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Research ArticleOpen Access

Outcome of COVID-19 in hospitalised immunocompromised patients: An analysis of the WHO ISARIC CCP-UK prospective cohort study

Lance Turtle1*, Mathew Thorpe2, Thomas M. Drake2, Maaike Swets3, Carlo Palmieri4, Clark D. Russell5, Antonia Ho6, Stephen Aston7, Daniel G. Wootton1, Alex Richter8, Thushan I. de Silva9, Hayley E. Hardwick10, Gary Leeming11, Andy Law12, Peter J. M. Openshaw13, Ewen M. Harrison2, J. Kenneth Baillie14, Malcolm G. Semple15, Annemarie B. Docherty16

1NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom; Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

2Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom

3Department of Infectious Diseases, Leiden University Medical Centre, Leiden University, Leiden, the Netherlands; The Roslin Institute, Easter Bush campus, University of Edinburgh, Edinburgh, United Kingdom

4Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom

5University of Edinburgh Centre for Inflammation Research, Queen’s Medical Research Institute, Edinburgh, United Kingdom

6MRC-University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, United Kingdom

7Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom; Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom

8Institute of Cancer and Genomic Science, College of Medical and Dental Science, University of Birmingham, Birmingham, United Kingdom; University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

9Department of Infection, Immunity and Cardiovascular Disease, Medical School, The University of Sheffield, Sheffield, United Kingdom

10NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom

11Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom

12The Roslin Institute, Easter Bush campus, University of Edinburgh, Edinburgh, United Kingdom

13National Heart and Lung Institute, Imperial College London, London, United Kingdom

14The Roslin Institute, Easter Bush campus, University of Edinburgh, Edinburgh, United Kingdom; Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, United Kingdom; Baillie Gifford Pandemic Science Hub, Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom

15NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom; Respiratory Medicine, Alder Hey Children’s Hospital, Liverpool, United Kingdom

16Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; Intensive Care Unit, Royal Infirmary Edinburgh, Edinburgh, United Kingdom

* Correspondence: lance.turtle@liverpool.ac.uk

PLOS Medicine — Volume 20, Issue 1 (2023-01)

Abstract

BackgroundImmunocompromised patients may be at higher risk of mortality if hospitalised with Coronavirus Disease 2019 (COVID-19) compared with immunocompetent patients. However, previous studies have been contradictory. We aimed to determine whether immunocompromised patients were at greater risk of in-hospital death and how this risk changed over the pandemic.Methods and findingsWe included patients > = 19 years with symptomatic community-acquired COVID-19 recruited to the ISARIC WHO Clinical Characterisation Protocol UK prospective cohort study. We defined immunocompromise as immunosuppressant medication preadmission, cancer treatment, organ transplant, HIV, or congenital immunodeficiency. We used logistic regression to compare the risk of death in both groups, adjusting for age, sex, deprivation, ethnicity, vaccination, and comorbidities. We used Bayesian logistic regression to explore mortality over time. Between 17 January 2020 and 28 February 2022, we recruited 156,552 eligible patients, of whom 21,954 (14%) were immunocompromised. In total, 29% (n = 6,499) of immunocompromised and 21% (n = 28,608) of immunocompetent patients died in hospital. The odds of in-hospital mortality were elevated for immunocompromised patients (adjusted OR 1.44, 95% CI [1.39, 1.50], p < 0.001). Not all immunocompromising conditions had the same risk, for example, patients on active cancer treatment were less likely to have their care escalated to intensive care (adjusted OR 0.77, 95% CI [0.7, 0.85], p < 0.001) or ventilation (adjusted OR 0.65, 95% CI [0.56, 0.76], p < 0.001). However, cancer patients were more likely to die (adjusted OR 2.0, 95% CI [1.87, 2.15], p < 0.001). Analyses were adjusted for age, sex, socioeconomic deprivation, comorbidities, and vaccination status. As the pandemic progressed, in-hospital mortality reduced more slowly for immunocompromised patients than for immunocompetent patients. This was particularly evident with increasing age: the probability of the reduction in hospital mortality being less for immunocompromised patients aged 50 to 69 years was 88% for men and 83% for women, and for those >80 years was 99% for men and 98% for women. The study is limited by a lack of detailed drug data prior to admission, including steroid doses, meaning that we may have incorrectly categorised some immunocompromised patients as immunocompetent.ConclusionsImmunocompromised patients remain at elevated risk of death from COVID-19. Targeted measures such as additional vaccine doses, monoclonal antibodies, and nonpharmaceutical preventive interventions should be continually encouraged for this patient group.Trial registrationISRCTN 66726260.

Cite This Article

Turtle, L., Thorpe, M., Drake, T., Swets, M., Palmieri, C., Russell, C., Ho, A., Aston, S., Wootton, D., Richter, A., de Silva, T., Hardwick, H., Leeming, G., Law, A., Openshaw, P., Harrison, E., Baillie, J., Semple, M., Docherty, A. (2023). Outcome of COVID-19 in hospitalised immunocompromised patients: An analysis of the WHO ISARIC CCP-UK prospective cohort study. PLOS Medicine, 20(1), online. https://doi.org/10.1371/journal.pmed.1004086

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