COVID-19-related deaths: a 2-year inter-wave comparison of mortality data from Germany

Impact of the COVID-19 pandemic on admissions of deceased to an institute of legal medicine in Germany

All over the world, the COVID-19 pandemic has impacted mortality beyond deaths that can be directly attributed to the viral disease. This study investigates the effects of the pandemic on admissions of deceased to a large institute of legal medicine and metropolitan morgue in Germany. Employing statistical models, the general time trend was separated from the effect of the pandemic in terms of place of death, autopsy category, age and sex. In addition, the pandemic's impact on one of the structurally most important public health determinants, poverty, on numbers of admissions in different place of death categories was analyzed. We find that the pandemic has caused a significant increase in admissions of those who died at residential addresses, which appears to be primarily driven by SARS-CoV-2 negative cases, and those who died in retirement and care facilities, with a significant overrepresentation of SARS-CoV-2 positive cases. A high degree of poverty in a neighborhood does not impact the likelihood to be admitted to the institute in those two categories before or during the pandemic. For dead bodies found in public spaces, however, a poverty variable causes a significant increase in the number of admissions during the pre-pandemic phase. Interestingly, this effect is reversed during the pandemic period. The number of admissions without an autopsy being ordered or requested increased significantly during the pandemic. Further, the COVID-19 pandemic caused a significant increase in admissions in the senile population. Our results indicate that the reluctance of treating physicians to conduct house calls to certify a death has persisted throughout the pandemic and has caused a surge of admissions of deceased to the institute of legal medicine without any criminological indications or subsequent rise in forensic autopsy orders.

Persistent mortality in critical COVID-19 ICU cases from wild-type to delta variant: A descriptive cohort study

The SARS-CoV-2 pandemic led to significant advancements in treatment and vaccination, contributing to a decline in overall COVID-19-related mortality. However, it remains unclear whether the mortality rate for critical cases treated on intensive care units has also decreased. This multicentric, multinational retrospective observational study analyzed 447 critically ill COVID-19 patients treated on ICUs across ten study centers in Germany and Austria. Patients were categorized into two periods: period 1 (March 2020 to May 2021, n = 316) and period 2 (June 2021 to January 2022, n = 131). Despite evolving treatment strategies and widespread vaccine availability in period 2, 30-day mortality remained unchanged (30% in period 1 vs. 37% in period 2; HR 1.26, 95% CI: 0.90-1.79, p = 0.181). Further outcomes, including ICU-free days (p = 0.735), ventilatory support-free days (p = 0.699), vasopressor-free days (p = 0.379), and dialysis-free days (p = 0.396), also showed no significant differences. Notably, 81% (106 of 131) of ICU patients in period 2 were unvaccinated, underscoring the persistent vulnerability of this group. These findings suggest that while public health measures reduced overall COVID-19 severity, critical illness remained highly lethal. Further research is needed to explore targeted interventions for high-risk ICU patients and to better understand the factors contributing to persistent mortality despite medical advancements.

Epidemiological characterization of COVID-19 in children under 18 years old in Mexico: an analysis of the pandemic

Objective

The study aimed to describe the characteristics and risk factors associated with disease severity across six waves of COVID-19 in the pediatric population in Mexico.

Methods

A cohort study was conducted using data from the Mexican Ministry of Health, covering the period from March 2020 to March 2023. The dataset included patients under 18 years of age with confirmed SARS-CoV-2 infection. Univariate, bivariate, and logistic regression analyses were performed to determine demographic and clinical characteristics, mortality across waves, and age group distributions.

Results

Of the total cohort, 9.5% were children, with 497,428 confirmed cases. Among these, 50% were male, 4.4% required hospitalization, and there were 1,447 (0.03%) deaths. The highest prevalence was observed in the 12-17-year age group (52%), followed by the 5-11-year age group (32%), with incidence rates peaking towards the end of 2021 and the early 2022. Although the 0-2-year age group represented 9.6% of cases, it had higher hospitalization (40%), ICU admission (58%), and case fatality rate (CFR) (44%). Cardiovascular disease, hypertension, diabetes and immunosuppression were identified as risk factors for severe outcomes. The initial wave displayed the highest CFR (OR 5.28) especially in children aged 0-2 years.

Conclusions

Children were less affected during the pandemic compared to adults; however, children under two years-old experienced more severe outcomes. Currently, with 95% of the population estimated to be immune due to vaccination and/or prior infection, children under 2 years of age are now at higher risk of severe disease and should be evaluated for vaccination as a public health policy.

Comparison of clinical outcomes in hospitalized patients with COVID-19 or non-COVID-19 community-acquired pneumonia in a prospective observational cohort study

PURPOSE

Coronavirus disease 2019 (COVID-19) and non-COVID-19 community-acquired pneumonia (NC-CAP) often result in hospitalization with considerable risks of mortality, ICU treatment, and long-term morbidity. A comparative analysis of clinical outcomes in COVID-19 CAP (C-CAP) and NC-CAP may improve clinical management.

METHODS

Using prospectively collected CAPNETZ study data (January 2017 to June 2021, 35 study centers), we conducted a comprehensive analysis of clinical outcomes including in-hospital death, ICU treatment, length of hospital stay (LOHS), 180-day survival, and post-discharge re-hospitalization rate. Logistic regression models were used to examine group differences between C-CAP and NC-CAP patients and associations with patient demography, recruitment period, comorbidity, and treatment.

RESULTS

Among 1368 patients (C-CAP: n = 344; NC-CAP: n = 1024), C-CAP showed elevated adjusted probabilities for in-hospital death (aOR 4.48 [95% CI 2.38-8.53]) and ICU treatment (aOR 8.08 [95% CI 5.31-12.52]) compared to NC-CAP. C-CAP patients were at increased risk of LOHS over seven days (aOR 1.88 [95% CI 1.47-2.42]). Although ICU patients had similar in-hospital mortality risk, C-CAP was associated with length of ICU stay over seven days (aOR 3.59 [95% CI 1.65-8.38]). Recruitment period influenced outcomes in C-CAP but not in NC-CAP. During follow-up, C-CAP was linked to a reduced risk of re-hospitalization and mortality post-discharge (aOR 0.43 [95% CI 0.27-0.70]).

CONCLUSION

Distinct clinical trajectories of C-CAP and NC-CAP underscore the need for adapted management to avoid acute and long-term morbidity and mortality amid the evolving landscape of CAP pathogens.

The spatial-temporal variations and influencing factors of COVID-19 case fatality rate: a worldwide study in 30 countries from February 2021 to May 2022

To evaluate the variations in COVID-19 case fatality rates (CFRs) across different regions and waves, and the impact of public health interventions, social and economic characteristics, and demographic factors on COVID-19 CFRs, we collected data from 30 countries with the highest incidence rate in three waves. We summarized the CFRs of different countries and continents in each wave through meta-analysis. Spearman's correlation and multiple linear regression were employed to estimate the correlation between influencing factors and reduction rates of CFRs. Significant differences in CFRs were observed among different regions during the three waves (P < 0.001). An association was found between the changes in fully vaccinated rates (r s  = 0.41), population density (r s  = 0.43), the proportion of individuals over 65 years old (r s  = 0.43), and the reduction rates of case fatality rate. Compared to Wave 1, the reduction rates in Wave 2 were associated with population density (β = 0.19, 95%CI: 0.05-0.33) and smoking rates (β = -4.66, 95%CI: -8.98 - -0.33), while in Wave 3 it was associated with booster vaccine rates (β = 0.60, 95%CI: 0.11-1.09) and hospital beds per thousand people (β = 4.15, 95%CI: 1.41-6.89). These findings suggest that the COVID-19 CFRs varied across different countries and waves, and promoting booster vaccinations, increasing hospital bed capacity, and implementing tobacco control measures can help reduce CFRs.

A Gaussia luciferase reporter assay for the evaluation of coronavirus Nsp5/3CLpro activity

Human coronaviruses (hCoVs) infect millions of people every year. Among these, MERS, SARS-CoV-1, and SARS-CoV-2 caused significant morbidity and mortality and their emergence highlights the risk of possible future coronavirus outbreaks. Therefore, broadly-active anti-coronavirus drugs are needed. Pharmacological inhibition of the hCoV protease Nsp5 (3CLpro) is clinically beneficial as shown by the wide and effective use of Paxlovid (nirmatrelvir, ritonavir). However, further treatment options are required due to the risk of drug resistance. To facilitate the assessment of coronavirus protease function and its pharmacological inhibition, we developed an assay allowing rapid and reliable quantification of Nsp5 activity under biosafety level 1 conditions. It is based on an ACE2-Gal4 transcription factor fusion protein separated by a Nsp5 recognition site. Cleavage by Nsp5 releases the Gal4 transcription factor, which then induces the expression of Gaussia luciferase. Our assay is compatible with Nsp5 proteases from all hCoVs and allows simultaneous measurement of inhibitory and cytotoxic effects of the tested compounds. Proof-of-concept measurements confirmed that nirmatrelvir, GC376 and lopinavir inhibit SARS-CoV-2 Nsp5 function. Furthermore, the assay accurately predicted the impact of Nsp5 mutations on catalytic activity and inhibitor sensitivity. Overall, the reporter assay is suitable for evaluating viral protease activity.

SARS-CoV-2 infections in patients, health care workers and hospital outbreaks during the first 3 waves of the pandemic: a retrospective analysis in a secondary care hospital network in Germany

BACKGROUND

Hospital infections with SARS-CoV-2 continued during the initial waves of the pandemic worldwide. So far, Data on the dynamics of these infections and the economic burden of outbreaks are rare.

METHODS

We retrospectively analysed SARS-CoV-2 infections in patients, hospital employees and nosocomial infections resulting in outbreaks in two hospitals of a secondary care hospital network in Germany during the initial 3 pandemic waves (03/2020-06/2021). In addition to hospital infections, we evaluated infection prevention strategies and the economic burden of hospital outbreaks.

RESULTS

A total of 396 patients with SARS-CoV-2 infection were hospitalized in both hospitals. The risk factors for severe disease and death increased with age, male sex and a CRB-65 score > 0. The most frequent symptom was dyspnoea (30.1%). Sixty-five patients died, most of whom were in the 2nd wave. A total of 182 (12.5%) hospital employees were infected, 63 (34.6%) of whom were involved in outbreaks. An occupational risk of infection during outbreaks was particularly common among nurses and HCWs working on regular wards. Eleven hospital outbreaks led to high economic impact on both hospitals through the loss of manpower as result of infected employees, temporary locked wards, blocked beds, a reduced number of total hospitalized patients and increased personnel costs.

CONCLUSION

Continuously adaptation of infection prevention strategies is a valuable tool to keep hospitals safe places for patients and employees. We do need more analyses of the different pandemic waves and applied infection prevention strategies to learn from weak points.

TRIAL REGISTRATION

This research was conducted in accordance with the Declaration of Helsinki and national standards. The study protocol was approved by the relevant ethics committee of the Chamber of Physicians Westphalia-Lippe and University of Münster (no. 2021-475-f-S). The study was registered on 25th August 2021 at the German Clinical Trials Register (DRKS00025865).

Evolution of in-hospital patient characteristics and predictors of death in the COVID-19 pandemic across four waves: are they moving targets with implications for patient care?

Objectives

The aim of this work was to study characteristics, outcomes and predictors of all-cause death in inpatients with SARS-CoV-2 infection across the pandemic waves in one large teaching hospital in Italy to optimize disease management.

Methods

All patients with SARS-CoV-2 infection admitted to our center from March 2020 to June 2022 were included in this retrospective observational cohort study. Both descriptive and regression tree analyses were applied to identify factors influencing all-cause mortality.

Results

527 patients were included in the study (65.3% with moderate and 34.7% with severe COVID-19). Significant evolutions of patient characteristics were found, and mortality increased in the last wave with respect to the third wave notwithstanding vaccination. Regression tree analysis showed that in-patients with severe COVID-19 had the greatest mortality across all waves, especially the older adults, while prognosis depended on the pandemic waves in patients with moderate COVID-19: during the first wave, dyspnea was the main predictor, while chronic kidney disease emerged as determinant factor afterwards.

Conclusion

Patients with severe COVID-19, especially the older adults during all waves, as well as those with moderate COVID-19 and concomitant chronic kidney disease during the most recent waves require more attention for monitoring and care. Therefore, our study drives attention towards the importance of co-morbidities and their clinical impact in patients with COVID-19 admitted to hospital, indicating that the healthcare system should adapt to the evolving features of the epidemic.