Prevalence and predictors of death and severe disease in patients hospitalized due to COVID-19: A comprehensive systematic review and meta-analysis of 77 studies and 38,000 patients

Comparison of fatalities due to COVID-19 and other nonexternal causes during the first five pandemic waves : Results from multiple cause of death statistics in Bavaria

BACKGROUND

Older age is a risk factor for a fatal course of SARS-CoV‑2 infection, possibly due to comorbidities whose exact role in this context, however, is not yet well understood. In this paper, the characteristics and comorbidities of persons who had died of COVID-19 in Bavaria by July 2022 are shown and compared with the characteristics of other fatalities during the pandemic.

METHODS

Based on data from multiple cause of death statistics, odds ratios for dying from COVID-19 (compared to dying from other nonexternal causes of death) were calculated by using logistic regression models, stratified by age, sex, and pandemic waves.

RESULTS

In Bavaria, a total of 24,479 persons (6.5% of all deaths) officially died from COVID-19 between March 2020 and July 2022. In addition to increasing age and male sex, preexisting diseases and comorbidities such as obesity, degenerative diseases of the nervous system, dementia, renal insufficiency, chronic lower respiratory diseases, and diabetes mellitus were significantly associated with COVID-19-related deaths. Dementia was mainly associated with increased COVID-19 mortality during the first and second waves, while obesity was strongly associated during the fourth wave.

DISCUSSION

The frequency of specific comorbidities in COVID-19 deaths varied over the course of the pandemic. This suggests that wave-specific results also need to be interpreted against the background of circulating virus variants, changing immunisation levels, and nonpharmaceutical interventions in place at the time.

Clinical effectiveness of nirmatrelvir plus ritonavir for patients with COVID-19 and preexisting psychiatric disorders

OBJECTIVES

This study assessed the clinical effectiveness of the combination of nirmatrelvir and ritonavir (NMV-r) in treating nonhospitalized patients with COVID-19 who have preexisting psychiatric disorders.

METHODS

Patients diagnosed with COVID-19 and psychiatric disorders between 1 March 2020, and 1 December 2022, were included using the TriNetX network. The primary outcome was the composite outcome of all-cause emergency department (ED) visits, hospitalization, or death within 30 days.

RESULTS

Propensity score matching yielded two cohorts of 20,633 patients each. The composite outcome of all-cause ED visits, hospitalization, or death within 30 days was 3.57% (737 patients) in the NMV-r cohort and 5.69% (1176) in the control cohort, resulting in a reduced risk in the NMV-r cohort (HR: 0.657; 95% confidence interval (CI): 0.599-0.720). The NMV-r cohort exhibited a lower risk of all-cause hospitalization (HR: 0.385; 95% CI: 0.328-0.451) and all-cause death (HR: 0.110; 95% CI: 0.053-0.228) compared with the control group.

CONCLUSION

NMV-r could mitigate the risk of adverse outcomes in nonhospitalized patients with COVID-19 and preexisting psychiatric disorders. However, only a limited number of patients in this population received adequate treatment, thus emphasizing the importance of promoting its appropriate use.

Clinical characteristics, imaging, and lung function among patients with persistent dyspnea of COVID-19: a retrospective observational cohort study

The available medical literature on lung function and corresponding clinical characteristics among symptomatic survivors of Corona Virus Disease 2019 (long COVID) is sparse. Primary physicians referred patients who manifested persistent dyspnea months after their index case of infection to a designated clinic. Patients underwent symptom-driven, quality-of-life, physical, and focused respiratory [pulmonary function tests and computed tomography (CT) of the chest] evaluations and were followed over time. In this paper, we present our findings. Patients with abnormal CT imaging were more likely to be of advanced age and to have been hospitalized during their COVID-19 infection. Forced exhaled volume in the first second, forced vital capacity (FVC), total lung capacity, and diffusion capacity of carbon monoxide measurements were found to be significantly lower in patients with abnormal CT imaging. Multivariate regression of clinical characteristics uncovered a significant association between FVC, body mass index, history of hospitalization, and diabetes mellitus. In conclusion, longer-term studies will help further our understanding of the risk factors, disease course, and prognosis of long COVID patients.

Use of chronic medications and risk of death due to COVID-19 in hospitalised patients

OBJECTIVES

To evaluate the potential association between chronic exposure to medication and death related to COVID-19.

METHODS

This is a retrospective cross-sectional study that included all patients hospitalised due to COVID-19 from 11 March to 4 June 2020 in our centre. Chronic patient medication was classified by the Anatomical Therapeutic Chemical (ATC) classification; demographic and clinical data were analysed. Multivariate logistic regression models were used to estimate the adjusted odds ratios (aOR) of death for each drug exposure; each aOR represents an independent model adjusted by clinical factors related to COVID-19 mortality.

RESULTS

The study included 978 patients with a mean (SD) age of 64.5 (17.7) years who were predominantly male (531, 54.3%). Of all 978 patients, 182 (18.61%) died during the follow-up of the study. The most common Charlson Comorbidity Index (CCI) was 0, 4.2% were smokers, 16.7% were obese, 47.4% had hypertension, and 19.4% were diabetic. Most patients (70.8%) were prescribed at least one treatment, 32.5% used >5 treatments, and 8.6% >10. Our data suggest that COVID-19 hospitalised patients taking trimethoprim and analogues, leukotriene receptor antagonists, calcineurin inhibitors, aldosterone antagonists, selective immunosuppressants, propulsives, insulins and analogues, and benzodiazepine derivatives have a higher risk of death.

CONCLUSIONS

This study investigated the association between chronic exposure to drugs and the risk of death in COVID-19 patients. Our results have shed some light on the impact of chronic drug exposure on the risk of severe COVID-19; however, further research is needed to increase the understanding about its relevance.

A Year After Implementation of the Telehealth Waiver: Being Offered and Utilizing Video-Specific Telehealth Among Dual-Eligible Medicare Recipients During the COVID-19 Pandemic

OBJECTIVE

Telehealth is an essential tool to provide access to care while reducing infection exposure for high-risk populations during the COVID-19 pandemic. Our study aims to examine factors associated with telehealth availability and usage among Medicare and dual-eligible recipients 1 year after implementation of the Medicare's temporary telehealth waiver.

DESIGN, SETTING, AND PARTICIPANT

A cross-sectional, phone survey with a national representative sample of Medicare recipients. We obtained a final study sample from the Winter 2021 COVID-19 Supplement of Medicare Current Beneficiary Survey dataset (N = 10 586). We examined associations for being offered and having had telehealth visits or any video telehealth visits during the pandemic since November 1, 2020.

MAIN OUTCOME MEASURES

Our primary outcomes were being offered any telehealth, being offered any video telehealth, having had any telehealth visit, and having had any video telehealth.

RESULTS

Although dual eligibility was not significantly associated with being offered or having had any telehealth services during the pandemic, those who were dual eligible were more likely to have had video telehealth visits (adjusted odds ratio = 1.39, 95% confidence interval 1.04-1.86, P = .03) compared with those with non-dual eligibility. Recipients with disability eligibility, technology access, and severe chronic conditions were more likely to have been offered or have had telehealth. At the same time, those who lived in the nonmetropolitan area were less likely to have been offered or have had telehealth, including video telehealth.

CONCLUSIONS

Our findings suggest that the federal waivers to expand telehealth services were successful in continuing care for vulnerable Medicare recipients. The providers' specific outreach and intervention efforts to offer telehealth visits are crucial for dual-eligible recipients. To increase video telehealth uptake, technology access and services to rural areas should be prioritized.

Immunisation efficacy of a stabilised SARS-CoV-2 spike glycoprotein in two geriatric animal models

Age is associated with reduced efficacy of vaccines and linked to higher risk of severe COVID-19. Here we determined the impact of ageing on the efficacy of a SARS-CoV-2 vaccine based on a stabilised Spike glycoprotein (S-29) that had previously shown high efficacy in young animals. Thirteen to 18-month-old golden Syrian hamsters (GSH) and 22-23-month-old K18-hCAE2 mice were immunised twice with S-29 protein in AddaVaxTM adjuvant. GSH were intranasally inoculated with SARS-CoV-2 either two weeks or four months after the booster dose, while all K18-hACE2 mice were intranasally inoculated two weeks after the second immunisation. Body weight and clinical signs were recorded daily post-inoculation. Lesions and viral load were investigated in different target tissues. Immunisation induced seroconversion and production of neutralising antibodies; however, animals were only partially protected from weight loss. We observed a significant reduction in the amount of viral RNA and a faster viral protein clearance in the tissues of immunized animals. Infectious particles showed a faster decay in vaccinated animals while tissue lesion development was not altered. In GSH, the shortest interval between immunisation and inoculation reduced RNA levels in the lungs, while the longest interval was equally effective in reducing RNA in nasal turbinates; viral nucleoprotein amount decreased in both tissues. In mice, immunisation was able to improve the survival of infected animals. Despite the high protection shown in young animals, S-29 efficacy was reduced in the geriatric population. Our research highlights the importance of testing vaccine efficacy in older animals as part of preclinical vaccine evaluation.

The Intersections of COVID-19, HIV, and Race/Ethnicity: Machine Learning Methods to Identify and Model Risk Factors for Severe COVID-19 in a Large U.S. National Dataset

We investigate risk factors for severe COVID-19 in persons living with HIV (PWH), including among racialized PWH, using the U.S. population-sampled National COVID Cohort Collaborative (N3C) data released from January 1, 2020 to October 10, 2022. We defined severe COVID-19 as hospitalized with invasive mechanical ventilation, extracorporeal membrane oxygenation, discharge to hospice or death. We used machine learning methods to identify highly ranked, uncorrelated factors predicting severe COVID-19, and used multivariable logistic regression models to assess the associations of these variables with severe COVID-19 in several models, including race-stratified models. There were 3 241 627 individuals with incident COVID-19 cases and 81 549 (2.5%) with severe COVID-19, of which 17 445 incident COVID-19 and 1 020 (5.8%) severe cases were among PWH. The top highly ranked factors of severe COVID-19 were age, congestive heart failure (CHF), dementia, renal disease, sodium concentration, smoking status, and sex. Among PWH, age and sodium concentration were important predictors of COVID-19 severity, and the effect of sodium concentration was more pronounced in Hispanics (aOR 4.11 compared to aOR range: 1.47-1.88 for Black, White, and Other non-Hispanics). Dementia, CHF, and renal disease was associated with higher odds of severe COVID-19 among Black, Hispanic, and Other non-Hispanics PWH, respectively. Our findings suggest that the impact of factors, especially clinical comorbidities, predictive of severe COVID-19 among PWH varies by racialized groups, highlighting a need to account for race and comorbidity burden when assessing the risk of PWH developing severe COVID-19.

Case-control study of behavioural and societal risk factors for sporadic SARS-CoV-2 infections, Germany, 2020-2021 (CoViRiS study)

During the COVID-19 pandemic in Germany, a variety of societal activities were restricted to minimize direct personal interactions and, consequently, reduce SARS-CoV-2 transmission. The aim of the CoViRiS study was to investigate whether certain behaviours and societal factors were associated with the risk of sporadic symptomatic SARS-CoV-2 infections. Adult COVID-19 cases and frequency-matched population controls were interviewed by telephone regarding activities that involved contact with other people during the 10 days before illness onset (cases) or before the interview (controls). Associations between activities and symptomatic SARS-CoV-2 infection were analysed using logistic regression models adjusted for potential confounding variables. Data of 859 cases and 1 971 controls were available for analysis. The risk of symptomatic SARS-CoV-2 infection was lower for individuals who worked from home (adjusted odds ratio (aOR) 0.5; 95% confidence interval (CI) 0.3-0.6). Working in a health care setting was associated with a higher risk (aOR: 1.5; 95% CI: 1.1-2.1) as were private indoor contacts, personal contacts that involved shaking hands or hugging, and overnight travelling within Germany. Our results are in line with some of the public health recommendations aimed at reducing interpersonal contacts during the COVID-19 pandemic.

Younger age is associated with cardiovascular pathological phenotype of severe COVID-19 at autopsy

Introduction

COVID-19 affects patients of all ages. There are few autopsy studies focusing on the younger population. We assessed an autopsy cohort aiming to understand how age influences pathological outcomes in fatal COVID-19.

Methods

This study included autopsied patients, aged 6 months to 83 years, with confirmed COVID-19 in 2020-2021. We collected tissue samples from deceased patients using a minimally invasive autopsy protocol and assessed pathological data following a systematic approach.

Results

Eighty-six patients were included, with a median age of 55 years (IQR 32.3-66.0). We showed that age was significantly lower in patients with acute heart ischemia (p = 0.004), myocarditis (p = 0.03) and lung angiomatosis (p < 0.001), and significantly higher in patients with exudative diffuse alveolar damage (p = 0.02), proliferative diffuse alveolar damage (p < 0.001), lung squamous metaplasia (p = 0.003) and lung viral atypia (p = 0.03), compared to patients without those findings. We stratified patients by their age and showed that cardiovascular findings were more prevalent in children and young adults. We performed principal component analysis and cluster of pathological variables, and showed that cardiovascular variables clustered and covariated together, and separated from pulmonary variables.

Conclusion

We showed that age modulates pathological outcomes in fatal COVID-19. Younger age is associated with cardiovascular abnormalities and older age with pulmonary findings.

Protective MVA-ST Vaccination Robustly Activates T Cells and Antibodies in an Aged-Hamster Model for COVID-19

Aging is associated with a decline in immune system functionality. So-called immunosenescence may impair the successful vaccination of elderly people. Thus, improved vaccination strategies also suitable for an aged immune system are required. Modified Vaccinia virus Ankara (MVA) is a highly attenuated and replication-deficient vaccinia virus that has been established as a multipurpose viral vector for vaccine development against various infections. We characterized a recombinant MVA expressing a prefusion-stabilized version of SARS-CoV-2 S protein (MVA-ST) in an aged-hamster model for COVID-19. Intramuscular MVA-ST immunization resulted in protection from disease and severe lung pathology. Importantly, this protection was correlated with a potent activation of SARS-CoV-2 specific T-cells and neutralizing antibodies. Our results suggest that MVA vector vaccines merit further evaluation in preclinical models to contribute to future clinical development as candidate vaccines in elderly people to overcome the limitations of age-dependent immunosenescence.

Does the Impact of COVID-19 on Patients With Systemic Sclerosis Change Over Time?

OBJECTIVE

The outcome of patients with COVID-19 improved over the pandemic, including patients with systemic rheumatic diseases. However, data on patients with systemic sclerosis (SSc) are lacking. This study aimed to assess the outcome of patients with both SSc and COVID-19 over several waves.

METHODS

Patients with both SSc and COVID-19 who were registered in the European Scleroderma Trials and Research group (EUSTAR) were collected between April 2020 and April 2021. Patients were assigned to waves 1, 2, or 3 depending on the date of their COVID-19 diagnosis. Primary endpoints were death, intensive care unit stay, or ventilatory support (severe outcome). Subgroup analyses of patients who were hospitalized or died were conducted. General and SSc-specific characteristics and treatment were compared over the waves. Descriptive statistics and multivariate logistic regression were applied.

RESULTS

A total of 333 patients were included; 57 patients (17%) had a severe outcome, and 30 patients (9%) died. Compared to wave 1, significantly fewer patients with SSc suffered from severe COVID-19 in waves 2 and 3 (28.2% vs 9.8% and 12.7%; P < 0.001), fewer patients required hospitalization (46.7% vs 19.6% and 25.5%; P < 0.001) or ventilatory support (24.0% vs 8.7% and 10.9%; P = 0.001), and fewer patients died (15.7% vs 5.0% and 7.5%; P = 0.011). Patients were significantly younger, more often men, had less frequent arterial hypertension, and less SSc cardiac involvement over waves 1 to 3. Patients received significantly less medium to high doses of corticosteroids as they did SSc treatment.

CONCLUSION

The outcome of patients with both SSc and COVID-19 improved significantly over time because of intrinsic and extrinsic factors.

Association between nirmatrelvir plus ritonavir and the outcomes of non-hospitalized obese patients with COVID-19

OBJECTIVE

To investigate the association between nirmatrelvir plus ritonavir (NMV-r) and the outcomes of non-hospitalized obese patients with coronavirus disease 2019 (COVID-19).

METHODS

This retrospective cohort study used the TriNetX research network to identify non-hospitalized obese adult patients with COVID-19 between 1 January 2022 and 30 June 2023. Propensity score matching was used to match patients receiving NMV-r (NMV-r group) with those not receiving NMV-r (control group). The primary outcome was the compositive outcome of all-cause emergency department (ED) visits, hospitalization or death during the 30-day follow-up period.

RESULTS

Using propensity score matching methods, two cohorts of 30,969 patients each with balanced baseline characteristics were identified. During the follow-up period, the NMV-r group had a lower risk of all-cause ED visits, hospitalization or death [4.80% (n=1489) vs 5.50% (n=1705); hazard ratio (HR) 0.900, 95% confidence interval (CI) 0.839-0.965]. Compared with the control group, the NMV-r group had a lower risk of all-cause ED visits (HR 0.812, 95% CI 0.740-0.891) and all-cause mortality (HR 0.089, 95% CI 0.027-0.288). The lower risk in the NMV-r group compared with the control group was observed consistently in most subgroup analyses according to body mass index (30.0-34.9 kg/m2: HR 0.68, 95% CI 0.55-0.82; 35.0-39.9 kg/m2: HR 0.67, 95% CI 0.52-0.87), age (4-64 years: HR 0.83, 95% CI 0.75-0.92; ≥65 years: HR 0.88, 95% CI 0.79-0.98), sex (men: HR 0.69, 95% CI 0.60-0.79; women: HR 0.69, 95% CI 0.63-0.76) and vaccination status (unvaccinated: HR 0.75, 95% CI 0.70-0.81).

CONCLUSION

NMV-r is associated with reduced risk of all-cause ED visits, hospitalization and death for non-hospitalized obese patients with COVID-19. Accordingly, these findings support the use of NMV-r in obese patients.

Mortality Increased Among Hospitalized Patients with Cirrhosis Before and Following Different Waves of the COVID-19 Pandemic

BACKGROUND

The Coronavirus disease 2019 (COVID-19) pandemic disrupted patient care and worsened the morbidity and mortality of some chronic diseases. The impact of the COVID-19 pandemic on hospitalizations and outcomes in patients with cirrhosis both before and during different time periods of the pandemic has not been evaluated.

AIMS

Describe characteristics of hospitalized patients with cirrhosis and evaluate inpatient mortality and 30-day readmission before and after the start of the COVID-19 pandemic.

METHODS

Retrospective single-center cohort study of all hospitalized patients with cirrhosis from 2018 to 2022. Time periods within the COVID-19 pandemic were defined using reference data from the World Health Organization and Centers for Disease Control. Adjusted odds ratios from logistic regression were used to assess differences between periods.

RESULTS

33,926 unique hospitalizations were identified. Most patients were over age 60 years across all time periods of the pandemic. More Hispanic patients were hospitalized during COVID-19 than before COVID-19. Medicare and Medicaid are utilized less frequently during COVID-19 than before COVID-19. After controlling for age and gender, inpatient mortality was significantly higher during all COVID-19 periods except Omicron compared to before COVID-19. The odds of experiencing a 30-day readmission were 1.2 times higher in the pre-vaccination period compared to the pre-COVID-19 period.

CONCLUSION

Inpatient mortality among patients with cirrhosis has increased during the COVID-19 pandemic compared to before COVID-19. Although COVID-19 infection may have had a small direct pathologic effect on the natural history of cirrhotic liver disease, it is more likely that other factors are impacting this population.

Dissecting Clinical Features of COVID-19 in a Cohort of 21,312 Acute Care Patients

COVID-19 has resulted in over 645 million hospitalization and 7 million deaths globally. However, many questions still remain about clinical complications in COVID-19 and if these complications changed with different circulating SARS-CoV-2 strains. We analyzed a 2.5-year retrospective cohort of 47,063 encounters for 21,312 acute care patients at five Central Texas hospitals and define distinct trajectory groups (TGs) with latent class mixed modeling, based on the World Health Organization COVID-19 Ordinal Scale. Using this TG framework, we evaluated the association of demographics, diagnoses, vitals, labs, imaging, consultations, and medications with COVID-19 severity and broad clinical outcomes. Patients within 6 distinct TGs differed in manifestations of multi-organ disease and multiple clinical factors. The proportion of mild patients increased over time, particularly during Omicron waves. Age separated mild and fatal patients, though did not distinguish patients with severe versus critical disease. Male and Hispanic/Latino demographics were associated with more severe/critical TGs. More severe patients had a higher rate of neuropsychiatric diagnoses, consultations, and brain imaging, which did not change significantly in severe patients across SARS-CoV-2 variant waves. More severely affected patients also demonstrated an immunological signature of high neutrophils and immature granulocytes, and low lymphocytes and monocytes. Interestingly, low albumin was one of the best lab predictors of COVID-19 severity in association with higher malnutrition in severe/critical patients, raising concern of nutritional insufficiency influencing COVID-19 outcomes. Despite this, only a small fraction of severe/critical patients had nutritional labs checked (pre-albumin, thiamine, Vitamin D, B vitamins) or received targeted interventions to address nutritional deficiencies such as vitamin replacement. Our findings underscore the significant link between COVID-19 severity, neuropsychiatric complications, and nutritional insufficiency as key risk factors of COVID-19 outcomes and raise the question of the need for more widespread early assessment of patients' neurological, psychiatric, and nutritional status in acute care settings to help identify those at risk of severe disease outcomes.

COVID-19 and Nutrition: Focus on Chronic Kidney Disease

Some chronic diseases, including chronic kidney disease (CKD), may be associated with poor outcomes, including a high rate of hospitalization and death after COVID-19 infection. In addition to the vaccination program, diet intervention is essential for boosting immunity and preventing complications. A healthy diet containing bioactive compounds may help mitigate inflammatory responses and oxidative stress caused by COVID-19. In this review, we discuss dietary interventions for mitigating COVID-19 complications, including in persons with CKD, which can worsen COVID-19 symptoms and its clinical outcomes, while diet may help patients with CKD to resist the ravages of COVID-19 by improving the immune system, modulating gut dysbiosis, mitigating COVID-19 complications, and reducing hospitalization and mortality. The concept of food as medicine, also known as culinary medicine, for patients with CKD can be extrapolated to COVID-19 infection because healthy foods and nutraceuticals have the potential to exert an important antiviral, anti-inflammatory, and antioxidant role.

Differences in the severity and mortality risk factors for patients hospitalized for COVID-19 pneumonia between the early wave and the very late stage of the pandemic

Background

Since China's dynamic zero-COVID policy is cancelled on December 7, 2022, the rapidly growing number of patients has brought a major public health challenge. This study aimed to assess whether there were differences in the severity and mortality risk factors for patients hospitalized for COVID-19 pneumonia between the early wave and the very late stage of the pandemic.

Methods

A retrospective cross-sectional study was carried out using data from 223 hospitalized patients diagnosed with COVID-19 pneumonia during the Omicron surge in Xi'an People's Hospital (Xi'an Fourth Hospital) from December 8, 2022, to January 31, 2023. Univariable and multivariable logistic regression analyses were used to identify potential risk factors associated with the severity and mortality of COVID-19 pneumonia during the first wave of the pandemic after the dynamic zero-COVID policy was retracted. Differences in the severity and mortality risk factors were assessed at different stages of the pandemic, mainly from demographic, clinical manifestation, laboratory tests and radiological findings of patients on admission.

Results

The mean age of the 223 participants was 71.2 ± 17.4. Compared with the patients in the initial stage of the pandemic, the most common manifestation among patients in this study was cough (90.6%), rather than fever (79.4%). Different from the initial stage of the pandemic, older age, chest tightness, elevated neutrophil-to-lymphocyte ratio (NLR), decreased albumin (ALB) level and ground glass opacification (GGO) in radiological finding were identified as severity risk factors, instead of mortality risk factors for COVID-19 patients in the very late stage of the pandemic. Arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ≤300 mmHg, cardiovascular disease and laboratory findings including elevated levels of D-dimer, α-hydroxybutyrate dehydrogenase (α-HBDH), total bilirubin (TBIL), alanine aminotransferase (ALT), urea nitrogen (BUN), creatinine (CR), fasting blood glucose (FBG) and decreased platelet count (PLT) were still associated with mortality in the very late stage of the pandemic.

Conclusion

Monitoring continuously differences in the severity and mortality risk factors for COVID-19 patients between different stages of the pandemic could provide evidence for exploring uncharted territory in the coming post-pandemic era.

Animal models to study the neurological manifestations of the post-COVID-19 condition

More than 40% of individuals infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have experienced persistent or relapsing multi-systemic symptoms months after the onset of coronavirus disease 2019 (COVID-19). This post-COVID-19 condition (PCC) has debilitating effects on the daily life of patients and encompasses a broad spectrum of neurological and neuropsychiatric symptoms including olfactory and gustative impairment, difficulty with concentration and short-term memory, sleep disorders and depression. Animal models have been instrumental to understand acute COVID-19 and validate prophylactic and therapeutic interventions. Similarly, studies post-viral clearance in hamsters, mice and nonhuman primates inoculated with SARS-CoV-2 have been useful to unveil some of the aspects of PCC. Transcriptomic alterations in the central nervous system, persistent activation of immune cells and impaired hippocampal neurogenesis seem to have a critical role in the neurological manifestations observed in animal models infected with SARS-CoV-2. Interestingly, the proinflammatory transcriptomic profile observed in the central nervous system of SARS-CoV-2-inoculated mice partially overlaps with the pathological changes that affect microglia in humans during Alzheimer's disease and aging, suggesting shared mechanisms between these conditions. None of the currently available animal models fully replicates PCC in humans; therefore, multiple models, together with the fine-tuning of experimental conditions, will probably be needed to understand the mechanisms of PCC neurological symptoms. Moreover, given that the intrinsic characteristics of the new variants of concern and the immunological status of individuals might influence PCC manifestations, more studies are needed to explore the role of these factors and their combinations in PCC, adding further complexity to the design of experimental models.

Risk factors for death in hospitalized COVID-19 patients in Africa: A systematic review and meta-analysis

BACKGROUND

The coronavirus disease 2019 has quickly spread worldwide since it first appeared in Wuhan, China, in late 2019. The most affected country in Africa was South Africa. This study aimed to identify the risk factors for death in hospitalized COVID-19 patients in Africa.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched articles from the following database: PubMed, Embase, Cochrane Library, Medline, and COVID-19 Research Database. We used Google Scholar for gray literature. The language used in this article was English. The last search was conducted on January 15, 2023. Pooled HRs, or ORs, and 95% confidence intervals, were calculated separately to identify the risk factors for death in hospitalized COVID-19 patients. Heterogeneity was assessed by Cochran's Q statistic and the I2 test. The Egger test was used to assess publication bias. Subgroup analysis was performed to determine the source of heterogeneity. Data analysis was performed using Stata version 17. A P value < .05 was considered significant.

RESULTS

A total of 16,600 articles were obtained from the database search; finally, 16 articles met the inclusion criteria and were eligible for data extraction. The analysis revealed that the pooled prevalence of mortality in hospitalized COVID-19 patients was 13.9%. Advanced age was a significant risk factor for death in hospitalized COVID-19 patients, with the pooled coronavirus mortality HR and OR being 3.73 (95% CI: 2.27-5.19) and 1.04 (95% CI: 1.02-1.06), respectively. In addition, male gender (pOR 1.23; 95% CI: 1.07-1.40), patients with diabetes mellitus (DM) (pOR 1.26; 95% CI: 1.01-1.51), hypertension (HTN) (pOR 1.56; 95% CI: 1.27-1.85), chronic kidney disease (CKD) (pHR 5.43; 95% CI: 0.18-10.67), severe or critical conditions (pOR 9.04; 95% CI: 3.14-14.94) had a significantly increased risk of coronavirus-related mortality. The main limitations of the present study stem from the predominant use of published studies, which could introduce publication bias.

CONCLUSION

According to this study, advanced age, male gender, hypertension, diabetes mellitus, chronic kidney disease, and severe or critical condition were clinical risk factors associated with death outcomes in hospitalized COVID-19 patients in Africa.

Psychological experience of home-quarantined older women with COVID-19 in Hong Kong: A qualitative study

BACKGROUND

The surge of positive COVID-19 cases taxed the local health care system and left many older adults initiating home self-care practices. The study aimed to explore the psychological experiences of home-quarantined older women diagnosed with COVID-19 in Hong Kong.

METHODS

Ten semi-structured telephone interviews were held among older women from March to April 2022. Inductive thematic analysis was used to analyse the data.

RESULTS

Older women experienced psychological distress, anxiety and depression after being infected with COVID-19. The source of their psychological difficulties included fear of losing control over one's health and dignity, feeling a burden to one's family, conflict in balancing risks and responsibilities, and being overwhelmed by the tragic news reported in media. Meanwhile, the participants demonstrated resilience following the infection and found meaning in their experiences, and grew mentally.

CONCLUSIONS

The older women in this study have identified the negative impact having a diagnosis and being home-quarantine means to them and their family. Yet, they were also able to take some positives from this. Importantly, the older women report being able to build greater resilience, optimism and wisdom towards COVID-19 in general and feel better prepared for the potential of future positive diagnoses.

Immediate cause and the role of multimorbidity in deaths associated with COVID 19 among hospitalized patients in a low resource district in Kerala India: A record-based case-control analysis

Introduction

Multimorbidity is the coexistence of two or more chronic medical conditions in a person. The study aims to investigate the immediate cause of death and risk factors of mortality including multimorbidity among patients hospitalized with SARS CoV2 infection in Kasaragod district in Kerala, India.

Methods

A record-based case-control study was done using the hospital records and follow-up surveillance system of SARS-COV 2 patients admitted in the Kasaragod district. SARS-COV 2 patients who had expired during the study period from June to December 2020 and reported as COVID-19 deaths (N = 226) were the cases, and an equal number of hospital controls were the study participants.

Results

The mean (SD) age of the cases and controls were found to be 64.6 (14.2) years and 61.5 (13.4) years, respectively. Covid pneumonia alone was reported as the cause of death in more than half (52%) of the study participants. This was followed by cardiovascular events (8.5%) and acute kidney injury (6.5%). Among individual comorbidities among people who expired, diabetes mellitus (53%) was the most common, followed by hypertension (46%) and cardiovascular diseases (23%). More than 50% were found to have multimorbidity. Logistic regression showed chronic kidney disease (CKD) (Adjusted odds ratio (AOR) = 2.18 (1.24-3.83)) and malignancy (AOR = 3.05 (1.27-7.32)) to be significantly associated with mortality as individual determinants. Hypertension-diabetes mellitus [AOR = 1.68 (1.02-2.76), P = 0.043] and hypertension-CKD [AOR = 3.49 (1.01-12.01), P = 0.48] dyads were multimorbidities significantly associated with mortality.

Conclusion

Combinations of hypertension with diabetes mellitus and CKD were found to be significant determinants for mortality in hospitalized COVID-19 patients. Uniformity in death certification is required to understand the causes and contributors to death in COVID-19.

Association of polymorphisms in long pentraxin 3 and its plasma levels with COVID-19 severity

COVID-19 is an infectious respiratory disease caused by SARS-CoV-2. Pentraxin 3 (PTX3) is involved in the activation and regulation of the complement system, demonstrating an important role in the pathogenesis of COVID-19. The aim was to evaluate the association of single nucleotide polymorphisms in PTX3 and its plasma levels with the severity of COVID-19. This is a retrospective cohort study, carried out between August 2020 and July 2021, including patients with confirmed COVID-19 hospitalized in 2 hospitals in the Northeast Region of Brazil. Polymorphisms in PTX3 (rs1840680 and rs2305619) were determined by real-time PCR. PTX3 plasma levels were measured by ELISA. Serum levels of interleukin (IL)-6, IL-8, and IL-10 were determined by flow cytometry. A multivariate logistic regression model was used to identify parameters independently associated with COVID-19 severity. P values  < 0.05 were considered significant. The study included 496 patients, classified as moderate (n = 267) and severe (n = 229) cases. The PTX3 AA genotype (rs1840680) was independently associated with protection against severe COVID-19 (P = 0.037; odds ratio = 0.555). PTX3 plasma levels were significantly associated with COVID-19 severity and mortality (P < 0.05). PTX3 levels were significantly correlated with IL-6, IL-8, IL-10, C-reactive protein, total leukocytes, neutrophil-to-lymphocyte ratio, urea, creatinine, ferritin, length of hospital stay, and higher respiratory rate (P < 0.05). Our results revealed a protective effect of the PTX3 AA genotype (rs1840680) on the development of severe forms of COVID-19. Additionally, PTX3 plasma levels were associated with the severity of COVID-19. The results of this study provide evidence of an important role of PTX3 in the immunopathology of COVID-19.

Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio, are they markers of COVID-19 severity or old age and frailty? A comparison of two distinct cohorts

The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are simple markers of systemic inflammatory responses. It has been previously suggested that they can predict COVID-19 severity. Age and frailty may also influence their values. This study aimed to evaluate the impact of COVID-19 severity versus age and frailty on NLR and PLR values. This was a retrospective, observational two cohorts' comparative study. The first cohort is comprised of patents positive for SARS-CoV-2, with mild or asymptomatic disease, admitted to designated COVID-19 departments in a large geriatric medical center (GMC). The second included patients with COVID-19 admitted to designated COVID-19 departments in a large general hospital for symptomatic disease from March 2020 to March 2021. We compared baseline characteristics including comorbidities and chronic medications, disease symptoms, laboratory tests and compared the NLR and PLR between the two groups. The 177 patients admitted to the COVID-designated department in the GMC were over three decades older than the 289 COVID-19 patients admitted to the general hospital care (HC). They had substantially more comorbidities and chronic medications. All common disease symptoms were significantly more common in the HC group. Almost two thirds of the GMC patients remained asymptomatic compared to 2.1% in the HC group. Inflammatory markers, such as CRP and LDH, were significantly higher in the HC group. The NLR and PLR were both significantly higher in the GMC cohort comprised of older frailer patients with milder disease. NLR and PLR seem to be affected more by age and frailty than COVID-19 severity.

Severe Acute Respiratory Syndrome Associated Infections

Viral infections are some of the most common sources of respiratory illness in pediatric and adult populations worldwide. Influenza and coronaviruses are viral pathogens that could lead to severe respiratory illness and death. More recently, respiratory illness from coronaviruses, accounts for more than 1 million deaths in the United States alone. This article will explore the epidemiology, pathogenesis, diagnosis, treatment, and prevention of severe acute respiratory syndrome caused by coronavirus-2, and Middle Eastern respiratory syndrome.

The effectiveness of COVID deaths to COVID policies: A robust conditional approach

This paper examines the effectiveness of four major COVID-19 social distancing policies, (i) shelter-in-place orders (SIPO), (ii) non-essential business closures, (iii) mandatory quarantine for travelers, and (iv) bans on large gatherings, on both COVID cases and COVID deaths. Results indicate that states are highly ineffective in producing the fraction of the population that does not have COVID-19 or the fraction of the population that does not die from COVID-19. We find that having any form of social distancing policies increases the fraction of the population not considered a positive COVID-19 case by 23.5 percentage points. Results also show that having any of the four major social distancing policies reduces the fraction of the population who has died of COVID-19 by 1.3 percentage points between March 1, 2020 and September 1, 2020; during the first 100 days, effectiveness would improve by 2.1 percentage points. Evidence suggests that there is no effective uniform national COVID-19 social distancing policy. Furthermore, conditional efficiency regressions after 100 days suggest that behavioral noncompliance and premature expiration of social distancing policies both negatively impact effectiveness. Partial regression plots suggest that bans on large gatherings and the closure of non-essential businesses were the two most impactful COVID-19 social distancing policies.

Experiences of aftermath of COVID-19 in relation to social, financial and health related aspects among previously hospitalized patients: a qualitative exploration

Background

There is increasing evidence of long-term consequences of COVID-19. The world has seen multidimensional impact of the pandemic and Bangladesh is no exception to that. Policymakers in Bangladesh laid out strategies to curb the initial spread of COVID-19. However, long-term consequences of COVID-19 received little or no attention in the country. Evidence suggests that people presumed to be recovered face multidimensional post-covid consequences. This study aimed to describe the aftermath of COVID-19 in relation to social, financial and health related aspects among previously hospitalized patients.

Methods

This descriptive qualitative study includes participants (n = 14) who were previously hospitalized for COVID-19 and returned home after recovery. The participants were part of a mixed method study from which they were purposively selected. Semi-structured in-depth interviews were conducted over telephone. Inductive content analysis was used to analyze the data.

Results

Twelve sub-categories emerged from the data analysis which converged into five main categories. The main categories included perspective on physical health, financial struggle, life adjustment, interplay between different domains, and spontaneous support.

Conclusion

The lived experiences of COVID-19 recovered patients highlighted multidimensional impact on their daily lives. Physical and psychological wellbeing found to be related to the effort of restoring financial status. People's perception about life altered due to pandemic, for few the pandemic was an opportunity to grow while others found it difficult to accept the hardship. Such multidimensional post COVID-19 impact on people's lives and wellbeing holds considerable implication for response and mitigation plan for future related pandemics.

Diabetes and deaths of COVID-19 patients: Systematic review of meta-analyses

Background

COVID-19 is affecting all kinds of patients including diabetics. This article provides an overview of conducted meta-analyses regarding the effect of diabetes on the deaths of COVID-19 patients.

Methodology

The study was conducted as per preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement.

Data sources

The relevant meta-analyses were searched on PubMed till April 2021 and data was extracted from 24 relevant meta-analyses. The overall estimate was calculated in terms of odds ratio or relative risk with a 95% confidence interval.

Results

A total of 09 meta-analyses showed the association of diabetes with the death of COVID-19 patients and 15 meta-analyses have reported the association of diabetes with other comorbidities in the death of COVID-19 patients. The pooled odds ratio or relative risk has shown a significant association of diabetes alone or its associated comorbidities with deaths of COVID-19 patients.

Conclusion

Patients with diabetes and its associated comorbidities need more monitoring if get SARS-Cov-2 infection to reduce deaths.

The controversial effect of smoking and nicotine in SARS-CoV-2 infection

The effects of nicotine and cigarette smoke in many diseases, notably COVID-19 infection, are being debated more frequently. The current basic data for COVID-19 is increasing and indicating the higher risk of COVID-19 infections in smokers due to the overexpression of corresponding host receptors to viral entry. However, current multi-national epidemiological reports indicate a lower incidence of COVID-19 disease in smokers. Current data indicates that smokers are more susceptible to some diseases and more protective of some other. Interestingly, nicotine is also reported to play a dual role, being both inflammatory and anti-inflammatory. In the present study, we tried to investigate the effect of pure nicotine on various cells involved in COVID-19 infection. We followed an organ-based systematic approach to decipher the effect of nicotine in damaged organs corresponding to COVID-19 pathogenesis (12 related diseases). Considering that the effects of nicotine and cigarette smoke are different from each other, it is necessary to be careful in generalizing the effects of nicotine and cigarette to each other in the conducted researches. The generalization and the undifferentiation of nicotine from smoke is a significant bias. Moreover, different doses of nicotine stimulate different effects (dose-dependent response). In addition to further assessing the role of nicotine in COVID-19 infection and any other cases, a clever assessment of underlying diseases should also be considered to achieve a guideline for health providers and a personalized approach to treatment.

SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups

Liver is unlikely the key organ driving mortality in coronavirus disease 2019 (COVID-19) however, liver function tests (LFTs) abnormalities are widely observed mostly in moderate and severe cases. According to this review, the overall prevalence of abnormal LFTs in COVID-19 patients ranges from 2.5% to 96.8% worldwide. The geographical variability in the prevalence of underlying diseases is the determinant for the observed discrepancies between East and West. Multifactorial mechanisms are implicated in COVID-19-induced liver injury. Among them, hypercytokinemia with "bystander hepatitis", cytokine storm syndrome with subsequent oxidative stress and endotheliopathy, hypercoagulable state and immuno-thromboinflammation are the most determinant mechanisms leading to tissue injury. Liver hypoxia may also contribute under specific conditions, while direct hepatocyte injury is an emerging mechanism. Except for initially observed severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) tropism for cholangiocytes, more recent cumulative data show SARS-CoV-2 virions within hepatocytes and sinusoidal endothelial cells using electron microscopy (EM). The best evidence for hepatocellular invasion by the virus is the identification of replicating SARS-CoV-2 RNA, S protein RNA and viral nucleocapsid protein within hepatocytes using in-situ hybridization and immunostaining with observed intrahepatic presence of SARS-CoV-2 by EM and by in-situ hybridization. New data mostly derived from imaging findings indicate possible long-term sequelae for the liver months after recovery, suggesting a post-COVID-19 persistent live injury.

Early-stage predictors of deterioration among 3145 nonsevere SARS-CoV-2-infected people community-isolated in Wuhan, China: A combination of machine learning algorithms and competing risk survival analyses

OBJECTIVE

To determine which early-stage variables best predicted the deterioration of coronavirus disease 2019 (COVID-19) among community-isolated people infected with severe acute respiratory syndrome coronavirus 2 and to test the performance of prediction using only inexpensive-to-measure variables.

METHODS

Medical records of 3145 people isolated in two Fangcang shelter hospitals (large-scale community isolation centers) from February to March 2020 were accessed. Two complementary methods-machine learning algorithms and competing risk survival analyses-were used to test potential predictors, including age, gender, severity upon admission, symptoms (general symptoms, respiratory symptoms, and gastrointestinal symptoms), computed tomography (CT) signs, and comorbid chronic diseases. All variables were measured upon (or shortly after) admission. The outcome was deterioration versus recovery of COVID-19.

RESULTS

More than a quarter of the 3145 people did not present any symptoms, while one-third ended isolation due to deterioration. Machine learning models identified moderate severity upon admission, old age, and CT ground-glass opacity as the most important predictors of deterioration. Removing CT signs did not degrade the performance of models. Competing risk models identified age ≥ 35 years, male gender, moderate severity upon admission, cough, expectoration, CT patchy opacity, CT consolidation, comorbid diabetes, and comorbid cardiovascular or cerebrovascular diseases as significant predictors of deterioration, while a stuffy or runny nose as a predictor of recovery.

CONCLUSIONS

Early-stage prediction of COVID-19 deterioration can be made with inexpensive-to-measure variables, such as demographic characteristics, severity upon admission, observable symptoms, and self-reported comorbid diseases, among asymptomatic people and mildly to moderately symptomatic patients.

In-Hospital Outcomes of COVID-19 Associated Myocarditis (from a Nationwide Inpatient Sample Database Study)

The prevalence of COVID-19 infection-related myocarditis, its in-hospital cardiovascular outcomes, and its impact on hospital cost and stay at national level are not well studied in the literature. The Nationwide Inpatient Sample Database from 2020 was queried to identify patients with COVID-19 and myocarditis versus those without myocarditis. Cardiovascular outcomes and resource utilization were studied among cohorts with COVID-19, with and without myocarditis, using descriptive statistics, multivariate regression matching, and propensity score matching using STATA version 17. Of 1,678,995 patients, 3,565 (0.21%) had COVID-19 with myocarditis, and 1,675,355 (99.78%) had COVID-19 without myocarditis. On multivariate regression analysis, we found higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.27 to 1.9) in patients with myocarditis than in those without myocarditis, in addition to higher odds of major adverse cardiovascular and cerebrovascular events (aOR 3.54, 95% CI 2.8 to 4.4), acute kidney injury (aOR 1.29, 95% CI 1.27 to 1.9), heart failure (aOR 2.77, 95% CI 2.3 to 3.4), cardiogenic shock (aOR 10.2, 95% CI 7.9 to 13), myocardial infarction (aOR 5.74, 95% CI 4.5 to 7.3), and use of mechanical circulatory support (aOR 2.81, 95% CI 1.6 to 4.9). The propensity-matched cohort also favored similar outcomes. In conclusion, patients with COVID-19 and myocarditis had worse clinical outcomes, having a higher rate of in-hospital mortality, major adverse cardiovascular and cerebrovascular events with longer length of hospital stay, and higher hospitalization costs. Large prospective trials are necessary to validate these findings with diagnostic measures, including biopsy and cardiac magnetic resonance imaging for the extent of myocardial involvement.

Predictors of Mortality Among Post-COVID-19 Discharged Patients in Northern India: A Case-Control Study

Introduction The post-discharge all-cause mortality of COVID-19 disease is known, but predictors for the same have not been studied as much. The objective of this study was to develop an understanding of predictors of mortality to guide in prioritizing patient care and preventive approaches. Methods This current research is a single-center unmatched case-control study conducted at a tertiary care center in northern India, between April and September 2022. The data were extracted retrospectively from the hospital's electronic medical records of patients with the assistance of trained physicians using a standardized data extraction sheet. Results A total of 184 patients were enrolled and were segregated into two groups, cases and control, with 92 in each. The mean age of patients was 49.3 ± 17.53 years. The mortality group had a higher mean age (53.24 ± 18.53 yrs) as compared to the control group (45.37 ± 15.58 yrs, p=0.002). Bivariate analysis revealed a significant difference in the two groups with respect to O₂ saturation at the time of admission (case - 91.12 ± 12.49 %, control - 95.46 ± 5.01 %, p=0.003); maximum O₂ flow rate (L/min) (case - 11.01 ± 22.2, control - 6.41 ± 13.31, p=0.04); ICU need (p=0.005), cancer (p=0.001), O₂ requirement at discharge (p=0.001) and acute kidney injury (AKI; p=0.007). On multiple regression analysis, cancer (adjusted odds ratio (aOR) - 2.469; 95% CI 1.183-5.150, p=0.016), ICU admission (aOR - 2.446; 95% CI 1.212-4.938, p=0.013), oxygen at discharge (aOR - 2.340; 95% CI 0.971-5.640, p=0.0586) and AKI (aOR - 5.6; 95% CI 2.351- 13.370, p=0.00) only found to be significant. Conclusion Among the patients released from the hospital post-COVID-19 treatment, the following aspects oxygen requirement (2.3 times), malignancy (2.4 times), ICU admission (2.4 times), and AKI (5.6 times) are risk factors of mortality. The presence of these variables would warrant a close follow-up for these patients in order to decrease post-COVID mortality.

Crosstalk between COVID-19 Infection and Kidney Diseases: A Review on the Metabolomic Approaches

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19, a respiratory disorder. Various organ injuries have been reported in response to this virus, including kidney injury and, in particular, kidney tubular injury. It has been discovered that infection with the virus does not only cause new kidney disease but also increases treatment difficulty and mortality rates in people with kidney diseases. In individuals hospitalized with COVID-19, urinary metabolites from several metabolic pathways are used to distinguish between patients with acute kidney injury (AKI) and those without. This review summarizes the pathogenesis, pathophysiology, treatment strategies, and role of metabolomics in relation to AKI in COVID-19 patients. Metabolomics is likely to play a greater role in predicting outcomes for patients with kidney disease and COVID-19 with varying levels of severity in the near future as data on metabolic profiles expand rapidly. Here, we also discuss the correlation between COVID-19 and kidney diseases and the available metabolomics approaches.

The prevalence of metabolic conditions before and during the COVID-19 pandemic and its association with health and sociodemographic factors

BACKGROUND

There is a dearth of evidence on the relationship between COVID-19 and metabolic conditions among the general U.S. population. We examined the prevalence and association of metabolic conditions with health and sociodemographic factors before and during the COVID-19 pandemic.

METHODS

Data were drawn from the 2019 (N = 5,359) and 2020 (N = 3,830) Health Information National Trends Surveys on adults to compare observations before (2019) and during (2020) the COVID-19 pandemic. We conducted weighted descriptive and multivariable logistic regression analyses to assess the study objective.

RESULTS

During the pandemic, compared to pre-pandemic, the prevalence of diabetes (18.10% vs. 17.28%) has increased, while the prevalence of hypertension (36.38% vs. 36.36%) and obesity (34.68% vs. 34.18%) has remained similar. In general, the prevalence of metabolic conditions was higher during the pandemic (56.09%) compared to pre-pandemic (54.96%). Compared to never smokers, former smokers had higher odds of metabolic conditions (AOR = 1.38, 95% CI = 1.01, 1.87 and AOR = 1.57, 95% CI = 1.10, 2.25) before and during the pandemic, respectively. People with mild anxiety/depression symptoms (before: AOR = 1.52, 95% CI = 1.06, 2.19 and during: AOR = 1.55, 95% CI = 1.01, 2.38) had higher odds of metabolic conditions relative to those with no anxiety/depression symptoms.

CONCLUSION

This study found increased odds of metabolic conditions among certain subgroups of US adults during the pandemic. We recommend further studies and proper allocation of public health resources to address these conditions.

Disease severity in hospitalized COVID-19 patients: comparing routine surveillance with cohort data from the LEOSS study in 2020 in Germany

INTRODUCTION

Studies investigating risk factors for severe COVID-19 often lack information on the representativeness of the study population. Here, we investigate factors associated with severe COVID-19 and compare the representativeness of the dataset to the general population.

METHODS

We used data from the Lean European Open Survey on SARS-CoV-2 infected patients (LEOSS) of hospitalized COVID-19 patients diagnosed in 2020 in Germany to identify associated factors for severe COVID-19, defined as progressing to a critical disease stage or death. To assess the representativeness, we compared the LEOSS cohort to cases of hospitalized patients in the German statutory notification data of the same time period. Descriptive methods and Poisson regression models were used.

RESULTS

Overall, 6672 hospitalized patients from LEOSS and 132,943 hospitalized cases from the German statutory notification data were included. In LEOSS, patients above 76 years were less likely represented (34.3% vs. 44.1%). Moreover, mortality was lower (14.3% vs. 21.5%) especially among age groups above 66 years. Factors associated with a severe COVID-19 disease course in LEOSS included increasing age, male sex (adjusted risk ratio (aRR) 1.69, 95% confidence interval (CI) 1.53-1.86), prior stem cell transplantation (aRR 2.27, 95% CI 1.53-3.38), and an elevated C-reactive protein at day of diagnosis (aRR 2.30, 95% CI 2.03-2.62).

CONCLUSION

We identified a broad range of factors associated with severe COVID-19 progression. However, the results may be less applicable for persons above 66 years since they experienced lower mortality in the LEOSS dataset compared to the statutory notification data.

Prevalence, attitude, knowledge, and risk perception towards COVID-19 in COPD patients associated to biomass exposure

Chronic obstructive pulmonary disease (COPD) patients due to biomass exposure (BE-COPD) could be more affected than COPD due to tobacco smoke (TE-COPD) by the coronavirus disease 2019 (COVID-19) pandemic. The aim of this work was to determine the prevalence of COVID-19 in BE-COPD and TE-COPD and if housing conditions, poor attitude, knowledge, and risk perception towards COVID-19, particularly in BE-COPD women, could represent a risk factor for contagion.An 11% prevalence of COVID-19 was found with no significant difference between COPD groups. The BE-COPD group showed poorer socioeconomic status. No significant differences were found to be associated with SARS-CoV-2 infection regarding housing conditions, poor knowledge, attitude, and risk perception towards COVID-19. Living in urban areas and perceiving risk in COVID-19 were significantly associated with increased adherence to sanitary measures and concern of contagion. Around 40% of all patients showed poor risk perception and adherence to sanitary measures towards COVID-19.

Liver pathology in COVID-19 related death and leading role of autopsy in the pandemic

BACKGROUND

Information on liver involvement in patients with coronavirus disease 2019 is currently fragmented.

AIM

To highlight the pathological changes found during the autopsy of severe acute respiratory syndrome coronavirus 2 positive patients.

METHODS

A systematic literature search on PubMed was carried out until June 21, 2022.

RESULTS

A literature review reveals that pre-existing liver disease and elevation of liver enzyme in these patients are not common; liver enzyme elevations tend to be seen in those in critical conditions. Despite the poor expression of viral receptors in the liver, it seems that the virus is able to infect this organ and therefore cause liver damage. Unfortunately, to date, the search for the virus inside the liver is not frequent (16% of the cases) and only a small number show the presence of the virus. In most of the autopsy cases, macroscopic assessment is lacking, while microscopic evaluation of livers has revealed the frequent presence of congestion (42.7%) and steatosis (41.6%). Less frequent is the finding of hepatic inflammation or necrosis (19%) and portal inflammation (18%). The presence of microthrombi, frequently found in the lungs, is infrequent in the liver, with only 12% of cases presenting thrombotic formations within the vascular tree.

CONCLUSION

To date, the greatest problem in interpreting these modifications remains the association of the damage with the direct action of the virus, rather than with the inflammation or alterations induced by hypoxia and hypovolemia in patients undergoing oxygen therapy and decompensated patients.

Risk of hospitalization in a sample of COVID-19 patients with and without chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Patients with chronic obstructive pulmonary disease (COPD) may have worse coronavirus disease-2019 (COVID-19)-related outcomes. We compared COVID-19 hospitalization risk in patients with and without COPD.

METHODS

This retrospective cohort study included patients ≥40 years, SARS-CoV-2 positive, and with Kaiser Permanente Northern California membership ≥1 year before COVID-19 diagnosis (electronic health records and claims data). COVID-19-related hospitalization risk was assessed by sequentially adjusted logistic regression models and stratified by disease severity. Secondary outcome was death/hospice referral after COVID-19.

RESULTS AND DISCUSSION

Of 19,558 COVID-19 patients, 697 (3.6%) had COPD. Compared with patients without COPD, COPD patients were older (median age: 69 vs 53 years); had higher Elixhauser Comorbidity Index (5 vs 0) and more median baseline outpatient (8 vs 4), emergency department (2 vs 1), and inpatient (2 vs 1) encounters. Unadjusted analyses showed increased odds of hospitalization with COPD (odds ratio [OR]: 3.93; 95% confidence interval [CI]: 3.40-4.60). After full risk adjustment, there were no differences in odds of hospitalization (OR: 1.14, 95% CI: 0.93-1.40) or death/hospice referral (OR: 0.96, 95% CI: 0.72-1.27) between patients with and without COPD. Primary/secondary outcomes did not differ by COPD severity, except for higher odds of hospitalization in COPD patients requiring supplemental oxygen versus those without COPD (OR: 1.84, 95% CI: 1.02-3.33).

CONCLUSIONS

Except for hospitalization among patients using supplemental oxygen, no differences in odds of hospitalization or death/hospice referral were observed in the COVID-19 patient sample depending on whether they had COPD.

A Multiple-Center, Retrospective Study of Characteristics and Outcomes of Hospitalized COVID-19 Patients with Cardiovascular Disease in North Iran

Background

In this retrospective study, we investigated the outcomes and demographic characteristics of COVID-19 patients with and without a history of CVD.

Methods

This large retrospective, multicenter study was performed on inpatients with suspected COVID-19 pneumonia who were admitted across four hospitals in Babol, Northern Iran.Demographic data, clinical data, and cycle threshold value (Ct) results of Real Time PCR were obtained. Then, participants were divided into two groups: (1) cases with CVDs, (2) cases without CVDs.

Results

A total of 11097 suspected COVID-19 cases with a mean ± SD age of 53 ±25.3 (range: 0 to 99) years were involved in the present study. Out of whom 4599 (41.4%) had a positive RT-PCR result. Of those, 1558 (33.9%) had underlying CVD. Patients with CVD had significantly more co-morbidities such as hypertension, kidney disease, and diabetes. Moreover, 187 (12%) and 281 (9.2%) of patients with and without CVD died, respectively. Also, mortality rate was significantly high among the three groups of Ct value in patients with CVD, with the highest mortality in those with Ct between 10 and 20 (Group A = 19.9%).

Conclusions

In summary, our results highlight that CVD is a major risk factor for hospitalization and the severe consequences of COVID-19. Death in CVD group is significantly higher compared to non-CVD. In addition, the results show that age-related diseases can be a serious risk factor for the severe consequences of COVID-19.

Chronic alcohol intake regulates expression of SARS-CoV2 infection-relevant genes in an organ-specific manner

BACKGROUND

Chronic alcohol consumption and alcohol use disorder have a tremendous impact on the patient's psychological and physiological health. There is evidence that chronic alcohol consumption influences SARS-CoV2 infection risk, but so far, the molecular mechanism underlying such an effect is unknown.

METHODS

We generated the expression data of SARS-CoV2 infection-relevant genes (Ace2, Tmprss2, and Mas) in different organs in rat models of chronic alcohol exposure and alcohol dependence. Ace2 and Tmprss2 represent the virus entry point, whereas Mas activates the anti-inflammatory response once the cells are infected.

RESULTS

Across three different chronic alcohol test conditions, we found a consistent upregulation of Ace2 gene expression in the lung, which has been shown to be the most affected organ in COVID-19 patients. Other organs such as liver, ileum, kidney, heart, and brain also showed upregulation of Ace2 and Mas gene expression but less consistently across the different animal models, while Tmprss2 expression was unaffected in all conditions.

CONCLUSIONS

We conclude that alcohol-induced upregulation of Ace2 gene expression can lead to an elevated stochastic probability of virus entry into cells and may thus confer a molecular risk for SARS-CoV2 infection.

Association between vaccination status and COVID-19-related health outcomes among community-dwelling COVID-19 patients in Nara, Japan

BACKGROUND

Many previous studies have reported COVID-19 vaccine effectiveness, but there are few studies in Japan. This community-based, retrospective observational study investigated the association between vaccination status and COVID-19-related health outcomes in COVID-19 patients by SARS-CoV-2 variant type.

METHODS

The study participants were 24,314 COVID-19 patients aged 12 or older whose diagnoses were reported to the Nara Prefecture Chuwa Public Health Center from April 2021 to March 2022, during periods when the alpha, delta, and omicron variants of COVID-19 were predominant. The outcome variables were severe health consequences (SHC) (i.e., ICU admission and COVID-19-related death), hospitalization, and extension of recovery period. The explanatory variable was vaccination status at least 14 days prior to infection. Covariates included gender, age, population size, the number of risk factors for aggravation, and the number of symptoms at diagnosis. The generalized estimating equations of the multivariable Poisson regression models were used to estimate the adjusted incidence proportion (AIP) and 95% confidence interval (CI) for each health outcome. We performed stratified analyses by SARS-CoV-2 variant type, but the association between vaccination status and COVID-19-related health outcomes was stratified only for the delta and omicron variants due to the small number of vaccinated patients during the alpha variant.

RESULTS

Of the 24,314 participants, 255 (1.0%) had SHC; of the 24,059 participants without SHC, 2,102 (8.7%) were hospitalized; and of the 19,603 participants without SHC, hospitalization, and missing data on recovery period, 2,960 (15.1%) had extension of recovery period. Multivariable Poisson regression models showed that regardless of SARS-CoV-2 variant type or health outcome, those who received two or more vaccine doses had significantly lower risk of health outcomes than those who did not receive the vaccine, and there was a dose-response relationship in which the AIP for health outcomes decreased with an increased number of vaccinations.

CONCLUSION

A higher number of vaccinations were associated with lower risk of COVID-19-related health outcomes, not only in the delta variant but also in the omicron variant. Our findings suggest that increasing the number of COVID-19 vaccine doses can prevent severe disease and lead to early recovery of patients not requiring hospitalization.

Predicting alveolar ventilation heterogeneity in pulmonary fibrosis using a non-uniform polyhedral spring network model

Pulmonary Fibrosis (PF) is a deadly disease that has limited treatment options and is caused by excessive deposition and cross-linking of collagen leading to stiffening of the lung parenchyma. The link between lung structure and function in PF remains poorly understood, although its spatially heterogeneous nature has important implications for alveolar ventilation. Computational models of lung parenchyma utilize uniform arrays of space-filling shapes to represent individual alveoli, but have inherent anisotropy, whereas actual lung tissue is isotropic on average. We developed a novel Voronoi-based 3D spring network model of the lung parenchyma, the Amorphous Network, that exhibits more 2D and 3D similarity to lung geometry than regular polyhedral networks. In contrast to regular networks that show anisotropic force transmission, the structural randomness in the Amorphous Network dissipates this anisotropy with important implications for mechanotransduction. We then added agents to the network that were allowed to carry out a random walk to mimic the migratory behavior of fibroblasts. To model progressive fibrosis, agents were moved around the network and increased the stiffness of springs along their path. Agents migrated at various path lengths until a certain percentage of the network was stiffened. Alveolar ventilation heterogeneity increased with both percent of the network stiffened, and walk length of the agents, until the percolation threshold was reached. The bulk modulus of the network also increased with both percent of network stiffened and path length. This model thus represents a step forward in the creation of physiologically accurate computational models of lung tissue disease.

Prognostic factors for mortality, intensive care unit and hospital admission due to SARS-CoV-2: a systematic review and meta-analysis of cohort studies in Europe

BACKGROUND

As mortality from coronavirus disease 2019 (COVID-19) is strongly age-dependent, we aimed to identify population subgroups at an elevated risk for adverse outcomes from COVID-19 using age-/gender-adjusted data from European cohort studies with the aim to identify populations that could potentially benefit from booster vaccinations.

METHODS

We performed a systematic literature review and meta-analysis to investigate the role of underlying medical conditions as prognostic factors for adverse outcomes due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including death, hospitalisation, intensive care unit (ICU) admission and mechanical ventilation within three separate settings (community, hospital and ICU). Cohort studies that reported at least age and gender-adjusted data from Europe were identified through a search of peer-reviewed articles published until 11 June 2021 in Ovid Medline and Embase. Results are presented as odds ratios with 95% confidence intervals and absolute risk differences in deaths per 1000 COVID-19 patients.

FINDINGS

We included 88 cohort studies with age-/gender-adjusted data from 6 653 207 SARS-CoV-2 patients from Europe. Hospital-based mortality was associated with high and moderate certainty evidence for solid organ tumours, diabetes mellitus, renal disease, arrhythmia, ischemic heart disease, liver disease and obesity, while a higher risk, albeit with low certainty, was noted for chronic obstructive pulmonary disease and heart failure. Community-based mortality was associated with a history of heart failure, stroke, diabetes and end-stage renal disease. Evidence of high/moderate certainty revealed a strong association between hospitalisation for COVID-19 and solid organ transplant recipients, sleep apnoea, diabetes, stroke and liver disease.

INTERPRETATION

The results confirmed the strong association between specific prognostic factors and mortality and hospital admission. Prioritisation of booster vaccinations and the implementation of nonpharmaceutical protective measures for these populations may contribute to a reduction in COVID-19 mortality, ICU and hospital admissions.

Coronary artery calcification: Effects on severity and survival in patients with COVID-19

Background

The aim of this study was to evaluate the effect of coronary artery calcification on disease severity and prognosis in patients with coronavirus disease-2019 (COVID-19).

Materials and Methods

One hundred and forty-one patients with COVID-19 were included in this study. The severity of pulmonary involvement and calcification of coronary arteries were assessed by computed tomography scan and calcification was classified by two methods: Weston and segmental. In both the methods, patients were divided into three groups with scores of 0, 1-6, and 7-12, which are called groups 1, 2, and 3, respectively.

Results

The mean age of patients was 54.26 ± 14.55. Difference in score of pulmonary involvement was reported to be significant between deceased and discharged patients (11.73 ± 5.26 and 7.28 ± 4.47, P = 0.002, respectively). In Weston score system, the chance of recovery of Group 1 patients was significantly higher than Group 3 (odds ratio [OR] =6.72, P = 0.05, 95% confidence interval [CI] =1.901-50.257). Similar results were observed in the segmental scoring system (OR =6.34, P = 0.049, 95% CI =1.814-49.416). Despite the higher chance of severe disease in patients with coronary artery calcification, this increase was not statistically significant in either Weston or segmental methods (OR =0.47, P = 0.23 and OR =0.85, P = 0.79, respectively).

Conclusion

Coronary artery calcification in patients with COVID-19 has a significant association with poor prognosis. However, no significant relationship was observed between this issue and the severity.

The Course of COVID-19 in Patients with Systemic Autoimmune Rheumatic Diseases

Patients with systemic autoimmune rheumatic disease (SARD) have increased susceptibility to viral infections, including SARS-CoV-2. The aim of this study was to analyse the SARD patient population with COVID-19 (coronavirus disease 2019) in terms of baseline characteristics, severity, course and outcomes of the disease compared with the non-SARD group, and to identify factors associated with prognosis, including remdesivir therapy efficacy. Retrospective study comprised 8220 COVID-19 cases from the SARSTer database, including 185 with SARD. Length of hospitalisation, duration of oxygen therapy, mortality and the need for HFNO (high-flow nasal oxygen) and/or NIV (noninvasive ventilation) were significantly higher in the SARD versus non-SARD group. There was no difference in clinical features on admission to hospital. Patients with SARD were older and more likely to have cardiovascular, pulmonary and chronic kidney diseases. Age, the presence of cardiovascular disease, more severe conditions on admission and higher inflammatory marker values were found to be risk factors for death in the SARD group. In patients with SARD treated with remdesivir, there was a trend towards improved mortality but without statistical significance. Length of hospitalisation, 28-day mortality and the need for HFNO and/or NIV were higher in the SARD group. These patients often had other chronic diseases and were older.

Comparing antibiotic prescriptions in primary care between SARS-CoV-2 and influenza: a retrospective observational study

BACKGROUND

Antibiotics are frequently prescribed during viral respiratory infection episodes in primary care. There is limited information about antibiotic prescription during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in primary care and its association with risk factors for an adverse course.

AIM

To compare the proportion of antibiotic prescriptions between patients with COVID-19 and influenza or influenza-like symptoms, and to assess the association between antibiotic prescriptions and risk factors for an adverse course of COVID-19.

DESIGN & SETTING

An observational cohort study using pseudonymised and coded routine healthcare data extracted from 85 primary care practices in the Netherlands.

METHOD

Adult patients with influenza and influenza-like symptoms were included from the 2017 influenza season to the 2020 season. Adult patients with suspected or confirmed COVID-19 were included from the first (15 February 2020-1 August 2020) and second (1 August 2020-1 January 2021) SARS-CoV-2 waves. Proportions of antibiotic prescriptions were calculated for influenza and COVID-19 patients. Odds ratios (ORs) were used to compare the associations of antibiotic prescriptions in COVID-19 patients with risk factors, hospital admission, intensive care unit (ICU) admission, and mortality.

RESULTS

The proportion of antibiotic prescriptions during the first SARS-CoV-2 wave was lower than during the 2020 influenza season (9.6% versus 20.7%), difference 11.1% (95% confidence interval [CI] = 8.7 to 13.5). During the second SARS-CoV-2 wave, antibiotic prescriptions were associated with being aged ≥70 years (OR 2.05; 95% CI = 1.43 to 2.93), the number of comorbidities (OR 1.46; 95% CI = 1.18 to 1.82), and admission to hospital (OR 3.19; 95% CI = 2.02 to 5.03) or ICU (OR 4.64; 95% CI = 2.02 to 10.62).

CONCLUSION

Antibiotic prescription was less common during the SARS-CoV-2 pandemic than during influenza seasons, and was associated with an adverse course and its risk factors. The findings suggest a relatively targeted prescription policy of antibiotics in primary care during COVID-19.

“I’m scared that if I have the vaccine, it’s going to make my lung condition worse, not better.” COVID-19 vaccine acceptance in adults with underlying health conditions – a qualitative investigation

Background

Sustained uptake of COVID-19 vaccines, including booster doses, will continue to be key to minimising morbidity and mortality caused by COVID-19. Because hesitancy can affect people’s motivation to get vaccinated, understanding and addressing factors influencing acceptance is critical to achieving high uptake. This is especially the case for adults with underlying health conditions, who are at increased risk of severe illness from COVID-19. The aim of this study was to investigate barriers and facilitators of COVID-19 vaccine acceptance in adults with underlying health conditions during the initial rollout of COVID-19 vaccines in Australia.

Methods

We conducted semi-structured, qualitative interviews with 15 adults with underlying health conditions in New South Wales (NSW) in April 2021, focusing on their previous vaccination experiences and feelings about COVID-19 vaccination. We categorised participants as accepting, hesitant or refusing. We analysed interviews thematically, informed by the World Health Organization (WHO) Behavioural and Social Drivers of Vaccination framework.

Results

Most (12/15) participants were hesitant about COVID-19 vaccination. Barriers to COVID-19 vaccine acceptance included concerns about vaccine safety and effectiveness; heightened perceptions of risk regarding the vaccines; low perceptions of COVID-19 risk; and negative social influences. Facilitators included perceived benefits of vaccination and positive social influences.

Conclusions

For some adults with underlying health conditions, perceptions of heightened vulnerability to COVID-19 vaccine side effects contributed to vaccine hesitancy during the initial rollout of COVID-19 vaccines. We recommend supporting GPs and specialists to proactively reach out and recommend COVID-19 vaccination to this population; encouraging chronic disease organisations to act as trusted advocates of COVID-19 vaccination; and actively communicating evolving knowledge about vaccine safety.

Predicting COVID-19 progression in hospitalized patients in Belgium from a multi-state model

Objectives

To adopt a multi-state risk prediction model for critical disease/mortality outcomes among hospitalised COVID-19 patients using nationwide COVID-19 hospital surveillance data in Belgium.

Materials and methods

Information on 44,659 COVID-19 patients hospitalised between March 2020 and June 2021 with complete data on disease outcomes and candidate predictors was used to adopt a multi-state, multivariate Cox model to predict patients' probability of recovery, critical [transfer to intensive care units (ICU)] or fatal outcomes during hospital stay.

Results

Median length of hospital stay was 9 days (interquartile range: 5-14). After admission, approximately 82% of the COVID-19 patients were discharged alive, 15% of patients were admitted to ICU, and 15% died in the hospital. The main predictors of an increased probability for recovery were younger age, and to a lesser extent, a lower number of prevalent comorbidities. A patient's transition to ICU or in-hospital death had in common the following predictors: high levels of c-reactive protein (CRP) and lactate dehydrogenase (LDH), reporting lower respiratory complaints and male sex. Additionally predictors for a transfer to ICU included middle-age, obesity and reporting loss of appetite and staying at a university hospital, while advanced age and a higher number of prevalent comorbidities for in-hospital death. After ICU, younger age and low levels of CRP and LDH were the main predictors for recovery, while in-hospital death was predicted by advanced age and concurrent comorbidities.

Conclusion

As one of the very few, a multi-state model was adopted to identify key factors predicting COVID-19 progression to critical disease, and recovery or death.

Agreement and differential use of laboratory methods for the detection and quantification of SARS-CoV-2 in experimentally infected animals

Rodents are widely used for the development of COVID-19-like animal models, the virological outcome being determined through several laboratory methods reported in the literature. Our objective was to assess the agreement between methods performed on different sample types from 342 rodents experimentally infected with SARS-CoV-2 (289 golden Syrian hamsters and 53 K18-hACE2 mice). Our results showed moderate agreement between methods detecting active viral replication, and that increasing viral loads determined by either RT-qPCR or infectious viral titration corresponded to increasing immunohistochemical scores. The percentage of agreement between methods decreased over experimental time points, and we observed poor agreement between RT-qPCR results and viral titration from oropharyngeal swabs. In conclusion, RT-qPCR and viral titration on tissue homogenates are the most reliable techniques to determine the presence and replication of SARS-CoV-2 in the early and peak phases of infection, and immunohistochemistry is valuable to evaluate viral distribution patterns in the infected tissues.

Risk factors for SARS-CoV-2 related mortality and hospitalization before vaccination: A meta-analysis

The literature remains scarce regarding the varying point estimates of risk factors for COVID-19 associated mortality and hospitalization. This meta-analysis investigates risk factors for mortality and hospitalization, estimates individual risk factor contribution, and determines drivers of published estimate variances. We conducted a systematic review and meta-analysis of COVID-19 related mortality and hospitalization risk factors using PRISMA guidelines. Random effects models estimated pooled risks and meta-regression analyses estimated the impact of geographic region and study type. Studies conducted in North America and Europe were more likely to have lower effect sizes of mortality attributed to chronic kidney disease (OR: 0.21, 95% CI: 0.09-0.52 and OR: 0.25, 95% CI: 0.10-0.63, respectively). Retrospective studies were more likely to have decreased effect sizes of mortality attributed to chronic heart failure compared to prospective studies (OR: 0.65, 95% CI: 0.44-0.95). Studies from Europe and Asia (OR: 0.42, 95% CI: 0.30-0.57 and OR: 0.49, 95% CI: 0.28-0.84, respectively) and retrospective studies (OR: 0.58, 95% CI: 0.47-0.73) reported lower hospitalization risk attributed to male sex. Significant geographic population-based variation was observed in published comorbidity related mortality risks while male sex had less of an impact on hospitalization among European and Asian populations or in retrospective studies.

Air quality in Germany as a contributing factor to morbidity from COVID-19

BACKGROUND

The SARS-CoV-2 virus has been spreading in Germany since January 2020, with regional differences in incidence, morbidity, and mortality. Long-term exposure to air pollutants as nitrogen dioxide (NO₂), nitrogen monoxide (NO), ozone (O₃), and particulate matter (<10 μm PM₁₀, <2.5 μm PM_2.5) has a negative impact on respiratory functions. We analyze the association between long-term air pollution and the outcome of SARS-CoV-2 infections in Germany.

METHODS

We conducted an observational study in Germany on county-level, investigating the association between long-term (2010-2019) air pollutant exposure (European Environment Agency, AirBase data set) and COVID-19 incidence, morbidity, and mortality rate during the first outbreak of SARS-CoV-2 (open source data Robert Koch Institute). We used negative binominal models, including adjustment for risk factors (age, sex, days since first COVID-19 case, population density, socio-economic and health parameters).

RESULTS

After adjustment for risk factors in the tri-pollutant model (NO₂, O₃, PM_2.5) an increase of 1 μg/m³ NO₂ was associated with an increase of the need for intensive care due to COVID-19 by 4.2% (95% CI 1.011-1.074), and mechanical ventilation by 4.6% (95% CI 1.010-1.084). A tendency towards an association of NO₂ with COVID-19 incidence was indicated, as the results were just outside of the defined statistical significance (+1.6% (95% CI 1.000-1.032)). Long-term annual mean NO₂ level ranged from 4.6 μg/m³ to 32 μg/m³.

CONCLUSIONS

Our results indicate that long-term NO₂ exposure may have increased susceptibility for COVID-19 morbidity in Germany. The results demonstrate the need to reduce ambient air pollution to improve public health.