Prevalent comorbidities among young and underprivileged: Death portrait of COVID-19 among 235 555 hospitalized patients in Brazil

Abstract

Background COVID 19 has been alarmingly spreading worldwide, with Brazil ranking third in total number of cases and second in deaths. Being a continental country, which comprises many ethnic groups and an engrained social inequality, the pandemic evidenced this heterogeneous discrepancy. We aimed to estimate the impact of associated risk factors, isolated or combined, on COVID 19 severeness, detecting specific epidemiological profiles for multiple age ranges in hospitalized Brazilians. Methods In this large retrospective cohort study, we used open-access data from the Ministry of Health of Brazil with COVID 19 confirmed hospitalized patients annotated in SRAG system between February and August 2020, a total of 235555 entries. The association of COVID 19 death with socio-demographic and clinical characteristics was analysed and presented as odds ratios adjusted by confounding co-variables. We also presented marginal mean aOR values for high-order interactions either by or not another fixed level or condition. We kept all other variables in the multivariate logistic models in their mean values or equal proportions. Findings Younger individuals with one or more comorbidities had an adjusted odds ratio up to four-fold compared to those without it, in the same age interval. Younger diabetic patients either self-declared as brown ethnicity (aOR 5,58, 95% CI 4,97-6,25; p < 0,0001) or with some other associated comorbidities, mainly chronic hematologic disease (21,09, 13,64-32,6; p < 0,0001) and obesity (aOR 21,7, 95% CI not calculated; p < 0,0001), resulted in outstanding death risk. Age over 60, particularly over 90 (28,91, 24,5-34,11; p < 0,001), usage of invasive ventilatory support (16,23, 14,05-18,75; p < 0,001), admission to intensive care units (3,14, 2,82-3,48; p < 0,001), multiple respiratory symptoms (3,24, 2,79-3,75; p < 0,0001), black ethnicity (1,78, 1,52-2,07; p < 0,05), and diagnosis previous to hospitalization (1,32, 1,19-1,47; p < 0,05) were associated with higher death odds. As protective factors, with roughly one third less death risk, we found hospitalization duration of (4, 7] days and illness onset to hospitalization over 6 days. Interpretation We found evidence for increased COVID 19 risk in two distinct groups: younger patients with prevalent comorbidities, especially in brown ethnicity, and patients with black ethnicity. We speculate that the pro-inflammatory synergism of COVID 19 and comorbidities, promoting an overproduction of cytokines, is partially the cause of higher mortality in this young group. Brazilian black and brown are underprivileged populations, with structural social inequality, limited healthcare access and, thus, remarkable disease vulnerability. Our study supplies essential data to patient stratification upon admission, optimizing hospital management, and to guide public policy determinations, including group prioritization for COVID 19 vaccination in Brazil.

Risk Assessment and Rationalization of Health Resource Allocation: Lessons From the Brazilian COVID-19 Cohort in 2020

“…Another limitation of our estimates was that we considered the marginal effects of comorbidities in isolation, disregarding the possibilities of interaction between them. However, it is already known that the accumulation of any comorbidities increases the risk of death especially among young people (Pietre et al, 2021;Maciel et al, 2020). Finally, the present study evaluated only symptomatic cases, possibly medium to severe.…”

“…Efficient implementation of in-hospital triage in individuals of different ages with diverse clinical presentations of COVID-19 will be of great help. A previous study has considered age, symptoms, and comorbidities as independent clinical risk factors to provide patients' risk profiles (Pietre et al, 2021). This study aimed to bring new clinical evidence to assessing relative risk and to establish a better flow of care in a setting of limited healthcare resources, focusing on the interactions between age (age strata), symptoms, and comorbidities and their association with healthcare resource demand, such as VS and ICU admission, and COVID-19-related death.…”

Estatística Cardiovascular – Brasil 2023

“…•Já Pietre et al , em 2021, reportaram dados obtidos da mesma base até agosto de 2020 (n=181.964, 96.567 mortes), ressaltando maior risco de mortalidade por síndrome respiratória aguda grave em pacientes mais jovens com diabetes e autodeclarados negros (aOR 5,58, IC 95% 4,97-6,25; p<0,0001) e naqueles com obesidade ou doenças hematológicas (aOR 21,09, IC 95% 13,64-32,06) vs. seus controles. 344 …”

“…•In 2021, Pietre et al reported on data obtained from that same database up to August 2020 (n=181 964, 96 567 deaths), emphasizing the higher risk of mortality from severe acute respiratory syndrome among younger patients with diabetes and self-reported Black individuals (aOR 5.58; 95% CI, 4.97-6.25; p<0.0001) and among those with obesity or hematological diseases (aOR 21.09; 95% CI, 13.64-32.06) as compared to their controls. 344 …”