Mortality due to COVID-19 infection: A comparison of first and second waves

High PEEP/low FiO2 ventilation is associated with lower mortality in COVID-19

RATIONALE

The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO2 ventilation on outcomes during the second wave in the Netherlands.

METHODS

Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality.

RESULTS

This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings.

CONCLUSIONS

High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS.

Earlier vs. later time period of COVID-19 infection and emergent autoimmune signs, symptoms, and serologies

OBJECTIVE

Autoantibodies and autoimmune diseases after SARS-CoV-2 infection are widely reported. Given evolving variants, milder infections, and increasing population vaccination, we hypothesized that SARS-CoV-2 infection earlier in the pandemic would be associated with more autoimmune connective tissue disease (CTD) symptoms and immunologic abnormalities.

METHODS

Patients ≥18 years old with COVID-19 3/1/2020-8/15/2022 completed the CTD Screening Questionnaire and were tested for 27 autoimmune serologies, SARS-CoV-2 serologies, cell-bound complement activation products (CB-CAPs), and T and B lymphocyte immunophenotypes by flow cytometry. We assessed relationships between symptoms, serologies, and immunophenotypes in earlier (3/1/2020-1/31/2021) vs. later (2/1/2021-8/15/2022) periods, with different predominating SARS-CoV-2 viruses.

RESULTS

57 subjects had earlier and 23 had later pandemic COVID-19. 35 % of earlier vs. 17 % of later pandemic patients had CTD symptoms (p 0.18). More patients were antinuclear antibody (ANA) positive (44 % vs. 13 %, p 0.01) and had lupus anticoagulant (11 % vs. 4 %, p 0.67). After adjustment for age, race, and sex, earlier (vs. later) COVID-19 was associated with increased ANA positivity (OR 4.60, 95%CI 1.17, 18.15). No subjects had positive CB-CAPs. T and B cell immunophenotypes and SARS-CoV-2 serologies did not differ by group. In heatmap analyses, higher autoantibody variety was seen among those with infection in the early pandemic.

CONCLUSION

In this sample, having COVID-19 infection in the earlier (pre-2/1/2021) vs. later pandemic was associated with more CTD symptoms, ANA positivity, and autoantibody reactivities. Earlier SARS-CoV-2 variants circulating in a less vaccinated population with less natural immunity may have been more immunogenic.

COVID-19 in three waves in a tertiary referral hospital in Belgium: a comparison of patient characteristics, management, and outcome

PURPOSE

Few studies have compared patient characteristics, clinical management, and outcome of patients with COVID-19 between the different epidemic waves. In this study, we describe patient characteristics, treatment, and outcome of patients admitted for COVID-19 in the Antwerp University Hospital over the first three epidemic waves of 2020-2021.

METHODS

Retrospective observational study of COVID-19 patients in a Belgian tertiary referral hospital. All adult patients with COVID-19, hospitalized between February 29, 2020, and June 30, 2021, were included. Standardized routine medical data was collected from patient records. Risk factors were assessed with multivariable logistic regression.

RESULTS

We included 722 patients, during the first (n = 179), second (n = 347) and third (n = 194) wave. We observed the lowest disease severity at admission during the first wave, and more elderly and comorbid patients during the second wave. Throughout the subsequent waves we observed an increasing use of corticosteroids and high-flow oxygen therapy. In spite of increasing number of complications throughout the subsequent waves, mortality decreased each wave (16.6%,15.6% 11.9% in 1st, 2nd and 3rd wave respectively). C-reactive protein above 150 mg/L was predictive for the need for intensive care unit admission (odds ratio (OR) 3.77, 95% confidence interval (CI) 2.32-6.15). A Charlson comorbidity index ≥ 5 (OR 5.68, 95% CI 2.54-12.70) and interhospital transfers (OR 3.78, 95% CI 2.05-6.98) were associated with a higher mortality.

CONCLUSIONS

We observed a reduction in mortality each wave, despite increasing comorbidity. Evolutions in patient management such as high-flow oxygen therapy on regular wards and corticosteroid use may explain this favorable evolution.

A cohort study of patients hospitalised with SARS-CoV-2 infection in Ontario: patient characteristics and outcomes by wave

INTRODUCTION

Each wave of the COVID-19 pandemic exhibited a unique combination of epidemiological, social and structural characteristics. We explore similarities and differences in wave-over-wave characteristics of patients hospitalised with COVID-19.

METHODS

This was a population-based study in Ontario province, Canada. Patients hospitalised with SARS-CoV-2 between 26 February 2020 and 31 March 2022 were included. An admission was considered related to SARS-CoV-2 infection if the provincial inpatient or outpatient hospital databases contained the ICD-10 diagnostic codes U071/U072 or the Ontario Laboratories Information System indicated a positive SARS-CoV-2 test result (PCR or rapid antigen testing) during the admission or up to two weeks prior. The primary outcome was 90-day mortality (modified Poisson regression). Secondary outcomes were use of critical care during the admission (logistic regression) and total length-of-stay (linear regression with heteroskedastic-consistent standard-error estimators). All models were adjusted for demographic characteristics, neighbourhood socioeconomic factors and indicators of illness severity.

RESULTS

There were 73,201 SARS-CoV-2-related admissions: 6127 (8%) during wave 1 (wild-type), 14,371 (20%) during wave 2 (wild-type), 16,653 (23%) during wave 3 (Alpha), 5678 (8%) during wave 4 (Delta) and 30,372 (42%) during wave 5 (Omicron). SARS-CoV-2 was the most responsible diagnosis for 70% of admissions during waves 1-2 and 42% in wave 5. The proportion of admitted patients who were long-term care residents was 18% (n = 1111) during wave 1, decreasing to 10% (n = 1468) in wave 2 and <5% in subsequent waves. During waves 1-3, 46% of all admitted patients resided in a neighbourhood assigned to the highest ethnic diversity quintile, which declined to 27% during waves 4-5. Compared to wave 1, 90-day mortality was similar during wave 2 (adjusted risk ratio [aRR]: 1.00 [95% CI: 0.95-1.04]), but lower during wave 3 (aRR: 0.89 [0.85-0.94]), wave 4 (aRR: 0.85 [0.79-0.91]) and wave 5 (aRR: 0.83 [0.80-0.88]). Improvements in survival over waves were observed among elderly patients (p-interaction <0.0001). Critical care admission was significantly less likely during wave 5 than previous waves (adjusted odds ratio: 0.50 [0.47-0.54]). The length of stay was a median of 8.5 (3.6-23.8) days during wave 1 and 5.3 (2.2-12.6) during wave 5. After adjustment, the mean length of stay was on average -10.4 (-11.1 to -9.8) days, i.e. shorter, in wave 5 vs wave 1.

CONCLUSION

Throughout the pandemic, sociodemographic characteristics of patients hospitalised with SARS-CoV-2 changed over time, particularly in terms of ethnic diversity, but still disproportionately affected patients from more marginalised regions. Improved survival and reduced use of critical care during the Omicron wave are reassuring.

N. A Comparative Study on the General and Otolaryngological Manifestations of COVID-19 in the Hospitalized Population of the Telangana Region During the First and Second Waves

Introduction  Some common symptoms of coronavirus disease 2019 (COVID-19) are fever, cough, and shortness of breath. But ear, nose, and throat (ENT) manifestations such as loss of smell and taste are also very common. Objectives  To compare the general and otorhinolaryngological manifestations of COVID-19 and to compare the treatments given and mortality rate during its two waves. Methods  This retrospective study was conducted on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases in a tertiary care teaching hospital. Six hundred patients were included in the 1st wave sample and 516 were in the 2nd wave sample. The data collected included demographics, comorbidities, general, and ENT symptoms, need for ventilatory support, oxygen therapy, and mortality for both the waves. Results  Fever, malaise, and myalgia were more frequently presented in the first wave than in the second, whereas shortness of breath was more common in the second wave. In the second wave, a significant increase in anosmia cases was reported, whereas sore throat, nasal obstruction, dysphagia, nasal discharge, and sneezing were significantly reduced compared with the first wave ( p  < 0.001). The case fatality rate increased from 11.33 to 21.55% ( p  < 0.001) from the 1 st to the 2 nd wave. The patients who died in the second wave were younger than those in the first wave. Two doses of vaccination showed protection from the death over those not vaccinated and those who only received one dose ( p  < 0.05). Conclusion  Ear, nose, and throat (ENT) manifestations are very common along with the general symptoms. As anosmia and dysgeusia are early presenting symptoms in COVID-19 patients, all physicians should screen patients for ENT symptoms.

Long-term survival comparison between the first and second waves among 265 critical COVID-19 patients admitted to the ICU: A retrospective cohort study

BACKGROUD

Management of severe COVID-19 patients admitted to ICU considerably evolved during the first months of the pandemic. It is unclear, however, whether these changes improved long-term survival of these critically ill patients.

METHODS

We conducted a retrospective cohort study in adults with COVID-19 pneumonia admitted to a French ICU between February 2020 and January 2021, a timeframe that covered the first two waves of the pandemic. Primary outcome was to compare long-term survival between the first and second waves. Survival predictor were identified using a Cox proportional-hazards model.

RESULTS

We included 265 patients in the cohort: 140 (52.8 %) and 125 (47.2 %) belonging to the first and second waves, respectively. Baseline characteristics of the patients were similar between the two waves. During W2, use of early corticotherapy increased (86.4% vs. 17.8 %; p <0.001), as well as high-flow oxygen therapy use (68.5% vs. 37.4 %; p<0.001). Need for invasive mechanical ventilation decreased (49.6% vs. 72.9 %; p <0.001) and ICU length of stay was shorter (11 [6-22] vs 19 [8-32]days; p = 0.008). ICU mortality was 32.8 % without significant difference between waves. Survival analysis revealed that 3 variables were independently associated with a worse long-term prognosis: a higher SAPS II score (1.05 [1.04-1.06]; p<0.001), a higher age (1.05 [1.01-1.08]; p = 0.005) and admission during W2 (2.22 [1.15-4.28]; p = 0.017).

DISCUSSION

Despite substantial changes on management of severe COVID-19 patients, we observed a decreased long-term survival among patients admitted during the second wave. We also noted a shorter ICU length of stay.

The Influence of SARS-CoV-2 Infection on Acute Myocardial Infarction Outcomes

BACKGROUND

This multicenter retrospective study with a control group was designed to assess the influence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on the outcomes of patients with myocardial infarction (MI).

METHODS

A total of 129 patients with COVID-19 who were treated for MI were included in this study. The control group comprised 129 comparable patients without SARS-CoV-2 infection. The in-hospital, out-of-hospital, and overall mortality were analyzed.

RESULTS

A total of thirty-one (24%) patients died in the study group, and two (1.6%) patients died in the control group (OR = 20.09; CI: 4.69-85.97; p < 0.001). Similar results were observed in all analyzed patient subgroups. Multivariable Cox regression analysis confirmed the significant influence of SARS-CoV-2 infection on in-hospital outcomes (HR: 8.48459; CI: 1.982-36.320; p = 0.004). Subanalysis of the groups with COVID-19 plus ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI) revealed comparable mortality rates: 14 (21.12%) patients in the NSTEMI group and 17 (26.98%) patients in the STEMI subgroup died (OR: 1.3; CI: 0.56-3.37; p = 0.45). During out-of-hospital observation, no differences in mortality were observed (OR: 0.77; CI: 0.11-4.07; p = 0.73).

CONCLUSIONS

SARS-CoV-2 infection affects the in-hospital outcomes of patients with both MI and COVID-19, regardless of MI type (STEMI vs. NSTEMI).

Comparison of out-of-hospital cardiac arrests during the COVID-19 pandemic with those before the pandemic: an updated systematic review and meta-analysis

The coronavirus disease of 2019 (COVID-19) pandemic, directly and indirectly, affected the emergency medical care system and resulted in worse out-of-hospital cardiac arrest (OHCA) outcomes and epidemiological features compared with those before the pandemic. This review compares the regional and temporal features of OHCA prognosis and epidemiological characteristics. Various databases were searched to compare the OHCA outcomes and epidemiological characteristics during the COVID-19 pandemic with before the pandemic. During the COVID-19 pandemic, survival and favorable neurological outcome rates were significantly lower than before. Survival to hospitalization, return of spontaneous circulation, endotracheal intubation, and use of an automated external defibrillator (AED) decreased significantly, whereas the use of a supraglottic airway device, the incidence of cardiac arrest at home, and response time of emergency medical service (EMS) increased significantly. Bystander CPR, unwitnessed cardiac arrest, EMS transfer time, use of mechanical CPR, and in-hospital target temperature management did not differ significantly. A subgroup analysis of the studies that included only the first wave with those that included the subsequent waves revealed the overall outcomes in which the epidemiological features of OHCA exhibited similar patterns. No significant regional differences between the OHCA survival rates in Asia before and during the pandemic were observed, although other variables varied by region. The COVID-19 pandemic altered the epidemiologic characteristics, survival rates, and neurological prognosis of OHCA patients. Review registration: PROSPERO (CRD42022339435).

Burden of disease in patients hospitalised with COVID-19 during the first and second pandemic wave in Switzerland: a nationwide cohort study

AIM OF THE STUDY

The first and second waves of the COVID-19 pandemic led to a tremendous burden of disease and influenced several policy directives, prevention and treatment strategies as well as lifestyle and social behaviours. We aimed to describe trends of hospitalisations with COVID-19 and hospital-associated outcomes in these patients during the first two pandemic waves in Switzerland.

METHODS

In this nationwide retrospective cohort study, we used in-hospital claims data of patients hospitalised with COVID-19 in Switzerland between January 1st and December 31st, 2020. First, stratified by wave (first wave: January to May, second wave: June to December), we estimated incidence rates (IR) and rate differences (RD) per 10,000 person-years of COVID-19-related hospitalisations across different age groups (0-9, 10-19, 20-49, 50-69, and ≥70 years). IR was calculated by counting the number of COVID-19 hospitalisations for each patient age stratum paired with the number of persons living in Switzerland during the specific wave period. Second, adjusted odds ratios (aOR) of outcomes among COVID-19 hospitalisations were calculated to assess the association between COVID-19 wave and outcomes, adjusted for potential confounders.

RESULTS

Of 36,517 hospitalisations with COVID-19, 8,862 (24.3%) were identified during the first and 27,655 (75.7%) during the second wave. IR for hospitalisations with COVID-19 was highest during the second wave and among patients above 50 years (50-69 years: first wave: 31.49 per 10,000 person-years; second wave: 62.81 per 10,000 person-years; RD 31.32 [95% confidence interval [CI]: 29.56 to 33.08] per 10,000 person-years; IRR 1.99 [95% CI: 1.91 to 2.08]; ≥70 years: first wave: 88.59 per 10,000 person-years; second wave: 228.41 per 10,000 person-years; RD 139.83 [95% CI: 135.42 to 144.23] per 10,000 person-years; IRR 2.58 [95% CI: 2.49 to 2.67]). While there was no difference in hospital readmission, when compared with the first wave, patients hospitalised during the second wave had a lower probability of death (aOR 0.88 [95% CI: 0.81 to 0.95], ARDS (aOR 0.56 [95% CI: 0.51 to 0.61]), ICU admission (aOR 0.66 [95% CI: 0.61 to 0.70]), and need for ECMO (aOR 0.60 [95% CI: 0.38 to 0.92]). LOS was -16.1 % (95% CI: -17.8 to -14.2) shorter during the second wave.

CONCLUSION

In this nationwide cohort study, rates of hospitalisations with COVID-19 were highest among adults older than 50 years and during the second wave. Except for hospital readmission, the likelihood of adverse outcomes was lower during the second pandemic wave, which may be explained by advances in the understanding of the disease and improved treatment options.

COVID-19 Convalescent Plasma and Clinical Trials: Understanding Conflicting Outcomes

Convalescent plasma (CP) recurs as a frontline treatment in epidemics because it is available as soon as there are survivors. The COVID-19 pandemic represented the first large-scale opportunity to shed light on the mechanisms of action, safety, and efficacy of CP using modern evidence-based medicine approaches. Studies ranging from observational case series to randomized controlled trials (RCTs) have reported highly variable efficacy results for COVID-19 CP (CCP), resulting in uncertainty. We analyzed variables associated with efficacy, such as clinical settings, disease severity, CCP SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) antibody levels and function, dose, timing of administration (variously defined as time from onset of symptoms, molecular diagnosis, diagnosis of pneumonia, or hospitalization, or by serostatus), outcomes (defined as hospitalization, requirement for ventilation, clinical improvement, or mortality), CCP provenance and time for collection, and criteria for efficacy. The conflicting trial results, along with both recent WHO guidelines discouraging CCP usage and the recent expansion of the FDA emergency use authorization (EUA) to include outpatient use of CCP, create confusion for both clinicians and patients about the appropriate use of CCP. A review of 30 available RCTs demonstrated that signals of efficacy (including reductions in mortality) were more likely if the CCP neutralizing titer was >160 and the time to randomization was less than 9 days. The emergence of the Omicron variant also reminds us of the benefits of polyclonal antibody therapies, especially as a bridge to the development and availability of more specific therapies.

Comparison of the First and Second Wave of Infections by SARS-CoV-2: A Retrospective and Longitudinal Study From a Primary Health Care Center in Santiago of Chile

The current COVID-19 pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Many countries have reported the experience of at least two contagion waves, describing associated mortality rates and population behavior. The analysis of the effect of this pandemic in different localities can provide valuable information on the key factors to consider in the face of future massive infectious diseases. This work describes the first retrospective and comparative study about behavior during the first and second waves of the COVID-19 pandemic in Chile from a primary Healthcare Center. From 19,313 real-time quantitative PCR (RT-qPCR) tests assessed, the selected 1,694 positive diagnostics showed a decrease in mortality rate in the second wave (0.6%) compared with the first (4.6%). In addition, we observed that infections in the second wave were mainly in young patients with reduced comorbidities. The population with a complete vaccination schedule shows a decrease in the duration of symptoms related to the disease, and patients with more comorbidities tend to develop severe illness. This report provides evidence to partially understand the behavior and critical factors in the severity of the COVID-19 pandemic in the population of Santiago of Chile.

Reduction in risk of death among patients admitted with COVID-19 between first and second epidemic waves in New York City

Many regions have experienced successive epidemic waves of COVID-19 since the emergence of SARS-CoV-2 with heterogeneous differences in mortality. Elucidating factors differentially associated with mortality between epidemic waves may inform clinical and public health strategies. We examined clinical and demographic data among patients admitted with COVID-19 during the first (March-June 2020) and second (December 2020-March 2021) epidemic waves at an academic medical center in New York City. Hospitalized patients (N=4631) had lower mortality during the second wave (14%) than the first (23%). Patients in the second wave had a lower 30-day mortality (Hazard Ratio (HR) 0.52, 95% CI 0.44, 0.61) than those in the first wave. The mortality decrease persisted after adjusting for confounders except for the volume of COVID-19 admissions (HR 0.88, 95% CI 0.70, 1.11), a measure of health system strain. Several demographic and clinical patient factors were associated with an increased risk of mortality independent of wave.

Article summary

Using clinical and demographic data from COVID-19 hospitalizations at a tertiary New York City medical center, we show that a reduction in mortality during the second epidemic wave was associated with decreased strain on healthcare resources.