Factors Contributing to COVID-19 Mortality In-hospital and after Discharge: Results of an Ambivalent Cohort Study from a Tribal District of Kerala, India.

INTRODUCTION

The morbidity and mortality burden of the COVID-19 pandemic was high in socioeconomically deprived areas. Identifying the factors associated with in-hospital mortality in such settings will help physicians prioritize the scarce resources for the more needy individuals.

OBJECTIVE

To study the demographic, clinical, and biochemical factors associated with in-hospital mortality in COVID-19 patients in Wayanad, Kerala, India. We also report the incidence of post-COVID symptoms and the mortality rate in the survivors of COVID-19 pneumonia.

MATERIALS AND

METHODS

The study design was a record-based retrospective cohort, and the study participants were 402 patients admitted with moderate to severe COVID-19 at the secondary care hospital of Wayanad, Kerala, India, during late 2020 and early 2021. In-hospital mortality was the major outcome variable, and we expressed the mortality risk in terms of relative risks (RRs). Factors associated with the same were assessed using Chi-square, Fisher's exact tests, and t-tests depending upon the type of exposure variable. Dose-response relationships were assessed using Chi-square for trend. A subgroup of consented survivors (n = 156) was followed to study the post-COVID symptoms and mortality rate outside the hospital. We constructed binary logistic models to find out the independent predictors of mortality.

RESULTS

The patient group (n = 402) was composed of individuals aged 18-95 years, and two-thirds (n = 258) were men. The in-hospital mortality rate was 17.7%. The risk of mortality increased with age, multimorbidity, and extent of hypoxia, peripheral oxygen saturation/fraction of inspired oxygen [SpO2/FiO2 (SF)] ratio, D-dimer, serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), serum creatinine, and blood urea. The case fatality rate (CFR) had a dose-response relationship with the number of comorbidities. Out of the individual comorbidities analyzed, systemic arterial hypertension [RR = 1.5 (1.16-1.83)], cancer [RR = 4.7 (1.38-15.6)], and neurological disorders [RR = 5.8 (1.6-21.16)] were significantly associated with mortality in the hospital. According to the binary logistic regression analysis, age, hypoxia at the time of admission, intensive care unit (ICU) admission, serum creatinine, and SF ratio were the significant predictors of mortality. Most of the patients (73%) complained of some symptoms during follow-up. Easy fatigability and tiredness were the most common post-COVID symptoms, followed by exertional breathlessness, myalgia, decreased sleep, weight loss, and cough.

CONCLUSION

The physician should prioritize patients with multimorbidity and markers of organ involvement to save lives in resource-poor settings during pandemics and large infectious disease outbreaks affecting the community. The early diagnosis and management of comorbidities should be included in pandemic or outbreak preparedness to reduce morbidity and mortality.