Undiagnosed comorbidities among individuals hospitalised with COVID-19 in South African public hospitals.

BACKGROUND: Previous studies have reported comorbid disease, including hypertension, diabetes mellitus, chronic cardiac and renal disease, malignancy, HIV, tuberculosis (TB) and obesity, to be associated with COVID­19 mortality. National demographic surveys have reported a high proportion of undiagnosed and untreated comorbid disease in South Africa (SA). OBJECTIVES: To determine the number of individuals with previously undiagnosed HIV, TB and non-communicable diseases (NCDs) among patients hospitalised with COVID­19, and the level of medical control of these chronic diseases. METHODS: We conducted a sentinel surveillance study to collect enhanced data on HIV, TB and NCDs among individuals with COVID­19 admitted to 16 secondary-level public hospitals in six of the nine provinces of SA. Trained surveillance officers approached all patients who met the surveillance case definition for inclusion in the study, and consenting patients were enrolled. The data collection instrument included questions on past medical history to determine the self-reported presence of comorbidities. The results of clinical and laboratory testing introduced as part of routine clinical care for hospitalised COVID­19 patients were collected for the study, to objectively determine the presence of hypertension, diabetes, HIV and TB and the levels of control of diabetes and HIV. RESULTS: On self-reported history, the most prevalent comorbidities were hypertension (n=1 658; 51.5%), diabetes (n=855; 26.6%) and HIV (n=603; 18.7%). The prevalence of self-reported active TB was 3.1%, and that of previous TB 5.5%. There were 1 254 patients admitted with COVID­19 (39.0%) who met the body mass index criteria for obesity. On clinical and laboratory testing, 87 patients were newly diagnosed with HIV, 29 with TB, 215 with diabetes and 40 with hypertension during their COVID­19 admission. There were 151/521 patients living with HIV (29.0%) with a viral load >1 000 copies/mL and 309/570 (54.2%) with a CD4 count <200 cells/µL. Among 901 patients classified as having diabetes, 777 (86.2%) had a glycated haemoglobin (HbA1c) level ≥6.5%. CONCLUSION: The study revealed a high prevalence of comorbid conditions among individuals with COVID­19 admitted to public hospitals in SA. In addition, a significant number of patients had previously undiagnosed hypertension, diabetes, HIV and active TB, and many and poorly controlled chronic disease, as evidenced by high HbA1c levels in patients with diabetes, and high viral loads and low CD4 levels in patients with HIV. The findings highlight the importance of strengthening health systems and care cascades for chronic disease management, which include prevention, screening for and effectively treating comorbidities, and ensuring secure and innovative supplies of medicines in primary healthcare during the COVID­19 pandemic.

Long COVID in South Africa: Persistent symptoms in patients hospitalized with SARS-CoV-2

Introduction/ Background: Despite a greater understanding of acute COVID-19 risk factors for severity and mortality, less is known about the long-term complications may arise after acute illness. Long COVID refers to a wide range of new, returning, or ongoing health problems experienced by COVID-19 survivors ≥4 weeks after initial infection with SARS-CoV-2. Methods: The aim of this study was to characterize physical and psychosocial sequelae in patients one month after hospital discharge, estimate the prevalence of and risk factors associated with Long COVID. In this prospective cohort study using the International Severe Acute Respiratory and emerging Infection Consortium multi-country protocol, patients ≥18 years who had been hospitalised with confirmed SARSCoV- 2 between December 2020 & August 2021 were interviewed at one month from hospital discharge with a standardised questionnaire for the evaluation of symptoms, health-related quality of life, functional and occupational status. Multivariable logistic regression models were used to determine factors associated with persistent outcomes. Results: In total, 2,410 previously hospitalised COVID-19 survivors were enrolled. Patients had a median age of 52 (IQR 41-61) and 1,280 (53.1%) were women. At onemonth follow-up, 1,978 (82.1%) patients reported one or more persistent symptom(s). The most common symptoms reported were fatigue (64.9%), shortness of breath (34.8%), headaches (20.0%), weakness in arms or legs (18.8%) and confusion or lack of concentration (16.0%). Factors associated with new or persistent symptoms following acute COVID-19 illness were white (aOR 1.48;95% CI [1.11-1.97]) and mixed race (1.90 [1.17-3.10]);ICU admission (2.53 [1.78- 3.62]);≥3 comorbidities (1.90 [1.18-3.03]);and ≥4 acute symptoms (5.25 [3.82-7.21]). Impact: Hospitalised patients with confirmed SARS-CoV-2 infection are at a significant risk for persistent COVIDrelated symptoms after 1 month from hospitalisation which may necessitate additional post discharge follow up that is not typically necessary following acute viral infections. This may have additional impacts on the individual and collective economic output. Conclusion: The majority of patients reported persistent symptoms at one month from hospital discharge and that there is a significant impact of Long COVID on functional and occupational status. Significant risk factors included white & mixed race;ICU admission;≥3 comorbidities and ≥4 acute COVID-19 symptoms.

Long-COVID: An evolving problem with an extensive impact

Persistence of symptoms or development of new symptoms relating to SARS-CoV-2 infection late in the course of COVID-19 is an increasingly recognised problem facing the globally infected population and its health systems. 'Long-COVID' or 'COVID long-haulers' generally describes those persons with COVID-19 who experience symptoms for >28 days after diagnosis, whether laboratory confirmed or clinical. Symptoms are as markedly heterogeneous as seen in acute COVID-19 and may be constant, fluctuate, or appear and be replaced by symptoms relating to other systems with varying frequency. Such multisystem involvement requires a holistic approach to management of long-COVID, and descriptions of cohorts from low- and middle-income countries are eagerly awaited. Although many persons with long-COVID will be managed in primary care, others will require greater input from rehabilitation medicine experts. For both eventualities, planning is urgently required to ensure that the South African public health service is ready and able to respond.