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

Abstract

Background Immunocompromised 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 findings We 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. Approximately 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. Conclusions Immunocompromised 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 registration ISRCTN 66726260.

SARS-CoV-2 antibody responses post-vaccination in UK healthcare workers with pre-existing medical conditions: a cohort study

“…Among the 80 HCWs who had no or low antibody response, most had underlying medical conditions, including immunosuppression or organ transplant, and 72 had received ChAdOx1 vaccination. These were also identified as the main risk factors for having lower antibody levels in the multivariable regression model, similar to previous studies reporting lower anti-spike IgG levels in HCWs with any comorbidity compared with healthy HCWs,22 and low antibody levels or seroconversion rates in organ transplant or immunosuppressed patients,23 24 leading to a higher risk of mortality following SARS-CoV-2 infection 25 26. Therefore, it may be helpful to routinely assess post-vaccination antibody levels in HCWs with comorbidities, especially immunosuppression or organ transplantation.…”

Systematic review and meta‐analysis of the clinical effectiveness of tixagevimab/cilgavimab for prophylaxis of COVID‐19 in immunocompromised patients

“…Around 500 000 immunocompromised people live in the United Kingdom (UK) 2 . These individuals are at significantly increased risk of COVID‐19‐related complications compared with the population 3–5 . Patients may be immunocompromised for a number of reasons, including morbidities and treatment regimes.…”

“…2 These individuals are at significantly increased risk of COVID-19-related complications compared with the population. [3][4][5] Patients may be immunocompromised for a number of reasons, including morbidities and treatment regimes. Morbidities include cancer, haematological malignancies, solid organ and bone marrow transplant, renal disease, autoimmune disease, primary immunodeficiencies, liver disease, HIV or immune-mediated inflammatory disorders.…”

Immunocompromised individuals are at increased risk of COVID‐19 breakthrough infection, hospitalization, and death in the post‐vaccination era: A systematic review

“…Since the beginning of the COVID‐19 pandemic, immunocompromised (IC) individuals were identified as a high‐risk group due to an increased risk of severe COVID‐19 outcomes (hospitalization and death) 1–3 . IC individuals form a significant proportion of the population with around 500,000 individuals in the United Kingdom 4 reported to be IC.…”