Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: a cohort study,The Lancet HIV

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Risk factors for COVID-19-related in-hospital mortality in a high HIV and tuberculosis prevalence setting in South Africa: a cohort study
The Lancet HIV ( IF 16.1 ) Pub Date : 2021-08-04 , DOI: 10.1016/s2352-3018(21)00151-x
Waasila Jassat ₁ , Cheryl Cohen ₂ , Stefano Tempia ₃ , Maureen Masha ₄ , Susan Goldstein ₅ , Tendesayi Kufa ₆ , Pelagia Murangandi ₇ , Dana Savulescu ₁ , Sibongile Walaza ₂ , Jamy-Lee Bam ₈ , Mary-Ann Davies ₈ , Hans W Prozesky ₉ , Jonathan Naude ₁₀ , Ayanda T Mnguni ₁₁ , Charlene A Lawrence ₈ , Hlengani T Mathema ₁ , Jarrod Zamparini ₁₂ , John Black ₁₃ , Ruchika Mehta ₁₄ , Arifa Parker ₉ , Perpetual Chikobvu ₁₅ , Halima Dawood ₁₆ , Ntshengedzeni Muvhango ₁₇ , Riaan Strydom ₁₈ , Tsholofelo Adelekan ₁₉ , Bhekizizwe Mdlovu ₂₀ , Nirvasha Moodley ₂₁ , Eunice L Namavhandu ₂₂ , Paul Rheeder ₂₃ , Jacqueline Venturas ₁₂ , Nombulelo Magula ₂₄ , Lucille Blumberg ₁ ,

Affiliation

Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.
Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.
Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; MassGenics, Duluth, GA, USA.
Right to Care, Johannesburg, South Africa.
South Africa Medical Research Council Centre for Health Economics and Decision Science-PRICELESS SA, University of the Witwatersrand, Johannesburg, South Africa.
Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa.
Division of Global HIV and TB, Centers for Disease Control and Prevention, Pretoria, South Africa.
Western Cape Department of Health, Cape Town, South Africa.
Tygerberg Hospital and Division of Infectious Disease, University of Stellenbosch, Cape Town, South Africa.
Mitchells Plain District Hospital, Cape Town, South Africa.
Khayelitsha District Hospital, Cape Town, South Africa.
Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
Livingstone Hospital, Walter Sisulu University, Nelson Mandela Bay, South Africa.
Klerksdorp-Tshepong Hospital, University of Witwatersrand, Klerksdorp, South Africa.
Free State Department of Health, Bloemfontein, South Africa.
Grey's Hospital, Pietermaritzburg, South Africa.
Limpopo Department of Health, Polokwane, South Africa.
Northern Cape Department of Health, Kimberley, South Africa.
Gauteng Department of Health, Johannesburg, South Africa.
Mpumalanga Department of Health, Nelspruit, South Africa.
KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa.
Eastern Cape Department of Health, Bisho, South Africa.
School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
Department of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa.

Background

The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19.

Methods

In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality.

Findings

Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals.

Interpretation

Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment.

Funding

South African National Government.

中文翻译：

南非 HIV 和结核病高流行地区 COVID-19 相关住院死亡率的危险因素：一项队列研究

背景

COVID-19、非传染性疾病以及艾滋病毒和肺结核等慢性传染病之间的相互作用尚不清楚，尤其是在非洲的低收入和中等收入国家。南非在 15-49 岁人群中的全国 HIV 流行率为 19%，在所有年龄段的人群中结核病流行率为 0·7%。我们使用南非具有全国代表性的医院监测系统，旨在调查与 COVID-19 患者住院死亡率相关的因素。

方法

在这项队列研究中，我们使用了提交给 DATCOV 的数据，DATCOV 是一个全国性的 COVID-19 住院主动医院监测系统，用于 2020 年 3 月 5 日至 3 月 27 日期间因实验室确诊的 SARS-CoV-2 感染住院的患者， 2021. 年龄、性别、种族或民族以及合并症（高血压、糖尿病、慢性心脏病、慢性肺病和哮喘、慢性肾病、过去 5 年的恶性肿瘤、艾滋病毒以及过去和现在的肺结核）被认为是风险与 COVID-19 相关的住院死亡率的因素。主要结局 COVID-19 住院死亡率被定义为在住院期间发生的与 COVID-19 相关的死亡，不包括因其他原因或出院后发生的死亡；所以，仅包括具有已知住院结局（死亡或活着出院）的患者。链式方程多重插补用于解释缺失数据，随机效应多变量逻辑回归模型用于评估 HIV 状态和潜在合并症对 COVID-19 住院死亡率的作用。

发现

在因实验室确诊的 SARS-CoV-2 感染和已知的住院结果数据而入院的 219 265 人中，51 037 人（23·3%）死亡。有可用数据的个体中最常见的合并症是 163 350 人中有 61 098 人（37·4%）患有高血压，159 932 人中有 43 885 人（27·4%）患有糖尿病，13 793 人中有 13 793 人（9·1%）患有艾滋病毒（9·1%） 151 779. 146 381 人中有 5282 人（3·6%）报告了结核病。年龄增长是 COVID-19 住院死亡率的最强预测因素。其他相关因素包括 HIV 感染（调整优势比 1·34, 95% CI 1·27–1·43），既往结核病 (1·26, 1·15–1·38)，当前结核病 (1·42, 1 ·22–1·64)，过去和现在的结核病 (1·48, 1·32–1·67) 与从未患过结核病的比较，以及其他描述的 COVID-19 危险因素，例如男性；非白人种族；近5年有基础高血压、糖尿病、慢性心脏病、慢性肾病、恶性肿瘤；和公共卫生部门的治疗。在调整其他因素后，未接受抗逆转录病毒治疗（ART；调整优势比 1·45，95% CI 1·22–1·72）的 HIV 感染者比接受 ART 的 HIV 感染者更有可能在医院死亡。在 HIV 感染者中，其他合并症的患病率为 29·2%，而在 HIV 未感染者中为 30·8%。在 HIV 感染者和 HIV 未感染者中，合并症数量的增加与 COVID-19 住院死亡风险增加有关。未接受抗逆转录病毒治疗的 HIV 感染者（ART；调整优势比 1·45，95% CI 1·22–1·72）比接受 ART 的 HIV 感染者更有可能在医院死亡。在 HIV 感染者中，其他合并症的患病率为 29·2%，而在 HIV 未感染者中为 30·8%。在 HIV 感染者和 HIV 未感染者中，合并症数量的增加与 COVID-19 住院死亡风险增加有关。未接受抗逆转录病毒治疗的 HIV 感染者（ART；调整优势比 1·45，95% CI 1·22–1·72）比接受 ART 的 HIV 感染者更有可能在医院死亡。在 HIV 感染者中，其他合并症的患病率为 29·2%，而在 HIV 未感染者中为 30·8%。在 HIV 感染者和 HIV 未感染者中，合并症数量的增加与 COVID-19 住院死亡风险增加有关。