Patient trajectories among hospitalised COVID-19 patients vaccinated with an mRNA vaccine in Norway: a register-based cohort study

Objectives With most of the Norwegian population vaccinated against COVID-19, an increasing number and proportion of COVID-19 related hospitalisations are occurring among vaccinated patients. To support patient management and capacity planning in hospitals, we estimated the length of stay (LoS) in hospital and odds of intensive care (ICU) admission and in-hospital mortality among COVID-19 patients ≥18 years who had been vaccinated with an mRNA vaccine, compared to unvaccinated patients. Methods Using national registry data, we conducted a cohort study on SARS-CoV-2 positive patients hospitalised in Norway between 1 February and 30 September 2021, with COVID-19 as the main cause of hospitalisation. We used a Cox proportional hazards model to examine the association between vaccination status and LoS. We used logistic regression to examine the association between vaccination status and ICU admission and in-hospital mortality. Results We included 2,361 patients, including 70 (3%) partially vaccinated and 183 (8%) fully vaccinated. Fully vaccinated patients 18-79 years had a shorter LoS in hospital overall (adjusted hazard ratio for discharge: 1.35, 95%CI: 1.07-1.72), and lower odds of ICU admission (adjusted odds ratio: 0.57, 95%CI: 0.33-0.96). Similar estimates were observed when collectively analysing partially and fully vaccinated patients. We observed no difference in the LoS for patients not admitted to ICU, nor odds of in-hospital death between vaccinated and unvaccinated patients. Conclusions Vaccinated patients hospitalised with COVID-19 in Norway have a shorter LoS and lower odds of ICU admission than unvaccinated patients. These findings can support patient management and ongoing capacity planning in hospitals.

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Clinical course and risk factors of fatal adverse outcomes in COVID-19 patients in Korea: a nationwide retrospective cohort study

Scientific Reports ◽

10.1038/s41598-021-89548-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Juhyun Song ◽

Dae Won Park ◽

Jae-hyung Cha ◽

Hyeri Seok ◽

Joo Yeong Kim ◽

...

Keyword(s):

Risk Factors ◽

Cohort Study ◽

Retrospective Cohort ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Adverse Outcomes ◽

Cox Proportional Hazards Model ◽

Icu Admission ◽

Hazards Model

AbstractWe investigated association between epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) patients and clinical outcomes in Korea. This nationwide retrospective cohort study included 5621 discharged patients with COVID-19, extracted from the Korea Disease Control and Prevention Agency (KDCA) database. We compared clinical data between survivors (n = 5387) and non-survivors (n = 234). We used logistic regression analysis and Cox proportional hazards model to explore risk factors of death and fatal adverse outcomes. Increased odds ratio (OR) of mortality occurred with age (≥ 60 years) [OR 11.685, 95% confidence interval (CI) 4.655–34.150, p < 0.001], isolation period, dyspnoea, altered mentality, diabetes, malignancy, dementia, and intensive care unit (ICU) admission. The multivariable regression equation including all potential variables predicted mortality (AUC = 0.979, 95% CI 0.964–0.993). Cox proportional hazards model showed increasing hazard ratio (HR) of mortality with dementia (HR 6.376, 95% CI 3.736–10.802, p < 0.001), ICU admission (HR 4.233, 95% CI 2.661–6.734, p < 0.001), age ≥ 60 years (HR 3.530, 95% CI 1.664–7.485, p = 0.001), malignancy (HR 3.054, 95% CI 1.494–6.245, p = 0.002), and dyspnoea (HR 1.823, 95% CI 1.125–2.954, p = 0.015). Presence of dementia, ICU admission, age ≥ 60 years, malignancy, and dyspnoea could help clinicians identify COVID-19 patients with poor prognosis.

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Serum sodium on admission affects postoperative in-hospital mortality in acute aortic dissection patients

PLoS ONE ◽

10.1371/journal.pone.0261168 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261168

Author(s):

Pengfei Huang ◽

Hongyan Wang ◽

Dong Ma ◽

Yongbo Zhao ◽

Xiao Liu ◽

...

Keyword(s):

Aortic Dissection ◽

Hospital Mortality ◽

Serum Sodium ◽

Proportional Hazards ◽

Acute Aortic Dissection ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

Hospital Death ◽

Hazards Model

Background Acute aortic dissection (AAD) is very fatal without surgical treatment. Higher serum sodium can increase in-hospital mortality of many diseases; however, the effect of serum sodium on postoperative in-hospital mortality in AAD patients remains unknown. Methods We collected a total of 415 AAD patients from January 2015 to December 2019. Patients were classified into four categories (Q1-Q4) according to the admission serum sodium quartile. The cox proportional hazards model evaluated the association between serum sodium and in-hospital mortality. All-cause in-hospital mortality was set as the endpoint. Results By adjusting many covariates, cox proportional hazards model revealed the in-hospital mortality risk of both Q3 and Q4 groups was 3.086 (1.242–7.671, P = 0.015) and 3.370 (1.384–8.204, P = 0.007) respectively, whereas the risk of Q2 group was not significantly increased. Univariate and multiple Cox analysis revealed that Stanford type A, serum glucose, α-hydroxybutyrate dehydrogenase and serum sodium were risk factors correlated with in-hospital death in AAD patients. Conclusion The study indicates that the admission serum sodium of AAD patients has a vital impact on postoperative hospital mortality.

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Serum Sodium, Patient Symptoms, and Clinical Outcomes in Hospitalized Patients with COVID-19

Journal of Primary Care & Community Health ◽

10.1177/21501319211067349 ◽

2022 ◽

Vol 13 ◽

pp. 215013192110673

Author(s):

Timothy E. Yen ◽

Andy Kim ◽

Maura E. Benson ◽

Saee Ratnaparkhi ◽

Ann E. Woolley ◽

...

Keyword(s):

Cohort Study ◽

Hospital Mortality ◽

Prospective Cohort Study ◽

Serum Sodium ◽

Prospective Cohort ◽

Hospitalized Patients ◽

Lower Odds ◽

Icu Admission ◽

Gi Symptoms ◽

Patient Reported

Introduction: Disorders of serum sodium (SNa) are common in hospitalized patients with COVID-19 and may reflect underlying disease severity. However, the association of SNa with patient-reported outcomes is not clear. Methods: The Brigham and Women’s Hospital COVID-19 Registry is a prospective cohort study of consecutively admitted adult patients with confirmed SARS-CoV-2 infection (n = 809). We examined the associations of SNa (continuous and tertiles) on admission with: (1) patient symptoms obtained from detailed chart review; and (2) in-hospital mortality, length of stay, and intensive care unit (ICU) admission using unadjusted and adjusted logistic regression models. Covariates included demographic data and comorbidities. Results: Mean age was 60 years, 48% were male, and 35% had diabetes. The most frequent symptoms were cough (64%), fever (60%), and shortness of breath (56%). In adjusted models, higher SNa (per mmol/L) was associated with lower odds of GI symptoms (OR 0.96; 95% CI 0.92-0.99), higher odds of confusion (OR 1.08; 95% CI 1.04-1.13), in-hospital mortality (OR 1.06; 95% CI 1.02-1.11), and ICU admission (OR 1.09; 95% CI 1.05-1.13). The highest sodium tertile (compared with the middle tertile) showed similar associations, in addition to lower odds of either anosmia or ageusia (OR 0.30; 95% CI 0.12-0.74). Conclusion: In this prospective cohort study of hospitalized patients with COVID-19, hypernatremia was associated with higher odds of confusion and in-hospital mortality. These findings may aid providers in identifying high-risk patients who warrant closer attention, thereby furthering patient-centered approaches to care.

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Impact of Renin-Angiotensin-Aldosterone System Inhibition on Mortality in Critically Ill COVID-19 Patients with Pre-Existing Hypertension: A Prospective Cohort Study

10.21203/rs.3.rs-898264/v1 ◽

2021 ◽

Author(s):

Kei Sato ◽

Nicole White ◽

Jonathon P. Fanning ◽

Nchafatso Obonyo ◽

Michael H. Yamashita ◽

...

Keyword(s):

Cohort Study ◽

Hospital Mortality ◽

Hospital Stay ◽

Critically Ill ◽

Length Of Hospital Stay ◽

Hospital Death ◽

Renin Angiotensin Aldosterone System ◽

Renin Angiotensin ◽

Icu Admission ◽

The Impact

Abstract BackgroundThe influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients.MethodsData from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 746 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission.ResultsA total of 746 patients were included - 543 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 203 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.73, 95% CI, 0.58 to 0.93). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.4 days (95% CI: 19.9 to 23.0 days) in ICU and 6.7 days (5.9 to 7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1 to 18.5 days) and 6.3 days (5.0 to 7.7 days), respectively. When analysed separately, there was insufficient evidence of differential effects between ACEi and ARB use on the hazards of death and discharge.ConclusionsIn critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay.

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Characteristics, outcomes and risk factors for mortality of 522 167 patients hospitalised with COVID-19 in Brazil: a retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2021-049089 ◽

2021 ◽

Vol 11 (5) ◽

pp. e049089

Author(s):

Marcia C Castro ◽

Susie Gurzenda ◽

Eduardo Marques Macário ◽

Giovanny Vinícius A França

Keyword(s):

Risk Factors ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Cox Proportional Hazards ◽

Secondary Outcome ◽

Hospital Death ◽

Factors Associated ◽

Icu Admission ◽

Hospitalised Patients

ObjectiveTo provide a comprehensive description of demographic, clinical and radiographic characteristics; treatment and case outcomes; and risk factors associated with in-hospital death of patients hospitalised with COVID-19 in Brazil.DesignRetrospective cohort study of hospitalised patients diagnosed with COVID-19.SettingData from all hospitals across Brazil.Participants522 167 hospitalised patients in Brazil by 14 December 2020 with severe acute respiratory illness, and a confirmed diagnosis for COVID-19.Primary and secondary outcome measuresPrevalence of symptoms and comorbidities was compared by clinical outcomes and intensive care unit (ICU) admission status. Survival was assessed using Kaplan Meier survival estimates. Risk factors associated with in-hospital death were evaluated with multivariable Cox proportional hazards regression.ResultsOf the 522 167 patients included in this study, 56.7% were discharged, 0.002% died of other causes, 30.7% died of causes associated with COVID-19 and 10.2% remained hospitalised. The median age of patients was 61 years (IQR, 47–73), and of non-survivors 71 years (IQR, 60–80); 292 570 patients (56.0%) were men. At least one comorbidity was present in 64.5% of patients and in 76.8% of non-survivors. From illness onset, the median times to hospital and ICU admission were 6 days (IQR, 3–9) and 7 days (IQR, 3–10), respectively; 15 days (IQR, 9–24) to death and 15 days (IQR, 11–20) to hospital discharge. Risk factors for in-hospital death included old age, Black/Brown ethnoracial self-classification, ICU admission, being male, living in the North and Northeast regions and various comorbidities. Age had the highest HRs of 5.51 (95% CI: 4.91 to 6.18) for patients≥80, compared with those ≤20.ConclusionsCharacteristics of patients and risk factors for in-hospital mortality highlight inequities of COVID-19 outcomes in Brazil. As the pandemic continues to unfold, targeted policies that address those inequities are needed to mitigate the unequal burden of COVID-19.

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Incidence and Outcomes of Acute Kidney Injury in Patients Admitted to Hospital With COVID-19: A Retrospective Cohort Study

Canadian Journal of Kidney Health and Disease ◽

10.1177/20543581211027759 ◽

2021 ◽

Vol 8 ◽

pp. 205435812110277

Author(s):

Tyler Pitre ◽

Angela (Hong Tian) Dong ◽

Aaron Jones ◽

Jessica Kapralik ◽

Sonya Cui ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Cohort Study ◽

Hospital Mortality ◽

Disease Severity ◽

Retrospective Cohort Study ◽

Odds Ratio ◽

Retrospective Cohort ◽

Kidney Injury ◽

Icu Admission

Background: The incidence of acute kidney injury (AKI) in patients with COVID-19 and its association with mortality and disease severity is understudied in the Canadian population. Objective: To determine the incidence of AKI in a cohort of patients with COVID-19 admitted to medicine and intensive care unit (ICU) wards, its association with in-hospital mortality, and disease severity. Our aim was to stratify these outcomes by out-of-hospital AKI and in-hospital AKI. Design: Retrospective cohort study from a registry of patients with COVID-19. Setting: Three community and 3 academic hospitals. Patients: A total of 815 patients admitted to hospital with COVID-19 between March 4, 2020, and April 23, 2021. Measurements: Stage of AKI, ICU admission, mechanical ventilation, and in-hospital mortality. Methods: We classified AKI by comparing highest to lowest recorded serum creatinine in hospital and staged AKI based on the Kidney Disease: Improving Global Outcomes (KDIGO) system. We calculated the unadjusted and adjusted odds ratio for the stage of AKI and the outcomes of ICU admission, mechanical ventilation, and in-hospital mortality. Results: Of the 815 patients registered, 439 (53.9%) developed AKI, 253 (57.6%) presented with AKI, and 186 (42.4%) developed AKI in-hospital. The odds of ICU admission, mechanical ventilation, and death increased as the AKI stage worsened. Stage 3 AKI that occurred during hospitalization increased the odds of death (odds ratio [OR] = 7.87 [4.35, 14.23]). Stage 3 AKI that occurred prior to hospitalization carried an increased odds of death (OR = 5.28 [2.60, 10.73]). Limitations: Observational study with small sample size limits precision of estimates. Lack of nonhospitalized patients with COVID-19 and hospitalized patients without COVID-19 as controls limits causal inferences. Conclusions: Acute kidney injury, whether it occurs prior to or after hospitalization, is associated with a high risk of poor outcomes in patients with COVID-19. Routine assessment of kidney function in patients with COVID-19 may improve risk stratification. Trial registration: The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

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Regular Use of VKA Prior to COVID-19 Associated with Lower 7-Day Survival in Hospitalized Frail Elderly COVID-19 Patients: The GERIA-COVID Cohort Study

Nutrients ◽

10.3390/nu13010039 ◽

2020 ◽

Vol 13 (1) ◽

pp. 39

Author(s):

Pierre Ménager ◽

Olivier Brière ◽

Jennifer Gautier ◽

Jérémie Riou ◽

Guillaume Sacco ◽

...

Keyword(s):

Cohort Study ◽

Vitamin K ◽

Frail Elderly ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

Clinical Severity ◽

Survival Times ◽

Short Term Mortality

Background. Vitamin K concentrations are inversely associated with the clinical severity of COVID-19. The objective of this cohort study was to determine whether the regular use of vitamin K antagonist (VKA) prior to COVID-19 was associated with short-term mortality in frail older adults hospitalized for COVID-19. Methods. Eighty-two patients consecutively hospitalized for COVID-19 in a geriatric acute care unit were included. The association of the regular use of VKA prior to COVID-19 with survival after 7 days of COVID-19 was examined using a propensity-score-weighted Cox proportional-hazards model accounting for age, sex, severe undernutrition, diabetes mellitus, hypertension, prior myocardial infarction, congestive heart failure, prior stroke and/or transient ischemic attack, CHA2DS2-VASc score, HAS-BLED score, and eGFR. Results. Among 82 patients (mean ± SD age 88.8 ± 4.5 years; 48% women), 73 survived COVID-19 at day 7 while 9 died. There was no between-group difference at baseline, despite a trend for more frequent use of VKA in those who did not survive on day 7 (33.3% versus 8.2%, p = 0.056). While considering “using no VKA” as the reference (hazard ratio (HR) = 1), the HR for 7-day mortality in those regularly using VKA was 5.68 [95% CI: 1.17; 27.53]. Consistently, COVID-19 patients using VKA on a regular basis had shorter survival times than the others (p = 0.031). Conclusions. Regular use of VKA was associated with increased mortality at day 7 in hospitalized frail elderly patients with COVID-19.

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Abstract 14873: Is There Difference in Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS) between Hospitals With and Without Onsite Cardiac Surgery Backup?

Circulation ◽

10.1161/circ.130.suppl_2.14873 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tomonori Akasaka ◽

Seiji Hokimoto ◽

Noriaki Tabata ◽

Kenji Sakamoto ◽

Kenichi Tsujita ◽

...

Keyword(s):

Cardiac Surgery ◽

Clinical Outcomes ◽

Primary Endpoint ◽

Proportional Hazards Model ◽

Cox Proportional Hazards Model ◽

Bleeding Complications ◽

Hospital Death ◽

Coronary Syndrome ◽

Significant Difference ◽

The Impact

Background: Based on 2011 ACCF/AHA/SCAI PCI guideline, it is recommended that PCI should be performed at hospital with onsite cardiac surgery. But, recent data suggests that there is no significant difference in clinical outcomes following primary or elective PCI between hospitals with and without onsite cardiac surgery. The proportion of PCI centers without onsite cardiac surgery comprises approximately more than half of all PCI centers in Japan. We examined the impact of with or without onsite cardiac surgery on clinical outcomes following PCI to ACS. Methods: From Aug 2008 to March 2011, subjects (n=2288) were enrolled from the Kumamoto Intervention Conference Study (KICS), which is a multicenter registry, and enrolling consecutive patients undergoing PCI in 15 centers in Japan. Patients were assigned to two groups treated in hospitals with (n=1954) or without (n=334) onsite cardiac surgery. Clinical events were followed up for 12 months. Primary endpoint was in-hospital death, cardiovascular death, myocardial infarction, and stroke. And we monitored other events those were non-cardiovascular deaths, bleeding complications, revascularizations, and emergent CABG. Results: There was no overall significant difference in primary endpoint between hospitals with and without onsite cardiac surgery (9.6%vs9.5%; P=0.737). There was also no significant difference when events in primary endpoint were considered separately. In other events, only revascularization was more frequently seen in hospitals with onsite cardiac surgery (22.1%vs12.9%; P<0.001). Kaplan-Meier analysis for primary endpoint showed that there was no significant difference between two groups (Log Rank P=0.943). By cox proportional hazards model analysis for primary endpoint, without onsite cardiac surgery was not a predictive factor for primary endpoint (HR 0.969, 95%CI 0.704-1.333; P=0.845). We performed propensity score matching analysis to correct for the disparate patient numbers between two groups, and there was also no significant difference for primary endpoint (6.9% vs 8.0%; P=0.544). Conclusions: There is no significant difference in clinical outcomes following PCI for ACS between hospitals with and without onsite cardiac surgery backup in Japan.

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High Risk of Deep Neck Infection in Patients with Type 1 Diabetes Mellitus: A Nationwide Population-Based Cohort Study

Journal of Clinical Medicine ◽

10.3390/jcm7110385 ◽

2018 ◽

Vol 7 (11) ◽

pp. 385 ◽

Cited By ~ 8

Author(s):

Geng-He Chang ◽

Meng-Chang Ding ◽

Yao-Hsu Yang ◽

Yung-Hsiang Lin ◽

Chia-Yen Liu ◽

...

Keyword(s):

Diabetes Mellitus ◽

Type 1 Diabetes ◽

Cohort Study ◽

Type 1 Diabetes Mellitus ◽

Proportional Hazards Model ◽

Cox Proportional Hazards Model ◽

Deep Neck Infection ◽

Research Database ◽

Neck Infection

Objective: To investigate the risk of deep neck infection (DNI) in patients with type 1 diabetes mellitus (T1DM). Methods: The database of the Registry for Catastrophic Illness Patients, affiliated to the Taiwan National Health Insurance Research Database, was used to conduct a retrospective cohort study. In total, 5741 patients with T1DM and 22,964 matched patients without diabetes mellitus (DM) were enrolled between 2000 and 2010. The patients were followed up until death or the end of the study period (31 December 2013). The primary outcome was the occurrence of DNI. Results: Patients with T1DM exhibited a significantly higher cumulative incidence of DNI than did those without DM (p < 0.001). The Cox proportional hazards model showed that T1DM was significantly associated with a higher incidence of DNI (adjusted hazard ratio, 10.71; 95% confidence interval, 6.02–19.05; p < 0.001). The sensitivity test and subgroup analysis revealed a stable effect of T1DM on DNI risk. The therapeutic methods (surgical or nonsurgical) did not differ significantly between the T1DM and non-DM cohorts. Patients with T1DM required significantly longer hospitalization for DNI than did those without DM (9.0 ± 6.2 vs. 4.1 ± 2.0 days, p < 0.001). Furthermore, the patients with T1DM were predisposed to DNI at a younger age than were those without DM. Conclusions: T1DM is an independent risk factor for DNI and is associated with a 10-fold increase in DNI risk. The patients with T1DM require longer hospitalizations for DNI and are younger than those without DM.

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Associations between SARS-CoV-2 variants and risk of COVID-19 hospitalization among confirmed cases in Washington State: a retrospective cohort study

10.1101/2021.09.29.21264272 ◽

2021 ◽

Author(s):

Miguel I. Paredes ◽

Stephanie Lunn ◽

Michael Famulare ◽

Lauren A. Frisbie ◽

Ian Painter ◽

...

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Sentinel Surveillance ◽

Cox Proportional Hazards Model ◽

Ancestral Lineage ◽

Significant Difference

Background: The COVID–19 pandemic is now dominated by variant lineages; the resulting impact on disease severity remains unclear. Using a retrospective cohort study, we assessed the risk of hospitalization following infection with nine variants of concern or interest (VOC/VOI). Methods: Our study includes individuals with positive SARS–CoV–2 RT PCR in the Washington Disease Reporting System and with available viral genome data, from December 1, 2020 to July 30, 2021. The main analysis was restricted to cases with specimens collected through sentinel surveillance. Using a Cox proportional hazards model with mixed effects, we estimated hazard ratios (HR) for the risk of hospitalization following infection with a VOC/VOI, adjusting for age, sex, and vaccination status. Findings: Of the 27,814 cases, 23,170 (83.3%) were sequenced through sentinel surveillance, of which 726 (3.1%) were hospitalized due to COVID–19. Higher hospitalization risk was found for infections with Gamma (HR 3.17, 95% CI 2.15–4.67), Beta (HR: 2.97, 95% CI 1.65–5.35), Delta (HR: 2.30, 95% CI 1.69–3.15), and Alpha (HR 1.59, 95% CI 1.26–1.99) compared to infections with an ancestral lineage. Following VOC infection, unvaccinated patients show a similar higher hospitalization risk, while vaccinated patients show no significant difference in risk, both when compared to unvaccinated, ancestral lineage cases. Interpretation: Infection with a VOC results in a higher hospitalization risk, with an active vaccination attenuating that risk. Our findings support promoting hospital preparedness, vaccination, and robust genomic surveillance.

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