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1.
Eur J Epidemiol ; 36(6): 605-617, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1270521

ABSTRACT

Ethnic minorities have experienced disproportionate COVID-19 mortality rates in the UK and many other countries. We compared the differences in the risk of COVID-19 related death between ethnic groups in the first and second waves the of COVID-19 pandemic in England. We also investigated whether the factors explaining differences in COVID-19 death between ethnic groups changed between the two waves. Using data from the Office for National Statistics Public Health Data Asset, a linked dataset combining the 2011 Census with primary care and hospital records and death registrations, we conducted an observational cohort study to examine differences in the risk of death involving COVID-19 between ethnic groups in the first wave (from 24th January 2020 until 31st August 2020) and the first part of the second wave (from 1st September to 28th December 2020). We estimated age-standardised mortality rates (ASMR) in the two waves stratified by ethnic groups and sex. We also estimated hazard ratios (HRs) for ethnic-minority groups compared with the White British population, adjusted for geographical factors, socio-demographic characteristics, and pre-pandemic health conditions. The study population included over 28.9 million individuals aged 30-100 years living in private households. In the first wave, all ethnic minority groups had a higher risk of COVID-19 related death compared to the White British population. In the second wave, the risk of COVID-19 death remained elevated for people from Pakistani (ASMR: 339.9 [95% CI: 303.7-376.2] and 166.8 [141.7-191.9] deaths per 100,000 population in men and women) and Bangladeshi (318.7 [247.4-390.1] and 127.1 [91.1-171.3] in men and women) background but not for people from Black ethnic groups. Adjustment for geographical factors explained a large proportion of the differences in COVID-19 mortality in the first wave but not in the second wave. Despite an attenuation of the elevated risk of COVID-19 mortality after adjusting for sociodemographic characteristics and health status, the risk was substantially higher in people from Bangladeshi and Pakistani background in both the first and the second waves. Between the first and second waves of the pandemic, the reduction in the difference in COVID-19 mortality between people from Black ethnic background and people from the White British group shows that ethnic inequalities in COVID-19 mortality can be addressed. The continued higher rate of mortality in people from Bangladeshi and Pakistani background is alarming and requires focused public health campaign and policy changes.


Subject(s)
COVID-19/mortality , Minority Groups/statistics & numerical data , Adult , Aged , Aged, 80 and over , Cohort Studies , England/epidemiology , Female , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2
2.
Lancet Digit Health ; 3(7): e425-e433, 2021 07.
Article in English | MEDLINE | ID: covidwho-1246269

ABSTRACT

BACKGROUND: Public policy measures and clinical risk assessments relevant to COVID-19 need to be aided by risk prediction models that are rigorously developed and validated. We aimed to externally validate a risk prediction algorithm (QCovid) to estimate mortality outcomes from COVID-19 in adults in England. METHODS: We did a population-based cohort study using the UK Office for National Statistics Public Health Linked Data Asset, a cohort of individuals aged 19-100 years, based on the 2011 census and linked to Hospital Episode Statistics, the General Practice Extraction Service data for pandemic planning and research, and radiotherapy and systemic chemotherapy records. The primary outcome was time to COVID-19 death, defined as confirmed or suspected COVID-19 death as per death certification. Two periods were used: (1) Jan 24 to April 30, 2020, and (2) May 1 to July 28, 2020. We assessed the performance of the QCovid algorithms using measures of discrimination and calibration. Using predicted 90-day risk of COVID-19 death, we calculated r2 values, Brier scores, and measures of discrimination and calibration with corresponding 95% CIs over the two time periods. FINDINGS: We included 34 897 648 adults aged 19-100 years resident in England. 26 985 (0·08%) COVID-19 deaths occurred during the first period and 13 177 (0·04%) during the second. The algorithms had good discrimination and calibration in both periods. In the first period, they explained 77·1% (95% CI 76·9-77·4) of the variation in time to death in men and 76·3% (76·0-76·6) in women. The D statistic was 3·761 (3·732-3·789) for men and 3·671 (3·640-3·702) for women and Harrell's C was 0·935 (0·933-0·937) for men and 0·945 (0·943-0·947) for women. Similar results were obtained for the second time period. In the top 5% of patients with the highest predicted risks of death, the sensitivity for identifying deaths in the first period was 65·94% for men and 71·67% for women. INTERPRETATION: The QCovid population-based risk algorithm performed well, showing high levels of discrimination for COVID-19 deaths in men and women for both time periods. QCovid has the potential to be dynamically updated as the pandemic evolves and, therefore, has potential use in guiding national policy. FUNDING: UK National Institute for Health Research.


Subject(s)
Algorithms , COVID-19/mortality , Risk Assessment/statistics & numerical data , Adult , Aged , Aged, 80 and over , Cohort Studies , Databases, Factual , England/epidemiology , Female , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2 , Young Adult
3.
BMJ ; 372: n693, 2021 03 31.
Article in English | MEDLINE | ID: covidwho-1166413

ABSTRACT

OBJECTIVE: To quantify rates of organ specific dysfunction in individuals with covid-19 after discharge from hospital compared with a matched control group from the general population. DESIGN: Retrospective cohort study. SETTING: NHS hospitals in England. PARTICIPANTS: 47 780 individuals (mean age 65, 55% men) in hospital with covid-19 and discharged alive by 31 August 2020, exactly matched to controls from a pool of about 50 million people in England for personal and clinical characteristics from 10 years of electronic health records. MAIN OUTCOME MEASURES: Rates of hospital readmission (or any admission for controls), all cause mortality, and diagnoses of respiratory, cardiovascular, metabolic, kidney, and liver diseases until 30 September 2020. Variations in rate ratios by age, sex, and ethnicity. RESULTS: Over a mean follow-up of 140 days, nearly a third of individuals who were discharged from hospital after acute covid-19 were readmitted (14 060 of 47 780) and more than 1 in 10 (5875) died after discharge, with these events occurring at rates four and eight times greater, respectively, than in the matched control group. Rates of respiratory disease (P<0.001), diabetes (P<0.001), and cardiovascular disease (P<0.001) were also significantly raised in patients with covid-19, with 770 (95% confidence interval 758 to 783), 127 (122 to 132), and 126 (121 to 131) diagnoses per 1000 person years, respectively. Rate ratios were greater for individuals aged less than 70 than for those aged 70 or older, and in ethnic minority groups compared with the white population, with the largest differences seen for respiratory disease (10.5 (95% confidence interval 9.7 to 11.4) for age less than 70 years v 4.6 (4.3 to 4.8) for age ≥70, and 11.4 (9.8 to 13.3) for non-white v 5.2 (5.0 to 5.5) for white individuals). CONCLUSIONS: Individuals discharged from hospital after covid-19 had increased rates of multiorgan dysfunction compared with the expected risk in the general population. The increase in risk was not confined to the elderly and was not uniform across ethnicities. The diagnosis, treatment, and prevention of post-covid syndrome requires integrated rather than organ or disease specific approaches, and urgent research is needed to establish the risk factors.


Subject(s)
COVID-19/complications , Hospitalization/statistics & numerical data , Multiple Organ Failure/epidemiology , Patient Readmission/statistics & numerical data , Adult , Aged , COVID-19/diagnosis , COVID-19/mortality , COVID-19/virology , Cardiovascular Diseases/epidemiology , Case-Control Studies , Diabetes Mellitus/epidemiology , England/epidemiology , Female , Humans , Male , Middle Aged , Patient Discharge/statistics & numerical data , Respiratory Tract Diseases/epidemiology , Retrospective Studies , Risk Factors , SARS-CoV-2/genetics , SARS-CoV-2/isolation & purification
4.
Eur J Prev Cardiol ; 2021 Feb 21.
Article in English | MEDLINE | ID: covidwho-1091243

ABSTRACT

AIMS: Cardiovascular diseases (CVDs) increase mortality risk from coronavirus infection (COVID-19). There are also concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both 'direct', through infection, and 'indirect', through changes in healthcare. METHODS AND RESULTS: We used (i) national mortality data for England and Wales to investigate trends in non-COVID-19 and CVD excess deaths; (ii) routine data from hospitals in England (n = 2), Italy (n = 1), and China (n = 5) to assess indirect pandemic effects on referral, diagnosis, and treatment services for CVD; and (iii) population-based electronic health records from 3 862 012 individuals in England to investigate pre- and post-COVID-19 mortality for people with incident and prevalent CVD. We incorporated pre-COVID-19 risk (by age, sex, and comorbidities), estimated population COVID-19 prevalence, and estimated relative risk (RR) of mortality in those with CVD and COVID-19 compared with CVD and non-infected (RR: 1.2, 1.5, 2.0, and 3.0).Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous (peak RR 1.14). CVD service activity decreased by 60-100% compared with pre-pandemic levels in eight hospitals across China, Italy, and England. In China, activity remained below pre-COVID-19 levels for 2-3 months even after easing lockdown and is still reduced in Italy and England. For total CVD (incident and prevalent), at 10% COVID-19 prevalence, we estimated direct impact of 31 205 and 62 410 excess deaths in England (RR 1.5 and 2.0, respectively), and indirect effect of 49 932 to 99 865 deaths. CONCLUSION: Supply and demand for CVD services have dramatically reduced across countries with potential for substantial, but avoidable, excess mortality during and after the pandemic.

6.
Int J Epidemiol ; 49(6): 1951-1962, 2021 01 23.
Article in English | MEDLINE | ID: covidwho-990692

ABSTRACT

BACKGROUND: We estimated population-level associations between ethnicity and coronavirus disease 2019 (COVID-19) mortality using a newly linked census-based data set and investigated how ethnicity-specific mortality risk evolved during the pandemic. METHODS: We conducted a retrospective cohort study of respondents to the 2011 Census of England and Wales in private households, linked to death registrations and adjusted for emigration (n = 47 872 412). The outcome of interest was death involving COVID-19 between 2 March 2020 and 15 May 2020. We estimated hazard ratios (HRs) for ethnic-minority groups compared with the White population, controlling for individual, household and area characteristics. HRs were estimated on the full outcome period and separately for pre- and post-lockdown periods. RESULTS: In age-adjusted models, people from all ethnic-minority groups were at elevated risk of COVID-19 mortality; the HRs for Black males and females were 3.13 (95% confidence interval: 2.93 to 3.34) and 2.40 (2.20 to 2.61), respectively. However, in fully adjusted models for females, the HRs were close to unity for all ethnic groups except Black [1.29 (1.18 to 1.42)]. For males, the mortality risk remained elevated for the Black [1.76 (1.63 to 1.90)], Bangladeshi/Pakistani [1.35 (1.21 to 1.49)] and Indian [1.30 (1.19 to 1.43)] groups. The HRs decreased after lockdown for all ethnic groups, particularly Black and Bangladeshi/Pakistani females. CONCLUSION: Differences in COVID-19 mortality between ethnic groups were largely attenuated by geographical and socio-demographic factors, though some residual differences remained. Lockdown was associated with reductions in excess mortality risk in ethnic-minority populations, which has implications for a second wave of infection.


Subject(s)
COVID-19/ethnology , COVID-19/mortality , Censuses , Death Certificates , Mortality/ethnology , SARS-CoV-2/isolation & purification , Social Determinants of Health , Adolescent , Adult , African Americans , Age Factors , COVID-19/diagnosis , Cohort Studies , England/epidemiology , Family Characteristics , Female , Humans , Male , Middle Aged , Pandemics , Residence Characteristics/classification , Residence Characteristics/statistics & numerical data , Retrospective Studies , Sex Factors , Socioeconomic Factors , Wales/epidemiology , Young Adult
7.
BMJ Open ; 10(11): e043828, 2020 11 17.
Article in English | MEDLINE | ID: covidwho-934100

ABSTRACT

OBJECTIVES: To estimate the impact of the COVID-19 pandemic on cancer care services and overall (direct and indirect) excess deaths in people with cancer. METHODS: We employed near real-time weekly data on cancer care to determine the adverse effect of the pandemic on cancer services. We also used these data, together with national death registrations until June 2020 to model deaths, in excess of background (pre-COVID-19) mortality, in people with cancer. Background mortality risks for 24 cancers with and without COVID-19-relevant comorbidities were obtained from population-based primary care cohort (Clinical Practice Research Datalink) on 3 862 012 adults in England. RESULTS: Declines in urgent referrals (median=-70.4%) and chemotherapy attendances (median=-41.5%) to a nadir (lowest point) in the pandemic were observed. By 31 May, these declines have only partially recovered; urgent referrals (median=-44.5%) and chemotherapy attendances (median=-31.2%). There were short-term excess death registrations for cancer (without COVID-19), with peak relative risk (RR) of 1.17 at week ending on 3 April. The peak RR for all-cause deaths was 2.1 from week ending on 17 April. Based on these findings and recent literature, we modelled 40% and 80% of cancer patients being affected by the pandemic in the long-term. At 40% affected, we estimated 1-year total (direct and indirect) excess deaths in people with cancer as between 7165 and 17 910, using RRs of 1.2 and 1.5, respectively, where 78% of excess deaths occured in patients with ≥1 comorbidity. CONCLUSIONS: Dramatic reductions were detected in the demand for, and supply of, cancer services which have not fully recovered with lockdown easing. These may contribute, over a 1-year time horizon, to substantial excess mortality among people with cancer and multimorbidity. It is urgent to understand how the recovery of general practitioner, oncology and other hospital services might best mitigate these long-term excess mortality risks.


Subject(s)
COVID-19/epidemiology , Models, Statistical , Neoplasms/epidemiology , Pandemics , Population Surveillance , SARS-CoV-2 , Adult , Cause of Death/trends , England/epidemiology , Female , Follow-Up Studies , Humans , Male , Middle Aged , Multimorbidity/trends , Survival Rate/trends , Time Factors
8.
Heart ; 107(2): 113-119, 2021 01.
Article in English | MEDLINE | ID: covidwho-808650

ABSTRACT

OBJECTIVE: To describe the place and causes of acute cardiovascular death during the COVID-19 pandemic. METHODS: Retrospective cohort of adult (age ≥18 years) acute cardiovascular deaths (n=5 87 225) in England and Wales, from 1 January 2014 to 30 June 2020. The exposure was the COVID-19 pandemic (from onset of the first COVID-19 death in England, 2 March 2020). The main outcome was acute cardiovascular events directly contributing to death. RESULTS: After 2 March 2020, there were 28 969 acute cardiovascular deaths of which 5.1% related to COVID-19, and an excess acute cardiovascular mortality of 2085 (+8%). Deaths in the community accounted for nearly half of all deaths during this period. Death at home had the greatest excess acute cardiovascular deaths (2279, +35%), followed by deaths at care homes and hospices (1095, +32%) and in hospital (50, +0%). The most frequent cause of acute cardiovascular death during this period was stroke (10 318, 35.6%), followed by acute coronary syndrome (ACS) (7 098, 24.5%), heart failure (6 770, 23.4%), pulmonary embolism (2 689, 9.3%) and cardiac arrest (1 328, 4.6%). The greatest cause of excess cardiovascular death in care homes and hospices was stroke (715, +39%), compared with ACS (768, +41%) at home and cardiogenic shock (55, +15%) in hospital. CONCLUSIONS AND RELEVANCE: The COVID-19 pandemic has resulted in an inflation in acute cardiovascular deaths, nearly half of which occurred in the community and most did not relate to COVID-19 infection suggesting there were delays to seeking help or likely the result of undiagnosed COVID-19.


Subject(s)
Acute Coronary Syndrome , COVID-19 , Cause of Death , Mortality/trends , Stroke , Acute Coronary Syndrome/etiology , Acute Coronary Syndrome/mortality , Adult , Aged , Aged, 80 and over , COVID-19/diagnosis , COVID-19/epidemiology , Causality , England/epidemiology , Female , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Outcome and Process Assessment, Health Care , Residence Characteristics/statistics & numerical data , Retrospective Studies , SARS-CoV-2/isolation & purification , Stroke/etiology , Stroke/mortality
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