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Nguyen LH, Cao Y, Hur J, Mehta RS, Sikavi DR, Wang Y, Ma W, Wu K, Song M, Giovannucci EL, Rimm EB, Willett WC, Garrett WS, Izard J, Huttenhower C, Chan AT. The Sulfur Microbial Diet Is Associated With Increased Risk of Early-Onset Colorectal Cancer Precursors. Gastroenterology 2021; 161:1423-1432.e4. [PMID: 34273347 PMCID: PMC8545755 DOI: 10.1053/j.gastro.2021.07.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diet may contribute to the increasing incidence of colorectal cancer (CRC) before age 50 (early-onset CRC). Microbial metabolism of dietary sulfur produces hydrogen sulfide (H2S), a gastrointestinal carcinogen that cannot be easily measured at scale. As a result, evidence supporting its role in early neoplasia is lacking. METHODS We evaluated long-term adherence to the sulfur microbial diet, a dietary index defined a priori based on increased abundance of 43 bacterial species involved with sulfur metabolism, with risk of CRC precursors among 59,013 individuals who underwent lower endoscopy in the Nurses' Health Study II (1991-2015), a prospective cohort study with dietary assessment every 4 years through validated food frequency questionnaires and an assessment of dietary intake during adolescence in 1998. The sulfur microbial diet was characterized by intake high in processed meats, foods previously linked to CRC development, and low in mixed vegetables and legumes. Multivariable logistic regression for clustered data was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS We documented 2911 cases of early-onset adenoma. After adjusting for established risk factors, higher sulfur microbial diet scores were associated with increased risk for early-onset adenomas (ORquartile [Q]4 vs Q1, 1.31; 95% CI, 1.10-1.56, Ptrend = .02), but not serrated lesions. Compared with the lowest, women in the highest quartile of sulfur microbial diet scores had significantly increased risk of early-onset adenomas with greater malignant potential (ORQ4 vs Q1, 1.65 for villous/tubulovillous histology; 95% CI, 1.12-2.43; Ptrend = .04). Similar trends for early-onset adenoma were observed based on diet consumed during adolescence. In contrast, no clear association for adenomas was identified after age 50. CONCLUSIONS Our findings in a cohort of young women support a role for dietary interactions with gut sulfur-metabolizing bacteria in early-onset colorectal carcinogenesis, possibly beginning in adolescence.
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Affiliation(s)
- Long H Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri; Alvin J. Siteman Cancer Center, Washington University School of Medicine in St. Louis, St Louis, Missouri; Division of Gastroenterology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Jinhee Hur
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Raaj S Mehta
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Daniel R Sikavi
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yiqing Wang
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Wenjie Ma
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mingyang Song
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Edward L Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eric B Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wendy S Garrett
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jacques Izard
- Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska; Nebraska Food for Health Center, University of Nebraska, Lincoln, Nebraska; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
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Sikavi DR, Cai JX, Leung R, Carroll TL, Chan WW. Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients With Laryngopharyngeal Reflux Symptoms. Clin Transl Gastroenterol 2021; 12:e00408. [PMID: 34597279 PMCID: PMC8487779 DOI: 10.14309/ctg.0000000000000408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/04/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The pathophysiology of laryngopharyngeal reflux (LPR) remains incompletely understood. Proximal esophageal motor dysfunction may impair bolus clearance, increasing the risk of pharyngeal refluxate exposure. We aimed to evaluate the association of proximal esophageal contractility with objective reflux metrics. METHODS We evaluated adults with LPR symptoms undergoing high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing at a tertiary center between March 2018 and August 2019. Routine parameters per Chicago classification were obtained on HRM. Proximal esophageal contractility was evaluated using proximal contractile integral (PCI), which quantifies contractile pressure >20 mm Hg for the region spanning the distal margin of the upper esophageal sphincter and transition zone. Univariate (Kendall correlation and Student t test) and multivariable (general linear regression and logistic regression) analyses were performed. RESULTS We enrolled 138 patients (66.7% women, mean age 57.1 years) in this study. Lower PCI was associated with an elevated risk of increased pharyngeal reflux (adjusted odds ratio 0.83 per 100 mm Hg-s-cm change in PCI, 95% confidence interval: 0.69-0.98), with a trend toward increased bolus exposure time and total reflux events, after multivariable adjustment. The relationship between PCI and pharyngeal reflux was strongest among participants without a primary motility disorder on HRM (adjusted odds ratio 0.63, 95% confidence interval: 0.42-0.85, P interaction = 0.04). Among continuously expressed reflux parameters, lower PCI was significantly associated with more distal acid reflux events (β = -0.0094, P = 0.03) and total reflux events (β = -0.0172, P = 0.05), after adjusting for confounders. DISCUSSION Reduced proximal esophageal contractility as assessed by decreased PCI on HRM independently predicted increased pharyngeal reflux in patients with LPR symptoms, particularly among those without a coexisting motility disorder.
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Affiliation(s)
| | - Jennifer X. Cai
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
| | - Ryan Leung
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
| | - Thomas L. Carroll
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W. Chan
- Harvard Medical School, Boston, Massachusetts, USA;
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA;
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Sikavi DR, Cai JX, Carroll TL, Chan WW. Prevalence and clinical significance of esophageal motility disorders in patients with laryngopharyngeal reflux symptoms. J Gastroenterol Hepatol 2021; 36:2076-2082. [PMID: 33373479 DOI: 10.1111/jgh.15391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/12/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Esophageal motor dysfunction may underlie impaired bolus/refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of esophageal dysmotility and its correlation with reflux parameters and symptoms in LPR is not well established. The aim of this study was to evaluate the prevalence of coexisting esophageal dysmotility among patients with suspected LPR. METHODS This was a retrospective cohort study of 194 consecutive patients with LPR symptoms referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing at a tertiary center in March 2018 to August 2019. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, dominant symptom intensity, and 12-Item Short-Form Health Survey. HRM findings were categorized using Chicago Classification v3.0. RESULTS Abnormal findings on HRM were identified in 84 (43.3%) patients, with ineffective esophageal motility (n = 60, 30.9%) as the most common diagnosis. A disorder of esophagogastric junction outflow or a major disorder of peristalsis was identified in 26 (13.4%) patients, including 2 (1%) with achalasia and 7 (3.6%) with jackhammer esophagus. Reflux burden (distal, proximal, or pharyngeal) on combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing did not differ across HRM findings. Patients reporting esophageal symptoms were more likely to have a primary motility disorder (odds ratio 2.34, P = 0.04). However, no significant differences in Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, or 12-Item Short-Form Health Survey were noted across HRM diagnoses. CONCLUSION Esophageal motility disorders are prevalent among patients with LPR symptoms, including up to one in seven with esophagogastric junction outflow or major peristaltic disorder. Patients with abnormal motility more likely report esophageal symptoms. Clinicians should be aware of these coexisting conditions, particularly in those with refractory symptoms.
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Affiliation(s)
- Daniel R Sikavi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer X Cai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas L Carroll
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Sikavi DR, Nguyen LH, Haruki K, Ugai T, Ma W, Wang DD, Thompson KN, Yan Y, Branck T, Wilkinson JE, Akimoto N, Zhong R, Lau MC, Mima K, Kosumi K, Morikawa T, Rimm EB, Garrett WS, Izard J, Cao Y, Song M, Huttenhower C, Ogino S, Chan AT. The Sulfur Microbial Diet and Risk of Colorectal Cancer by Molecular Subtypes and Intratumoral Microbial Species in Adult Men. Clin Transl Gastroenterol 2021; 12:e00338. [PMID: 34333506 PMCID: PMC8323793 DOI: 10.14309/ctg.0000000000000338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/05/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION We recently described the sulfur microbial diet, a pattern of intake associated with increased gut sulfur-metabolizing bacteria and incidence of distal colorectal cancer (CRC). We assessed whether this risk differed by CRC molecular subtypes or presence of intratumoral microbes involved in CRC pathogenesis (Fusobacterium nucleatum and Bifidobacterium spp.). METHODS We performed Cox proportional hazards modeling to examine the association between the sulfur microbial diet and incidence of overall and distal CRC by molecular and microbial subtype in the Health Professionals Follow-Up Study (1986-2012). RESULTS We documented 1,264 incident CRC cases among 48,246 men, approximately 40% of whom had available tissue data. After accounting for multiple hypothesis testing, the relationship between the sulfur microbial diet and CRC incidence did not differ by subtype. However, there was a suggestion of an association by prostaglandin synthase 2 (PTGS2) status with a multivariable adjusted hazard ratio for highest vs lowest tertile of sulfur microbial diet scores of 1.31 (95% confidence interval: 0.99-1.74, Ptrend = 0.07, Pheterogeneity = 0.04) for PTGS2-high CRC. The association of the sulfur microbial diet with distal CRC seemed to differ by the presence of intratumoral Bifidobacterium spp. with an adjusted hazard ratio for highest vs lowest tertile of sulfur microbial diet scores of 1.65 (95% confidence interval: 1.14-2.39, Ptrend = 0.01, Pheterogeneity = 0.03) for Bifidobacterium-negative distal CRC. We observed no apparent heterogeneity by other tested molecular markers. DISCUSSION Greater long-term adherence to the sulfur microbial diet could be associated with PTGS2-high and Bifidobacterium-negative distal CRC in men. Additional studies are needed to further characterize the role of gut microbial sulfur metabolism and CRC.
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Affiliation(s)
- Daniel R. Sikavi
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Long H. Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Koichiro Haruki
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tomotaka Ugai
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dong D. Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kelsey N. Thompson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Yan Yan
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Tobyn Branck
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jeremy E. Wilkinson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Naohiko Akimoto
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rong Zhong
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mai Chan Lau
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kosuke Mima
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Keisuke Kosumi
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Teppei Morikawa
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric B. Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Wendy S. Garrett
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jacques Izard
- Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri, USA
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Shuji Ogino
- Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Cancer Immunology and Cancer Epidemiology Programs, Dana-Farber Harvard Cancer Center, Boston, Massachusetts, USA
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Lee KA, Ma W, Sikavi DR, Drew DA, Nguyen LH, Bowyer RCE, Cardoso MJ, Fall T, Freidin MB, Gomez M, Graham M, Guo C, Joshi AD, Kwon S, Lo C, Lochlainn MN, Menni C, Murray B, Mehta R, Song M, Sudre CH, Bataille V, Varsavsky T, Visconti A, Franks PW, Wolf J, Steves CJ, Ourselin S, Spector TD, Chan AT. Cancer and Risk of COVID-19 Through a General Community Survey. Oncologist 2021; 26:e182-e185. [PMID: 32845538 PMCID: PMC7460944 DOI: 10.1634/theoncologist.2020-0572] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/18/2020] [Indexed: 12/30/2022] Open
Abstract
Individuals with cancer may be at high risk for coronavirus disease 2019 (COVID-19) and adverse outcomes. However, evidence from large population-based studies examining whether cancer and cancer-related therapy exacerbates the risk of COVID-19 infection is still limited. Data were collected from the COVID Symptom Study smartphone application since March 29 through May 8, 2020. Among 23,266 participants with cancer and 1,784,293 without cancer, we documented 10,404 reports of a positive COVID-19 test. Compared with participants without cancer, those living with cancer had a 60% increased risk of a positive COVID-19 test. Among patients with cancer, current treatment with chemotherapy or immunotherapy was associated with a 2.2-fold increased risk of a positive test. The association between cancer and COVID-19 infection was stronger among participants >65 years and males. Future studies are needed to identify subgroups by tumor types and treatment regimens who are particularly at risk for COVID-19 infection and adverse outcomes.
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Affiliation(s)
- Karla A. Lee
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Wenjie Ma
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel R. Sikavi
- Department of Medicine, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - David A. Drew
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Long H. Nguyen
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Ruth C. E. Bowyer
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - M. Jorge Cardoso
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Tove Fall
- Department of Clinical Sciences, Lund UniversityMalmöSweden
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala UniversitySweden
| | - Maxim B. Freidin
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Maria Gomez
- Department of Clinical Sciences, Lund UniversityMalmöSweden
| | - Mark Graham
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Chuan‐Guo Guo
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Amit D. Joshi
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Sohee Kwon
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Chun‐Han Lo
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Mary Ni Lochlainn
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Cristina Menni
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Benjamin Murray
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Raaj Mehta
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Carole H. Sudre
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Veronique Bataille
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Thomas Varsavsky
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Alessia Visconti
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Paul W. Franks
- Department of Clinical Sciences, Lund UniversityMalmöSweden
| | | | - Claire J. Steves
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Sebastien Ourselin
- School of Biomedical Engineering & Imaging Sciences, King's College LondonLondonUnited Kingdom
| | - Tim D. Spector
- Department of Twin Research and Genetic Epidemiology, King's College LondonLondonUnited Kingdom
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health. BostonMassachusettsUSA
- Broad Institute of MIT and HarvardCambridgeMassachusettsUSA
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6
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Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, Mehta RS, Warner ET, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Sudre CH, Cardoso MJ, Wolf J, Spector TD, Ourselin S, Steves CJ, Chan AT. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health 2020; 5:e475-e483. [PMID: 32745512 PMCID: PMC7491202 DOI: 10.1016/s2468-2667(20)30164-x] [Citation(s) in RCA: 1267] [Impact Index Per Article: 316.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data for front-line health-care workers and risk of COVID-19 are limited. We sought to assess risk of COVID-19 among front-line health-care workers compared with the general community and the effect of personal protective equipment (PPE) on risk. METHODS We did a prospective, observational cohort study in the UK and the USA of the general community, including front-line health-care workers, using self-reported data from the COVID Symptom Study smartphone application (app) from March 24 (UK) and March 29 (USA) to April 23, 2020. Participants were voluntary users of the app and at first use provided information on demographic factors (including age, sex, race or ethnic background, height and weight, and occupation) and medical history, and subsequently reported any COVID-19 symptoms. We used Cox proportional hazards modelling to estimate multivariate-adjusted hazard ratios (HRs) of our primary outcome, which was a positive COVID-19 test. The COVID Symptom Study app is registered with ClinicalTrials.gov, NCT04331509. FINDINGS Among 2 035 395 community individuals and 99 795 front-line health-care workers, we recorded 5545 incident reports of a positive COVID-19 test over 34 435 272 person-days. Compared with the general community, front-line health-care workers were at increased risk for reporting a positive COVID-19 test (adjusted HR 11·61, 95% CI 10·93-12·33). To account for differences in testing frequency between front-line health-care workers and the general community and possible selection bias, an inverse probability-weighted model was used to adjust for the likelihood of receiving a COVID-19 test (adjusted HR 3·40, 95% CI 3·37-3·43). Secondary and post-hoc analyses suggested adequacy of PPE, clinical setting, and ethnic background were also important factors. INTERPRETATION In the UK and the USA, risk of reporting a positive test for COVID-19 was increased among front-line health-care workers. Health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds. Additional follow-up of these observational findings is needed. FUNDING Zoe Global, Wellcome Trust, Engineering and Physical Sciences Research Council, National Institutes of Health Research, UK Research and Innovation, Alzheimer's Society, National Institutes of Health, National Institute for Occupational Safety and Health, and Massachusetts Consortium on Pathogen Readiness.
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Affiliation(s)
- Long H Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David A Drew
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark S Graham
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Amit D Joshi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Chuan-Guo Guo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wenjie Ma
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Raaj S Mehta
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erica T Warner
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center on Genomics, Vulnerable Populations, and Health Disparities, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel R Sikavi
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Chun-Han Lo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Sohee Kwon
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mingyang Song
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Lorelei A Mucci
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Meir J Stampfer
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Walter C Willett
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - A Heather Eliassen
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jaime E Hart
- Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jorge E Chavarro
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Karla A Lee
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Mary Ni Lochlainn
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Thomas Varsavsky
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Carole H Sudre
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - M Jorge Cardoso
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | | | - Tim D Spector
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Claire J Steves
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Immunology and Infectious Disease, Harvard T H Chan School of Public Health, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA; Massachusetts Consortium on Pathogen Readiness, Cambridge, MA, USA.
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7
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Chan AT, Drew DA, Nguyen LH, Joshi AD, Ma W, Guo CG, Lo CH, Mehta RS, Kwon S, Sikavi DR, Magicheva-Gupta MV, Fatehi ZS, Flynn JJ, Leonardo BM, Albert CM, Andreotti G, Beane-Freeman LE, Balasubramanian BA, Brownstein JS, Bruinsma F, Cowan AN, Deka A, Ernst ME, Figueiredo JC, Franks PW, Gardner CD, Ghobrial IM, Haiman CA, Hall JE, Deming-Halverson SL, Kirpach B, Lacey JV, Marchand LL, Marinac CR, Martinez ME, Milne RL, Murray AM, Nash D, Palmer JR, Patel AV, Rosenberg L, Sandler DP, Sharma SV, Schurman SH, Wilkens LR, Chavarro JE, Eliassen AH, Hart JE, Kang JH, Koenen KC, Kubzansky LD, Mucci LA, Ourselin S, Rich-Edwards JW, Song M, Stampfer MJ, Steves CJ, Willett WC, Wolf J, Spector T. The COronavirus Pandemic Epidemiology (COPE) Consortium: A Call to Action. Cancer Epidemiol Biomarkers Prev 2020; 29:1283-1289. [PMID: 32371551 PMCID: PMC7357669 DOI: 10.1158/1055-9965.epi-20-0606] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 01/08/2023] Open
Abstract
The rapid pace of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) pandemic presents challenges to the real-time collection of population-scale data to inform near-term public health needs as well as future investigations. We established the COronavirus Pandemic Epidemiology (COPE) consortium to address this unprecedented crisis on behalf of the epidemiology research community. As a central component of this initiative, we have developed a COVID Symptom Study (previously known as the COVID Symptom Tracker) mobile application as a common data collection tool for epidemiologic cohort studies with active study participants. This mobile application collects information on risk factors, daily symptoms, and outcomes through a user-friendly interface that minimizes participant burden. Combined with our efforts within the general population, data collected from nearly 3 million participants in the United States and United Kingdom are being used to address critical needs in the emergency response, including identifying potential hot spots of disease and clinically actionable risk factors. The linkage of symptom data collected in the app with information and biospecimens already collected in epidemiology cohorts will position us to address key questions related to diet, lifestyle, environmental, and socioeconomic factors on susceptibility to COVID-19, clinical outcomes related to infection, and long-term physical, mental health, and financial sequalae. We call upon additional epidemiology cohorts to join this collective effort to strengthen our impact on the current health crisis and generate a new model for a collaborative and nimble research infrastructure that will lead to more rapid translation of our work for the betterment of public health.
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Affiliation(s)
- Andrew T Chan
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David A Drew
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Long H Nguyen
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amit D Joshi
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wenjie Ma
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chuan-Guo Guo
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chun-Han Lo
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raaj S Mehta
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sohee Kwon
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel R Sikavi
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marina V Magicheva-Gupta
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zahra S Fatehi
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jacqueline J Flynn
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brianna M Leonardo
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christine M Albert
- Department of Cardiology, Cedars-Sinai Hospital, Los Angeles, California
| | - Gabriella Andreotti
- Division of Cancer Epidemiology & Genetics, Occupational and Environmental Epidemiology Branch, National Institutes of Health, National Cancer Institute, Bethesda, Maryland
| | - Laura E Beane-Freeman
- Division of Cancer Epidemiology & Genetics, Occupational and Environmental Epidemiology Branch, National Institutes of Health, National Cancer Institute, Bethesda, Maryland
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Houston, Texas
| | - John S Brownstein
- Computational Epidemiology Group, Boston Children's Hospital, Boston, Massachusetts
| | - Fiona Bruinsma
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Annie N Cowan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Jane C Figueiredo
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Hospital, Los Angeles, California
| | - Paul W Franks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Genetic and Molecular Epidemiology, Lund University, Malmo, Sweden
| | - Christopher D Gardner
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California
| | - Irene M Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christopher A Haiman
- Department of Preventive Medicine, Keck School of Medicine, Norris Comprehensive Cancer Center and the Epidemiology and Genetics Division, Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Janet E Hall
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | | | - Brenda Kirpach
- Hennepin Health Care Research Institute, Berman Center for Outcomes and Clinical Research, Minneapolis, Minnesota
| | - James V Lacey
- Division of Health Analytics, Department of Computational and Quantitative Medicine, City of Hope, Duarte, California
| | | | - Catherine R Marinac
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Maria Elena Martinez
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
- Moores Cancer Center, University of California, San Diego, La Jolla California
| | - Roger L Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Anne M Murray
- Hennepin Health Care Research Institute, Berman Center for Outcomes and Clinical Research, Minneapolis, Minnesota
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), New York, New York
- Department of Epidemiology and Biostatistics, School of Public Health, City University of New York (CUNY), New York, New York
| | - Julie R Palmer
- Slone Epidemiology Center, School of Medicine, Boston University, Boston, Massachusetts
| | | | - Lynn Rosenberg
- Slone Epidemiology Center, School of Medicine, Boston University, Boston, Massachusetts
| | - Dale P Sandler
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Houston, Texas
| | - Shepherd H Schurman
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | | | - Jorge E Chavarro
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - A Heather Eliassen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jaime E Hart
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jae Hee Kang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Laura D Kubzansky
- Department of Social and Behavioral Sciences and Lee Kum Sheung Center for Health and Happiness, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lorelei A Mucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sebastien Ourselin
- Department of Twin Research & Genetic Epidemiology, Kings College, London, United Kingdom
| | - Janet W Rich-Edwards
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mingyang Song
- Clinical & Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meir J Stampfer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Claire J Steves
- Department of Twin Research & Genetic Epidemiology, Kings College, London, United Kingdom
| | - Walter C Willett
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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8
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Nguyen LH, Drew DA, Joshi AD, Guo CG, Ma W, Mehta RS, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Graham MS, Sudre CH, Cardoso MJ, Wolf J, Ourselin S, Steves CJ, Spector TD, Chan AT. Risk of COVID-19 among frontline healthcare workers and the general community: a prospective cohort study. medRxiv 2020:2020.04.29.20084111. [PMID: 32511531 PMCID: PMC7273299 DOI: 10.1101/2020.04.29.20084111] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Data for frontline healthcare workers (HCWs) and risk of SARS-CoV-2 infection are limited and whether personal protective equipment (PPE) mitigates this risk is unknown. We evaluated risk for COVID-19 among frontline HCWs compared to the general community and the influence of PPE. Methods We performed a prospective cohort study of the general community, including frontline HCWs, who reported information through the COVID Symptom Study smartphone application beginning on March 24 (United Kingdom, U.K.) and March 29 (United States, U.S.) through April 23, 2020. We used Cox proportional hazards modeling to estimate multivariate-adjusted hazard ratios (aHRs) of a positive COVID-19 test. Findings Among 2,035,395 community individuals and 99,795 frontline HCWs, we documented 5,545 incident reports of a positive COVID-19 test over 34,435,272 person-days. Compared with the general community, frontline HCWs had an aHR of 11·6 (95% CI: 10·9 to 12·3) for reporting a positive test. The corresponding aHR was 3·40 (95% CI: 3·37 to 3·43) using an inverse probability weighted Cox model adjusting for the likelihood of receiving a test. A symptom-based classifier of predicted COVID-19 yielded similar risk estimates. Compared with HCWs reporting adequate PPE, the aHRs for reporting a positive test were 1·46 (95% CI: 1·21 to 1·76) for those reporting PPE reuse and 1·31 (95% CI: 1·10 to 1·56) for reporting inadequate PPE. Compared with HCWs reporting adequate PPE who did not care for COVID-19 patients, HCWs caring for patients with documented COVID-19 had aHRs for a positive test of 4·83 (95% CI: 3·99 to 5·85) if they had adequate PPE, 5·06 (95% CI: 3·90 to 6·57) for reused PPE, and 5·91 (95% CI: 4·53 to 7·71) for inadequate PPE. Interpretation Frontline HCWs had a significantly increased risk of COVID-19 infection, highest among HCWs who reused PPE or had inadequate access to PPE. However, adequate supplies of PPE did not completely mitigate high-risk exposures. Funding Zoe Global Ltd., Wellcome Trust, EPSRC, NIHR, UK Research and Innovation, Alzheimer's Society, NIH, NIOSH, Massachusetts Consortium on Pathogen Readiness.
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Affiliation(s)
- Long H. Nguyen
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David A. Drew
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
| | - Amit D. Joshi
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
| | - Chuan-Guo Guo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Wenjie Ma
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Raaj S. Mehta
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Daniel R. Sikavi
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Chun-Han Lo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sohee Kwon
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
| | - Mingyang Song
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Lorelei A. Mucci
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meir J. Stampfer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Walter C. Willett
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - A. Heather Eliassen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jaime E. Hart
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jorge E. Chavarro
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Janet W. Rich-Edwards
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School. Boston, MA, U.S.A
| | | | | | - Karla A. Lee
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, U.K
| | - Mary Ni Lochlainn
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, U.K
| | - Thomas Varsavsky
- School of Biomedical Engineering & Imaging Sciences, King’s College London. London, U.K
| | - Mark S. Graham
- School of Biomedical Engineering & Imaging Sciences, King’s College London. London, U.K
| | - Carole H. Sudre
- School of Biomedical Engineering & Imaging Sciences, King’s College London. London, U.K
| | - M. Jorge Cardoso
- School of Biomedical Engineering & Imaging Sciences, King’s College London. London, U.K
| | | | - Sebastien Ourselin
- School of Biomedical Engineering & Imaging Sciences, King’s College London. London, U.K
| | - Claire J. Steves
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, U.K
| | - Tim D. Spector
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, U.K
| | - Andrew T. Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School. Boston, MA, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health. Boston, MA, USA
- Broad Institute of MIT and Harvard. Cambridge, MA, USA
- Massachusetts Consortium on Pathogen Readiness, Cambridge, MA, USA
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