CONCLUSION

Approximately one million excess deaths occurred in 2020 in these 29 high income countries. Age standardised excess death rates were higher in men than women in almost all countries. Excess deaths substantially exceeded reported deaths from covid-19 in many countries, indicating that determining the full impact of the pandemic on mortality requires assessment of excess deaths. Many countries had lower deaths than expected in children <15 years. Sex inequality in mortality widened further in most countries in 2020.

Association between obesity and hospital mortality in critical COVID-19: a retrospective cohort study

BACKGROUND

The impact of obesity on outcomes in acute respiratory distress syndrome (ARDS) is not well understood and remains controversial. Recent studies suggest that obesity might be associated with higher morbidity and mortality in respiratory disease caused by SARS-CoV-2 (COVID-19 disease). Our objective was to evaluate the association between obesity and hospital mortality in critical COVID-19 patients.

METHODS

We conducted a retrospective cohort study in a tertiary academic center located in Montréal between March and August 2020. We included all consecutive adult patients admitted to the ICU for COVID-19-confirmed respiratory disease. Our main outcome was hospital mortality. We estimated the association between obesity, using the body mass index as a continuous variable, and hospital survival by fitting a multivariable Cox proportional hazards model.

RESULTS

We included 94 patients. Median [q1, q3] body mass index (BMI) was 29 [26-32] kg/m² and 37% of patients were obese (defined as BMI > 30 kg/m²). Hospital mortality for the entire cohort was 33%. BMI was significantly associated with hospital mortality (hazard ratio [HR] = 2.49 per 10 units BMI; 95% CI, from 1.69 to 3.70; p < 0.001) even after adjustment for sex, age and obesity-related comorbidities (adjusted HR = 3.50; 95% CI from 2.03 to 6.02; p < 0.001).

CONCLUSIONS

Obesity was prevalent in hospitalized patients with critical illness secondary to COVID-19 disease and a higher BMI was associated with higher hospital mortality. Further studies are needed to validate this association and to better understand its underlying mechanisms.