Survival of Critically Ill COVID-19 Patients in Sweden During the First Two and a Half Years of the Pandemic.

OBJECTIVES: Some studies have examined survival trends among critically ill COVID-19 patients, but most were case reports, small cohorts, and had relatively short follow-up periods. We aimed to examine the survival trend among critically ill COVID-19 patients during the first two and a half years of the pandemic and investigate potential predictors across different variants of concern periods. DESIGN: Prospective cohort study. SETTING: Swedish ICUs, between March 6, 2020, and December 31, 2022. PATIENTS: Adult COVID-19 ICU patients of 18 years old or older from the Swedish Intensive Care Register (SIR) that were linked to multiple other national registers. MEASUREMENT AND MAIN RESULTS: Survival probability and predictors of COVID-19 death were estimated using Kaplan-Meier and Cox regression analysis. Of 8975 patients, 2927 (32.6%) died. The survival rate among COVID-19 critically ill patients appears to have changed over time, with a worse survival in the Omicron period overall. The adjusted hazard ratios (aHRs) comparing older and younger ages were consistently strong but slightly attenuated in the Omicron period. After adjustment, the aHR of death was significantly higher for men, older age (40+ yr), low income, and with comorbid chronic heart disease, chronic lung disease, impaired immune disease, chronic renal disease, stroke, and cancer, and for those requiring invasive or noninvasive respiratory supports, who developed septic shock or had organ failures (p < 0.05). In contrast, foreign-born patients, those with booster vaccine, and those who had taken steroids had better survival (aHR = 0.87; 95% CI, 0.80-0.95; 0.74, 0.65-0.84, and 0.91, 0.84-0.98, respectively). Observed associations were similar across different variant periods. CONCLUSIONS: In this nationwide Swedish cohort covering over two and a half years of the pandemic, ICU survival rates changed over time. Older age was a strong predictor across all periods. Furthermore, most other mortality predictors remained consistent across different variant periods.

Factors related to quality of life in community-dwelling adults in Sleman Regency, Special Region of Yogyakarta, Indonesia: Results from a cross-sectional study.

BACKGROUND: Quality of life studies in low- and middle-income countries have demonstrated the influence of socioeconomic factors on the quality of life (QoL). However, further studies are required to confirm this association in developing countries with rapidly ageing populations. Using Ferrans et al.'s QoL model, this study aimed to identify the factors associated with the QoL of community-dwelling adults in Indonesia. METHODS: A cross-sectional study among 546 community-dwelling adults aged 50+ years was conducted in Yogyakarta, Indonesia, in 2018. QoL was measured using the Short Form 12 questionnaire, which consists of a summary of physical and mental health. We performed stepwise logistic regression analyses to determine odds ratios (ORs) with 95% confidence intervals (CIs) and examined the association between the QoL (physical and mental health) and demographic characteristics, socioeconomic status, financial management behaviour, multimorbidity status, nutritional status, cognitive impairment status, depression status, and independence. Statistical significance was set at p<0.05. RESULTS: Among the respondents, 15% reported poor physical health, and 9.2% reported poor mental health. Good physical health was significantly associated with the absence of chronic disease (OR 2.39; 95% CI: 1.07-5.33), independence in activities of daily living (OR 3.90; 95% CI 1.57-9.67) and instrumental activities of daily living (OR 4.34; 95% CI 2.28-8.26). Absence of depression was significantly associated with good mental health (OR 2.80; 95% CI 1.3-5.96). CONCLUSION: The QoL of community-dwelling adults in Indonesia is associated with activities of daily living and instrumental activities of daily living, as well as the absence of chronic disease and depression. Efforts should be made to prevent chronic disease and delay functional decline through healthy lifestyles and routine physical and mental health screenings.

The sociodemographic patterning of sick leave and determinants of longer sick leave after mild and severe COVID-19: a nationwide register-based study in Sweden.

BACKGROUND: Studies on sociodemographic differences in sick leave after coronavirus disease 2019 (COVID-19) are limited and research on COVID-19 long-term health consequences has mainly addressed hospitalized individuals. The aim of this study was to investigate the social patterning of sick leave and determinants of longer sick leave after COVID-19 among mild and severe cases. METHODS: The study population, from the Swedish multi-register observational study SCIFI-PEARL, included individuals aged 18-64 years in the Swedish population, gainfully employed, with a first positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 1 January 2020 until 31 August 2021 (n = 661 780). Using logistic regression models, analyses were adjusted for sociodemographic factors, vaccination, prior sick leave, comorbidities and stratified by hospitalization. RESULTS: In total, 37 420 (5.7%) individuals were on sick leave due to COVID-19 in connection with their first positive COVID-19 test. Individuals on sick leave were more often women, older, had lower income and/or were born outside Sweden. These differences were similar across COVID-19 pandemic phases. The highest proportion of sick leave was seen in the oldest age group (10.3%) with an odds ratio of 4.32 (95% confidence interval 4.18-4.47) compared with the youngest individuals. Among individuals hospitalized due to COVID-19, the sociodemographic pattern was less pronounced, and in some models, even reversed. The intersectional analysis revealed considerable variability in sick leave between sociodemographic groups (range: 1.5-17.0%). CONCLUSION: In the entire Swedish population of gainfully employed individuals, our findings demonstrated evident sociodemographic differences in sick leave due to COVID-19. In the hospitalized group, the social patterning was different and less pronounced.

Covid-19 vaccine effectiveness against post-covid-19 condition among 589 722 individuals in Sweden: population based cohort study.

OBJECTIVE: To investigate the effectiveness of primary covid-19 vaccination (first two doses and first booster dose within the recommended schedule) against post-covid-19 condition (PCC). DESIGN: Population based cohort study. SETTING: Swedish Covid-19 Investigation for Future Insights-a Population Epidemiology Approach using Register Linkage (SCIFI-PEARL) project, a register based cohort study in Sweden. PARTICIPANTS: All adults (≥18 years) with covid-19 first registered between 27 December 2020 and 9 February 2022 (n=589 722) in the two largest regions of Sweden. Individuals were followed from a first infection until death, emigration, vaccination, reinfection, a PCC diagnosis (ICD-10 diagnosis code U09.9), or end of follow-up (30 November 2022), whichever came first. Individuals who had received at least one dose of a covid-19 vaccine before infection were considered vaccinated. MAIN OUTCOME MEASURE: The primary outcome was a clinical diagnosis of PCC. Vaccine effectiveness against PCC was estimated using Cox regressions adjusted for age, sex, comorbidities (diabetes and cardiovascular, respiratory, and psychiatric disease), number of healthcare contacts during 2019, socioeconomic factors, and dominant virus variant at time of infection. RESULTS: Of 299 692 vaccinated individuals with covid-19, 1201 (0.4%) had a diagnosis of PCC during follow-up, compared with 4118 (1.4%) of 290 030 unvaccinated individuals. Covid-19 vaccination with any number of doses before infection was associated with a reduced risk of PCC (adjusted hazard ratio 0.42, 95% confidence interval 0.38 to 0.46), with a vaccine effectiveness of 58%. Of the vaccinated individuals, 21 111 received one dose only, 205 650 received two doses, and 72 931 received three or more doses. Vaccine effectiveness against PCC for one dose, two doses, and three or more doses was 21%, 59%, and 73%, respectively. CONCLUSIONS: The results of this study suggest a strong association between covid-19 vaccination before infection and reduced risk of receiving a diagnosis of PCC. The findings highlight the importance of primary vaccination against covid-19 to reduce the population burden of PCC.

Age and sex differences in cause-specific excess mortality and years of life lost associated with COVID-19 infection in the Swedish population.

BACKGROUND: Estimating excess mortality and years of life lost (YLL) attributed to coronavirus disease 19 (COVID-19) infection provides a comprehensive picture of the mortality burden on society. We aimed to estimate the impact of the COVID-19 pandemic on age- and sex-specific excess mortality and YLL in Sweden during the first 17 months of the pandemic. METHODS: In this population-based observational study, we calculated age- and sex-specific excess all-cause mortality and excess YLL during 2020 and the first 5 months of 2021 and cause-specific death [deaths from cardiovascular disease (CVD), cancer, other causes and deaths excluding COVID-19] in 2020 compared with an average baseline for 2017-19 in the whole Swedish population. RESULTS: COVID-19 deaths contributed 9.9% of total deaths (98 441 deaths, 960 305 YLL) in 2020, accounting for 75 151 YLL (7.7 YLL/death). There were 2672 (5.7%) and 1408 (3.0%) excess deaths, and 19 141 (3.8%) and 3596 (0.8%) excess YLL in men and women, respectively. Men aged 65-110 years and women aged 75-110 years were the greatest contributors. Fewer deaths and YLL from CVD, cancer and other causes were observed in 2020 compared with the baseline adjusted to the population size in 2020. CONCLUSIONS: Compared with the baseline, excess mortality and YLL from all causes were experienced in Sweden during 2020, with a higher excess observed in men than in women, indicating that more men died at a younger age while more women died at older ages than expected. A notable reduction in deaths and YLL due to CVD suggests a displacement effect from CVD to COVID-19.

Pre- and post-vaccination characteristics and risk factors for COVID-19 outcomes in a Swedish population-based cohort of COPD patients.

Rationale: Evidence on risk factors for Coronavirus disease 2019 (COVID-19) outcomes among patients with COPD in relation to COVID-19 vaccination remains limited. The objectives of the present study were to characterise determinants of COVID-19 infection, hospitalisation, intensive care unit (ICU) admission and death in COPD patients in their unvaccinated state compared to when vaccinated. Methods: We included all COPD patients in the Swedish National Airway Register (SNAR). Events of COVID-19 infection (test and/or healthcare encounter), hospitalisation, ICU admission and death were identified from 1 January 2020 to 30 November 2021. Using adjusted Cox regression, associations between baseline sociodemographics, comorbidities, treatments, clinical measurements and COVID-19 outcomes, during unvaccinated and vaccinated follow-up time, were analysed. Results: The population-based COPD cohort included 87 472 patients, among whom 6771 (7.7%) COVID-19 infections, 2897 (3.3%) hospitalisations, 233 (0.3%) ICU admissions and 882 (1.0%) COVID-19 deaths occurred. During unvaccinated follow-up, risk of COVID-19 hospitalisation and death increased with age, male sex, lower education, non-married status and being foreign-born. Comorbidities increased risk of several outcomes, e.g. respiratory failure for infection and hospitalisation (adjusted hazard ratios (HR) 1.78, 95% CI 1.58-2.02 and 2.51, 2.16-2.91, respectively), obesity for ICU admission (3.52, 2.29-5.40) and cardiovascular disease for mortality (2.80, 2.16-3.64). Inhaled COPD therapy was associated with infection, hospitalisation and death. COPD severity was also associated with COVID-19, especially hospitalisation and death. Although the risk factor panorama was similar, COVID-19 vaccination attenuated HRs for some risk factors. Conclusion: This study provides population-based evidence on predictive risk factors for COVID-19 outcomes and highlights the positive implications of COVID-19 vaccination for COPD patients.

Occupational role and COVID-19 among foreign-born healthcare workers in Sweden: a registry-based study.

BACKGROUND: Many studies report that foreign-born healthcare workers (HCWs) in high-income countries have an elevated risk of COVID-19. However, research has not yet specifically evaluated the distribution of COVID-19 among foreign-born workers in different healthcare work groups. We examined the risk of COVID-19 infection and hospitalization among foreign-born HCWs in different occupational roles in Sweden. METHODS: We linked occupational data (2019) of 783 950 employed foreign-born workers (20-65 years) to COVID-19 data registered between 1 January 2020 and 30 September 2021. We used Cox proportional hazards regression to estimate the hazard ratio (HR) with 95% confidence intervals (95% CIs) of COVID-19 infection and hospitalization in eight healthcare occupational groups vs. non-HCWs and assessed whether region of birth modified the association between healthcare occupations and COVID-19. RESULTS: All HCWs had a higher risk of COVID-19 outcomes than non-HCWs, but the risk differed by occupational role. Hospital-based assistant nurses had the highest risk (infection: HR 1.78; 95% CI 1.72-1.85; hospitalization: HR 1.79; 95% CI 1.52-2.11); allied HCWs had the lowest risk (infection: HR 1.22; 95% CI 1.10-1.35; hospitalization: HR 0.98; 95% CI 0.59-1.63). The relative hazard of the outcomes varied across foreign-born workers from different regions. For example, the relative risk of COVID-19 infection associated with being a physician compared to a non-HCW was 31% higher for African-born than European-born workers. CONCLUSIONS: The risk of COVID-19 among foreign-born HCWs differed by occupational role and immigrant background. Public health efforts that target occupational exposures as well as incorporate culturally responsive measures may help reduce COVID-19 risk among foreign-born HCWs.

A comprehensive characterization of patients diagnosed with post-COVID-19 condition in Sweden 16 months after the introduction of the International Classification of Diseases Tenth Revision diagnosis code (U09.9): a population-based cohort study.

OBJECTIVES: The objective of this study was to provide a comprehensive characterization of patients diagnosed with post-COVID-19 condition (PCC) during the first 16 months of use of the International Classification of Diseases revision 10 (ICD-10) diagnosis code U09.9 in Sweden. METHODS: We used data from national registers and primary health care databases for all adult inhabitants of the two largest regions in Sweden, comprising 4.1 million inhabitants (approximately 40% of the Swedish population). We present the cumulative incidence and incidence rate of PCC overall and among subgroups and describe patients with COVID-19 with or without PCC regarding sociodemographic characteristics, comorbidities, subsequent diseases, COVID-19 severity, and virus variants. RESULTS: Of all registered COVID-19 cases available for PCC diagnosis (n = 506,107), 2.0% (n = 10,196) had been diagnosed with PCC using ICD-10 code U09.9 as of February 15, 2022 in the two largest regions in Sweden. The cumulative incidence was higher among women than men (2.3% vs 1.6%, P <0.001). The majority of PCC cases (n = 7162, 70.2%) had not been hospitalized for COVID-19. This group was more commonly female (69.9% vs 52.9%, P <0.001), had a tertiary education (51.0% vs 44.1%, P <0.001), and was older (median age difference 5.7 years, P <0.001) than non-hospitalized patients with COVID-19 without PCC. CONCLUSION: This characterization furthers the understanding of patients diagnosed with PCC and could support policy makers with appropriate societal and health care resource allocation.

Family structure and depressive symptoms among older adults in China: A marginal structural model analysis.

BACKGROUND: Mental well-being in the aging population is inevitably linked to families due to the reliance of older adults on family members. This study investigates the causal relationship between family structure and depressive symptoms among Chinese older adults in general and between gender and residential areas. METHODS: We used China Health and Retirement Longitudinal Study (CHARLS) panel data, covering four data collection rounds over seven years. Family structure was classified into single-member, couple, nuclear family, and extended family. Taking into account time-varying confounding, we estimated the causal effects of family structure on depressive symptoms using marginal structural models. RESULTS: Older people with cumulative exposure to single-member family type had an increased odds of depressive symptoms by an average of 33 % (95 % CI: 1.22-1.44) than their counterparts who lived in the couple family. Additionally, older people living in extended families also had 6 % higher odds of experiencing depressive symptoms (95 % CI: 1.00, 1.11). The longitudinal associations were consistent across gender groups and residential areas (p-value for interaction is 0.6638 for gender and 0.7043 for the residential area). LIMITATION: The time-varying confounders (e.g., chronic health conditions) included in the analysis are based on self-reported data, which may be subject to measurement errors. CONCLUSION: The risk of depressive symptoms is greater for older individuals living alone and in extended families. Screening for depression in the older population, particularly those living in "at-risk" households, is recommended.

Effectiveness of COVID-19 Vaccines over 13 Months Covering the Period of the Emergence of the Omicron Variant in the Swedish Population.

BACKGROUND: We estimated real-world vaccine effectiveness (VE) against COVID-19 infection, hospitalization, ICU admission, and death up to 13 months after vaccination. VE before and after the emergence of Omicron was investigated. METHODS: We used registered data from the entire Swedish population above age 12 (n = 9,153,456). Cox regression with time-varying exposure was used to estimate weekly/monthly VE against COVID-19 outcomes from 27 December 2020 to 31 January 2022. The analyses were stratified by age, sex, and vaccine type (BNT162b2, mRNA-1273, and AZD1222). RESULTS: Two vaccine doses offered good long-lasting protection against infection before Omicron (VE were above 85% for all time intervals) but limited protection against Omicron infection (dropped to 43% by week four and no protection by week 14). For severe COVID-19 outcomes, higher VE was observed during the entire follow-up period. Among individuals above age 65, the mRNA vaccines showed better VE against infection than AZD1222 but similar high VE against hospitalization. CONCLUSIONS: Our findings provide strong evidence for long-term maintained protection against severe COVID-19 by the basic two-dose schedule, supporting more efforts to encourage unvaccinated persons to get the basic two doses, and encourage vaccinated persons to get a booster to ensure better population-level protection.

COVID-19 in people aged 18-64 in Sweden in the first year of the pandemic: Key factors for severe disease and death.

Background: Studies on risk factors for severe COVID-19 in people of working age have generally not included non-working persons or established population attributable fractions (PAFs) for occupational and other factors. Objectives: We describe the effect of job-related, sociodemographic, and other exposures on the incidence, relative risks and PAFs of severe COVID-19 in individuals aged 18-64. Methods: We conducted a registry-based study in Swedish citizens aged 18-64 from 1 January 2020 to 1 February 2021 with respect to COVID-19-related hospitalizations and death. Results: Of 6,205,459 persons, 272,043 (7.5%) were registered as infected, 3399 (0.05%) needed intensive care, and 620 (0.01%) died, with an estimated case fatality rate of 0.06% over the last 4-month period when testing was adequate. Non-Nordic origin was associated with a RR for need of intensive care of 3·13, 95%CI 2·91-3·36, and a PAF of 32·2% after adjustment for age, sex, work, region and comorbidities. In a second model with occupation as main exposure, and adjusted for age, sex, region, comorbidities and origin, essential workers had an RR of 1·51, 95%CI, 1·35-1·6, blue-collar workers 1·18, 95%CI 1·06-1·31, school staff 1·21, 95%CI 1·01-1·46, and health and social care workers 1·89, 95%CI 1·67-2·135) compared with people able to work from home, with altogether about 13% of the PAF associated with these occupations. Essential workers and blue-collar workers, but no other job categories had higher risk of death, adjusted RRs of 1·79, 95%CI 1·34-2·38 and 1·37, 95%CI 1·04-1·81, with adjusted PAFs of altogether 9%. Conclusion: Among people of working age in Sweden, overall mortality and case fatality were low. Occupations that require physical presence at work were associated with elevated risk of needing intensive care for COVID-19, with 14% cases attributable to this factor, and 9% of deaths.

Socioeconomic disparities in the burden of hypertension among Indonesian adults - a multilevel analysis.

BACKGROUND: Hypertension remains a problem of public health across various socioeconomic groups, despite its high prevalence. However, few studies account for geographical variation in examining socioeconomic inequalities and hypertension in Indonesia. OBJECTIVE: To investigate the burden of hypertension in Indonesia based on prevalence, awareness, treatment, and control of hypertension among adults; and assess whether or not the burdens vary according to geographical variation and socioeconomic status. METHODS: In Wave 5 of the Indonesian Family Life Survey in 2015, 32,034 individuals aged 15 and over participated in the study. Concentration Curves (CC) and Concentration Indexes (CI) were used to analyse socioeconomic inequality. We used multilevel logistic regression to assess biological, geographical variation, and socioeconomic factors associated with the burden of hypertension, adjusting for potential covariates. RESULTS: The prevalence of hypertension in Indonesia was 26.1%, and only 26.9% of those with hypertension were aware of their condition. Approximately 22.5% of hypertensive patients received treatment, but only 28.2% had controlled blood pressure and reached the therapeutic goal. Low socioeconomic groups were more prone to hypertension (CI = -0.047 in urban and CI = -0.075 in rural). In contrast, awareness, treatment, and control of hypertension were more concentrated in higher socioeconomic groups. CONCLUSIONS: The high prevalence of hypertension, low awareness of the condition, poor compliance with treatment, and poor control of the condition, as well as the existing socioeconomic inequality, make this a significant determinant of public health issue in Indonesia. There is a need for effective programs for the prevention of hypertension and better management of hypertensive patients.

Potential and challenges for an integrated management of tuberculosis, diabetes mellitus, and hypertension: A scoping review protocol.

In many low- and middle-income countries (LMICs), the epidemiological transition is characterized by an increased burden of non-communicable diseases (NCDs) and the persistent challenge of infectious diseases. The transmission of tuberculosis, one of the leading infectious diseases, can be halted through active screening of risk groups and early case findings. Studies have reported comorbidities between tuberculosis (TB) and NCDs, which necessitates the development of an integrated disease management model. This scoping review discusses the possibilities and problems of integration in managing TB and NCDs, with a particular emphasis on diabetic mellitus (DM) and hypertension screening and control. We will conduct this review following Arksey and O'Malley's framework for scoping review. We will use key terms related to integrated management, i.e., screening, diagnosis, treatment, and care, of TB, DM, and hypertension in PubMed, Scopus Database, and ScienceDirect for research published from January 2005 to July 2021. This review will also consider grey literature, including unpublished literature and international disease management guidelines on TB, DM, and hypertension from WHO or other health professional organization. We will export the search results to citation manager software (EndNote). We will remove duplicates and apply the inclusion and exclusion criteria to identify the set of papers for the review. After screening the titles and abstract, two authors will independently review the full text of selected studies and extract the data. We will synthesize all selected studies qualitatively and the results will be discussed with the experts. The results will be used as the basis of the development of a guideline for integrated TB, DM, and hypertension management.

Protective effects of statins on COVID-19 risk, severity and fatal outcome: a nationwide Swedish cohort study.

The impact of statins on COVID-19 remains unclear. This study aims to investigate whether statin exposure assessed both in the population and in well-defined cohorts of COVID-19 patients may affect the risk and severity of COVID-19 using nationwide Swedish population-based register data. A population ≥ 40 years was selected by age/sex-stratified random sampling from the Swedish population on 1 Jan 2020. COVID-19 outcomes were identified from the SmiNet database, the National Patient Register and/or Cause-of-Death Register and linked with the National Prescribed Drug Register and sociodemographic registers. Statin exposure was defined as any statin prescriptions in the year before index date. In Cox regressions, confounding was addressed using propensity score ATT (Average Treatment effect in the Treated) weighting. Of 572,695 individuals in the overall cohort, 22.3% had prior statin treatment. After ATT weighting, protective effects were observed among statin user for hospitalization and COVID-19 death in the overall cohort and onset cohort. In the hospitalized cohort, statin use was only associated with lower risk for death (HR = 0.86, 95% CI 0.79-0.95), but not ICU admission. Statin-treated individuals appear to have lower COVID-19 mortality than nonusers, whether assessed in the general population, from COVID-19 onset or from hospitalization.

Initiation of antihypertensive drugs to patients with confirmed COVID-19-A population-based cohort study in Sweden.

PURPOSE: Hypertension is an important risk factor for severe outcomes in patients with COVID-19, and antihypertensive drugs may have a protective effect. However, the pandemic may have negatively impacted health care services for chronic diseases. The aim of this study was to assess initiations of antihypertensive medicines in patients infected by COVID-19. METHODS: A cohort study including all Swedish residents 20-80 years old with a COVID-19 positive test compared with an unexposed group without COVID-19 matched for age, sex, and index date (date of confirmed COVID-19). Data were collected within SCIFI-PEARL, a study including linked data on COVID tests, hospital diagnoses, dispensed prescriptions, and socioeconomic data from Swedish national registers. Initiations of different antihypertensive drugs were studied from March 2020 until October 2020. Associations between COVID-19 and initiation of antihypertensives were assessed by a multivariable Cox proportional hazards model. RESULTS: A total of 224 582 patients (exposed and unexposed) were included. After adjusting for cardiovascular comorbidities and education level, ACEi was the most commonly initiated antihypertensive agent to patients with COVID-19. Hazard ratio and 95% confidence interval for initiation of drug therapy was 1.83 [1.53-2.19] for ACEi, followed by beta-blockers 1.74 [1.55-1.95], calcium channel blockers 1.61 [1.41-1.83], angiotensin receptor blockers 1.61 [1.40-1.86], and diuretics 1.53 [1.32-1.77]. CONCLUSION: All antihypertensive medicines were initiated more frequently in COVID-19 patients. This can either be associated with hypertension caused by the COVID-19 infection, more frequent diagnosis of hypertension among people with COVID-19 since they consult health care, or residual confounding factors not adjusted for in the study.

Severe COVID-19 in people 55 and older during the first year of the pandemic in Sweden.

BACKGROUND: Exposure to many contacts is the main risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, while risk of serious disease and death is chiefly determined by old age and comorbidities. Relative and population-attributable fractions (PAFs) of multiple medical and social exposures for COVID-19 outcomes have not been evaluated among older adults. OBJECTIVES: We describe the effect of multiple exposures on the odds of testing positive for the virus and of severe disease (hospital care or death) and PAFs in Swedish citizens aged 55 years and above. METHODS: We used national registers to follow all citizens aged 55 years and above with respect to (1) testing positive, (2) hospitalization, and (3) death between 31 January 2020 and 1 February 2021. RESULTS: Of 3,410,241 persons, 156,017 (4.6%, mean age 68.3 years) tested positive for SARS-CoV-2, while 35,999 (1.1%, mean age 76.7 years) were hospitalized or died (12,384 deaths, 0.4%, mean age 84.0 years). Among the total cohort, the proportion living without home care or long-term care was 98.8% among persons aged 55-64 and 22.1% of those aged 95 and above. After multiple adjustment, home care and long-term care were associated with odds ratios of 7.9 (95% confidence interval [CI] 6.8-9.1) and 22.5 (95% CI 19.6-25.7) for mortality, with PAFs of 21.9% (95% CI 20.9-22.9) and 33.3% (95% CI 32.4-34.3), respectively. CONCLUSION: Among Swedish residents aged 55 years and above, those with home care or long-term care had markedly increased risk for COVID-19 death during the first year of the pandemic, with over 50% of deaths attributable to these factors.

The social patterning of Covid-19 vaccine uptake in older adults: A register-based cross-sectional study in Sweden.

BACKGROUND: A broad vaccination coverage is crucial for preventing the spread of Covid-19 and reduce serious illness or death. The aim of this study was to examine social inequalities in Covid-19 vaccination uptake as of 17th May 2021 among Swedish adults aged ≥ 60 years. METHODS: The study population comprised a general population cohort aged 60 years or older (n = 350,805), representative of the Swedish population. Data were collected through the nationwide linked multi-register observational study SCIFI-PEARL, and associations between sociodemographic determinants and Covid-19 vaccination uptake were analysed using logistic regression. Intersectional analyses of sociodemographic heterogeneity were performed by taking several overlapping social dimensions into account. Data availability extended to 17 May 2021. FINDINGS: The overall vaccination coverage was 87·2% by 17th May 2021. Younger age, male sex, lower income, living alone, and being born outside Sweden, were all associated with a lower uptake of vaccination. The lowest Covid-19 vaccination uptake was seen in individuals born in low-or middle-income countries, of which only 60% had received vaccination, with an odds ratio (OR) of not being vaccinated of 6·05 (95% CI: 5·85-6·26) compared to individuals born in Sweden. These associations persisted after adjustments for possible confounding factors. The intersectional analyses showed even larger variations in vaccination in cross-classified sociodemographic subgroups (ranging from 44% to 97%) with marked differences in uptake of vaccination within sociodemographic groups. INTERPRETATION: The uptake of Covid-19 vaccine during the spring of 2021 in Sweden varied substantially both between and within sociodemographic groups. The use of an intersectional approach, taking several overlapping social dimensions into account at the same time rather than only using one-dimensional measures, contributes to a better understanding of the complexity in the uptake of vaccination. FUNDING: SciLifeLab / Knut & Alice Wallenberg Foundation, Swedish Research Council, Swedish government ALF-agreement, FORMAS.

Occupation and COVID-19 diagnosis, hospitalisation and ICU admission among foreign-born and Swedish-born employees: a register-based study.

BACKGROUND: Research on occupation and risk of COVID-19 among foreign-born workers is lacking. We investigated whether working in essential occupations was associated with COVID-19 diagnosis, hospitalisation and intensive care unit (ICU) admission and whether foreign-born workers in similar occupations as Swedish-born individuals had a higher risk of the studied outcomes. METHODS: Occupational data (2018-2019) of 326 052 employees (20-65 years) who were resident in Sweden as of 1 January 2020 were linked to COVID-19 data registered from 1 January 2020 to 28 February 2021. We analysed the risk of COVID-19 outcomes in different occupational groups and in four immigrant/occupation intersectional groups using Cox proportional hazards regression with adjustments for sociodemographic and socioeconomic characteristics and pre-existing comorbidities. RESULTS: We identified 29797, 1069 and 152 cases of COVID-19 diagnosis, hospitalisations and ICU admissions, respectively, in our cohort. Workers in essential occupations had an elevated risk of COVID-19 diagnosis, hospitalisation, and ICU admissions. Healthcare workers had a higher risk of all the outcomes compared with other essential workers. Relative to Swedish-born workers in non-essential occupations, foreign-born workers in essential occupations had 1.85 (95% CI 1.78 to 1.93), 3.80 (95% CI 3.17 to 4.55) and 3.79 (95% CI 2.33 to 6.14) times higher risk of COVID-19 diagnosis, hospitalisation and ICU admission, respectively. The corresponding risks among Swedish-born workers in essential occupations were 1.44 (95% CI 1.40 to 1.49), 1.30 (95% CI 1.08 to 1.56) and 1.46 (95% CI 0.90 to 2.38). CONCLUSION: Occupation was associated with COVID-19 outcomes and contributed to the burden of COVID-19 among foreign-born individuals in this study.

Psychosocial Risk Factors and Cardiovascular Disease and Death in a Population-Based Cohort From 21 Low-, Middle-, and High-Income Countries.

Importance: Stress may increase the risk of cardiovascular disease (CVD). Most studies on stress and CVD have been conducted in high-income Western countries, but whether stress is associated with CVD in other settings has been less well studied. Objective: To investigate the association of a composite measure of psychosocial stress and the development of CVD events and mortality in a large prospective study involving populations from 21 high-, middle-, and low-income countries across 5 continents. Design, Setting, and Participants: This population-based cohort study used data from the Prospective Urban Rural Epidemiology study, collected between January 2003 and March 2021. Participants included individuals aged 35 to 70 years living in 21 low-, middle-, and high-income countries. Data were analyzed from April 8 to June 15, 2021. Exposures: All participants were assessed on a composite measure of psychosocial stress assessed at study entry using brief questionnaires concerning stress at work and home, major life events, and financial stress. Main Outcomes and Measures: The outcomes of interest were stroke, major coronary heart disease (CHD), CVD, and all-cause mortality. Results: A total of 118 706 participants (mean [SD] age 50.4 [9.6] years; 69 842 [58.8%] women and 48 864 [41.2%] men) without prior CVD and with complete baseline and follow-up data were included. Of these, 8699 participants (7.3%) reported high stress, 21 797 participants (18.4%) reported moderate stress, 34 958 participants (29.4%) reported low stress, and 53 252 participants (44.8%) reported no stress. High stress, compared with no stress, was more likely with younger age (mean [SD] age, 48.9 [8.9] years vs 51.1 [9.8] years), abdominal obesity (2981 participants [34.3%] vs 10 599 participants [19.9%]), current smoking (2319 participants [26.7%] vs 10 477 participants [19.7%]) and former smoking (1571 participants [18.1%] vs 3978 participants [7.5%]), alcohol use (4222 participants [48.5%] vs 13 222 participants [24.8%]), and family history of CVD (5435 participants [62.5%] vs 20 255 participants [38.0%]). During a median (IQR) follow-up of 10.2 (8.6-11.9) years, a total of 7248 deaths occurred. During the course of follow-up, there were 5934 CVD events, 4107 CHD events, and 2880 stroke events. Compared with no stress and after adjustment for age, sex, education, marital status, location, abdominal obesity, hypertension, smoking, diabetes, and family history of CVD, as the level of stress increased, there were increases in risk of death (low stress: hazard ratio [HR], 1.09 [95% CI, 1.03-1.16]; high stress: 1.17 [95% CI, 1.06-1.29]) and CHD (low stress: HR, 1.09 [95% CI, 1.01-1.18]; high stress: HR, 1.24 [95% CI, 1.08-1.42]). High stress, but not low or moderate stress, was associated with CVD (HR, 1.22 [95% CI, 1.08-1.37]) and stroke (HR, 1.30 [95% CI, 1.09-1.56]) after adjustment. Conclusions and Relevance: This cohort study found that higher psychosocial stress, measured as a composite score of self-perceived stress, life events, and financial stress, was significantly associated with mortality as well as with CVD, CHD, and stroke events.

Swedish Covid-19 Investigation for Future Insights - A Population Epidemiology Approach Using Register Linkage (SCIFI-PEARL).

BACKGROUND: In response to the Covid-19 pandemic, we designed and initiated a nationwide linked multi-register, regularly updated, observational study for timely response to urgent scientific questions. AIM: To describe the SCIFI-PEARL (Swedish Covid-19 Investigation for Future Insights - a Population Epidemiology Approach using Register Linkage) linked database encompassing essentially all known diagnosed Swedish Covid-19 patients plus a large general population comparison cohort and outline its utility in the current and future phases of the pandemic. METHODS: Individuals with Covid-19 from the entire country are identified on a regularly updated basis, from different sources: all individuals from SmiNet, the national database of notifiable diseases, with positive SARS-CoV-2 polymerase chain reaction (PCR) test results; patients identified in the healthcare system by condition (ICD-10) or procedure codes in the National Patient Register or Cause-of-Death Register; patients identified through several disease-specific national quality registers (NQRs); and in two regions additionally patients identified in primary care. A comparison population was obtained by stratified random sampling from Swedish national population registers. Data from all these registers plus the National Prescribed Drug Register, the Cancer Register, national sociodemographic registers, some additional NQRs, the National Vaccination Register, and further data sources, are then linked to all study subjects (Covid-19 cases and population cohort). New cases in the study population and all data for all subjects are updated every few months, as required. CONCLUSION AND UTILITY: The SCIFI-PEARL study cohort captures Swedish residents with Covid-19 on an ongoing basis, includes a representative general population comparison cohort, and links to a broad range of national and regional healthcare data for a comprehensive longitudinal view of the Covid-19 pandemic. By combining high-quality national registers with short time delay and continuous repeated linkage and updating, the project brings timely and internationally relevant data for epidemiological research on SARS-CoV-2. Our efforts provide an example and important learnings for similar efforts internationally in the future.