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Risk Factors for Developing Severe COVID-19 in China

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Risk Factors for Developing Severe COVID-19 in China Geng et al. Infect Dis Poverty (2021) 10:48 https://doi.org/10.1186/s40249-021-00820-9 RESEARCH ARTICLE Open Access Risk factors for developing severe COVID-19 in China: an analysis of disease surveillance data Meng‑Jie Geng1, Li‑Ping Wang1, Xiang Ren1, Jian‑Xing Yu2, Zhao‑Rui Chang1, Can‑Jun Zheng1, Zhi‑Jie An3, Yu Li1, Xiao‑Kun Yang1, Hong‑Ting Zhao1, Zhong‑Jie Li1*, Guang‑Xue He4* and Zi‑Jian Feng1* Abstract Background: COVID‑19 has posed an enormous threat to public health around the world. Some severe and critical cases have bad prognoses and high case fatality rates, unraveling risk factors for severe COVID‑19 are of signifcance for predicting and preventing illness progression, and reducing case fatality rates. Our study focused on analyz‑ ing characteristics of COVID‑19 cases and exploring risk factors for developing severe COVID‑19. Methods: The data for this study was disease surveillance data on symptomatic cases of COVID‑19 reported from 30 provinces in China between January 19 and March 9, 2020, which included demographics, dates of symptom onset, clinical manifestations at the time of diagnosis, laboratory fndings, radiographic fndings, underlying disease history, and exposure history. We grouped mild and moderate cases together as non‑severe cases and categorized severe and critical cases together as severe cases. We compared characteristics of severe cases and non‑severe cases of COVID‑19 and explored risk factors for severity. Results: The total number of cases were 12 647 with age from less than 1 year old to 99 years old. The severe cases were 1662 (13.1%), the median age of severe cases was 57 years [Inter‑quartile range(IQR): 46–68] and the median age of non‑severe cases was 43 years (IQR: 32–54). The risk factors for severe COVID‑19 were being male [adjusted odds ratio (aOR) 1.3, 95% CI: 1.2–1.5]; fever (aOR 2.3, 95% CI: 2.0–2.7), cough (aOR 1.4, 95% CI: 1.2–1.6), fatigue (aOR 1.3, 95% CI:= 1.2–1.5), and chronic kidney disease= (aOR 2.5, 95% CI: 1.4–4.6), hypertension= (aOR 1.5, 95% CI: 1.2–1.8)= and diabetes (aOR 1.96, 95% CI: 1.6–2.4). With the increase= of age, risk for the severity was gradually= higher [20–39 years (aOR 3.9, 95%= CI: 1.8–8.4), 40–59 years (aOR 7.6, 95% CI: 3.6–16.3), 60 years (aOR 20.4, 95% CI: 9.5–43.7)], and longer= time from symtem onset to diagnosis= [3–5 days (aOR 1.4, 95%≥ CI: 1.2–1.7), =6–8 days (aOR 1.8, 95% CI: 1.5–2.1), 9 days(aOR 1.9, 95% CI: 1.6–2.3)]. = = ≥ = Conclusions: Our study showed the risk factors for developing severe COVID‑19 with large sample size, which included being male, older age, fever, cough, fatigue, delayed diagnosis, hypertension, diabetes, chronic kidney diasease. Based on these factors, the severity of COVID‑19 cases can be predicted. So cases with these risk factors should be paid more attention to prevent severity. Keywords: COVID‑19, Severe case, Non‑severe case, Risk factor Background Coronavirus disease 2019 (COVID-19) is caused by *Correspondence: [email protected]; [email protected]; [email protected] severe acute respiratory syndrome coronavirus 2 (SARS- 1 Division of Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China CoV-2) and is transmitted by respiratory droplets and 4 National Institute for Viral Disease Control and Prevention, Chinese contacts. Sources of infection are cases and asympto- Center for Disease Control and Prevention, Beijing, China matic infections, infectivity starts from the incubation Full list of author information is available at the end of the article period and becomes relatively strong within fve days © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Geng et al. Infect Dis Poverty (2021) 10:48 Page 2 of 10 after symptom onset, the populations are generally sus- leading to increasing risks of adverse outcome and death ceptible to infection [1]. Te contagiousness of SARS- [18, 19]. Tis study was mainly focued on analyzing char- CoV-2 is higher than severe acute respiratory syndrome acteristics of COVID-19 cases and identifying the risk coronavirus (SARS-CoV) and Middle East respiratory factors for severe COVID-19 cases in order to prevent syndrome coronavirus (MERS-CoV), and the scale of poor prognosis. morbidity and mortality of COVID-19 are far greater than Severe Acute Respiratory Syndrome (SARS) and Methods Middle East Respiratory Syndrome (MERS) [2–4]. Te Setting, subjects, and data availability World Health Organization (WHO) declared COVID-19 Te study setting was in 30 provinces outside Hubei a public health emergency of international concern on Province in the mainland of China. Geographic classif- January 30, 2020 [5]. COVID-19 has brought great bur- cation into regions (eastern, central, and western) were den on the public health worldwide; as of December 27, based on socioeconomic level which were in accordance 2020, more than 210 countries and regions worldwide with the National Bureau of Statistics of China [20]. have reported 79.2 million cases and more than 1.7 mil- Subjects were symptomatic COVID-19 cases reported lion deaths [6]. Te National Health Commission of the to the Chinese Center for Disease Control and Preven- People’s Republic of China made COVID-19 a Class B tion (China CDC) COVID-19 online reporting system. notifable infectious diseases, but managed COVID-19 as Te National Health Commission’s Protocol for Preven- a Class A infectious disease [7, 8]. tion and Control of COVID-19 issued by National Health COVID-19 causes lots of symptoms, including fever, Commission of the People’s Republic of China specifed cough, fatigue, and the clinical spectrum of COVID-19 that county (district) level disease control and prevention pneumonia ranges from mild to critical. More than 80% agencies must complete an initial epidemiological inves- infected individuals are asymptomatic or develop mild tigation within 24 h upon receiving a report of a COVID- upper respiratory tract symptoms were reported [9], 19 case and should submit investigation questionnaires and parts of cases have severe courses that can include to COVID-19 online reporting system. Epidemiological dyspnea, hypoxemia, Acute Respiratory Distress Syn- investigations include basic demographic data, initial drome (ARDS), shock, and even death. Mild and mod- symptoms at the time of diagnosis, laboratory fndings erate cases can recover after symptomatic treatment, and imaging features on admission, health-care-seeking but severe and critical patients require early interven- behaviors and epidemiological history [21]. tion, respiratory support and sometimes intensive care We included data of symptomatic cases of COVID- unit (ICU) care [10]. Te case fatality rates of severe and 19 reported from January 19 to March 9, 2020. We critical cases are relatively high, critical patients wit- matched information of cases in the COVID-19 online ness signifcantly higher mortality which is up to 49.0%, reporting system with their information in the National by contrast with 2.3% for overall COVID-19 patients [9, Notifable Diseases Reporting System (NNDRS) based 11]. Due to the higher mortality of severe cases, there is on national ID card number. Ten we linked demo- a need to explore the risk factors for severity, prevent graphic data, date of symptom onset, date of diagnosis, developing severe cases, followed by reducing the case and fnal clinical severity with epidemiological history, fatality rate. clinical manifestations, laboratory fndings, radio- Most studies on exploring risk factors for COVID- graphic features, and underlying diseases in the online 19 severity in China were with limited sample size and reporting system. We then created a de-identifed and most focused on infuence of clinical characteristics and unifed dataset for all analyses. treatments on severity [12–14]. Whereas comparisons of Te information in our study were from NNDRS and severe and non-severe cases and the infuences of early COVID-19 case reporting system. Analyses of these symptoms on predicating progression of COVID-19 need data are routine work, which are involved with rela- to be further explored. tive divisions in China CDC. Wuhan reached the highest peak of the COVID- 19 outbreak around February 12, 2020, diagnosis and treatment may have been delayed because the medical Defnitions resources for COVID-19 were limited at that time [15]. Case defnitions were based on Guidelines on Diag- During early stage, the COVID-19 case fatality rate in nosis and Treatment of Patients with COVID-19, Hubei Province was higher than other provinces in main- which classifes cases as mild, moderate, severe, and land China [16, 17].
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