Background COVID-19 pandemic has led to overloading of health systems all over the world. For reliable risk stratification, knowledge on factors predisposing to SARS-CoV-2 infection and to severe COVID-19 disease course is needed for decision-making at the individual, provider, and government levels. Data to identify these factors should be easily obtainable. Methods and findings Retrospective cohort study of nationwide e-health databases in Estonia. We used longitudinal health records from 66,295 people tested positive for SARS-CoV-2 RNA from 26 February 2020 to 28 February 2021 and 254,958 randomly selected controls from the reference population with no known history of SARS-CoV-2 infection or clinical COVID-19 diagnosis (case to control ratio 1:4) to predict risk factors of infection and severe course of COVID-19. We analysed sociodemographic and health characteristics of study participants. The SARS-CoV-2 infection risk was slightly higher among women, and was higher among those with comorbid conditions or obesity. Dementia (RRR 3.77, 95%CI 3.30⎼4.31), renal disease (RRR 1.88, 95%CI 1.56⎼2.26), and cerebrovascular disease (RRR 1.81, 95%CI 1.64⎼2.00) increased the risk of infection. Of all SARS-CoV-2 infected people, 92% had a non-severe disease course, 4.8% severe disease (requiring hospitalisation), 1.7% critical disease (needing intensive care), and 1.5% died. Male sex, increasing age and comorbid burden contributed significantly to more severe COVID-19, and the strength of association for male sex increased with the increasing severity of COVID-19 outcome. The strongest contributors to critical illness (expressed as RRR with 95% CI) were renal disease (7.71, 4.71⎼12.62), the history of previous myocardial infarction (3.54, 2.49⎼5.02) and obesity (3.56, 2.82⎼4.49). The strongest contributors to a lethal outcome were renal disease (6.48, 3.74⎼11.23), cancer (3.81, 3.06⎼4.75), liver disease (3.51, 1.36⎼9.02) and cerebrovascular disease (3.00, 2.31⎼3.89). Conclusions We found divergent effect of age and gender on infection risk and severity of COVID-19. Age and gender did not contribute substantially to infection risk, but did so for the risk of severe disease Co-morbid health conditions, especially those affecting renin-angiotensin system, had an impact on both the risk of infection and severe disease course. Age and male sex had the most significant impact on the risk of severe COVID-19. Taking into account the role of ACE2 receptors in the pathogenesis of SARS-CoV-2 infection, as well as its modulating action on the renin-angiotensin system in cardiovascular and renal diseases, further research is needed to investigate the influence of hormonal status on ACE2 expression in different tissues, which may be the basis for the development of COVID-19 therapies.

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Background Post-acute COVID-19 sequelae refers to a variety of health complications involving different organ systems that have been described among individuals after acute phase of illness. Data from unselected population groups with long-time follow up is needed to comprehensively describe the full spectrum of post-acute COVID-19 complications. Methods In this retrospective nationwide cohort study, we used data obtained from electronic health record database. Our primary cohort were adults hospitalized with confirmed COVID-19 and matched (age, sex, Charlson Comorbidity Index) unaffected controls from general population. Individuals included from February 2020 until March 2021 were followed up for 12 months. We estimated risks of all-cause mortality, readmission and incidence of 16 clinical sequelae after acute COVID-19 phase. Using a frailty Cox model, we compared incidences of outcomes in two cohorts. Results The cohort comprised 3949 patients older than 18 years who were alive 30 days after COVID-19 hospital admission and 15511 controls. Among cases 40.3% developed at least one incident clinical sequelae after the acute phase of SARS-CoV-2 infection, which was two times higher than in general population group. We report substantially higher risk of all-cause mortality (adjusted hazard ratio (aHR) = 2.57 (95%CI 2.23–2.96) and hospital readmission aHR = 1.73 (95%CI 1.58–1.90) among hospitalized COVID-19 patients. We found that the risks for new clinical sequalae were significantly higher in COVID-19 patients than their controls, especially for dementia aHR = 4.50 (95% CI 2.35–8.64), chronic lower respiratory disease aHR = 4.39 (95% CI 3.09–6.22), liver disease aHR 4.20 (95% CI 2.01–8.77) and other (than ischemic) forms of heart diseases aHR = 3.39 (95%CI 2.58–4.44). Conclusion Our results provide evidence that the post-acute COVID-19 morbidity within the first year after COVID-19 hospitalization is substantial. Risks of all-cause mortality, hospitalisation and majority of clinical sequelae were significantly higher in hospitalized COVID-19 patients than in general population controls and warrant targeted prevention efforts.

Theme: 'Reducing the risk of chronic diseases in general practice/family medicine'

Питання організації охорони здоров'я One of the cornerstones of the Estonian health care reforms has been the reorganization of the pri mary level medical care. It was started in 1991 by commencing training for family doctors [1, 2]. Since 1993, the list of medical specialties in Estonia also contains family medicine, and by the present time more than 800 family doctors have been trained. In 1998 a new financing scheme for family doctors came into force, foreseeing the establishment of patient lists. It introduced a combined payment mechanism and a partial gatekeeping function for family doctors, and rendered the status of an independent contractor to family practitioners [3]. The aim of the reform in primary health care was to establish the primary health care system that is easily accessible and is based on trained and fully responsible family practitioners. Several studies have shown that the access to the doctors is one of the most important determinants of patient satisfaction with the care [4, 5].Al though priorities regarding different aspects of family practice vary significantly among different countries, the absolute requirements for good family practice as reported by patients are: the possibility of making appointments with in a short time, quick service in urgent situations, a family physician who really takes his/her time to listen and talk during the consultation. All these priorities refer particularly to accessible clinical care [6]. The common policy in the Estonian family medicine is that patients with urgent problems should be seen on the same day, while other patients should be granted an appointment in three days. These standard rules are fixed in the family doctor's job description. Since October 2002, when the Health Insurance Act came into force, all patients who have health insurance can visit their family doctors for free. According to the same act, family practitioners may ask up to EEK50 (€3.3, US$3.9) for a home visit. The aim of the study was to investigate the temporal accessibility and financial accessibility of family doctors in Estonia from the patients' point of view.

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Background Decisions about the continued need for control measures and the effect of introducing COVID-19 vaccinations rely on accurate and population-based data on SARS-CoV-2 positivity and risk factors for testing positive. Methods In this interrupted time series of population-based nationwide cross-sectional studies, data from nasopharyngeal testing and questionnaires were used to estimate the SARS-CoV-2 RNA prevalence and factors associated with test positivity over the 1st year of the COVID-19 epidemic. The study is registered with the ISRCTN Registry, ISRCTN10182320. Results Between April 23, 2020 and February 2, 2021, results were available from 34,915 individuals and 27,870 samples from 11 consecutive studies. The percentage of people testing positive for SARS-CoV-2 decreased from 0.27% (95% CI 0.10% - 0.59%) in April to 0.04% (95% CI 0.00% - 0.22%) by the end of May and remained very low (0.01%, 95% CI 0.00% - 0.17%) until the end of August, followed by an increase since November (0.37%, 95% CI 0.18% - 0.68%) that escalated to 2.69% (95% CI 2.08% - 2.69%) in January 2021. In addition to substantial change in time, an increasing number of household members (for one additional OR 1.15, 95% CI 1.02-1.29), reporting current symptoms of COVID-19 (OR 2.21, 95% CI 1.59-3.09), and completing questionnaire in the Russian language (OR 1.85, 95% CI 1.15-2.99) were associated with increased odds for SARS-CoV-2 RNA positivity. Conclusions SARS-CoV-2 population prevalence needs to be carefully monitored as vaccine programmes are rolled out in order to inform containment decisions.

Aims The aim was to evaluate the effect of the intervention by proactively sharing a patient’s high polygenic risk score (PRS) for coronary artery disease (CAD). Outcomes included: 1) reduction in cardiovascular disease (CVD) risk factors over 12 months; 2) difference in purchased prescriptions of lipid-lowering and antihypertensive drugs between intervention group and control group subjects; and 3) opinion of the participating physicians and subjects on PRS usefulness. Methods This randomised controlled trial (RCT) was conducted among middle-aged subjects with a top 20% CAD polygenic risk score in a family medicine setting. Participants were selected from 26,953 Estonian Biobank cohort participants. Subjects were informed and counselled about their PRS score and CAD risk using the visual tool at baseline (visit I), counselling session (visit II), and on the final visit III at 12 months. Results The primary endpoint was not significantly different. However, the intervention group participants had a significantly higher probability of initiating statin treatment compared with controls. Their levels of LDL cholesterol (LDL-C) were significantly decreased compared to baseline on visit III and significantly lower than in the control group. The vast majority of participating family physicians believe that finding out about genetic risks will affect the subject’s lifestyle and medication compliance. Conclusions Most of our outcome measures were in favour of this intervention. Participants achieved larger changes in cholesterol and blood pressure values. The vast majority (98.4%) of family physicians are interested in continuing to use genetic risk assessment in practice.