African-American COVID-19 Mortality: A Sentinel Event

Determinants of COVID-19 severity in Ethiopia: a multicentre case-control study

OBJECTIVE

It was necessary to understand the determinants of severe COVID-19 in order to deliver targeted healthcare services to prevent further complications and mortality. Identifying the factors associated with severe COVID-19 in Addis Ababa, Ethiopia, is the aim of this study.

DESIGN

A case-control study was conducted from October 2021 to March 2022.

SETTING

The study was conducted at three public COVID-19 treatment centres including Ekka Kotebe General, St. Peter Hospital and St. Paul's Hospital.

PARTICIPANTS

The study participants were COVID-19 patients admitted to three COVID-19 treatment centres. Cases were patients admitted with severe COVID-19, and controls were patients with mild or moderate COVID-19. A total of 306 patients (153 cases and 153 controls) selected by simple random sampling technique participated in this study.

OUTCOME MEASURES AND ANALYSIS

Data were collected by a face-to-face or telephone interviewer using a structured questionnaire. COVID-19 admission category, clinical and biomedical characteristics and comorbidity-related data were extracted from the participant's medical record. Multivariable binary logistic regression analysis was used to identify predictors of COVID-19 severity.

RESULTS

The odds of being old were 4.54 times higher among severe COVID-19 cases (adjusted odds ratio (AOR)=4.54, 95% CI=2.499 to 8.24), the odds of being male were 2.72 times higher among severe COVID-19 cases (AOR=2.72, 95% CI=1.46 to 5.057), being vaccinated for COVID-19 decreases the severity by 55.1% (AOR=0.449, 95% CI=0.251 to 0.801), having good knowledge about COVID-19 decreases by 65% (AOR=0.35%, 95% CI=0.195 to 0.63) among patients with severe COVID-19, the odds of being diabetic were 10.2 times higher among severe COVID-19 cases (AOR=10.2, 95% CI=4.596 to 22.61) and the odds of being hypertensive were 2.3 times higher among severe COVID-19 cases (AOR=2.26, 95% CI=1.092 to 4.685).

CONCLUSION

Male, older age, diabetes or hypertension comorbidity, COVID-19 vaccination and having inadequate knowledge about COVID-19 were determinant factors of severe COVID-19.

Exploring the COVID-19 Knowledge, Attitudes, and Practices (KAPs) in the Black Community: a Scoping Review

INTRODUCTION AND BACKGROUND

Racial minorities have been the focal point of media coverage, attributing the disproportionate impact of COVID-19 to their individual actions; however, the ability to engage in preventative practices can also depend on one's social determinants of health. Individual actions can include knowledge, attitudes, and practices (KAPs). Since Black communities are among those disproportionately affected by COVID-19, this scoping review explores what is known about COVID-19 KAPs among Black populations.

METHODS

A comprehensive literature search was conducted in 2020 for articles written in English from the Medline, Embase, and PsycInfo databases. Reviews, experimental research, and observational studies were included if they investigated at least one of COVID-19 KAP in relation to the pandemic and Black communities in OECD peer countries including Canada, the United States, and the United Kingdom.

RESULTS AND ANALYSIS

Thirty-one articles were included for analysis, and all employed observational designs were from the United States. The following KAPs were examined: 6 (18.8%) knowledge, 21 (65.6%) attitudes, and 22 (68.8%) practices. Black communities demonstrated high levels of adherence to preventative measures (e.g., lockdowns) and practices (e.g., mask wearing), despite a strong proportion of participants believing they were less likely to become infected with the virus, and having lower levels of COVID-19 knowledge, than other racial groups.

CONCLUSIONS AND IMPLICATIONS

The findings from this review support that Black communities highly engage in COVID-19 preventative practices within their realm of control such as mask-wearing and hand washing and suggest that low knowledge does not predict low practice scores among this population.

Primordial prevention: Reducing consumption of sugar-sweetened beverages in racial/ethnic populations

Beyond pharmacotherapy in adulthood, primordial prevention in United States (U.S.) children and adolescents is needed to avoid the upcoming tsunami of cardiometabolic and cardiovascular disease (CVD). Healthcare disparities were unmasked by the disparate morbidity and mortality of COVID-19 in racial/ethnic populations, especially in persons with obesity, diabetes, and CVD. One potential successful strategic improvement of childhood cardiovascular health is to reduce sugar consumption in early life as CVD is the number one cause of death in patients with Type 2 diabetes (T2D). Furthermore, cardiologists treat more patients with T2D than endocrinologists. This commentary challenges cardiovascular specialists and other clinicians to address the increasing burden of cardiometabolic and CVD in adults, especially in racial/ethnic populations, by supporting primordial prevention in childhood.

An Analysis of COVID-19 Mortality During the Dominancy of Alpha, Delta, and Omicron in the USA

BACKGROUND

The objective of the study was to measure the risk of death due to COVID-19 in relation to individuals' characteristics, and severity of their disease during the dominant periods of Alpha, Delta, and Omicron variants have influenced mortality rates.

METHODS

This study was conducted using COVID-19 Centers for Disease Control and Prevention (CDC) Case Surveillance Public Data Taskforce for 57 states, and United States territories between January 1, 2020 and March 20, 2022. Multivariable binary Hyperbolastic regression of type I was used to analyzes the data.

RESULTS

Seniors and ICU-admitted patients had the highest risk of death. For each additional percent increase in fully vaccinated individuals, the odds of death deceased by 1%. The odds of death prior to vaccine availability, compared to post vaccine availability, was 1.27. When comparing the time periods each variant was dominant, the odds of death was 3.45-fold higher during Delta compared to Alpha. All predictor variables had P-values ≤.001.

CONCLUSION

There was a noticeable difference in the odds of death among subcategories of age, race/ethnicity, sex, PMCs, hospitalization, ICU, vaccine availability, variant, and percent of fully vaccinated individuals.

Increased COVID-19 Infection Risk Drives Racial and Ethnic Disparities in Severe COVID-19 Outcomes

COVID-19 inequities have been well-documented. We evaluated whether higher rates of severe COVID-19 in racial and ethnic minority groups were driven by higher infection rates by evaluating if disparities remained when analyses were restricted to people with infection. We conducted a retrospective cohort study of adults insured through Kaiser Permanente (Colorado, Northwest, Washington), follow-up in March-September 2020. Laboratory results and hospitalization diagnosis codes identified individuals with COVID-19. Severe COVID-19 was defined as invasive mechanical ventilation or mortality. Self-reported race and ethnicity, demographics, and medical comorbidities were extracted from health records. Modified Poisson regression estimated adjusted relative risks (aRRs) of severe COVID-19 in full cohort and among individuals with infection. Our cohort included 1,052,774 individuals, representing diverse racial and ethnic minority groups (e.g., 68,887 Asian, 41,243 Black/African American, 93,580 Hispanic or Latino/a individuals). Among 7,399 infections, 442 individuals experienced severe COVID-19. In the full cohort, severe COVID-19 aRRs for Asian, Black/African American, and Hispanic individuals were 2.09 (95% CI: 1.36, 3.21), 2.02 (1.39, 2.93), and 2.09 (1.57, 2.78), respectively, compared to non-Hispanic Whites. In analyses restricted to individuals with COVID-19, all aRRs were near 1, except among Asian Americans (aRR 1.82 [1.23, 2.68]). These results indicate increased incidence of severe COVID-19 among Black/African American and Hispanic individuals is due to higher infection rates, not increased susceptibility to progression. COVID-19 disparities most likely result from social, not biological, factors. Future work should explore reasons for increased severe COVID-19 risk among Asian Americans. Our findings highlight the importance of equity in vaccine distribution.

Impact of Social Deprivation on Hospitalization and Intensive Care Unit Admission among COVID-19 Patients: A Systematic Review and Meta-Analysis

Background

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged groups; however, the association between socioeconomic status and healthcare utilization among COVID-19 patients remains unclear. Therefore, a systematic review and meta-analysis was conducted to assess the association between socioeconomic status and hospitalization and intensive care unit admission among COVID-19 patients.

Methods

PubMed, Embase, and the Cochrane Register of Controlled Trials were searched for relevant literature (updated to Jun 2022). Studies that investigated the association of social deprivation with hospitalization and intensive care unit admission in COVID-19 patients were included. The primary outcomes included risk of hospitalization and intensive care unit admission, measured by odds ratio.

Results

Eleven studies covering 2,423,095 patients were included in the meta-analysis. Socially disadvantaged patients had higher odds of hospitalization in comparison to socially advantaged patients (odds ratio 1.25, 95% confidence interval: 1.14 to 1.38; P<0.01). The odds of intensive care unit admission among more deprived patients was not significantly different from that of less deprived patients (odds ratio 1.03, 95% confidence interval: 0.78 to 1.35; P=0.85). These findings were proven robust through subgroup and sensitivity analyses.

Conclusion

Socially disadvantaged populations have higher odds of hospitalization if they become infected with COVID-19. More effective medical support and interventions for these vulnerable populations are required to reduce inequity in healthcare utilization and alleviate the burden on healthcare systems.

Association between median household income, state Medicaid expansion status, and COVID-19 outcomes across US counties

Objective

To study the relationship between county-level COVID-19 outcomes (incidence and mortality) and county-level median household income and status of Medicaid expansion of US counties.

Methods

Retrospective analysis of 3142 US counties was conducted to study the relationship between County-level median-household-income and COVID-19 incidence and mortality per 100,000 people in US counties, January-20th-2021 through December-6^th-2021. County median-household-income was log-transformed and stratified by quartiles. Multilevel-mixed-effects-generalized-linear-modeling adjusted for county socio-demographic and comorbidities and tested for Medicaid-expansion-times-income-quartile interaction on COVID-19 outcomes.

Results

There was no significant difference in COVID-19 incidence-rate across counties by income quartiles or by Medicaid expansion status. Conversely, for non-Medicaid-expansion states, counties in the lowest income quartile had a 41% increase in COVID-19 mortality-rate compared to counties in the highest income quartile. Mortality-rate was not related to income in counties from Medicaid-expansion states.

Conclusions

Median-household-income was not related to COVID-19 incidence-rate but negatively related to COVID-19 mortality-rate in US counties of states without Medicaid-expansion.

Racial disparities in symptomatology and outcomes of COVID-19 among adults of Arkansas

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Few reports have suggested that non-Hispanic Blacks may present with different symptoms for COVID-19 than non-Hispanic Whites.

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In this novel study comprising of representative sample of over 60,000 racially diverse population of Arkansas adults, we investigated patterns in symptomatology and outcomes of COVID-19.

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We found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics affected more, with specific or all symptoms, compared to NH-whites.

•

Acknowledging differences in presentation in symptoms at clinical setting will aid in accurate diagnoses of patients that present with COVID-19.

Few reports have suggested that non-Hispanic (NH) blacks may present with different symptoms for COVID-19 than NH-whites. The objective of this study was to investigate patterns in symptomatology and COVID-19 outcomes by race/ethnicity among adults in Arkansas. Data on COVID-19 symptoms were collected on day of testing, 7th and 14th day among participants at UAMS mobile testing units throughout the state of Arkansas. Diagnosis for SARS-CoV-2 infection was confirmed via nasopharyngeal swab and RT-PCR methods. Data analysis was conducted using Chi-square test and Poisson regression to assess the differences in characteristics by race/ethnicity. A total of 60,648 individuals were RT-PCR tested from March 29, 2020 through October 7, 2020. Among adults testing positive, except shortness of breath, Hispanics were more likely to report all symptoms than NH-whites or NH-blacks. NH-whites were more likely to report fever (19.6% vs. 16.6%), cough (27.5% vs. 26.1%), shortness of breath (13.6% vs. 9.6%), sore throat (16.7% vs. 10.7%), chills (12.5% vs. 11.8%), muscle pain (15.6% vs. 12.4%), and headache (20.3% vs. 17.8%). NH-blacks were more likely to report loss of taste/smell (10.9% vs. 10.6%). To conclude, we found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics more often affected with specific or all symptoms, compared to NH-whites. Due to the cross-sectional study design, these findings do not necessarily reflect biological differences by race/ethnicity; however, they suggest that certain race/ethnicities may have underlying differences in health status that impact COVID-19 outcomes.

Social characterization of COVID-19 in the state of Amazonas, Brazil

OBJECTIVES

To compare the number of deaths that occurred in the state of Amazonas and in Brazil, from March 16^th to August 20^th 2020, using the variables skin color, sex, place of death, age group and association with COVID-19, and secondly, to verify whether between 2019 and 2020, in the period from March 16^th to August 20^th, there was a significant change in the number of deaths from diseases not associated with COVID-19.

METHODS

We searched the databases of the Brazilian public agency "Transparency Portal" for the data on deaths that occurred in the state of Amazonas and Brazil in the period from March 16^th to August 20^th, 2019 and 2020. The absolute frequencies and percentages of the variables studied were used for statistical analysis.

RESULTS

COVID-19 was responsible for an 11.01% increase in deaths in Brazil; however, this rate quadrupled in the state of Amazonas. In relation to age group, there was a similar percentage between Amazonas and the national average. The stratified analysis showed significant differences between genders and races, with higher death rates in men and people of brown/black skin. The number of deaths at home increased significantly, especially those from causes not associated with COVID-19.

CONCLUSIONS

The national drop in deaths from diseases not associated with COVID between March and August 2020 in Brazil is misleading and may be due to the result of misreported causes of death.

Effects of Medicaid expansion on alcohol and opioid treatment admissions in U.S. racial/ethnic groups

BACKGROUND

Excessive drinking and opioid misuse exact a high toll on U.S. lives and differentially affect U.S. racial/ethnic groups in exposure and resultant harms. Increasing access to specialty treatment is an important policy strategy to mitigate this, particularly for lower-income and racial/ethnic minority persons who face distinctive barriers to care. We examined whether the U.S. Affordable Care Act's Medicaid expansion improved treatment utilization in the overall population and for Black, Latino, and White Americans separately.

METHODS

We analyzed total and Medicaid-insured alcohol and opioid treatment admissions per 10,000 adult, state residents using 2010-2016 data from SAMHSA's Treatment Episode Data Set (N = 20 states), with difference-in-difference models accounting for state fixed effects and time-varying state demographic characteristics, treatment need, and treatment supply.

RESULTS

Total treatment admission rates in the overall population declined for alcohol and remained roughly flat for opioids in both expansion and non-expansion states from 2010 through 2016. By contrast, estimated Medicaid-insured alcohol and opioid treatment rates rose in expansion states and decreased in non-expansion states following Medicaid expansion in 2014. The latter results were found for alcohol treatment in the total population and in each racial/ethnic group, as well as for Black and White Americans for opioid treatment.

CONCLUSIONS

Medicaid expansion was associated with greater specialty treatment entry at a time when alcohol and opioid treatment rates were declining or flat. Findings underscore benefits of expanding Medicaid eligibility to increase treatment utilization for diverse racial/ethnic groups, but also suggest an emerging treatment disparity between lower-income Americans in expansion and non-expansion states.

Sign of the times: Community engagement to refine a cardiovascular mHealth intervention through a virtual focus group series during the COVID-19 Pandemic

Background

African-Americans are underrepresented in mobile health intervention research studies which can perpetuate health inequities and the digital divide. A community-based, user-centered approach to designing mobile health interventions may increase their sociocultural relevance and effectiveness, especially with increased smartphone use during the coronavirus disease 2019 pandemic. We aimed to refine an existing mobile health intervention via a virtual focus group series.

Methods

African-American community members (n = 15) from churches in Minneapolis-St. Paul and Rochester, Minnesota were enrolled in a virtual (via videoconferencing), three-session focus group series over five months to refine a cardiovascular health-focused mobile health application (FAITH! [Fostering African-American Improvement in Total Health!] App). Participants accessed the app via their smartphones and received a Fitbit synced to the app. Participants engaged with multimedia cardiovascular health-focused education modules, a sharing board for social networking, and diet/physical activity self-monitoring. Participant feedback on app features prompted iterative revisions to the FAITH! App. Primary outcomes were app usability (assessed via Health Information Technology Usability Evaluation Scale range: 0–5) and user satisfaction.

Results

Participants (mean age [SD]: 56.9 [12.3] years, 86.7% female) attended a mean 2.8 focus groups (80% attended all sessions). The revised FAITH! App exceeded the goal Health Information Technology Usability Evaluation Scale score threshold of ≥4 (mean: 4.39, range: 3.20–4.95). Participants positively rated updated app content, visual appeal, and use of social incentives to maintain engagement. Increasing user control and refinement of the moderated sharing board were identified as areas for future improvement.

Conclusions

Community-partnered, virtual focus groups can optimize usability and increase participant satisfaction of mobile health lifestyle interventions that aim to promote cardiovascular health in African-Americans.

Rationale and protocol for a pilot randomized controlled trial of a cognitive prescription intervention for reducing dementia risk factors among African Americans

BACKGROUND & PURPOSE

African Americans (AAs) are twice as likely to develop dementia than Whites, which may be driven by poorer dementia knowledge and lifestyle factors. This article provides the rationale and protocol for a pilot clinical trial examining a tailored multi-domain lifestyle modification intervention in middle-aged and older AAs. This study will explore the feasibility and efficacy of individualized Cognitive Prescriptions (CogRx) which target five domains: physical activity, cognitive activity, diet, sleep, and social activity. Theoretical underpinnings include Social Cognitive Theory and the Health Belief Model, which suggest that tailored risk factor information, goal-setting, and outcome expectations along with addressing self-efficacy and barriers will promote behavior change.

STUDY DESIGN

This study plans to enroll 150 community-dwelling AA participants aged 45-65 without significant cognitive impairment. After baseline assessment including data-driven assessment of deficiencies in each of the five CogRx domains, participants are randomized with equal allocation to either: psychoeducation + CogRx, psychoeducation only, or no-contact control. The psychoeducation and CogRx groups receive general psychoeducation on dementia prevalence, prognosis, and risk factors, while the CogRx group also receives information on their risk factor profile and develops a tailored 3-month intervention plan, consisting of simple evidence-based strategies to implement. The CogRx condition receives text-messaging reminders and adherence queries and provides feedback on this program.

CONCLUSION

This study tests a novel multi-domain dementia prevention intervention and has several strengths, including enrolling middle-aged AAs with a focus on prevention, assessing adherence and self-efficacy, tailoring the intervention, and examining dementia knowledge. The goal is to yield new perspectives on person-centered dementia prevention approaches in diverse populations, and ultimately impact clinical and public health recommendations for maintaining cognitive health, thereby reducing disparities in dementia. Modifications to study design due to COVID-19 and future directions are discussed.

Assessing the Impact of Insurance Type on COVID-19 Mortality in Black and White Patients in the Largest Healthcare System in the State of Georgia

Importance

The increased COVID-19 mortality for Black individuals over White individuals may be explained by the known racial disparities in access to insurance.

Objective

To determine whether racial disparities in COVID-19 mortality still exist when Blacks and Whites are equally insured.

Design

Routinely collected data on race, mortality, type of insurance, known risk factors, and lab results from the EPIC Patient Management System were analyzed using a multivariable logistic regression model.

Setting

Piedmont Healthcare is the largest hospital system in Georgia. Due to its multiple locations across the state of Georgia, it receives a relatively equitably insured population.

Participants

All patients hospitalized with a positive COVID-19 status between March 1 and November 30, 2020.

Main Outcomes

We hypothesized that Black patients would not have higher odds of mortality than White patients, and that type of insurance would predict COVID-19 mortality.

Results

6,881 (3,674 Black, 3,207 White; 48% male, mean age = 60) patients were included. Race was not a significant predictor of COVID-19 mortality (p>0.05). When controlling for age and insurance, the mortality rate for Black patients was not statistically significant from that for White patients (p>0.05). Compared to those relying on Medicare, patients with commercial (OR=0.68, 95% CI: 0.48-0.96) or out-of-pocket (self-pay) insurance (OR=0.22, 95% CI: 0.03-0.88) had lower odds of mortality.

Conclusions

National trends of racial disparities in COVID-19 mortality may be partially explained by disparities in insurance.

Juntos: A Model for Language Congruent Care to Better Serve Spanish-Speaking Patients with COVID-19

Coronavirus disease 2019 (COVID-19) exacerbated pre-existing health disparities and disproportionately affected the Latino community. Clinicians identified communication barriers as a major challenge in care for COVID-19 Latino patients with limited English proficiency (LEP). To address these challenges, Juntos (Together) consult service was established to promote language-congruent care with cultural sensitivity, identify barriers to safe discharge, and facilitate referral to appropriate resources. Spanish speaking volunteer health care providers worked synergistically with medical teams caring for LEP Latino patients. Volunteers were trained on consultant responsibilities and discharge planning resources. The program was evaluated by a satisfaction survey distributed to providers who requested a Juntos consult and Juntos volunteers. Between May 5 and July 30, 2020, 19 individuals volunteered time to the Juntos consult service, 12 (63%) Latinos, 14 (74%) physicians, and 5 (26%) staff. The service supported 127 patients, 76 (60%) males, mean age 42 (±16), 83 (65%) uninsured, and 91 (72%) without primary care. The most common referral sources were medical units (52, 41%) and intensive care units (47, 37%). The most common services offered were family engagement (55, 43%), goals of care (35, 28%), and mental status assessment (26, 20%). The majority of providers who consulted Juntos were very satisfied (48/59, 81%) with the care delivered. The Juntos service offered critical support tailored to the patients' and primary teams' needs. The experience reinforced the need for cultural-based communication to provide optimal care to LEP patients. The Juntos consult service could be a model for providing language-congruent care even beyond COVID-19, but to do so will require institutional investment and rigorous outcomes evaluation.

A 3D structural SARS-CoV-2-human interactome to explore genetic and drug perturbations

Emergence of new viral agents is driven by evolution of interactions between viral proteins and host targets. For instance, increased infectivity of SARS-CoV-2 compared to SARS-CoV-1 arose in part through rapid evolution along the interface between the spike protein and its human receptor ACE2, leading to increased binding affinity. To facilitate broader exploration of how pathogen-host interactions might impact transmission and virulence in the ongoing COVID-19 pandemic, we performed state-of-the-art interface prediction followed by molecular docking to construct a three-dimensional structural interactome between SARS-CoV-2 and human. We additionally carried out downstream meta-analyses to investigate enrichment of sequence divergence between SARS-CoV-1 and SARS-CoV-2 or human population variants along viral-human protein-interaction interfaces, predict changes in binding affinity by these mutations/variants and further prioritize drug repurposing candidates predicted to competitively bind human targets. We believe this resource ( http://3D-SARS2.yulab.org ) will aid in development and testing of informed hypotheses for SARS-CoV-2 etiology and treatments.

COVID-19 Case Fatality and Alzheimer's Disease

Previous studies have identified dementia as a risk factor for death from coronavirus disease 2019 (COVID-19). However, it is unclear whether Alzheimer's disease (AD) is an independent risk factor for COVID-19 case fatality rate. In a retrospective cohort study, we identified 387,841 COVID-19 patients through TriNetX. After adjusting for demographics and comorbidities, we found that AD patients had higher odds of dying from COVID-19 compared to patients without AD (Odds Ratio: 1.20, 95%confidence interval: 1.09-1.32, p < 0.001). Interestingly, we did not observe increased mortality from COVID-19 among patients with vascular dementia. These data are relevant to the evolving COVID-19 pandemic.

Disparities in the COVID-19 pandemic: A clarion call for preventive cardiology

In 2020, COVID-19 was the third leading cause of death in the US, with increased hospitalizations and mortality linked to factors such as obesity, hypertension, diabetes, higher social vulnerability, and lower socioeconomic status. These multiple factors contribute to inequities in COVID-19 outcomes, including among older persons, members of racial/ethnic populations, and persons experiencing homelessness. Perhaps the best pathway to overcome the distressing high degree of death and disability due to COVID-19 has shown to be immunization with widespread acceptance, uptake, and vaccine access. Especially in racial/ethnic communities, it is important to utilize trusted leaders to overcome common vaccine misconceptions and barriers. This commentary summarizes the keynote lecture given to the Cardiometabolic Health Congress (CMHC) addressing the intersection of social injustice, cardiovascular and cardiometabolic disparities, and increased COVID-19 morbidity and mortality in racial/ethnic populations in the US.

Current Understanding of Clinical Manifestations of COVID-19 in Glomerular Disease

Background

The novel coronavirus disease (COVID-19), also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an evolving pandemic with significant mortality. Information about the impact of infection on glomerular disease patients in particular has been lacking. Understanding the virus's effect in glomerular disease is constantly changing. This review article summarizes the data published thus far on COVID-19 and its manifestations in pre-existing and de novo glomerular disease.

Summary

While patients with glomerular disease may be at higher risk of severe COVID-19 due to their immunosuppressed status, some data suggest that a low amount of immunosuppression may be helpful in mitigating the systemic inflammatory response which is associated with high mortality rates in COVID-19. There have been a few case reports on COVID-19 causing glomerular disease relapse in patients. Multiple mechanisms have been proposed for kidney injury, proteinuria, and hematuria in the setting of COVID-19. More commonly, these are caused by direct tubular injury due to hemodynamic instability and hypoxic injury. However, the cytokine storm induced by COVID-19 may trigger common post-viral glomerular disease such as IgA nephropathy, anti-GBM, and ANCA vasculitis that have also been described in COVID-19 patients. Collapsing glomerulopathy, a hallmark of HIV-associated nephropathy, is being reported SARS-CoV-2 cases, particularly in patients with high-risk APOL1 alleles. Direct viral invasion of glomerular structures is hypothesized to cause a podocytopathy due to virus's affinity to ACE2, but evidence for this remains under study.

Key Messages

Infection with SARS-CoV-2 may cause glomerular disease in certain patients. The mechanism of de novo glomerular disease in the setting of COVID-19 is under study. The management of patients with existing glomerular disease poses unique challenges, especially with regard to immunosuppression management. Further studies are needed to inform clinician decisions about the management of these patients during the COVID-19 pandemic.

Structural racism and risk of SARS-CoV-2 in pregnancy

BACKGROUND

Structural racism leads to adverse health outcomes, as highlighted by inequities in COVID-19 infections. We characterized Black/White disparities among pregnant women with SARS-CoV-2 in Cuyahoga County which has some of the most extreme health disparities in the U.S., such as a rate of Black infant mortality that is three times that of White counterparts.

METHODS

This was a retrospective cohort study using data collected as part of public health surveillance between March 16, 2020 until October 1, 2020. This study aimed to compare Black and Non-Black pregnant women infected with SARS-CoV-2 to understand how the distribution of risk factors may differ by race. Outcomes included age, gestational age at infection, medical co-morbidities, exposure history, socio-economic status, occupation, symptom severity and pregnancy complications.

FINDINGS

One hundred and sixty-two women were included. 81 (50%) were Black, 67 (41%) White, 9 (0·05%) Hispanic, 2 (0·01%) Asian; and three did not self-identify with any particular race. More than half who supplied occupational information (n = 132) were essential workers as classified by the CDC definition (55%, n = 73). Black women were younger (p = 0·0062) and more likely to identify an occupational contact as exposing them to SARS-CoV-2 (p = 0·020). Non-Black women were more likely to work from home (p = 0·018) and indicate a personal or household contact as their exposure (p = 0·020). Occupation was a risk factor for severe symptoms (aOR 4·487, p = 0·037). Most Black women lived in areas with median income <$39,000 and Black women were more likely to have a preterm delivery (22·2% versus 0%, p = 0·026).

INTERPRETATION

Many pregnant women infected by SARS-CoV-2 are essential workers. Black women are more likely than White counterparts to have occupational exposure as the presumed source for their infection. Limitations in occupational options and controlling risk in these positions could be related to lower socio-economic status, resulting from a long history of structural racism in Cuyahoga County as evidenced by redlining and other policies limiting opportunities for people of color.

FUNDING

none.

Racial disparities in COVID-19 pandemic cases, hospitalisations, and deaths: A systematic review and meta-analysis

Background

People from racial minority groups in western countries experience disproportionate socioeconomic and structural determinants of health disadvantages. These disadvantages have led to inequalities and inequities in health care access and poorer health outcomes. We report disproportionate disparities in prevalence, hospitalisation, and deaths from COVID-19 by racial minority populations.

Methods

We conducted a systematic literature search of relevant databases to identify studies reporting on prevalence, hospitalisations, and deaths from COVID-19 by race groups between 01 January 2020 – 15 April 2021. We grouped race categories into Blacks, Hispanics, Whites and Others. Random effects model using the method of DerSimonian and Laird were fitted, and forest plot with respective ratio estimates and 95% confidence interval (CI) for each race category, and subgroup meta-regression analyses and the overall pooled ratio estimates for prevalence, hospitalisation and mortality rate were presented.

Results

Blacks experienced significantly higher burden of COVID-19: prevalence ratio 1.79 (95% confidence interval (CI) = 1.59-1.99), hospitalisation ratio 1.87 (95% CI = 1.69-2.04), mortality ratio 1.68 (95% CI = 1.52-1.83), compared to Whites: prevalence ratio 0.70 (95% CI = 0.0.64-0.77), hospitalisation ratio 0.74 (95% CI = 0.65-0.82), mortality ratio 0.82 (95% CI = 0.78-0.87). Also, Hispanics experienced a higher burden: prevalence ratio 1.78 (95% CI = 1.63-1.94), hospitalisation ratio 1.32 (95% CI = 1.08-1.55), mortality ratio 0.94 (95% CI = 0.84-1.04) compared to Whites. A higher burden was also observed for Other race groups: prevalence ratio 1.43 (95% CI = 1.19-1.67), hospitalisation ratio 1.12 (95% CI = 0.89-1.35), mortality ratio 1.06 (95% CI = 0.89-1.23) compared to Whites. The disproportionate burden among Blacks and Hispanics remained following correction for publication bias.

Conclusions

Blacks and Hispanics have been disproportionately affected by COVID-19. This is deeply concerning and highlights the systemically entrenched disadvantages (social, economic, and political) experienced by racial minorities in western countries; and this study underscores the need to address inequities in these communities to improve overall health outcomes.

Determinantes sociales y desafíos para la deconstrucción social de la pandemia por COVID-19

Objetivo: analizar los determinantes sociales de salud y su relación con el impacto de la COVID-19 en la salud de personas y comunidades, con el fin de suscitar nuevas reflexiones sobre los desafíos sociales que implica el abordaje de esta enfermedad. Síntesis del contenido: la salud y la enfermedad son construidas y determinadas socialmente. Ambas están presentes en la forma en que vivimos y el tipo de sociedad que construimos. La pandemia actual ha evidenciado nuevamente profundas disparidades que están vinculadas a un mayor riesgo. Si bien la COVID-19 puede afectar a todas las personas, los impactos derivados de ella se perciben de formas diferentes según el estado de vulnerabilidad en el que se encuentre cada individuo, que es dado principalmente por determinantes sociales. Por tanto, cumplir con medidas de confinamiento en casa, higiene y distanciamiento social se convierten en una cuestión de privilegio imposible de acatar para ciertos sectores, especialmente en los países de América Latina. Conclusiones:el abordaje de la pandemia como problema social requiere mirar más allá de las características del virus, su capacidad de propagación y los factores biológicos individuales, para enfocarse en los verdaderos determinantes sociales y así promover equidad en los servicios de salud e identificar dónde intervenir de manera efectiva. La reconstrucción de la sociedad pospandemia exige que la salud sea comprendida y practicada como un derecho humano y un bien público garantizado por el Estado. De lo contrario, una de las consecuencias de abordar la pandemia como un "problema del virus" es perpetuar la negligencia en los procesos políticos, económicos y sociales, es decir, exige un análisis amplio de los contextos y las circunstancias sociales.

Coronavirus disease 2019 in heart transplant recipients: Risk factors, immunosuppression, and outcomes

Background

COVID-19 continues to inflict significant morbidity and mortality, particularly on patients with preexisting health conditions. The clinical course, outcomes, and significance of immunosuppression regimen in heart transplant recipients with COVID-19 remains unclear.

Methods

We included the first 99 heart transplant recipients at participating centers with COVID-19 and followed patients until resolution. We collected baseline information, symptoms, laboratory studies, vital signs, and outcomes for included patients. The association of immunosuppression regimens at baseline with severe disease were compared using logistic regression, adjusting for age and time since transplant.

Results

The median age was 60 years, 25% were female, and 44% were white. The median time post-transplant to infection was 5.6 years. Overall, 15% died, 64% required hospital admission, and 7% remained asymptomatic. During the course of illness, only 57% of patients had a fever, and gastrointestinal symptoms were common. Tachypnea, oxygen requirement, elevated creatinine and inflammatory markers were predictive of severe course. Age ≥ 60 was associated with higher risk of death and the use of the combination of calcineurin inhibitor, antimetabolite, and prednisone was associated with more severe disease compared to the combination of calcineurin inhibitor and antimetabolite alone (adjusted OR = 7.3, 95% CI 1.8-36.2). Among hospitalized patients, 30% were treated for secondary infection, acute kidney injury was common and 17% required new renal replacement therapy.

Conclusions

We present the largest study to date of heart transplant patients with COVID-19 showing common atypical presentations and a high case fatality rate of 24% among hospitalized patients and 16% among symptomatic patients.

Racial disparities in Coronavirus Disease 2019 (COVID-19) outcomes

PURPOSE OF REVIEW

The Coronavirus Disease 2019 (COVID-19) pandemic has exposed preexisting racial disparities in the healthcare system. This review discusses racial-ethnic differences in COVID-19 related outcomes with an emphasis on the social determinants of health that are responsible for these disparities.

RECENT FINDINGS

Higher hospitalizations and deaths have been reported amongst minority individuals after a COVID-19 infection. Cardiovascular disease and its risk factors are also more common in minority populations and negatively impact clinical outcomes after a COVID-19 illness. The racial disparities seen after COVID-19 infections appear to be driven by multiple preexisting comorbidities, adverse socioeconomic conditions, and lack of access to healthcare. These disadvantages were present before the COVID-19 pandemic. To effectively reduce disparities in outcomes of COVID-19 and the impact of the virus on minority communities, a multifaceted approach will be needed.

SUMMARY

Government-backed policies that foster health equity and promote easily accessible testing and fair distribution of COVID-19 therapies and vaccines are necessary to successfully combat racial disparities in COVID-19 outcomes.

Performance of intensive care unit severity scoring systems across different ethnicities in the USA: a retrospective observational study

BACKGROUND

Despite wide use of severity scoring systems for case-mix determination and benchmarking in the intensive care unit (ICU), the possibility of scoring bias across ethnicities has not been examined. Guidelines on the use of illness severity scores to inform triage decisions for allocation of scarce resources, such as mechanical ventilation, during the current COVID-19 pandemic warrant examination for possible bias in these models. We investigated the performance of the severity scoring systems Acute Physiology and Chronic Health Evaluation IVa (APACHE IVa), Oxford Acute Severity of Illness Score (OASIS), and Sequential Organ Failure Assessment (SOFA) across four ethnicities in two large ICU databases to identify possible ethnicity-based bias.

METHODS

Data from the electronic ICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III (MIMIC-III) database, built from patient episodes in the USA from 2014-15 and 2001-12, respectively, were analysed for score performance in Asian, Black, Hispanic, and White people after appropriate exclusions. Hospital mortality was the outcome of interest. Discrimination and calibration were determined for all three scoring systems in all four groups, using area under receiver operating characteristic (AUROC) curve for different ethnicities to assess discrimination, and standardised mortality ratio (SMR) or proxy measures to assess calibration.

FINDINGS

We analysed 166 751 participants (122 919 eICU-CRD and 43 832 MIMIC-III). Although measurements of discrimination were significantly different among the groups (AUROC ranging from 0·86 to 0·89 [p=0·016] with APACHE IVa and from 0·75 to 0·77 [p=0·85] with OASIS), they did not display any discernible systematic patterns of bias. However, measurements of calibration indicated persistent, and in some cases statistically significant, patterns of difference between Hispanic people (SMR 0·73 with APACHE IVa and 0·64 with OASIS) and Black people (0·67 and 0·68) versus Asian people (0·77 and 0·95) and White people (0·76 and 0·81). Although calibrations were imperfect for all groups, the scores consistently showed a pattern of overpredicting mortality for Black people and Hispanic people. Similar results were seen using SOFA scores across the two databases.

INTERPRETATION

The systematic differences in calibration across ethnicities suggest that illness severity scores reflect statistical bias in their predictions of mortality.

FUNDING

There was no specific funding for this study.

Heart Failure Hospitalizations and Risk Factors among the Multi-Ethnic Population from a Middle Income Country: The Suriname Heart Failure Studies

INTRODUCTION

Heart failure (HF) is an emerging epidemic with poor disease outcomes and differences in its prevalence, etiology and management between and within world regions. Hypertension (HT) and ischemic heart disease (IHD) are the leading causes of HF. In Suriname, South-America, data on HF burden are lacking. The aim of this Suriname Heart Failure I (SUHF-I) study, is to assess baseline characteristics of HF admitted patients in order to set up the prospective interventional SUHF-II study to longitudinally determine the effectiveness of a comprehensive HF management program in HF patients.

METHODS

A cross-sectional analysis was conducted of Thorax Center Paramaribo (TCP) discharge data from January 2013-December 2015. The analysis included all admissions with primary or secondary discharge of HF ICD-10 codes I50-I50.9 and I11.0 and the following variables: patient demographics (age, sex, and ethnicity), # of readmissions, risk factors (RF) for HF: HT, diabetes mellitus (DM), smoking, and left ventricle (LV) function. T-tests were used to analyze continuous variables and Chi-square test for categorical variables. Differences were considered statistically significant when a p-value <0.05 is obtained.

RESULTS

895 patients (1:1 sex ratio) with either a primary (80%) or secondary HF diagnosis were admitted. Female patients were significantly older (66.2 ± 14.8 years, p < 0.01) at first admission compared to male patients (63.5 ± 13.7 years) and the majority of admissions were of Hindustani and Creole descent. HT, DM and smoking were highly prevalent respectively 62.6%, 38.9 and 17.3%. There were 379 readmissions (29.1%) and 7% of all admissions were readmissions within 30 days and 16% were readmissions for 31-365 day. IHD is more prevalent in patients from Asian descendant (52.2%) compared to African descendant (11.7%). Whereas, HT (39.3%) is more prevalent in African descendants compared to Asian descendants (12.7%). There were no statistically significant differences in age, sex, ethnicity, LV function and RFs between single admitted and readmitted patients.

CONCLUSION

RF prevalence, ethnic differences and readmission rates in Surinamese HF patients are in line with reports from other Caribbean and Latin American countries. These results are the basis for the SUHF-II study which will aid in identifying the country specific and clinical factors for the successful development of a multidisciplinary HF management program.

National Disparities in COVID-19 Outcomes between Black and White Americans

BACKGROUND

There is very limited comprehensive information on disparate outcomes of black and white patients with COVID-19 infection. Reports from cities and states have suggested a discordant impact on black Americans, but no nationwide study has yet been performed. We sought to understand the differential outcomes for black and white Americans infected with COVID-19.

METHODS

We obtained case-level data from the Centers for Disease Control and Prevention on 76,442 white and 48,338 non-Hispanic Black patients diagnosed with COVID-19, ages 0 to >80+, outlining information on hospitalization, ICU admission, ventilation, and death outcomes. Multivariate Poisson regressions were used to estimate the association of race, treating white as the reference group, controlling for sex, age group, and the presence of comorbidities.

RESULTS

Black patients were generally younger than white, were more often female, and had larger numbers of comorbidities. Compared to white patients with COVID-19, black patients had 1.4 times the risk of hospitalization (RR 1.42, p < 0.001), and almost twice the risk of requiring ICU care (RR 1.68, p < 0.001) or ventilatory support (RR 1.81, p < 0.001) after adjusting for covariates. Black patients saw a 1.36 times increased risk of death (RR 1.36, p < 0.001) compared to white. Disparities between black and white outcomes increased with advanced age.

CONCLUSION

Despite the initial descriptions of COVID-19 being a disease that affects all individuals, regardless of station, our data demonstrate the differential racial effects in the United States. This current pandemic reinforces the need to assess the unequal effects of crises on disadvantaged populations to promote population health.

Racial/ethnic minority and neighborhood disadvantage leads to disproportionate mortality burden and years of potential life lost due to COVID-19 in Chicago, Illinois

Epidemiological studies have highlighted the disparate impact of coronavirus disease 2019 (COVID-19) on racial and ethnic minority and socioeconomically disadvantaged populations, but data at the neighborhood-level is sparse. The objective of this study was to investigate the disparate impact of COVID-19 on disadvantaged neighborhoods and racial/ethnic minorities in Chicago, Illinois. Using data from the Cook County Medical Examiner, we conducted a neighborhood-level analysis of COVID-19 decedents in Chicago and quantified age-standardized years of potential life lost (YPLL) due to COVID-19 among demographic subgroups and neighborhoods with geospatial clustering of high and low rates of COVID-19 mortality. We show that age-standardized YPLL was markedly higher among the non-Hispanic (NH) Black (559 years per 100,000 population) and the Hispanic (811) compared with NH white decedents (312). We demonstrate that geomapping using residential address data at the individual-level identifies hot-spots of COVID-19 mortality in neighborhoods on the Northeast, West, and South areas of Chicago that reflect a legacy of residential segregation and persistence of inequality in education, income, and access to healthcare. Our results may contribute to ongoing public health and community-engaged efforts to prevent the spread of infection and mitigate the disproportionate loss of life among these communities due to COVID-19 as well as highlight the urgent need to broadly target neighborhood disadvantage as a cause of pervasive racial inequalities in life and health.

Performance of intensive care unit severity scoring systems across different ethnicities

BACKGROUND

Despite wide utilisation of severity scoring systems for case-mix determination and benchmarking in the intensive care unit, the possibility of scoring bias across ethnicities has not been examined. Recent guidelines on the use of illness severity scores to inform triage decisions for allocation of scarce resources such as mechanical ventilation during the current COVID-19 pandemic warrant examination for possible bias in these models. We investigated the performance of three severity scoring systems (APACHE IVa, OASIS, SOFA) across ethnic groups in two large ICU databases in order to identify possible ethnicity-based bias.

METHOD

Data from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care were analysed for score performance in Asians, African Americans, Hispanics and Whites after appropriate exclusions. Discrimination and calibration were determined for all three scoring systems in all four groups.

FINDINGS

While measurements of discrimination -area under the receiver operating characteristic curve (AUROC) -were significantly different among the groups, they did not display any discernible systematic patterns of bias. In contrast, measurements of calibration -standardised mortality ratio (SMR) -indicated persistent, and in some cases significant, patterns of difference between Hispanics and African Americans versus Asians and Whites. The differences between African Americans and Whites were consistently statistically significant. While calibrations were imperfect for all groups, the scores consistently demonstrated a pattern of over-predicting mortality for African Americans and Hispanics.

INTERPRETATION

The systematic differences in calibration across ethnic groups suggest that illness severity scores reflect bias in their predictions of mortality.

FUNDING

LAC is funded by the National Institute of Health through NIBIB R01 EB017205. There was no specific funding for this study.

Retaining Adolescent and Young Adult Participants in Research During a Pandemic: Best Practices From Two Large-Scale Developmental Neuroimaging Studies (NCANDA and ABCD)

The novel coronavirus pandemic that emerged in late 2019 (COVID-19) has created challenges not previously experienced in human research. This paper discusses two large-scale NIH-funded multi-site longitudinal studies of adolescents and young adults - the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) and the Adolescent Brain Cognitive Development (ABCD) Study - and valuable approaches to learn about adaptive processes for conducting developmentally sensitive research with neuroimaging and neurocognitive testing across consortia during a global pandemic. We focus on challenges experienced during the pandemic and modifications that may guide other projects, such as implementing adapted protocols that protect the safety of participants and research staff, and addressing assessment challenges through the use of strategies such as remote and mobile assessments. Given the pandemic's disproportionate impacts on participants typically underrepresented in research, we describe efforts to retain these individuals. The pandemic provides an opportunity to develop adaptive processes that can facilitate future studies' ability to mobilize effectively and rapidly.

Susceptibility to COVID-19 in populations with health disparities: Posited involvement of mitochondrial disorder, socioeconomic stress, and pollutants

SARS-CoV-2 is a novel betacoronavirus that has caused the global health crisis known as COVID-19. The implications of mitochondrial dysfunction with COVID-19 are discussed as well as deregulated mitochondria and inter-organelle functions as a posited comorbidity enhancing detrimental outcomes. Many environmental chemicals (ECs) and endocrine-disrupting chemicals can do damage to mitochondria and cause mitochondrial dysfunction. During infection, SARS-CoV-2 via its binding target ACE2 and TMPRSS2 can disrupt mitochondrial function. Viral genomic RNA and structural proteins may also affect the normal function of the mitochondria-endoplasmic reticulum-Golgi apparatus. Drugs considered for treatment of COVID-19 should consider effects on organelles including mitochondria functions. Mitochondrial self-balance and clearance via mitophagy are important in SARS-CoV-2 infection, which indicate monitoring and protection of mitochondria against SARS-CoV-2 are important. Mitochondrial metabolomic analysis may provide new indicators of COVID-19 prognosis. A better understanding of the role of mitochondria during SARS-CoV-2 infection may help to improve intervention therapies and better protect mitochondrial disease patients from pathogens as well as people living with poor nutrition and elevated levels of socioeconomic stress and ECs.

Perspective Adjunctive Therapies for COVID-19: Beyond Antiviral Therapy

The coronavirus disease 2019 (COVID-19) pandemic is the largest health crisis ever faced worldwide. It has resulted in great health and economic costs because no effective treatment is currently available. Since infected persons vary in presentation from healthy asymptomatic mild symptoms to those who need intensive care support and eventually succumb to the disease, this illness is considered to depend primarily on individual immunity. Demographic distribution and disease severity in several regions of the world vary; therefore, it is believed that natural inherent immunity provided through dietary sources and traditional medicines could play an important role in infection prevention and disease progression. People can boost their immunity to prevent them from infection after COVID-19 exposure and can reduce their inflammatory reactions to protect their organ deterioration in case suffering from the disease. Some drugs with in-situ immunomodulatory and anti-inflammatory activity are also identified as adjunctive therapy in the COVID-19 era. This review discusses the importance of COVID-19 interactions with immune cells and inflammatory cells; and further emphasizes the possible pathways related with traditional herbs, medications and nutritional products. We believe that such pathophysiological pathway approach treatment is rational and important for future development of new therapeutic agents for prevention or cure of COVID-19 infection.

COVID-19: a Review of the Literature Regarding African American Patient Outcomes

In December 2019, COVID-19 was detected in Wuhan, China, and declared a pandemic in March 2020. The Centers for Disease Control and Prevention (CDC) says it has been detected in nearly 200 countries and is an ongoing concern in the United States. Various reports provided anecdotal evidence that many ethnic minorities and specifically African Americans have become ill and died from COVID-19. Coincidentally, several states have provided data that at least initially corroborate the anecdotes. Narratives and descriptive data were compiled from medical and public health professionals to ascertain whether medical evidence supports the over-representation of state-level total infections and deaths of African Americans. The ramifications are critical for African Americans, non-medical professional, citizens, and also to the reduction and mitigation of the novel coronavirus as an American pandemic. The medical and health policy literature suggests that African Americans are burdened with a disproportionate share of persons contracting and dying due to COVID-19. Authors and witnesses believe that their occupation as essential workers, poverty, health access, government distrust, comorbidities, and Social Determinants of Health (SDH) are important factors for further research. For these reasons, federal funding of a rigorous and robust national public health study of COVID-19 and African Americans is highly recommended and the next logical step to develop mitigation strategies that reduce infection, mortality, and disparate medical outcomes.

Vulnerabilidade da população negra brasileira frente à evolução da pandemia por COVID-19

Introdução: Devido as iniquidades históricas, o contexto pandêmico do COVID-19 tem impactado de maneira distinta os segmentos sociais, exigindo um acompanhamento especial às minorias étnico-raciais que vivem em situação de vulnerabilidade. Nesse sentido, o estudo tem como objetivo analisar a vulnerabilidade da população negra brasileira frente à evolução da pandemia por COVID-19. Materiais e Métodos: Trata-se de um estudo documental, descritivo, quantitativo, realizada a partir dos boletins epidemiológicos coronavírus publicados pelo Ministério da Saúde do Brasil. Foram avaliadas duas variáveis dos boletins epidemiológicos coronavírus a partir da raça/cor: hospitalizações por síndrome respiratória aguda grave e óbito por Covid-19. Resultados: Entre os boletins nº 9 e nº 18 evidenciou-se o aumento sustentado nas taxas de internação por síndrome respiratória aguda grave (de 23,9% para 54,7%) e óbito (de 34,3% para 61,3%) entre pessoas de raça/cor negra e redução constante na hospitalização (de 73% para 43,3%) e óbito (de 62,9% para 36,5%) entre pessoas brancas. Constata-se que pessoas negras têm maiores chances de internação por SRAG e morte por COVID-19 no Brasil, o que implica maior situação de vulnerabilidade. Discussão: Acredita-se que esse cenário desfavorável entre pessoas negras se deve a dificuldade ou impossibilidade de realização de isolamento social, à prevalência de comorbidades que precipitam quadros graves do COVID-19, as dificuldades no acesso aos serviços de saúde e ao racismo institucional. Conclusão: faz-se necessário a implementação de uma rede de proteção social a esse grupo racial, com o objetivo de reduzir o acometimento da doença e a letalidade do vírus.

Frequency and outcomes of gastrointestinal symptoms in patients with Corona Virus Disease-19

OBJECTIVES

To characterize the frequency and association of gastrointestinal (GI) symptoms with outcomes in patients with corona virus disease 2019  (COVID-19) admitted to the hospital.

METHODS

Records were retrospectively collected from patients admitted to a tertiary care center in Washington, D.C., with confirmed COVID-19 from March 15, 2020  to July 15, 2020. After adjusting for clinical demographics and comorbidities, multivariate logistic regression analysis was performed.

RESULTS

The most common  presenting symptoms of COVID-19 in patients that were admitted to the hospital were cough (38.4%), shortness of breath (37.5%), and fever (34.3%), followed by GI symptoms in 25.9% of patients. The most common GI symptom was diarrhea (12.8%) followed by nausea or vomiting (10.5%), decreased appetite (9.3%), and abdominal pain (3.8%). Patients with diarrhea were more likely to die (odds ratio [OR] 2.750; p = 0.006; confidence interval [CI] 1.329-5.688), be admitted to the intensive care unit (ICU) (OR 2.242; p = 0.019; CI 1.139-4.413), and be intubated (OR 3.155; p = 0.002; CI 1.535-6.487). Additional outcomes analyzed were need for vasopressors, presence of shock, and acute kidney injury. Patients with  diarrhea  were 2.738 (p = 0.007; CI 1.325-5.658), 2.467 (p = 0.013; CI 1.209-5.035), and 2.694 (p = 0.007; CI 1.305-5.561) times more likely to experience these outcomes, respectively.

CONCLUSIONS

Screening questions should be expanded to include common GI symptoms in patients with COVID-19. Health care providers should note whether their patient is presenting with diarrhea due to the potential implications on disease severity and outcomes.

Predicting the second wave of COVID-19 in Washtenaw County, MI

The COVID-19 pandemic has highlighted the patchwork nature of disease epidemics, with infection spread dynamics varying wildly across countries and across states within the US. To explore this issue, we study and predict the spread of COVID-19 in Washtenaw County, MI, which is home to University of Michigan and Eastern Michigan University, and in close proximity to Detroit, MI, a major epicenter of the epidemic in Michigan. We apply a discrete and stochastic network-based modeling framework allowing us to track every individual in the county. In this framework, we construct contact networks based on synthetic population datasets specific for Washtenaw County that are derived from US Census datasets. We assign individuals to households, workplaces, schools, and group quarters (such as prisons or long term care facilities). In addition, we assign casual contacts to each individual at random. Using this framework, we explicitly simulate Michigan-specific government-mandated workplace and school closures as well as social distancing measures. We perform sensitivity analyses to identify key model parameters and mechanisms contributing to the observed disease burden in the three months following the first observed cases of COVID-19 in Michigan. We then consider several scenarios for relaxing restrictions and reopening workplaces to predict what actions would be most prudent. In particular, we consider the effects of 1) different timings for reopening, and 2) different levels of workplace vs. casual contact re-engagement. We find that delaying reopening does not reduce the magnitude of the second peak of cases, but only delays it. Reducing levels of casual contact, on the other hand, both delays and lowers the second peak. Through simulations and sensitivity analyses, we explore mechanisms driving the magnitude and timing of a second wave of infections upon re-opening. We find that the most significant factors are workplace and casual contacts and protective measures taken by infected individuals who have sought care. This model can be adapted to other US counties using synthetic population databases and data specific to those regions.

The COVID-19 and Influenza "Twindemic": Barriers to Influenza Vaccination and Potential Acceptance of SARS-CoV2 Vaccination in African Americans

Influenza is a contagious respiratory virus that causes a significant annual health burden in the United States (US). In spite of effective yearly vaccinations to protect individuals against influenza-related health complications, especially with certain chronic co-morbid illnesses, persistent racial/ethnic disparities exist in influenza immunization. African Americans continue to experience low vaccination uptake, stemming, at least in part, from years of bias in and mistrust of orthodox medicine, safety concerns, and environmental barriers to vaccine access. The novel respiratory coronavirus, SARS-CoV2, causes COVID-19, leading to a pandemic that in the U.S. has exerted severe physical, psychological, and economic tolls on the African Americans and other disadvantaged communities. These two respiratory-borne virus' cause disparate effects in the black community, unmasking persistent disparities in healthcare. Unfortunately, suboptimal influenza immunization acceptance exacerbates flu-related adverse health outcomes, similar to difficulties from the effects of the COVID-19 pandemic. In consideration of the impending influenza-COVID-19 "twindemic", robust educational campaigns, policy initiatives, and novel approaches to influenza immunization must be considered for the African American community to build trust in the health benefits of the influenza vaccination and, ultimately, to trust in the health benefits of potential SARS-CoV2 vaccines, when available for the general public.

The IGNITE trial: Participant recruitment lessons prior to SARS-CoV-2

Full and diverse participant enrollment is critical to the success and generalizability of all large-scale Phase III trials. Recruitment of sufficient participants is among the most significant challenges for many studies. The novel SARS-CoV-2 coronavirus pandemic has further changed and challenged the landscape for clinical trial execution, including screening and randomization. The Investigating Gains in Neurocognition in an Intervention Trial of Exercise (IGNITE) study has been designed as the most comprehensive test of aerobic exercise effects on cognition and brain health. Here we assess recruitment into IGNITE prior to the increased infection rates in the United States, and examine new challenges and opportunities for recruitment with a goal of informing the remaining required recruitment as infection containment procedures are lifted. The results may assist the design and implementation of recruitment for future exercise studies, and outline opportunities for study design that are flexible in the face of emerging threats.

COVID-19 in multiple sclerosis patients and risk factors for severe infection

Multiple sclerosis (MS) patients have been considered a higher-risk population for COVID-19 due to the high prevalence of disability and disease-modifying therapy use; however, there is little data identifying clinical characteristics of MS associated with worse COVID-19 outcomes. Therefore, we conducted a multicenter prospective cohort study looking at the outcomes of 40 MS patients with confirmed COVID-19. Severity of COVID-19 infection was based on hospital course, where a mild course was defined as the patient not requiring hospital admission, moderate severity was defined as the patient requiring hospital admission to the general floor, and most severe was defined as requiring intensive care unit admission and/or death. 19/40(47.5%) had mild courses, 15/40(37.5%) had moderate courses, and 6/40(15%) had severe courses. Patients with moderate and severe courses were significantly older than those with a mild course (57[50-63] years old and 66[58.8-69.5] years old vs 48[40-51.5] years old, P = 0.0121, P = 0.0373). There was differing prevalence of progressive MS phenotype in those with more severe courses (severe:2/6[33.3%]primary-progressing and 0/6[0%]secondary-progressing, moderate:1/14[7.14%] and 5/14[35.7%] vs mild:0/19[0%] and 1/19[5.26%], P = 0.0075, 1 unknown). Significant disability was found in 1/19(5.26%) mild course-patients, but was in 9/15(60%, P = 0.00435) of moderate course-patients and 2/6(33.3%, P = 0.200) of severe course-patients. Disease-modifying therapy prevalence did not differ among courses (mild:17/19[89.5%], moderate:12/15[80%] and severe:3/6[50%], P = 0.123). MS patients with more severe COVID-19 courses tended to be older, were more likely to suffer from progressive phenotype, and had a higher degree of disability. However, disease-modifying therapy use was not different among courses.

Modeling the Political Economy and Multidimensional Factors of COVID-19 Cases in Nigeria

Both the clinical and epidemiological significance attached to COVID-19 cases by a small, but growing literature on coronavirus are not in any way undermined by the relevance of political economy and multidimensional impacts of other factors on the virus, particularly from country specific stance. In light of the stark reality, this study unravels the political economy and multidimensional factors of COVID-19 cases in Nigeria using the daily data spanning 27th of February through 26th of May, 2020. This paper deploys a variety of count data estimators to estimate the effects of political economy and ethno-religious factors on COVID-19 cases in Nigeria. The parameter estimates reveal that the odds of the Hausa ethnic group in human-to-human transmission of the virus, to be in the "Certain Zero" group is relatively less as compared to other ethnic groups in the country. A plausible reason, particularly for the vulnerable group can be attributed, in part, to their low levels of educational attainment as well as their staunch religious belief with respect to the act of soul taking as being the exclusive property of the creator than the created. Thus, addressing ethno-religious concerns together with socioeconomic factors remain the formidable mitigation policy choices to combating the scourge of the global virus of COVID-19.

Value of Advance Care Directives for Patients With Serious Illness in the Era of COVID Pandemic: A Review of Challenges and Solutions

Advance care directives (ACDs) are instructions regarding what types of medical treatments a patient desires and/or who they would like to designate as a healthcare surrogate to make important healthcare decisions when the patient is mentally incapacitated. At end-of-life, when faced with poor prognosis for a meaningful health-related quality of life, most patients indicate their preference to abstain from aggressive, life-sustaining treatments. Patients whose wishes are left unsaid often receive burdensome life sustain therapy by default, prolonging patient suffering. The CoVID pandemic has strained our healthcare resources and raised the need for prioritization of life-sustaining therapy. This highlights the urgency of ACDs more than ever. Despite ACDs' potential to provide patients with care that aligns with their values and preferences and reduce resource competition, there has been relatively little conversation regarding the overlap of ACDs and CoVID-19. There is low uptake among patients, lack of training for healthcare professionals, and inequitable adoption in vulnerable populations. However, solutions are forthcoming and may include electronic medical record completion, patient outreach efforts, healthcare worker programs to increase awareness of at-risk minority patients, and restructuring of incentives and reimbursement policies. This review carefully describes the above challenges and unique opportunities to address them in the CoVID-19 era. If solutions are leveraged appropriately, ACDs have the potential to address the described challenges and ethically resolve resource conflicts during the current crisis and beyond.

Characteristics and Outcomes of Latinx Patients With COVID-19 in Comparison With Other Ethnic and Racial Groups

BACKGROUND

There is a limited understanding of the impact of coronavirus disease 2019 (COVID-19) on the Latinx population. We hypothesized that Latinx patients would be more likely to be hospitalized and admitted to the intensive care unit (ICU) than White patients.

METHODS

We analyzed all patients with COVID-19 in 12 Massachusetts hospitals between February 1 and April 14, 2020. We examined the association between race, ethnicity, age, reported comorbidities, and hospitalization and ICU admission using multivariable regression.

RESULTS

Of 5190 COVID-19 patients, 29% were hospitalized; 33% required the ICU, and 4.3% died. Forty-six percent of patients were White, 25% Latinx, 14% African American, and 3% Asian American. Ethnicity and race were significantly associated with hospitalization. More Latinx and African American patients in the younger age groups were hospitalized than whites. Latinxs and African Americans disproportionally required the ICU, with 39% of hospitalized Latinx patients requiring the ICU compared with 33% of African Americans, 24% of Asian Americans, and 30% of Whites (P < .007). Within each ethnic and racial group, age and male gender were independently predictive of hospitalization. Previously reported preexisting comorbidities contributed to the need for hospitalization in all racial and ethnic groups (P < .05). However, the observed disparities were less likely related to reported comorbidities, with Latinx and African American patients being admitted at twice the rate of Whites, regardless of such comorbidities.

CONCLUSIONS

Latinx and African American patients with COVID-19 have higher rates of hospitalization and ICU admission than White patients. The etiologies of such disparities are likely multifactorial and cannot be explained only by reported comorbidities.

Outcomes and clinical practice in patients with COVID-19 admitted to the intensive care unit in Montréal, Canada: a descriptive analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada.

METHODS

A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality.

RESULTS

A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids.

INTERPRETATION

Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.

Determinants of survival after severe acute respiratory syndrome coronavirus 2 infection in Mexican outpatients and hospitalised patients

Objectives

This study aimed to evaluate the association of chronic diseases and indigenous ethnicity on the poor prognosis of outpatients with coronavirus disease 2019 (COVID-19) and hospitalised patients in Mexico.

Study design

The study design is an observational study of consecutive COVID-19 cases that were treated in Mexican healthcare units and hospitals between February 27 and April 27, 2020.

Methods

Epidemiological, clinical and sociodemographic data were analysed from outpatients and hospitalised patients. Cox regression models were used to analyse the risk of mortality after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Results

In total, 15,529 patients with COVID-19 were characterised; 62.6% of patients were aged older than 40 years, 57.8% were men and 1.4% were of indigenous ethnicity. A high proportion had a history of diabetes (18.4%), hypertension (21.9%) and obesity (20.9%). Among hospitalised patients, 11.2% received health care in the intensive care unit. Advanced age, male sex, indigenous ethnicity and having a history of chronic diseases, such as hypertension, diabetes and obesity, were significantly associated with a high risk of death after SARS-CoV-2 infection. Diabetes and obesity were the comorbidities most highly associated with death through the models used in this study. Moreover, living in Mexico City and Mexico State (where there is easy access to medical services) and walking (rather than driving or getting public transport) were negatively associated with mortality after SARS-CoV-2 infection.

Conclusions

Diabetes, hypertension and obesity combined with older age, male sex and indigenous ethnicity increase the risk of death after SARS-CoV-2 infection in the Mexican population. It is recommended that the incidence of COVID-19 is monitored in indigenous communities, and access to health services is increased nationwide.

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Chronic diseases and indigenous ethnicity were positively associated with COVID-19 mortality.

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Living in a city with more access to medical services was negatively associated with mortality.

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Walking was negatively associated with mortality.

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Health services coverage should be strengthened in indigenous communities.

Analysis of type I IFN response and T cell activation in severe COVID-19/HIV-1 coinfection: A case report

RATIONALE

Complex immune dysregulation in interferon (IFN) and T cell response has been observed in human immunodeficiency virus (HIV-1)-infected patients as well as in coronavirus disease-2019 (COVID-19) patients. However, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)/HIV-1 coinfection has been described in only few cases worldwide and no data are available on immunological outcomes in HIV-1-patients infected with SARS-CoV-2. Hence, this study aims to compare type I IFN response and T cell activation levels between a SARS-CoV-2/HIV-1-coinfected female patient and age-matched HIV-1-positive or uninfected women.

PATIENT CONCERNS

A 52-year-old woman diagnosed with SARS-CoV-2/HIV-1 coinfection, ten HIV-1-positive women and five age-matched-healthy individuals were enrolled in this study.

DIAGNOSES

SARS-CoV-2 infection caused severe pneumonia in the second week of illness in HIV-1-positive patient under protease inhibitors. Chest high-resolution computed tomography images of the SARS-CoV-2/HIV-1-coinfected patient showed bilateral ground-glass opacities.

INTERVENTIONS

SARS-CoV-2/HIV-1-coinfected female patient under darunavir/cobicistat regimen received a 7-days hydroxychloroquine therapy. Analysis of IFNα/β mRNA levels and CD4 and CD8 T cell (CD38, human leukocyte antigen-DR [HLA-DR], CD38 HLA-DR) frequencies were performed by RT/real-time PCR assays and flow cytometry, respectively. Median relative difference (MRD) was calculated for each immunological variable. For values greater than reference, MRD should be a positive number and for values that are smaller, MRD should be negative.

OUTCOMES

The severe pneumonia observed in SARS-CoV-2/HIV-1-positive patient under protease inhibitors was reversed by a 7-days hydroxychloroquine therapy. At the end of treatment, on day 7, patient reported resolution of fever, normalization of respiratory rate (14 breaths/min), and improved oxygen arterial pressure with a FiO2 of 30%. MRD values for IFNα/β and CD4 and CD8 T cells expressing CD38 and/or HLA-DR found in SARS-CoV-2-/HIV-1-coinfected woman were approximatively equal to 0 when refereed respectively to HIV-1-positive female patients [MRDs IFNα/β: median -0.2545 (range: -0.5/0.1); T cells: median -0.11 (range: -0.8/1.3)] and ≥ 6 when referred to healthy individuals [MRDs IFNα/β: median 28.45 (range: 15/41.9); T cells: median 10 (range 6/22)].

LESSONS

These results indicate that SARS-CoV-2 infection in HIV-1-positive female patient was associated with increased levels of IFNα/β-mRNAs and T cell activation compared to healthy individuals.

Estimating the impacts of lockdown on Covid-19 cases in Nigeria

The study examines the extent to which lockdown measures impact on COVID-19 confirmed cases in Nigeria. Six indicators of lockdown entailing retail and recreation, grocery and pharmacy, parks, transit stations, workplaces, and residential, are considered. The empirical evidence is anchored on the negative binomial regression estimator, due to the count nature of the dataset on the daily cases of the virus. The study established the key following findings: First, retail and recreation, grocery and pharmacy, parks, transit stations, and workplaces are statistically significant and negatively signed as relevant predictors of the virus. Second, the impact of residential is positive and statistically significant at the conventional level. Lastly, the results are robust to an alternative estimator of Poisson Regression. The emanated policy message centres on the need to direct efforts toward ensuring total compliance to the lockdown rules as it holds the key to keeping the virus under check.