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2.
Ann Am Thorac Soc ; 2022 Jun 22.
Article in English | MEDLINE | ID: covidwho-1902679

ABSTRACT

RATIONALE: There are limited data on the impact of the COVID-19 pandemic on intensive care unit (ICU) recovery clinic care delivery practices. OBJECTIVES: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. METHODS: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semi-structured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. RESULTS: Twenty-nine participants from fifteen international sites participated in the study. Participants identified three patient-level key themes which influenced care delivery in ICU recovery programs: 1) social isolation; 2) decreased emotional reserve in patients and families; and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both clinician-level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and practice-level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. CONCLUSION: Our study demonstrated that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery which highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.

3.
Br J Anaesth ; 128(6): 980-989, 2022 06.
Article in English | MEDLINE | ID: covidwho-1828009

ABSTRACT

BACKGROUND: Patients with COVID-19 can require critical care for prolonged periods. Patients with persistent critical Illness can have complex recovery trajectories, but this has not been studied for patients with COVID-19. We examined the prevalence, risk factors, and long-term outcomes of critically ill patients with COVID-19 and persistent critical illness. METHODS: This was a national cohort study of all adults admitted to Scottish critical care units with COVID-19 from March 1, 2020 to September 4, 20. Persistent critical illness was defined as a critical care length of stay (LOS) of ≥10 days. Outcomes included 1-yr mortality and hospital readmission after critical care discharge. Fine and Gray competing risk analysis was used to identify factors associated with persistent critical Illness with death as a competing risk. RESULTS: A total of 2236 patients with COVID-19 were admitted to critical care; 1045 patients were identified as developing persistent critical Illness, comprising 46.7% of the cohort but using 80.6% of bed-days. Patients with persistent critical illness used more organ support, had longer post-critical care LOS, and longer total hospital LOS. Persistent critical illness was not significantly associated with long-term mortality or hospital readmission. Risk factors associated with increased hazard of persistent critical illness included age, illness severity, organ support on admission, and fewer comorbidities. CONCLUSIONS: Almost half of all patients with COVID-19 admitted to critical care developed persistent critical illness, with high resource use in critical care and beyond. However, persistent critical illness was not associated with significantly worse long-term outcomes compared with patients who were critically ill for shorter periods.


Subject(s)
COVID-19 , Critical Illness , Adult , COVID-19/epidemiology , Cohort Studies , Critical Illness/epidemiology , Hospital Mortality , Humans , Intensive Care Units , Length of Stay , Prevalence , Retrospective Studies
4.
PLoS One ; 17(3): e0264971, 2022.
Article in English | MEDLINE | ID: covidwho-1742014

ABSTRACT

BACKGROUND: Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents. MATERIALS AND METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken. RESULTS: Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye. CONCLUSION: This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503).


Subject(s)
Bereavement , Grief , Family , Humans , Intensive Care Units , Risk Factors
5.
BJA: The British Journal of Anaesthesia ; 128(3):e253-e254, 2022.
Article in English | Academic Search Complete | ID: covidwho-1705601
6.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-315782

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) can lead to significant respiratory failure with between 14% and 18% of hospitalised patients requiring critical care admission. This study describes the impact of socioeconomic deprivation on 30-day survival following critical care admission for COVID-19, and the impact of the COVID-19 pandemic on critical care capacity in Scotland.Methods: This cohort study used linked national hospital records including ICU, virology testing and national death records to identify and describe patients with COVID-19 admitted to a critical care unit in Scotland. Multivariable logistic regression was used to assess the impact of deprivation on 30-day mortality. Critical care capacity was described by reporting the percentage of baseline ICU bed utilisation required.Results: There were 735 patients with COVID-19 admitted to critical care units across Scotland from 1/3/2020 to 20/6/2020. There was a higher proportion of patients from more deprived areas, with 183 admissions (24.9%) from the most deprived quintile and 100 (13.6%) from the least deprived quintile. 30-day mortality was 34.8%. After adjusting for age, sex and ethnicity, mortality was significantly higher in patients from the most deprived quintile (OR 1.97, 95%CI 1.13, 3.41, p=0.016). ICUs serving populations with higher levels of deprivation spent a greater amount of time over their baseline ICU bed capacity.Conclusion: Patients with COVID-19 living in areas with greater socioeconomic deprivation had a higher frequency of critical care admission and a higher adjusted 30-day mortality. ICUs in health boards with higher levels of socioeconomic deprivation had both higher peak occupancy and longer duration of occupancy over normal maximum capacity.Funding Statement: None.Declaration of Interests: All authors declare: no support from any organisation for the submitted work;no financial relationships with any organisations that might have an interest in the submitted work in the previous three years;NL is Director of Research, Intensive Care Society;JM is funded by a THIS.Institute (University of Cambridge) Research Fellowship (PD-2019-02-16). Ethics Approval Statement: The Scottish Intensive Care Society Audit Group in Public Health Scotland has a legislative remit to process personal data in relation to public health. Linkage to additional datasets was approved following scrutiny by the Public Benefit and Privacy Panel for Health and Social Care (ref 1920-0093). Access and use of the data for the purpose of this work were approved following a Public Health Scotland information governance review of linking additional internal datasets to identify patients with COVID-19. Only analysts working in Public Health Scotland had access to the linked patient data which could only be accessed via an NHS secure network.

7.
BMJ Open Respir Res ; 8(1)2021 12.
Article in English | MEDLINE | ID: covidwho-1566370

ABSTRACT

BACKGROUND: There are limited data describing the long-term outcomes of severe COVID-19. We aimed to evaluate the long-term psychosocial and physical consequences of severe COVID-19 for patients. METHODS: We conducted a multicentre observational cohort study; between 3 and 7 months posthospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. Standardised questionnaires concerning emotional, physical and social recovery, including information on employment, were completed by patients. Using propensity score matching, we explored outcomes between patients admitted to critical care with and without COVID-19, using data from the same recovery programme. RESULTS: Between July 2020 and December 2020, 93 patients who had been admitted to critical with COVID-19 participated. Emotional dysfunction was common: 46.2% of patients had symptoms of anxiety and 34.4% symptoms of depression. At follow-up 53.7% of previously employed patients had returned to employment; there was a significant difference in return to employment across the socio-economic gradient, with lower numbers of patients from the most deprived areas returning to employment (p=0.03). 91 (97.8%) COVID-19 patients were matched with 91 non-COVID-19 patients. There were no significant differences in any measured outcomes between the two cohorts. INTERPRETATION: Emotional and social problems are common in survivors of severe COVID-19 infection. Coordinated rehabilitation is required to ensure patients make an optimal recovery.


Subject(s)
COVID-19 , Anxiety/epidemiology , Anxiety/etiology , Cohort Studies , Humans , SARS-CoV-2 , Surveys and Questionnaires
8.
BMJ Open Respir Res ; 8(1)2021 12.
Article in English | MEDLINE | ID: covidwho-1555746

ABSTRACT

BACKGROUND: Critically ill patients often experience several transitions of care following critical illness. Research has explored the challenges which patients have with medication management across these transitions. It is unclear whether patients admitted to critical care due to COVID-19 will have similar challenges. The aim of this study was to explore medication management in critical care survivors following severe COVID-19. METHODS: Between 3 and 7 months post hospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. During the clinic consultation a medication review was performed by a pharmacist. This included medicines reconciliation, assessing the appropriateness of each of the prescribed medications and identification of medication changes. We also assessed changes to pain management in the discharge period. RESULTS: In total, 78 patients had a full medication review available. Over 70% of patients were taking an increased dose of medicine or a new medicine at clinic. There was a significant overall increase in new medication during the clinic consultation, across different British National Formulary classifications (OR: 1.73 (95% CI: 1.28 to 2.34), p<0.001). Compared with pre critical care admission, there was a significant increase in the number of patients taking regular analgesia following severe COVID-19 infection (23 (29.5%) vs 39 (50%), p<0.001). CONCLUSION: Following severe COVID-19, patients may require new or increasing doses of medicines. Ongoing review of these patients is crucial to ensure optimal outcomes.


Subject(s)
COVID-19 , Critical Care , Humans , Pharmacists , SARS-CoV-2
10.
Lancet Respir Med ; 9(11): 1328-1341, 2021 11.
Article in English | MEDLINE | ID: covidwho-1537208

ABSTRACT

As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.


Subject(s)
COVID-19/complications , COVID-19/therapy , Disease Progression , Fatigue , Humans , Survivors
11.
BMJ Open ; 11(10): e052214, 2021 Oct 04.
Article in English | MEDLINE | ID: covidwho-1450607

ABSTRACT

OBJECTIVE: To comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK. DESIGN: Cross-sectional, self-administered, predominantly closed-question, electronic, online survey. SETTING: Institutions providing adult critical care services identified from national databases. PARTICIPANTS: Multiprofessional critical care clinicians delivering services at each site. RESULTS: Responses from 176 UK hospital sites were included (176/242, 72.7%). Inpatient recovery and follow-up services were present at 127/176 (72.2%) sites, adopting multiple formats of delivery and primarily delivered by nurses (n=115/127, 90.6%). Outpatient services ran at 130 sites (73.9%), predominantly as outpatient clinics. Most services (n=108/130, 83.1%) were co-delivered by two or more healthcare professionals, typically nurse/intensive care unit (ICU) physician (n=29/130, 22.3%) or nurse/ICU physician/physiotherapist (n=19/130, 14.6%) teams. Clinical psychology was most frequently lacking from inpatient or outpatient services. Lack of funding was consistently the primary barrier to service provision, with other barriers including logistical and service prioritisation factors indicating that infrastructure and profile for services remain inadequate. Posthospital discharge physical rehabilitation programmes were relatively few (n=31/176, 17.6%), but peer support services were available in nearly half of responding institutions (n=85/176, 48.3%). The effects of the COVID-19 pandemic resulted in either increasing, decreasing or reformatting service provision. Future plans for long-term service transformation focus on expansion of current, and establishment of new, outpatient services. CONCLUSION: Overall, these data demonstrate a proliferation of recovery, follow-up and rehabilitation services for critically ill adults in the past decade across the UK, although service gaps remain suggesting further work is required for guideline implementation. Findings can be used to enhance survivorship for critically ill adults, inform policymakers and commissioners, and provide comparative data and experiential insights for clinicians designing models of care in international healthcare jurisdictions.


Subject(s)
COVID-19 , Critical Illness , Cross-Sectional Studies , Follow-Up Studies , Humans , Pandemics , Research Report , SARS-CoV-2 , United Kingdom
12.
Lancet Reg Health Eur ; 8: 100186, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1397545

ABSTRACT

BACKGROUND: This study sought to establish the long-term effects of Covid-19 following hospitalisation. METHODS: 327 hospitalised participants, with SARS-CoV-2 infection were recruited into a prospective multicentre cohort study at least 3 months post-discharge. The primary outcome was self-reported recovery at least ninety days after initial Covid-19 symptom onset. Secondary outcomes included new symptoms, disability (Washington group short scale), breathlessness (MRC Dyspnoea scale) and quality of life (EQ5D-5L). FINDINGS: 55% of participants reported not feeling fully recovered. 93% reported persistent symptoms, with fatigue the most common (83%), followed by breathlessness (54%). 47% reported an increase in MRC dyspnoea scale of at least one grade. New or worse disability was reported by 24% of participants. The EQ5D-5L summary index was significantly worse following acute illness (median difference 0.1 points on a scale of 0 to 1, IQR: -0.2 to 0.0). Females under the age of 50 years were five times less likely to report feeling recovered (adjusted OR 5.09, 95% CI 1.64 to 15.74), were more likely to have greater disability (adjusted OR 4.22, 95% CI 1.12 to 15.94), twice as likely to report worse fatigue (adjusted OR 2.06, 95% CI 0.81 to 3.31) and seven times more likely to become more breathless (adjusted OR 7.15, 95% CI 2.24 to 22.83) than men of the same age. INTERPRETATION: Survivors of Covid-19 experienced long-term symptoms, new disability, increased breathlessness, and reduced quality of life. These findings were present in young, previously healthy working age adults, and were most common in younger females. FUNDING: National Institute for Health Research, UK Medical Research Council, Wellcome Trust, Department for International Development and the Bill and Melinda Gates Foundation.

13.
Curr Opin Crit Care ; 27(5): 506-512, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1315715

ABSTRACT

PURPOSE OF REVIEW: Intensive care unit (ICU) survivorship has gained significant attention over the course of the COVID-19 pandemic. In this review, we summarize the contemporary literature in relation to the epidemiology and management of post-ICU problems. RECENT FINDINGS: Survivors of critical illness can have complex physical, social, emotional and cognitive needs in the months following hospital discharge. Emerging evidence has shown that pre-ICU characteristics such as educational attainment, alongside in-ICU factors such as delirium, may contribute to worsening outcomes. Evidence regarding the impact of post-ICU recovery services is evolving, but models such as post-ICU clinics and peer support programs are gaining rapid momentum. SUMMARY: Future research should focus on modifiable risk factors and how identification and treatment of these can improve outcomes. Furthermore, rigorous evaluation of postacute critical care recovery services is necessary.


Subject(s)
COVID-19 , Critical Illness , Humans , Intensive Care Units , Pandemics , SARS-CoV-2
14.
Lancet Reg Health Eur ; 6: 100121, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1271708

ABSTRACT

BACKGROUND: : This study aimed to understand the impact of a critical care admission on long-term outcomes, compared to other hospitalised patients without a critical care encounter. A secondary aim was to examine the interrelationship between emotional, physical, and social problems during recovery. METHODS: : We utilised data from the UK Biobank, an on-going, prospective population-based cohort study. We employed propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital (first admission to hospital available) without critical care. Structural equation modelling was used to analyse emotional, physical and social outcomes following critical illness and the relationships between these health domains. FINDINGS: : Data from 1,618 patients were analysed. The median time to follow-up in the critical care cohort was 4427 days (IQR:788-6146) vs 4516 days (IQR: 811-6369) in the non-critical care, hospitalised cohort. Across the two time periods assessed (pre and post 2000), patients exposed to critical care were more likely to experience mental health issues such as depression (p < 0.01) and social isolation (p = 0.01) following discharge from hospital. The critical care cohort were also more likely to have social problems such as the requirement for government funded welfare support (p = 0.02). In the critical care cohort, social and emotional health were closely correlated (p < 0.001, 95% CI:0.33-0.54). The nature of physical problems changed over time; pre-2000 there was a significant difference between the critical and non-critical care in physical outcomes following discharge from hospital, however, there was no difference detected between the two cohorts post-2000. INTERPRETATION: This cohort study has demonstrated that survivors of critical illness have different psycho-social outcomes to matched patients, hospitalised without a critical care encounter. FUNDING: JM is funded by a THIS.Institute (University of Cambridge) Research Fellowship (PD-2019-02-16). AHL is part of the Social and Public Health Sciences Unit, funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).

15.
Lancet Reg Health Eur ; 1: 100005, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1265776

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to significant respiratory failure with between 14% and 18% of hospitalised patients requiring critical care admission. This study describes the impact of socioeconomic deprivation on 30-day survival following critical care admission for COVID-19, and the impact of the COVID-19 pandemic on critical care capacity in Scotland. METHODS: This cohort study used linked national hospital records including ICU, virology testing and national death records to identify and describe patients with COVID-19 admitted to critical care units in Scotland. Multivariable logistic regression was used to assess the impact of deprivation on 30-day mortality. Critical care capacity was described by reporting the percentage of baseline ICU bed utilisation required. FINDINGS: There were 735 patients with COVID-19 admitted to critical care units across Scotland from 1/3/2020 to 20/6/2020. There was a higher proportion of patients from more deprived areas, with 183 admissions (24.9%) from the most deprived quintile and 100 (13.6%) from the least deprived quintile. Overall, 30-day mortality was 34.8%. After adjusting for age, sex and ethnicity, mortality was significantly higher in patients from the most deprived quintile (OR 1.97, 95%CI 1.13, 3.41, p=0.016). ICUs serving populations with higher levels of deprivation spent a greater amount of time over their baseline ICU bed capacity. INTERPRETATION: Patients with COVID-19 living in areas with greatest socioeconomic deprivation had a higher frequency of critical care admission and a higher adjusted 30-day mortality. ICUs in health boards with higher levels of socioeconomic deprivation had both higher peak occupancy and longer duration of occupancy over normal maximum capacity. FUNDING: None.

17.
BMJ Open ; 11(3): e043887, 2021 03 10.
Article in English | MEDLINE | ID: covidwho-1127585

ABSTRACT

INTRODUCTION: Very little is known about possible clinical sequelae that may persist after resolution of acute COVID-19. A recent longitudinal cohort from Italy including 143 patients followed up after hospitalisation with COVID-19 reported that 87% had at least one ongoing symptom at 60-day follow-up. Early indications suggest that patients with COVID-19 may need even more psychological support than typical intensive care unit patients. The assessment of risk factors for longer term consequences requires a longitudinal study linked to data on pre-existing conditions and care received during the acute phase of illness. The primary aim of this study is to characterise physical and psychosocial sequelae in patients post-COVID-19 hospital discharge. METHODS AND ANALYSIS: This is an international open-access prospective, observational multisite study. This protocol is linked with the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) and the WHO's Clinical Characterisation Protocol, which includes patients with suspected or confirmed COVID-19 during hospitalisation. This protocol will follow-up a subset of patients with confirmed COVID-19 using standardised surveys to measure longer term physical and psychosocial sequelae. The data will be linked with the acute phase data. Statistical analyses will be undertaken to characterise groups most likely to be affected by sequelae of COVID-19. The open-access follow-up survey can be used as a data collection tool by other follow-up studies, to facilitate data harmonisation and to identify subsets of patients for further in-depth follow-up. The outcomes of this study will inform strategies to prevent long-term consequences; inform clinical management, interventional studies, rehabilitation and public health management to reduce overall morbidity; and improve long-term outcomes of COVID-19. ETHICS AND DISSEMINATION: The protocol and survey are open access to enable low-resourced sites to join the study to facilitate global standardised, longitudinal data collection. Ethical approval has been given by sites in Colombia, Ghana, Italy, Norway, Russia, the UK and South Africa. New sites are welcome to join this collaborative study at any time. Sites interested in adopting the protocol as it is or in an adapted version are responsible for ensuring that local sponsorship and ethical approvals in place as appropriate. The tools are available on the ISARIC website (www.isaric.org). PROTOCOL REGISTRATION NUMBER: osf.io/c5rw3/ PROTOCOL VERSION: 3 August 2020 EUROQOL ID: 37035.


Subject(s)
COVID-19/diagnosis , COVID-19/psychology , Colombia , Ghana , Humans , Italy , Longitudinal Studies , Norway , Prospective Studies , Risk Factors , Russia , South Africa , United Kingdom
18.
Int Emerg Nurs ; 56: 100984, 2021 05.
Article in English | MEDLINE | ID: covidwho-1091827

ABSTRACT

INTRODUCTION: Emergency departments have seen altered patterns of attendance since the beginning of the COVID-19 pandemic, with reductions in the number of attendances for non-COVID-19 - patients. We assessed the use of the emergency department by frequent attenders during the height of the COVID-19 pandemic and explored any changes in emergency department attendance by this group. METHODS: As part of ongoing improvement work, we utilised a cohort design to evaluate the difference in patterns of attendance for the frequent attender group in a single centre. We created a 2019 'top attender' cohort and a similar cohort for 2020. We compared admission patterns between the two time periods in order to understand the impact of the COVID-19 pandemic on this group. RESULTS: Both groups were predominately male. Mental health and substance misuse use problems were common across both cohorts. The majority of patients lived in a socio-economically deprived areas. The median number emergency department visits in 2019, for the top attender cohort was 6 (IQR: 4-9) vs 4 (IQR: 2-7) for the top attender cohort of 2020 (p < .0013). CONCLUSION: This single centre evaluation has shown a significant reduction in emergency department attendances for a frequent attender cohort in a single centre. Future work should investigate the longer-term impact which the COVID-19 pandemic has had on this patient group.


Subject(s)
COVID-19/epidemiology , Emergency Service, Hospital/statistics & numerical data , Health Services Misuse/statistics & numerical data , Adult , Female , Humans , Male , Mental Disorders/therapy , Middle Aged , Pandemics , SARS-CoV-2 , Substance-Related Disorders/therapy , Vulnerable Populations
20.
Lancet Respir Med ; 9(3): e24, 2021 03.
Article in English | MEDLINE | ID: covidwho-1069058

Subject(s)
COVID-19 , Humans , SARS-CoV-2
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