Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-CoV-2 status in England

Deciphering Factors Linked With Reduced Severe Acute Respiratory Syndrome Coronavirus 2 Susceptibility in the Swiss HIV Cohort Study

BACKGROUND

Factors influencing susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain to be resolved. Using data from the Swiss HIV Cohort Study on 6270 people with human immunodeficiency virus (HIV) and serologic assessment for SARS-CoV-2 and circulating human coronavirus (HCoV) antibodies, we investigated the association of HIV-related and general parameters with SARS-CoV-2 infection.

METHODS

We analyzed SARS-CoV-2 polymerase chain reaction test results, COVID-19-related hospitalizations, and deaths reported to the Swiss HIV Cohort Study between 1 January 2020 and 31 December 2021. Antibodies to SARS-CoV-2 and HCoVs were determined in prepandemic (2019) and pandemic (2020) biobanked plasma samples and compared with findings in HIV-negative individuals. We applied logistic regression, conditional logistic regression, and bayesian multivariate regression to identify determinants of SARS-CoV-2 infection and antibody responses to SARS-CoV-2 in people with HIV.

RESULTS

No HIV-1-related factors were associated with SARS-CoV-2 acquisition. High prepandemic HCoV antibodies were associated with a lower risk of subsequent SARS-CoV-2 infection and with higher SARS-CoV-2 antibody responses on infection. We observed a robust protective effect of smoking on SARS-CoV-2 infection risk (adjusted odds ratio, 0.46 [95% confidence interval, .38-.56]; P < .001), which occurred even in previous smokers and was highest for heavy smokers.

CONCLUSIONS

Our findings of 2 independent protective factors, smoking and HCoV antibodies, both affecting the respiratory environment, underscore the importance of the local immune milieu in regulating susceptibility to SARS-CoV-2.

Gender-Based Socio-Economic Inequalities in the Pre-Vaccination Era of the COVID-19 Pandemic in Istanbul: A Neighborhood-Level Analysis of Excess Mortality

Worldwide excess mortality (EM) data have the potential to provide a better estimation of the impact of the pandemic. This study aims to investigate and map the inequalities in EM in Istanbul during the pre-vaccination era of the COVID-19 pandemic in 2020 and its association with selected demographic and socio-economic variables at the neighborhood level according to gender. This ecological study was conducted with the EM data of Istanbul. The EM data were obtained from the Istanbul Metropolitan Municipality (IMM) and analyzed according to socio-demographic indicators (gender, age), neighborhood-level indicators (population density, educational attainment) and neighborhood vulnerability (socio-economic and transportation) for the 808 neighborhoods, then presented separately according to gender to examine gender-specific factors. Socio-economic and transportation vulnerability indexes are provided the IMM. The excess mortality rate per 1000 (EMR) in 2020 has been calculated by using the number of deaths in the years 2018-2019. We have mapped EMRs of each neighborhood and used linear regression analysis in three datasets to examine gender specific factors. EMRs in Istanbul showed two peaks one in April and one in November. Male EMRs were higher compared to females in Istanbul during the pre-vaccination era of the pandemic. Higher EMRs were observed in neighborhoods with a higher share of 50+ year old age groups and higher neighborhood socio-economic vulnerability scores. Neighborhood socio-economic vulnerability was significantly associated with EMRs in males but not in females. Unequal distribution of EM between neighborhoods underlines the need for gender-specific pandemic measures to alleviate the burden of the COVID-19 pandemic, especially in socio-economically vulnerable settings. Increased use of area-based indicators with a gender perspective can enhance pandemic measures.

Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024

BACKGROUND

Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993.

OBJECTIVE

We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework.

METHODS

Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC.

RESULTS

We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval.

CONCLUSIONS

The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

Intensive Care Unit Mortality Trends during the First Two Years of the COVID-19 Pandemic in Greece: A Multi-Center Retrospective Study

Data on COVID-19 mortality among patients in intensive care units (ICUs) from Eastern and/or Southern European countries, including Greece, are limited. The purpose of this study was to evaluate the ICU mortality trends among critically ill COVID-19 patients during the first two years of the pandemic in Greece and to further investigate if certain patients' clinical characteristics contributed to this outcome. We conducted a multi-center retrospective observational study among five large university hospitals in Greece, between February 2020 and January 2022. All adult critically ill patients with confirmed COVID-19 disease who required ICU admission for at least 24 h were eligible. In total, 1462 patients (66.35% males) were included in this study. The mean age of this cohort was 64.9 (±13.27) years old. The 28-day mortality rate was 35.99% (n = 528), while the overall in-hospital mortality was 50.96% (n = 745). Cox regression analysis demonstrated that older age (≥65 years old), a body mass index within the normal range, and a delay in ICU admission from symptom onset, as well as worse baseline clinical severity scores upon ICU admission, were associated with a greater risk of death. Mortality of critically ill COVID-19 patients was high during the first two years of the pandemic in Greece but comparable to other countries. Risk factors for death presented in this study are not different from those that have already been described for COVID-19 in other studies.

COVID-19 pandemic among adults with intellectual disabilities: Implementing a social model of disability in crisis and trauma situations

A growing body of evidence has attested to the higher impact of COVID-19 on individuals with intellectual disabilities (IDs) than on members of the general population during the pandemic, mainly showing their higher vulnerability. However, we believe it is important to better understand how their situation interacts with the specific circumstances of the pandemic. In this article we discuss recent findings regarding individuals with IDs through the lens of two theories - the social disability model and the ecological model of trauma and recovery - and propose an integration, namely a social model of disability in crisis and trauma situations. Such a model allows for a wider perspective on understanding the way people living with disabilities (PLWDs) cope in these situations, integrating the individual aspects of coping with the social and environmental ones.

Comparing methods to predict baseline mortality for excess mortality calculations

BACKGROUND

The World Health Organization (WHO)'s excess mortality estimates presented in May 2022 stirred controversy, due in part to the high estimate provided for Germany, which was later attributed to the spline model used. This paper aims to reproduce the problem using synthetic datasets, thus allowing the investigation of its sensitivity to parameters, both of the mortality curve and of the used method, thereby shedding light on the conditions that gave rise to this error and identifying possible remedies.

METHODS

A negative binomial model was used accounting for long-term change, seasonality, flu seasons, and heat waves. Simulated mortality curves from this model were then analysed using simple methods (mean, linear trend), the WHO method, and the method of Acosta and Irizarry.

RESULTS

The performance of the WHO's method with its original parametrization was indeed very poor, however it can be profoundly improved by a better choice of parameters. The Acosta-Irizarry method outperformed the WHO method despite being also based on splines, but it was also dependent on its parameters. Linear extrapolation could produce very good results, but was highly dependent on the choice of the starting year, while the average was the worst in almost all cases.

CONCLUSIONS

Splines are not inherently unsuitable for predicting baseline mortality, but caution should be taken. In particular, the results suggest that the key issue is that the splines should not be too flexible to avoid overfitting. Even after having investigated a limited number of scenarios, the results suggest that there is not a single method that outperforms the others in all situations. As the WHO method on the German data illustrates, whatever method is chosen, it remains important to visualize the data, the fit, and the predictions before trusting any result. It will be interesting to see whether further research including other scenarios will come to similar conclusions.

The Association of Hypertension with Increased Mortality Rate During the COVID-19 Pandemic: An Update with Meta-analysis

BACKGROUND AND AIM

The impact of multiple risk factors on COVID-19 mortality has been previously reported in multiple systematic reviews and meta-analyses. The aim of this review is to provide a comprehensive update on the association between hypertension (HTN) and mortality in patients with COVID-19.

METHODS

A systematic review and meta-analysis were performed and followed the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. A search was achieved using PubMed, Scopus, and Cochrane Databases for research publications on hypertension, COVID-19, and mortality published between December 2019 and August 2022.

RESULTS

A total of 23 observational studies involving 611,522 patients from 5 countries (China, Korea, the UK, Australia, and the USA) were included in our study. The confirmed number of COVID-19 with HTN cases in each study ranged from 5 to 9964. The mortality ranged from 0.17% to 31% in different studies. Pooled results show that the mortality rate of COVID-19 among the included studies ranges from a minimum of 0.39 (95% CI 0.13-1.12) to a maximum of 5.74 (95% CI 3.77-8.74). Out of the 611,522 patients, 3119 died which resulted in an overall mortality prevalence of 0.5%. Subgroup analyses indicated that patients with COVID-19 who have hypertension and male patients had slightly less risk of mortality than female patients [the percentage of men > 50%; OR 1.33: 95% CI (1.01, 1.76); the percentage of men ≤ 50%: OR 2.26; and 95% CI (1.15, 4.48)]. Meta-regression analysis results also showed a statistically significant association between hypertension and COVID-19 mortality.

CONCLUSION

This systematic review and meta-analysis suggest that hypertension may not be the only risk factor associated with the increased mortality rate during the COVID-19 pandemic. In addition, a combination of other comorbidities and old age appears to increase the risk of mortality from COVID-19. The impact of hypertension on mortality rate among COVID-19 patients.

Are people with disabilities at higher risk of COVID-19-related mortality?: a systematic review and meta-analysis

OBJECTIVES

To undertake a systematic review and meta-analysis to estimate the relative risk of COVID-19-related mortality among people with disabilities compared to people without disabilities.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched four databases from March 1, 2020, to August 15, 2022. We included prospective studies with a baseline assessment of disability and a longitudinal assessment of the COVID-19-related mortality. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. We undertook random-effects meta-analyses to calculate pooled adjusted hazard ratios for COVID-19-related mortality for people with disabilities, also disaggregated by disability type and study setting.

RESULTS

We identified 2596 articles throughout the electronic data search, and 56 studies were included in the review. Most (73%) had a moderate risk of bias. The pooled adjusted effect estimate for COVID-19-related mortality in people with disabilities compared to those without was 2.7 (95% confidence interval [CI]: 2.4-3.2). Heterogeneity between the studies was high (τ2 = 0.28, I2 = 97%). Effect estimates were highest for population-based samples (3.3, 95% CI: 2.7-3.9), compared to hospital settings (2.1, 95% CI: 1.7-2.7). Risk was not elevated among people with disabilities in care home settings (1.6, 95% CI: 0.7-3.5). Disaggregation by disability type showed that people with intellectual disabilities were at the highest relative risk of COVID-19 mortality.

DISCUSSION

Risk of COVID-19 mortality is elevated among people with disabilities, especially people with intellectual disabilities. Efforts are needed to collect better routine data on disability and to include people with disabilities in the pandemic response for COVID-19.

Two complementary approaches to estimate an excess of mortality: The case of Switzerland 2022

OBJECTIVE

During the COVID-19 pandemic, excess mortality has generally been estimated comparing overall mortality in a given year with either past mortality levels or past mortality trends, with different results. Our objective was to illustrate and compare the two approaches using mortality data for Switzerland in 2022, the third year of the COVID-19 pandemic.

METHODS

Using data from the Swiss Federal Statistical Office, standardized mortality rates and life expectancies in 2022 were compared with those of the last pre-pandemic year 2019 (first approach), as well as with those that would be expected if the pre-pandemic downward trend in mortality had continued during the pandemic (second approach). The pre-pandemic trend was estimated via a Poisson log-linear model on age-specific mortality over the period 2010-19.

RESULTS

Using the first approach, we estimated in Switzerland in 2022 an excess mortality of 2.6% (95%CI: 1.0%-4.1%) for men and 2.5% (95%CI: 1.0%-4.0%) for women, while the excess mortality rose to 8.4% (95%CI: 6.9%-9.9%) for men and 6.0% (95%CI: 4.6%-7.5%) for women using the second approach. Age classes over 80 were the main responsible for the excess mortality in 2022 for both sexes using the first approach, although a significant excess mortality was also found in most age classes above 30 using the second approach. Life expectancy in 2022 has been reduced by 2.7 months for men and 2.4 months for women according to the first approach, whereas it was reduced by respectively 8.8 and 6.0 months according to the second approach.

CONCLUSIONS

The excess mortality and loss of life expectancy in Switzerland in 2022 are around three times greater if the pre-pandemic trend is taken into account than if we simply compare 2022 with 2019. These two different approaches, one being more speculative and the other more factual, can also be applied simultaneously and provide complementary results. In Switzerland, such a dual-approach strategy has shown that the pre-pandemic downward trend in mortality is currently halted, while pre-pandemic mortality levels have largely been recovered by 2022.

Urban public health emergencies and the COVID-19 pandemic. Part 1: Social and spatial inequalities in the COVID-city

COVID-19 has had unprecedented impacts on urban life on a global scale, representing the worst pandemic in living memory. In this introduction to the first of two parts of a Special Issue on urban public health emergencies, we suggest that the COVID-19 outbreak, and associated attempts to manage the pandemic, reproduced and ultimately exacerbated the social and spatial divides that striate the contemporary city. Here, we draw on evidence from the papers in Part 1 of the Special Issue to summarise the uneven urban geographies of COVID-19 evident at the inter- and intra-urban level, emphasising the particular vulnerabilities and risks borne by racialised workers who found it difficult to practise social distancing in either their home or working life. Considering the interplay of environmental, social and biological factors that conspired to create hotspots of COVID-19 infection, and the way these are connected to the racialised capitalism that underpins contemporary urban development, this introduction suggests that reflection on public health emergencies in the city is not just essential from a policy perspective but helps enrich theoretical debates on the nature of contemporary urbanisation in its 'planetary' guise.

Access to General Practitioners during the COVID-19 pandemic in Portugal-A survey study of patient experiences in an urban setting

BACKGROUND

In 2020, Portugal had high levels of unmet health care needs. Primary Care was reported as the main source of unmet needs.

OBJECTIVES

To describe face-to-face and remote access to GPs in Portugal during the COVID-19 pandemic. To discover patient experiences and attitudes to access to care. To identify determinants of access to care.

METHODS

A survey of a random sample of 4,286 adults registered in a group of Family Practices was conducted in 2021. Paper questionnaires were sent by post to patients who had no e-mail address registered with the practice. Patients with an e-mail address were sent a link to an online questionnaire. Outcomes were reported waiting times for face-to-face and remote contacts with GPs, dichotomized to ascertain compliance with standards. Associations between participant characteristics and outcome variables were tested using logistic regression.

RESULTS

Waiting times for face-to-face consultations with GPs during the pandemic often exceeded the maximum waiting times (MWT) set by the National Health Service. Remote contacts were mostly conducted within acceptable standards. Waiting times for speaking with the GP over the phone were rated as 'poor' by 40% and 27% reported requests for these calls as unmet. The odds of getting care over MWT increased for participants who reported poorer digital skills. Participants were less likely to get non-urgent consultations over MWT if they found it easy to use the online patient portal to book appointments (odds ratio 0.24; 99% confidence intervals 0.09-0.61), request prescriptions (0.18; 0.04-0.74) or insert personal data (0.18; 0.04-0.95).

CONCLUSION

Patient reported access to GPs during the pandemic was uneven in Portugal. Obtaining non-urgent consultations and remote contacts over MWT affected mainly those patients with poor digital skills. Telephone access to GPs received the worse ratings. Access through traditional pathways must remain available, to prevent the widening of inequities.

Excess deaths by cause and place of death in England and Wales during the first year of COVID-19

Using officially registered weekly mortality data, we estimate a counterfactual death count in the absence of the pandemic and we calculate the number of excess deaths in England and Wales during 2020 after the pandemic onset. We also break down those figures by region, age, gender, place of death, and cause of death. Our results suggest that there were 82,428 (95% Confidence interval [CI]: 78,402 to 86,415) excess deaths, and 88.9% (95% CI: 84.8%-93.5%) of them was due to COVID-19, suggesting that non-COVID-19 excess mortality may have been slightly higher that what has been previously estimated. Regarding deaths not due to COVID-19, persons older than 45 years old who died at their homes, mainly from heart diseases and cancer, were the most affected group. Across all causes of death, there was increased excess mortality from dementia and Alzheimer's disease, diabetes, Parkinson's disease and heart-related disease, while at the same period there was a reduction in deaths from pneumonia and influenza, stroke as well as infectious diseases and accidents. Supported by regional panel event estimates, our results highlight how measures to mitigate the pandemic spread and ease the pressure on healthcare service systems may adversely affect out-of-hospital mortality from other causes.

Novel intervention to promote COVID-19 protective behaviours among Black and South Asian communities in the UK: protocol for a mixed-methods pilot evaluation

INTRODUCTION

Culturally appropriate interventions to promote COVID-19 health protective measures among Black and South Asian communities in the UK are needed. We aim to carry out a preliminary evaluation of an intervention to reduce risk of COVID-19 comprising a short film and electronic leaflet.

METHODS AND ANALYSIS

This mixed methods study comprises (1) a focus group to understand how people from the relevant communities interpret and understand the intervention's messages, (2) a before-and-after questionnaire study examining the extent to which the intervention changes intentions and confidence to carry out COVID-19 protective behaviours and (3) a further qualitative study exploring the views of Black and South Asian people of the intervention and the experiences of health professionals offering the intervention. Participants will be recruited through general practices. Data collection will be carried out in the community.

ETHICS AND DISSEMINATION

The study received Health Research Authority approval in June 2021 (Research Ethics Committee Reference 21/LO/0452). All participants provided informed consent. As well as publishing the findings in peer-reviewed journals, we will disseminate the findings through the UK Health Security Agency, NHS England and the Office for Health Improvement and Disparities and ensure culturally appropriate messaging for participants and other members of the target groups.

COVID-19 clinical outcomes by patient disability status: A retrospective cohort study

BACKGROUND

People with disabilities might experience worse clinical outcomes of SARS-CoV-2 infection, but evidence is limited.

OBJECTIVE

To investigate if people with disabilities requiring assistance are more likely to experience severe COVID-19 or death.

METHODS

Data from the Johns Hopkins COVID-19 Precision Medicine Analytics Platform Registry (JH-CROWN) included 6494 adult patients diagnosed with COVID-19 and admitted between March 4, 2020-October 29, 2021. Severe COVID-19 and death were defined using the occurrence and timing of clinical events. Assistive needs due to disabilities were reported by patients or their proxies upon admission. Multivariable-adjusted Cox proportional hazards models were used to examine the associations between disability status and severe COVID-19 or death. Primary models adjusted for demographics and secondary models additionally adjusted for clinical covariates.

RESULTS

In this clinical cohort (47-73 years, 49% female, 39% Black), patients with disabilities requiring assistance had 1.35 times (95% confidence interval [CI]:1.01, 1.81) the hazard of severe COVID-19 among patients <65 years, but not among those ≥65 years, equating to an additional 17.5 severe COVID-19 cases (95% CI:7.7, 28.2) per 100 patients. A lower risk of mortality was found among patients <65 years, but this finding was not robust due to the small number of deaths.

CONCLUSIONS

People with disabilities requiring assistance aged <65 years are more likely to develop severe COVID-19. Although our study is limited by using a medical model of disability, these analyses intend to further our understanding of COVID-19 outcomes among people with disabilities. Also, standardized disability data collection within electronic health records is needed.

Risk of Covid-19 Severe Outcomes and Mortality in Migrants and Ethnic Minorities Compared to the General Population in the European WHO Region: a Systematic Review

The Covid-19 pandemic has had a major impact on migrants and ethnic minorities (MEMs). Socio-economic factors and legal, administrative and language barriers are among the reasons for this increased susceptibility. The aim of the study is to investigate the impact of Covid-19 on MEMs compared to the general population in terms of serious outcomes. We conducted a systematic review collecting studies on the impact of Covid-19 on MEMs compared to the general population in the WHO European Region regarding hospitalisation, intensive care unit (ICU) admission and mortality, published between 01/01/2020 and 19/03/2021. Nine researchers were involved in selection, study quality assessment and data extraction. Of the 82 studies included, 15 of the 16 regarding hospitalisation for Covid-19 reported an increased risk for MEMs compared to the white and/or native population and 22 out of the 28 studies focusing on the ICU admission rates found an increased risk for MEMs. Among the 65 studies on mortality, 43 report a higher risk for MEMs. An increased risk of adverse outcomes was reported for MEMs. Social determinants of health are among the main factors involved in the genesis of health inequalities: a disadvantaged socio-economic status, a framework of structural racism and asymmetric access to healthcare are linked to increased susceptibility to the consequences of Covid-19. These findings underline the need for policymakers to consider the socio-economic barriers when designing prevention plans.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12134-023-01007-x.

Risk for Severe COVID-19 Outcomes among Persons with Intellectual Disabilities, the Netherlands

The COVID-19 pandemic has disproportionately affected persons in long-term care, who often experience health disparities. To delineate the COVID-19 disease burden among persons with intellectual disabilities, we prospectively collected data from 36 care facilities for 3 pandemic waves during March 2020-May 2021. We included outcomes for 2,586 clients with PCR-confirmed SARS-CoV-2 infection, among whom 161 had severe illness and 99 died. During the first 2 pandemic waves, infection among persons with intellectual disabilities reflected patterns observed in the general population, but case-fatality rates for persons with intellectual disabilities were 3.5 times higher and were elevated among those >40 years of age. Severe outcomes were associated with older age, having Down syndrome, and having >1 concurrent condition. Our study highlights the disproportionate COVID-19 disease burden among persons with intellectual disabilities and the need for disability-inclusive research and policymaking to inform disease surveillance and public health policies for this population.

Mortality in COVID-19 among women on hormone replacement therapy: a retrospective cohort study

BACKGROUND

Limited recent observational data have suggested that there may be a protective effect of oestrogen on the severity of COVID-19 disease. Our aim was to investigate the association between hormone replacement therapy (HRT) or combined oral contraceptive pill (COCP) use and the likelihood of death in women with COVID-19.

METHODS

We undertook a retrospective cohort study using routinely collected computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. We identified a cohort of 1,863,478 women over 18 years of age from 465 general practices in England. Mixed-effects logistic regression models were used to quantify the association between HRT or COCP use and all-cause mortality among women diagnosed with confirmed or suspected COVID-19 in unadjusted and adjusted models.

RESULTS

There were 5,451 COVID-19 cases within the cohort. HRT was associated with a reduction in all-cause mortality in COVID-19 (adjusted OR 0.22, 95% CI 0.05 to 0.94). There were no reported events for all-cause mortality in women prescribed COCPs. This prevented further examination of the impact of COCP.

CONCLUSIONS

We found that HRT prescription within 6 months of a recorded diagnosis of COVID-19 infection was associated with a reduction in all-cause mortality. Further work is needed in larger cohorts to examine the association of COCP in COVID-19, and to further investigate the hypothesis that oestrogens may contribute a protective effect against COVID-19 severity.

High LACE index scores are associated with disproportionate excess deaths in hospital amongst patients with COVID-19

Risk factors for COVID-19-related outcomes have been variably reported. We used the standardised LACE index to examine admissions and in-hospital mortality associated with COVID-19. Data were collected in the pre-pandemic period (01-04-2019 to 29-02-2020) from 10,173 patients (47.7% men: mean age ± standard deviation = 68.3 years ± 20.0) and in the pandemic period (01-03-2019 to 31-03-2021) from 12,434 patients. With the latter, 10,982 were without COVID-19 (47.4% men: mean age = 68.3 years ± 19.6) and 1452 with COVID-19 (58.5% men: mean age = 67.0 years ± 18.4). Admissions and mortality were compared between pre-pandemic and pandemic patients, according to LACE index. Admission rates rose disproportionately with higher LACE indices amongst the COVID-19 group. Mortality rates amongst the pre-pandemic, pandemic non-COVID-19 and COVID-19 groups with LACE index scores < 4 were 0.7%, 0.5%, 0%; for scores 4-9 were 5.0%, 3.7%, 8.9%; and for scores ≥ 10 were: 24.2%, 20.4%, 43.4%, respectively. The area under the curve receiver operating characteristic for predicting mortality by LACE index was 76% for COVID-19 and 77% for all non-COVID-19 patients. The risk of age and sex-adjusted mortality did not differ from the pre-pandemic group for COVID-19 patients with LACE index scores < 4. However, risk increased drastically for scores from 4 to 9: odds ratio = 3.74 (95% confidence interval = 2.63-5.32), and for scores ≥ 10: odds ratio = 4.02 (95% confidence interval = 3.38-4.77). In conclusion, patients with LACE index scores ≥ 4 have disproportionally greater risk of COVID-19 hospital admissions and deaths, in support of previous studies in patients without COVID-19. However, of importance, our data also emphasise their increased risk in patients with COVID-19. Because the LACE index has a good predictive power of mortality, it should be considered for routine use to identify high-risk COVID-19 patients.

Mortality from angiotensin-converting enzyme-inhibitors and angiotensin receptor blockers in people infected with COVID-19: a cohort study of 3.7 million people

BACKGROUND

Concerns have been raised that angiotensin-converting enzyme-inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) might facilitate transmission of severe acute respiratory syndrome coronavirus 2 leading to more severe coronavirus disease (COVID-19) disease and an increased risk of mortality. We aimed to investigate the association between ACE-I/ARB treatment and risk of death amongst people with COVID-19 in the first 6 months of the pandemic.

METHODS

We identified a cohort of adults diagnosed with either confirmed or probable COVID-19 (from 1 January to 21 June 2020) using computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. This comprised 465 general practices in England, United Kingdom with a nationally representative population of 3.7 million people. We constructed mixed-effects logistic regression models to quantify the association between ACE-I/ARBs and all-cause mortality among people with COVID-19, adjusted for sociodemographic factors, comorbidities, concurrent medication, smoking status, practice clustering, and household number.

RESULTS

There were 9,586 COVID-19 cases in the sample and 1,463 (15.3%) died during the study period between 1 January 2020 and 21 June 2020. In adjusted analysis ACE-I and ARBs were not associated with all-cause mortality (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.85-1.21 and OR 0.84, 95% CI 0.67-1.07, respectively).

CONCLUSION

Use of ACE-I/ARB, which are commonly used drugs, did not alter the odds of all-cause mortality amongst people diagnosed with COVID-19. Our findings should inform patient and prescriber decisions concerning continued use of these medications during the pandemic.

COVID-19 Vaccination Intentions amongst Healthcare Workers: A Scoping Review

A worldwide vaccination programme is the chosen strategy against the COVID-19 pandemic. Vaccine hesitancy, however, forms a threat to achieving a high degree of vaccination. Healthcare workers (HCWs) are exposed to greater risks, in addition to HCWs who care for people with intellectual disabilities (ID). However, little is still known about these groups' vaccine hesitancy. This review aims to provide insight into the intentions and attitudes of HCWs on COVID-19 vaccination, including those who care for people with ID. The search included both types and was conducted in nine databases. A total of 26 papers were identified concerning the vaccine intentions of 43,199 HCWs worldwide. The data were gathered both quantitively and qualitatively. The papers were analysed for all of the themes regarding vaccine intentions, which were: (1) percentages of vaccine willingness; (2) predictors of willingness; (3) attitudes of willingness and hesitancy; (4) sources of vaccination information; (5) contextual factors and changes in COVID-19 vaccine acceptance over time; and (6) future strategies for interventions. Concerns about vaccine safety, efficacy and short- and long-term side effects were the most prominent in HCWs and, therefore, should be addressed in future intervention strategies. Furthermore, interactive interventions are recommended to facilitate exchange, and accurate information should be accessible to target groups on social media platforms.

Differences in Clinical Presentation With Long COVID After Community and Hospital Infection and Associations With All-Cause Mortality: English Sentinel Network Database Study

BACKGROUND

Most studies of long COVID (symptoms of COVID-19 infection beyond 4 weeks) have focused on people hospitalized in their initial illness. Long COVID is thought to be underrecorded in UK primary care electronic records.

OBJECTIVE

We sought to determine which symptoms people present to primary care after COVID-19 infection and whether presentation differs in people who were not hospitalized, as well as post-long COVID mortality rates.

METHODS

We used routine data from the nationally representative primary care sentinel cohort of the Oxford-Royal College of General Practitioners Research and Surveillance Centre (N=7,396,702), applying a predefined long COVID phenotype and grouped by whether the index infection occurred in hospital or in the community. We included COVID-19 infection cases from March 1, 2020, to April 1, 2021. We conducted a before-and-after analysis of long COVID symptoms prespecified by the Office of National Statistics, comparing symptoms presented between 1 and 6 months after the index infection matched with the same months 1 year previously. We conducted logistic regression analysis, quoting odds ratios (ORs) with 95% CIs.

RESULTS

In total, 5.63% (416,505/7,396,702) and 1.83% (7623/416,505) of the patients had received a coded diagnosis of COVID-19 infection and diagnosis of, or referral for, long COVID, respectively. People with diagnosis or referral of long COVID had higher odds of presenting the prespecified symptoms after versus before COVID-19 infection (OR 2.66, 95% CI 2.46-2.88, for those with index community infection and OR 2.42, 95% CI 2.03-2.89, for those hospitalized). After an index community infection, patients were more likely to present with nonspecific symptoms (OR 3.44, 95% CI 3.00-3.95; P<.001) compared with after a hospital admission (OR 2.09, 95% CI 1.56-2.80; P<.001). Mental health sequelae were more strongly associated with index hospital infections (OR 2.21, 95% CI 1.64-2.96) than with index community infections (OR 1.36, 95% CI 1.21-1.53; P<.001). People presenting to primary care after hospital infection were more likely to be men (OR 1.43, 95% CI 1.25-1.64; P<.001), more socioeconomically deprived (OR 1.42, 95% CI 1.24-1.63; P<.001), and with higher multimorbidity scores (OR 1.41, 95% CI 1.26-1.57; P<.001) than those presenting after an index community infection. All-cause mortality in people with long COVID was associated with increasing age, male sex (OR 3.32, 95% CI 1.34-9.24; P=.01), and higher multimorbidity score (OR 2.11, 95% CI 1.34-3.29; P<.001). Vaccination was associated with reduced odds of mortality (OR 0.10, 95% CI 0.03-0.35; P<.001).

CONCLUSIONS

The low percentage of people recorded as having long COVID after COVID-19 infection reflects either low prevalence or underrecording. The characteristics and comorbidities of those presenting with long COVID after a community infection are different from those hospitalized. This study provides insights into the presentation of long COVID in primary care and implications for workload.

Trends of in-Hospital and ICU Mortality in COVID-19 Patients Over the Fourth and Fifth COVID-19 Surges in Iran: A Retrospective Cohort Study from Iran

Objective

The current study aimed to investigate the temporal trend of in-hospital and intensive care unit (ICU) mortality of coronavirus disease 2019 (COVID-19) patients over 6 months in the spring and summer of 2021 in Iran.

Design

We performed an observational retrospective cohort study.

Setting

Qazvin Province- Iran during 6 month from April to September 2021.

Participants

All 14355 patients who were hospitalized with confirmed COVID-19 in hospitals of Qazvin Province.

Intervention

No intervention.

Main outcome measures

The trends of overall in-hospital mortality and ICU mortality were the main outcome of interest. We obtained crude and adjusted in-hospital and ICU mortality rates for each month of admission and over surge and lull periods of the disease.

Results

The overall in-hospital mortality, early mortality and ICU mortality were 8.8%, 3.2% and 67.6%, respectively. The trend for overall mortality was almost plateau ranging from 6.5% in July to 10.7% in April. The lowest ICU mortality was 60.0% observed in April, whereas it reached a peak in August (ICU mortality = 75.7%). Admission on surge days of COVID-19 was associated with an increased risk of overall mortality (Odds ratio = 1.3, 95% confidence interval = 1.1, 1.5). The comparison of surge and lull status showed that the odds of ICU mortality in the surge of COVID-19 was 1.7 higher than in the lull period (P-value < 0.001).

Conclusions

We found that the risk of both overall in-hospital and ICU mortality increased over the surge period and fourth and fifth waves of severe acute respiratory syndrome coronavirus 2 infection in Iran. The lack of hospital resources and particularly ICU capacities to respond to the crisis during the surge period is assumed to be the main culprit.

Sociodemographic disparities in COVID-19 seroprevalence across England in the Oxford RCGP primary care sentinel network

OBJECTIVES

To monitor changes in seroprevalence of SARS-CoV-2 antibodies in populations over time and between different demographic groups.

METHODS

A subset of practices in the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) sentinel network provided serum samples, collected when volunteer patients had routine blood tests. We tested these samples for SARS-CoV-2 antibodies using Abbott (Chicago, USA), Roche (Basel, Switzerland) and/or Euroimmun (Luebeck, Germany) assays, and linked the results to the patients' primary care computerised medical records. We report seropositivity by region and age group, and additionally examined the effects of gender, ethnicity, deprivation, rurality, shielding recommendation and smoking status.

RESULTS

We estimated seropositivity from patients aged 18-100 years old, which ranged from 4.1% (95% CI 3.1-5.3%) to 8.9% (95% CI 7.8-10.2%) across the different assays and time periods. We found higher Euroimmun seropositivity in younger age groups, people of Black and Asian ethnicity (compared to white), major conurbations, and non-smokers. We did not observe any significant effect by region, gender, deprivation, or shielding recommendation.

CONCLUSIONS

Our results suggest that prior to the vaccination programme, most of the population remained unexposed to SARS-CoV-2.

COVID-19 infection and outcomes in a population-based cohort of 17 203 adults with intellectual disabilities compared with the general population

BACKGROUND

Adults with intellectual disabilities (ID) may be at higher risk of COVID-19 death. We compared COVID-19 infection, severe infection, mortality, case fatality and excess deaths, among adults with, and without, ID.

METHODS

Adults with ID in Scotland's Census, 2011, and a 5% sample of other adults, were linked to COVID-19 test results, hospitalisation data and deaths (24 January 2020-15 August 2020). We report crude rates of COVID-19 infection, severe infection (hospitalisation/death), mortality, case fatality; age-standardised, sex-standardised and deprivation-standardised severe infection and mortality ratios; and annual all-cause mortality for 2020 and 2015-2019.

FINDINGS

Successful linkage of 94.9% provided data on 17 203 adults with, and 188 634 without, ID. Adults with ID had more infection (905/100 000 vs 521/100 000); severe infection (538/100 000 vs 242/100 000); mortality (258/100 000 vs 116/100 000) and case fatality (30% vs 24%). Poorer outcomes remained after standardisation: standardised severe infection ratio 2.61 (95% CI 1.81 to 3.40) and mortality ratio 3.26 (95% CI 2.19 to 4.32). These were higher at ages 55-64: 7.39 (95% CI 3.88 to 10.91) and 19.05 (95% CI 9.07 to 29.02), respectively, and in men, and less deprived neighbourhoods. All-cause mortality was slightly higher in 2020 than 2015-2019 for people with ID: standardised mortality ratio 2.50 (95% CI 2.18 to 2.82) and 2.39 (95% CI 2.28 to 2.51), respectively.

CONCLUSION

Adults with ID had more COVID-19 infections, and worse outcomes once infected, particularly adults under 65 years. Non-pharmaceutical interventions directed at formal and informal carers are essential to reduce transmission. All adults with ID should be prioritised for vaccination and boosters regardless of age.

Primary care consultations for respiratory tract symptoms during the COVID-19 pandemic: a cohort study including 70,000 people in South West England

BACKGROUND

Primary care consultations for respiratory tract symptoms including identifying and managing COVID-19 during the pandemic have not been characterized.

METHODS

A retrospective cohort analysis using routinely collected records from 70,431 adults aged 18+ in South England within the Electronic Care and Health Information Analytics (CHIA) database. Total volume and type of consultations (face-to-face, home visits, telephone, email/video, or out of hours) for respiratory tract symptoms between 1 January and 31 July 2020 (during the first wave of the pandemic) were compared with the equivalent period in 2019 for the same cohort. Descriptive statistics were used to summarize consultations by sociodemographic and clinical characteristics, and by COVID-19 diagnosis and outcomes (death, hospitalization, and pneumonia).

RESULTS

Overall consultations for respiratory tract symptoms increased by 229% during the pandemic compared with the preceding year. This included significant increases in telephone consultations by 250%, a 1,574% increase in video/email consultations, 105% increase in home visits, and 92% increase in face-to-face consultations. Nearly 60% of people who presented with respiratory symptoms were tested for COVID-19 and 16% confirmed or clinically suspected to have the virus. Those with complications including pneumonia, requiring hospitalization, and who died were more likely to be seen in-person.

CONCLUSION

During the pandemic, primary care substantially increased consultations for respiratory tract symptoms to identify and manage people with COVID-19. These findings should be balanced against national reports of reduced GP workload for non-COVID care.

Investigating the uptake, effectiveness and safety of COVID-19 vaccines: protocol for an observational study using linked UK national data

INTRODUCTION

The novel coronavirus SARS-CoV-2, which emerged in December 2019, has caused millions of deaths and severe illness worldwide. Numerous vaccines are currently under development of which a few have now been authorised for population-level administration by several countries. As of 20 September 2021, over 48 million people have received their first vaccine dose and over 44 million people have received their second vaccine dose across the UK. We aim to assess the uptake rates, effectiveness, and safety of all currently approved COVID-19 vaccines in the UK.

METHODS AND ANALYSIS

We will use prospective cohort study designs to assess vaccine uptake, effectiveness and safety against clinical outcomes and deaths. Test-negative case-control study design will be used to assess vaccine effectiveness (VE) against laboratory confirmed SARS-CoV-2 infection. Self-controlled case series and retrospective cohort study designs will be carried out to assess vaccine safety against mild-to-moderate and severe adverse events, respectively. Individual-level pseudonymised data from primary care, secondary care, laboratory test and death records will be linked and analysed in secure research environments in each UK nation. Univariate and multivariate logistic regression models will be carried out to estimate vaccine uptake levels in relation to various population characteristics. VE estimates against laboratory confirmed SARS-CoV-2 infection will be generated using a generalised additive logistic model. Time-dependent Cox models will be used to estimate the VE against clinical outcomes and deaths. The safety of the vaccines will be assessed using logistic regression models with an offset for the length of the risk period. Where possible, data will be meta-analysed across the UK nations.

ETHICS AND DISSEMINATION

We obtained approvals from the National Research Ethics Service Committee, Southeast Scotland 02 (12/SS/0201), the Secure Anonymised Information Linkage independent Information Governance Review Panel project number 0911. Concerning English data, University of Oxford is compliant with the General Data Protection Regulation and the National Health Service (NHS) Digital Data Security and Protection Policy. This is an approved study (Integrated Research Application ID 301740, Health Research Authority (HRA) Research Ethics Committee 21/HRA/2786). The Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub meets NHS Digital's Data Security and Protection Toolkit requirements. In Northern Ireland, the project was approved by the Honest Broker Governance Board, project number 0064. Findings will be made available to national policy-makers, presented at conferences and published in peer-reviewed journals.

Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

Background:

Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability.

Methods:

We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1, 2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤ 64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity.

Results:

Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [CI] 1.19–1.56) and greater risk of readmission (relative risk 1.77, 95% CI 1.14–2.75). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability.

Interpretation:

Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.

COVID-19 Pandemic and Individuals With Intellectual Disability: Special Olympics as an Example of Organizational Responses and Challenges

The COVID-19 pandemic is a worldwide crisis. It has been, and is, an extreme challenge for our health care and prevention systems, and for society as a whole. Among many facets of life, physical activity and sport has been heavily impacted. The aim of this viewpoint article is to highlight the effect of the COVID-19 pandemic on individuals with an intellectual disability, with a particular focus on physical activity and Special Olympics. Specific objectives are (a) to share what the literature reveals about the impact of COVID-19 on the health and well-being of individuals with an intellectual disability, (b) to examine what is known about the impact of the pandemic on physical activity of individuals with an intellectual disability, (c) to describe Special Olympics program responses during the pandemic, and (d) to recommend areas for future research.

Factors associated with excess all-cause mortality in the first wave of the COVID-19 pandemic in the UK: A time series analysis using the Clinical Practice Research Datalink

BACKGROUND

Excess mortality captures the total effect of the Coronavirus Disease 2019 (COVID-19) pandemic on mortality and is not affected by misspecification of cause of death. We aimed to describe how health and demographic factors were associated with excess mortality during, compared to before, the pandemic.

METHODS AND FINDINGS

We analysed a time series dataset including 9,635,613 adults (≥40 years old) registered at United Kingdom general practices contributing to the Clinical Practice Research Datalink. We extracted weekly numbers of deaths and numbers at risk between March 2015 and July 2020, stratified by individual-level factors. Excess mortality during Wave 1 of the UK pandemic (5 March to 27 May 2020) compared to the prepandemic period was estimated using seasonally adjusted negative binomial regression models. Relative rates (RRs) of death for a range of factors were estimated before and during Wave 1 by including interaction terms. We found that all-cause mortality increased by 43% (95% CI 40% to 47%) during Wave 1 compared with prepandemic. Changes to the RR of death associated with most sociodemographic and clinical characteristics were small during Wave 1 compared with prepandemic. However, the mortality RR associated with dementia markedly increased (RR for dementia versus no dementia prepandemic: 3.5, 95% CI 3.4 to 3.5; RR during Wave 1: 5.1, 4.9 to 5.3); a similar pattern was seen for learning disabilities (RR prepandemic: 3.6, 3.4 to 3.5; during Wave 1: 4.8, 4.4 to 5.3), for black or South Asian ethnicity compared to white, and for London compared to other regions. Relative risks for morbidities were stable in multiple sensitivity analyses. However, a limitation of the study is that we cannot assume that the risks observed during Wave 1 would apply to other waves due to changes in population behaviour, virus transmission, and risk perception.

CONCLUSIONS

The first wave of the UK COVID-19 pandemic appeared to amplify baseline mortality risk to approximately the same relative degree for most population subgroups. However, disproportionate increases in mortality were seen for those with dementia, learning disabilities, non-white ethnicity, or living in London.

The reported effects of the COVID-19 pandemic on people with intellectual disability and their carers: a scoping review

BACKGROUND

People with an intellectual disability are a vulnerable group during COVID-19 due to multi-morbidity, frailty, underlying conditions/health problems, social circumstances and limitations in understanding. This place them at greater risk of more severe outcomes from COVID-19.

OBJECTIVE

To chart the evidence of the effects of the COVID-19 pandemic on people with intellectual disability and their carers reported in the research.

METHODS

A scoping review method was used to review literature published across eight databases in 2020 and included manual searches of reference lists of included articles.

RESULTS

Sixteen studies were selected for inclusion. The findings highlight that professionals, people with intellectual disability and their carers were keen to comply with pandemic related public health guidance. However, implementing infection prevention and control measures in certain contexts for people with intellectual disability was challenging. Thereby a rights-based, person-centred approach to care is essential and professionals need to extend their understanding and practice of collaborative working to include people with intellectual disability and their family/carers. The findings highlight that compliance with public health guidance and infection control measures can be difficult for people with intellectual disability to implement.

CONCLUSIONS

There is limited good quality robust research on COVID-19 and people with intellectual disability and/or their carers experiences.

Comparing COVID-19 mortality across selected states in India: The role of age structure

Background

Mortality rates provide an opportunity to identify and act on the health system intervention for preventing deaths. Hence, it is essential to appreciate the influence of age structure while reporting mortality for a better summary of the magnitude of the epidemic.

Objectives

We described and compared the pattern of COVID-19 mortality standardized by age between selected states and India from January to November 2020.

Methods

We initially estimated the Indian population for 2020 using the decadal growth rate from the previous census (2011). This was followed by estimations of crude and age-adjusted mortality rate per million for India and the selected states. We used this information to perform indirect-standardization and derive the age-standardized mortality rates for the states for comparison. In addition, we derived a ratio for age-standardized mortality to compare across age groups within the state. We extracted information regarding COVID-19 deaths from the Integrated Disease Surveillance Programme special surveillance portal up to November 16, 2020.

Results

The crude mortality rate of India stands at 88.9 per million population (118,883/1,337,328,910). Age-adjusted mortality rate (per-million) was highest for Delhi (300.5) and lowest for Kerala (35.9). The age-standardized mortality rate (per million) for India is (<15 years = 1.6, 15–29 years = 6.3, 30–44 years = 35.9, 45–59 years = 198.8, 60–74 years = 571.2, ≥75 years = 931.6). The ratios for age-standardized mortality increase proportionately from 45 to 59 years age group across all the states.

Conclusion

There is high COVID-19 mortality not only among the elderly ages, but we also identified heavy impact of COVID-19 on the working population. Therefore, we recommend further evaluation of age-adjusted mortality for all States and inclusion of variables like gender, socio-economic status for standardization while identifying at-risk populations and implementing priority public health actions.

Gout during the SARS-CoV-2 pandemic: increased flares, urate levels and functional improvement

Introduction

Gout is the most common inflammatory arthritis, but was not considered in most COVID-19 and rheumatic diseases reports. Our aim was to describe changes in clinical data, treatment, function and quality of life for gout patients during COVID-19 pandemic.

Methods

Prospective, descriptive and analytical study of 101 consecutive gout (ACR/EULAR 2015) patients from our clinic evaluated during pandemic by phone call (n=52) or phone call + face-to-face (n=68) that accepted to participate. Variables are demographics, clinical and treatment data, HAQ, EQ5D questionnaires and COVID-19-related data. Patients were divided in two groups: flare (n=36) or intercritical gout (n=65) also; available pre-pandemic data was obtained from 71 patients. Statistical analyses are X², paired t-test and Wilcoxon test.

Results

Included gout patients were males (95.8%), mean (SD) age 54.7 (10.7) years and disease duration 16.4 (9.8) years; 90% received allopurinol, 50% colchicine as prophylaxis and 25% suspended ≥ 1 medication. Comparison of pre-pandemic vs pandemic data showed > flares (4.4% vs 36%, p=0.01), more flares in the last 6 months: 0.31 (0.75) vs 1.71 (3.1), (p=0.004 and > urate levels: 5.6 (1.7)vs 6.7 (2.2) mg/dL, p=0.016. Unexpectedly, function and quality-of-life scores improved: HAQ score 0.65 (2.16) vs 0.12 (0.17), p= 0.001. Seven patients were COVID-19-confirmed cases; they had significantly more flares, higher urate levels and lower allopurinol doses and two died.

Conclusions

In gout patients, flares were 9 times more frequent during pandemic also, they had increased urate levels but led to an unexpected improvement in HAQ and functionality scores. Resilience and lifestyle changes in gout during COVID-19 pandemic require further studies.

Key Points • COVID-19 pandemic is associated with 4 times more flares in gout patients. • Increased flares were also seen in previously well-controlled gout patients. • Increased serum urate levels were also found in gout patients during pandemic. • In our gout clinic, 8/101 patients were diagnosed as COVID-19+, and two of them died.

Deaths involving COVID-19 by self-reported disability status during the first two waves of the COVID-19 pandemic in England: a retrospective, population-based cohort study

Background

People with learning disabilities are at substantially increased risk of COVID-19 mortality, but evidence on risks of COVID-19 mortality for disabled people more generally is limited. We aimed to use population-level data to estimate the association between self-reported disability and death involving COVID-19 during the first two waves of the COVID-19 pandemic in England.

Methods

We conducted a retrospective, population-based cohort study of adults aged 30–100 years living in private households or communal establishments in England, using data from the Office for National Statistics Public Health Data Asset. Participants were present at the 2011 Census and alive on Jan 24, 2020. Participants reported being limited a lot in their daily activities, limited a little, or not limited at all, in response to a question from the 2011 Census. The outcome was death involving COVID-19, occurring between Jan 24, 2020, and Feb 28, 2021. We used Cox proportional hazards regression to calculate hazard ratios (HRs) for the association between disability and death involving COVID-19, sequentially adjusting for age, residence type (private household, care home, or other communal establishment), geographical characteristics (local authority district and population density), sociodemographic characteristics (ethnicity, highest qualification, Index of Multiple Deprivation decile, household characteristics [National Statistics Socio-economic Classification of the household reference person, tenure of household, household size, family status, household composition, and key worker in household], key worker type, individual and household exposure to disease, and individual and household proximity to others), and health status (pre-existing health conditions, body-mass index, and number of admissions to hospital and days spent in hospital over the previous 3 years).

Findings

29 293 845 adults were included in the study (13 806 623 [47%] men, 15 487 222 [53%] women), of whom 3 038 772 (10%) reported being limited a little and 2 011 576 (7%) reported being limited a lot. During follow-up, 105 213 people died from causes involving COVID-19 in England, 61 416 (58%) of whom were disabled. Age-adjusted analyses showed higher mortality involving COVID-19 among disabled people who were limited a lot (HR 3·05 [95% CI 2·98–3·11] for men; 3·48 [3·41–3·56] for women) and disabled people who were limited a little (HR 1·88 [1·84–1·92] for men; 2·03 [1·98–2·08] for women) than among non-disabled people. Adjustment for residence type, geography, sociodemographics, and health conditions reduced but did not eliminate the associations between disability and death involving COVID-19 (HR 1·35 [1·32–1·38] for men who were limited a lot; 1·21 [1·18–1·23] for men who were limited a little; 1·55 [1·51–1·59] for women who were limited a lot; and 1·28 [1·25–1·31] for women who were limited a little).

Interpretation

Given the association between disability and mortality involving COVID-19, verification of these findings and consideration of recommendations for protective measures are now required.

Funding

None.

Shielding, hospital admission and mortality among 1216 people with total laryngectomy in the UK during the COVID-19 pandemic: A cross-sectional survey from the first national lockdown

BACKGROUND

People with a total laryngectomy (PTL) rely on a permanent opening in their neck (stoma) to breathe. This altered anatomy may increase susceptibility to contracting and transmitting SARS-CoV-2.

AIMS

To report on (1) the frequency and characteristics of PTL who tested positive for COVID-19, (2) the receipt of advice regarding shielding and patient self-reports of shielding, (3) hospital admissions and length of stay, and (4) mortality rates in this group during the first UK national lockdown.

METHODS & PROCEDURES

This is a cross-sectional survey and case note review. National Health Service (NHS) centres providing care to PTL were invited to participate via the Royal College of Speech and Language Therapists' (RCSLT) Head & Neck Clinical Excellence Networks and through social media. PTL were reviewed by their speech and language therapist either in person or via telehealth between 30 March and 30 September 2020. Data were collected within the time frame covered by the Control of Patient Information (COPI) notice issued for COVID-19 and included information on COVID-19 testing, shielding, hospital admissions, length of stay and deaths. Information was submitted to the lead NHS site using a custom designed data-capture worksheet. Analysis was performed using descriptive statistics, including proportions and frequency counts. Pearson's Chi squared tests were used to compare categorical data using a 5% significance level.

OUTCOMES & RESULTS

Data were obtained from 1216 PTL from 26 centres across the UK. A total of 81% were male; mean age was 70 years (28-97 years). Of the total group, 12% received a COVID-19 test. A total of 24 (2% of total sample) tested positive for COVID-19. Almost one-third of PTL (32%) received a government letter or were advised to shield by a healthcare professional. During the data collection time frame, 12% had a hospital admission (n = 151) with a median length of stay of 1 day (1-133 days), interquartile range (IQR) = 17 days. A total of 20 of these admissions (13%) had tested positive for COVID-19 with a median length of stay of 26 days, IQR = 49 days. The overall mortality was 4% (41 patients), with eight deaths occurring within 28 days of testing positive for COVID-19.

CONCLUSIONS & IMPLICATIONS

This study highlighted the lack of routine national data for neck-breathers with which to compare the current findings. Greater testing in the community is necessary to understand the prevalence of COVID-19 in PTL and if this group is indeed more susceptible. The potential for nasopharyngeal and tracheal aspirates to show differing results when testing for COVID-19 in neck-breathers requires further investigation.

WHAT THIS PAPER ADDS

What is already known on the subject? People with total laryngectomy (PTL) have an altered anatomy for breathing and speaking. The presence of a neck stoma poses an additional virus entry point aside from the nose, mouth and conjunctiva. This could increase the susceptibility to COVID-19 for PTL. What this paper adds? This is the first national audit to provide data on shielding, hospital admissions and mortality for patients with total laryngectomy in the UK over the pandemic. The overall mortality in PTL over the first lockdown did not appear to be higher than the "best case" estimates from previous years. However, one in three PTL who acquired COVID-19 and were admitted to hospital, died within 28 days of testing positive. These findings are relevant to the current care and management of PTL over the pandemic but also highlights important knowledge gaps. What are the potential or actual clinical implications of this work? This study highlights gaps in the collection of baseline information on hospital admissions, length of stay and mortality for people with laryngectomy in the UK, restricting comparisons between the current data and historical data. The need for further research on whether neck-breathers should be tested via both nasopharyngeal and tracheal aspirates is important not just currently, but also in case of any future respiratory epidemics.

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

OBJECTIVE

Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned.

METHODS

IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives.

RESULTS

All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits.

CONCLUSIONS

Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.

PRINCIPLE trial demonstrates scope for in-pandemic improvement in primary care antibiotic stewardship: a retrospective sentinel network cohort study

BACKGROUND

The Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE) has provided in-pandemic evidence that azithromycin and doxycycline were not beneficial in the early primary care management of COVID-19.

AIM

To explore the extent of azithromycin and doxycycline in-pandemic use, and the scope for trial findings impacting on practice.

DESIGN & SETTING

Crude rates of prescribing and respiratory tract infections (RTI) in 2020 were compared with 2019, using the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC).

METHOD

A negative binomial model was used to compare azithromycin and doxycycline lower respiratory tract infections (LRTI), upper respiratory tract infections (URTI), and influenza-like-illness (ILI) in 2020 with 2019; reporting incident rate ratios (IRR) between years, and 95% confidence intervals (95% CI).

RESULTS

Azithromycin prescriptions increased 7% in 2020 compared with 2019, whereas doxycycline decreased by 7%. Concurrently, LRTI and URTI incidence fell by over half (58.3% and 54.4%, respectively) while ILI rose slightly (6.4%). The overall percentage of RTI prescribed azithromycin rose from 0.51% in 2019 to 0.72% in 2020 (risk difference of 0.214% [95% CI = 0.211 to 0.217]); doxycycline rose from 11.86% in 2019 to 15.79% in 2020 (risk difference: 3.93% [95% CI = 3.73 to 4.14]). The adjusted IRR showed azithromycin prescribing was 22% higher in 2020 (IRR = 1.22, 95% CI = 1.19 to 1.26, P<0.0001), for every unit rise in confirmed COVID-19 there was an associated 3% rise in prescription (IRR = 1.03, 95% CI = 1.02 to 1.03, P<0.0001); whereas these measures were static for doxycycline.

CONCLUSION

PRINCIPLE demonstrates scope for improved antimicrobial stewardship during a pandemic.

Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform

OBJECTIVE

To assess the association between learning disability and risk of hospital admission and death from covid-19 in England among adults and children.

DESIGN

Population based cohort study on behalf of NHS England using the OpenSAFELY platform.

SETTING

Patient level data were obtained for more than 17 million people registered with a general practice in England that uses TPP software. Electronic health records were linked with death data from the Office for National Statistics and hospital admission data from NHS Secondary Uses Service.

PARTICIPANTS

Adults (aged 16-105 years) and children (<16 years) from two cohorts: wave 1 (registered with a TPP practice as of 1 March 2020 and followed until 31 August 2020); and wave 2 (registered 1 September 2020 and followed until 8 February 2021). The main exposure group consisted of people on a general practice learning disability register; a subgroup was defined as those having profound or severe learning disability. People with Down's syndrome and cerebral palsy were identified (whether or not they were on the learning disability register).

MAIN OUTCOME MEASURE

Covid-19 related hospital admission and covid-19 related death. Non-covid-19 deaths were also explored.

RESULTS

For wave 1, 14 312 023 adults aged ≥16 years were included, and 90 307 (0.63%) were on the learning disability register. Among adults on the register, 538 (0.6%) had a covid-19 related hospital admission; there were 222 (0.25%) covid-19 related deaths and 602 (0.7%) non-covid deaths. Among adults not on the register, 29 781 (0.2%) had a covid-19 related hospital admission; there were 13 737 (0.1%) covid-19 related deaths and 69 837 (0.5%) non-covid deaths. Wave 1 hazard ratios for adults on the learning disability register (adjusted for age, sex, ethnicity, and geographical location) were 5.3 (95% confidence interval 4.9 to 5.8) for covid-19 related hospital admission and 8.2 (7.2 to 9.4) for covid-19 related death. Wave 2 produced similar estimates. Associations were stronger among those classified as having severe to profound learning disability, and among those in residential care. For both waves, Down's syndrome and cerebral palsy were associated with increased hazards for both events; Down's syndrome to a greater extent. Hazard ratios for non-covid deaths followed similar patterns with weaker associations. Similar patterns of increased relative risk were seen for children, but covid-19 related deaths and hospital admissions were rare, reflecting low event rates among children.

CONCLUSIONS

People with learning disability have markedly increased risks of hospital admission and death from covid-19, over and above the risks observed for non-covid causes of death. Prompt access to covid-19 testing and healthcare is warranted for this vulnerable group, and prioritisation for covid-19 vaccination and other targeted preventive measures should be considered.

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

Background

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

Methods

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

Results

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

Conclusions

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

Social determinants of COVID-19 incidence and outcomes: A rapid review

Early reports indicate that the social determinants of health are implicated in COVID-19 incidence and outcomes. To inform the ongoing response to the pandemic, we conducted a rapid review of peer-reviewed studies to examine the social determinants of COVID-19. We searched Ovid MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials from December 1, 2019 to April 27, 2020. We also searched the bibliographies of included studies, COVID-19 evidence repositories and living evidence maps, and consulted with expert colleagues internationally. We included studies identified through these supplementary sources up to June 25, 2020. We included English-language peer-reviewed quantitative studies that used primary data to describe the social determinants of COVID-19 incidence, clinical presentation, health service use and outcomes in adults with a confirmed or presumptive diagnosis of COVID-19. Two reviewers extracted data and conducted quality assessment, confirmed by a third reviewer. Forty-two studies met inclusion criteria. The strongest evidence was from three large observational studies that found associations between race or ethnicity and socioeconomic deprivation and increased likelihood of COVID-19 incidence and subsequent hospitalization. Limited evidence was available on other key determinants, including occupation, educational attainment, housing status and food security. Assessing associations between sociodemographic factors and COVID-19 was limited by small samples, descriptive study designs, and the timeframe of our search. Systematic reviews of literature published subsequently are required to fully understand the magnitude of any effects and predictive utility of sociodemographic factors related to COVID-19 incidence and outcomes. PROSPERO: CRD4202017813.

Azithromycin for community treatment of suspected COVID-19 in people at increased risk of an adverse clinical course in the UK (PRINCIPLE): a randomised, controlled, open-label, adaptive platform trial

BACKGROUND

Azithromycin, an antibiotic with potential antiviral and anti-inflammatory properties, has been used to treat COVID-19, but evidence from community randomised trials is lacking. We aimed to assess the effectiveness of azithromycin to treat suspected COVID-19 among people in the community who had an increased risk of complications.

METHODS

In this UK-based, primary care, open-label, multi-arm, adaptive platform randomised trial of interventions against COVID-19 in people at increased risk of an adverse clinical course (PRINCIPLE), we randomly assigned people aged 65 years and older, or 50 years and older with at least one comorbidity, who had been unwell for 14 days or less with suspected COVID-19, to usual care plus azithromycin 500 mg daily for three days, usual care plus other interventions, or usual care alone. The trial had two coprimary endpoints measured within 28 days from randomisation: time to first self-reported recovery, analysed using a Bayesian piecewise exponential, and hospital admission or death related to COVID-19, analysed using a Bayesian logistic regression model. Eligible participants with outcome data were included in the primary analysis, and those who received the allocated treatment were included in the safety analysis. The trial is registered with ISRCTN, ISRCTN86534580.

FINDINGS

The first participant was recruited to PRINCIPLE on April 2, 2020. The azithromycin group enrolled participants between May 22 and Nov 30, 2020, by which time 2265 participants had been randomly assigned, 540 to azithromycin plus usual care, 875 to usual care alone, and 850 to other interventions. 2120 (94%) of 2265 participants provided follow-up data and were included in the Bayesian primary analysis, 500 participants in the azithromycin plus usual care group, 823 in the usual care alone group, and 797 in other intervention groups. 402 (80%) of 500 participants in the azithromycin plus usual care group and 631 (77%) of 823 participants in the usual care alone group reported feeling recovered within 28 days. We found little evidence of a meaningful benefit in the azithromycin plus usual care group in time to first reported recovery versus usual care alone (hazard ratio 1·08, 95% Bayesian credibility interval [BCI] 0·95 to 1·23), equating to an estimated benefit in median time to first recovery of 0·94 days (95% BCI -0·56 to 2·43). The probability that there was a clinically meaningful benefit of at least 1·5 days in time to recovery was 0·23. 16 (3%) of 500 participants in the azithromycin plus usual care group and 28 (3%) of 823 participants in the usual care alone group were hospitalised (absolute benefit in percentage 0·3%, 95% BCI -1·7 to 2·2). There were no deaths in either study group. Safety outcomes were similar in both groups. Two (1%) of 455 participants in the azothromycin plus usual care group and four (1%) of 668 participants in the usual care alone group reported admission to hospital during the trial, not related to COVID-19.

INTERPRETATION

Our findings do not justify the routine use of azithromycin for reducing time to recovery or risk of hospitalisation for people with suspected COVID-19 in the community. These findings have important antibiotic stewardship implications during this pandemic, as inappropriate use of antibiotics leads to increased antimicrobial resistance, and there is evidence that azithromycin use increased during the pandemic in the UK.

FUNDING

UK Research and Innovation and UK Department of Health and Social Care.