Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa

Boulle, Andrew; Davies, Mary-Ann; Hussey, Hannah; Ismail, Muzzammil; Morden, Erna; Vundle, Ziyanda; Zweigenthal, Virginia; Mahomed, Hassan; Paleker, Masudah; Pienaar, David; Tembo, Yamanya; Lawrence, Charlene; Isaacs, Washiefa; Mathema, Hlengani; Allen, Derick; Allie, Taryn; Bam, Jamy-Lee; Buddiga, Kasturi; Dane, Pierre; Heekes, Alexa; Matlapeng, Boitumelo; Mutemaringa, Themba; Muzarabani, Luckmore; Phelanyane, Florence; Pienaar, Rory; Rode, Catherine; Smith, Mariette; Tiffin, Nicki; Zinyakatira, Nesbert; Cragg, Carol; Marais, Frederick; Mudaly, Vanessa; Voget, Jacqueline; Davids, Jody; Roodt, Francois; van Zyl Smit, Nellis; Vermeulen, Alda; Adams, Kevin; Audley, Gordon; Bateman, Kathleen; Beckwith, Peter; Bernon, Marc; Blom, Dirk; Boloko, Linda; Botha, Jean; Boutall, Adam; Burmeister, Sean; Cairncross, Lydia; Calligaro, Gregory; Coccia, Cecilia; Corin, Chadwin; Daroowala, Remy; Dave, Joel A; De Bruyn, Elsa; De Villiers, Martin; Deetlefs, Mimi; Dlamini, Sipho; Du Toit, Thomas; Endres, Wilhelm; Europa, Tarin; Fieggan, Graham; Figaji, Anthony; Frankenfeld, Petro; Gatley, Elizabeth; Gina, Phindile; Govender, Evashan; Grobler, Rochelle; Gule, Manqoba Vusumuzi; Hanekom, Christoff; Held, Michael; Heynes, Alana; Hlatswayo, Sabelo; Hodkinson, Bridget; Holtzhausen, Jeanette; Hoosain, Shakeel; Jacobs, Ashely; Kahn, Miriam; Kahn, Thania; Khamajeet, Arvin; Khan, Joubin; Khan, Riaasat; Khwitshana, Alicia; Knight, Lauren; Kooverjee, Sharita; Krogscheepers, Rene; Jacque Kruger, Jean; Kuhn, Suzanne; Laubscher, Kim; Lazarus, John; Le Roux, Jacque; Lee Jones, Scott; Levin, Dion; Maartens, Gary; Majola, Thina; Manganyi, Rodgers; Marais, David; Marais, Suzaan; Maritz, Francois; Maughan, Deborah; Mazondwa, Simthandile; Mbanga, Luyanda; Mbatani, Nomonde; Mbena, Bulewa; Meintjes, Graeme; Mendelson, Marc; Möller, Ernst; Moore, Allison; Ndebele, Babalwa; Nortje, Marc; Ntusi, Ntobeko; Nyengane, Funeka; Ofoegbu, Chima; Papavarnavas, Nectarios; Peter, Jonny; Pickard, Henri; Pluke, Kent; Raubenheimer, Peter J; Robertson, Gordon; Rozmiarek, Julius; Sayed, A; Scriba, Matthias; Sekhukhune, Hennie; Singh, Prasun; Smith, Elsabe; Soldati, Vuyolwethu; Stek, Cari; van den berg, Robert; van der Merwe, Le Roux; Venter, Pieter; Vermooten, Barbra; Viljoen, Gerrit; Viranna, Santhuri; Vogel, Jonno; Vundla, Nokubonga; Wasserman, Sean; Zitha, Eddy; Lomas-Marais, Vanessa; Lombard, Annie; Stuve, Katrin; Viljoen, Werner; Basson, De Vries; Le Roux, Sue; Linden-Mars, Ethel; Victor, Lizanne; Wates, Mark; Zwanepoel, Elbe; Ebrahim, Nabilah; Lahri, Sa'ad; Mnguni, Ayanda; Crede, Thomas; de Man, Martin; Evans, Katya; Hendrikse, Clint; Naude, Jonathan; Parak, Moosa; Szymanski, Patrick; Van Koningsbruggen, Candice; Abrahams, Riezaah; Allwood, Brian; Botha, Christoffel; Henndrik Botha, Matthys; Broadhurst, Alistair; Claasen, Dirkie; Daniel, Che; Dawood, Riyaadh; du Preez, Marie; Du Toit, Nicolene; Erasmus, Kobie; Koegelenberg, Coenraad F N; Gabriel, Shiraaz; Hugo, Susan; Jardine, Thabiet; Johannes, Clint; Karamchand, Sumanth; Lalla, Usha; Langenegger, Eduard; Louw, Eize; Mashigo, Boitumelo; Mhlana, Nonte; Mnqwazi, Chizama; Moodley, Ashley; Moodley, Desiree; Moolla, Saadiq; Mowlana, Abdurasiet; Nortje, Andre; Olivier, Elzanne; Parker, Arifa; Paulsen, Chané; Prozesky, Hans; Rood, Jacques; Sabela, Tholakele; Schrueder, Neshaad; Sithole, Nokwanda; Sithole, Sthembiso; Taljaard, Jantjie J; Titus, Gideon; Van Der Merwe, Tian; van Schalkwyk, Marije; Vazi, Luthando; Viljoen, Abraham J; Yazied Chothia, Mogamat; Naidoo, Vanessa; Alan Wallis, Lee; Abbass, Mumtaz; Arendse, Juanita; Armien, Rizqa; Bailey, Rochelle; Bello, Muideen; Carelse, Rachel; Forgus, Sheron; Kalawe, Nosi; Kariem, Saadiq; Kotze, Mariska; Lucas, Jonathan; McClaughlin, Juanita; Murie, Kathleen; Najjaar, Leilah; Petersen, Liesel; Porter, James; Shaw, Melanie; Stapar, Dusica; Williams, Michelle; Aldum, Linda; Berkowitz, Natacha; Girran, Raakhee; Lee, Kevin; Naidoo, Lenny; Neumuller, Caroline; Anderson, Kim; Begg, Kerrin; Boerlage, Lisa; Cornell, Morna; de Waal, Renée; Dudley, Lilian; English, René; Euvrard, Jonathan; Groenewald, Pam; Jacob, Nisha; Jaspan, Heather; Kalk, Emma; Levitt, Naomi; Malaba, Thoko; Nyakato, Patience; Patten, Gabriela; Schneider, Helen; Shung King, Maylene; Tsondai, Priscilla; Van Duuren, James; van Schaik, Nienke; Blumberg, Lucille; Cohen, Cheryl; Govender, Nelesh; Jassat, Waasila; Kufa, Tendesayi; McCarthy, Kerrigan; Morris, Lynn; Hsiao, Nei-yuan; Marais, Ruan; Ambler, Jon; Ngwenya, Olina; Osei-Yeboah, Richard; Johnson, Leigh; Kassanjee, Reshma; Tamuhla, Tsaone

BACKGROUND: Risk factors for COVID-19 death in sub-Saharan Africa and the effects of HIV and tuberculosis on COVID-19 outcomes are unknown. METHODS: We conducted a population cohort study using linked data from adults attending public sector health facilities in the Western Cape, South Africa. We used Cox-proportional hazards models adjusted for age, sex, location and comorbidities to examine the association between HIV, tuberculosis and COVID-19 death from 1 March-9 June 2020 among (i) public sector “active patients” (≥1 visit in the 3 years before March 2020), (ii) laboratory-diagnosed COVID-19 cases and (iii) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19 comparing HIV positive vs. negative adults using modelled population estimates. RESULTS: Among 3,460,932 patients (16% HIV positive), 22,308 were diagnosed with COVID-19, of whom 625 died. COVID-19 death was associated with male sex, increasing age, diabetes, hypertension and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR] 2.14; 95% confidence interval [CI] 1.70-2.70), with similar risks across strata of viral load and immunosuppression. Current and previous tuberculosis were associated with COVID-19 death (aHR [95%CI] 2.70 [1.81-4.04] and 1.51 [1.18-1.93] respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95%CI 1.96-2.86); population attributable fraction 8.5% (95%CI 6.1-11.1). CONCLUSION: While our findings may over-estimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both HIV and current tuberculosis were independently associated with increased COVID-19 mortality. The associations between age, sex and other comorbidities and COVID-19 mortality were similar to other settings.