Epidemiological, socio-demographic and clinical features of the early phase of the COVID-19 epidemic in Ecuador

Association between olfactory dysfunction and COVID-19 severity: A prospective study in a highly complex hospital in Peru

INTRODUCTION

Olfactory dysfunction has been included among the early symptoms of coronavirus disease (COVID-19). Evidence suggests that a relationship exists between the duration of olfaction disorders and the probability of developing severe COVID-19. Given the scope of the COVID-19 pandemic, this study aimed to determine the frequency of smell alteration and its association with the severity of COVID-19 in a referral hospital in Peru, which is one of the most affected countries in the Latin American region.

MATERIALS AND METHODS

This study was an observational, prospective cohort study that included patients with COVID-19 who were treated at the Hospital Nacional Edgardo Rebagliati Martins from August to November 2020. To assess the association, the chi-square test of independence or Fisher's exact test was performed. The outcome variable was COVID-19 severity, and the exposure variable was olfactory dysfunction. The first data collection was in the emergency department and the follow-up was via telephone.

RESULTS

A total of 179 patients were included. The mean age was 61.6 ± 15.5 years, and 129 patients (72.1%) were male. Olfactory dysfunction was observed in 43 patients (24%). An inverse association was found between age and olfactory dysfunction (P = .002). No significant association was found between COVID-19 severity level and olfactory alteration (P = .056). However, a direct association was found between COVID-19 severity and age (P = .003), cough (P < .001), and respiratory distress (P = .003).

CONCLUSION

This study did not find any association between the severity of COVID-19 and olfactory dysfunction. It showed a low incidence rate of smell alteration compared with studies from other regions. Moreover, smell alteration was associated with younger age.

A proposed analytical approach to estimate excess daily mortality rates in Ecuador

Background

The COVID-19 pandemic has proved deadly all over the globe; however, one of the most lethal outbreaks occurred in Ecuador.

Aims

This study aims to highlight the pandemic's impact on the most affected countries worldwide in terms of excess deaths per capita and per day.

Methods

An ecological study of all-cause mortality recorded in Ecuador was performed. To calculate the excess deaths relative to the historical average for the same dates in 2017, 2018, and 2019, we developed a bootstrap method based on the central tendency measure of mean. A Poisson fitting analysis was used to identify trends on officially recorded all-cause deaths and COVID-19 deaths. A bootstrapping technique was used to emulate the sampling distribution of our expected deaths estimator μ ⌢ d e a t h s by simulating the data generation and model fitting processes daily since the first confirmed case.

Results

In Ecuador, during 2020, 115,070 deaths were reported and 42,453 were cataloged as excess mortality when compared to 2017-2019 period. Ecuador is the country with the highest recorded excess mortality in the world within the shortest timespan. In one single day, Ecuador recorded 1,120 deaths (6/100,000), which represents an additional 408% of the expected fatalities.

Conclusion

Adjusting for population size and time, the hardest-hit country due to the COVID-19 pandemic was Ecuador. The mortality excess rate shows that the SARS-CoV-2 virus spread rapidly in Ecuador, especially in the coastal region. Our results and the proposed new methodology could help to address the real situation of the number of deaths during the initial phase of pandemics.

Causal effect of air pollution and meteorology on the COVID-19 pandemic: A convergent cross mapping approach

Environmental factors have been suspected to influence the propagation and lethality of COVID-19 in the global population. However, most of the studies have been limited to correlation analyses and did not use specific methods to address the dynamic of the causal relationship between the virus and its external drivers. This work focuses on inferring and understanding the causal effect of critical air pollutants and meteorological parameters on COVID-19 by using an Empirical Dynamic Modeling approach called Convergent Cross Mapping. This technique allowed us to identify the time-delayed causation and the sign of interactions. Considering its remarkable urban environment and mortality rate during the pandemic, Quito, Ecuador, was chosen as a case study. Our results show that both urban air pollution and meteorology have a causal impact on COVID-19. Even if the strength and the sign of the causality vary over time, a general trend can be drawn. NO2, SO2, CO and PM2.5 have a positive causation for COVID-19 infections (ρ > 0.35 and ∂ > 9.1). Contrary to current knowledge, this study shows a rapid effect of pollution on COVID-19 cases (1 < lag days <24) and a negative impact of O3 on COVID-19-related deaths (ρ = 0.53 and ∂ = -0.3). Regarding the meteorology, temperature (ρ = 0.24 and ∂ = -0.4) and wind speed (ρ = 0.34 and ∂ = -3.9) tend to mitigate the epidemiological consequences of SARS-CoV-2, whereas relative humidity seems to increase the excess deaths (ρ = 0.4 and ∂ = 0.05). A causal network is proposed to synthesize the interactions between the studied variables and to provide a simple model to support the management of coronavirus outbreaks.

Epidemiological contemplation for a currently pragmatic COVID-19 health passport: a perspective

The coronavirus disease 2019 (COVID-19) has caused a global pandemic that has wreaked havoc on the lives of millions of people around the world. Confinement measures aim to reduce the epidemic's spread and minimize the burden of morbidity and mortality. In response to the challenges caused by the pandemic, digital health passports have been developed exponentially. We highlight the latent epidemiological barriers to health passports to achieve standardized digital care platforms. This review paper not only highlights the epidemiological barriers but also articulates the possible infrastructure required to make the International Standard for a multi-factor authenticated and validated health passport.

Vaccination against influenza viruses reduces infection, not hospitalization or death, from respiratory COVID-19: A systematic review and meta-analysis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 and has brought a huge burden in terms of human lives. Strict social distance and influenza vaccination have been recommended to avoid co-infections between influenza viruses and SARS-CoV-2. Scattered reports suggested a protective effect of influenza vaccine on COVID-19 development and severity. We analyzed 51 studies on the capacity of influenza vaccination to affect infection with SARS-CoV-2, hospitalization, admission to Intensive Care Units (ICU), and mortality. All subjects taken into consideration did not receive any anti-SARS-CoV-2 vaccine, although their status with respect to previous infections with SARS-CoV-2 is not known. Comparison between vaccinated and not-vaccinated subjects for each of the four endpoints was expressed as odds ratio (OR), with 95% confidence intervals (CIs); all analyses were performed by DerSimonian and Laird model, and Hartung-Knapp model when studies were less than 10. In a total of 61 029 936 subjects from 33 studies, influenza vaccination reduced frequency of SARS-CoV-2 infection [OR plus 95% CI = 0.70 (0.65-0.77)]. The effect was significant in all studies together, in health care workers and in the general population; distance from influenza vaccination and the type of vaccine were also of importance. In 98 174 subjects from 11 studies, frequency of ICU admission was reduced with influenza vaccination [OR (95% CI) = 0.71 (0.54-0.94)]; the effect was significant in all studies together, in pregnant women and in hospitalized subjects. In contrast, in 4 737 328 subjects from 14 studies hospitalization was not modified [OR (95% CI) = 1.05 (0.82-1.35)], and in 4 139 660 subjects from 19 studies, mortality was not modified [OR (95% CI) = 0.76 (0.26-2.20)]. Our study emphasizes the importance of influenza vaccination in the protection against SARS-CoV-2 infection.

Parity of esteem: A global COVID-19 vaccination approach for people with mental illnesses, based on facts from 34 countries; recommendations and solutions

Background

The coronavirus disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has detrimental effects on physical and mental health. Patients with severe mental illness are at higher risk of contracting the virus due to social determinants of health. Vulnerable populations include the elderly, people with pre-existing conditions, and those exposed to SARS-CoV-2. Unfortunately, only a few countries have updated vaccination strategies to prioritize patients with mental illnesses. Therefore, we aimed to explore whether individuals with mental disorders are prioritized in vaccine allocation strategies in different world regions. They are often neglected in policymaking but are highly vulnerable to the threatening complications of COVID-19.

Methods

A questionnaire was developed to record details regarding COVID-19 vaccination and prioritizations for groups of persons with non-communicable diseases (NCDs), mental disorders, and substance use disorders (SUDs). NCDs were defined according to the WHO as chronic diseases that are the result of a combination of genetic, physiological, environmental, and behavioral factors such as cardiovascular diseases, cancer, respiratory diseases, and diabetes.

Results

Most countries surveyed (80%) reported healthcare delivery via a nationalized health service. It was found that 82% of the countries had set up advisory groups, but only 26% included a mental health professional. Most frequently, malignancy (68%) was prioritized followed by diabetes type 2 (62%) and type 1 (59%). Only nine countries (26%) prioritized mental health conditions.

Conclusion

The spread of the coronavirus has exposed both the strengths and flaws of our healthcare systems. The most vulnerable groups suffered the most and were hit first and faced most challenges. These findings raise awareness that patients with mental illnesses have been overlooked in immunization campaigns. The range of their mortality, morbidity, and quality of life could have widened due to this delay.

Maternal mortality and COVID-19: A nationwide ecological analysis from Ecuador

BACKGROUND

During the COVID-19 pandemic, distinct population subsets, including pregnant women, have been differentially affected. While over 90% of COVID-19-infected pregnant women experience a benign course, a subset demonstrates marked clinical exacerbation. Symptomatic pregnant individuals, in particular, present a heightened risk of severe disease in comparison to their non-pregnant counterparts.

OBJECTIVE

The objective of this study is to systematically evaluate the epidemiological characteristics of COVID-19 in pregnant women, assess related maternal mortalities, ascertain the case fatality rate, and delineate associated risk factors.

DESIGN

This is a comprehensive population-based ecological study.

METHODOLOGY

A population-based study was conducted to investigate the epidemiological patterns of COVID-19-associated morbidity and mortality in pregnant women in Ecuador from 27 February 2020 to 14 May 2021.

RESULTS

A total of 3274 positive COVID-19 cases were identified among pregnant women, with 22 official fatalities, yielding a case fatality rate of 0.67%. The majority of cases were of Mestizo ethnicity (92.66%); however, the highest case fatality rate was noted among indigenous pregnant women (case fatality rate = 1.25%), those aged between 40 and 44 years (case fatality rate = 2.68%), and those with a history of comorbidities (2.08%). Pregnant women residing at lower altitudes (<2500 m) exhibited a higher incidence rate (0.20/100,000) compared to those at higher altitudes (>2500 m), which stood at 0.17/100,000.

CONCLUSION

The COVID-19 pandemic has profoundly impacted pregnant women in Ecuador during the first 14 months, particularly those with comorbidities, older age, and of indigenous ethnicity. These factors have heightened their vulnerability and susceptibility to severe COVID-19 infection and subsequent mortality. This underscores the urgency for comprehensive protective measures, including prioritization for vaccination. Further studies are needed to inform tailored prevention strategies and therapeutic interventions for these high-risk groups.

Poor regulation, desperation, and misinformation, a countrywide analysis of self-medication and prescription patterns in Ecuador during the COVID-19 pandemic

BACKGROUND

The rapid spread of the SARS-CoV-2 virus during the early phase of the pandemic led to an unprecedented global health crisis. Various factors have influenced self-medication practices among the general population and unsubstantiated prescribing practices among healthcare professionals.

OBJECTIVE

This study aimed to describe trends in the purchase and sale of medicines during the COVID-19 pandemic period (2020-2022) in Ecuador, by comparing them with pre-pandemic periods.

METHODS

In this study, a cross-sectional design was employed to conduct a comprehensive analysis of 28 pharmacological groups, categorized according to the Anatomical Therapeutic Chemical Classification (ATC). Utilizing an integrated drug consumption database, the study examined physician prescribing data, medicine usage, and spending levels in Ecuador during the COVID-19 pandemic. The analysis involved computing absolute differences in monthly resolution, calculating excessive expenditure in comparison to previous yearly averages, and using Defined Daily Dose (DDD) methodology for internationally comparable results. Furthermore, a correlation analysis was performed to investigate potential associations between prescribed and consumed medicines and the number of new cases and deaths.

RESULTS

In Ecuador, the average yearly expenditure among these groups prior to the pandemic (2017-2019) amounted to $150,646,206 USD, whereas during 2020 and 2021, the same groups represented a total expenditure of $228,327,210, reflecting a significant increase. The excess expenditure during this period reached 51.4%, equivalent to $77,681,004 USD. Notably, 13% of this expenditure consisted of Over the Counter (OTC) Medicines. The study also identified a remarkable surge in sales of ivermectin, which increased by 2,057%, and hydroxychloroquine, which increased by 171%, as measured by DDD.

CONCLUSIONS

This study highlights the substantial consumption of medicines by the population in Ecuador during the pandemic. It is concerning that many medications were sold without proven therapeutic indications, indicating that misinformation and desperation may have led to improper prescribing by physicians and patients resorting to ineffective drugs. Moreover, since the sale of these therapeutic drugs requires a prescription, poor regulation, and a lack of control within pharmacies likely contributed to such practices.

Epidemiological analysis over two years of SARS-CoV-2 circulation in southern Brazil: old and novel predictors of COVID-19 outcome

The overwhelming majority of SARS-CoV-2 epidemiological studies cover a narrow time period, making general knowledge about the COVID-19 pandemic difficult. To assess COVID-19-related host aspects in the overall pandemic, we analyzed COVID-19 cases during the first two years of SARS-CoV-2 circulation in southern Brazil. Herein, 390 patients admitted in 2020-2022 to a Brazilian public referral hospital were allocated into two groups according to the COVID-19 outcome: hospital discharge (n=237) or death (n=153). In the univariate analysis, several variables, including sociodemographic, clinical and laboratory aspects (primary data), were significantly different between the analyzed groups. In multivariate logistic regression, eight of these factors remained associated with the COVID-19 outcome. In particular, we report oxygen supplementation and the need for hemodialysis as predictors of hospital discharge and death from COVID-19, respectively. To the best of our knowledge, none of these findings have been previously reported in the Brazilian or world population. In conclusion, our results contribute to current knowledge by demonstrating that factors described at different times may remain associated with COVID-19 over the pandemic and by identifying novel predictors of COVID-19 outcome.

Coinfection of SARS-CoV-2 with other respiratory pathogens in outpatients from Ecuador

Worldwide, the COVID-19 pandemic caused by SARS-CoV-2 has enormously impacted healthcare systems, especially in low and middle-income countries. Coinfections with respiratory pathogens in COVID-19 patients may contribute to worse outcomes. This study identified the presence of 12 viral coinfections and pneumococcal carriers among individuals with SARS-CoV-2 infection in outpatient and community settings in Ecuador. From January 2020 to November 2021, 215 nasopharyngeal and nasal swabs were taken from individuals who reported symptoms of COVID-19 or had known exposure to someone with confirmed or suspected COVID-19. One hundred fifty-eight tested positive for SARS-CoV-2 by RT-qPCR and coinfections were detected in 12% (19/158) of SARS-CoV-2-positive patients; the most frequent coinfection was with influenza A virus at 4.4% (7/158; 95% CI: 1.2-7.6), followed by respiratory syncytial virus with 3.1% (5/158; 95% CI: 0.4-5.8), and finally rhinovirus and human coronavirus NL63 with 1.2% (2/158). Pneumococcal carriage was detected in 3.7% (6/158; 95% CI: 0.76-6.64) of SARS-CoV-2 cases. Influenza B, adenovirus, human metapneumovirus (HMPV), parainfluenza virus types 1, 2, and 3, and human coronavirus HKU1 were undetected. To our knowledge, this is the first study of coinfection of SARS-CoV-2 and respiratory pathogens performed on outpatients in Latin America. The high proportion of outpatients with viral coinfections reported in our cohort allows us to suggest that testing for SARS-CoV-2 and other common respiratory pathogens should be carried out to ensure accurate diagnoses, prompt patient treatment, and appropriate isolation.

Immediate and long-term changes in infectious diseases in China at the "First-level-response", "Normalized-control" and "Dynamic-COVID-zero" stages from 2020 to 2022: a multistage interrupted-time-series-analysis

BACKGROUND

From January 2020 to December 2022, China implemented "First-level-response", "Normalized-control" and "Dynamic-COVID-zero" to block the COVID-19 epidemic; however, the immediate and long-term impact of three strategies on other infectious diseases and the difference in their impact is currently unknown. We aim to provide a more comprehensive understanding of the impact of non-pharmacological interventions (NPIs) on infectious diseases in China.

METHODS

We collected data on the monthly case count of infectious diseases in China from January 2015 to July 2022. After considering long-term trends using the Cox-Stuart test, we performed the two ratio Z tests to preliminary analyze the impact of three strategies on infectious diseases. Next, we used a multistage interrupted-time-series analysis fitted by the Poisson regression to evaluate and compare the immediate and long-term impact of three strategies on infectious diseases in China.

RESULTS

Compared to before COVID-19, the incidence of almost all infectious diseases decreased immediately at stages 1, 2, and 3; meanwhile, the slope in the incidence of many infectious diseases also decreased at the three stages. However, the slope in the incidence of all sexually transmitted diseases increased at stage 1, the slope in the incidence of all gastrointestinal infectious diseases increased at stage 2, and the slope in the incidence of some diseases such as pertussis, influenza, and brucellosis increased at stage 3. The immediate and long-term limiting effects of "Normalized-control" on respiratory-transmitted diseases were weaker than "First-level-response" and the long-term limiting effects of "Dynamic-COVID-zero" on pertussis, influenza, and hydatid disease were weaker than "Normalized-control".

CONCLUSIONS

Three COVID-19 control strategies in China have immediate and long-term limiting effects on many infectious diseases, but there are differences in their limiting effects. Evidence from this study shows that pertussis, influenza, brucellosis, and hydatid disease began to recover at stage 3, and relaxation of NPIs may lead to the resurgence of respiratory-transmitted diseases and vector-borne diseases.

Development and validation of a scoring system to predict mortality in patients hospitalized with COVID-19: A retrospective cohort study in two large hospitals in Ecuador

OBJECTIVE

To develop and validate a scoring system to predict mortality among hospitalized patients with COVID-19.

METHODS

Retrospective cohort study. We analyzed 5,062 analyzed hospitalized patients with COVID-19 treated at two hospitals; one each in Quito and Guayaquil, from February to July 2020. We assessed predictors of mortality using survival analyses and Cox models. We randomly divided the database into two sets: (i) the derivation cohort (n = 2497) to identify predictors of mortality, and (ii) the validation cohort (n = 2565) to test the discriminative ability of a scoring system. After multivariate analyses, we used the final model's β-coefficients to build the score. Statistical analyses involved the development of a Cox proportional hazards regression model, assessment of goodness of fit, discrimination, and calibration.

RESULTS

There was a higher mortality risk for these factors: male sex [(hazard ratio (HR) = 1.32, 95% confidence interval (95% CI): 1.03-1.69], per each increase in a quartile of ages (HR = 1.44, 95% CI: 1.24-1.67) considering the younger group (17-44 years old) as the reference, presence of hypoxemia (HR = 1.40, 95% CI: 1.01-1.95), hypoglycemia and hospital hyperglycemia (HR = 1.99, 95% CI: 1.01-3.91, and HR = 1.27, 95% CI: 0.99-1.62, respectively) when compared with normoglycemia, an AST-ALT ratio >1 (HR = 1.55, 95% CI: 1.25-1.92), C-reactive protein level (CRP) of >10 mg/dL (HR = 1.49, 95% CI: 1.07-2.08), arterial pH <7.35 (HR = 1.39, 95% CI: 1.08-1.80) when compared with normal pH (7.35-7.45), and a white blood cell count >10 × 103 per μL (HR = 1.76, 95% CI: 1.35-2.29). We found a strong discriminative ability in the proposed score in the validation cohort [AUC of 0.876 (95% CI: 0.822-0.930)], moreover, a cutoff score ≥39 points demonstrates superior performance with a sensitivity of 93.10%, a specificity of 70.28%, and a correct classification rate of 72.66%. The LR+ (3.1328) and LR- (0.0981) values further support its efficacy in identifying high-risk patients.

CONCLUSION

Male sex, increasing age, hypoxemia, hypoglycemia or hospital hyperglycemia, AST-ALT ratio >1, elevated CRP, altered arterial pH, and leucocytosis were factors significantly associated with higher mortality in hospitalized patients with COVID-19. A statistically significant Cox regression model with strong discriminatory power and good calibration was developed to predict mortality in hospitalized patients with COVID-19, highlighting its potential clinical utility.

Factors associated with COVID-19 length of hospitalization and mortality during four epidemic waves, March 2020-November 2021, Suriname

Objectives

To determine the sociodemographic risk factors associated with coronavirus disease 2019 (COVID-19) mortality in Suriname.

Methods

This was a retrospective cohort study. All registered deaths from COVID-19 in Suriname (n=1112) between March 13, 2020 and November 11, 2021 were included. Data were collected from medical records and included demographic variables and hospitalization duration of patients who died. Descriptive statistics, chi-squared tests, ANOVA models, and logistic regression analyses were used to determine associations between sociodemographic variables, length of hospitalization, and mortality during four epidemic waves.

Results

The case fatality rate over the study period was 22 per 1 000 population. The first epidemic wave was from July to August 2020, the second from December 2020 to January 2021, the third from May to June 2021, and the fourth from August to September 2021. Significant differences were found in the number of deaths and hospitalization duration by wave (p<0.001). Patients were more likely to have a longer hospitalization during the first (OR 1.66; 95% CI: 0.98, 2.82) and third waves (OR 2.37; 95% CI: 1.71, 3.28) compared with the fourth wave. Significant differences in mortality were also seen between ethnicities by wave (p=0.010). Compared with the mixed and other group, people of Creole ethnicity (OR 2.7; 95% CI: 1.33, 5.29) and Tribal people (OR 2.8; 95% CI: 1.12, 7.02) were more likely to die during the fourth wave than the third wave.

Conclusions

Tailored interventions are needed for males, people of Creole descent, Tribal and Indigenous peoples, and people older than 65 years.

Gender Differences in Response to COVID-19 Infection and Vaccination

Since COVID-19 first appeared, a number of follow-up events have taken place. In an effort to find a solution to this catastrophe, a great deal of study and analysis has been conducted. Because of the high morbidity and exceptionally large losses, scientists are being pushed to conduct more research and find vaccination and treatments. The virus has a wide range of effects, one of which is how it affects sexual activity in both men and women. The impact of the cardiovascular system and susceptibility to embolism, lung stress, and infection heightens the probability of hospitalization in the intensive care unit for pregnant women who have contracted COVID-19. There is no evidence of infection being passed from mother to child. In the current review, the role of COVID-19 infection and vaccination on male and female sexual activity, hormones, and the menstrual cycle for females, as well as on male sex hormones and sexual activity during infection and after vaccination, are being investigated. There are no reports of the virus being isolated from the semen of an infected patient or recently recovered patients. A recent investigation on the influence of the virus on gender susceptibility to sexual organs and function has been uncovered throughout this study.

COVID-19 seroprevalence among local authority workers from Orléans Métropole, the Community of Communes of the Terres du Val de Loire, the local public service management centre of the Loiret department and the Region Centre Val de Loire: a prospective epidemiological study

OBJECTIVE

To evaluate the SARS-CoV-2 seroprevalence among local authority workers, depending on their position and potential interaction with the public.

METHODS

A cohort of volunteer participants was recruited among local authority workers of the Centre Val de Loire region in France, to be tested using a rapid serological test (COVID-PRESTO). The collected data were analysed by comparing different parameters including, gender, age, position held, and contact or not with the public. The study was carried out from August to December 2020 and included 3228 participants (n=3228), from 18 to 65 years old.

RESULTS

The seroprevalence of SARS-CoV-2 among local authority workers was estimated at 3.04%. No significant difference could be observed according to the position held by the workers and whether they were or not in contact with the public. Nevertheless, a significant difference was observed between the different investigating centres, in correlation with the geographical location.

CONCLUSION

Contact with members of the public was not a critical parameter for SARS-CoV-2 seroprevalence as long as protective measures are applied. Among the population included in the study, childcare workers were more at risk of getting infected by the virus.

TRIAL REGISTRATION NUMBER

NCT04387968.

Social deprivation and SARS-CoV-2 testing: a population-based analysis in a highly contrasted southern France region

Background

Testing was the cornerstone of the COVID-19 epidemic response in most countries until vaccination became available for the general population. Social inequalities generally affect access to healthcare and health behaviors, and COVID-19 was rapidly shown to impact deprived population more drastically. In support of the regional health agency in Provence-Alpes-Côte d'Azur (PACA) in South-Eastern France, we analyzed the relationship between testing rate and socio-demographic characteristics of the population, to identify gaps in testing coverage and improve targeting of response strategies.

Methods

We conducted an ecological analysis of SARS-CoV-2/COVID-19 testing rate in the PACA region, based on data aggregated at the finest spatial resolution available in France (IRIS) and by periods defined by public health implemented measures and major epidemiological changes. Using general census data, population density, and specific deprivation indices, we used principal component analysis followed by hierarchical clustering to define profiles describing local socio-demographic characteristics. We analyzed the association between these profiles and testing rates in a generalized additive multilevel model, adjusting for access to healthcare, presence of a retirement home, and the age profile of the population.

Results

We identified 6 socio-demographic profiles across the 2,306 analyzed IRIS spatial units: privileged, remote, intermediate, downtown, deprived, and very deprived (ordered by increasing social deprivation index). Profiles also ranged from rural (remote) to high density urban areas (downtown, very deprived). From July 2020 to December 2021, we analyzed SARS-CoV-2/COVID-19 testing rate over 10 periods. Testing rates fluctuated strongly but were highest in privileged and downtown areas, and lowest in very deprived ones. The lowest adjusted testing rate ratios (aTRR) between privileged (reference) and other profiles occurred after implementation of a mandatory healthpass for many leisure activities in July 2021. Periods of contextual testing near Christmas displayed the largest aTRR, especially during the last periods of 2021 after the end of free convenience testing for unvaccinated individuals.

Conclusion

We characterized in-depth local heterogeneity and temporal trends in testing rates and identified areas and circumstances associated with low testing rates, which the regional health agency targeted specifically for the deployment of health mediation activities.

Solar desalination/purification (solar stills, humidification-dehumidification, solar disinfection) in high altitude during COVID19: Insights of gastrointestinal manifestations and systems' mechanism

From the starting of the pandemic different transmission routes of the pathogen was brought into the spotlight by researchers from different disciplines. This matter in high-altitudes was more boosted as the main parameters were not exactly realized. In this review we are about to highlight the possibility of consuming contaminated water generated form solar water desalination/disinfection systems in highlands. Three systems including solar still, solar disinfection (which experimented by the authors in 2019 in high altitude) and humidification-dehumidification were consider in this context. Ascribe to the risks of pathogens transmission in solar desalination/disinfection systems where the water resources are heavily polluted in every corner of the world, highlighting the risk of consuming water in high-altitude where there are many other parameters associated with spread of pathogen is of great importance. As it was reported, reliability of solar desalination and solar water disinfections systems against contaminated water by the novel coronavirus remained on the question because the virus can be transmitted by vapor in solar stills due to tiny particle size (60-140 nm) and would not be killed by solar disinfections due to low-temperature of operation <40 °C while for HDH contamination of both water and air by sars-cov-2 could be a concern. Although the SARS-CoV-2 is not a waterborne pathogen, its capability to replicate in stomach and infection of gastrointestinal glandular suggested the potential of transmission via fecal-oral. Eventually, it was concluded that using solar-based water treatment as drinking water in high altitude regions should be cautiously consider and recommendations and considerations are presented. Importantly, this critical review not only about the ongoing pandemic, but it aims is to highlight the importance of produced drinking water by systems for future epidemic/pandemic to prevent spread and entering a pathogen particularly in high-altitude regions via a new routes.

Fatal work accidents in Ecuador from 2014 to 2020: How the age of the deceased worker relates to the accidents' temporal and geographical characteristics

This article analyzes the relationship between the age of male workers deceased in work accidents and temporal (year, month, day of the week, working shifts), geographic (provinces), and economic sector characteristics in which the accidents occurred in Ecuador between 2014 and 2020. Available data on fatal accidents from the Ecuadorian Social Security Institute (IESS) were collected. The results, which report both frequencies and proportions (rates), indicate that fatal accidents have decreased in the period, although the average age of deceased workers has increased. No significant differences were found regarding the month, day of the week, and work shift, nor in the frequency of accidents or the age of the deceased workers. However, differences were found in terms of geographical areas and sectors of economic activity. This study contributes to the literature as it is the first to analyze the temporal and geographical characteristics of fatal accidents about the age of the deceased worker.

Communication inequalities and health disparities among vulnerable groups during the COVID-19 pandemic - a scoping review of qualitative and quantitative evidence

BACKGROUND

The COVID-19 pandemic has exacerbated health disparities in vulnerable groups (e.g., increased infection, hospitalization, and mortality rates in people with lower income, lower education, or ethnic minorities). Communication inequalities can act as mediating factors in this relationship. Understanding this link is vital to prevent communication inequalities and health disparities in public health crises. This study aims to map and summarize the current literature on communication inequalities linked with health disparities (CIHD) in vulnerable groups during the COVID-19 pandemic and to identify research gaps.

METHODS

A scoping review of quantitative and qualitative evidence was conducted. The literature search followed the guidelines of PRISMA extension for scoping reviews and was performed on PubMed and PsycInfo. Findings were summarized using a conceptual framework based on the Structural Influence Model by Viswanath et al. RESULTS: The search yielded 92 studies, mainly assessing low education as a social determinant and knowledge as an indicator for communication inequalities. CIHD in vulnerable groups were identified in 45 studies. The association of low education with insufficient knowledge and inadequate preventive behavior was the most frequently observed. Other studies only found part of the link: communication inequalities (n = 25) or health disparities (n = 5). In 17 studies, neither inequalities nor disparities were found.

CONCLUSIONS

This review supports the findings of studies on past public health crises. Public health institutions should specifically target their communication to people with low education to reduce communication inequalities. More research about CIHD is needed on groups with migrant status, financial hardship, not speaking the language in the country of residence, sexual minorities, and living in deprived neighborhoods. Future research should also assess communication input factors to derive specific communication strategies for public health institutions to overcome CIHD in public health crises.

A competing risk survival analysis of the sociodemographic factors of COVID-19 in-hospital mortality in Ecuador

This study aimed to analyze the effect of sociodemographic characteristics on COVID-19 in-hospital mortality in Ecuador from March 1 to December 31, 2020. This retrospective longitudinal study was performed with data from publicly accessible registries of the Ecuadorian National Institute of Statistics and Censuses (INEC). Data underwent a competing risk analysis with estimates of the cumulative incidence function (CIF). The effect of covariates on CIFs was estimated using the Fine-Gray model and results were expressed as adjusted subdistribution hazard ratios (SHR). The analysis included 30,991 confirmed COVID-19 patients with a mean age of 56.57±18.53 years; 60.7% (n = 18,816) were men and 39.3% (n = 12,175) were women. Being of advanced age, especially older than or equal to 75 years (SHR = 17.97; 95%CI: 13.08-24.69), being a man (SHR = 1.29; 95%CI: 1.22-1.36), living in rural areas (SHR = 1.18; 95%CI: 1.10-1.26), and receiving care in a public health center (SHR = 1.64; 95%CI: 1.51-1.78) were factors that increased the incidence of death from COVID-19, while living at an elevation higher than 2,500 meters above sea level (SHR = 0.69; 95%CI: 0.66-0.73) decreased this incidence. Since the incidence of death for individuals living in rural areas and who received medical care from the public sector was higher, income and poverty are important factors in the final outcome of this disease.

High SARS-CoV-2 infection rates and viral loads in community-dwelling individuals from rural indigenous and mestizo communities from the Andes during the first wave of the COVID-19 pandemic in Ecuador

Background

Neglected indigenous groups and underserved rural populations in Latin America are highly vulnerable to COVID-19 due to poor health infrastructure and limited access to SARS-CoV-2 diagnosis. The Andean region in Ecuador includes a large number of isolated rural mestizo and indigenous communities living under poverty conditions.

Objective

We herein present a retrospective analysis of the surveillance SARS-CoV-2 testing in community-dwelling populations from four provinces in the Ecuadorian Andes, carried out during the first weeks after the national lockdown was lifted in June 2020.

Results

A total number of 1,021 people were tested for SARS-CoV-2 by RT-qPCR, resulting in an overall high infection rate of 26.2% (268/1,021, 95% CI: 23.6-29%), which was over 50% in several communities. Interestingly, community-dwelling super spreaders with viral loads over 10⁸ copies/mL represented 7.46% (20/268, 95% CI: 4.8-11.1%) of the SARS-CoV-2 infected population.

Conclusion

These results support that COVID-19 community transmission in rural communities from the Andean region was happening at the early stages of the COVID-19 pandemic in Ecuador and point out the weakness of the COVID-19 control program. Community-dwelling individuals in neglected rural and indigenous communities should be considered for a successful control and surveillance program in future pandemics in low- and middle-income countries.

Why were some countries more successful than others in curbing early COVID-19 mortality impact? A cross-country configurational analysis

Why was there considerable variation in initial COVID-19 mortality impact across countries? Through a configurational lens, this paper examines which configurations of five conditions-a delayed public-health response, past epidemic experience, proportion of elderly in population, population density, and national income per capita-influence early COVID-19 mortality impact measured by years of life lost (YLL). A fuzzy-set qualitative comparative analysis (fsQCA) of 80 countries identifies four distinctive pathways associated with high YLL rate and four other different pathways leading to low YLL rate. Results suggest that there is no singular "playbook"-a set of policies that countries can follow. Some countries failed differently, whereas others succeeded differently. Countries should take into account their situational contexts to adopt a holistic response strategy to combat any future public-health crisis. Regardless of the country's past epidemic experience and national income levels, a speedy public-health response always works well. For high-income countries with high population density or past epidemic experience, they need to take extra care to protect elderly populations who may otherwise overstretch healthcare capacity.

A comprehensive study of Ecuadorian adult patients with a mild and moderate presentation of COViD-19

AIM

To characterize non-hospitalized patients with mild and moderate clinical presentation.

METHODS

We performed an epidemiological, observational, descriptive, and cross-sectional study carried out in Ecuador, with 1,447 participants between 18 and 66 years, non-hospitalized, with a molecular RT-PCR test for SARS-CoV2. We analyzed demographic characteristics according to sex, age group, clinical findings, behavior after diagnosis, family and social behavior, sequelae, clinical evolution, type of exposure, and personal history.

RESULTS

The sample analyzed had a mean age of 37 years (95% CI 18-66), women 713 individuals (49.27%), men 733 individuals (50.66%). Age group distribution was 18-30 years, 524 individuals (36.29%), 31-45, 538 individuals (37.26), and more of 45 years, 382 individuals (26.46%). 1416 individuals were mestizos (97.99%). According to the province of residence from Pichincha were 1019 patients (70.52%), followed by Imbabura, 93 patients (6.44%), and the others 335 (23.15%) patients come from all over the country. In women, the most common findings were fever >38°C (54.40%), sputum (27.43%) and hypoxia (16.32%); HTN (5.75%) and hypercholesterolemia (3.69%). Men were more prevalent in all other findings. Comorbidities were more prevalent in all those over 45 years of age. COVID-19 antibodies test was positive in 416 patients (28.85%). Neuropsychiatric symptoms such as sleep disorders, generalized anxiety disorder, depressed mood, and chronic fatigue were more prevalent in men than women. Still, generalized anxiety disorder and chronic fatigue were more common in individuals of 31 to 45 years. 868 patients (60.07%) were in contact with a known infected person, 318 patients (22.02%) were health workers, and 782 patients (57.63%) were informed about work exposure. 545 patients (37.72%) were overweight, primarily women 310 (42.29%). 609 patients (42.65%) showed symptoms after the acute period, and 331 individuals (23.49%) reported some sequelae.

CONCLUSION

The epidemiological and clinical behavior of hospitalized and critical patients differs greatly from ambulatory or mild or moderate symptoms. It is essential to highlight those non-hospitalized patients constitute the predominant population of patients, hence the importance of adequate management that would directly affect the development of complicated forms and, consequently, the collapse of healthcare centers. It is vitally important to open more investigations that compare hospitalized and outpatient patients to have a clearer picture of the epidemic.

The deadly impact of COVID-19 among children from Latin America: The case of Ecuador

Background

The SARS-CoV-2 pandemic remains a critical global health concern, with older adults being the most vulnerable group. Nonetheless, it is crucial to recognize that COVID-19 has caused numerous deaths in children worldwide. Emerging evidence indicates that infants and breastfeeding children, particularly those aged below one year, face a greater risk of hospitalization and mortality than older children with COVID-19.

Objective

This study aimed to describe the epidemiology of COVID-19 among children during the early phase of the pandemic in Ecuador.

Methods

We conducted a country-wide population-based analysis of the epidemiology of COVID-19, using incidence and mortality data reported from Ecuador between February 15, 2020 and May 14 2021. Measurements of frequency, central tendency, dispersion, and absolute differences were calculated for all categorical and continuous variables.

Results

At least 34,001 cases (23,587 confirmed cases, 5,315 probable and 5,099 suspected) and 258 COVID-19 related deaths have been reported among children in Ecuador during the first 16 months of the pandemic. The overall incidence rate was 612 cases per 100,000 children, the mortality rate was 3 per 100,000, while the case fatality rate was 0.76%. The highest risk group for infection was children and adolescents between 15 and 19 years of age; however, the highest mortality rate occurred in children under one year of age. The largest provinces, such as Pichincha, Guavas and Manabí, were the ones that reported the highest number of cases, 27%, 12.1% and 10.8%, respectively.

Conclusions

This study is the first to report on COVID-19 epidemics among children in Ecuador. Our findings reveal that younger children have a lower risk of SARS-CoV-2 infection, but a higher risk of mortality compared to older children and adolescents. Additionally, we observed significant disparities in infection rates and outcomes among children living in rural areas, those with comorbidities, and those from indigenous ethnic groups.

A Multicenter Study about the Population Treated in the Respiratory Triage Stations Deployed by the Red Cross during the COVID-19 Pandemic

BACKGROUND

Care demand exceeded the availability of human and material resources during the COVID-19 pandemic, which is the reason why triage was fundamental. The objective is to know the clinical and sociodemographic factors of confirmed or suspected COVID-19 cases in triage stations from different Ecuadorian provinces.

METHOD

A multicenter study with a retrospective and descriptive design. The patients included were those who accessed the Respiratory Triage stations deployed by the Ecuadorian Red Cross in eight Ecuadorian provinces during March and April 2021. Triage allows for selecting patients that need urgent treatment and favors efficacy of health resources.

RESULTS

The study population consisted of a total of 21,120 patients, of which 43.1% were men and 56.9% were women, with an age range between 0 and 98 years old. Severity of COVID-19 behaved differently according to gender, with mild symptoms predominating in women and severe or critical symptoms in men. Higher incidence of critical cases was observed in patients over 65 years old. It was observed that overweight predominated in critical, severe, and moderate cases, while the body mass index of patients with mild symptoms was within the normal range.

CONCLUSIONS

The Ecuadorian Red Cross units identified some suspected COVID-19 cases, facilitating their follow-up and isolation. Fever was the most significant early finding.

Influenza and Pneumococcal Vaccination and the Risk of COVID-19: A Systematic Review and Meta-Analysis

A number of studies have investigated the potential on-specific effects of some routinely administered vaccines (e.g., influenza, pneumococcal) on COVID-19 related outcomes, with contrasting results. In order to elucidate this discrepancy, we conducted a systematic review and meta-analysis to assess the association between seasonal influenza vaccination and pneumococcal vaccination with SARS-CoV-2 infection and its clinical outcomes. PubMed and medRxiv databases were searched up to April 2022. A random effects model was used in the meta-analysis to pool odds ratio (OR) and adjusted estimates with 95% confidence intervals (CIs). Heterogeneity was quantitatively assessed using the Cochran's Q and the I2 index. Subgroup analysis, sensitivity analysis and assessment of publication bias were performed for all outcomes. In total, 38 observational studies were included in the meta-analysis and there was substantial heterogeneity. Influenza and pneumococcal vaccination were associated with lower risk of SARS-CoV-2 infection (OR: 0.80, 95% CI: 0.75-0.86 and OR: 0.70, 95% CI: 0.57-0.88, respectively). Regarding influenza vaccination, it seems that the majority of studies did not properly adjust for all potential confounders, so when the analysis was limited to studies that adjusted for age, gender, comorbidities and socioeconomic indices, the association diminished. This is not the case regarding pneumococcal vaccination, for which even after adjustment for such factors the association persisted. Regarding harder endpoints such as ICU admission and death, current data do not support the association. Possible explanations are discussed, including trained immunity, inadequate matching for socioeconomic indices and possible coinfection.

Health Benefits of Residence at Moderate Altitude Do Not Reduce COVID-19 Mortality

Moderate altitude (1000−2000 m above sea level) residence is emerging as a protective factor from the mortality of various causes, including of cardiovascular diseases. Conversely, mortality from certain respiratory diseases is higher at these altitudes than in lowlands. These divergent outcomes could indicate either beneficial or detrimental effects of altitude on the mortality of COVID-19 that primarily infects the respiratory tract but results in multi-organ damage. Previous epidemiological data indeed suggest divergent outcomes of moderate to high altitude residence in various countries. Confounding factors, such as variations in the access to clinical facilities or selection biases of investigated populations, may contribute to the equivocation of these observations. We interrogated a dataset of the complete population of an Alpine country in the center of Europe with relatively similar testing and clinical support conditions across altitude-levels of residence (up to around 2000 m) to assess altitude-dependent mortality from COVID-19 throughout 2020. While a reduced all-cause mortality was confirmed for people living higher than 1000 m, no differences in the mortality from COVID-19 between the lowest and the highest altitude regions were observed for the overall population and the population older than 60 years as well. Conversely, COVID-19 mortality seems to have been reduced in the very old (>85 years) women at moderate altitudes.

Epidemiological Characteristics of Deaths from COVID-19 in Peru during the Initial Pandemic Response

BACKGROUND AND AIM

Peru is the country with the highest mortality rate from COVID-19 globally, so the analysis of the characteristics of deaths is of national and international interest. The aim was to determine the epidemiological characteristics of deaths from COVID-19 in Peru from 28 March to 21 May 2020.

METHODS

Deaths from various sources were investigated, including the COVID-19 Epidemiological Surveillance and the National System of Deaths (SINADEF). In all, 3851 deaths that met the definition of a confirmed case and had a positive result of RT-PCR or rapid test IgM/IgG, were considered for the analysis. We obtained the epidemiological variables and carried out an analysis of time defined as the pre-hospital time from the onset of symptoms to hospitalization, and hospital time from the date of hospitalization to death.

RESULTS

Deaths were more frequent in males (72.0%), seniors (68.8%) and residents of the region of Lima (42.7%). In 17.8% of cases, the death occurred out-of-hospital, and 31.4% had some comorbidity. The median of pre-hospital time was 7 days (IQR: 4.0-9.0) and for the hospital time was 5 days (IQR: 3.0-9.0). The multivariable analysis with Poisson regression with robust variance found that the age group, comorbidity diagnosis and the region of origin significantly influenced pre-hospital time; while sex, comorbidity diagnosis, healthcare provider and the region of origin significantly influenced hospital time.

CONCLUSION

Deaths occurred mainly in males, seniors and on the coast, with considerable out-of-hospital deaths. Pre-hospital time was affected by age group, the diagnosis of comorbidities and the region of origin; while, hospital time was influenced by gender, the diagnosis of comorbidities, healthcare provider and the region of origin.

A Systematic Review and Quality Evaluation of Studies on Long-Term Sequelae of COVID-19

COVID-19 made its debut as a pandemic in 2020; since then, more than 607 million cases and at least 6.5 million deaths have been reported worldwide. While the burden of disease has been described, the long-term effects or chronic sequelae are still being clarified. The aim of this study was to present an overview of the information available on the sequelae of COVID-19 in people who have suffered from the infection. A systematic review was carried out in which cohort studies, case series, and clinical case reports were included, and the PubMed, Scielo, SCOPUS, and Web of Science databases were extracted. Information was published from 2020 to 1 June 2022, and we included 26 manuscripts: 9 for pulmonary, 6 for cardiac, 2 for renal, 8 for neurological and psychiatric, and 6 for cutaneous sequelae. Studies showed that the most common sequelae were those linked to the lungs, followed by skin, cutaneous, and psychiatric alterations. Women reported a higher incidence of the sequelae, as well as those with comorbidities and more severe COVID-19 history. The COVID-19 pandemic has not only caused death and disease since its appearance, but it has also sickened millions of people around the globe who potentially suffer from serious illnesses that will continue to add to the list of health problems, and further burden healthcare systems around the world.

High rates of SARS-CoV-2 infection in funeral home workers in Ecuador: Is it an occupational risk for COVID-19?

Aim

The COVID-19 outbreak has already caused more than 6.5 million deaths, overwhelming health systems worldwide. The unusual demand for funeral home services could make these workers a potential risk group for occupational exposure to SARS-CoV-2 associated with corpses management for COVID-19 patients.

Methodology

This is a cross-sectional study aimed to describe the infection rate of SARS-CoV-2 in funeral home staff by testing them with RT-qPCR in Quito, Ecuador. A total of 232 funeral home workers, representing more than 40% of funeral home personnel in Quito, were included in the study, in June 2020, immediately after the population lockdown was lifted in Ecuador.

Results

A total of 48 individuals tested positive for SARS-CoV-2, yielding an infection rate of 20.7%. The SARS-CoV-2 infection rate was 18.1 and 20.0% among personnel managing corpses or not managing corpses, respectively. Among the SARS-CoV-2 positive patients, 81.3% reported no symptoms related to COVID-19, and 3 individuals had high viral loads over 10⁸ copies/ml.

Conclusion

The high SARS-CoV-2 infection rate in funeral home staff suggested a potential occupational risk for COVID-19 but not related to corpses management. Public health guidelines for safe corpses management for COVID-19 victims and safe funeral services should be reinforced.

Risk factors for SARS-CoV-2 related mortality and hospitalization before vaccination: A meta-analysis

The literature remains scarce regarding the varying point estimates of risk factors for COVID-19 associated mortality and hospitalization. This meta-analysis investigates risk factors for mortality and hospitalization, estimates individual risk factor contribution, and determines drivers of published estimate variances. We conducted a systematic review and meta-analysis of COVID-19 related mortality and hospitalization risk factors using PRISMA guidelines. Random effects models estimated pooled risks and meta-regression analyses estimated the impact of geographic region and study type. Studies conducted in North America and Europe were more likely to have lower effect sizes of mortality attributed to chronic kidney disease (OR: 0.21, 95% CI: 0.09-0.52 and OR: 0.25, 95% CI: 0.10-0.63, respectively). Retrospective studies were more likely to have decreased effect sizes of mortality attributed to chronic heart failure compared to prospective studies (OR: 0.65, 95% CI: 0.44-0.95). Studies from Europe and Asia (OR: 0.42, 95% CI: 0.30-0.57 and OR: 0.49, 95% CI: 0.28-0.84, respectively) and retrospective studies (OR: 0.58, 95% CI: 0.47-0.73) reported lower hospitalization risk attributed to male sex. Significant geographic population-based variation was observed in published comorbidity related mortality risks while male sex had less of an impact on hospitalization among European and Asian populations or in retrospective studies.

What have we learned about socioeconomic inequalities in the spread of COVID-19? A systematic review

This article aims to provide a better understanding of the associations between groups of socioeconomic variables and confirmed cases of COVID-19. The focus is on cross-continental differences of reported positive, negative, unclear, or no associations. A systematic review of the literature is conducted on the Web of Science and SCOPUS databases. Our search identifies 314 eligible studies published on or before 31 December 2021. We detect nine groups of frequently used socioeconomic variables and results are presented by region of the world (Africa, Asia, Europe, Middle East, North American and South America). The review expands to describe the most used statistical and modelling techniques as well as inclusion of additional dimensions such as demographic, healthcare weather and mobility. Meanwhile findings agree on the generalized positive impact of population density, per capita GDP and urban areas on transmission of infections, contradictory results have been found concerning to educational level and income.

A comparative analysis of SARS-CoV-2 viral load across different altitudes

SARS-CoV-2 has spread throughout the world, including areas located at high or very high altitudes. There is a debate about the role of high altitude hypoxia on viral transmission, incidence, and COVID-19 related mortality. This is the first comparison of SARS-CoV-2 viral load across elevations ranging from 0 to 4300 m. To describe the SARS-CoV-2 viral load across samples coming from 62 cities located at low, moderate, high, and very high altitudes in Ecuador. An observational analysis of viral loads among nasopharyngeal swap samples coming from a cohort of 4929 patients with a RT-qPCR test positive for SARS-CoV-2. The relationship between high and low altitude only considering our sample of 4929 persons is equal in both cases and not significative (p-value 0.19). In the case of low altitude, adding the sex variable to the analysis, it was possible to find a significative difference between men and women (p-value < 0.05). Considering initially sex and then altitude, it was possible to find a significative difference between high and low altitude for men (p-value 0.05). There is not enough evidence to state that viral load is affected directly by altitude range but adding a new variable as sex in the analysis shows that the presence of new variables influences the relationship of altitude range and viral load. There is no evidence that viral loads (Ct and copies/ml) differ at low or high altitude. Using sex as a co-factor, we found that men have higher viral loads than women at low and moderate altitude locations, while living at high altitude, no differences were found. When Ct values were aggregated by low, moderate, and high viral load, we found no significant differences when sex was excluded from the analysis. We conclude that viral load is not directly affected by altitude, but COVID-19 incidence and mortality are rather affected by socio-demographic and idiosyncratic dynamics.

Association between influenza vaccination and SARS-CoV-2 infection and its outcomes: systematic review and meta-analysis

BACKGROUND

World Health Organization recommends that influenza vaccines should benefit as much of the population as possible, especially where resources are limited. Corona virus disease 2019 (COVID-19) has become one of the greatest threats to health systems worldwide. The present study aimed to extend the evidence of the association between influenza vaccination and COVID-19 to promote the former.

METHODS

In this systematic review, four electronic databases, including the Cochrane Library, PubMed, Embase, and Web of Science, were searched for related studies published up to May 2022. All odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by meta-analysis.

RESULTS

A total of 36 studies, encompassing 55,996,841 subjects, were included in this study. The meta-analysis for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection provided an OR of 0.80 (95% CI: 0.73-0.87). The statistically significant estimates for clinical outcomes were 0.83 (95% CI: 0.72-0.96) for intensive care unit admission, 0.69 (95% CI: 0.57-0.84) for ventilator support, and 0.69 (95% CI: 0.52-0.93) for fatal infection, while no effect seen in hospitalization with an OR of 0.87 (95% CI: 0.68-1.10).

CONCLUSION

Influenza vaccination helps limit SARS-CoV-2 infection and severe outcomes, but further studies are needed.

REGISTRATION

PROSPERO, CRD42022333747.

Case Fatality Rate of COVID-19 and its Relationship to Sociodemographic Characteristics in Ecuador, 2020

Objective: To analyze sociodemographic factors’ influence on COVID-19 case fatality rate (CFR) in Ecuador on a subnational level.

Methods: Publicly available register-based observational study. A retrospective cohort of COVID-19 infections between epidemiological weeks 8–53 in the Ecuadorian public healthcare system was determined from available records. Statistical analyses were conducted to evaluate CFR trends according to factors such as sex, age, location, and healthcare provider.

Results: Overall CFR was 9.4%; by canton, median CFR was 5.2%, with some cantons with much higher rates, like Santa Elena (39.1%). Overall CFR decreased during the period, from 16.6% (week 8) to 2.63% (week 53). Being in a rural area was an independent protective factor. Patients over 65 had a hazard ratio of 11.38 (95% CI [11.05, 11.72]). Sex, ethnicity, and treatment from public facilities were also associated with death risk.

Conclusion: CFR is a proxy indicator of COVID-19 impact in Ecuador, and this location-based analysis provides new information on the disease’s specific impact subnationally. Overall COVID-19 CFR during the entire period was high, suggesting the need to improve COVID-19 care in Ecuador.

COVID-19 mortality and excess mortality among working-age residents in California, USA, by occupational sector: a longitudinal cohort analysis of mortality surveillance data

BACKGROUND

During the first year of the COVID-19 pandemic, workers in essential sectors had higher rates of SARS-CoV-2 infection and COVID-19 mortality than those in non-essential sectors. It is unknown whether disparities in pandemic-related mortality across occupational sectors have continued to occur during the periods of SARS-CoV-2 variants and vaccine availability.

METHODS

In this longitudinal cohort study, we obtained data from the California Department of Public Health on all deaths occurring in the state of California, USA, from Jan 1, 2016, to Dec 31, 2021. We restricted our analysis to residents of California who were aged 18-65 years at time of death and died of natural causes. We classified the occupational sector into nine essential sectors; non-essential; or unemployed or without an occupation provided on the death certificate. We calculated the number of COVID-19 deaths in total and per capita that occurred in each occupational sector. Separately, using autoregressive integrated moving average models, we estimated total, per-capita, and relative excess natural-cause mortality by week between March 1, 2020, and Nov 30, 2021, stratifying by occupational sector. We additionally stratified analyses of occupational risk into counties with high versus low vaccine uptake, categorising high-uptake regions as counties where at least 50% of the population were fully vaccinated according to US guidelines by Aug 1, 2021.

FINDINGS

From March 1, 2020, to Nov 30, 2021, 24 799 COVID-19 deaths were reported in residents of California aged 18-65 years and an estimated 28 751 (95% prediction interval 27 853-29 653) excess deaths. People working in essential sectors were associated with higher COVID-19 deaths and excess deaths than were those working in non-essential sectors, with the highest per-capita COVID-19 mortality in the agriculture (131·8 per 100 000 people), transportation or logistics (107·1 per 100 000), manufacturing (103·3 per 100 000), facilities (101·1 per 100 000), and emergency (87·8 per 100 000) sectors. Disparities were wider during periods of increased infections, including during the Nov 29, 2020, to Feb 27, 2021, surge in infections, which was driven by the delta variant (B.1.617.2) and occurred during vaccine uptake. During the June 27 to Nov 27, 2021 surge, emergency workers had higher COVID-19 mortality (113·7 per 100 000) than workers from any other sector. Workers in essential sectors had the highest COVID-19 mortality in counties with low vaccination uptake, a difference that was more pronounced during the period of the delta infection surge during Nov 29, 2020, to Feb 27, 2021.

INTERPRETATION

Workers in essential sectors have continued to bear the brunt of high COVID-19 and excess mortality throughout the pandemic, particularly in the agriculture, emergency, manufacturing, facilities, and transportation or logistics sectors. This high death toll has continued during periods of vaccine availability and the delta surge. In an ongoing pandemic without widespread vaccine coverage and with anticipated threats of new variants, the USA must actively adopt policies to more adequately protect workers in essential sectors.

FUNDING

US National Institute on Aging, Swiss National Science Foundation, and US National Institute on Drug Abuse.

Sustained COVID-19 community transmission and potential super spreading events at neglected afro-ecuadorian communities assessed by massive RT-qPCR and serological testing of community dwelling population

Background

Neglected ethnic minorities from underserved rural populations in Latin America are highly vulnerable to coronavirus disease 2019 (COVID-19) due to poor health infrastructure and limited access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnosis. Esmeraldas is a mainly rural province of the Coastal Region of Ecuador characterized by a high presence of Afro-Ecuadorian population living under poverty conditions.

Objective

We herein present a retrospective analysis of the surveillance SARS-CoV-2 testing in community-dwelling population from Esmeraldas carried out by our university laboratory in collaboration with regional health authorities during the first week of October 2020, in a region where no public SARS-CoV-2 detection laboratory was available at that time.

Results

A total number of 1,259 people were tested for SARS-CoV-2 by Reverse Transcription quantitative Polimerasa Chain Reaction (RT-qPCR), resulting in an overall infection rate of 7.7% (97/1259, 95% CI: [6.32–9.35%]) for SARS-CoV-2, up to 12.1% in some communities. Interestingly, community-dwelling super spreaders with viral loads over 10⁸ copies/ml represented 6.2% of the SARS-CoV-2-infected population. Furthermore, anti-SARS-CoV-2 IgG serological tests were applied to the same study group, yielding an overall seroprevalence of 11.68% (95% CI: [9.98–13.62%]) but as high as 24.47% at some communities.

Conclusion

These results support active COVID-19 community transmission in Esmeraldas province during the first semester of the COVID-19 pandemic as it has been shown for other rural communities in the Ecuadorian Coastal Region.

The Association Between Previous Influenza Vaccination and COVID-19 Infection Risk and Severity: A Systematic Review and Meta-analysis

INTRODUCTION

The association between influenza vaccination and COVID-19 remains controversial. This meta-analysis aimed to investigate whether influenza vaccination reduces the susceptibility and severity of SARS-CoV-2 infection.

METHODS

A systematic literature search of PubMed, Web of Science, the Cochrane Library, Embase, China National Knowledge Infrastructure, SinoMed, Wanfang Data Knowledge Service Platform, and China Science and Technology Journal VIP Database was conducted from database inception to August 2021. The pooled RR with 95% CI was used to estimate the effect of influenza vaccination on COVID-19. The I² value was used to assess heterogeneity. If I²>50%, the random-effects model was used as the pooling method.

RESULTS

A total of 23 published articles with 1,037,445 participants were identified. This meta-analysis showed that influenza vaccination was associated with reduced risk of COVID-19 infection (RR=0.83, 95% CI=0.76, 0.90) and hospitalization (RR=0.71, 95% CI=0.59, 0.84), although not significantly associated with intensive care unit admission and death (risk of intensive care unit admission: RR=0.93, 95% CI=0.64, 1.36; risk of death: RR=0.83, 95% CI=0.68, 1.01). Further analysis suggested that the tetravalent influenza vaccine may be associated with a reduced risk of COVID-19 infection (RR=0.74, 95% CI=0.65, 0.84).

DISCUSSION

The results suggest that influenza vaccination is associated with reduced susceptibility to or disease severity of COVID-19 and that influenza vaccination may reduce the risk of COVID-19 and improve clinical outcomes.

SARS-CoV-2 Viral Load Analysis at Low and High Altitude: A Case Study from Ecuador

SARS-CoV-2 has spread throughout the world, including remote areas such as those located at high altitudes. There is a debate about the role of hypobaric hypoxia on viral transmission and COVID-19 incidence. A descriptive cross-sectional analysis of SARS-CoV-2 infection and viral load among patients living at low (230 m) and high altitude (3800 m) in Ecuador was completed. Within these two communities, the total number of infected people at the time of the study was 108 cases (40.3%). The COVID-19 incidence proportion at low altitude was 64% while at high altitude was 30.3%. The mean viral load from those patients who tested positive was 3,499,184 copies/mL (SD = 23,931,479 copies/mL). At low altitude (Limoncocha), the average viral load was 140,223.8 copies/mL (SD = 990,840.9 copies/mL), while for the high altitude group (Oyacachi), the mean viral load was 6,394,789 copies/mL (SD = 32,493,469 copies/mL). We found no statistically significant differences when both results were compared (p = 0.056). We found no significant differences across people living at low or high altitude; however, men and younger populations had higher viral load than women older populations, respectively.

The Impact of Active Screening and Management on COVID-19 in Plateau Region of Sichuan, China

Background

In December 2019, the cases of pneumonia of unknown etiology emerged in Wuhan, China, and rapidly spread throughout the country. The disease was later designated by the World Health Organization (WHO) as Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Few studies have assessed the clinical characteristics of COVID-19 and control strategies used to mitigate disease spread in high-altitude plateau regions of China.

Study Objective

To assess the impact of real-world strategies to control COVID-19 spread in remote plateau regions.

Methods

A retrospective study was performed to assess the epidemiology of COVID-19 and strategies used to control disease spread in the high-altitude plateau of Sichuan, China from 24 January 2020 to 19 March 2020.

Results

COVID-19 spread and outbreaks in Sichuan were attributed to mass gatherings. A total of 70 patients and 20 asymptomatic individuals were found in the hypoxic plateau region of Sichuan. Twelve patients were admitted after the onset of symptoms, while 58 patients and 20 asymptomatic individuals were found by active screening. The symptomatic patients included those with uncomplicated illness (16/70, 22.9%), mild pneumonia (44/70, 62.9%), and severe pneumonia (10/70, 14.3%). Most patients in the study area showed relatively mild and atypical symptoms such as low or no fever and dyspnea. The incidence of severe pneumonia, fever, dyspnea, and interstitial abnormalities identified by chest CT were all significantly lower in screened patients than those admitted after symptom onset (P < 0.05). Severe pneumonia was noted in patients with chronic conditions like hypertension, diabetes etc. as compared to less severe pneumonia in healthy subjects (P <0.05). No patients died and all were eventually discharged.

Conclusion

Mass gatherings increased risk of spread of SARS-CoV-2 responsible for COVID-19. Active screening and early management have collectively contributed to reduced incidence of severe pneumonia and satisfactory prognoses of infections with COVID-19 in this hypoxic plateau region.

Clinicodemographic profile and predictors of poor outcome in hospitalised COVID-19 patients: a single-centre, retrospective cohort study from India

OBJECTIVES

Primary objective was to study the clinicodemographic profile of hospitalised COVID-19 patients at a tertiary-care centre in India. Secondary objective was to identify predictors of poor outcome.

SETTING

Single centre tertiary-care level.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Consecutively hospitalised adults patients with COVID-19.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome variable was in-hospital mortality. Covariables were known comorbidities, clinical features, vital signs at the time of admission and on days 3-5 of admission, and initial laboratory investigations.

RESULTS

Intergroup differences were tested using χ² or Fischer's exact tests, Student's t-test or Mann-Whitney U test. Predictors of mortality were evaluated using multivariate logistic regression model. Out of 4102 SARS-CoV-2 positive patients admitted during 1-year period, 3268 (79.66%) survived to discharge and 834 (20.33%) died in the hospital. Mortality rates increased with age. Death was more common among males (OR 1.51, 95% CI 1.25 to 1.81). Out of 261 cases analysed in detail, 55.1% were in mild, 32.5% in moderate and 12.2% in severe triage category. Most common clinical presentations in the subgroup were fever (73.2%), cough/coryza (65.5%) and breathlessness (54%). Hypertension (45.2%), diabetes mellitus (41.8%) and chronic kidney disease (CKD; 6.1%) were common comorbidities. Disease severity on admission (adjusted OR 12.53, 95% CI 4.92 to 31.91, p<0.01), coagulation defect (33.21, 3.85-302.1, p<0.01), CKD (5.67, 1.08-29.64, p=0.04), high urea (11.05, 3.9-31.02, p<0.01), high prothrombin time (3.91, 1.59-9.65, p<0.01) and elevated ferritin (1.02, 1.00-1.03, p=0.02) were associated with poor outcome on multivariate regression. A strong predictor of mortality was disease progression on days 3-5 of admission (adjusted OR 13.66 95% CI 3.47 to 53.68).

CONCLUSION

COVID-19 related mortality in hospitalised adult patients at our center was similar to the developed countries. Progression in disease severity on days 3-5 of admission or days 6-13 of illness onset acts as 'turning point' for timely referral or treatment intensification for optimum use of resources.

Ecuadorian university English teachers' reflections on emergency remote teaching during the COVID-19 pandemic

COVID-19 struck at the beginning of 2020, affecting, among others, the education industry. As a result, a lock-down quarantine was declared, and on-campus classes were suspended. Accordingly, emergency remote teaching (ERT) was set into motion to solve the education issue. This research aimed to obtain the reflections of 20 Ecuadorian polytechnic university English teachers on their experiences using ERT during two semesters. This paper is based on an explanatory sequential mixed-methods research design that used a Likert-scale survey and interviews to respond to the established research questions. The findings show that, in a general sense, teachers were not ready for the sudden shift to ERT, which generated feelings of anxiety. The most significant disadvantage reported was the extra workload caused by adapting materials and giving feedback to students. The study suggests that changing classes from on-campus to ERT was not easy to carry out at the beginning of the pandemic. There are practical implications for language department managers as it gives them light to prepare for the continuing pandemic and any other crisis that might require ERT to be in practice again.

High-altitude is associated with better short-term survival in critically ill COVID-19 patients admitted to the ICU

Background

Multiple studies have attempted to elucidate the relationship between chronic hypoxia and SARS-CoV-2 infection. It seems that high-altitude is associated with lower COVID-19 related mortality and incidence rates; nevertheless, all the data came from observational studies, being this the first one looking into prospectively collected clinical data from severely ill patients residing at two significantly different altitudes.

Methods

A prospective cohort, a two-center study among COVID-19 confirmed adult patients admitted to a low (sea level) and high-altitude (2,850 m) ICU unit in Ecuador was conducted. Two hundred and thirty confirmed patients were enrolled from March 15^th to July 15^th, 2020.

Results

From 230 patients, 149 were men (64.8%) and 81 women (35.2%). The median age of all the patients was 60 years, and at least 105 (45.7%) of patients had at least one underlying comorbidity, including hypertension (33.5%), diabetes (16.5%), and chronic kidney failure (5.7%). The APACHE II scale (Score that estimates ICU mortality) at 72 hours was especially higher in the low altitude group with a median of 18 points (IQR: 9.5–24.0), compared to 9 points (IQR: 5.0–22.0) obtained in the high-altitude group. There is evidence of a difference in survival in favor of the high-altitude group (p = 0.006), the median survival being 39 days, compared to 21 days in the low altitude group.

Conclusion

There has been a substantial improvement in survival amongst people admitted to the high-altitude ICU. Residing at high-altitudes was associated with improved survival, especially among patients with no comorbidities. COVID-19 patients admitted to the high-altitude ICU unit have improved severity-of-disease classification system scores at 72 hours.

Measuring disability-adjusted life years (DALYs) due to COVID-19 in Scotland, 2020

Background

Disability-adjusted life years (DALYs) combine the impact of morbidity and mortality and can enable comprehensive, and comparable, assessments of direct and indirect health harms due to COVID-19. Our aim was to estimate DALYs directly due to COVID-19 in Scotland, during 2020; and contextualise its population impact relative to other causes of disease and injury.

Methods

National deaths and daily case data were used. Deaths were based on underlying and contributory causes recorded on death certificates. We calculated DALYs based on the COVID-19 consensus model and methods outlined by the European Burden of Disease Network. DALYs were presented as a range, using a sensitivity analysis based on Years of Life Lost estimates using: cause-specific; and COVID-19 related deaths. All COVID-19 estimates were for 2020.

Results

In 2020, estimates of COVID-19 DALYs in Scotland ranged from 96,500 to 108,200. Direct COVID-19 DALYs were substantial enough to be framed as the second leading cause of disease and injury, with only ischaemic heart disease having a larger impact on population health. Mortality contributed 98% of total DALYs.

Conclusions

The direct population health impact of COVID-19 has been very substantial. Despite unprecedented mitigation efforts, COVID-19 developed from a single identified case in early 2020 to a condition with an impact in Scotland second only to ischaemic heart disease. Periodic estimation of DALYs during 2021, and beyond, will provide indications of the impact of DALYs averted due to the national rollout of the vaccination programme and other continued mitigation efforts, although new variants may pose significant challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00862-x.

High SARS-CoV-2 Infection Rates Among Special Forces Police Units During the Early Phase of the COVID-19 Pandemic in Ecuador

Background

At the beginning of the COVID-19 pandemic, health workers and first-responders, such as police officers, were in charge of trying to contain a disease that was unknown at that time. The lack of information and the tremendous need to contain new outbreaks put police officers at higher risk.

Methodology

A cross-sectional study was conducted to describe SARS-CoV-2 infection rates among Police Special Forces Officers in Quito, Ecuador. In this study, 163 community-dwelling police officers from elite divisions voluntarily participated in our SARS-CoV-2 detection program using reverse transcription quantitative real-time PCR (RT-qPCR).

Results

A total of 20 out of 163 police officers tested positive for SARS-CoV-2, yielding an infection rate of 12.3%. Within this cohort, 10% (2/20) of SARS-CoV-2 positive individuals were potentially super spreaders with viral loads over 10⁸ copies/ul. About 85% of the SARS-CoV-2 positive individuals were asymptomatic and 15% reported mild symptoms related to COVID-19.

Conclusions

We found a high SARS-CoV-2 infection rate within the special forces police officers that, beyond a high health risk for themselves, their families, and coworkers. Our results point out the need for permanent SARS-CoV-2 testing among asymptomatic essential workers and first-responders to avoid local outbreaks and to prevent work-place absenteeism among police special units.

Spatial mapping and socio-demographic determinants of COVID-19 mortality in India

Background

COVID-19 is caused by SARS-CoV-2. The first case of COVID-19 was detected in Wuhan city of China in December 2019. Geographic information system (GIS) mapping is important for the surveillance of infectious diseases.

Objectives

The objectives of the study are to map spatially total cases and case fatality rate of COVID-19 and to build a linear regression model for mortality based on socio-demographic variables.

Methology

We plotted the epidemiological data of COVID-19 of Indian states as on 11^th May 2021 using the Q-GIS software. We used socio-demographic variables as the predictors of COVID-19 mortality and developed a linear regression model.

Results

Adjusted R-squared in linear regression model based on socio-demographic variables for COVID-19 deaths is 0.82.

Conclusions

There are spatial variations in COVID-19 cases and deaths.

Ecuadorian university English teachers' reflections on emergency remote teaching during the COVID-19 pandemic

COVID-19 appeared at the beginning of 2020, affecting, among others, the education industry. As a result, a lock-down quarantine was declared, and on-campus classes were suspended. Accordingly, emergency remote teaching (ERT) was set into motion to solve the education issue. This investigation surveyed 20 Ecuadorian polytechnic university English teachers and obtained their reflections on their experience with ERT. This paper bases on mixed-methods research that used a Likert-scaled survey and interviews to respond to the established research questions. The results show that, in a general sense, teachers were not ready for the sudden shift to ERT, which generated feelings of anxiety. The most significant disadvantage reported was the extra workload caused by adapting materials and giving feedback to students. COVID-19 struck at the beginning of 2020, affecting, among others, the education industry. As a result, a lockdown quarantine was declared, and on-campus classes were suspended. Accordingly, emergency remote teaching (ERT) was set into motion to solve the education issue. This research aimed to obtain the reflections of 20 Ecuadorian polytechnic university English teachers on their experiences using ERT during two semesters. This paper is based on an explanatory sequential mixed-methods research design that used a Likert-scale survey and interviews to respond to the established research questions. In a general sense, the findings show that teachers were not ready for the sudden shift to ERT at the beginning of the pandemic, which generated feelings of anxiety. The most significant disadvantage reported was the extra workload caused by adapting materials and giving feedback to students. The study suggests that changing classes from on-campus to emergency remote teaching was not easy to carry out at the beginning of the pandemic. There are practical implications for language department managers as it gives them light to prepare for the continuing pandemic and any other crisis that might require ERT to be in practice again.

Presence of SARS-CoV-2 RNA on Surfaces of Public Places and a Transportation System Located in a Densely Populated Urban Area in South America

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible RNA virus that causes COVID-19. Being aware of the presence of the virus on different types of surfaces and in different environments, and having a protocol for its detection, is important to understand the dynamics of the virus and its shedding patterns. In Ecuador, the detection of viral RNA in urban environmental samples has not been a priority. The present study analyzed samples from two densely populated neighborhoods and one public transportation system in Quito, Ecuador. Viral RNA presence was assessed using RT-LAMP. Twenty-eight out of 300 surfaces tested positive for SARS-CoV-2 RNA (9.33%). Frequently touched surfaces, especially in indoor spaces and on public transportation, were most likely to be positive for viral RNA. Positivity rate association for the two neighborhoods and for the surface type was not found. This study found viral RNA presence on urban surfaces; this information provides an insight into viral dissemination dynamics. Monitoring environmental SARS-CoV-2 could support the public health prevention strategies in Quito, Ecuador.

EPIDEMIOLOGICAL DETERMINANTS FOR THE SPREAD OF COVID-19 IN RIYADH PROVINCE OF SAUDI ARABIA

Background and objective

Coronavirus Disease 2019 (COVID-19) has affected millions of individuals all over the world. In addition to the patients' compelling indications, various sociodemographic characteristics were identified to influence infection complications. The purpose of this study was to assess the impact of the aforementioned parameters on the dissemination of COVID-19 among residents of Saudi Arabia's Riyadh region.

Materials and Methods

In the Saudi Arabian province of Riyadh, a cross-sectional retrospective analysis of COVID-19 incidences, recoveries, and case-fatality ratio (CFR) was undertaken. The study was carried out by gathering daily COVID-19 records from the ministry of health's official websites between October 2020 and September 2021. The influencing factors were obtained from the statistical authority. Using the SPSS IBM 25 software, the data was examined. The association between demographic factors as well as the presence of comorbidity on the COVID-19 outcome was determined using Spearman's correlation and regression tests. P<0.05 was considered to indicate the significance of the results.

Results

The data from the study indicated that the highest number of COVID-19 cases were recorded in June 2021, and peak recovery was observed in July 2021. The CFR declined progressively from October 2020 to just over 1, even when the cases peaked. A significant (p<0.05) correlation between diabetes and COVID-19 incidences was observed . The recovery rate had a significant (p<0.05) association with the literacy rate and those aged 14 - 49 years old. Presences of co-morbidities such as Dyslipidemia, hypertension, diabetes, asthma, stroke and heart failure have negatively affected the recovery from COVID-19 in the population. The CFR is significantly (p< 0.05) associated with people over 60, hypertensive patients, and asthma patients. Regression analysis suggested that the risk of complications due to COVID-19 infection is more in males, people above 60 years age and those suffering from co-morbidities .

Conclusions

The findings of the study indicate an association between several of the characteristics studied, such as gender, age, and comorbidity, and the spread of infection, recovery, and mortality. To restrict the spread of COVID-19 and prevent its complications, effective measures are required to control the modifiable risk factors.