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Cummings MJ, Bakamutumaho B, Lutwama JJ, Owor N, Che X, Astorkia M, Postler TS, Kayiwa J, Kiconco J, Muwanga M, Nsereko C, Rwamutwe E, Nayiga I, Kyebambe S, Haumba M, Bosa HK, Ocom F, Watyaba B, Kikaire B, Tomoiaga AS, Kisaka S, Kiwanuka N, Lipkin WI, O'Donnell MR. COVID-19 immune signatures in Uganda persist in HIV co-infection and diverge by pandemic phase. Nat Commun 2024; 15:1475. [PMID: 38368384 PMCID: PMC10874401 DOI: 10.1038/s41467-024-45204-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 01/17/2024] [Indexed: 02/19/2024] Open
Abstract
Little is known about the pathobiology of SARS-CoV-2 infection in sub-Saharan Africa, where severe COVID-19 fatality rates are among the highest in the world and the immunological landscape is unique. In a prospective cohort study of 306 adults encompassing the entire clinical spectrum of SARS-CoV-2 infection in Uganda, we profile the peripheral blood proteome and transcriptome to characterize the immunopathology of COVID-19 across multiple phases of the pandemic. Beyond the prognostic importance of myeloid cell-driven immune activation and lymphopenia, we show that multifaceted impairment of host protein synthesis and redox imbalance define core biological signatures of severe COVID-19, with central roles for IL-7, IL-15, and lymphotoxin-α in COVID-19 respiratory failure. While prognostic signatures are generally consistent in SARS-CoV-2/HIV-coinfection, type I interferon responses uniquely scale with COVID-19 severity in persons living with HIV. Throughout the pandemic, COVID-19 severity peaked during phases dominated by A.23/A.23.1 and Delta B.1.617.2/AY variants. Independent of clinical severity, Delta phase COVID-19 is distinguished by exaggerated pro-inflammatory myeloid cell and inflammasome activation, NK and CD8+ T cell depletion, and impaired host protein synthesis. Combining these analyses with a contemporary Ugandan cohort of adults hospitalized with influenza and other severe acute respiratory infections, we show that activation of epidermal and platelet-derived growth factor pathways are distinct features of COVID-19, deepening translational understanding of mechanisms potentially underlying SARS-CoV-2-associated pulmonary fibrosis. Collectively, our findings provide biological rationale for use of broad and targeted immunotherapies for severe COVID-19 in sub-Saharan Africa, illustrate the relevance of local viral and host factors to SARS-CoV-2 immunopathology, and highlight underemphasized yet therapeutically exploitable immune pathways driving COVID-19 severity.
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Affiliation(s)
- Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Barnabas Bakamutumaho
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Julius J Lutwama
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Nicholas Owor
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Xiaoyu Che
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Maider Astorkia
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Thomas S Postler
- Department of Microbiology and Immunology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - John Kayiwa
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Jocelyn Kiconco
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | | | | | | | - Irene Nayiga
- Entebbe Regional Referral Hospital, Entebbe, Uganda
| | | | - Mercy Haumba
- Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
| | - Henry Kyobe Bosa
- Uganda Peoples' Defence Forces, Kampala, Uganda
- Ministry of Health, Kampala, Uganda
| | | | - Benjamin Watyaba
- European and Developing Countries Clinical Trials Partnership-Eastern Africa Consortium for Clinical Research, Uganda Virus Research Institute, Entebbe, Uganda
| | - Bernard Kikaire
- European and Developing Countries Clinical Trials Partnership-Eastern Africa Consortium for Clinical Research, Uganda Virus Research Institute, Entebbe, Uganda
- Department of Pediatrics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Alin S Tomoiaga
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Accounting, Business Analytics, Computer Information Systems, and Law, Manhattan College, New York, NY, USA
| | - Stevens Kisaka
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - W Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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2
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Kwizera A, Kabatooro D, Atumanya P, Tumukunde J, Kalungi J, Mwanje AK, Obua D, Agaba P, Sendagire C, Nakibuuka J, Owachi D, Dünser MW, Alenyo-Ngabirano A, Olaro C, Kyobe-Bosa H, Kirenga BJ, Nakiyingi L, Kiwanuka N, Kateete DP, Joloba M, Sewankambo N, Summers C. Respiratory Support Techniques for COVID-19-Related ARDS in a Sub-Saharan African Country: A Multicenter Observational Study. Chest 2023; 164:369-380. [PMID: 36773933 PMCID: PMC9911971 DOI: 10.1016/j.chest.2023.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/19/2023] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Limited data from low-income countries report on respiratory support techniques in COVID-19-associated ARDS. RESEARCH QUESTION Which respiratory support techniques are used in patients with COVID-19-associated ARDS in Uganda? STUDY DESIGN AND METHODS A multicenter, prospective, observational study was conducted at 13 Ugandan hospitals during the pandemic and included adults with COVID-19-associated ARDS. Patient characteristics, clinical and laboratory data, initial and most advanced respiratory support techniques, and 28-day mortality were recorded. Standard tests, log-rank tests, and logistic regression analyses were used for statistical analyses. RESULTS Four hundred ninety-nine patients with COVID-19-associated ARDS (mild, n = 137; moderate, n = 247; and severe, n = 115) were included (ICU admission, 38.9%). Standard oxygen therapy (SOX), high-flow nasal oxygen (HFNO), CPAP, noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) was used as the first-line (most advanced) respiratory support technique in 37.3% (35.3%), 10% (9.4%), 11.6% (4.8%), 23.4% (14.4%), and 17.6% (36.6%) of patients, respectively. The first-line respiratory support technique was escalated in 19.8% of patients. Twenty-eight-day mortality was 51.9% (mild ARDS, 13.1%; moderate ARDS, 62.3%; severe ARDS, 75.7%; P < .001) and was associated with respiratory support techniques as follows: SOX, 19.9%; HFNO, 31.9%; CPAP, 58.3%; NIV 61.1%; and IMV, 83.9% (P < .001). Proning was used in 79 patients (15.8%; 59 of 79 awake) and was associated with lower mortality (40.5% vs 54%; P = .03). The oxygen saturation to Fio2 ratio (OR, 0.99; 95% CI, 0.98-0.99; P < .001) and respiratory rate (OR, 1.07; 95% CI, 1.03-1.12; P = .002) at admission and NIV (OR, 6.31; 95% CI, 2.29-17.37; P < .001) or IMV (OR, 8.08; 95% CI, 3.52-18.57; P < .001) use were independent risk factors for death. INTERPRETATION SOX, HFNO, CPAP, NIV, and IMV were used as respiratory support techniques in patients with COVID-19-associated ARDS in Uganda. Although these data are observational, they suggest that the use of SOX and HFNO therapy as well as awake proning are associated with a lower mortality resulting from COVID-19-associated ARDS in a resource-limited setting.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Daphne Kabatooro
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patience Atumanya
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joyce Kalungi
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Arthur Kavuma Mwanje
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Obua
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Agaba
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Cornelius Sendagire
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda; Uganda Heart Institute, Kampala, Uganda
| | - Jane Nakibuuka
- Department of Medicine and Intensive Care Unit, Mulago National Referral Hospital, Kampala, Uganda
| | | | - Martin W Dünser
- Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | | | | | - Henry Kyobe-Bosa
- Ministry of Health, Kampala, Uganda; Uganda Peoples Defence Forces, Kampala, Uganda; Kellogg College, University of Oxford, Oxford, England
| | - Bruce J Kirenga
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Makerere University Lung Institute, Kampala, Uganda
| | - Lydia Nakiyingi
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Noah Kiwanuka
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David Patrick Kateete
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses Joloba
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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3
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Cummings MJ, Bakamutumaho B. Improving Outcomes for ARDS in Sub-Saharan Africa: The Time Is Now. Chest 2023; 164:275-277. [PMID: 37558319 DOI: 10.1016/j.chest.2023.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY.
| | - Barnabas Bakamutumaho
- National Influenza Centre, Department of Arbovirology, Emerging and Re-emerging Infectious Diseases, Uganda Virus Research Institute, Entebbe, Uganda
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4
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Anesi GL, Savarimuthu SM, Invernizzi J, Hyman R, Ramkillawan A, Eddey C, Wise RD, Smith MTD. ICU Mortality Across Prepandemic and Pandemic Cohorts in a Resource-Limited Setting: A Critical Care Resiliency Analysis From South Africa. CHEST CRITICAL CARE 2023; 1:100005. [PMID: 39211576 PMCID: PMC11360720 DOI: 10.1016/j.chstcc.2023.100005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Hospital adaptation and resiliency, required during public health emergencies to optimize outcomes, are understudied especially in resource-limited settings. RESEARCH QUESTION What are the prepandemic and pandemic critical illness outcomes in a resource-limited setting and in the context of capacity strain? STUDY DESIGN AND METHODS We performed a retrospective cohort study among patients admitted to ICUs at two public hospitals in the KwaZulu-Natal Department of Health in South Africa preceding and during the COVID-19 pandemic (2017-2022). We used multivariate logistic regression to analyze the association between three patient cohorts (prepandemic non-COVID-19, pandemic non-COVID-19, and pandemic COVID-19) and ICU capacity strain and the primary outcome of ICU mortality. RESULTS Three thousand two hundred twenty-one patients were admitted to the ICU during the prepandemic period and 2,539 patients were admitted to the ICU during the pandemic period (n = 375 [14.8%] with COVID-19 and n = 2,164 [85.2%] without COVID-19). The prepandemic and pandemic non-COVID-19 cohorts were similar. Compared with the non-COVID-19 cohorts, the pandemic COVID-19 cohort showed older age, higher rates of chronic cardiovascular disease and diabetes, less extrapulmonary organ dysfunction, and longer ICU length of stay. Compared with the prepandemic non-COVID-19 cohort, the pandemic non-COVID-19 cohort showed similar odds of ICU mortality (OR, 1.06; 95% CI, 0.90-1.25; P = .50) whereas the pandemic COVID-19 cohort showed significantly increased odds of ICU mortality (OR, 3.91; 95% CI, 3.03-5.05 P < .0005). ICU occupancy was not associated with ICU mortality in either the COVID-19 cohort (OR, 1.05 per 10% change in ICU occupancy; 95% CI, 0.96-1.14; P = .27) or the pooled non-COVID-19 cohort (OR, 1.01 per 10% change in ICU occupancy; 95% CI, 0.98-1.03; P = .52). INTERPRETATION Patients admitted to the ICU before and during the pandemic without COVID-19 were broadly similar in clinical characteristics and outcomes, suggesting critical care resiliency, whereas patients admitted to the ICU with COVID-19 showed important clinical differences and significantly higher mortality.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stella M Savarimuthu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Invernizzi
- Department of Anaesthesia and Critical Care, Harry Gwala Regional Hospital, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Robyn Hyman
- Department of Anaesthesia and Critical Care, Harry Gwala Regional Hospital, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Arisha Ramkillawan
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Creaghan Eddey
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
| | - Robert D Wise
- Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Intensive Care Department, John Radcliffe Hospital, Oxford University Trust Hospitals, Oxford, England
| | - Michelle T D Smith
- Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg
- Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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5
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Ssetaba LJ, Mirembe J, Omega J, Okot J, Kiguli S, Nakwagala FN, Bongomin F. Coronavirus disease–2019 morbidity and mortality among health care workers in Uganda. Ther Adv Infect Dis 2022; 9:20499361221136415. [PMID: 36406814 PMCID: PMC9666413 DOI: 10.1177/20499361221136415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Health care workers (HCWs) are at increased risk of acquiring coronavirus
disease 2019 (COVID-19). This study aimed to determine and compare the
morbidity and mortality rates due to COVID-19 among the HCWs and the general
population (non-HCWs). Methods: We conducted a retrospective chart review. We accessed electronic database of
participants admitted at Mulago National Referral Hospital COVID-19
Treatment Unit (CTU) between March 2020 and September 2021. Participants
with missing occupations were excluded. Results: Of 594 eligible participants, 6.4% (n = 38) were HCWs.
Compared with non-HCWs, HCWs were much younger (48 versus
55 years, p = 0.020). The proportion of participants with
severe disease (73.7% versus 77.6%,
p = 0.442), who had not received COVID-19 vaccine (91.2%
versus 94.7%, p = 0.423), mortality
rate (44.7% versus 54.8%, p = 0.243) and
the median length of hospitalization (6 versus 7 days,
p = 0.913) were similar among HCWs and non-HCWs,
respectively. A higher proportion of HCWs required oxygen therapy (24.3%
versus 9.7%, p < 0.01). At
admission, the presence of cough (p = 0.723),
breathlessness (p = 0.722), fever
(p = 0.19), sore throat (p = 0.133),
comorbidities (p = 0.403) and headache
(p = 0.162) were similar across groups. Rhinorrhoea was
more common among HCWs (34.4% versus 16.6%,
p = 0.017). Among HCWs, nurses had the highest
morbidity (52.6%) and mortality (58.8%). Conclusion: The morbidity and mortality among HCWs in Uganda were substantial, with a low
COVID-19 vaccination rate and a higher requirement for oxygen therapy
despite a younger age.
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Affiliation(s)
- Leoson Junior Ssetaba
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joy Mirembe
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jotham Omega
- Department of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Jerom Okot
- Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Sarah Kiguli
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Felix Bongomin
- Faculty of Medicine, Gulu University, P. O. Box, 166, Gulu, Uganda
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