Risk factors for COVID-19 mortality among telehealth patients in Bangladesh: A prospective cohort study
Authors: Sania Ayesha , Mahmud Ayesha S. , Alschuler Daniel M. , Urmi Tamanna , Chowdhury Shayan , Lee Seonjoo , Mostari Shabnam , Shaikh Forhad Zahid , Sojib Kawsar Hosain , Khan Tahmid , Khan Yiafee , Chowdhury Anir , Arifeen Shams el 
Published: June 2023

Background and objective
Estimating the contribution of risk factors of mortality due to COVID-19 is particularly important in settings with low vaccination coverage and limited public health and clinical resources. Very few studies of risk factors of COVID-19 mortality used high-quality data at an individual level from low- and middle-income countries (LMICs). We examined the contribution of demographic, socioeconomic and clinical risk factors of COVID-19 mortality in Bangladesh, a lower middle-income country in South Asia.

Methods
We used data from 290,488 lab-confirmed COVID-19 patients who participated in a telehealth service in Bangladesh between May 2020 and June 2021, linked with COVID-19 death data from a national database to study the risk factors associated with mortality. Multivariable logistic regression models were used to estimate the association between risk factors and mortality. We used classification and regression trees to identify the risk factors that are the most important for clinical decision-making.

Findings
This study is one of the largest prospective cohort studies of COVID-19 mortality in a LMIC, covering 36% of all lab-confirmed COVID-19 cases in the country during the study period. We found that being male, being very young or elderly, having low socioeconomic status, chronic kidney and liver disease, and being infected during the latter pandemic period were significantly associated with a higher risk of mortality from COVID-19. Males had 1.15 times higher odds (95% Confidence Interval, CI: 1.09, 1.22) of death compared to females. Compared to the reference age group (20–24 years olds), the odds ratio of mortality increased monotonically with age, ranging from an odds ratio of 1.35 (95% CI: 1.05, 1.73) for ages 30–34 to an odds ratio of 21.6 (95% CI: 17.08, 27.38) for ages 75–79 year group. For children 0–4 years old the odds of mortality were 3.93 (95% CI: 2.74, 5.64) times higher than 20–24 years olds. Other significant predictors were severe symptoms of COVID-19 such as breathing difficulty, fever, and diarrhea. Patients who were assessed by a physician as having a severe episode of COVID-19 based on the telehealth interview had 12.43 (95% CI: 11.04, 13.99) times higher odds of mortality compared to those assessed to have a mild episode. The finding that the telehealth doctors’ assessment of disease severity was highly predictive of subsequent COVID-19 mortality, underscores the feasibility and value of the telehealth services.

Conclusions
Our findings confirm the universality of certain COVID-19 risk factors—such as gender and age—while highlighting other risk factors that appear to be more (or less) relevant in the context of Bangladesh. These findings on the demographic, socioeconomic, and clinical risk factors for COVID-19 mortality can help guide public health and clinical decision-making. Harnessing the benefits of the telehealth system and optimizing care for those most at risk of mortality, particularly in the context of a LMIC, are the key takeaways from this study.