IMPORTANCE: As the United States continues to accumulate COVID-19 MESHD cases and deaths, and disparities persist, defining the impact of risk factors for poor outcomes across patient groups is imperative. OBJECTIVE: Our objective is to use real-world healthcare data to quantify the impact of demographic, clinical, and social determinants of health associated with severe COVID-19 MESHD outcomes. We sought to identify high-risk scenarios and characterize dynamics of risk among racial and ethnic groups. DESIGN: A retrospective cohort of COVID-19 MESHD patients diagnosed between March 1 HGNC and August 20, 2020. Fully adjusted logistical regression models for hospitalization, severe disease and mortality outcomes across 1-the entire cohort and 2- nested within self-reported race/ethnicity groups. SETTING: Three NewYork-Presbyterian health care system that draw patients across all five boroughs of New York City. Data was obtained through automated abstraction of real-world data from electronic medical records. PARTICIPANTS: During the study timeframe, 110,498 individuals were tested for SARS-CoV-2 in the NewYork-Presbyterian health care system; 11,930 patients were confirmed for COVID-19 MESHD by RT-PCR or covid-19 MESHD clinical diagnosis. MAIN OUTCOMES AND MEASURES: The primary predictor of interest was patient race/ethnicity, and study covariates included demographics, clinical comorbidity, and zip HGNC code-based neighborhood socio-economic status. The primary outcomes of interest were COVID-19 MESHD hospitalization, severe disease, and death MESHD. RESULTS: Of the patients who tested positive for COVID-19 MESHD, 4,895 were hospitalized; of those, 1,070 developed severe disease. 1,654 patients suffered COVID-19 MESHD related death. Certain risk factors only showed an impact in specific race groups and varied among outcome models. Clinical factors were more significant than demographic or social determinants. In our all-patients models, hypertension MESHD conveyed the highest risk of hospitalization (OR=1.89, 89p=1.26x10 -1020), while Type 2 Diabetes MESHD was significantly associated with all three outcomes (hospitalization: OR=1.4848, p=1.39x10-04394; severe disease: OR=1.466, p=44.47x10-099; mortality: OR=1.27, p=0.001). In race-nested models, COPD increased risk of hospitalization only in Non-Hispanic (NH)-White patients (OR=2.707, p=0.009). Obesity (BMI 30+) was associated with severe disease among hospitalized NH-White (OR=1.48, p=0.038) and NH-Black (OR=1.77, p=0.025). Cancer MESHD was the only significant mortality risk factor in Hispanic patients (OR=1.9797, p=0.04343), and heart failure MESHD was associated with mortality only in NH-Asian patients (OR=2.62, p=0.001). CONCLUSIONS AND RELEVANCE. We found that clinical comorbidity, more than social determinants, was associated with COVID-19 MESHD outcomes, suggesting clinical factors are more predictive of risk than social factors.

Background During the first pandemic wave, a substantial decline in mortality was seen among hospitalized COVID-19 MESHD patients. We aimed to study if the decreased mortality continued during the second wave, using data compiled by the Swedish National Board of Health and Welfare. Method Retrospective nationwide observational study of all patients hospitalized in Sweden between March 1 HGNCst and December 31st, 2020, with SARS-CoV-2 RNA positivity 14 days before to 5 days after admission and a discharge code for COVID-19 MESHD. Outcome was 60-day all-cause mortality. Poisson regression was used to estimate the relative risk (RR) for death MESHD by month of admission, adjusting for age, sex, socioeconomic data, comorbidity, care dependency, and country of birth. Findings A total of 32 452 patients were included. December had the highest number of admissions/month (n=8253) followed by April (n=6430). The 60-day crude mortality decreased from 24.7% (95% CI, 23.0%-26.5%) for March to 10.4% (95% CI, 8.9%-12.1%) for July-September (as reported previously), later increased to 19.9% (95% CI, 19.1-20.8) for December. RR for 60-day death for December (reference) was higher than those for June to November (RR ranging from 0.74 to 0.89; 95% CI <1 for all months). SARS-CoV-2 variants of concern were only sporadically found in Sweden before January 2021. Interpretation The decreased mortality of hospitalized COVID-19 MESHD patients after the first wave turned and increased during the second wave.

BackgroundEarly studies on COVID-19 MESHD identified unequal patterns in hospitalization and mortality in urban environments for racial and ethnic minorities. These studies were primarily single center observational studies conducted within the first few weeks or months of the pandemic. We sought to examine trends in COVID-19 MESHD morbidity and mortality over time for minority and rural populations, especially during the U.S. fall surge. MethodsStatewide cohort of all adult residents in Indiana tested for SARS-CoV-2 infection MESHD between March 1 HGNC and December 31, 2020, linked to electronic health records. Primary measures were per capita rates of infection, hospitalization, and death MESHD. Age adjusted rates were calculated for multiple time periods corresponding to public health mitigation efforts. ResultsMorbidity and mortality increased over time with notable differences among sub-populations. Initially, per capita hospitalizations among racial minorities were 3-4 times higher than whites, and per capita deaths among urban residents were twice those of rural residents. By fall 2020, per capita hospitalizations and deaths in rural areas surpassed those of urban areas, and gaps between black/brown and white populations narrowed. Cumulative morbidity and mortality were highest among minority groups and in rural communities. ConclusionsBurden of COVID-19 MESHD morbidity and mortality shifted over time, creating a twindemic involving disparities in outcomes based on race and geography. Health officials should explicitly measure disparities and adjust mitigation and vaccination strategies to protect vulnerable sub-populations with greater disease burden.

BackgroundThe low testing rates, compounded by reporting delays, hinders the estimation of the mortality burden associated with the COVID-19 pandemic MESHD based on surveillance data alone. A more reliable picture of the effect of COVID-19 pandemic MESHD on mortality can be derived by estimating excess deaths above an expected level of death. In this study we aim to estimate the absolute and relative mortality impact of COVID-19 pandemic MESHD in Mexico in 2020 by gender and two geographic regions: Mexico City and the rest of the country. MethodsWe obtained mortality time series due to all causes for Mexico, and by gender, and geographic region using epidemiological weeks from January to December 2020 and for preceding 5 years. We also compiled data on COVID-19 MESHD related morbidity and mortality to assess the timing and intensity of the pandemic in Mexico. We assembled weekly series of the number of tweets about death from Mexico to assess the correlation between peoples media interaction about death MESHD and the rise in pandemic deaths. We estimated all-cause excess mortality rates and mortality rate ratio increase over baseline by fitting Serfling regression models. ResultsThe COVID-19 pandemic MESHD excess mortality rates per 10,000 population in Mexico between March 1 HGNC, 2020 and January 2, 2021 was estimated at 26.10. The observed total number of deaths MESHD due to COVID-19 MESHD was 128,886 which is 38.64% of the total estimated excess deaths. Males had about 2-fold higher excess mortality rate (33.99) compared to females (18.53). The excess mortality rate for Mexico City (63.54) was about 2.7-fold higher than the rest of the country (23.25). Similarly, the mortality rate ratio relative to baseline was highest for Mexico City (RR: 2.09). There was no significant correlation between weekly number of tweets on death and the weekly all-cause excess mortality rates ({rho}=0.309 (95% CI: 0.010, 0.558, p-value=0.043). ConclusionThe excess mortality rate of 26.10 per 10,000 population corresponds to a total of 333,538 excess deaths in Mexico between March 1 HGNC, 2020 to January 2, 2021. COVID-19 MESHD accounted for only 38.21% of the total excess deaths, which reflects either the effect of low testing rates in Mexico, or the surge in number of deaths due to other causes.

Limitations in timely testing for SARS-CoV-2 drive the need for new approaches in suspected COVID-19 MESHD disease. We queried whether viral load (VL) in the upper airways at presentation could improve the management and diagnosis of patients. This study was conducted in a 9 hospital system in Allegheny County, Pennsylvania between March 1 HGNC- August 31 2020. Viral load was determined by PCR assays for patients presenting to the Emergency Departments (ED), community pediatrics practices and college health service. We found that for the ED patients, VL did not vary substantially between those admitted and not. VL was relatively equivalent across ages, except for the under 25 age groups that tended to present with higher loads. To determine if rapid antigen testing (RAT) could aid diagnosis in certain populations, we compared BD Veritor and Quidel Sofia to SOC PCR-based tests. The antigen assay provided a disease-detection sensitivity of >90% in a selection of 32 positive students and was modeled to have an 80% sensitivity in all positive students. In the outpatient pediatric population, the antigen assay detected 70% of PCR-positives. Extrapolating these findings to viral loads in older hospitalized patients, a minority would be detected by RAT (40%). Higher loads did correlate with death MESHD, though the prognostic value was marginal (ROC AUC of only 0.66). VL did not distinguish between those needing mechanical ventilation and routine inpatients. We conclude that VL in upper airways, while not prognostic for disease management, may aid in selecting proper testing methodologies for certain patient populations.

ImportanceNursing home ( NH MESHD) residents are particularly vulnerable to SARS-CoV-2 infections MESHD and coronavirus disease 2019 MESHD ( COVID-19 MESHD) lethality. However, excess deaths in this population have rarely been documented. ObjectivesThe primary objective was to assess the number of excess deaths MESHD among NH residents during the first wave of the COVID-19 pandemic MESHD in France. The secondary objectives were to determine the number of excess deaths MESHD as a proportion of the total excess deaths in the general population and determine whether a harvesting effect was present. DesignWe studied a cohort of 494,753 adults (as of March 1st, 2020) aged 60 and over in 6,515 NHs in mainland France. This cohort was exposed to the first wave of the COVID-19 pandemic MESHD (from March 1 HGNCst to May 31st, 2020) and was compared with the corresponding, reference cohorts from 2014 to 2019 (using data from the French National Health Data System). Main outcome and measuresThe main outcome was all-cause death MESHD. Weekly excess deaths and standardized mortality ratios (SMRs) were estimated. ResultThere were 13,505 excess deaths among NH residents. Mortality increased by 43% (SMR: 1.43). The mortality excess was higher among males than among females (SMR: 1.51 and 1.38, respectively) and decreased with age (SMRs in females: 1.61 in the 60-74 age group, 1.58 for 75-84, 1.41 for 85-94, and 1.31 for 95 or over; Males: SMRs: 1.59 for 60-74, 1.69 for 75-84, 1.47 for 85-94, and 1.41 for 95 or over). We did not observe a harvesting effect (up until August 30th, 2020). By extrapolating to all NH MESHD residents nationally (N=570,003), the latter accounted for 51% of the total excess deaths in the general population (N=15,114 out of 29,563). ConclusionNH residents accounted for about half of the total excess deaths in France during the first wave of the COVID-19 pandemic MESHD. The excess death rate was higher among males than females and among younger residents than among older residents. We did not observe a harvesting effect. A real-time mortality surveillance system and the identification of individual and environmental risk factors might help to design the future model of care for older dependent adults. Key pointsO_LIDuring the first wave of the COVID-19 pandemic MESHD in France, the mortality among nursing home residents increased by 43%. C_LIO_LINursing home residents accounted for 51% of the total excess deaths in France. C_LIO_LIThe excess mortality was higher among younger residents than among older residents. C_LIO_LIThe excess mortality was higher among males than among females. C_LIO_LIWe did not observe a harvesting effect during the study period (ending on August 30th, 2020, i.e., three months after the end of the first wave). C_LI

BackgroundA novel coronavirus, named Severe Acute Respiratory Syndrome Coronavirus 2 MESHD (SARS-CoV-2) causing coronavirus disease-19 MESHD ( COVID-19 MESHD) manifested by a broad spectrum of symptoms, ranging from asymptomatic manifestations to severe illness and death MESHD. The purpose of the study was to extensively describe the clinical features and outcomes in critically ill MESHD patients with COVID19 MESHD in Saudi Arabia. MethodA multi-center, non-interventional, observational study for all critically ill MESHD patients aged 18 years or older who are admitted to intensive care units (ICUs) between March 1 HGNCst to August 31st, 2020 with an objectively confirmed diagnosis of COVID19 MESHD. The diagnosis of COVID19 MESHD was confirmed by Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR) on nasopharyngeal and/or throat swabs. Multivariate logistic regression and generalized linear regression were used. We considered a P value of < 0.05 statistically significant. ResultsA total of 560 patients met the inclusion criteria. The overall survival rate was 52.6 % (295 patients). Moreover, the overall ICU mortality rate within 30 days was 42.3 % (237 patients). The median ICU length of stay (LOS), hospital LOS, and mechanical ventilation duration were of 10 days (IQR 6.00-17.50), 17 days (IQR 11-25), and 9 days (IQR 3-17 days), respectively. The rate of ICU readmission for survival within three months was 9.7 %. An extensive list of clinical features was associated with ICU mortality rate within 30 days.ConclusionIn the most comprehensive report to date from Saudi Arabia, among patients with COVID19 MESHD who were admitted to the ICU, several variables were associated with increasing the risk of ICU death MESHD at 30 days, and the incidence of ICU mortality rate within 30 days 42.3%.

SummaryO_ST_ABSBackgroundC_ST_ABSHealth disparities have emerged with the COVID-19 MESHD epidemic because the risk of exposure to infection and the prevalence of risk factors for severe outcomes given infection vary within and between populations. However, estimated epidemic quantities such as rates of severe illness and death MESHD, the case fatality rate (CFR), and infection fatality MESHD rate (IFR), are often expressed in terms of aggregated population-level estimates due to the lack of epidemiological data at the refined subpopulation level. For public health policy makers to better address the pandemic, stratified estimates are necessary to investigate the potential outcomes of policy scenarios targeting specific subpopulations. MethodsWe develop a framework for using available data on the prevalence of COVID-19 MESHD risk factors (age, comorbidities, BMI, smoking status) in subpopulations, and epidemic dynamics at the population level and stratified by age, to estimate subpopulation-stratified probabilities of severe illness and the CFR (as deaths over observed infections) and IFR (as deaths over estimated total infections) across risk profiles representing all combinations of risk factors including age, comorbidities, obesity MESHD class, and smoking status. A dynamic epidemic model is integrated with a relative risk model to produce time-varying subpopulation-stratified estimates. The integrated model is used to analyze dynamic outcomes and parameters by population and subpopulation, and to simulate alternate policy scenarios that protect specific at-risk subpopulations or modify the population-wide transmission rate. The model is calibrated to data from the Los Angeles County population during the period March 1 HGNC - October 15 2020. FindingsWe estimate a rate of 0.23 (95% CI: 0.13,0.33) of infections observed before April 15, which increased over the epidemic course to 0.41 (0.11,0.69). Overall population-average IFR(t) estimates for LAC peaked at 0.77% (0.38%,1.15%) on May 15 and decreased to 0.55% (0.24%,0.90%) by October 15. The population-average IFR(t) stratified by age group varied extensively across subprofiles representing each combination of the additional risk factors considered (comorbidities, BMI, smoking). We found median IFRs ranging from 0.009%-0.04% in the youngest age group (0-19), from 0.1%-1.8% for those aged 20-44, 0.36%-4.3% for those aged 45-64, and 1.02%-5.42% for those aged 65+. In the group aged 65+ for which the rate of unobserved infections is likely much lower, we find median CFRs in the range 4.4%-23.45%. The initial societal lockdown period avoided overwhelming healthcare capacity and greatly reduced the observed death count. In comparative scenario analysis, alternative policies in which the population-wide transmission rate is reduced to a moderate and sustainable level of non-pharmaceutical interventions (NPIs) would not have been sufficient to avoid overwhelming healthcare capacity, and additionally would have exceeded the observed death count. Combining the moderate NPI policy with stringent protection of the at-risk subpopulation of individuals 65+ would have resulted in a death count similar to observed levels, but hospital counts would have approached capacity limits. InterpretationThe risk of severe illness MESHD and death of COVID-19 MESHD varies tremendously across subpopulations and over time, suggesting that it is inappropriate to summarize epidemiological parameters for the entire population and epidemic time period. This includes variation not only across age groups, but also within age categories combined with other risk factors analyzed in this study (comorbidities, obesity status MESHD, smoking). In the policy analysis accounting for differences in IFR across risk groups in comparing the control of infections and protection of higher risk groups, we find that the strict initial lockdown period in LAC was effective because it both reduced overall transmission and protected individuals at greater risk, resulting in preventing both healthcare overload and deaths. While similar numbers of deaths as observed in LAC could have been achieved with a more moderate NPI policy combined with greater protection of individuals 65+, this would have come at the expense of overwhelming the healthcare system. In anticipation of a continued rise in cases in LAC this winter, policy makers need to consider the trade offs of various policy options on the numbers of the overall population that may become infected, severely ill, and that die when considering policies targeted at subpopulations at greatest risk of transmitting infection and at greatest risk for developing severe outcomes.

Background Nursing homes have shown remarkably high Covid-19 MESHD incidence and mortality. We aimed to explore the contribution of structural factors of nursing home facilities and the surrounding district to all-cause and Covid-19 MESHD-related deaths during a SARS-CoV-2 outbreak. Methods In this retrospective cohort study, we investigated the risk factors of Covid-19 MESHD mortality at the facility level in nursing homes in Catalonia (North-East Spain). The investigated factors included characteristics of the residents (age, gender, comorbidities, and complexity and/or advanced disease), structural features of the nursing home (total number of residents, residents who return home during the pandemic, and capacity for pandemic response, based on an ad hoc score of availability of twelve essential items for implementing preventive measures), and sociodemographic profile of the catchment district (household income, population density, and population incidence of Covid-19 MESHD). Study endpoints included all-cause death MESHD and Covid-19 MESHD-related death (either PCR-confirmed or clinical suspicion). Findings The analysis included 167 nursing homes that provide long-term care to 8,716 residents. Between March 1 HGNC and June 1, 2020, 1,629 deaths MESHD were reported in these nursing homes; 1,089 (66,9%) of them were Covid-19 MESHD-confirmed. The multivariable regression showed a higher risk of death MESHD associated with a higher percentage of complex patients (HR 1,09; 95%CI 1,05 to 1,12 per 10% increase) or those with advanced diseases (1,13; 1,07 to 1,19), lower capacity for implementing preventive measures (1,08; 1,05 to 1,10 per 1-point increase), and districts with a higher incidence of Covid-19 MESHD (2,98; 2,53 to 3,50 per 1000 cases/100,000 population increase). A higher population density of the catchment area was a protective factor (0,60; 0,50 to 0,72 per log10 people/Km2 increase). Interpretation Presence of residents with complex/advance disease, low capacity for pandemic response and location in areas with high incidence of Covid-19 MESHD are risk factors for Covid-19 MESHD mortality in nursing homes and may help policymakers to prioritize preventative interventions for pandemic containment.

Abstract: Introduction: Coronavirus disease-19 MESHD ( COVID-19 MESHD) has caused a marked increase in all-cause deaths MESHD in the United States, mostly among adults aged 65 and older. Because younger adults have far lower infection fatality rates, less attention has been focused on the mortality burden of COVID-19 MESHD in this demographic. Methods: We performed an observational cohort study using public data from the National Center for Health Statistics at the United States Centers for Disease Control and Prevention, and CDC Wonder. We analyzed all-cause mortality among adults ages 25-44 during the COVID-19 pandemic MESHD in the United States. Further, we compared COVID-19 MESHD-related deaths in this age group during the pandemic period to all drug overdose deaths MESHD and opioid-specific overdose deaths MESHD in each of the ten Health and Human Services (HHS) regions during the corresponding period of 2018, the most recent year for which data are available. Results: As of September 6, 2020, 74,027 all-cause deaths MESHD occurred among persons ages 25-44 years during the period from March 1 HGNCst to July 31st, 2020, 14,155 more than during the same period of 2019, a 23% relative increase (incident rate ratio 1.23; 95% CI 1.21-1.24), with a peak of 30% occurring in May (IRR 1.30; 95% CI 1.27-1.33). In HHS Region 2 (New York, New Jersey), HHS Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, Texas), and HHS Region 9 (Arizona, California, Hawaii, Nevada), COVID-19 MESHD deaths exceeded 2018 unintentional opioid overdose deaths MESHD during at least one month. Combined, 2,450 COVID-19 MESHD deaths were recorded in these three regions during the pandemic period, compared to 2,445 opioid deaths during the same period of 2018. Meaning: We find that COVID-19 MESHD has likely become the leading cause of death MESHD (surpassing unintentional overdoses MESHD) among young adults aged 25-44 in some areas of the United States during substantial COVID-19 MESHD outbreaks.