Risk Factors for Coronavirus Disease 2019 (COVID-19) Death in a Population Cohort Study from the Western Cape Province, South Africa
Authors:   Western Cape Department of Health in collaboration with the National Institute for Communicable Diseases, 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 , Kruger Jean Jacque , 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 , Botha Matthys Henndrik , 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 , Wallis Lee Alan , 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 
Published: August 2020

Abstract

Background
Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (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 associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector “active patients” (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates.

Results
Among 3 460 932 patients (16% living with HIV), 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 loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81–4.04] and 1.51 [95% CI, 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).

Conclusions
While our findings may overestimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both living with HIV and having 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 those in other settings.