COVID-19 HOSPITALIZATION RISK AFTER SARS-CoV-2 VACCINATION AND OUTPATIENT TREATMENT

Background: Given effectiveness of SARS-CoV-2 vaccines and outpatient antiviral and monoclonal antibody therapy for reducing progression to severe COVID-19, we sought to estimate the impact of these interventions on risk of hospitalization following SARS-CoV-2 infection in a large US healthcare system. Method(s): All patients >=18 of age in the UNC Health system, with first positive SARS-CoV-2 RT-PCR test or U07.1 ICD-10-CM (diagnosis date) during 07/01/2021- 05/31/2022, were included. The outcome was first hospitalization with U07.1 ICD-10-CM primary diagnosis <=14 days after SARS-CoV-2 diagnosis date. SARS-CoV-2 vaccinations were included if received >=14 days prior to diagnosis. Outpatient therapies were included if administered after diagnosis date and before hospital admission. Age, gender, race, ethnicity, and comorbidities associated with COVID-19 (using ICD-10-CM, if documented >=14 days prior to diagnosis date) were also evaluated. Risk ratios for hospitalization were estimated using generalized linear models, and predictors identified using extreme gradient boosting using feature influence with Shapley additive explanations algorithm. Result(s): The study population included 54,886 patients, 41% men and 27% >=60 years of age. One-third of SARS-CoV-2 diagnoses occurred July-December 2021 and 67% December-May 2022 (predominantly Delta and Omicron variants, respectively). Overall 7.0% of patients were hospitalized for COVID-19, with median hospitalization stay of 5 days (IQR: 3-9). 32% and 12% of patients received >=1 SARS-CoV-2 vaccine dose and outpatient therapy, respectively. Unadjusted and age-adjusted hospitalization risk decreased with vaccination and outpatient therapy (TABLE). Comparing patients who received 3 vaccine doses versus none we observed a 66% relative reduction in risk, with stronger association for more recent vaccination. For patients who received nirmatrelvir/ ritonavir versus no therapy we observed a 99% relative reduction in risk. In predictive models, older age was the most influential predictor of being hospitalized with COVID-19, while vaccination and outpatient therapy were the most influential factors predicting non-hospitalization. Conclusion(s): The impact of recent SARS-CoV-2 vaccination and outpatient antiviral and monoclonal antibody therapy on reducing COVID-19 hospitalization risk was striking in this large healthcare system covering Delta and Omicron variant timeframes. SARS-CoV-2 vaccinations and outpatient therapeutics are critical for preventing severe COVID-19. Unadjusted and age-adjusted risk ratios for hospitalization among patients with SARS-CoV-2.

Emergency Department (ED) Use among Persons With HIV (PWH) before and during the COVID-19 Pandemic

Background. Substantial changes in access and delivery of primary HIV care occurred during the COVID-19 pandemic. To assess how care access changed during the COVID-19 pandemic, we estimated ED use among PWH in care 2017-2021 in the southeastern US. Methods. For each calendar year, among PWH in care in the UNC CFAR HIV Clinical Cohort (defined as having a clinic visit in the current or prior year), we estimated the percent of patients with >= 1 ED visit in a given year, overall and by age, gender, race/ethnicity, HIV viral load (VL), and CD4 count. We estimated risk ratios (RRs) comparing patient characteristics and years 2020-2021 vs. 2017-2019, using Poisson regression with generalized estimating equations to account for repeated measures. Results. Among 2129 PWH in care 2017-2021 (N=1700-1800 in each year), 57% identified as Black, 31% White, 8% Hispanic, 26% women, with median age of 47 years (IQR 35-55). During the study period, there were 3645 ED visits over 8813 person-years, a rate of 41.4 ED visits-per 100 person-years(95% CI 36.8-46.5) per 100 person-years. The 845 PWHwith at least one ED visit during the study period contributed amedian of 2 visits each (IQR1-5). The unadjusted probability of having>=1 EDvisit in a given year was higher among women vs. men (RR=1.14, 95% CI 0.99-1.32), Black vs. White PWH (1.31, 1.13-1.52), with VL >= 40 copies/mL (1.40, 1.20-1.64), and with CD4 < 200 (1.66, 1.32-2.09) or 200-349 (1.50, 1.25-1.79) vs. >= 500 cells/muL;age was not associated with ED use. Comparedwith 2017-2019, the annual probability of having>=1 EDvisit was lower in 2020-2021, with RRs of 0.83 (95% CI 0.76-0.90) in unadjusted analyses and 0.80 (95%CI 0.71-0.90) after adjusting for demographics, VL, and CD4. There was also a significant unadjusted decrease for 2020-2021 vs. 2017-2019 among women, men, PWH who were Black, White, < 40 or 50-59 years old, and with CD4 >500 (Fig. B-F, all P< 0.05). Conclusion. Among PWH in HIV care, ED use was higher among women, Black PWH, and PWH with poorly controlled HIV. ED use decreased 2020-2021 in most groups, indicating that PWH during the COVID-19 pandemic may be delaying seeking care for acute conditions, or accessing care in other ways. Work is ongoing to characterize reasons for ED visits across calendar years and examine the impact of reduced ED utilization among PWH.

Applied Medical Anthropology and Structurally Informed Emergency Care in the Evolving Context COVID-19

This article describes the integration of medical anthropologists as direct members of health care teams within a large, urban teaching hospital as a means to address the role of structural inequality in unequal health care delivery within the context of COVID-19. The pandemic starkly underlined the role structural forces such as food insecurity, housing instability, and unequal access to health insurance play among vulnerable populations that seek health care, particularly within the emergency department (ED). There is a critical need to recognize the reality that disease acquisition is a cultural process. This is a significant limitation of the biomedical model, which often considers disease as a separate entity from the social contexts in which disease is found. Further, a focus on patient-centered care can open the door for critical, clinically applied, medical anthropologists to team with physicians, merging ethnographic methods with health data and the socially constructed realities of patients' lived experience to build new pathways of care. These pathways may better prepare physicians and health care systems to respond to novel threats like COVID-19, which are rooted in pathophysiological origins but have outcome distributions driven by cultural and structural determinants. To this end, we propose a reconfiguration of dominant biomedical ideologies around disease acquisition and spread by examining our work since 2018, which sees anthropologists embedded both locally and systematically in the creation of anthropologically informed treatment pathways for socially complex disease states like HIV, Hepatitis C, and Opioid Use Disorder (Henderson 2018). Understanding how these socially complex diseases concentrate and interact in populations is a potential opportunity to model solutions for other widespread and complex health care crises, including COVID-19.