OBJECTIVES:Some studies have examined survival trends among critically ill COVID-19 patients, but most were case reports, small cohorts, and had relatively short follow-up periods. We aimed to examine the survival trend among critically ill COVID-19 patients during the first two and a half years of the pandemic and investigate potential predictors across different variants of concern periods. DESIGN:Prospective cohort study. SETTING:Swedish ICUs, between March 6, 2020, and December 31, 2022. PATIENTS:Adult COVID-19 ICU patients of 18 years old or older from the Swedish Intensive Care Register (SIR) that were linked to multiple other national registers. MEASUREMENT AND MAIN RESULTS:Survival probability and predictors of COVID-19 death were estimated using Kaplan-Meier and Cox regression analysis. Of 8975 patients, 2927 (32.6%) died. The survival rate among COVID-19 critically ill patients appears to have changed over time, with a worse survival in the Omicron period overall. The adjusted hazard ratios (aHRs) comparing older and younger ages were consistently strong but slightly attenuated in the Omicron period. After adjustment, the aHR of death was significantly higher for men, older age (40+ yr), low income, and with comorbid chronic heart disease, chronic lung disease, impaired immune disease, chronic renal disease, stroke, and cancer, and for those requiring invasive or noninvasive respiratory supports, who developed septic shock or had organ failures ( p < 0.05). In contrast, foreign-born patients, those with booster vaccine, and those who had taken steroids had better survival (aHR = 0.87; 95% CI, 0.80-0.95; 0.74, 0.65-0.84, and 0.91, 0.84-0.98, respectively). Observed associations were similar across different variant periods. CONCLUSIONS:In this nationwide Swedish cohort covering over two and a half years of the pandemic, ICU survival rates changed over time. Older age was a strong predictor across all periods. Furthermore, most other mortality predictors remained consistent across different variant periods.

Introduction: Assessing COVID-19 risk in asthma patients is challenging due to disease heterogeneity and complexity. We hypothesized that potential risk factors for COVID-19 may differ among asthma age groups, hindering important insights when studied together. Methods: We included a population-based cohort of asthma patients from the Swedish National Airway Register (SNAR) and linked to data from several national health registers. COVID-19 outcomes included infection, hospitalization, and death from Jan 2020 until Feb 2021. Asthma patients were grouped by ages 12-17, 18-39, 40-64, and >= 65 years. Characteristics of asthma patients with different COVID-19 outcomes were compared with those in their age-corresponding respective source population. Results: Among 201,140 asthma patients studied, 11.2% were aged 12-17 years, 26.4% 18-39, 37.6% 40-64, and 24.9% >65 years. We observed 18,048 (9.0%) COVID-19 infections, 2172 (1.1%) hospitalizations, and 336 (0.2%) COVID-19 deaths. Deaths occurred only among patients aged >40. When comparing COVID-19 cases to source asthma populations by age, large differences in potential risk factors emerged, mostly for COVID-19 hospitalizations and deaths. For ages 12-17, these included education, employment, autoimmune, psychiatric, and depressive conditions, and use of short-acting I3-agonists (SABA) and inhaled corticosteroids (ICS). In the 18-39 age group, largest differences were for age, marital status, respiratory failure, anxiety, and body mass index. Ages 40-64 displayed notable differences for sex, birth region, cancer, oral corticosteroids, antihistamines, and smoking. For those aged >65, largest differences were observed for cardiovascular comorbidities, type 1 diabetes, chronic obstructive pulmonary disease, allergic conditions, and specific asthma treatments (ICS-SABA, ICS-long-acting bronchodilators (LABA)). Asthma control and lung function were important across all age groups. Conclusion: We identify distinct differences in COVID-19-related risk factors among asthma patients of different ages. This information is essential for assessing COVID-19 risk in asthma patients and for tailoring patient care and public health strategies accordingly. Plain language summary: Why was the study done? Asthma patients may be more susceptible to COVID-19 outcomes. Asthma affects all ages, and COVID-19-related risk factors may vary with age. Investigating factors that contribute to COVID-19 infection, hospitalization, and mortality within distinct age groups of asthma patients can yield a more comprehensive understanding of the age-specific nuances of COVID-19 risk. What did the researchers do and find? We analyzed sociodemographic characteristics, comorbidities, prescribed medications, and clinical characteristics of asthma patients with COVID-19 in different age groups and compared them with their age-corresponding source asthma populations. Potential risk factors for COVID-19 and its outcomes differed by age group For ages 12-17, these included education, employment, autoimmune, psychiatric, and depressive conditions, and use of short-acting I3-agonists (SABA) and inhaled corticosteroids (ICS). In the 18-39 age group, largest differences were for age, marital status, respiratory failure, anxiety, and body mass index. Ages 40-64 displayed notable differences for sex, birth region, cancer, oral corticosteroids, antihistamines, and smoking. For those aged >65, largest differences were observed for cardiovascular comorbidities, type 1 diabetes, chronic obstructive pulmonary disease, allergic asthma, and specific asthma treatments (ICS-SABA, ICS -long -acting bronchodilators (LABA)). Asthma control and lung function were important across all age groups. What do these results mean? These results emphasize the importance of recognizing age -specific patterns contributing to COVID-19 risk for consideration in causal analyses. The findings also highlight the necessity for age -specific approaches in both clinical and public health interventions in managing COVID-19 in asthma patients.

Objectives While glucocorticoid (GC) treatment initiated for COVID-19 reduces mortality, it is unclear whether GC treatment prior to COVID-19 affects mortality. Long-term GC use raises infection and thromboembolic risks. We investigated if patients with oral GC use prior to COVID-19 had increased mortality overall and by selected causes.Design Population-based observational cohort study.Settings Population-based register data in Sweden.Participants All patients infected with COVID-19 in Sweden from January 2020 to November 2021 (n=1 200 153).Outcome measures Any prior oral GC use was defined as ≥1 GC prescription during 12 months before index. High exposure was defined as ≥2 GC prescriptions with a cumulative prednisolone dose ≥750 mg or equivalent during 6 months before index. GC users were compared with COVID-19 patients who had not received GCs within 12 months before index. We used Cox proportional hazard models and 1:2 propensity score matching to estimate HRs and 95% CIs, controlling for the same confounders in all analyses.Results 3378 deaths occurred in subjects with any prior GC exposure (n=48 806; 6.9%) and 14 850 among non-exposed (n=1 151 347; 1.3%). Both high (HR 1.98, 95% CI 1.87 to 2.09) and any exposure (1.58, 1.52 to 1.65) to GCs were associated with overall death. Deaths from pulmonary embolism, sepsis and COVID-19 were associated with high GC exposure and, similarly but weaker, with any exposure. High exposure to GCs was associated with increased deaths caused by stroke and myocardial infarction.Conclusion Patients on oral GC treatment prior to COVID-19 have increased mortality, particularly from pulmonary embolism, sepsis and COVID-19.

Purpose Population-based studies provide conflicting evidence about how inhaled corticosteroids (ICS) impact COVID-19 outcomes among COPD patients. We investigated whether regular ICS exposure affects risk, severity, or survival in SARS-CoV-2 infection, using a nationwide linked Swedish population register database. Patients and Methods During January–December 2020, we studied two defined Swedish adult populations – Whole population [≥40 years] (N = 5243479), and COPD subpopulation [≥40 years] (N = 133372), in three study cohorts, respectively: 1. Overall cohort (index date 1 Jan 2020), 2. COVID-19 diagnosed sub-cohort (index date = diagnosis date), and 3. COVID-19 hospitalized sub-cohort (index date = admission date). Regular exposure was defined as ≥3 ICS prescriptions in the year before index. Hazard ratios (HRs) for outcomes (COVID-19 onset, hospitalization, ICU admission, or death) related to ICS exposure were estimated using Cox regression. Confounding was controlled by propensity score methods applying Average Treatment effect in the Treated (ATT) weighting. Results Regular ICS use was associated with only very slightly increased onset of COVID-19, hospitalization, ICU admission, and death in the overall whole population cohort and in the overall COPD subpopulation cohort, except for ICU admission (marginally non-significant HRs, up to 1.13); and no clear increase in the diagnosed sub-cohorts. However, in the COVID-19 hospitalized COPD sub-cohort, ICS therapy showed reduced risks against progression to ICU admission and death, significant for death (HR 0.82 95% CI [0.67–0.99]). Conclusion For COPD patients, ICS therapy offers some protection against progression to ICU admission and death among COVID-19 hospitalized patients. Our findings alleviate concerns about increased risks of COVID-19 by ICS treatment and provide evidence supporting the continuation of ICS therapy for COPD patients.

Rationale Evidence on risk factors for Coronavirus disease 2019 (COVID-19) outcomes among patients with COPD in relation to COVID-19 vaccination remains limited. The objectives of the present study were to characterise determinants of COVID-19 infection, hospitalisation, intensive care unit (ICU) admission and death in COPD patients in their unvaccinated state compared to when vaccinated. Methods We included all COPD patients in the Swedish National Airway Register (SNAR). Events of COVID-19 infection (test and/or healthcare encounter), hospitalisation, ICU admission and death were identified from 1 January 2020 to 30 November 2021. Using adjusted Cox regression, associations between baseline sociodemographics, comorbidities, treatments, clinical measurements and COVID-19 outcomes, during unvaccinated and vaccinated follow-up time, were analysed. Results The population-based COPD cohort included 87 472 patients, among whom 6771 (7.7%) COVID-19 infections, 2897 (3.3%) hospitalisations, 233 (0.3%) ICU admissions and 882 (1.0%) COVID-19 deaths occurred. During unvaccinated follow-up, risk of COVID-19 hospitalisation and death increased with age, male sex, lower education, non-married status and being foreign-born. Comorbidities increased risk of several outcomes, e.g. respiratory failure for infection and hospitalisation (adjusted hazard ratios (HR) 1.78, 95% CI 1.58–2.02 and 2.51, 2.16–2.91, respectively), obesity for ICU admission (3.52, 2.29–5.40) and cardiovascular disease for mortality (2.80, 2.16–3.64). Inhaled COPD therapy was associated with infection, hospitalisation and death. COPD severity was also associated with COVID-19, especially hospitalisation and death. Although the risk factor panorama was similar, COVID-19 vaccination attenuated HRs for some risk factors. Conclusion This study provides population-based evidence on predictive risk factors for COVID-19 outcomes and highlights the positive implications of COVID-19 vaccination for COPD patients.

Background: We estimated real-world vaccine effectiveness (VE) against COVID-19 infection, hospitalization, ICU admission, and death up to 13 months after vaccination. VE before and after the emergence of Omicron was investigated. Methods: We used registered data from the entire Swedish population above age 12 (n = 9,153,456). Cox regression with time-varying exposure was used to estimate weekly/monthly VE against COVID-19 outcomes from 27 December 2020 to 31 January 2022. The analyses were stratified by age, sex, and vaccine type (BNT162b2, mRNA-1273, and AZD1222). Results: Two vaccine doses offered good long-lasting protection against infection before Omicron (VE were above 85% for all time intervals) but limited protection against Omicron infection (dropped to 43% by week four and no protection by week 14). For severe COVID-19 outcomes, higher VE was observed during the entire follow-up period. Among individuals above age 65, the mRNA vaccines showed better VE against infection than AZD1222 but similar high VE against hospitalization. Conclusions: Our findings provide strong evidence for long-term maintained protection against severe COVID-19 by the basic two-dose schedule, supporting more efforts to encourage unvaccinated persons to get the basic two doses, and encourage vaccinated persons to get a booster to ensure better population-level protection.

Background: Inhaled corticosteroid therapy (ICS) is an important therapeutic modality in chronic respiratory diseases, and patients with chronic obstructive pulmonary disease (COPD) are severely affected by COVID-19. The role of ICS in COVID-19 has been studied, however, ambiguities remain, especially for COPD patients. Aim: To investigate whether ongoing regular exposure to ICS affects risk, severity or survival in SARS-CoV-2 infection, using a large linked Swedish population register database. Methods: From January to December 2020, we studied in two study populations (general population and COPD patients) three different study cohorts: 1. the whole group, 2. COVID-19-diagnosed individuals, and 3. hospitalized COVID-19 patients. Ongoing regular exposure to ICS was defined as ≥1 ICS prescriptions during the year before the index date. Studied outcomes were: COVID-19 diagnosis, hospitalization, intensive care and death. Results: After matching, in the general population ICS therapy was not associated with an increased onset or COVID-19, hospitalization, ICU admission or fatal outcomes, both in the general cohort and COPD patients group. Similarly, in patients who acquired COVID-19, ICS therapy was not associated with hospitalization, ICU admission or death in both groups. A slight increase for ICU admission was observed in the hospitalized general patients cohort who received ICS therapy (H.R. 1.22 [1.05, 1.42]), however, COPD patients did not have an increased risk for adverse outcomes. Conclusion: Patients receiving ICS therapy did not have an increased risk for acquiring Covid 19, hospitalization, ICU admission or fatal outcomes.

Background With large-scale COVID-19 vaccination implemented world-wide, safety signals needing rapid evaluation will emerge. We report population-based, age- and-sex-specific background incidence rates of conditions representing potential vaccine adverse events of special interest (AESI) for the Swedish general population using register data. Methods We studied an age/sex-stratified random 10% sample of the Swedish population on 1 Jan 2020, followed for AESI outcomes during 1 year, as the COVID-19 pandemic emerged and developed, before the start of vaccinations. We selected and defined the following outcomes based on information from regulatory authorities, large-scale adverse events initiatives and previous studies: aseptic meningitis, febrile seizure, Kawasaki syndrome, MISC, post-infectious arthritis, arthritis, myocarditis, ARDS, myocardial infarction, stroke, ischemic stroke, hemorrhagic stroke, venous thromboembolism, pulmonary embolism, kidney failure, liver failure, erythema multiforme, disseminated intravascular coagulation, autoimmune thyroiditis, and appendicitis. We calculated incidence rates stratified by age, sex and time period (quarters of 2020), and classified them using Council of International Organizations of Medical Sciences (CIOMS) categories: very common, common, uncommon, rare, or very rare. Results We included 972,723 study subjects, representing the Swedish national population on 1 Jan 2020. We found that AESI incidence rates vary greatly by age and in some cases sex. Several common AESIs showed expected increase with age, while some (e.g. appendicitis, aseptic meningitis, autoimmune thyroiditis, Kawasaki syndrome and MISC) were more common in young people, and others exhibited a flatter age pattern (e.g. myocarditis, DIC and erythema multiforme). Consequently, the CIOMS classification for AESIs varied widely according to age. Considerable variability was suggested for some AESI rates across the 4 quarters of 2020, potentially related to pandemic waves, seasonal variation, healthcare system overload or other healthcare delivery effects. Conclusion Age, sex, and timing of rates are important to consider when background AESI rates are compared to corresponding rates observed with COVID-19 vaccines.

Background Lockdown measures are the backbone of containment measures for the COVID-19 pandemic both in high-income countries (HICs) and low- and middle-income countries (LMICs). However, in view of the inevitably-occurring second and third global covid-19 wave, assessing the success and impact of containment measures on the epidemic curve of COVID-19 and people’s compliance with such measures is crucial for more effective policies. To determine the containment measures influencing the COVID-19 epidemic curve in nine targeted countries across high-, middle-, and low-income nations. Methods Four HICs (Germany, Sweden, Italy, and South Korea) and five LMICs (Mexico, Colombia, India, Nigeria, and Nepal) were selected to assess the association using interrupted time series analysis of daily case numbers and deaths of COVID-19 considering the following factors: The “stringency index (SI)” indicating how tight the containment measures were implemented in each country; and the level of compliance with the prescribed measures using human mobility data. Additionally, a scoping review was conducted to contextualize the findings. Results Most countries implemented quite rigorous lockdown measures, particularly the LMICs (India, Nepal, and Colombia) following the model of HICs (Germany and Italy). Exceptions were Sweden and South Korea, which opted for different strategies. The compliance with the restrictions—measured as mobility related to home office, restraining from leisure activities, non-use of local transport and others—was generally good, except in Sweden and South Korea where the restrictions were limited. The endemic curves and time-series analysis showed that the containment measures were successful in HICs but not in LMICs. Conclusion The imposed lockdown measures are alarming, particularly in resource-constrained settings where such measures are independent of the population segment, which drives the virus transmission. Methods for examining people’s movements or hardships that are caused by covid- no work, no food situation are inequitable. Novel and context-adapted approach of dealing with the COVID-19 crisis are therefore crucial.

The unprecedented novel Coronavirus disease, COVID-19, which emerged in December 2019 has been labeled "disease X" by the World Health Organization (WHO) based on its rate and extent of spread as well as harsh ramifications.In response, different nations have adopted different management approaches hinging on various considerations, among them the WHO recommendations.Uganda has incorporated lockdowns, a measure that has affected schools, hospitals, businesses, places of worship, markets, public transport, and a rise in abuse of human rights in the form of police brutality, and domestic violence [1].However, contextual factors such as socioeconomic realities and poverty pose a different set of problems for the mitigation and suppression of efforts for COVID-19, especially for vulnerable populations.Eventually, the effects of these interventions pitch down to individual citizens but invariably disproportionately affect vulnerable populations such as street children.This commentary examines the effects of mitigation efforts of COVID-19 on street children who roam the streets of Ugandan cities and whose plight barely gets on the research as well as policy agenda [2].This paper also draws parallels with similar stories from street children in a few other African countries.