Ramona Whittington
From: Roxana Cruz Sent: Tuesday, January 12, 2021 5:37 PM To: Medical Directors; catherine.threatt; Lindsay Lanagan; Myrta Garcia; Jennifer Mertz; [email protected] Cc: ClinicalTeam; Shelby Tracy; Jana Eubank; Daniel Diaz; Nancy Gilliam; Ramona Whittington; Missy Apodaca Subject: COVID-19 Vaccine Weekly Update Attachments: Interim+suggested+actions+for+COVID+variant+surveillance_1.05.2021.pdf; COVID-19-Surveillance- Worksheet-annotated-508+highlighted.pdf; 5-things-to-know_COVID Vaccine Msg.pdf; Lancet Article_6mo post COVID Consequences.pdf; Health-Center-Response-to-COVID-19-Infographic- January-1.pdf; COVIDVaccineAllocation-Week5.pdf
Importance: High
Dear Fellow Medical Directors,
This is your weekly update for the COVID‐19 Vaccines, we have included the links and attachments which you may find useful for review and implementation at your health centers. We have also included resources for therapeutics for non‐ hospitalized high risk patients, post‐COVID care, educational opportunities, and messaging for your health center staff and patients.
As of 1/12/2021: 39 Texas Health Centers (76 Clinic Sites) have been allocated a total of 15,500 doses to date Which includes the 1,000 doses allocated to 10 Texas health center sites during Week 5 (01/11/2021)
62 Health Centers are either “Approved” and/or “Pending Approval” 121 Approved Health Center sites
That brings us to 9 health Centers with “Signatures pending” needing signatures from CMO or CEO (total of 14 clinic sites). I will reach out this week via e‐mail to see if and how TACHC can support your efforts. 10 Health Center clinic sites “In Progress” (need action or completion from the health center) 37 Health Center clinic sites “Pending Approval” ‐> action needed by DSHS 10 Health Center organizations have NOT registered to date
WEEK 5 (01/11/2021) Allocations (list is attached) 10 Health Centers received vaccine allocation this week, as follows:
o Communicare Health Centers West 1102 Barclay St San Antonio BEXAR (100 doses) o East Texas Border Health Clinic dba Genesis PrimeCare 1011 S William Street Atlanta CASS (100 doses) o Accelhealth Stephenville 135 River North Blvd Stephenville ERATH (100 doses) o Wellness Pointe/South 040587 2131 South Mobberly Longview GREGG (100 doses) o Hope Clinic Alief 14438 Bellaire Blvd Houston HARRIS (100 doses) o Carevide 4311 Wesley St Greenville HUNT (100 doses) o Gateway Community Health Center Inc. ‐ Hebbronvill 473 State Highway 285 Hebbronville JIM HOGG (100 doses) o (Atascosa) Live Oak Community Health Center 105 E Thornton Three Rivers LIVE OAK (100 Doses) o Coastal Bend Wellness Foundation 2882 Holly Rd Corpus Christi NUECES (100 doses) o Cactus Health 700 N Main St Fort Stockton PECOS (100 doses)
1 U.S. Department of Health and Human Services Alex Azar’s statement today (01/12/2021) indicates federal alignment with Texas’ priorities. https://www.krqe.com/health/coronavirus/hhs‐dept‐of‐defense‐to‐hold‐operation‐warp‐speed‐ briefing/ Furthermore, based on the FDA EUA and scientific evidence, two doses are required and will be available and should be administered with appropriate timing (Pfizer second dose should be at 2 days and Moderna vaccine second dose should occur at 28 days).
Post‐COVID Consequences “At 6 months after acute infection, COVID‐19 survivors were mainly troubled with fatigue or muscle weakness, sleep difficulties, and anxiety or depression. Patients who were more severely ill during their hospital stayhad more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations, and are the main target population for intervention of long‐term recovery.” https://www.thelancet.com/action/showPdf?pii=S0140‐6736%2820%2932656‐8 (article attached) Clinician Outreach and Communication Activity (CoCA Call) “ Treating Long‐COVID: Clinician Experience with Post‐Acute COVID‐19 Care” Thursday, January 28, 2021, at 1:00 PM – 2:00 PM CT Webinar Link: https://www.zoomgov.com/j/1606808037?pwd=NUx3a1hQd2tVWVZBU0JobFgxUDJ2Zz09external icon
Messaging/Infographics NACHC Infographic (01/01/2021) NATIONAL FINDINGS ON HEALTH CENTERS' RESPONSE TO COVID‐19 TACHC “5Things to Know About COVID‐19 Vaccines”
Therapeutics for COVID‐19 Today, HHS launched a web‐based COVID‐19 outpatient treatment locator to assist healthcare providers and patients in finding potential locations for treatment with monoclonal antibody therapeutics. These medicines are authorized for emergency use in treating patients with mild or moderate COVID‐19 who are at high risk of developing severe symptoms and requiring hospitalization. Currently 13 Therapeutic sites are available in Texas: [email protected]
The COVID‐19 therapeutics distribution page shows locations where these monoclonal antibody therapeutics have been delivered, including the facility name and address and which monoclonal antibody therapeutic has been delivered to the site. Only facilities that are open to the general public are listed. The locator does not include facilities that receive the monoclonal antibody therapeutics for outpatient treatment of specific groups, such as for patients in long‐term care facilities, skilled nursing facilities, psychiatric facilities, or prisons.
Press release: https://www.hhs.gov/about/news/2021/01/11/hhs‐launches‐web‐based‐locator‐for‐ covid‐19‐outpatient‐treatment‐sites‐for‐monoclonal‐antibodies.html
Join tomorrow’s Monoclonal Antibody ECHO session: “HHS/ASPR COVID‐19 Outpatient Therapeutics Mini‐Series Monoclonal Antibodies: A Healthcare System's Approach” – Registration link below Two items worth noting: 1. The 2 main speakers are from Mass General Hospital, including Dr. Raj Gandhi who is a member of both the NIH and IDSA COVID‐19 Treatment Guidelines panels. 2. The panel includes 2 speakers from long‐term care (pharmacist and director of nursing) who worked together to administer 38 courses of bamlanivimab in 6 days during a nursing home outbreak in San Antonio.
COVID‐19 Variant On January 10, 2021, we were notified of an identified SARS‐CoV‐2 B.1.1.7 Variant case in Nueces County. The case has been contact traced and the individual is in self‐isolation. Background: "In the United Kingdom (UK), a new variant strain of SARS‐CoV‐2 (known as 20B/501Y.V1, VOC 202012/01, or B.1.1.7 lineage) emerged with an unusually large number of mutations. This variant has since been detected in numerous countries around the world, including the United States (US) and Canada."
2 "B.1.1.7 lineage (a.k.a. 20B/501Y.V1 Variant of Concern (VOC) 202012/01) This variant has a mutation in the receptor binding domain (RBD) of the spike protein at position 501, where amino acid asparagine (N) has been replaced with tyrosine (Y). The shorthand for this mutation is N501Y. This variant also has several other mutations, including: o 69/70 deletion: occurred spontaneously many times and likely leads to a conformational change in the spike protein o P681H: near the S1/S2 furin cleavage site, a site with high variability in coronaviruses. This mutation has also emerged spontaneously multiple times. o ORF8 stop codon (Q27stop): mutation in ORF8, the function of which is unknown. This variant is estimated to have first emerged in the UK during September 2020. Since December 20, 2020, several countries have reported cases of the B.1.1.7 lineage, including the United States and Canada. Preliminary epidemiologic indicators suggest that this variant is associated with increased transmissibility (i.e., more efficient and rapid transmission). Currently there is no evidence to suggest that the variant has any impact on the severity of disease or vaccine efficacy." Please see the CDC link for further information on Emerging Variants of SARS‐CoV‐ 2: https://www.cdc.gov/coronavirus/2019‐ncov/more/science‐and‐research/scientific‐brief‐emerging‐variants.html
Additional Educational Opportunities: Americares COVID‐19 Training Series ‘Strategies for 2021’ In Brief: What are the Latest Developments With COVID? o Join our infection prevention and control specialists for this session which presents the most up‐to‐date evidence on COVID‐19. This session makes sense of the evolving evidence base to bring you the highlights of the most recent developments with the SARS‐CoV‐2 virus, immunity, risk factors, transmission, testing, treatment, and control measures. o Thursday, January 21 4pm ET | Register & Tuesday, January 26 11am ET | Register
Evaluating Health Center Response to the COVID‐19 Pandemic o In this session you will learn how to gather information about successes and challenges in the health center’s response for COVID‐19 and incorporate that information to improve your response going into 2021. You’ll receive an After‐Action Report template to use to document your areas for improvement. o Tuesday January 19 4pm ET | Register & Thursday, January 28 11am ET | Register
You Can’t Give What You Don’t Have: Self‐Care Strategies for the Busy Health Professional o This interactive workshop will help you identify and manage stress. You’ll identify common stress reactions and how our nervous system reacts to stress. You will also learn strategies for handling and preventing emotional distress and regulating the nervous system. o Wednesday, January 20 4pm ET | Register & Wednesday, January 27 11am ET | Register
We continue to talk with DSHS and advocate on behalf of our health centers for staff/HCWs in 1a and patients who are in the 1b category (which are most of our patients in health centers). Please know that we continue to push forward with DSHS and EVAP on the importance of health center staff and patients as a priority for this vaccine and we are developing a strategy here at TACHC which you should hear more about in the next few days.
Thank you for keeping us updated and for your commitment to your communities, Best wishes, Roxana
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Roxana L. Cruz, MD , FACP Director of Medical & Clinical Affairs
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Texas Association of Community Health Centers 5900 Southwest Parkway, Bldg. #3 Austin, Texas 78735 P (512) 329-5959 F (512) 329-9189 e-mail: [email protected] www.TACHC.org
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6 - 5 Facts to Know - COVID-19 Vaccines Vaccines help your body safely develop immunity to disease. Although this vaccine is new, getting a COVID-19 vaccine is key in reducing the spread of the virus. Below are five important facts to keep in mind about COVID-19 vaccines.
It's safe. The new COVID‑19 vaccines - Pfizer-BioNTech and Moderna - have been evaluated in tens of thousands of clinicians and volunteers during clinical #1 trials and were granted emergency use authorization (EUA) by the FDA. This was given because of a rigorous process based on scientific standards for safety, effectiveness, and manufacturing quality. Many people were recruited to participate and monitored closely throughout the trials to see if and how the vaccines offer protection to people of different ages, races, and ethnicities, as well as those with different medical conditions. As with all vaccines, rare side effects or allergic reactions are possible. Please speak with your health care provider about any past allergic responses. Since COVID-19 vaccine is new, safety monitoring will continue with routine updates. CDC and other federal partners monitor the new vaccines by using the reports from vaccine safety monitoring systems. Independent groups of experts from the ACIP and the CDC review all the safety data as it comes in and provide recommendations and regular updates. If a safety issue is detected, immediate action will be taken to determine the best course of action. Once you get the vaccine, you can help by reporting your own experience using one of the safety monitoring systems, like the COVID-specific V‑safe After Vaccination Health Checker; this app is very user friendly! It's highly effective. The administration of the COVID-19 Vaccine has been carefully reviewed #2 and there is clear evidence demonstrating that COVID-19 vaccines may prevent severe illness and may prevent people from getting COVID-19 altogether. To get full protection, you will need two doses. The vaccines are not interchangeable, so you will need two doses of the same vaccine, spaced out according to the manufacturer's recommendations. It's critical to get your second dose because full protection typically comes 1–2 weeks after that second shot. Ultimately, immunity reduces the spread of COVID-19.
It's not going to give you COVID-19.
COVID-19 vaccines have not been created using a live virus, nor a whole #3 virus; therefore, it cannot give you COVID-19. The technology (i.e. mRNA) used to create the vaccine has been available for a long time and has been studied for flu, Zika, rabies, and cytomegalovirus (CMV) to create a vaccine. This technology works with proteins in your body to develop immunity, but your DNA cannot be altered by the administration of the vaccine. The mRNA within the vaccine actually work as instructions for our cells to make a harmless piece of what is called the “spike protein.” The spike protein is found on the surface of the virus that causes COVID- 19; therefore, no virus is injected into your body, but your immune system is activated to protect and create immunity.
Symptoms such as low-grade fever and possible mild body aches are considered normal, and they are even signs that your body's immune system is building protection against the virus. Although you may experience some discomfort, any symptoms should go away in a few days. Talk with your provider and learn more about what to expect and get tips to reduce any discomfort that could possibly occur after vaccination.
It's protecting your community.
Texas has been working hard to distribute COVID-19 vaccine, and more #4 will become available in the coming weeks. The Texas Commissioner of Health appointed an Expert Vaccine Allocation Panel (EVAP) of diverse subject matter experts to make recommendations on vaccine allocation decisions. These include identifying groups that should be vaccinated first. The goal is to provide protection to the most vulnerable populations and connect their communities with critical Texas resources. As time goes on, more Texans will be able to get vaccinated.
It's going to take time and consistency.... that includes messaging! #5 Even after the COVID-19 vaccine, we need to keep using preventive measures such as maintaining distance between others, wearing masks, and practicing good hand hygiene. Texas is a big state and we will need tens of millions to get vaccinated before we get the community immunity we need. It will take time, but it is vital that we keep preventive measures in place with consistent messages to curb the spread of COVID- 19 in our communities.
Please help curb COVID-19 by getting vaccinated and encouraging others to do so too! For more information, visit these trusted sources: Texas Department of Health Services and Center for Disease Control and Prevention
Adapted from : www.dshs.texas.gov/coronavirus/immunize/vaccine.aspx https://www.cdc.gov/vaccines/covid-19/hcp/answering-questions.html NATIONAL FINDINGS ON HEALTH www.nachc.org @NACHC CENTERS' RESPONSE TO COVID-19
As of January 1, 2020
The Health Resources and Health Centers are Meeting Testing Needs in Their Communities Services Administration is surveying health centers weekly to track their COVID-19 response. 64% (884) of health centers responded this week. 98% 81% Since April 3rd, 7 million health center patients have been tested for COVID-19 and 13% have tested have the have walk-up or positive. ability to test drive-up testing This week: For Virus Detection For Antibody Detection 241,794 Patients were tested 7,421 Patients were tested Patients tested Patients tested 41,846 positive 2,720 positive of patients tested were of patients tested were 47% racial and/or ethnic 46% racial and/or ethnic minorities minorities of patients tested positive of patients tested positive 52% were racial and/or ethnic 41% were racial and/or ethnic minorities minorities
1 SINCE APRIL 3RD: Total patients tested Total patients testing positive
7,732,721 997,236 Health Centers Continue to Have Issues with Test Result Turnaround Time and PPE Access of Health Centers % of health centers that do not have Report COVID-19 adequate personal protective equipment 75% Test Results Have a (PPE) items for the next month Turnaround Time of 2 or More Days Surgical Masks N95/PPR Masks Gowns Gloves Face Masks/Goggles 0 10 20 30 40
COVID-19 Challenges to Health Center Operations and Budgets. This Week:
95% of health 633 health center 5% of health centers sites temporarily center staff are
conducted closed due2 to unable to report visits virtually COVID-19 to work due to COVID-19
1,940 staff Health center visit rates remain below tested normal at 75%4 positive3
Health Centers are also providing needed flu vaccines during the pandemic. This week: flu vaccinations of patients vaccinated 108,495 were administered 77% were racial and/or ethnic minorities
Source and Notes: Data presented in this fact sheet come from the Bureau of Primary Health Care, Health Resources and Services Administration, Health Center COVID-19 Survey collected on January 1, 2020. 64% (884) of federally-funded health centers responded. Survey data are preliminary and do not reflect all health centers. Some duplication of patients tested from week to week may occur. For more information, please visit https://bphc.hrsa.gov/emergency-response/coronavirus-healthcenter-data. 1.Total reported refers to the number of respondents for COVID-19 testing since the survey period starting on April 3, 2020. 2. Due to staff exposure, school closure, site/service closure, and other reasons. 3. Represents the number that tested positive for COVID-19 virus detection. 4. Visits refers to all visits regardless of service type (e.g. medical, dental, behavioral health, etc.), including virtual visits; visits the week prior to April 10 were 47% of pre-COVID normal rates. For more information, email [email protected] or visit www.nachc.org/coronavirus.
Human Infection with Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet GENERIC MMG COVID-19_MMG_V1_0_MMG_F_2020626
NAME ADDRESS (Street and No.) PHONE Hospital Record No. ______(last) (first) This information will not be sent to CDC LOCAL SUBJECT ID PID-3 ______REPORTING SOURCE TYPE 48766-0 NAME ______ﬦ physician ﬦ PH clinic ADDRESS ______SUBJECT ADDRESS STATE PID-11.4 ______ﬦ nurse ﬦ laboratory ZIP CODE 52831-5 ______SUBJECT ADDRESS COUNTY PID-11.9 ______ﬦ hospital ﬦ other clinic PHONE (______) ______ﬦ other source type ______SUBJECT ADDRESS ZIP CODE PID-11.5 ______CASE INFORMATION NNDSS ID OBR-3 ______Date of Birth ______Country of Birth 78746-5 __ Other Birthplace 21842-0 ______(Local Record/Case ID) PID-7 month day year Ethnic Group PID-22 H=Hispanic/Latino N=Not Hispanic/Latino O=Other ______U=Unknown Country of Usual Residence 77983-5 PID-10 Race ﬦAmerican Indian/Alaskan Native ﬦAsian ﬦBlack/African American ﬦNative Hawaiian/Pacific Islander ﬦWhite ﬦNot asked ﬦ Refused to answer ﬦOther 32624-9 ﬦ Unknown ______Sex M=male F=female U=unknown PID-8 Age at Case 77998 Investigation-3 ______Age Unit* Date Reported OBX-6 for 77998-3 77995 77995-9- 9 month day year ______Date First Reported to PHD ______Reporting State 77966-0 __ Earliest Date Reported to State 77973 - 6 month day year 7797077970-2- 2 month day year Reporting County 77967-8 _____ Earliest Date Reported to County ______National Reporting Jurisdiction 77968-6 _____ 77972-8 month day year CDC 2019-nCOV ID Date First 95366-1 ______If probable case, reason for case classification: 94659-0 Positive Specimen (mm/dd/yyyy) 95365-3 Meets clinical criteria AND epidemiologic evidence with no Case Investigation ______CASE ﬦ Confirmed confirmatory lab testing performed for COVID-19 Start Date 77979-3 month day year CLASS ﬦ Probable ﬦ Unknown Meets presumptive lab evidence AND either clinical criteria OR epidemiologic evidence DGMQID INV1315 ______STATUS ﬦ Suspected ﬦ Not a case [If Epi-X notification of travelers checked, DGMQID] 77990-0 Meets vital records criteria with no confirmatory lab testing Autopsy Laboratory reported Unknown DETECTION Clinical evaluation Provider reported Other (specify below) METHOD Contact tracing of case patient Routine physical examination ______INV159 Epi-X notification of travelers Routine surveillance ______HOSPITALIZATION INFORMATION
Illness Onset Date ______Illness End Date ______Illness Duration _____ Duration Units* ______11368-8 month day year 77976-9 month day year 77977-7 OBX-6 for 77977-7 Hospitalized? Y=yes N=no U=unknown Hospital Admission Date ______Hospital Discharge Date ______month day year 77974-4 8656-1 8649-6 month day year
Duration of Hospital Stay 0 – 998 ______Patient admitted to an Intensive Care Unit (ICU)? Y=yes N=no U=unknown 78033-8 999=unknown (days) 309904001 If hospitalized, was a translator/Interpreter required? Y=yes N=no U=unknown ICU Admission Date ______54588-9 95367-9 month day year If a translator was required, specify the patient's primary language: ______ICU Discharge Date ______month day year DEM142 95368-7 Pregnant at time of event? Y=yes N=no U=unknown If yes, trimester at illness onset: Number Weeks Gestation 77996-7 81271-9 81270-1 Date of Death ______Did subject die from illness/complications of illness? 77978-5 Y=yes N=no U=unknown PID-29 month day year *UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown This annotated worksheet is draft as of June 30, 2020 and is provided as a resource representing the data/structure of the Generic V2 HL7 message mapping guide (Generic_V2_0_MMG_F_R5_20171206 ) and the COVID-19 HL7 message mapping guide (COVID-19_MMG_V1_0_MMG_F20200626). JUN 2020 Page 1 of 5 CLINICAL INFORMATION INFORMATION SOURCE Medical records Patient interview Unknown DATE of ______75521-5 DIAGNOSIS Other (specify) ______month day year for CLINICAL DATA 77975-1 TESTING REASON Asymptomatic testing Contact investigation Community testing site Screening Symptomatic Other (specify) Unknown 67098-4
Symptoms present during course of illness? INV576 Y=yes N=no U=unknown Did symptom(s) resolve? Y=yes N=no U=unknown 95383-6 59455-6 N=no U=unknown Did the patient have another diagnosis/etiology ffor their illness? Y=yes (if yes, specify) 81885-6 ______
Y N U [Y=yes] INV919 Y N U [N=no] Y N U [U=unknown] Abdominal pain Subjective fever Runny nose Chest pain Fever >100.4F (38C) Sore throat SIGNS and Chills Headache Vomiting SYMPTOMS Cough Nausea Wheezing
56831118-1 Diarrhea New olfactory disorder Other (specify) ______Difficulty breathing New taste disorder ______Dyspnea Muscle aches ______Fatigue Rigors Unknown
Y N U NA [Y=yes; N=no; U=unknown] INV1314 Y N U NA [NA=not applicable] INV1314 CLINICAL 118 118 Acute respiratory distress syndrome (ARDS) Other (specify) 59455-6 ______FINDINGS 118 Abnormal EKG Pneumonia 75321-0 118 Abnormal chest x-ray Unknown
DURATION (days) INV1313 TREATMENT Y N U [Y=yes; N=no; U=unknown] Y N U DURATION (days) Mechanical ventilation/intubation 67453-1 Other (specify) _____ TYPE 55753-8 118 ECMO Unknown
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Did patient have underlying medical conditions INV235 and/or risk behaviors? Y=yes N=no U=unknown Provide response for each below: Underlying Conditions or Risk Factors INV1117 [Y=yes; N=no; U=unknown] INV1118 Y N U Y N U Y N U Y N U Autoimmune condition Current smoker Hypertension Psychological/psychiatric‡ Cardiovascular disease Diabetes mellitus Immunosuppressive condition Severe obesity (BMI=≥40) Chronic liver disease Disability† Other chronic disease Substance abuse Chronic lung disease Former smoker Other (specify) ______Unknown
Chonic renal disease †If disability, type 95377-8 ______‡If mental condition, type 91391-3 ______
DEMOGRAPHIC INFORMATION Tribal affiliation? Y=yes N=no U=unknown Tribal Name ______Enrolled Tribe Name ______
95369-5 95370-3 67884-7
RESIDENCE Acute care inpatient facility Homeless shelter Long term care facility Other (specify) ______at ILLNESS Apartment Hotel Mobile home Outside ONSET Assisted living facility House/single family Motel Rehabilitation facility 75617-1 Correctional facility Group home Nursing home Unknown 223366009 Was case-patient a healthcare provider (HCP) at time of illness onset? Y=yes N=no U=unknown If yes, select from below: HCP Environmental services Nurse Assisted living facility Hospital HCP 95372-9 OCCUPATION Respiratory therapist Physician Long term care facility Nursing home TYPE INV1316 WORKPLACE Other Unknown Rehabilitation facility Unknown SETTING Other (specify) ______
Page 2 of 5 EXPOSURE and IMPORTATION INFORMATION
In the 14 days prior to illness onset, did the patient have any of the following exposures: INV1085 (check all that apply) Y N U [Y=yes, N=no, U=unknown] INV1086 Y N U Y N U Airport/Airplane Other (specify) ______International travel Adult congregate living facility Correctional facility School/university Childcare facility Domestic travel Community event/mass gathering Unknown exposures in the 14 days prior to illness onset Animal (confirmed/suspected COVID-19) Type animal 95376-0 ______
Workplace Workplace critical infrastructure? Setting (specify) 95374-5 ______95373-7 Cruise ship or vessel travel as passenger Name of ship(s) TRAVEL53 1) ______2) ______
Contact withINV603 confirmed/probable COVID-19 case: community healthcare associated household other ______Unknown If contact with COVID-19 case, was this person a U.S. case? 95375-2 Linked Case Number INV1124 ______
82752-7 (mm/dd/yyyy) TRAVEL08 (mm/dd/yyyy) Country Departure Date Return Date International ______Destinations 82764-2 ______
TRAVEL ______State 82754-3 Departure Date 82752-7 (mm/dd/yyyy) Return Date TRAVEL08 (mm/dd/yyyy) HISTORY ______Domestic Destinations ______
______CASE DISEASE Indigenous In state, out of jurisdiction Out of state IMPORTED CODE 77982-7 International Unknown Yes, imported, but not able to determine source state/country
Imported Country INV153 Imported State INV154 _____ Imported County INV156 ______Imported City INV155 ______
Country of Exposure 77984-3 ______State or Province of Exposure 77985-0 ______
County of Exposure 77987-6 ______City of Exposure 77986-8 ______
Outbreak related? Y=yes N=no U=unknown Outbreak Name ______Transmission Mode ______77980-1 77981-9 77989-2
LALABORATORY INFORMATION Date Specimen Performing Performing Test Test Result Test Result Collected Specimen Laboratory Laboratory Type Result Units Quantitative 68963-8 Type Specimen ID INV290 INV291 LAB115 Type LAB628 mm dd yyyy 31208-2 LAB202 82771 -7
TEST RESULT SPECIMEN TYPE Q=Equivocal result 1 Bacterial isolate 9 CSF 17 NP swab 25 Saliva 33 Swab 41 Vesicle fluid E=Indeterminate 2 Blood 10 Crust 18 NP washing 26 Scab 34 Swab, skin lesion 42 Viral isolate N=Negative 3 Body fluid 11 DNA 19 Nucleic acid 27 Serum 35 Swab, nasal sinus 43 Other NS=No IgG significant rise 4 BAL 12 Dried blood 20 Oral fluid 28 Skin lesion 36 Swab, vesicular 44 Unknown X=Not done 5 Buccal smear 13 Lesion 21 Oral swab 29 Specimen 37 Swab, internal nose OTH=Other (specify) I=Pending 6 Buccal swab 14 Macular scraping 22 Plasma 30 Lung (BAL wash) 38 Throat swab P=Positive 7 Capillary blood 15 Microbial isolate 23 Respiratory 31 Lavage 39 Tissue S=IgG significant rise 8 Cataract 16 NP aspirate 24 RNA 32 Stool 40 Urine UNK=Unknown U=Unsatisfactory PERFORMING LABORATORY TYPE V=Vaccine type strain W=Wild type strain 1=CDC lab 2=commercial lab 3=hospital lab 4=other 5=other clinical lab 6=public health lab 7=unknown 8=VPD testing lab
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VACCINATION HISTORY INFORMATION
Vaccinated (has the case-patient ever received a vaccine against this disease)? VAC126 Y=yes N=no U=unknown
Number of doses against this disease received prior to illness onset? 0–6 99=unknown (doses) 82745 -1 Date of last vaccine dose against this disease prior to illness onset? VAC142 ______(mm/dd/yyyy)
Was the case-patient vaccinated as recommended by the ACIP? VAC148 Y=yes N=no U=unknown
Vaccine Vaccine National Vaccination Vaccine Vaccine Vaccination Date Vaccine Vaccine Expiration Type Manufacturer Drug Record Event Dose 30952 -6 Lot No. Date Information Number Code VAC109 Identifier 30956-7 30957-5 30959-1 30973-2 month day year VAC153 month day year VAC102 Source VAC147
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______Vaccine Type Vaccine Event Information Codes Vaccine 00=New immunization record 05=Other registy (historical) PHC1435=Patient/parent recall (historical) Manufacturer 01=Unspecified source 06=Birth certificate (historical) PHC1436=Patient/parent written record 02=Other provider (historical) 07=School record (historical) PHC1936=Immunization Information System PP=Primary care provider 08=Public agency (historical) 184225006=Medical record OTH=Other UNK=Unknown
Reason Not Vaccinated Per ACIP VAC149 1=religious exemption 5=MD diagnosis of previous disease 9=unknown 13=parent/patient unaware of recommendation 2=medical contraindication 6=too young 10=parent/patient forgot to vaccinate 14=missed opportunity 3=philosophical objection 7=parent/patient refusal 11=vaccine record incomplete/unavailable 15=foreign visitor 4=lab evidence of previous disease 8=other ______12=parent/patient report of previous disease 16=immigrant
Vaccine History Comments VAC133
CASE NOTIFICATION CONDITION 11065 Immediate National Notifiable Condition 77965-2 Y=yes N=no U=unknown CODE OBR-31
Date of First Verbal Notification to CDC ______Date of Electronic Case Notification to CDC ______77994-2 month day year OBR-22 month day year
Date First Electonic Submission ______State Case ID 77993-4 ______Legacy Case ID 77997-5 ______OBR-7 month day year
Notification Result Status OBR-25 Final results Correction Cannot obtain Jurisdiction Code 77969-4 ______
Binational Reporting Criteria 77988-4 ______MMWR WEEK 77991-8 MMWR YEAR 77992-6 ______
Current Occupation (type of work patient does) 85658-3 ______Current Occupation Standardized 85659-1 (NIOCCS code) __
Current Industry (type of business/industry in which patient works) 85078-4 ______Current Industry Standardized 85657-5 (NIOCCS code) _____
Person Reporting to CDC ______(first) Person Reporting to CDC Email 74547-1 ______@ ______
NAME 74549-7 ______(last) Person Reporting to CDC Phone Number 74548-9 (______) ______
Comments 77999-1
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CLINICAL CASE DEFINITION§ Suspect Meets supportive laboratory evidence¶ with no prior history of being a confirmed or probable case. Probable
Meets clinical criteria# AND epidemiologic linkage** with no confirmatory laboratory testing performed for SARS-C0V-2. Meets presumptive†† laboratory evidence. Meets vital records‡‡ criteria with no confirmatory laboratory testing performed for SARS-CoV2. Confirmed Meets confirmatory§§ laboratory evidence.
¶Detection of specific antibody in serum, plasma, or whole blood Detection of specific antigen by immunocytochemistry in an autopsy specimen [For suspect cases (positive serology only), jurisdictions may opt to place them in a registry for other epidemiological analyses or investigate to determine probable or confirmed status.] ______
#In the absence of a more likely diagnosis: • At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose OR • Any one of the following symptoms: cough, shortness of breath, difficulty breathing OR • Severe respiratory illness with at least one of the following: ◦ Clinical or radiographic evidence of pneumonia, or new olfactory disorder, new taste disorder ◦ Acute respiratory distress syndrome (ARDS). ______**One or more of the following exposures in the prior 14 days: • Close contact with a confirmed or probable case of COVID-19 disease; • Member of a risk cohort as defined by public health authorities during an outbreak. [Close contact is generally defined as being within 6 feet for at least 15 minutes. However, it depends on the exposure level and setting; for example, in the setting of an aerosol-generating procedure in healthcare settings without proper PPE, this may be defined as any duration. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact. ______††Detection of SARS CoV-2 by antigen test in a respiratory specimen. ______‡‡A death certificate that lists COVID-19 disease or SARS-CoV-2 as an underlying cause of death or a significant condition contributing to death. ______§§ Detection of SARS-CoV-2 RNA in a clinical or autopsy specimen using a molecular amplification test
§https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-02_COVID-19.pdf
CDC Interim Suggested Actions for Public Health Follow-up for COVID-19 Case Investigations Involving SARS-CoV-2 Genetic Variants of Concern (e.g., B.1.1.7) Version date: January 5, 2021 Note: This working document will be refined as additional information is available during a rapidly evolving situation.
1. Suggested priority data elements CDC suggests that, as part of public health follow-up for COVID-19 case investigations involving SARS-CoV-2 genetic variants of concern (e.g., B.1.1.7), state and local public health partners prioritize consistent completion of select data fields using the Human Infection with Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet. Four categories of select data fields (highlighted in accompanying annotated copy of the surveillance worksheet) to prioritize are suggested: 1. All basic patient demographic information; 2. Measures of severity, particularly hospitalization and ICU admission as well as death; 3. Select exposure information, including domestic and international travel, time spent in congregate settings (e.g., adult living facilities, schools, correctional facilities) as well as exposures to contacts in household and other settings; and 4. Vaccine history, including vaccination status and vaccine type and number of doses for vaccinated persons.
2. Linking epidemiologic and laboratory data Ad hoc efforts to link epidemiologic and laboratory data will be necessary on a case-by-case basis until routine processes for linkage are established. These efforts may require careful coordination at federal, state, and local levels across surveillance and laboratory programs in the public sector as well commercial laboratories and possibly other partners in the private sector. Ascertainment of accession ID numbers and corresponding case report IDs should be prioritized to facilitate linkages.
3. Retrieval of specimens or isolates for viral characterization at CDC Careful coordination across surveillance and laboratory programs in the public and private sectors is also required for retrieval of specimens or isolates for viral characterization at CDC. Ad hoc efforts will also be necessary for retrieval on a case-by-case basis until routine processes for linkage are established.
Additional information to facilitate the suggested actions described above can be found online.
4. Additional information If resources are available, health departments are requested to further inquire with cases to elucidate: a. All known contacts in the previous 7 days b. Confirm willingness of the individual to be contacted again for potential detailed interview Week 5 Texas COVID-19 Vaccine Allocation - Hub Providers This list includes only first doses of vaccine and does not include 121,875 doses allocated to the federal pharmacy/long-term care partnership. Addresses are shipping addresses, not necessarily where vaccination is occurring. Pfizer Moderna Total Provider Name Address City County Doses Doses Doses Bell County Public Health District 509 S 9th St Temple BELL 3900 0 3900 San Antonio Metro Health District 210 N Mel Waiters Way San Antonio BEXAR 0 9000 9000 University Health System 4502 Medical Dr San Antonio BEXAR 10725 0 10725 CHI St. Joseph College Station Hospital 1604 Rock Prairie Rd College Station BRAZOS 0 1200 1200 Cameron County Public Health 1390 W Expressway 83 San Benito CAMERON 0 6000 6000 Dallas County Health And Human Services 2377 N Stemmons Fwy Dallas DALLAS 0 6000 6000 Parkland Hospital 5200 Harry Hines Blvd Dallas DALLAS 6825 0 6825 UT Southwestern Medical Center 5323 Harry Hines Blvd Dallas DALLAS 0 10000 10000 Denton County Public Health 190 N. Valley Pkwy. Lewisville DENTON 0 3500 3500 El Paso Fire Department 301 George Perry El Paso EL PASO 0 5000 5000 University Medical Center of El Paso 4815 Alameda Ave El Paso EL PASO 0 5000 5000 Harris County Public Health 2223 West Loop South Houston HARRIS 0 8000 8000 Houston Health Department 8000 N Stadium Dr Houston HARRIS 0 8000 8000 Houston Methodist Hospital 6565 Fannin St Houston HARRIS 10725 0 10725 Doctors Hospital at Renaissance 5501 South McColl Road Edinburg HIDALGO 0 6500 6500 Hidalgo County Health and Human Services 1304 S 25th Ave Edinburg HIDALGO 0 5000 5000 City of Lubbock Health Department 806 18th St Lubbock LUBBOCK 0 5000 5000 Fort Duncan Regional Medical Center 3333 N Foster Maldonado Blvd Eagle Pass MAVERICK 0 1200 1200 Waco-McLennan County Public Health District 225 W Waco Dr Waco MCLENNAN 0 1500 1500 Ascension Providence Hospital 6901 Medical Pkwy Waco MCLENNAN 0 1500 1500 Corpus Christi-Nueces County Public Health District 1702 Horne Road Corpus Christi NUECES 0 4000 4000 Amarillo Public Health Department 1000 Martin Rd Amarillo POTTER 0 5000 5000 Northeast Texas Public Health District 815 N Broadway Ave Tyler SMITH 0 1500 1500 UT Health Science Center Tyler 11937 Us Highway 271 Tyler SMITH 0 1500 1500 Tarrant County Public Health 1101 S Main St Ste 1350 Fort Worth TARRANT 0 9000 9000 Texas Health Resources 1100 Bridgewood Fort Worth TARRANT 5850 4200 10050 Austin Public Health 15 Waller Street Austin TRAVIS 0 12000 12000 City of Laredo Health Department 2600 Cedar Ave Laredo WEBB 0 1200 1200 Week 5 Texas COVID-19 Vaccine Allocation - Additional Providers This list includes only first doses of vaccine and does not include 121,875 doses allocated to the federal pharmacy/long-term care partnership. Addresses are shipping addresses, not necessarily where vaccination is occurring. Pfizer Moderna Total Provider Name Address City County Doses Doses Doses Chi St Lukes Hlth Memorial Lufkin 1201 W Frank Ave Lufkin ANGELINA 0 100 100 Methodist Hospital South 1905 Hwy 97 E Jourdanton ATASCOSA 0 300 300 Bellville Medical Center 44 N. Cummings St. Bellville AUSTIN 0 100 100 A+ Life Style Medical Group 815 Hwy 71 W Bastrop BASTROP 0 100 100 Family Health Center Of Bastrop 3101 Highway 71 E Ste 101 Bastrop BASTROP 0 100 100 Seton Medical Center Harker Heights 850 West Central Texas Expresswy Harker Heights BELL 0 100 100 Castle Hills family practice 6409 Bandera Road San Antonio BEXAR 0 100 100 Communicare Health Centers West 1102 Barclay St San Antonio BEXAR 0 100 100 Cumberland Surgical Hospital 5330 North Loop 1604 West San Antonio BEXAR 0 200 200 Davila Pharmacy 1423 Guadalupe San Antonio BEXAR 0 200 200 Dshs HSR 8 Hq - San Antonio (Re) 7430 Louis Pasteur Dr San Antonio BEXAR 0 1000 1000 Healthsouth Riosa Rehabilitation Hospital Pharmacy 9119 Cinnamon Hl San Antonio BEXAR 0 300 300 Kindred Hosptial San Antonio Central 111 DALLAS STREET San Antonio BEXAR 0 100 100 Methodist Metropolitan Hospital 1310 McCullough Ave San Antonio BEXAR 0 300 300 Methodist Stone Oak Hospital 1139 E. Sonterra Blvd. San Antonio BEXAR 0 300 300 South Texas Spine And Surgical Hospital 18600 Hardy Oak Blvd San Antonio BEXAR 0 100 100 Southwest General Hospital 7400 Barlite Blvd San Antonio BEXAR 0 100 100 Texas Center For Infectious Disease 2303 Se Military Dr San Antonio BEXAR 0 200 200 The Emergency Clinic at the Pearl 2015 Broadway St. San Antonio BEXAR 0 100 100 Collom And Carney Main Clinic 5002 Cowhorn Creek Rd Texarkana BOWIE 0 300 300 Pam Specialthy Hospital Of Texarkana North 2400 St. Michael Drive 2nd Floor Texarkana BOWIE 0 100 100 Wadley Regional Medical Center 1000 Pine Texarkana BOWIE 0 200 200 CHI St. Joseph Health Rehabilitation Hospital, an 1600 Joseph Dr. Bryan BRAZOS 0 100 100 St Joseph Hospital (Meditech) 2801 Franciscan Dr Bryan BRAZOS 0 300 300 Texas A&M Health Family Care Clinic 2900 E 29th St Bryan BRAZOS 0 100 100 THE PHYSICIANS CENTRE HOSPITAL 3131 University Dr E Bryan BRAZOS 0 200 200 CHI St Joseph Primary Care- College Station 1512 Holleman Dr College Station BRAZOS 0 100 100 Big Bend Regional Health Center 2600 Highway North 118 Alpine BREWSTER 0 200 200 Hendrick Medical Center Brownwood 1501 Burnett Rd Brownwood BROWN 0 100 100 Ascension Seton HIghland Lakes 3201 S. Water Street Burnet BURNET 0 100 100 BSW Medical Center Marble Falls 810 Tx-71w Marble Falls BURNET 0 100 100 PAM Specialty Hospital of Luling 200 Memorial Dr Luling CALDWELL 0 200 200 Seton Edgar B Davis Hospital 130 Hays St Luling CALDWELL 0 100 100 Port Lavaca Clinic Associates P.A. 1200 N Virginia St Port Lavaca CALHOUN 0 100 100 Valley Regional Medical Center 100A E. Alton Gloor Brownsville CAMERON 0 300 300 DSHS PHR 11 601 W. Sesame Drive Harlingen CAMERON 0 1000 1000 Sanchez Mario A Do 106 N Main La Feria CAMERON 0 100 100 Ut Health Pittsburg Hospital 2701 Us Highway 271 N Pittsburg CAMP 0 100 100 East Texas Border Health Clinic dba Genesis PrimeCar1011 S William Street Atlanta CASS 0 100 100 Medical Center Of Dimmitt 300 W Halsell St Dimmitt CASTRO 0 100 100 LHD Cherokee County Health Department (RE) 803 College Ave Jacksonville CHEROKEE 0 200 200 Ut Health Jacksonville Hospital 501 S Ragsdale St Jacksonville CHEROKEE 0 100 100 Cochran Memorial Hospital 201 E Grant Ave Ste 100 Morton COCHRAN 0 100 100 Post Acute Medical Rehabilitation Hospital Of Allen, Te1001 Raintree Cir Allen COLLIN 0 100 100 Baylor Scott And White Medical Center - Centennial 12505 Lebanon Rd Frisco COLLIN 0 100 100 Medical City Frisco 5500 Frisco Square Blvd Frisco COLLIN 0 100 100 Baylor Scott and White MC Mckinney 5252 W University Dr McKinney COLLIN 0 100 100 Methodist McKinney Hospital 8000 W. Eldorado Pkwy McKinney COLLIN 0 100 100 Baylor Scott & White Medical Center - Plano 4700 Alliance Blvd Plano COLLIN 0 1000 1000 Surgery Center of Texas 6020 West Plano Parkway Plano COLLIN 0 100 100 The Medical Center Of Plano 3901 W 15th St Plano COLLIN 0 300 300 Collingsworth Family Medicine 1011 15th St Wellington COLLINGSWORTH 0 100 100 Columbus Community Hospital - Columbus 2 110 Shult Drive Columbus COLORADO 0 100 100 Post Acute Medical Specialty Hospital Of New Braunfe 1445 Hanz Dr New Braunfels COMAL 0 100 100 DSHS Gainesville 1714 Justice Center Blvd Gainesville COOKE 0 100 100 North Texas Medical Center 1900 Hospital Blvd Gainesville COOKE 0 100 100 Baylor University Med Cntr Dallas 3500 Gaston Ave Dallas DALLAS 0 1000 1000 Bluitt-Flowers Clinic 303 E Overton Rd Dallas DALLAS 0 200 200 Hatcher Station Health Center 4600 Scyene Rd Dallas DALLAS 0 100 100 Kindred Hospital Dallas Central 8050 Meadow Rd Dallas DALLAS 0 100 100 LifeCare Hospital of Dallas 1950 Record Crossing Dallas DALLAS 0 200 200 Irving Health Center-Parkland Health and Hospital Sys1800 N Britain Rd Irving DALLAS 0 100 100 Dawson County Hospital District 2200 North Bryan Avenue Lamesa DAWSON 0 100 100 Carrollton Springs 2225 Parker Rd Carrollton DENTON 0 400 400 Baylor Surgicare at Blue Star LLC 3800 Gaylord Parkway Frisco DENTON 0 100 100 UT Health Henderson Hospital 300 Wilson St Henderson DEWITT 0 100 100 Eastland Memorial Hospital Po Box 897 Eastland EASTLAND 0 100 100 Lhd Ector County Health Department (Re) 221 N Texas Ave Odessa ECTOR 0 500 500 Odessa Emergency Center, LLC 2731 N Grandview Ave Odessa ECTOR 0 100 100 Odessa Regional Medical Center 520 E 6th St Odessa ECTOR 0 100 100 Baylor Scott And White Medical Center - Waxahachie 2400 N. I-35e Waxahachie ELLIS 0 100 100 Accelhealth Stephenville 135 River North Blvd Stephenville ERATH 0 100 100 Fisher County Hospital District 774 State Highway 70 N Rotan FISHER 0 200 200 Foard County Clinic 200 North 1st Street Crowell FOARD 0 100 100 Silverado Hospice of Houston, Inc 4800 Sugar Grove Blvd Stafford FORT BEND 0 100 100 ST MICHAEL'S ELITE HOSPITAL 16000 SOUTHWEST FREEWAY Sugar Land FORT BEND 0 300 300 Shriners Hospitals For Children - Galveston 815 Market St Galveston GALVESTON 0 300 300 Hca Houston Healthcare Mainland 6801 Emmett F Lowry Expy Texas City GALVESTON 0 100 100 Hill Country Memorial Hospital 1020 S State Highway 16 Fredericksburg GILLESPIE 0 100 100 Dshs Goliad 329 W. Franklin Goliad GOLIAD 0 100 100 Memorial Hospital - Gonzales Po Box 587 Gonzales GONZALES 0 100 100 Sievers Medical Clinic 1110 Sarah DeWitt Dr. Gonzales GONZALES 0 100 100 Texoma Hospital Partners LLC 1810 US Hwy 82 West Sherman GRAYSON 0 400 400 Wnj Regional Medical Center 500 N Highland Ave Sherman GRAYSON 0 300 300 Select Specialty Hospital Longview Infection Control 700 E Marshall Ave Longview GREGG 0 100 100 Wellness Pointe/South 040587 2131 South Mobberly Longview GREGG 0 100 100 Bis Community Clinic 22140 Highway 90 N Bedias GRIMES 0 100 100 HCA Houston Healthcare North Cypress 21214 Northwest Fwy Cypress HARRIS 0 200 200 AD Hospital East, LLC 12950 East Frwy Houston HARRIS 0 100 100 Aldine Health Center 4755 Aldine Mail Route Rd Houston HARRIS 0 100 100 Ben Taub General Hospital 1504 Taub Loop Houston HARRIS 0 300 300 Emergency Care Of East Houston 15119 Wallisville Road Houston HARRIS 0 100 100 Hca Houston Healthcare Northwest 710 Cypress Creek Parkway Houston HARRIS 0 200 200 Healthbridge Children's Hospital 2929 Woodland Park Dr Houston HARRIS 0 100 100 Hope Clinic Alief 14438 Bellaire Blvd Houston HARRIS 0 100 100 Memorial Hermann Memorial City Medical Center 921 Gessner Rd Houston HARRIS 0 300 300 Memorial Hermann SE Hospital 11800 Astoria Blvd Houston HARRIS 0 300 300 City Of Humble Fire Department 110 W Main St Humble HARRIS 0 100 100 Texas Department of Criminal Justice Lynchner 2350 Atascocita Rd. Humble HARRIS 0 100 100 HCA Houston Healthcare Southeast 4000 spencer highway Pasadena HARRIS 0 200 200 HCA Houston Healthcare Clear Lake 500 Medical Center Blvd Webster HARRIS 0 200 200 Ascension Seton Health Center Buda 5235 Overpass Rd Buda HAYS 0 100 100 Seton Medical Center Hays 6001 Kyle Pkwy Kyle HAYS 0 400 400 Christus Trinity Mother Frances 1505 Hwy 19 S Athens HENDERSON 0 100 100 Ut Health East Texas Athens 2000 S Palestine St # 40024 Athens HENDERSON 0 100 100 UTHealth RGV PRIMARY CARE 230 N. 86TH ST Edinburg HIDALGO 0 100 100 South Texas Health System Mcallen 301 W Expressway 83 McAllen HIDALGO 0 200 200 Mission Regional Medical Center 900 S Bryan Rd Mission HIDALGO 0 200 200 Christus Mother Frances Hospital - Sulphur Springs 115 Airport Rd Sulphur Springs HOPKINS 0 100 100 Big Spring State Hospital 1901 N Us Highway 87 Big Spring HOWARD 0 200 200 Scenic Mountain Medical Ctr 1601 W 11th Pl Big Spring HOWARD 0 100 100 Carevide 4311 Wesley St Greenville HUNT 0 100 100 Beaumont Elite Emergency Center LLC 4004 College Street Beaumont JEFFERSON 0 100 100 Envoy Hospice 3180 College St, Beaumont JEFFERSON 0 100 100 Mid Jefferson Extended Care-Beaumont 860 S. 8th St Beaumont JEFFERSON 0 200 200 Mid Jefferson Extended Care-Nederland 2600 Highway 365 Nederland JEFFERSON 0 200 200 The Medical Center Of Southeast Texas 2555 Jimmy Johnson Blvd Port Arthur JEFFERSON 0 300 300 Gateway Community Health Center Inc. - Hebbronvill 473 State Highway 285 Hebbronville JIM HOGG 0 100 100 Burleson Public Health Authority 828 sw alsbury Burleson JOHNSON 0 100 100 Otto Kaiser Memorial Hopsital 3349 South Highway 181 Kenedy KARNES 0 100 100 Kendall County EMS 1175 N MAIN Boerne KENDALL 0 100 100 Kerrville State Hospital 721 Thompson Dr Kerrville KERR 0 100 100 Kimble Hospital 349 Reid Rd Junction KIMBLE 0 100 100 Paris Regional Medical Center 865 Deshong Dr Paris LAMAR 0 200 200 Lavaca Medical Center 1400 N Texana St Hallettsville LAVACA 0 200 200 Family Medicine Center - Groesbeck 701 Mcclintic Dr Groesbeck LIMESTONE 0 100 100 Live Oak Community Health Center 105 E Thornton Three Rivers LIVE OAK 0 100 100 Matagorda Regional Medical Center 104 7th Street Bay City MATAGORDA 0 100 100 Oceans Healthcare of Waco 5931 Crosslake Pkwy Waco MCLENNAN 0 100 100 LHD Medina CO Health Dept (RE) 3103 AVE G Hondo MEDINA 0 300 300 Medina Regional Hospital 3100 Avenue E Hondo MEDINA 0 100 100 LHD MILAM CO HEALTH DEPT (RE) 209 S. Houston Ave Cameron MILAM 0 200 200 CHI ST LUKES HEALTH WOODLANDS HOSP 17200 ST LUKES WAY Conroe MONTGOMERY 0 200 200 Houston Methodist The Woodlands Hsptl 17201 Interstate 45 S Conroe MONTGOMERY 0 300 300 Woodlands Specialty Hospital 25440 I-45 North Spring MONTGOMERY 0 100 100 Nacogdoches Memorial Hosp Care 1st 1106 South St Nacogdoches NACOGDOCHES 0 200 200 Nacogdoches Memorial Hospital 1204 N Mound St Nacogdoches NACOGDOCHES 0 200 200 Navarro Regional Hospital 3201 W State Highway 22 Corsicana NAVARRO 0 100 100 Rolling Plains Memorial Hosp Rural Hlth 201 E Arizona Ave Sweetwater NOLAN 0 200 200 Rolling Plains Memorial Hospital Employee And Patien 200 E Arizona Sweetwater NOLAN 0 100 100 CHRISTUS Spohn Family Health Center-Westside 4617 Greenwood Drive Corpus Christi NUECES 0 100 100 Christus Spohn Medical Group Coastal Bend Family M 5802 Saratoga Blvd Ste 150 Corpus Christi NUECES 0 100 100 Christus Spohn Quick Care Clinic 2606 Hospital Blvd. Corpus Christi NUECES 0 100 100 Coastal Bend Wellness Foundation 2882 Holly Rd Corpus Christi NUECES 0 100 100 Coastal ER II, LLC 4141 S Staples St. Corpus Christi NUECES 0 100 100 Texas A And M University Health 6300 Ocean Drive Corpus Christi NUECES 0 100 100 Dewitt Family Practice 3020 Garrett Dr Perryton OCHILTREE 0 100 100 Ochiltree General Hospital 3101 Garrett Drive Perryton OCHILTREE 0 200 200 Palo Pinto County Hospital District 400 Sw 25th Ave Mineral Wells PALO PINTO 0 100 100 UTHealth Carthage 409 West Cottage Road Carthage PANOLA 0 100 100 Cactus Health 700 N Main St Fort Stockton PECOS 0 100 100 Chi St Lukes Health Memorial Livingston 1717 Highway 59 Loop N Livingston POLK 0 100 100 Dshs Marfa 205 E El Paso St Marfa PRESIDIO 0 100 100 Prmc Healthcare Group, Inc - Clarksville 103 N College St Clarksville RED RIVER 0 200 200 North Runnels Hospital District 7821 Hwy 153 Winters RUNNELS 0 100 100 Sabine County Hospital 2301 Worth St Hemphill SABINE 0 100 100 Christus Trinity Mother Frances Rehabilitation Hospita3131 Troup Hwy Tyler SMITH 0 100 100 DSHS PHR 4/5N HQ - Tyler (RE) 2521 W Front St Tyler SMITH 0 1000 1000 Starr Co Memorial Hosp Rural Health 128 N Fm 3167 Rio Grande City STARR 0 100 100 Stephens Memorial Hospital 200 S Geneva St Breckenridge STEPHENS 0 100 100 Dshs Sonora Clinic 103 E Main St Sonora SUTTON 0 100 100 Kindred Hospital Tarrant County Arlington 1000 N. Cooper St. Arlington TARRANT 0 100 100 Medical Center Of Arlington 3301 Matlock Rd Arlington TARRANT 0 300 300 Jps Hospital 1500 South Main St Fort Worth TARRANT 0 100 100 Medical Center Alliance 3101 N Tarrant Pkwy Fort Worth TARRANT 0 100 100 Mesa Springs Hospital 5560 Mesa Springs Drive Fort Worth TARRANT 0 100 100 Metropolitan Area EMS Authority 2900 Alta Mere Drive Fort Worth TARRANT 0 100 100 Texas Health Care, P.L.L.C. 2821 Lackland Rd Ste 300 Fort Worth TARRANT 0 300 300 Kindred Mansfield 1802 FM 157 Mansfield TARRANT 0 200 200 Texas Health Hospital Mansfield 2300 Lonestar Road Mansfield TARRANT 0 100 100 Abilene Regional Medical Center 6250 Hwy 83/84 At Antilley Rd Abilene TAYLOR 0 100 100 DSHS Abilene 4601 S 1st St Abilene TAYLOR 0 500 500 Hendrick Medical Center 1900 Pine St Abilene TAYLOR 0 300 300 Texas Department of Criminal Justice MIDDLETON 13055 FM 3522 Abilene TAYLOR 0 100 100 Titus Regional Medical Center 2001 North Jefferson Mount Pleasant TITUS 0 300 300 Shannon Medical Center 120 E. Harris Ave San Angelo TOM GREEN 0 400 400 DSHS CENTRAL PHARMACY WAREHOUSE 1111 NORTH LOOP Austin TRAVIS 0 2900 2900 Hospice Austin 4107 Spicewood Springs Rd. Austin TRAVIS 0 200 200 Seton Medical Center Austin 1201 W 38th St Austin TRAVIS 0 300 300 Silverado Hospice - Austin 1701 Directors Boulevard Austin TRAVIS 0 100 100 South Austin Medical Center 901 W Ben White Blvd Austin TRAVIS 0 100 100 Texas Neuro Rehab Center 1106 W Dittmar Rd Austin TRAVIS 0 100 100 The Hospital At Westlake Medical Center 5656 Bee Caves Rd Ste M302 Austin TRAVIS 0 100 100 Texas Department of Criminal Justice Lewis 777 FM 3497 Woodville TYLER 0 100 100 Tyler County Hospital Family Medical Clinic 104 N Beech St Woodville TYLER 0 100 100 Uvalde Memorial Hospital 1025 Garner Field Rd. Uvalde UVALDE 0 100 100 Cadena Family Practice 2201 N Bedell Ave Ste A Del Rio VAL VERDE 0 300 300 Pam Specialty Hospital Of Victoria North 102 Medical Dr. Victoria VICTORIA 0 100 100 PAM Specialty Hospital of Victoria South 506 E. San Antonio St. Victoria VICTORIA 0 100 100 PAM Specialty Hospital of Victoria Southeast 2701 Hospital Drive, 6th Floor Victoria VICTORIA 0 100 100 Warm Springs Rehabilitation Hospital of VictoriaLL 101 James Coleman Drive Victoria VICTORIA 0 100 100 Huntsville Memorial Hospital 110 Memorial Dr. Huntsville WALKER 0 100 100 Texas Department of Criminal Justice Holliday 295 IH 45N Huntsville WALKER 0 100 100 Texas Department of Criminal Justice Wynne 810 FM 2821 Huntsville WALKER 0 100 100 Ward Memorial Hospital 406 S Gary Ave Monahans WARD 0 100 100 Clear Choice ER, LLC 7105 N. Bartlett Ave. Laredo WEBB 0 200 200 El Campo Memorial Hospital 303 Sandy Corner Rd El Campo WHARTON 0 100 100 El Campo Memorial Hospital Rhc 1403 Valhalla Dr Wharton WHARTON 0 200 200 Shamrock General Hospital 1000 S Main St Shamrock WHEELER 0 100 100 Parkview Rural Health Clinic - Wheeler 307 E. 9th Street Wheeler WHEELER 0 100 100 Family Emergency Rooms Cedar Park 3620 E. WHITESTONE BLVD. Cedar Park WILLIAMSON 0 300 300 St Davids Georgetown Hospital Pharmacy 2000 Scenic Dr Georgetown WILLIAMSON 0 100 100 Seton Medical Center Williamson 201 Seton Pkwy Round Rock WILLIAMSON 0 200 200 Wise Health System 609 Medical Center Dr Decatur WISE 0 300 300 Ut Health Quitman Hospital 117 N Winnsboro St Quitman WOOD 0 100 100 Olney Hamilton Hospital District 901 W Hamilton St Olney YOUNG 0 100 100 Articles
6-month consequences of COVID-19 in patients discharged from hospital: a cohort study
Chaolin Huang*, Lixue Huang*, Yeming Wang*, Xia Li*, Lili Ren*, Xiaoying Gu*, Liang Kang*, Li Guo*, Min Liu*, Xing Zhou, Jianfeng Luo, Zhenghui Huang, Shengjin Tu, Yue Zhao, Li Chen, Decui Xu, Yanping Li, Caihong Li, Lu Peng, Yong Li , Wuxiang Xie, Dan Cui, Lianhan Shang, Guohui Fan, Jiuyang Xu, Geng Wang, Ying Wang, Jingchuan Zhong, Chen Wang , Jianwei Wang†, Dingyu Zhang†, Bin Cao†
Summary Background The long-term health consequences of COVID-19 remain largely unclear. The aim of this study was to Published Online describe the long-term health consequences of patients with COVID-19 who have been discharged from hospital and January 8, 2021 https://doi.org/10.1016/ investigate the associated risk factors, in particular disease severity. S0140-6736(20)32656-8 See Online/Comment Methods We did an ambidirectional cohort study of patients with confirmed COVID-19 who had been discharged https://doi.org/10.1016/ from Jin Yin-tan Hospital (Wuhan, China) between Jan 7, 2020, and May 29, 2020. Patients who died before S0140-6736(21)00039-8 follow-up, patients for whom follow-up would be difficult because of psychotic disorders, dementia, or re- *Contributed equally admission to hospital, those who were unable to move freely due to concomitant osteoarthropathy or immobile †Contributed equally before or after discharge due to diseases such as stroke or pulmonary embolism, those who declined to participate, Medical Department those who could not be contacted, and those living outside of Wuhan or in nursing or welfare homes were all (C Huang MD, L Kang MD, excluded. All patients were interviewed with a series of questionnaires for evaluation of symptoms and health- D Zhang MD), and Department of COVID-19 Re-examination related quality of life, underwent physical examinations and a 6-min walking test, and received blood tests. A Clinic (X Li MD, X Zhou MD, stratified sampling procedure was used to sample patients according to their highest seven-category scale during J Luo MD, Z Huang MD, S Tu MD, their hospital stay as 3, 4, and 5–6, to receive pulmonary function test, high resolution CT of the chest, and Y Zhao MD, L Chen MD, ultrasonography. Enrolled patients who had participated in the Lopinavir Trial for Suppression of SARS-CoV-2 in D Xu, MD, Ya Li MD, C Li MS, L Peng MS), Jin Yin-tan China received severe acute respiratory syndrome coronavirus 2 antibody tests. Multivariable adjusted linear or Hospital, Wuhan, Hubei, China; logistic regression models were used to evaluate the association between disease severity and long-term health Wuhan Research Center for consequences. Communicable Disease Diagnosis and Treatment (C Huang, X Li, L Kang, X Zhou, Findings In total, 1733 of 2469 discharged patients with COVID-19 were enrolled after 736 were excluded. Patients J Luo, Z Huang, S Tu, D Zhang), had a median age of 57·0 (IQR 47·0–65·0) years and 897 (52%) were men. The follow-up study was done from Chinese Academy of Medical June 16, to Sept 3, 2020, and the median follow-up time after symptom onset was 186·0 (175·0–199·0) days. Fatigue Sciences, Wuhan, Hubei, China; or muscle weakness (63%, 1038 of 1655) and sleep difficulties (26%, 437 of 1655) were the most common symptoms. Department of Pulmonary and Critical Care Medicine, National Anxiety or depression was reported among 23% (367 of 1617) of patients. The proportions of median 6-min walking Center for Respiratory distance less than the lower limit of the normal range were 24% for those at severity scale 3, 22% for severity scale 4, Medicine, Center of Respiratory and 29% for severity scale 5–6. The corresponding proportions of patients with diffusion impairment were 22% for Medicine, National Clinical severity scale 3, 29% for scale 4, and 56% for scale 5–6, and median CT scores were 3·0 (IQR 2·0–5·0) for severity Research Center for Respiratory Diseases (L Huang MD, scale 3, 4·0 (3·0–5·0) for scale 4, and 5·0 (4·0–6·0) for scale 5–6. After multivariable adjustment, patients showed Ye Wang MD, X Gu PhD, Yo Li MD, an odds ratio (OR) 1·61 (95% CI 0·80–3·25) for scale 4 versus scale 3 and 4·60 (1·85–11·48) for scale 5–6 versus D Cui MD, L Shang MD, G Fan MS, scale 3 for diffusion impairment; OR 0·88 (0·66–1·17) for scale 4 versus scale 3 and OR 1·77 (1·05–2·97) for scale Prof C Wang MD, Prof B Cao MD), 5–6 versus scale 3 for anxiety or depression, and OR 0·74 (0·58–0·96) for scale 4 versus scale 3 and 2·69 (1·46–4·96) Institute of Clinical Medical Sciences (X Gu, G Fan), and for scale 5–6 versus scale 3 for fatigue or muscle weakness. Of 94 patients with blood antibodies tested at follow-up, Department of Radiology the seropositivity (96·2% vs 58·5%) and median titres (19·0 vs 10·0) of the neutralising antibodies were significantly (M Liu MD), China-Japan lower compared with at the acute phase. 107 of 822 participants without acute kidney injury and with estimated Friendship Hospital, Beijing, glomerular filtration rate (eGFR) 90 mL/min per 1·73 m² or more at acute phase had eGFR less than 90 mL/min per China; Institute of Respiratory Medicine (L Huang, Ye Wang, 1·73 m² at follow-up. X Gu, Yo Li, D Cui, L Shang, G Fan, Prof C Wang, Prof B Cao), Interpretation At 6 months after acute infection, COVID-19 survivors were mainly troubled with fatigue or muscle NHC Key Laboratory of weakness, sleep difficulties, and anxiety or depression. Patients who were more severely ill during their hospital stay Systems Biology of Pathogens and Christophe Merieux had more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations, and are the Laboratory, Institute of main target population for intervention of long-term recovery. Pathogen Biology (L Ren PhD, L Guo PhD, G Wang MS, Funding National Natural Science Foundation of China, Chinese Academy of Medical Sciences Innovation Fund for Yi Wang MS, J Zhong MS, Prof J Wang PhD), Key Medical Sciences, National Key Research and Development Program of China, Major Projects of National Science Laboratory of Respiratory and Technology on New Drug Creation and Development of Pulmonary Tuberculosis, and Peking Union Medical Disease Pathogenomics (L Ren, College Foundation. L Guo, G Wang, Yi Wang, J Zhong, Prof J Wang), Chinese Academy of Medical Sciences and Peking Copyright © 2021 Elsevier Ltd. All rights reserved. www.thelancet.com Published online January 8, 2021 https://doi.org/10.1016/S0140-6736(20)32656-8 1 Articles
Union Medical College, Beijing, China; Department of Research in context Pulmonary and Critical Care Medicine, Capital Medical Evidence before this study depression at follow-up. The percentage of patients with University, Beijing, China We searched PubMed for follow-up studies regarding pulmonary diffusion abnormality during follow-up is higher in (L Huang, Prof B Cao); Peking long-term consequences of COVID-19 up to Nov 5, 2020, patients with more severe disease at acute phase. These University Clinical Research without any language restrictions. The search terms were patients also have a higher CT score at follow-up. Ground glass Institute, Beijing, China (W Xie MD); Harbin Medical (COVID-19 OR SARS-CoV-2 OR Coronavirus disease 2019 OR opacity and irregular lines are the most common pattern at University, Harbin, 2019-nCoV) AND (survivor* OR recover* OR persistent OR follow-up. In multivariable analysis, women and participants Heilongjiang, China (D Cui); follow up OR discharge* OR long term OR sequelae). The studies with severity scale 5–6 have a higher risk of lung diffusion Beijing University of Chinese reported that patients with COVID-19 discharged from impairment, anxiety or depression, and fatigue or muscle Medicine, Beijing, China (L Shang); Tsinghua University hospitals might have persistent symptoms, abnormal patterns weakness. The seropositivity of the neutralising antibodies, School of Medicine, Beijing, in chest imaging manifestations, impaired lung functions, N-IgM, RBD-IgM, and S-IgM, N-IgA, RBD-IgA, and S-IgA China (J Xu MD); Department of and poor quality of life. However, the representativeness of the antibodies, and RBD-IgG, and neutralising antibody titres at Respiratory and Critical Care Medicine, West China Hospital, studies and the explicitness of provided information were follow-up were significantly lower compared with at acute Sichuan University, Chengdu, insufficient due to small numbers of cases and the short phase. Sichuan, China (G Wang); duration of follow-up (up to about 3 months after discharge). Implications of all the available evidence Tsinghua University-Peking The long-term health consequences of discharged patients with University Joint Center for Life At 6 months after symptom onset, patients with COVID-19 COVID-19 and the associated risk factors were still unknown. Sciences, Beijing, China had symptoms of fatigue or muscle weakness, sleep difficulties, (Prof C Wang, Prof B Cao) Added value of this study and anxiety or depression. Patients with a more severe illness Correspondence to: To our knowledge, this study is the largest cohort study (n=1733) during their hospital stay had increasingly impaired pulmonary Prof Bin Cao, Department of Pulmonary and Critical Care with the longest follow-up duration for the consequences of diffusion capacities and abnormal chest imaging Medicine, National Center for adult patients discharged from hospital recovering from manifestations, and these are the patients who are the main Respiratory Medicine, Center of COVID-19. Our findings showed that 76% of patients reported target population for intervention of long-term recovery. Respiratory Medicine, National at least one symptom at 6 months after symptom onset, The decline of neutralising antibodies raises concern for severe Clinical Research Center for Respiratory Diseases, China- and the proportion was higher in women. The most common acute respiratory syndrome coronavirus 2 re-infection. The risk Japan Friendship Hospital, symptoms were fatigue or muscle weakness and sleep of re-infection should be monitored for patients who present Beijing 100029, China difficulties. Additionally, 23% of patients reported anxiety or with new symptoms of COVID-19. [email protected]
Introduction Methods As of Jan 4, 2021, the global pandemic of COVID-19—an Study design and participants emerging infectious disease caused by severe acute This ambidirectional cohort study was done at Jin Yin-tan respiratory syndrome coronavirus 2 (SARS-CoV-2)—has Hospital, the first designated hospital for patients with For the WHO Coronavirus resulted in more than 83 million confirmed cases with COVID-19 in Wuhan, Hubei, China. We included all Disease Dashboard see more than 1·8 million deaths. The epidemiological and patients with laboratory confirmed COVID-19 who were https://covid19.who.int/ clinical characteristics, pathogenesis, and complications discharged from Jin Yin-tan Hospital between Jan 7, and of patients with COVID-19 at acute phase have been May 29, 2020. We excluded the following patients: explicitly described,1,2 but the long-term consequences of (1) those who died before the follow-up visit, (2) those for the illness remain largely unclear. whom follow-up would be difficult owing to psychotic Long-term follow-up studies on persistent symptoms, disorder, dementia, or re-admission to hospital attributed lung function, physical, and psychological problems of to underlying diseases, (3) those who were unable to discharged patients are urgently required.3 Only a few move freely due to concomitant osteoarthropathy or studies with limited sample size have been published, immobile before or after discharge due to diseases such with the longest follow-up duration of 3 months following as stroke or pulmonary embolism, (4) those who declined discharge from hospital.4–8 Some persisting symptoms to participate, (5) those unable to be contacted, and such as fatigue and dyspnoea,4,8 impaired pulmonary (6) those living outside of Wuhan or in nursing or welfare function,5,7 and chest image abnormalities 6 were reported homes. All discharged patients met uniform discharge in patients following hospital discharge, but the full criteria according to the Chinese clinical guidance for spectrum of post-discharge characteristics is still unknown. COVID-19 pneumonia diagnosis and treatment issued Furthermore, no studies have yet reported the extra- by the National Health Commission (ie, no fever for pulmonary organ manifestations that could persist after 3 consecutive days, improvement in respiratory symp damage in acute stage or are new onset after discharge. toms, obvious resolution and recovery of acute lesion We aimed to describe the long-term consequences of in lung imaging, and two negative test results for COVID-19 in patients after hospital discharge and SARS-CoV-2 24 h apart).9 identify the potential risk factors, including disease The study was approved by the Research Ethics severity, associated with these consequences. Commission of Jin Yin-tan Hospital (KY-2020–78.01).
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Written informed consent was obtained from all study assessment of generic health ranging from 0 to 100, participants. with higher scores representing better subjective health experience.14 They also underwent a physical examination Procedures and a 6-min walking test. We defined the acute phase as the time between symptom Venous blood samples were collected from all onset and hospital discharge. Clinical data for acute phase participants who attended for follow-up appointments for were retrieved from electronic medical records, including complete blood count, serum creatinine, haemoglobin, demographic characteristics (age, sex, education, and and glycated haemoglobin A1c (HbA1c). Furthermore, cigarette smoking); clinical characteristics (self-reported SARS-CoV-2 antibody concentrations were measured for comorbidities, symptom onset time, and chest images); participants that had previously been enrolled in the laboratory test results; and treatment (corticosteroids, Lopinavir Trial for Suppression of SARS-CoV-2 in China intravenous immunoglobulin, antibiotics, thymosin, and (LOTUS).10 Plasma samples at acute phase, collected with antivirals including lopinavir–ritonavir, arbidol, chloro a median duration of 23 (IQR 20–26) days after illness quine phosphate, and hydroxychloroquine). The disease onset, and follow-up were analysed simultaneously. The severity was characterised by the highest seven-category immunoglobulin (Ig) M, IgA, and IgG antibodies against scale during the hospital stay (termed the severity scale),10 the nucleoprotein, spike protein, and the receptor binding which consisted of the following categories: 1, not domain of the spike protein were evaluated by use of admitted to hospital with resumption of normal activities; enzyme-linked immunosorbent assay. The neutralising 2, not admitted to hospital, but unable to resume normal antibodies were titred on Vero cells by use of a micro activities; 3, admitted to hospital but not requiring neutralisation assay. The detailed test method was supplemental oxygen; 4, admitted to hospital but described in our previous antibody studies.15,16 requiring supplemental oxygen; 5, admitted to hospital Additionally, a stratified disproportional random requiring high-flow nasal cannula (HFNC), non-invasive sampling procedure according to severity scale was used mechanical ventilation (NIV), or both; 6, admitted to to select patients to undergo pulmonary function test, hospital requiring extracorporeal membrane oxygenation, ultrasonography of lower limb veins and abdomen, and invasive mechanical ventilation (IMV), or both; and 7, chest high resolution CT (HRCT). Patients requiring death. Data were managed using REDCap electronic data HFNC, NIV, or IMV (severity scale ≥5) were all invited to capture tools in order to minimise missing inputs and receive the pulmonary function test, ultrasound, and allow for real-time data validation and quality control. HRCT of chest. The ratio used to select patients not The appointment for the follow-up visit was set by requiring supplemental oxygen (severity scale 3) and trained medical staff via telephone. All participants were those requiring supplemental oxygen (severity scale 4) contacted in the order of their symptom onset date was 1:2. documented in their medical record. If the follow-up The pulmonary function test was done in the Lung appointment was missed, the patient was given two Function Laboratory of Jin Yin-tan Hospital using the opportunities to reschedule the visit. Master Screen PFT (Vyaire Medical GmbH, Hoechberg, Follow-up consultations were done in the outpatient Germany) according to American Thoracic Society guide clinic of Jin Yin-tan Hospital. All participants were lines.17 Chest HRCT was in the supine position during interviewed face-to-face by trained physicians and asked end-inspiration (SIEMENS SOMATOM PERSPECTIVE to complete a series of questionnaires, including a self- 64 CT scanner). Images were reconstructed at 1 mm slice reported symptom questionnaire (appendix pp 5–6), the thickness, with 1 mm increment, 512 mm × 512 mm. The See Online for appendix modified British Medical Research Council (mMRC) final chest CT images during the hospital stay and the dyspnoea scale, the EuroQol five-dimension five-level follow-up image were cross-compared. The CT features (EQ-5D-5L) questionnaire, the EuroQol Visual Analogue were evaluated by one experienced radiologist and one Scale (EQ-VAS), and an ischaemic stroke and cardio pulmonologist. We used a validated artificial intelligence vascular event registration form.11 For the symptom software to calculate the extent of anatomic involvement questionnaire, participants were asked to report newly of each of the five lobes, which was defined as the volume occurring and persistent symptoms, or any symptoms ratio of pneumonia lesions to each lung lobe,18 and worse than before COVID-19 development. The mMRC then calculated a semi-quantitative CT score to assess scale is a five-category scale to characterise the level of the pulmonary involvement.19,20 Briefly, the score was dyspnoea with physical activity in which higher scores calculated for each of the five lobes considering the extent correspond with increased dyspnoea.12 The EQ-5D-5L is a of anatomic involvement, as follows: 0, no involvement; validated questionnaire to evaluate patient quality of 1, less than 5% involvement; 2, 5–25% involvement; life by assessment of the following five factors: mobility, 3, 26–50% involvement; 4, 51–75% involvement; and self-care, usual activities, pain or discomfort, and anxiety 5, more than 75% involvement. The total CT score was the or depression. Categorisation within each factor is sum of the five lobe scores (0–25). Estimated glomerular divided into five levels that range from no problems to filtration rate (eGFR) was calculated using the Chronic extreme problems.13 The EQ-VAS is a patient’s subjective Kidney Disease-Epidemiology Collaboration equation.21 www.thelancet.com Published online January 8, 2021 https://doi.org/10.1016/S0140-6736(20)32656-8 3 Articles
Detailed diagnostic criteria for acute kidney injury, phase ×100. For associations of age, cigarette smoking, diabetes, and deep venous thrombosis of lower limb veins and education with outcome measure, the variables are presented in the appendix (p 3). The primary outcomes adjusted for the association of disease severity with included symptoms (fatigue or muscle weakness, sleep consequences (age, sex, cigarette smoking, education, difficulties, hair loss, smell disorder), exercise capacity comorbidity, corticosteroids, antivirals, and intravenous (distance walked in 6 min), health-related quality of life immunoglobulin) were all included in the models, except (pain or discomfort, anxiety or depression, mobility, for comorbidity. For association of comorbidity with personal care, and usual activity), lung function, and outcome, the aforementioned variables were all included. chest CT pattern at follow-up. The secondary outcomes For association of other factors including sex, cortico included extrapulmonary organ function (including steroid, antiviral, and intravenous immunoglobulin
eGFR, HbA1c, deep venous thrombosis of lower limbs, and with outcome, disease severity and the aforementioned ultrasonographic features of kidney, liver, spleen, and variables were included in the model. All tests were pancreas) and antibody titres and seropositivity. two-sided, and a p value less than 0·05 was considered statistically significant. We included all participants for Statistical analysis whom the variables of interest were available in the final Demographic characteristics and long-term health analysis, without imputing missing data. All statistical consequences of COVID-19 in patients were presented as analyses were done with SAS, version 9.4. median (IQR) for continuous variables and expressed as absolute values along with percentages for categorical Role of the funding source variables. Participants were categorised into three groups The funder of the study had no role in study design, data according to their severity scale during their hospital stay collection, data analysis, data interpretation, or writing of scale 3, not requiring supplemental oxygen; scale 4, the report. All authors had full access to all the data in the requiring supplemental oxygen; scale 5–6, requiring study and had final responsibility for the decision to HFNC, NIV, or IMV). Demographic characteristics and submit for publication. long-term consequences across participants with different categories of severity scale were shown. Long-term health Results consequences for men and women were also shown. For A total of 2469 patients with COVID-19 were discharged the comparison of symptoms, exercise capacity, and from Jin Yin-tan Hospital between Jan 7, and May 29, 2020, health-related quality of life between men and women, we and the follow-up study was done from June 16, 2020, to used the Mann-Whitney U test, χ2 test, or Fisher’s exact Sept 3, 2020. 736 patients were excluded because they did test where appropriate. Multivariable adjusted logistic not attend follow-up appointments for several reasons, regression models were used to estimate the odds ratios which are outlined in figure 1. Notably, 33 (1·3%) of the (ORs) and 95% CIs for association between disease 2469 patients died after discharge mainly due to severity and categorical outcomes. For association exacerbation of underlying pulmonary, heart, and kidney between disease severity and continuous outcomes, disease, and the detailed characteristics are shown in the multivariable adjusted linear regression models were appendix (pp 7–9). 25 patients were readmitted to hospital used to estimate the β estimates and 95% CIs. for underlying disease complications when contacted by Confounders including age, sex, cigarette smoking telephone for follow-up, with one of them admitted for (never-smoker, current smoker, former smoker); respiratory failure caused by underlying pulmonary education (college or higher, middle school or lower); fibrosis. Three patients developed ischaemic strokes, and comorbidity (hypertension, diabetes, cardiovascular dis one patient had an acute pulmonary embolism due to eases, cerebrovascular diseases, malignant tumour, deep venous thrombosis of lower limbs after discharge. chronic obstructive pulmonary disease, chronic kidney Finally, 1733 adult participants were enrolled for ques disease); corticosteroids; antivirals (lopinavir–ritonavir, tionnaire interview, physical examination, laboratory arbidol, chloroquine phosphate, hydroxychloroquine); tests, and a 6-min walking test. 94 of 1733 patients received and intravenous immunoglobulin were adjusted for. The a blood antibody test. 390 of 516 sampled patients comparison of antibody test results at acute phase and ascertained as eligible received a lung function test, chest follow-up was done with paired t tests for antibody titres HRCT, and ultrasonography of lower limb veins and and McNemar test for antibody seropositivity. abdomen (figure 1). The 126 remaining sampled patients Multivariable adjusted logistic regression analysis was did not undergo these tests because they were among the also used for exploring risk factors associated with 736 patients who did not attend the follow-up appointment. diffusion impairment, anxiety or depression, and fatigue The demographic and clinical characteristics of or muscle weakness, and linear regression analysis was participants are shown in table 1. The median age of used to assess the percentage change in CT score from the enrolled participants is 57·0 (47·0–65·0) years, acute phase to follow-up. The percentage change was with 897 (52%) men and 836 (48%) women. The most calculated by use of the following formula: (CT score at common comorbidity is hypertension (505 patients, acute phase–CT score at follow-up)/CT score at acute 29%), followed by diabetes (207 patients, 12%), and
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cardiovascular disease (128 patients, 7%). 1172 (68%) of participants with scale 4 or scale 5–6 compared with 1733 participants required oxygen therapy during their those with scale 3 (table 3). hospital stay, and 122 (7%) required HFNC, non-IMV, A total of 353 participants completed chest HRCT at or IMV. 76 participants (4%) were admitted to the follow-up. The median CT scores are 3·0 (IQR 2·0–5·0) intensive care unit (ICU). The median duration of for participants at scale 3, 4·0 (3·0–5·0) for participants at hospital stay was 14·0 (10·0–19·0) days and time scale 4, and 5·0 (4·0–6·0) among participants at scale 5–6, exclusively in the ICU was 14·0 (6·5–25·5) days. The with a significant difference between scale 3 and scale 5–6 proportion of men is higher among participants with (p=0·0005; table 3), which is also observed in the subgroup a higher severity scale: 49% (214 of 439) for severity analysis by sex (appendix pp 16–17). Additionally, men at scale 3, 52% (605 of 1172) for scale 4, and 64% (78 of 122) scale 4 had a significantly higher CT score than did those for scale 5–6. The median duration from symptom onset at scale 3 (p=0·028). Ground glass opacity (GGO) is the to follow-up visit is 186·0 (175·0–199·0) days and the most common HRCT pattern at follow-up, followed by median time from discharge to follow-up visit is irregular lines (table 3). The consolidation in acute phase 153·0 (146·0–160·0) days (table 1). is nearly full resolution at follow-up (appendix p 18). The 76% of patients (1265 of 1655) reported at least one detailed comparison of chest CT images during hospital symptom at follow-up (table 2) and a higher percentage stay and follow-up is shown in the appendix (p 18). was observed in women (appendix pp 10–11). The risk of Dynamic changes of chest images of a 41-year-old man presenting at least one symptom among participants with SARS-CoV-2 infection who received non-IMV during with scale 5–6 was higher than those with scale 3 his hospital stay are shown in the appendix (pp 20–21). (OR 2·42, 95% CI 1·15–5·08). The most common symp Bilateral consolidation, subpleural line, and GGO before toms after discharge were fatigue or muscle weakness discharge were almost completely absorbed approximately (1038 [63%] of 1655) and sleep difficulties (437 [26%] 5 months after discharge. of 1655; table 2). The risk of an mMRC score greater After multivariable adjustment, participants at scale 5–6 than 1 was significantly higher in participants with showed an OR 4·60 (95% CI 1·85–11·48) for diffusion scale 5–6 than those with scale 3 (OR 2·15, 95% CI 1·28–3·59; table 2). Full details of the EQ-5D-5L ques tionnaire are presented in the appendix (pp 12–13). 2469 discharged patients with COVID-19 Participants with scale 5–6 had more problems in mobility, pain or discomfort, and anxiety or depres sion than did those with scale 3 (all p<0·05; table 2). 23% (367 of 1617) of participants reported anxiety or 516 patients were selected to undergo pulmonary 1733 completed questionnaires*, physical function test, ultrasonography of lower limb examination, laboratory tests†, and 6-min depression at follow-up, which was more common in veins and abdomen, and chest HRCT walking test women (appendix pp 10–11). Compared with participants with scale 3, participants with scale 5–6 presented with shorter walking distance in meters in 6 min (479·0, 736 patients excluded 347 subjective rejection IQR 434·0–515·5 vs 495·0, 446·0–542·0) and a higher 65 living in a nursing or welfare home proportion of less than the lower limit of the normal 63 osteoarticular disease 62 unable to be contacted range (LLN); however, no significant difference was 56 dementia or psychotic disease observed for participants with scale 4. The proportion of 51 living outside Wuhan city patients with a median 6-min walking distance less than 33 died 30 immobile before discharge LLN was 24% (103 of 423) for scale 3, 22% (255 of 1153) 25 readmitted to hospitals for scale 4, and 29% (34 of 116) for scale 5–6 (table 2). 4 immobile after discharge (3 with ischaemic stroke and 1 with pulmonary 390 of the 516 patients ascertained as eligible received embolism) lung function tests, chest HRCT, and ultrasonography of lower limb veins and abdomen. A total of 349 participants completed the lung function test, and 41 were unable 126 patients were among the 736 who did not attend the follow-up appointment to complete it due to poor compliance. The proportion of participants with lung diffusion impairment was 22% (18 of 83) for scale 3, 29% (48 of 165) for scale 4, 390 sampled patients received lung function test, 94 patients who participated in LOTUS China chest HRCT, and ultrasonography of lower limb trial received blood antibody test and 56% (48 of 86) for scale 5–6 (table 3). A significant veins and abdomen difference was observed between scale 3 and scale 5–6, but not between scale 3 and scale 4. In the subgroup Figure 1: Flow chart of patients with COVID-19 discharged from Jin Yin-tan Hospital between Jan 7, and analysis by sex, both men and women with scale 5–6, and May 29, 2020 men with scale 4 had higher risk for decreased lung HRCT=high resolution CT. LOTUS= Lopinavir Trial for Suppression of SARS-CoV-2 in China. *A series of diffusion capacity than did those with scale 3 (all p<0·05) questionnaires included a self-reported symptom questionnaire, the modified British Medical Research Council dyspnoea scale, the EuroQol five-dimension five-level questionnaire, the EuroQol Visual Analogue Scale, and an (appendix p 14). Decreased total lung capacity (<80% of ischaemic stroke and cardiovascular event registration form. †Laboratory tests included a white cell count, predicted values) did not show a significant difference in lymphocyte count, serum creatinine, haemoglobin, and glycosylated haemoglobin. www.thelancet.com Published online January 8, 2021 https://doi.org/10.1016/S0140-6736(20)32656-8 5 Articles
impairment, OR 1·77 (1·05–2·97) for anxiety or depres for participants with scale 4 was not significant, but the sion, and OR 2·69 (1·46–4·96) for fatigue or muscle risk of fatigue or muscle weakness was lower than for weakness, compared with participants at scale 3 (figure 2). those with scale 3. The percentage change of CT score Risk of diffusion impairment and anxiety or depression from acute phase to follow-up was higher among
Total Scale 3: not requiring Scale 4: requiring Scale 5–6: requiring (n=1733) supplemental oxygen supplemental oxygen HFNC, NIV, or IMV (n=439) (n=1172) (n=122) Age, years 57·0 (47·0–65·0) 57·0 (46·0–65·0) 57·0 (48·0–65·0) 56·0 (48·0–65·0) Sex Men 897 (52%) 214 (49%) 605 (52%) 78 (64%) Women 836 (48%) 225 (51%) 567 (48%) 44 (36%) Education College or higher 499/1558 (32%) 132/405 (33%) 322/1045 (31%) 45/108 (42%) Middle school or lower 1059/1558 (68%) 273/405 (67%) 723/1045 (69%) 63/108 (58%) Cigarette smoking Never-smoker 1585/1731 (92%) 408 (93%) 1071/1170 (92%) 106 (87%) Current smoker 102/1731 (6%) 19 (4%) 69/1170 (6%) 14 (11%) Former smoker 44/1731 (3%) 12 (3%) 30/1170 (3%) 2 (2%) Comorbidities Hypertension 505 (29%) 129 (29%) 331 (28%) 45 (37%) Diabetes 207 (12%) 60 (14%) 132 (11%) 15 (12%) Cardiovascular diseases 128/1732 (7%) 41/438 (9%) 72 (6%) 15 (12%) Cerebrovascular diseases 47/1732 (3%) 11 (3%) 35/1171 (3%) 1 (1%) Malignant tumour 44 (3%) 9 (2%) 33 (3%) 2 (2%) Chronic obstructive pulmonary disorder 31 (2%) 6 (1%) 24 (2%) 1 (1%) Chronic kidney disease 27 (2%) 4 (1%) 21 (2%) 2 (2%) Systolic blood pressure ≥140 mm Hg 398/1724 (23%) 121 (28%) 251/1166 (22%) 26/119 (22%) Diastolic blood pressure ≥90 mm Hg 386/1724 (22%) 115 (26%) 253/1166 (22%) 18/119 (15%) Highest seven-category scale during hospital stay 3: admitted to hospital, not requiring supplemental 439 (25%) 439 (100%) NA NA oxygen 4: admitted to hospital, requiring supplemental oxygen 1172 (68%) NA 1172 (100%) NA 5: admitted to hospital, requiring HFNC or non-IMV or 112 (6%) NA NA 112 (92%) both 6: admitted to hospital, requiring ECMO or IMV, or both 10 (1%) NA NA 10 (8%) Treatment received during hospital stay Corticosteroids 398 (23%) 38 (9%) 275 (23%) 85 (70%) Antivirals 943 (54%) 222 (51%) 648 (55%) 73 (60%) Lopinavir–ritonavir 236 (14%) 40 (9%) 164 (14%) 32 (26%) Arbidol 831 (48%) 202 (46%) 568 (48%) 61 (50%) Chloroquine phosphate 4 (<1%) 0 3 (<1%) 1 (1%) Hydroxychloroquine 2 (<1%) 1 (<1%) 1 (<1%) 0 Antibiotics 1339 (77%) 254 (58%) 965 (82%) 120 (98%) Thymosin 289 (17%) 68 (15%) 202 (17%) 19 (16%) Intravenous immunoglobulin 345 (20%) 37 (8%) 238 (20%) 70 (57%) Length of hospital stay, days 14·0 (10·0–19·0) 11·0 (8·0–16·0) 14·0 (10·0–18·0) 35·0 (22·0–51·0) ICU admission 76 (4%) 0 32 (3%) 44 (36%) Length of ICU stay, days 14·0 (6·5–25·5) NA 7·0 (2·5–18·0) 20·0 (10·0–41·5) Time from symptom onset to admission, days 15·0 (11·0–25·0) 20·5 (12·0–43·0) 14·0 (10·0–22·0) 13·0 (11·0–17·0) Time from discharge to follow-up, days 153·0 (146·0–160·0) 151·0 (140·0–156·0) 154·0 (150·0–160·0) 157·0 (135·0–169·0) Time from symptom onset to follow-up, days 186·0 (175·0–199·0) 187·0 (175·0–198·0) 184·0 (175·0–196·0) 205·0 (189·5–217·0)
Data are n (%), n/N (%), or median (IQR). The differing denominators used indicate missing data. HFNC=high-flow nasal cannula for oxygen therapy. NIV=non-invasive ventilation. IMV=invasive mechanical ventilation. NA=not applicable. ECMO=extracorporeal membrane oxygenation. ICU=intensive care unit.
Table 1: Characteristics of enrolled patients
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participants with scale 4 and 5–6 than in those with muscle weakness, and negatively associated with scale 3. Women had an OR 2·22 (95% CI 1·24–3·98) for percentage of CT score changed, with the risk of diffusion diffusion impairment, OR 1·80 (1·39–2·34) for anxiety impairment 27% higher (OR 1·27, 95% CI 1·02–1·60) and or depression, and OR 1·33 (1·05–1·67) for fatigue or fatigue or muscle weakness 17% higher (OR 1·17, muscle weakness compared with men. Age was positively 1·07–1·27) per 10-year increase of age, and percentage associated with diffusion impairment and fatigue and of CT score 4% (1·37–6·64) lower per 10-year increase of
Total Seven-category scale OR or β (95% CI) (n=1733) Scale 3: not requiring Scale 4: requiring Scale 5–6: requiring Scale 4 vs 3 Scale 5–6 vs 3 supplemental oxygen supplemental oxygen HFNC, NIV, or IMV (n=439) (n=1172) (n=122) Symptoms Any one of the following 1265/1655 (76%) 344/424 (81%) 820/1114 (74%) 101/117 (86%) OR 0·70 (0·52 to 0·96)* OR 2·42 (1·15 to 5·08)* symptoms Fatigue or muscle weakness 1038/1655 (63%) 281/424 (66%) 662/1114 (59%) 95/117 (81%) OR 0·74 (0·58 to 0·96)* OR 2·69 (1·46 to 4·96)* Sleep difficulties 437/1655 (26%) 116/424 (27%) 290/1114 (26%) 31/117 (26%) OR 0·92 (0·71 to 1·21) OR 1·15 (0·68 to 1·94) Hair loss 359/1655 (22%) 93/424 (22%) 238/1114 (21%) 28/117 (24%) OR 0·99 (0·74 to 1·31) OR 1·17 (0·67 to 2·04) Smell disorder 176/1655 (11%) 55/424 (13%) 107/1114 (10%) 14/117 (12%) OR 0·69 (0·48 to 1·00) OR 0·90 (0·43 to 1·87) Palpitations 154/1655 (9%) 45/424 (11%) 96/1114 (9%) 13/117 (11%) OR 0·86 (0·58 to 1·28) OR 1·31 (0·61 to 2·80) Joint pain 154/1655 (9%) 51/424 (12%) 86/1114 (8%) 17/117 (15%) OR 0·56 (0·38 to 0·83)* OR 0·74 (0·36 to 1·50) Decreased appetite 138/1655 (8%) 42/424 (10%) 85/1114 (8%) 11/117 (9%) OR 0·84 (0·56 to 1·27) OR 1·56 (0·71 to 3·43) Taste disorder 120/1655 (7%) 37/424 (9%) 75/1114 (7%) 8/117 (7%) OR 0·84 (0·54 to 1·30) OR 0·80 (0·32 to 2·02) Dizziness 101/1655 (6%) 32/424 (8%) 60/1114 (5%) 9/117 (8%) OR 0·77 (0·48 to 1·22) OR 0·95 (0·39 to 2·31) Diarrhoea or vomiting 80/1655 (5%) 27/424 (6%) 48/1114 (4%) 5/117 (4%) OR 0·71 (0·42 to 1·22) OR 0·39 (0·11 to 1·42) Chest pain 75/1655 (5%) 19/424 (4%) 46/1114 (4%) 10/117 (9%) OR 0·94 (0·52 to 1·67) OR 2·55 (0·99 to 6·62) Sore throat or difficult to 69/1655 (4%) 20/424 (5%) 44/1114 (4%) 5/117 (4%) OR 0·91 (0·50 to 1·65) OR 1·21 (0·40 to 3·73) swallow Skin rash 47/1655 (3%) 16/424 (4%) 27/1114 (2%) 4/117 (3%) OR 0·64 (0·32 to 1·26) OR 0·71 (0·18 to 2·87) Myalgia 39/1655 (2%) 11/424 (3%) 24/1114 (2%) 4/117 (3%) OR 0·80 (0·38 to 1·69) OR 1·72 (0·47 to 6·27) Headache 33/1655 (2%) 10/424 (2%) 20/1114 (2%) 3/117 (3%) OR 0·76 (0·35 to 1·69) OR 1·53 (0·36 to 6·52) Low grade fever 2/1655 (<1%) 1/424 (<1%) 1/1114 (<1%) 0 NA NA mMRC score 0 1196/1615 (74%) 323/425 (76%) 802/1079 (74%) 71/111 (64%) NA NA ≥1 419/1615 (26%) 102/425 (24%) 277/1079 (26%) 40/111 (36%) OR 1·11 (0·84 to 1·46) OR 2·15 (1·28 to 3·59)* EQ-5D-5L questionnaire† Mobility: problems with 113/1622 (7%) 25/426 (6%) 72/1084 (7%) 16/112 (14%) OR 1·06 (0·63 to 1·78) OR 2·48 (1·12 to 5·48)* walking around Personal care: problems 11/1622 (1%) 0 10/1084 (1%) 1/112 (1%) NA NA with washing or dishing Usual activity: problems 25/1611 (2%) 5/425 (1%) 15/1076 (1%) 5/110 (5%) OR 1·10 (0·35 to 3·50) OR 3·42 (0·74 to 15·78) with usual activity Pain or discomfort 431/1616 (27%) 111/422 (26%) 274/1082 (25%) 46/112 (41%) OR 0·86 (0·66 to 1·13) OR 1·94 (1·19 to 3·16)* Anxiety or depression 367/1617 (23%) 98/425 (23%) 233/1081 (22%) 36/111 (32%) OR 0·88 (0·66 to 1·17) OR 1·77 (1·05 to 2·97)* Quality of life‡ 80·0 (70·0 to 90·0) 80·0 (70·0 to 90·0) 80·0 (75·0 to 90·0) 80·0 (70·0 to 87·5) β 2·68 (–1·55 to 6·91) β –2·33 (–10·60 to 5·95) Distance walked in 6 min, m 495·0 (440·0 to 538·0) 495·0 (446·0 to 542·0) 495·0 (439·0 to 537·0) 479·0 (434·0 to 515·5) β –9·25 (–18·80 to 0·26) β –32·50 (–51·40 to –13·60)§ Percentage of predicted 87·7 (75·9 to 101·1) 87·8 (76·3 to 101·3) 87·9 (76·3 to 101·5) 85·2 (72·9 to 98·6) β –1·58 (–3·59 to 0·43) β –5·61 (–9·60 to –1·62)* value¶ Less than lower limit of the 392/1692 (23%) 103/423 (24%) 255/1153 (22%) 34/116 (29%) OR 1·13 (0·81 to 1·57) OR 2·18 (1·18 to 4·03)* normal range|| eGFR<90 mL/min per 1·73 m² 487/1393 (35%) 121/338 (36%) 326/967 (34%) 40/88 (45%) OR 0·86 (0·63 to 1·19) OR 1·44 (0·76 to 2·70)
Data are n/N (%) or median (IQR), unless otherwise specified. The differing denominators used indicate missing data. OR=odds ratio. HFNC=high-flow nasal cannula for oxygen therapy. NIV=non-invasive ventilation. IMV=invasive mechanical ventilation. NA=not applicable. mMRC=modified British Medical Research Council. EQ-5D-5L=EuroQol five-dimension five-level questionnaire. eGFR=estimated glomerular filtration rate. *p<0·05. †Detailed results of EQ-5D-5L questionnaire are presented in the appendix (pp 12–13). ‡Quality of life was assessed using the EuroQol Visual Analogue Scale, ranging from 0 (worst imaginable health) to 100 (best imaginable health). §p<0·001. ¶Predicted values were calculated according to the method of Enright and Sherrill.22 ||The lower limit of the normal range was calculated by subtracting 153 m from the predicted value for men or by subtracting 139 m for women.
Table 2: Symptoms, exercise capacity, and health-related quality of life at follow-up according to severity scale
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Seven-category scale OR or β (95% CI) Scale 3: not requiring Scale 4: requiring Scale 5–6: requiring Scale 4 vs 3 Scale 5–6 vs 3 supplemental oxygen supplemental oxygen HFNC, NIV, or IMV Lung function Number of patients 89 172 88
FEV1 <80%, % of predicted 7 (8%) 4 (2%) 11 (13%) OR 0·14 (0·03 to 0·68)* OR 0·50 (0·09 to 2·93) FVC <80%, % of predicted 3 (3%) 1 (1%) 10 (11%) OR 0·11 (0·01 to 1·59) OR 2·09 (0·19 to 23·02)
FEV1/FVC <70% 7 (8%) 13 (8%) 2 (2%) OR 0·91 (0·29 to 2·80) OR 0·26 (0·03 to 1·93) TLC <80%, % of predicted 9/83 (11%) 17/165 (10%) 30/86 (35%) OR 0·89 (0·33 to 2·42) OR 3·00 (0·93 to 9·67) FRC <80%, % of predicted 5/83 (6%) 6/165 (4%) 16/84 (19%) OR 0·61 (0·17 to 2·16) OR 3·93 (0·97 to 15·82) RV <80%, % of predicted 16/83 (19%) 28/164 (17%) 43/86 (50%) OR 0·76 (0·33 to 1·75) OR 2·75 (1·03 to 7·37)* DLCO <80%, % of predicted† 18/83 (22%) 48/165 (29%) 48/86 (56%) OR 1·61 (0·80 to 3·25) OR 4·60 (1·85 to 11·48)* Chest CT Number of patients 95 163 95 At least one abnormal CT pattern 49 (52%) 87/161 (54%) 50/92 (54%) OR 0·93 (0·53 to 1·64) OR 0·81 (0·38 to 1·72) GGO 39 (41%) 78/161 (48%) 41/92 (45%) OR 1·19 (0·68 to 2·09) OR 0·93 (0·44 to 1·98) Irregular lines 10 (11%) 24/161 (15%) 22/92 (24%) OR 1·46 (0·60 to 3·52) OR 1·89 (0·64 to 5·61) Consolidation 0 4/161 (2%) 0 NA NA Interlobular septal thickening 1 (1%) 2/161 (1%) 0 NA NA Subpleural line 6 (6%) 5/161 (3%) 4/92 (4%) NA NA Reticular pattern 0 1/161 (1%) 1/92 (1%) NA NA Volume of lung lesions, cm³ 1·6 (0·6 to 5·6) 3·3 (0·8 to 12·4) 29·1 (4·6 to 77·3) β 7·45 (–12·40 to 27·28) β 34·37 (7·74 to 61·00)* Volume of consolidation, cm³ 0·2 (0·1 to 0·4) 0·3 (0·1 to 1·0) 1·6 (0·2 to 4·4) β 0·19 (–1·97 to 2·35) β 3·05 (0·14 to 5·95)* Volume of GGO, cm³ 1·4 (0·6 to 4·7) 2·9 (0·7 to 10·0) 26·3 (4·3 to 73·3) β 7·26 (–10·70 to 25·25) β 31·32 (7·16 to 55·48)* Volume ratio of lung lesion to total lung, % 0·0 (0·0 to 0·1) 0·1 (0·0 to 0·3) 0·7 (0·1 to 2·2) β –0·06 (–1·36 to 1·24) β 1·44 (–0·30 to 3·18) Volume ratio of consolidation to total lung, % 0·0 (0·0 to 0·0) 0·0 (0·0 to 0·0) 0·0 (0·0 to 0·1) NA NA Volume ratio of GGO to total lung, % 0·0 (0·0 to 0·1) 0·1 (0·0 to 0·2) 0·6 (0·1 to 1·9) β –0·07 (–1·20 to 1·07) β 1·23 (–0·29 to 2·76) CT score 3·0 (2·0 to 5·0) 4·0 (3·0 to 5·0) 5·0 (4·0 to 6·0) β 0·33 (–0·19 to 0·84) β 1·25 (0·56 to 1·95)‡
Data are absolute values, n (%), n/N (%), or median (IQR), unless otherwise specified. OR=odds ratio. HFNC=high-flow nasal cannula for oxygen therapy. NIV=non-invasive ventilation. IMV=invasive mechanical
ventilation. FEV1=forced expiratory volume in one second. FVC=forced vital capacity. TLC=total lung capacity. FRC=functional residual capacity. RV=residual volume. DLCO=diffusion capacity for carbon monoxide. GGO=ground glass opacity. NA=not applicable. *p<0·05. †Carbon monoxide diffusion capacity was not corrected for haemoglobin. ‡p<0·001.
Table 3: Lung function and chest CT at follow-up according to severity scale
age (figure 2). No significant association of age with for N-IgG, in ten (11%) for RBD-IgG, and in 20 (21%) anxiety or depression was observed. for S-IgG at follow-up. The concentrations decreased by Plasma samples of 94 patients who participated in the more than 20% in 76 (81%) participants for N-IgG, in LOTUS China trial10 were collected. The seropositivity 64 (68%) for RBD-IgG, and in 28 (30%) for S-IgG (96·2% vs 58·5%) and median titres (19·0 vs 10·0) of (appendix p 22). the neutralising antibodies were significantly lower The dynamic changes of white blood cell count, than at the acute phase (figure 3). The seropositivity of lymphocyte count, and haemoglobin concentrations from N-IgM, RBD-IgM, S-IgM, N-IgA, RBD-IgA, S-IgA, and symptom onset to follow-up, classified by severity scale, RBD-IgG at follow-up significantly decreased compared are presented in the appendix (pp 23–24). 488 patients had with that at acute phase (figure 3A). However, the lymphocytopenia (lymphocyte count <0·8 × 10⁹ per L) seropositivity of N-IgG and S-IgG antibodies did not show significant change. More than 90% of participants tested positive for all three IgG antibodies at follow-up. Figure 2: Risk factors associated with diffusion impairment and CT score (A), The longitudinal changes in antibody concentrations and anxiety or depression and fatigue or muscle weakness (B) were further evaluated, with the N-IgM, RBD-IgM, For associations of age, cigarette smoking, and education with outcome S-IgM, N-IgA, RBD-IgA, S-IgA, N-IgG, RBD-IgG, measure, the variables including age, gender, cigarette smoking, education, comorbidity, corticosteroids, antivirals, and intravenous immunoglobulin were and S-IgG concentrations, and neutralising antibody all included in the models. For association of comorbidity with outcome, the titres waning over time (figure 3B–E). However, aforementioned variables were all included together with comorbidity. heterogeneous responses were observed in IgG against For association of other factors including sex, corticosteroid, antiviral, and N, RBD, and S proteins. Compared with the con intravenous immunoglobulin with outcome, disease severity and the aforementioned variables were included in the model. OR (95% CI) or β (95% CI) centrations at acute phase, antibody concentrations for age indicates the risk of diffusion impairment, CT score, anxiety or depression, increased by more than 20% in seven (7%) participants and fatigue or muscle weakness per 10-year age increase. OR=odds ratio.
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A OR (95% CI) p value β (95% CI) p value
Age 1·27 (1·02 to 1·60) 0· 035 –4·00 (–6·64 to –1·37) 0·0032 Sex Men 1 (ref) 1 (ref) Women 2·22 (1·24 to 3·98) 0·0071 –6·69 (–13·7 to 0·35) 0·06 Cigarette smoking Never–smoker 1 (ref) 1 (ref) Current smoker 2·34 (0·80 to 6·80) 0·12 13·05 (–1·53 to 27·62) 0·08 Former smoker 2·52 (0·61 to 10·39) 0·20 –12·10 (–29·40 to 5·24) 0·17 Education Middle school or lower 1 (ref) 1 (ref) College or higher 1·57 (0·87 to 2·82) 0·14 3·44 (–4·09 to 10·96) 0·37 Comorbidity No 1 (ref) 1 (ref) Yes 1·12 (0·63 to 1·99) 0·71 –1·18 (–8·33 to 5·98) 0·75 Disease severity Scale 3 1 (ref) 1 (ref) Scale 4 1·61 (0·80 to 3·25) 0·18 8·87 (0·87 to 16·86) 0·031 Scale 5–6 4·60 (1·85 to 11·48) 0·0011 18·00 (7·06 to 28·93) 0·0014 Corticosteroids No 1 (ref) 1 (ref) Yes 1·18 (0·60 to 2·34) 0·63 –4·73 (–13·4 to 3·99) 0·29 Antiviral No 1 (ref) 1 (ref) Yes 0·94 (0·55 to 1·60) 0·81 0·59 (–5·86 to 7·03) 0·86 Intravenous immuoglobulins No 1 (ref) 1 (ref) Yes 0·94 (0·49 to 1·79) 0·85 1·02 (–7·41 to 9·44) 0·81
0510 15 –30 –15 0 15 30 Diffusion impairment Percentage change of CT score
B OR (95% CI) p value OR (95% CI) p value
Age 0·96 (0·87 to 1·06) 0·44 1·17 (1·07 to 1·27) 0·0008 Sex Men 1 (ref) 1 (ref) Women 1·80 (1·39 to 2·34) <0·0001 1·33 (1·05 to 1·67) 0·016 Cigarette smoking Never–smoker 1 (ref) 1 (ref) Current smoker 1·16 (0·67 to 2·00) 0·59 1·24 (0·78 to 1·98) 0·36 Former smoker 0·89 (0·36 to 2·19) 0·80 0·76 (0·38 to 1·52) 0·44 Education Middle school or lower 1 (ref) 1 (ref) College or higher 0·89 (0·67 to 1·19) 0·44 0·85 (0·66 to 1·09) 0·19 Comorbidity No 1 (ref) 1 (ref) Yes 0·97 (0·74 to 1·27) 0·84 1·08 (0·85 to 1·37) 0·52 Disease severity Scale 3 1 (ref) 1 (ref) Scale 4 0·88 (0·66 to 1·17) 0·37 0·74 (0·58 to 0·96) 0·024 Scale 5–6 1·77 (1·05 to 2·97) 0·031 2·69 (1·46 to 4·96) 0·0015 Corticosteroids No 1 (ref) 1 (ref) Yes 1·23 (0·88 to 1·72) 0·22 1·04 (0·77 to 1·42) 0·78 Antiviral No 1 (ref) 1 (ref) Yes 0·97 (0·76 to 1·24) 0·81 1·01 (0·81 to 1·26) 0·93 Intravenous immuoglobulins No 1 (ref) 1 (ref) Yes 0·77 (0·54 to 1·10) 0·15 0·96 (0·70 to 1·31) 0·78
012 302 4 6 Anxiety or depression Fatigue or muscle weakness
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Acute phase Follow-up A N RBD S B
* 100 † ‡ § * * 1·8 * * * 1·5 80 * * * * 1·2 60 0·9 40 0·6 0·3 Seropositivity (%) 20 0 Antibody titres (OD 450 nm) Antibody 0 N-IgM N-IgA N-IgG IgM IgA IgG IgM IgA IgG IgM IgA IgG
antibodies Neutralising
CD* ¶ E 80 * 1·2 1·8 1·5 60 0·9 * 1·2 40 0·6 * 0·9 * * 0·3 0·6 20 0·3 Neutralising antibody titres Neutralising antibody Antibody titres (OD 450 nm) Antibody 0·0 0 0·0 RBD-IgM RBD-IgA RBD-IgG S-IgM S-IgA S-IgG Neutralising antibodies
Figure 3: Temporal changes of seropositivity and antibody titres against SARS-CoV-2 (A) Seropositivity of each antibody indicated by the y-axis. Violin plots show the distribution of each antibody feature N (B), RBD (C), S (D), and neutralising antibodies (E) split across baseline and follow-up plasma samples of 94 individuals. The horizontal lines are used to indicate the value used to diagnose positivity from the antibody test. The comparison of antibody test results at acute phase and follow-up was done with paired t tests for antibody titres and McNemar test for antibody positive rates. Plasma samples at acute phase were collected during hospital stay with a median duration of 23 (IQR 20–26) days from illness onset. OD=optical density. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. p values indicate a comparison between acute phase and follow-up. *p<0·0001. †p=0·29. ‡p=0·039. §p=1·00. ¶p=0·021.
during the acute phase. Among those whose lymphocyte Discussion counts were available at follow-up, 97% had lymphocyte To our knowledge, this is the largest cohort study with counts 0·8 × 10⁹ per L or more. 58 patients without self- the longest follow-up duration assessing the health reported history of diabetes were newly diagnosed with consequences of adult patients discharged from hospital the condition at follow-up. Among 13 of these patients recovering from COVID-19. We found that at 6 months
with HbA1c tested during their hospital stay, one patient after symptom onset, most patients endorsed at least
showed normal HbA1c concentrations at acute phase, one symptom, particularly fatigue or muscle weakness, but abnormal concentrations at follow-up. Of the sleep difficulties, and anxiety or depression. More 390 participants who received ultrasonography, no deep severely ill patients had increased risk of pulmonary venous thrombosis of lower limbs was observed. The diffusion abnormality, fatigue or muscle weakness, and abdominal ultrasound results in these patients were also anxiety or depression. The seropositivity and titres of the normal (appendix p 19). neutralising antibodies were significantly lower than at The distribution of kidney function at acute phase and acute phase. follow-up is presented in the appendix (p 25). Among We found that fatigue or muscle weakness, sleep participants with eGFR available at follow-up, 35% (487 difficulties, and anxiety or depression were common, of 1393) had decreased eGFR (<90 mL/min per 1·73 m²; even at 6 months after symptom onset. This is consistent table 2). 101 (6%) of 1706 patients had acute kidney injury with data from previous SARS long term follow-up at acute phase. Among participants with eGFR available studies. Canadian researchers found that most SARS both at acute phase and follow-up, 479 (35%) of 1378 had survivors had good physical recovery from their illness, decreased eGFR at follow-up. Of 1016 participants but 33% reported a significant decrement in mental with non-acute kidney injury and normal eGFR value health 1 year later.23 A follow-up study of SARS survivors at acute phase, 822 had eGFR available at follow up, showed that 40% of patients still had a chronic fatigue with 107 (13%) presenting with decreased eGFR (appendix problem for a mean period of 41·3 months after SARS.24 p 25). We found that being a woman and severity of illness
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were risk factors for persistent psychological symptoms. kidney injury, with the potential to progress to end-stage Female SARS survivors had higher stress levels and kidney disease with dialysis.36 The limitation of serum higher levels of depression and anxiety.25 In a 3-month creatinine to diagnose acute kidney injury has been follow-up survey of 538 COVID-19 patients, Xiong and underscored, which might result in underestimation of colleagues8 found that physical decline or fatigue, post- patients with acute kidney injury at acute phase.37 For the activity polypnoea, and alopecia were more common in first time, we showed that 13% of patients without acute women than in men. The underlying mechanism of the kidney injury and with normal eGFR at the acute phase psychiatric consequences of COVID-19 is likely to be had decreased eGFR at follow-up. The persistent follow- multifactorial and might include the direct effects of viral up of discharged patients with COVID-19 is necessary infection, the immunological response, corticosteroid and essential, not only to understand the association therapy, ICU stay, social isolation, and stigma.26 between extrapulmonary diseases and SARS-CoV-2 The results of lung function assessment in this study infection, but also to find ways to reduce morbidity and showed that a considerable proportion (22–56% across mortality by efficient prevention. different severity scales) of participants had a pulmonary This study has several limitations. Firstly, the baseline diffusion abnormality 6 months after symptom onset. data of pulmonary function and 6-min walking distance This was consistent with findings that the most common are unavailable. However, the proportion of patients with abnormal CT pattern was pulmonary interstitial change chronic pulmonary and heart disease in this cohort is (GGOs and irregular lines), which were similar to the fairly low, although self-reported by patients which might long-term lung manifestations of SARS27 or influenza.28 have resulted in underestimation. The observed impaired Respiratory viral infection might potentially induce pulmonary function and exercise capacity cannot be distinct fibroblast activation in the convalescence phase.29 directly attributed to COVID-19. Secondly, for new symp The disease severity in the acute phase was found to be tom onset after COVID-19, the data were not stratified associated with pulmonary diffusion abnormality and further to determine if the symptoms were persistent percentage change of CT score in the multivariable following COVID-19, worsened after COVID-19 recovery, analysis. Our results did not suggest that corticosteroids or occurred post-discharge. Thirdly, patients with mild could accelerate the recovery of lung injury on pulmo COVID-19 symptoms who had stayed in Fangcang shelter nary function assessment and chest imaging, although hospitals38 were not enrolled. Further efforts are needed evidence has shown the benefits of corticosteroid to compare the long-term outcomes between inpatients treatment for patients with COVID-19.30,31 Whether the and outpatients. Finally, the number of participants with remaining radiological or pulmonary diffusion abnor SARS-CoV-2 antibody test results both at acute phase and malities completely resolve needs to be investigated in follow-up was limited. In the future, a larger sample is further follow-up studies. needed to clarify the dynamic changes of antibodies In this study, we found that the seropositivity and against SARS-CoV-2. median titres of the neutralising antibodies were At 6 months after symptom onset, fatigue or muscle significantly lower compared with at acute phase. In a weakness and sleep difficulties were the main symptoms report assessing 30 082 patients with mild-to-moderate of patients who had recovered from COVID-19. Risk of COVID-19, although antibody titres were stable over a anxiety or depression as an important psychological period of 3 months, a modest decline was observed at the complication and impaired pulmonary diffusion capac 5-month timepoint.32 Among asymptomatic individuals, ities were higher in patients with more severe illness. 81% had reduction of neutralising antibody concentra These results support that those with severe disease tions during the early convalescent phase.33 The decline of need post-discharge care. Longer follow-up studies in a neutralising antibodies observed in the present study and larger population are necessary to understand the full other studies raises concern for SARS-CoV-2 re-infection. spectrum of health consequences from COVID-19. The risk of re-infection should be monitored for patients Contributors who present with compatible symptoms of COVID-19. CW, BC, DZ, JW, YeW, and LR conceived and designed the study and Our study also investigated long-term extrapulmonary took responsibility for the integrity of the data and the accuracy of the data analysis. All authors had full access to all of the data in the study. organ manifestations and death during follow-up. For BC, YeW, LH, XG, GF, LS, JX, LG, and GW drafted the manuscript. example, persistent renal dysfunctions were observed, BC, XG, GF, YeW, LH, LS, LR, LG, and GW did the analysis and all some participants were newly diagnosed with diabetes, authors critically revised the manuscript for important intellectual and venous thromboembolic diseases, (including content and gave final approval for the version to be published. DZ, CH, LK, XL, XZ, YeW, LH, DC, JL, ZH, ST, YZ, LC, DX, YaL, CL, LP, and cardiovascular and cerebrovascular events) occurred. YoL completed the follow-up work. DZ, CH, LK, XL, XZ, YeW, LH, DC, Angiotensin-converting enzyme 2—enriched in the JL, ZH, ST, YZ, LC, DX, YaL, CL, LP, ML, WX, YiW, and JZ collected the renal proximal tubule34,35—could mediate the entry of data. All authors agree to be accountable for all aspects of the work in SARS-CoV-2 into epithelial cells to accumulate and ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. cause cytotoxicity and inflammatory cell infiltration. A previous study reported that persistent impairment in Declaration of interests We declare no competing interests. renal function can occur following an episode of acute www.thelancet.com Published online January 8, 2021 https://doi.org/10.1016/S0140-6736(20)32656-8 11 Articles
Data sharing 16 Guo L, Ren L, Yang S, et al. Profiling early humoral response to As subsequent follow-up investigations for COVID-19 are in progress, diagnose novel coronavirus disease (COVID-19). Clin Infect Dis 2020; data collected for the study, including individual participant data, and a 71: 778–85. data dictionary defining each field in the set, will not be made available 17 American Thoracic Society. Standardization of spirometry, 1994 to others. When all follow-up investigations are finished, data might be update. Am J Respir Crit Care Med 1995; 152: 1107–36. made available. 18 Liu F, Zhang Q, Huang C, et al. CT quantification of pneumonia lesions in early days predicts progression to severe illness in a Acknowledgments cohort of COVID-19 patients. Theranostics 2020; 10: 5613–22. This work was supported by the National Natural Science Foundation of 19 Pan F, Ye T, Sun P, et al. Time course of lung changes at chest CT China (82041011/H0104); Chinese Academy of Medical Sciences during recovery from coronavirus disease 2019 (COVID-19). Innovation Fund for Medical Sciences (CIFMS 2018-I2M-1–003 and Radiology 2020; 295: 715–21. 2020-I2M-CoV19–005); the National Key Research and Development 20 Francone M, Iafrate F, Masci GM, et al. Chest CT score in Program of China (2018YFC1200102); and Major Projects of National COVID-19 patients: correlation with disease severity and short-term Science and Technology on New Drug Creation and Development of prognosis. Eur Radiol 2020; published online July 4. https://doi.org/ Pulmonary Tuberculosis (2020ZX09201001). This work was also supported 10.1007/s00330-020-07033-y. by Peking Union Medical College Foundation (the China Evergrande 21 Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate Group, Jack Ma Foundation, Sino Biopharmaceutical, Ping An Insurance glomerular filtration rate. Ann Intern Med 2009; 150: 604–12. [Group], and New Sunshine Charity Foundation). We thank all patients 22 Enright PL, Sherrill DL. Reference equations for the six-minute who participated in this study and their families. We also thank all of the walk in healthy adults. Am J Respir Crit Care Med 1998; 158: 1384–87. staff of this follow-up study team (Qiongya Wang, Ying Liu, Wen Liu and 23 Tansey CM, Louie M, Loeb M, et al. One-year outcomes and health colleagues). We also appreciate the input from Geyi Wen from the China- care utilization in survivors of severe acute respiratory syndrome. Japan Friendship Hospital (Beijing, China) to the study design. Arch Intern Med 2007; 167: 1312–20. 24 Lam MH, Wing YK, Yu MW, et al. Mental morbidities and chronic References fatigue in severe acute respiratory syndrome survivors: long-term 1 Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. follow-up. Arch Intern Med 2009; 169: 2142–47. Pathophysiology, transmission, diagnosis, and treatment of 25 Lee AM, Wong JG, McAlonan GM, et al. Stress and psychological coronavirus disease 2019 (COVID-19): a review. JAMA 2020; distress among SARS survivors 1 year after the outbreak. 324: 782–93. Can J Psychiatry 2007; 52: 233–40. 2 Cevik M, Kuppalli K, Kindrachuk J, Peiris M. Virology, 26 Rogers JP, Chesney E, Oliver D, et al. Psychiatric and transmission, and pathogenesis of SARS-CoV-2. BMJ 2020; neuropsychiatric presentations associated with severe coronavirus 371: m3862. infections: a systematic review and meta-analysis with comparison 3 Yelin D, Wirtheim E, Vetter P, et al. Long-term consequences of to the COVID-19 pandemic. Lancet Psychiatry 2020; 7: 611–27. COVID-19: research needs. Lancet Infect Dis 2020; 20: 1115–17. 27 Xie L, Liu Y, Xiao Y, et al. Follow-up study on pulmonary function and 4 Carfi A, Bernabei R, Landi F. Persistent symptoms in patients after lung radiographic changes in rehabilitating severe acute respiratory acute COVID-19. JAMA 2020; 324: 603–05. syndrome patients after discharge. Chest 2005; 127: 2119–24. 5 Huang Y, Tan C, Wu J, et al. Impact of coronavirus disease 2019 on 28 Bai L, Gu L, Cao B, et al. Clinical features of pneumonia caused pulmonary function in early convalescence phase. Respir Res 2020; by 2009 influenza A(H1N1) virus in Beijing, China. Chest 2011; 21: 163. 139: 1156–64. 6 Liu C, Ye L, Xia R, et al. Chest CT and clinical follow-up of 29 Boyd DF, Allen EK, Randolph AG, et al. Exuberant fibroblast discharged patients with COVID-19 in Wenzhou City, Zhejiang, activity compromises lung function via ADAMTS4. Nature 2020; China. Ann Am Thorac Soc 2020; 17: 1231–37. 587: 466–71. 7 Zhao YM, Shang YM, Song WB, et al. Follow-up study of the 30 Horby P, Lim WS, Emberson JR, et al. Dexamethasone in pulmonary function and related physiological characteristics of hospitalized patients with Covid-19 - preliminary report. COVID-19 survivors three months after recovery. EClinicalMedicine N Engl J Med 2020; published online Jul 17. https://doi.org/10.1056/ 2020; 25: 100463. NEJMoa2021436. 8 Xiong Q, Xu M, Li J, et al. Clinical sequelae of COVID-19 survivors 31 Sterne JAC, Murthy S, Diaz JV, et al. Association between in Wuhan, China: a single-centre longitudinal study. administration of systemic corticosteroids and mortality among Clin Microbiol Infection 2020; published online Sept 23. critically ill patients with COVID-19: a meta-analysis. JAMA 2020; https://doi.org/10.1016/j.cmi.2020.09.023. 324: 1330–41. 9 China National Health Commission. Chinese clinical guidance for 32 Wajnberg A, Amanat F, Firpo A, et al. Robust neutralizing COVID-19 pneumonia diagnosis and treatment. http://kjfy. antibodies to SARS-CoV-2 infection persist for months. Science meetingchina.org/msite/news/show/cn/3337.html (accessed 2020; 370: 1227–30. Dec 10, 2020). 33 Long QX, Tang XJ, Shi QL, et al. Clinical and immunological 10 Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults assessment of asymptomatic SARS-CoV-2 infections. Nat Med 2020; hospitalized with severe Covid-19. N Engl J Med 2020; 382: 1787–99. 26: 1200–04. 11 Xie W, Wu Y, Wang W, et al. A longitudinal study of carotid plaque 34 Du M, Cai G, Chen F, Christiani DC, Zhang Z, Wang M. and risk of ischemic cardiovascular disease in the Chinese Multiomics evaluation of gastrointestinal and other clinical population. J Am Soc Echocardiogr 2011; 24: 729–37. characteristics of COVID-19. Gastroenterology 2020; 158: 2298–301.e7. 12 Mahler DA, Wells CK. Evaluation of clinical methods for rating 35 Vabret N, Britton GJ, Gruber C, et al. Immunology of COVID-19: dyspnea. Chest 1988; 93: 580–86. current state of the science. Immunity 2020; 52: 910–41. 13 Herdman M, Gudex C, Lloyd A, et al. Development and preliminary 36 Forni LG, Darmon M, Ostermann M, et al. Renal recovery after testing of the new five-level version of EQ-5D (EQ-5D-5L). acute kidney injury. Intensive Care Med 2017; 43: 855–66. Qual Life Res 2011; 20: 1727–36. 37 Bhatraju PK, Wurfel MM, Himmelfarb J. Trajectory of kidney 14 Rabin R, de Charro F. EQ-5D: a measure of health status from the function: the canary in sepsis. Am J Respir Crit Care Med 2020; EuroQol Group. Ann Med 2001; 33: 337–43. 202: 1211–12. 15 Ren L, Fan G, Wu W, et al. Antibody responses and clinical 38 Chen S, Zhang Z, Yang J, et al. Fangcang shelter hospitals: a novel outcomes in adults hospitalized with severe COVID-19: a post hoc concept for responding to public health emergencies. Lancet 2020; analysis of LOTUS China trial. Clin Infect Dis 2020; published 395: 1305–14. online Aug 25. https://doi.org/10.1093/cid/ciaa1247.
12 www.thelancet.com Published online January 8, 2021 https://doi.org/10.1016/S0140-6736(20)32656-8