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Killander Möller I, Hedberg P, Wagner P, Lindahl H, Nyström S, Blixt L, Eketorp Sylvan S, Nilsdotter-Augustinsson Å, Österborg A, Fredrikson M, Hansson L, Kahn F, Sparén P, Gisslén M, Nauclér P, Bergman P, Aleman S, Carlander C. Risk of COVID-19 hospitalisation by HIV-status and SARS-CoV-2 vaccination status during pre- and post-Omicron era in a national register-based cohort study in Sweden. Infect Dis (Lond) 2024:1-14. [PMID: 39320271 DOI: 10.1080/23744235.2024.2405582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/26/2024] [Accepted: 09/13/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND Data on the outcomes of COVID-19 in people living with HIV (PLHIV), specifically in relation to vaccination status, are lacking during the Omicron era. METHODS This nationwide registry-based study included all resident in Sweden ≥18 years with a positive SARS-CoV-2 PCR test during January 2021-February 2023. We estimated adjusted odds ratios (adjOR) for COVID-19 hospitalisation and severe COVID-19 (ICU admission and 90-day mortality), categorised by SARS-CoV-2 vaccination status (0-1, 2, and ≥3 doses), and HIV-status. Analyses were then categorised by time periods of pre-Omicron, Omicron during public testing, and Omicron after public testing. RESULTS 1348 PLHIV and 1 669 389 people without HIV (PWoH) were included. PLHIV were older, more migrant (65 vs. 22%) and male (59 vs. 46%). Of PLHIV, 96% were on antiretroviral treatment and 94% virally suppressed. AdjORs of COVID-19 hospitalisation were similar irrespective of HIV-status, controlled for demographics, calendar month of infection, comorbidities, and income. PLHIV were more likely to be hospitalised than PWoH during Omicron and public testing (adjOR 2.3, 95% CI 1.1-4.2), but not after public testing. The odds of severe COVID-19 were three times higher in PLHIV compared to PWoH vaccinated with 2 doses (adjOR 3.2, 95% CI 1.3-6.9), but not when vaccinated with ≥3 doses (adjOR 0.7, 95% CI 0.2-1.6). Migrant and low nadir CD4+ T-cells were associated with higher odds of hospitalisation in unvaccinated PLHIV. CONCLUSIONS This nationwide study, including mostly well-treated PLHIV, highlights the importance of vaccination with booster dose/s for effective protection against severe COVID-19 in PLHIV.KEY POINTPeople living with HIV compared to people without HIV did not have higher odds of COVID-19 hospitalisation irrespective of SARS-CoV-2 vaccination status (0-1 dose, 2 doses, ≥3 doses) when adjusting for known risk factors including comorbidities and socioeconomic status.
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Affiliation(s)
| | - Pontus Hedberg
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Philippe Wagner
- Department of Clinical Sciences, Orthopedics, Lund University, Lund, Sweden
- Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Västerås, Sweden
| | - Hannes Lindahl
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Nyström
- Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lisa Blixt
- Department of Hematology, Comprehensive Cancer Center, Karolinska University Hospital Solna, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Åsa Nilsdotter-Augustinsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Infectious Diseases in Östergötland County, Linköping University, Linköping, Sweden
| | - Anders Österborg
- Department of Hematology, Comprehensive Cancer Center, Karolinska University Hospital Solna, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine and Forum Östergötland, Faculty of Medicine, Linköping University, Linköping, Sweden
| | - Lotta Hansson
- Department of Hematology, Comprehensive Cancer Center, Karolinska University Hospital Solna, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Kahn
- Division of Infection Medicine, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Public Health Agency of Sweden, Solna, Sweden
| | - Pontus Nauclér
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Bergman
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Soo Aleman
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Carlander
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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2
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Leston M, Elson W, Ordóñez-Mena JM, Kar D, Whitaker H, Joy M, Roberts N, Hobbs FDR, de Lusignan S. Disparities in COVID-19 mortality amongst the immunosuppressed: A systematic review and meta-analysis for enhanced disease surveillance. J Infect 2024; 88:106110. [PMID: 38302061 PMCID: PMC10943183 DOI: 10.1016/j.jinf.2024.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Effective disease surveillance, including that for COVID-19, is compromised without a standardised method for categorising the immunosuppressed as a clinical risk group. METHODS We conducted a systematic review and meta-analysis to evaluate whether excess COVID-associated mortality compared to the immunocompetent could meaningfully subdivide the immunosuppressed. Our study adhered to UK Immunisation against infectious disease (Green Book) criteria for defining and categorising immunosuppression. Using OVID (EMBASE, MEDLINE, Transplant Library, and Global Health), PubMed, and Google Scholar, we examined relevant literature between the entirety of 2020 and 2022. We selected for cohort studies that provided mortality data for immunosuppressed subgroups and immunocompetent comparators. Meta-analyses, grey literature and any original works that failed to provide comparator data or reported all-cause or paediatric outcomes were excluded. Odds Ratios (OR) and 95% confidence intervals (CI) of COVID-19 mortality were meta-analysed by immunosuppressed category and subcategory. Subgroup analyses differentiated estimates by effect measure, country income, study setting, level of adjustment, use of matching and publication year. Study screening, extraction and bias assessment were performed blinded and independently by two researchers; conflicts were resolved with the oversight of a third researcher. PROSPERO registration number is CRD42022360755. FINDINGS We identified 99 unique studies, incorporating data from 1,542,097 and 56,248,181 unique immunosuppressed and immunocompetent patients with COVID-19 infection, respectively. Compared to immunocompetent people (pooled OR, 95%CI), solid organ transplants (2.12, 1.50-2.99) and malignancy (2.02, 1.69-2.42) patients had a very high risk of COVID-19 mortality. Patients with rheumatological conditions (1.28, 1.13-1.45) and HIV (1.20, 1.05-1.36) had just slightly higher risks than the immunocompetent baseline. Case type, setting income and mortality data matching and adjustment were significant modifiers of excess immunosuppressed mortality for some immunosuppressed subgroups. INTERPRETATION Excess COVID-associated mortality among the immunosuppressed compared to the immunocompetent was seen to vary significantly across subgroups. This novel means of subdivision has prospective benefit for targeting patient triage, shielding and vaccination policies during periods of high disease transmission.
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Affiliation(s)
- Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom.
| | - Willam Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Jose M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Heather Whitaker
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Old Campus Road, Old Campus Research Building, Headington, Oxford OX3 7DQ, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
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3
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Hanna JJ, Geresu LB, Diaz MI, Ho M, Casazza JA, Pickering MA, Lanier HD, Radunsky AP, Cooper LN, Saleh SN, Bedimo RJ, Most ZM, Perl TM, Lehmann CU, Turer RW, Chow JY, Medford RJ. Risk Factors for SARS-CoV-2 Infection and Severe Outcomes Among People With Human Immunodeficiency Virus: Cohort Study. Open Forum Infect Dis 2023; 10:ofad400. [PMID: 37577110 PMCID: PMC10416813 DOI: 10.1093/ofid/ofad400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023] Open
Abstract
Background Studies on COVID-19 in people with HIV (PWH) have had limitations. Further investigations on risk factors and outcomes of SARS-CoV-2 infection among PWH are needed. Methods This retrospective cohort study leveraged the national OPTUM COVID-19 data set to investigate factors associated with SARS-CoV-2 positivity among PWH and risk factors for severe outcomes, including hospitalization, intensive care unit stays, and death. A subset analysis was conducted to examine HIV-specific variables. Multiple variable logistic regression was used to adjust for covariates. Results Of 43 173 PWH included in this study, 6472 had a positive SARS-CoV-2 result based on a polymerase chain reaction test or antigen test. For PWH with SARS-CoV-2 positivity, higher odds were found for those who were younger (18-49 years), Hispanic White, African American, from the US South, uninsured, and a noncurrent smoker and had a higher body mass index and higher Charlson Comorbidity Index. For PWH with severe outcomes, higher odds were identified for those who were SARS-CoV-2 positive, older, from the US South, receiving Medicaid/Medicare or uninsured, a current smoker, and underweight and had a higher Charlson Comorbidity Index. In a subset analysis including PWH with HIV care variables (n = 5098), those with unsuppressed HIV viral load, a low CD4 count, and no antiretroviral therapy had higher odds of severe outcomes. Conclusions This large US study found significant ethnic, racial, and geographic differences in SARS-CoV-2 infection among PWH. Chronic comorbidities, older age, lower body mass index, and smoking were associated with severe outcomes among PWH during the COVID-19 pandemic. SARS-CoV-2 infection was associated with severe outcomes, but once we adjusted for HIV care variables, SARS-CoV-2 was no longer significant; however, low CD4 count, high viral load, and lack of antiretroviral therapy had higher odds of severe outcomes.
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Affiliation(s)
- John J Hanna
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Liyu B Geresu
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Healthcare Informatics, Children’s Health Hospitals and Health Care, Dallas, Texas, USA
| | - Marlon I Diaz
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Milan Ho
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Julia A Casazza
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Madison A Pickering
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heather D Lanier
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alexander P Radunsky
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lauren N Cooper
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sameh N Saleh
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Roger J Bedimo
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Zachary M Most
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Trish M Perl
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christoph U Lehmann
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Lyda Hill Department of Bioinformatics, UT Southwestern Medical Center, Dallas, Texas, USA
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Robert W Turer
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jeremy Y Chow
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Richard J Medford
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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4
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Moreno-Torres V, de Mendoza C, Martínez-Urbistondo M, Mills P, Treviño A, de la Fuente S, Díaz de Santiago A, Calderón-Parra J, Pintos-Pascual I, Corpas M, Soriano V. Predictors of in-hospital mortality in HIV-infected patients with COVID-19. QJM 2023; 116:57-62. [PMID: 36047831 DOI: 10.1093/qjmed/hcac215] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Underlying immunodeficiency is associated with severe COVID-19, but the prognosis of persons with human immunodeficiency virus (HIV) (PWH) with COVID-19 is under debate. Aim: assessment of the mortality rate and major determinants of death in HIV-infected patients hospitalized with COVID-19 in Spain before vaccine availability. Design: Retrospective nationwide public database analysis. METHODS Nationwide, retrospective, observational analysis of all hospitalizations with COVID-19 during year 2020 in Spain. Stratification was made according to HIV status. The National Registry of Hospital Discharges was used with the ICD-10 coding list. RESULTS A total of 117 694 adults were hospitalized with COVID-19 during 2020. Only 234 (0.2%) were HIV-positives. More than 95% were on antiretroviral therapy. Compared to HIV-negatives, PWH were younger (mean age 53.2 vs. 66.5 years old; P<0.001) and more frequently male (74.8% vs. 56.6%; P<0.001). Most co-morbidities predisposing to severe COVID-19 (diabetes, hypertension, dementia and cardiovascular disease) were more frequent in HIV-negatives. In contrast, the rate of baseline liver disease was over 6-fold higher in PWH (27.4% vs. 4.4%; P<0.001). In-hospital mortality was lower in PWH (9.4% vs. 16%; P=0.004). In multivariate analysis, older age, dementia and especially advanced liver disease (relative risk (RR): 7.6) were the major determinants of death in PWH hospitalized with COVID-19. CONCLUSION HIV-infected patients hospitalized in Spain with COVID-19 during 2020 had better survival than HIV-negatives, most likely explained by younger age and lower rate of co-morbidities. However, advanced liver disease was a major predictor of death in PWH hospitalized with COVID-19.
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Affiliation(s)
- V Moreno-Torres
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - C de Mendoza
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
- UNIR Health Sciences School and Medical Center, Calle García Martín 21, Pozuelo de Alarcón 28224, Madrid, Spain
| | - M Martínez-Urbistondo
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - P Mills
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - A Treviño
- UNIR Health Sciences School and Medical Center, Calle García Martín 21, Pozuelo de Alarcón 28224, Madrid, Spain
| | - S de la Fuente
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - A Díaz de Santiago
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - J Calderón-Parra
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - I Pintos-Pascual
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, Majadahonda 28222, Madrid, Spain
| | - M Corpas
- UNIR Health Sciences School and Medical Center, Calle García Martín 21, Pozuelo de Alarcón 28224, Madrid, Spain
- Genetics Unit, Cambridge Precision Medicine, Cambridge Biomedical Campus, Hills Road CB2 OAH, Cambridge, UK
| | - V Soriano
- UNIR Health Sciences School and Medical Center, Calle García Martín 21, Pozuelo de Alarcón 28224, Madrid, Spain
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Hedberg P, Granath F, Bruchfeld J, Askling J, Sjöholm D, Fored M, Färnert A, Naucler P. Post COVID-19 condition diagnosis: A population-based cohort study of occurrence, associated factors, and healthcare use by severity of acute infection. J Intern Med 2023; 293:246-258. [PMID: 36478477 PMCID: PMC9877994 DOI: 10.1111/joim.13584] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The occurrence and healthcare use trajectory of post COVID-19 condition (PCC) is poorly understood. Our aim was to investigate these aspects in SARS-CoV-2-positive individuals with and without a PCC diagnosis. METHODS We conducted a population-based cohort study of adults in Stockholm, Sweden, with a verified infection from 1 March 2020 to 31 July 2021, stratified by the severity of the acute infection. The outcome was a PCC diagnosis registered any time 90-360 days after a positive test. We performed Cox regression models to assess baseline characteristics associated with the PCC diagnosis. Individuals diagnosed with PCC were then propensity-score matched to individuals without a diagnosis to assess healthcare use beyond the acute infection. RESULTS Among 204,805 SARS-CoV-2-positive individuals, the proportion receiving a PCC diagnosis was 1% among individuals not hospitalized for their COVID-19 infection, 6% among hospitalized, and 32% among intensive care unit (ICU)-treated individuals. The most common new-onset symptom diagnosis codes among individuals with a PCC diagnosis were fatigue (29%) among nonhospitalized and dyspnea among both hospitalized (25%) and ICU-treated (41%) individuals. Female sex was associated with a PCC diagnosis among nonhospitalized and hospitalized individuals, with interactions between age and sex. Previous mental health disorders and asthma were associated with a PCC diagnosis among nonhospitalized and hospitalized individuals. Among individuals with a PCC diagnosis, the monthly proportion with outpatient care was substantially elevated up to 1 year after acute infection compared to before, with substantial proportions of this care attributed to PCC-related care. CONCLUSION The differential association of age, sex, comorbidities, and healthcare use with the severity of the acute infection indicates different trajectories and phenotypes of PCC, with incomplete resolution 1 year after infection.
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Affiliation(s)
- Pontus Hedberg
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Granath
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Judith Bruchfeld
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Rheumatology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Sjöholm
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Michael Fored
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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