Risk Factors for Hospitalization and Death From COVID-19 in South Sudan and Eastern Democratic Republic of the Congo

Background: Our study described demographic characteristics, exposures, and symptoms, and comorbidities to evaluate risk factors of hospitalization and mortality among cases in Juba, South Sudan (SSD) and North and South Kivu in eastern Democratic Republic of the Congo (DRC). Methods: This observational cohort of COVID-19 cases enrolled individuals presenting for care at one of five study facilities in SSD (n=1) or DRC (n=4) or referred from home-based care by mobile medical teams between December 2020– June 2021. Demographic characteristics, COVID-19 exposures, symptoms at presentation, as well as acute and chronic comorbidities were evaluated using a standard questionnaire at enrollment. Disease progression was characterized by location of care using mixed-effects regression models. Findings: 751 individuals were eligible for enrollment. Among cases followed to discharge or death (n=519), 375 were enrolled outpatients (75.7%). A similar number of cases were enrolled in DRC (n=262) and South Sudan (n=257). Overall mortality was 4.8% (95% CI: 3.2-6.9%); there were no outpatient deaths. Patients presenting with any symptoms had higher odds of hospitalization (AOR 2.78, 95% CI 1.47 –5.27) and all deaths occurred among symptomatic individuals. Odds of both hospitalization and mortality were greatest among cases with respiratory symptoms; presence of low oxygen levels on enrollment was strongly associated with both hospitalization (AOR 7.77, 95% CI: 4.22– 14.29) and mortality (AOR 25.29, 95% CI 6.42– 99.54). Presence of more than one chronic comorbidity was associated with 4.96 (95% CI 1.51– 16.31) times greater odds of death; neither infectious comorbidities evaluated (malaria, TB, and HIV) nor malnutrition were significantly associated with increased mortality. Interpretation: Consistent with prior literature, older age, low oxygen level, other respiratory symptoms, and chronic comorbidities were all risk factors for mortality. Patients presenting with these characteristics were more likely to be hospitalized, providing evidence of effective triage and referral. Clinical Trial Registration Details: The study is registered with ClinicalTrials.gov (NCT04568499). Funding Information: Funded by USAID (award 72OFDA20GR0221). Declaration of Interests: All authors have signed the IJCME declaration of interest forms and have no conflicts of interest to report. Ethics Approval Statement: This study was reviewed and approved by the Johns Hopkins University Institutional Review Board, the South Sudan Ministry of Health Ethics Committee, the University of Kinshasa School of Public Health , and the US CDC.