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1.
MEDICC Rev ; 23(1): 18-20, 2021 Jan.
Article | MEDLINE | ID: covidwho-1184136

ABSTRACT

On March 23, 2020, Cuba's Henry Reeve Emergency Medical Contingent began treating COVID-19 patients at Maggiore Hospital in Crema, Lombardy. Within days, the 52-member contingent comprised of 36 doctors and 15 nurses (plus 1 logistics specialist), together with Italian colleagues, were receiving patients in an adjacent fi eld hospital established and equipped for this purpose. At the time, Lombardy was the epicenter of COVID-19 transmission in Europe. Many of the Cubans in Lombardy were Contingent veterans, having served in postdisaster and epidemic scenarios in Chile, Pakistan, Haiti and elsewhere since the founding of the emergency medical team in 2005. Importantly, some had worked fi ghting the 2014 Ebola epidemic in West Africa. Even so, providing medical care during COVID-19 is a unique challenge, the likes of which had never before been seen by the Cuban team. Dr Carlos R. Pérez-Díaz, one of the Contingent's founding members, headed the team during its 60-day rotation in Lombardy, drawing on a wide array of professional experience. From 2006 to 2009, Dr Pérez-Díaz led the Cuban team posted at the Peltier Hospital in Djibouti, where he worked in the infectious disease department; in 2008, this team helped control a cholera outbreak that had spread to three countries. Following the 2010 earthquake in Chile, Dr Pérez-Díaz headed the team of Henry Reeve volunteers that provided free health services for 10 months in a tent hospital established to treat victims; he returned to Chile in 2015, again as head of the Henry Reeve Contingent, after severe fl ooding struck the Atacama region.


Subject(s)
/therapy , Medical Missions , Pneumonia, Viral/therapy , /epidemiology , Cuba , Female , Humans , Italy/epidemiology , Male , Pandemics , Pneumonia, Viral/epidemiology
2.
Arch Argent Pediatr ; 119(2): 76-82, 2021 04.
Article in English, Spanish | MEDLINE | ID: covidwho-1183983

ABSTRACT

INTRODUCTION: The objective of this study was to analyze available resources, guidelines in use, and preparedness to care for newborn infants at maternity centers in Argentina during the COVID-19 pandemic. METHOD: Cross-sectional study based on a survey administered to medical and nursing staff. In May 2020, Argentine facilities with more than 500 annual births were contacted; 58 % of these were from the public sector. RESULTS: In total, 104/147 facilities answered (71 %). All had guidelines for care during the pandemic, and 93 % indicated they had been trained on how to use them. A companion was not allowed during childbirth in 26 % of private facilities and in 60 % of public ones (p < 0.01). Deferred cord clamping was recommended in 87 %; rooming-in with asymptomatic newborns was promoted in 62 %; breastfeeding using protective measures was recommended in 70 %; and breast milk using a bottle, in 23 %. In 94 %, family visiting in the Neonatology Unit was restricted. Difficulties included the unavailability of individual rooms for symptomatic newborn infants and a potential shortage of health care staff and personal protective equipment. CONCLUSIONS: All facilities are aware of the national guidelines to fight the pandemic. Most have the resources to comply with the recommended protective measures. There is uncertainty as to whether personal protective equipment, staff, and physical space available at the different facilities would be enough if cases increased significantly.


Subject(s)
/prevention & control , Health Resources/supply & distribution , Infant Care/organization & administration , Infection Control/organization & administration , Maternal Health Services/organization & administration , Argentina/epidemiology , Cross-Sectional Studies , Female , Health Care Surveys , Health Policy , Humans , Infant Care/statistics & numerical data , Infant, Newborn , Infection Control/instrumentation , Infection Control/methods , Infection Control/statistics & numerical data , Male , Maternal Health Services/statistics & numerical data , Pandemics , Personal Protective Equipment/supply & distribution , Practice Guidelines as Topic , Pregnancy
3.
J Hosp Palliat Nurs ; 23(2): 120-127, 2021 Apr 01.
Article in English | MEDLINE | ID: covidwho-1183083

ABSTRACT

Outbreaks of COVID-19 among nursing homes, assisted living facilities, and other long-term care facilities in the United States have had devastating effects on residents. Restrictions such as banning visitors, sequestering residents, and testing health care staff have been implemented to mitigate the spread of the virus. However, consequences include a decline in mental and physical health, decompensation, and a sense of hopelessness among residents. We present and explore a case study at an assisted living facility addressing the ethical issues in balancing the management of the community versus the resident's right to autonomy and self-determination. A team of palliative care experts was brought into assisted living facilities to manage patients, care for well residents, and provide input in advance care planning and symptom management. The principles of self-determination and autonomy, stewardship, and distributive justice were explored. The use of nursing skills in triage and assessment, principles in public health, and the 8 domains of palliative care provided a comprehensive framework for structuring emergency operations. Palliative interventions and the role of palliative care nurses played an integral part in addressing ethical challenges in the containment of the virus and the deleterious effects of social isolation among the elderly.


Subject(s)
Assisted Living Facilities/ethics , Disease Outbreaks , Hospice and Palliative Care Nursing/ethics , Public Health/ethics , Aged , Assisted Living Facilities/organization & administration , Humans , Long-Term Care/ethics , Organizational Case Studies , United States/epidemiology
4.
J Hosp Palliat Nurs ; 23(2): 128-134, 2021 Apr 01.
Article in English | MEDLINE | ID: covidwho-1183082

ABSTRACT

Northern New Jersey was inside one of the worst initial coronavirus disease 2019 pandemic epicenters in the United States. At the peak of the pandemic surge in mid-April 2020, New Jersey saw 8045 hospitalized patients with severe coronavirus disease 2019 symptoms, of which 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of critically ill patients, the national opioid shortage, and transmission prevention measures for standard palliative care treatment protocols in place for refractory and/or end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the following Notes From the Field is to provide concise, pragmatic, and experiential reflection by 3 palliative care advanced practice nurses from 3 different hospital systems within the pandemic epicenter. The novel methods and opioid strategies implemented by their respective palliative care teams to ensure continued effective and appropriate treatment for end-of-life dyspnea are described. These accounts include Lessons Learned in order to assist others who may need to quickly implement changes in the future due to pandemic resurgence or second-wave events.


Subject(s)
/nursing , Disease Outbreaks , Dyspnea/nursing , Hospice and Palliative Care Nursing , /epidemiology , Hospitalization , Humans , New Jersey/epidemiology
5.
J Glaucoma ; 30(3): e50-e53, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1183056

ABSTRACT

PURPOSE: To report a case of bilateral acute angle-closure glaucoma associated with hyponatremia in the setting of chlorthalidone use and SARS-CoV-2 infection, and to demonstrate the challenges of managing this patient given her infectious status. METHODS: This was a case report. CASE: A 65-year-old woman taking chlorthalidone for hypertension presented to the emergency room with headache, pain, and blurry vision in both eyes and was found to be in bilateral acute angle closure. On laboratory investigation, she was severely hyponatremic and also tested positive for SARS-CoV-2. B-scan ultrasound demonstrated an apparent supraciliary effusion in the right eye. Following stabilization of her intraocular pressures with medical management, she ultimately underwent cataract extraction with iridectomies and goniosynechiolysis in both eyes. CONCLUSIONS: We report a rare case of bilateral acute angle-closure glaucoma associated with hyponatremia. Chlorthalidone use and perhaps SARS-CoV-2 infection may have contributed to this electrolyte abnormality and unique clinical presentation. In addition, we discuss the challenges of managing this complex patient with active SARS-CoV-2 infection during the pandemic.


Subject(s)
/epidemiology , Glaucoma, Angle-Closure/surgery , Intraocular Pressure/physiology , Iridectomy/methods , Acute Disease , Aged , Comorbidity , Female , Glaucoma, Angle-Closure/epidemiology , Glaucoma, Angle-Closure/physiopathology , Humans , Pandemics
6.
Lancet ; 397(10280): 1204-1212, 2021 03 27.
Article in English | MEDLINE | ID: covidwho-1182741

ABSTRACT

BACKGROUND: The degree to which infection with SARS-CoV-2 confers protection towards subsequent reinfection is not well described. In 2020, as part of Denmark's extensive, free-of-charge PCR-testing strategy, approximately 4 million individuals (69% of the population) underwent 10·6 million tests. Using these national PCR-test data from 2020, we estimated protection towards repeat infection with SARS-CoV-2. METHODS: In this population-level observational study, we collected individual-level data on patients who had been tested in Denmark in 2020 from the Danish Microbiology Database and analysed infection rates during the second surge of the COVID-19 epidemic, from Sept 1 to Dec 31, 2020, by comparison of infection rates between individuals with positive and negative PCR tests during the first surge (March to May, 2020). For the main analysis, we excluded people who tested positive for the first time between the two surges and those who died before the second surge. We did an alternative cohort analysis, in which we compared infection rates throughout the year between those with and without a previous confirmed infection at least 3 months earlier, irrespective of date. We also investigated whether differences were found by age group, sex, and time since infection in the alternative cohort analysis. We calculated rate ratios (RRs) adjusted for potential confounders and estimated protection against repeat infection as 1 - RR. FINDINGS: During the first surge (ie, before June, 2020), 533 381 people were tested, of whom 11 727 (2·20%) were PCR positive, and 525 339 were eligible for follow-up in the second surge, of whom 11 068 (2·11%) had tested positive during the first surge. Among eligible PCR-positive individuals from the first surge of the epidemic, 72 (0·65% [95% CI 0·51-0·82]) tested positive again during the second surge compared with 16 819 (3·27% [3·22-3·32]) of 514 271 who tested negative during the first surge (adjusted RR 0·195 [95% CI 0·155-0·246]). Protection against repeat infection was 80·5% (95% CI 75·4-84·5). The alternative cohort analysis gave similar estimates (adjusted RR 0·212 [0·179-0·251], estimated protection 78·8% [74·9-82·1]). In the alternative cohort analysis, among those aged 65 years and older, observed protection against repeat infection was 47·1% (95% CI 24·7-62·8). We found no difference in estimated protection against repeat infection by sex (male 78·4% [72·1-83·2] vs female 79·1% [73·9-83·3]) or evidence of waning protection over time (3-6 months of follow-up 79·3% [74·4-83·3] vs ≥7 months of follow-up 77·7% [70·9-82·9]). INTERPRETATION: Our findings could inform decisions on which groups should be vaccinated and advocate for vaccination of previously infected individuals because natural protection, especially among older people, cannot be relied on. FUNDING: None.


Subject(s)
Polymerase Chain Reaction , /immunology , /immunology , Adolescent , Adult , Aged , Child , Child, Preschool , Cohort Studies , Databases, Factual , Denmark/epidemiology , Female , Humans , Infant , Male , Middle Aged
7.
Lancet ; 397(10280): 1214-1228, 2021 03 27.
Article in English | MEDLINE | ID: covidwho-1182740

ABSTRACT

Guillain-Barré syndrome is the most common cause of acute flaccid paralysis worldwide. Most patients present with an antecedent illness, most commonly upper respiratory tract infection, before the onset of progressive motor weakness. Several microorganisms have been associated with Guillain-Barré syndrome, most notably Campylobacter jejuni, Zika virus, and in 2020, the severe acute respiratory syndrome coronavirus 2. In C jejuni-related Guillain-Barré syndrome, there is good evidence to support an autoantibody-mediated immune process that is triggered by molecular mimicry between structural components of peripheral nerves and the microorganism. Making a diagnosis of so-called classical Guillain-Barré syndrome is straightforward; however, the existing diagnostic criteria have limitations and can result in some variants of the syndrome being missed. Most patients with Guillain-Barré syndrome do well with immunotherapy, but a substantial proportion are left with disability, and death can occur. Results from the International Guillain-Barré Syndrome Outcome Study suggest that geographical variations exist in Guillain-Barré syndrome, including insufficient access to immunotherapy in low-income countries. There is a need to provide improved access to treatment for all patients with Guillain-Barré syndrome, and to develop effective disease-modifying therapies that can limit the extent of nerve injury. Clinical trials are currently underway to investigate some of the potential therapeutic candidates, including complement inhibitors, which, together with emerging data from large international collaborative studies on the syndrome, will contribute substantially to understanding the many facets of this disease.


Subject(s)
Disease Management , Guillain-Barre Syndrome/diagnosis , Guillain-Barre Syndrome/epidemiology , Guillain-Barre Syndrome/pathology , Guillain-Barre Syndrome/therapy , Diagnosis, Differential , Humans , Immunotherapy , Prognosis
8.
Nutrition ; 84: 111106, 2021 04.
Article in English | MEDLINE | ID: covidwho-1182641

ABSTRACT

OBJECTIVE: The 2019 coronavirus disease (COVID-19) pandemic has disproportionally affected a variety of patients with underlying risk factors such as respiratory and cardiovascular diseases, diabetes, obesity, and black race. Vitamin D deficiency, which can result in a compromised immune response, has been also linked to increased risk and increased morbidities associated with COVID-19. In the absence of large-scale longitudinal studies to determine the strength of association between vitamin deficiency and COVID-19, cross-sectional studies of large patient cohorts can be used. METHODS: We used the i2b2 patient's registry platform at the University of Florida Health Center to generate a count of patients using the international classification of diseases (ICD)-10 diagnosis codes for the period of October 1, 2015, through June 30, 2020. Logistic regression of the aggregates was used for the analysis. RESULTS: Patients with vitamin D deficiency were 4.6 times more likely to be positive for COVID-19 (indicated by the ICD-10 diagnostic code COVID19) than patients with no deficiency (P < 0.001). The association decreased slightly after adjusting for sex (odds ratio [OR] = 4.58; P < 0.001) and malabsorption (OR = 4.46; P < 0.001), respectively. The association decreased significantly but remained robust (P < 0.001) after adjusting for race (OR = 3.76; P < 0.001), periodontal disease status (OR = 3.64; P < 0.001), diabetes (OR = 3.28; P < 0.001), and obesity (OR = 2.27; P < 0.001), respectively. In addition, patients with vitamin D deficiency were 5 times more likely to be infected with COVID-19 than patients with no deficiency after adjusting for age groups (OR = 5.155; P < 0.001). CONCLUSIONS: Vitamin D deficiency is significantly associated with increased risk for COVID-19.


Subject(s)
/epidemiology , Vitamin D Deficiency/epidemiology , Vitamin D Deficiency/virology , Adolescent , Adult , Aged , Cross-Sectional Studies , Female , Florida/epidemiology , Humans , Logistic Models , Male , Middle Aged , Odds Ratio , Registries , Risk Factors , Vitamin D/blood , Vitamin D Deficiency/blood , Young Adult
9.
Health Policy ; 125(4): 535-540, 2021 04.
Article in English | MEDLINE | ID: covidwho-1182512

ABSTRACT

Real-time tracking of epidemic helps governments and health authorities make timely data-driven decisions. Official mortality data, whenever reliable and available, is usually published with a substantial delay. We report results of using newspapers obituaries to "nowcast" the mortality levels observed in Italy during the COVID-19 outbreak between February 24, 2020 and April 15, 2020. Mortality levels predicted using obituaries outperform forecasts based on past mortality according to several performance metrics, making obituaries a potentially valid alternative source of information to deal with epidemic surveillance.


Subject(s)
/mortality , Forecasting , Internet , Newspapers as Topic , Population Surveillance , Humans , Italy/epidemiology , Models, Statistical
10.
Euro Surveill ; 26(11)2021 03.
Article in English | MEDLINE | ID: covidwho-1181332

ABSTRACT

BackgroundA multi-tiered surveillance system based on influenza surveillance was adopted in the United Kingdom in the early stages of the coronavirus disease (COVID-19) epidemic to monitor different stages of the disease. Mandatory social and physical distancing measures (SPDM) were introduced on 23 March 2020 to attempt to limit transmission.AimTo describe the impact of SPDM on COVID-19 activity as detected through the different surveillance systems.MethodsData from national population surveys, web-based indicators, syndromic surveillance, sentinel swabbing, respiratory outbreaks, secondary care admissions and mortality indicators from the start of the epidemic to week 18 2020 were used to identify the timing of peaks in surveillance indicators relative to the introduction of SPDM. This timing was compared with median time from symptom onset to different stages of illness and levels of care or interactions with healthcare services.ResultsThe impact of SPDM was detected within 1 week through population surveys, web search indicators and sentinel swabbing reported by onset date. There were detectable impacts on syndromic surveillance indicators for difficulty breathing, influenza-like illness and COVID-19 coding at 2, 7 and 12 days respectively, hospitalisations and critical care admissions (both 12 days), laboratory positivity (14 days), deaths (17 days) and nursing home outbreaks (4 weeks).ConclusionThe impact of SPDM on COVID-19 activity was detectable within 1 week through community surveillance indicators, highlighting their importance in early detection of changes in activity. Community swabbing surveillance may be increasingly important as a specific indicator, should circulation of seasonal respiratory viruses increase.


Subject(s)
/prevention & control , Epidemiological Monitoring , /epidemiology , Humans , United Kingdom/epidemiology
11.
BMC Psychol ; 9(1): 55, 2021 Apr 12.
Article in English | MEDLINE | ID: covidwho-1181128

ABSTRACT

BACKGROUND: Poor mental health status and associated risk factors of public health workers have been overlooked during the COVID-19 pandemic. This study used the effort-reward imbalance model to investigate the association between work-stress characteristics (effort, over-commitment, reward) and mental health problems (anxiety and depression) among front-line public health workers during the COVID-19 pandemic in China. METHODS: A total of 4850 valid online questionnaires were collected through a self- constructed sociodemographic questionnaire, the adapted ERI questionnaire, the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder Scale (GAD-7). Hierarchical logistic regression analysis was conducted to investigate the association between ERI factors and mental health problems (i.e., depression and anxiety), with reward treated as a potential moderator in such associations. RESULTS: The data showed that effort and over-commitment were positively associated with depression and anxiety, while reward was negatively associated with depression and anxiety. Development and job acceptance were the two dimensions of reward buffered the harmful effect of effort/over-commitment on depression and anxiety, whereas esteem was non-significant. CONCLUSIONS: This study confirmed the harmful effects of effort and over-commitment on mental health among public health workers during the COVID-19 pandemic in China. Such effects could be alleviated through an appropriate reward system, especially the development and job acceptance dimensions of such a system. These findings highlight the importance of establishing an emergency reward system, comprising reasonable work-allocation mechanism, bonuses and honorary titles, a continuous education system and better career-development opportunities.


Subject(s)
Pandemics , China/epidemiology , Cross-Sectional Studies , Depression/epidemiology , Humans , Mental Health , Prevalence , Public Health , Reward , Stress, Psychological/epidemiology , Surveys and Questionnaires
13.
Pediatr Emerg Care ; 37(4): 232-236, 2021 Apr 01.
Article in English | MEDLINE | ID: covidwho-1180679

ABSTRACT

OBJECTIVES: The purposes of this study were to describe the clinical characteristics of febrile infants younger than 90 days with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, to investigate the prevalence of serious bacterial infections (SBIs) in these infants, and to compare the risk of SBI in SARS-CoV-2-positive febrile infants with sex- and age-matched SARS-CoV- 2-negative febrile infants. METHODS: This was a retrospective cohort study conducted from March to November 2020 in a tertiary children's hospital. Patients were identified by International Classification of Diseases, 10th Revision codes and included if age was younger than 90 days, a SARS-CoV-2 test was performed, and at least 1 bacterial culture was collected. Positive cases of SARS-CoV-2 were age- and sex-matched to negative controls for analysis. Serious bacterial infection was defined as a urinary tract infection, bacterial enteritis, bacteremia, and/or bacterial meningitis. RESULTS: Fifty-three SARS-CoV-2-positive infants were identified with a higher rate of respiratory symptoms and lower white blood cell and C-reactive protein values than their SARS-CoV-2 matched controls. The rate of SBI in the SARS-CoV-2-positive infants was 8% compared with 34% in the controls; the most common infections were urinary tract infections (6% vs 23%). There were no cases of bacteremia or bacterial meningitis in the COVID-19 (coronavirus disease 2019) infants and 2 (4%) cases of bacteremia in the controls. The relative risk of any SBI between the 2 groups was 0.22 (95% confidence interval, 0.1-0.6; P ≤ 0.001). CONCLUSIONS: These results suggest that febrile infants younger than 90 days with COVID-19 have lower rates of SBI than their matched SARS-CoV-2-negative controls. These data are consistent with previous studies describing lower risks of SBI in febrile infants with concomitant viral respiratory tract infections.


Subject(s)
Bacterial Infections/etiology , Emergency Service, Hospital/statistics & numerical data , Risk Assessment/methods , Bacterial Infections/epidemiology , Female , Follow-Up Studies , Humans , Infant , Infant, Newborn , Male , Prevalence , Retrospective Studies , United States
15.
Lancet Child Adolesc Health ; 5(4): 256-264, 2021 04.
Article in English | MEDLINE | ID: covidwho-1180151

ABSTRACT

BACKGROUND: The extent to which very young children contribute to the transmission of SARS-CoV-2 is unclear. We aimed to estimate the seroprevalence of antibodies against SARS-CoV-2 in daycare centres that remained open for key workers' children during a nationwide lockdown in France. METHODS: Children and staff who attended one of 22 daycare centres during a nationwide lockdown in France (between March 15 and May 9, 2020) were included in this cross-sectional, multicentre, seroprevalence study. Hospital staff not occupationally exposed to patients with COVID-19, or to children, were enrolled in a comparator group. The primary outcome was SARS-CoV-2 seroprevalence in children, daycare centre staff, and the comparator group. The presence of antibodies against SARS-CoV-2 in capillary whole blood was measured with a rapid chromatographic immunoassay. We computed raw prevalence as the percentage of individuals with a positive IgG or IgM test, and used Bayesian smoothing to account for imperfect sensitivity and specificity of the assay. This study is registered with ClinicalTrials.gov, NCT04413968. FINDINGS: Between June 4 and July 3, 2020, we enrolled 327 children (mean age 1·9 [SD 0·9] years; range 5 months to 4·4 years), 197 daycare centre staff (mean age 40 [12] years), and 164 adults in the comparator group (42 [12] years). Positive serological tests were observed for 14 children (raw seroprevalence 4·3%; 95% CI 2·6-7·1) and 14 daycare centre staff (7·7%; 4·2-11·6). After accounting for imperfect sensitivity and specificity of the assay, we estimated that 3·7% (95% credible interval [95% CrI] 1·3-6·8) of the children and 6·8% (3·2-11·5) of daycare centre staff had SARS-CoV-2 infection. The comparator group fared similarly to the daycare centre staff; nine participants had a positive serological test (raw seroprevalence 5·5%; 95% CI 2·9-10·1), leading to a seroprevalence of 5·0% (95% CrI 1·6-9·8) after accounting for assay characteristics. An exploratory analysis suggested that seropositive children were more likely than seronegative children to have been exposed to an adult household member with laboratory-confirmed COVID-19 (six [43%] of 14 vs 19 [6%] of 307; relative risk 7·1 [95% CI 2·2-22·4]). INTERPRETATION: According to serological test results, the proportion of young children in our sample with SARS-CoV-2 infection was low. Intrafamily transmission seemed more plausible than transmission within daycare centres. Further epidemiological studies are needed to confirm this exploratory hypothesis. FUNDING: Assistance Publique-Hôpitaux de Paris; Mairie de Paris, Conseil Départemental de Seine Saint Denis. TRANSLATIONS: For the French translation of the abstract see Supplementary Materials section.


Subject(s)
Antibodies, Viral/blood , Child Day Care Centers , /immunology , Adult , Child, Preschool , Cross-Sectional Studies , France/epidemiology , Humans , Immunoassay , Immunoglobulin G/blood , Immunoglobulin M/blood , Infant , Seroepidemiologic Studies
17.
Lancet Respir Med ; 9(4): 397-406, 2021 04.
Article in English | MEDLINE | ID: covidwho-1180129

ABSTRACT

BACKGROUND: Analysis of the effect of COVID-19 on the complete hospital population in England has been lacking. Our aim was to provide a comprehensive account of all hospitalised patients with COVID-19 in England during the early phase of the pandemic and to identify the factors that influenced mortality as the pandemic evolved. METHODS: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. All patients aged 18 years or older in England who completed a hospital stay (were discharged alive or died) between March 1 and May 31, 2020, and had a diagnosis of COVID-19 on admission or during their stay were included. In-hospital death was the primary outcome of interest. Multilevel logistic regression was used to model the relationship between death and several covariates: age, sex, deprivation (Index of Multiple Deprivation), ethnicity, frailty (Hospital Frailty Risk Score), presence of comorbidities (Charlson Comorbidity Index items), and date of discharge (whether alive or deceased). FINDINGS: 91 541 adult patients with COVID-19 were discharged during the study period, among which 28 200 (30·8%) in-hospital deaths occurred. The final multilevel logistic regression model accounted for age, deprivation score, and date of discharge as continuous variables, and sex, ethnicity, and Charlson Comorbidity Index items as categorical variables. In this model, significant predictors of in-hospital death included older age (modelled using restricted cubic splines), male sex (1·457 [1·408-1·509]), greater deprivation (1·002 [1·001-1·003]), Asian (1·211 [1·128-1·299]) or mixed ethnicity (1·317 [1·080-1·605]; vs White ethnicity), and most of the assessed comorbidities, including moderate or severe liver disease (5·433 [4·618-6·392]). Later date of discharge was associated with a lower odds of death (0·977 [0·976-0·978]); adjusted in-hospital mortality improved significantly in a broadly linear fashion, from 52·2% in the first week of March to 16·8% in the last week of May. INTERPRETATION: Reductions in the adjusted probability of in-hospital mortality for COVID-19 patients over time might reflect the impact of changes in hospital strategy and clinical processes. The reasons for the observed improvements in mortality should be thoroughly investigated to inform the response to future outbreaks. The higher mortality rate reported for certain ethnic minority groups in community-based studies compared with our hospital-based analysis might partly reflect differential infection rates in those at greatest risk, propensity to become severely ill once infected, and health-seeking behaviours. FUNDING: None.


Subject(s)
/mortality , Hospital Mortality/trends , Minority Groups/statistics & numerical data , Pandemics/statistics & numerical data , Patient Acceptance of Health Care/statistics & numerical data , Adolescent , Adult , Age Factors , Aged , Aged, 80 and over , Comorbidity , Datasets as Topic , Electronic Health Records/statistics & numerical data , England/epidemiology , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Retrospective Studies , Risk Factors , Severity of Illness Index , Sex Factors , Young Adult
18.
Lancet Respir Med ; 9(4): 407-418, 2021 04.
Article in English | MEDLINE | ID: covidwho-1180128

ABSTRACT

BACKGROUND: Most low-income and middle-income countries (LMICs) have little or no data integrated into a national surveillance system to identify characteristics or outcomes of COVID-19 hospital admissions and the impact of the COVID-19 pandemic on their national health systems. We aimed to analyse characteristics of patients admitted to hospital with COVID-19 in Brazil, and to examine the impact of COVID-19 on health-care resources and in-hospital mortality. METHODS: We did a retrospective analysis of all patients aged 20 years or older with quantitative RT-PCR (RT-qPCR)-confirmed COVID-19 who were admitted to hospital and registered in SIVEP-Gripe, a nationwide surveillance database in Brazil, between Feb 16 and Aug 15, 2020 (epidemiological weeks 8-33). We also examined the progression of the COVID-19 pandemic across three 4-week periods within this timeframe (epidemiological weeks 8-12, 19-22, and 27-30). The primary outcome was in-hospital mortality. We compared the regional burden of hospital admissions stratified by age, intensive care unit (ICU) admission, and respiratory support. We analysed data from the whole country and its five regions: North, Northeast, Central-West, Southeast, and South. FINDINGS: Between Feb 16 and Aug 15, 2020, 254 288 patients with RT-qPCR-confirmed COVID-19 were admitted to hospital and registered in SIVEP-Gripe. The mean age of patients was 60 (SD 17) years, 119 657 (47%) of 254 288 were aged younger than 60 years, 143 521 (56%) of 254 243 were male, and 14 979 (16%) of 90 829 had no comorbidities. Case numbers increased across the three 4-week periods studied: by epidemiological weeks 19-22, cases were concentrated in the North, Northeast, and Southeast; by weeks 27-30, cases had spread to the Central-West and South regions. 232 036 (91%) of 254 288 patients had a defined hospital outcome when the data were exported; in-hospital mortality was 38% (87 515 of 232 036 patients) overall, 59% (47 002 of 79 687) among patients admitted to the ICU, and 80% (36 046 of 45 205) among those who were mechanically ventilated. The overall burden of ICU admissions per ICU beds was more pronounced in the North, Southeast, and Northeast, than in the Central-West and South. In the Northeast, 1545 (16%) of 9960 patients received invasive mechanical ventilation outside the ICU compared with 431 (8%) of 5388 in the South. In-hospital mortality among patients younger than 60 years was 31% (4204 of 13 468) in the Northeast versus 15% (1694 of 11 196) in the South. INTERPRETATION: We observed a widespread distribution of COVID-19 across all regions in Brazil, resulting in a high overall disease burden. In-hospital mortality was high, even in patients younger than 60 years, and worsened by existing regional disparities within the health system. The COVID-19 pandemic highlights the need to improve access to high-quality care for critically ill patients admitted to hospital with COVID-19, particularly in LMICs. FUNDING: National Council for Scientific and Technological Development (CNPq), Coordinating Agency for Advanced Training of Graduate Personnel (CAPES), Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ), and Instituto de Salud Carlos III.


Subject(s)
/epidemiology , Epidemiological Monitoring , Healthcare Disparities/statistics & numerical data , Hospital Mortality/trends , Pandemics/statistics & numerical data , Adult , Aged , Aged, 80 and over , Brazil/epidemiology , /therapy , Comorbidity , Female , Geography , Health Services Accessibility/organization & administration , Health Services Accessibility/statistics & numerical data , Health Services Needs and Demand/statistics & numerical data , Humans , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Patient Admission/statistics & numerical data , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Young Adult
19.
Lancet Respir Med ; 9(4): 349-359, 2021 04.
Article in English | MEDLINE | ID: covidwho-1180127

ABSTRACT

BACKGROUND: Prognostic models to predict the risk of clinical deterioration in acute COVID-19 cases are urgently required to inform clinical management decisions. METHODS: We developed and validated a multivariable logistic regression model for in-hospital clinical deterioration (defined as any requirement of ventilatory support or critical care, or death) among consecutively hospitalised adults with highly suspected or confirmed COVID-19 who were prospectively recruited to the International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium (ISARIC4C) study across 260 hospitals in England, Scotland, and Wales. Candidate predictors that were specified a priori were considered for inclusion in the model on the basis of previous prognostic scores and emerging literature describing routinely measured biomarkers associated with COVID-19 prognosis. We used internal-external cross-validation to evaluate discrimination, calibration, and clinical utility across eight National Health Service (NHS) regions in the development cohort. We further validated the final model in held-out data from an additional NHS region (London). FINDINGS: 74 944 participants (recruited between Feb 6 and Aug 26, 2020) were included, of whom 31 924 (43·2%) of 73 948 with available outcomes met the composite clinical deterioration outcome. In internal-external cross-validation in the development cohort of 66 705 participants, the selected model (comprising 11 predictors routinely measured at the point of hospital admission) showed consistent discrimination, calibration, and clinical utility across all eight NHS regions. In held-out data from London (n=8239), the model showed a similarly consistent performance (C-statistic 0·77 [95% CI 0·76 to 0·78]; calibration-in-the-large 0·00 [-0·05 to 0·05]); calibration slope 0·96 [0·91 to 1·01]), and greater net benefit than any other reproducible prognostic model. INTERPRETATION: The 4C Deterioration model has strong potential for clinical utility and generalisability to predict clinical deterioration and inform decision making among adults hospitalised with COVID-19. FUNDING: National Institute for Health Research (NIHR), UK Medical Research Council, Wellcome Trust, Department for International Development, Bill & Melinda Gates Foundation, EU Platform for European Preparedness Against (Re-)emerging Epidemics, NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, NIHR HPRU in Respiratory Infections at Imperial College London.


Subject(s)
/diagnosis , Clinical Decision Rules , Clinical Decision-Making/methods , Clinical Deterioration , Aged , Aged, 80 and over , /therapy , Critical Care/statistics & numerical data , Female , Hospital Mortality , Humans , Intensive Care Units/statistics & numerical data , Logistic Models , Male , Middle Aged , Patient Admission/statistics & numerical data , Prognosis , Prospective Studies , Reproducibility of Results , Respiration, Artificial/statistics & numerical data , Severity of Illness Index , United Kingdom/epidemiology
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