COVID-19 Outcomes Among US Military Health System Beneficiaries Include Complications Across Multiple Organ Systems and Substantial Functional Impairment

Stephanie A Richard^{1

2}, Simon D Pollett^{1

2}, Charlotte A Lanteri³, Eugene V Millar^{1

2}, Anthony C Fries⁴, Ryan C Maves^{1

5}, Gregory C Utz^{1

2

5}, Tahaniyat Lalani^{1

2

6}, Alfred Smith⁶, Rupal M Mody⁷, Anuradha Ganesan^{1

2

8}, Rhonda E Colombo^{1

2

9

10}, Christopher J Colombo^{9

10}, David A Lindholm^{11

10}, Cristian Madar¹², Sharon Chi^{1

2

12}, Nikhil Huprikar^{8

10}, Derek T Larson^{10

13}, Samantha E Bazan¹⁴, Caroline English^{1

2}, Edward Parmelee^{1

2}, Katrin Mende^{1

2

11}, Eric D Laing¹⁵, Christopher C Broder¹⁵, Paul W Blair^{16

17}, Josh G Chenoweth^{2

17}, Mark P Simons¹, David R Tribble¹, Brian K Agan^{1

2}, Timothy H Burgess¹; EPICC COVID-19 Cohort Study Group

Collaborators, Affiliations

Collaborators

EPICC COVID-19 Cohort Study Group:
J Cowden, D Lindholm, A Markelz, K Mende, T Merritt, R Walter, T Wellington, S Bazan, N Dimascio-Johnson, E Ewers, K Gallagher, D Larson, M Odom, A Rutt, P Blair, J G Chenoweth, D Clark, S Chambers, C Colombo, R Colombo, C Conlon, K Everson, P Faestel, T Ferguson, L Gordon, S Grogan, S Lis, C Mount, D Musfeldt, D Odineal, R Sainato, C Schofield, C Skinner, M Stein, M Switzer, M Timlin, S Wood, R Carpenter, L Kim, K Kronmann, T Lalani, T Lee, A Smith, T Warkentien, J Arnold, C Berjohn, S Cammarata, S Husain, A Lane, R Maves, J Parrish, G Utz, S Chi, E Filan, K Fong, T Horseman, M Jones, A Kanis, A Kayatani, W Londeree, C Madar, J Masel, M McMahon, G Murphy, V Ngauy, P Schmidt, E Schoenman, C Uyehara, R Villacorta Lyew, B Agan, C Broder, T Burgess, C Byrne, C Coles, C English, P Hickey, E Laing, J Livezey, A Malloy, T Oliver, E Parmelee, S Pollett, M Rajnik, S Richard, J Rozman, M Sanchez, A Scher, M Simons, A L Snow, D Tribble, A Fries, A Farmer, B Barton, D Hostler, C Maldonado, T Musich, R Radcliffe, M Swain, M Banda, B Davis, T Hunter, O Ikpekpe-Magege, S Kemp, R Mody, M Wiggins, A Ganesan, D Gunasekera, N Huprikar

Affiliations

¹ Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
² Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.
³ Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.
⁴ US Air Force School of Aerospace Medicine, Wright-Patterson, Ohio, USA.
⁵ Naval Medical Center San Diego, San Diego, California, USA.
⁶ Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.
⁷ William Beaumont Army Medical Center, El Paso, Texas, USA.
⁸ Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
⁹ Madigan Army Medical Center, Joint Base Lewis McChord, Washington, USA.
¹⁰ Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹¹ Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.
¹² Tripler Army Medical Center, Honolulu, Hawaii, USA.
¹³ Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
¹⁴ Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA.
¹⁵ Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹⁶ Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹⁷ Austere environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation, Bethesda, Maryland, USA.

PMID: 34909439
PMCID: PMC8664684
DOI: 10.1093/ofid/ofab556

COVID-19 Outcomes Among US Military Health System Beneficiaries Include Complications Across Multiple Organ Systems and Substantial Functional Impairment

Stephanie A Richard et al. Open Forum Infect Dis. 2021.

. 2021 Nov 10;8(12):ofab556.

doi: 10.1093/ofid/ofab556. eCollection 2021 Dec.

Authors

Collaborators

EPICC COVID-19 Cohort Study Group:
J Cowden, D Lindholm, A Markelz, K Mende, T Merritt, R Walter, T Wellington, S Bazan, N Dimascio-Johnson, E Ewers, K Gallagher, D Larson, M Odom, A Rutt, P Blair, J G Chenoweth, D Clark, S Chambers, C Colombo, R Colombo, C Conlon, K Everson, P Faestel, T Ferguson, L Gordon, S Grogan, S Lis, C Mount, D Musfeldt, D Odineal, R Sainato, C Schofield, C Skinner, M Stein, M Switzer, M Timlin, S Wood, R Carpenter, L Kim, K Kronmann, T Lalani, T Lee, A Smith, T Warkentien, J Arnold, C Berjohn, S Cammarata, S Husain, A Lane, R Maves, J Parrish, G Utz, S Chi, E Filan, K Fong, T Horseman, M Jones, A Kanis, A Kayatani, W Londeree, C Madar, J Masel, M McMahon, G Murphy, V Ngauy, P Schmidt, E Schoenman, C Uyehara, R Villacorta Lyew, B Agan, C Broder, T Burgess, C Byrne, C Coles, C English, P Hickey, E Laing, J Livezey, A Malloy, T Oliver, E Parmelee, S Pollett, M Rajnik, S Richard, J Rozman, M Sanchez, A Scher, M Simons, A L Snow, D Tribble, A Fries, A Farmer, B Barton, D Hostler, C Maldonado, T Musich, R Radcliffe, M Swain, M Banda, B Davis, T Hunter, O Ikpekpe-Magege, S Kemp, R Mody, M Wiggins, A Ganesan, D Gunasekera, N Huprikar

Affiliations

¹ Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
² Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.
³ Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.
⁴ US Air Force School of Aerospace Medicine, Wright-Patterson, Ohio, USA.
⁵ Naval Medical Center San Diego, San Diego, California, USA.
⁶ Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.
⁷ William Beaumont Army Medical Center, El Paso, Texas, USA.
⁸ Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
⁹ Madigan Army Medical Center, Joint Base Lewis McChord, Washington, USA.
¹⁰ Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹¹ Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.
¹² Tripler Army Medical Center, Honolulu, Hawaii, USA.
¹³ Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
¹⁴ Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA.
¹⁵ Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹⁶ Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹⁷ Austere environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation, Bethesda, Maryland, USA.

PMID: 34909439
PMCID: PMC8664684
DOI: 10.1093/ofid/ofab556

Abstract

Background: We evaluated clinical outcomes, functional burden, and complications 1 month after coronavirus disease 2019 (COVID-19) infection in a prospective US Military Health System (MHS) cohort of active duty, retiree, and dependent populations using serial patient-reported outcome surveys and electronic medical record (EMR) review.

Methods: MHS beneficiaries presenting at 9 sites across the United States with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test, a COVID-19-like illness, or a high-risk SARS-CoV-2 exposure were eligible for enrollment. Medical history and clinical outcomes were collected through structured interviews and International Classification of Diseases-based EMR review. Risk factors associated with hospitalization were determined by multivariate logistic regression.

Results: A total of 1202 participants were enrolled. There were 1070 laboratory-confirmed SARS-CoV-2 cases and 132 SARS-CoV-2-negative participants. In the first month post-symptom onset among the SARS-CoV-2-positive cases, there were 212 hospitalizations, 80% requiring oxygen, 20 ICU admissions, and 10 deaths. Risk factors for COVID-19-associated hospitalization included race (increased for Asian, Black, and Hispanic compared with non-Hispanic White), age (age 45-64 and 65+ compared with <45), and obesity (BMI≥30 compared with BMI<30). Over 2% of survey respondents reported the need for supplemental oxygen, and 31% had not returned to normal daily activities at 1 month post-symptom onset.

Conclusions: Older age, reporting Asian, Black, or Hispanic race/ethnicity, and obesity are associated with SARS-CoV-2 hospitalization. A proportion of acute SARS-CoV-2 infections require long-term oxygen therapy; the impact of SARS-CoV-2 infection on short-term functional status was substantial. A significant number of MHS beneficiaries had not yet returned to normal activities by 1 month.

Keywords: COVID-19; burden; outcomes; predictive symptoms; risk.

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Figures

**Figure 1.**
Odds of hospitalization associated with risk factors in a multivariate logistic model, run separately for SARS-CoV-2-positive and -negative participants. To adjust for possible heterogeneity across by site, study site (military treatment facility covariate) was included in the model. Odds ratios were adjusted for the covariates shown in the figure plus study site. Abbreviation: SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

**Figure 2.**
Percentage of SARS-CoV-2-positive participants with diagnoses in different categories in the 30 days before and after SARS-CoV-2 symptom onset in the EPICC cohort. Abbreviations: CVD, cardiovascular disease; DPSO, Days post-symptom onset; EPICC, observational cohort study of the epidemiology, immunology, and clinical characteristics of pandemic infectious diseases; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

See this image and copyright information in PMC

References

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COVID-19 Outcomes Among US Military Health System Beneficiaries Include Complications Across Multiple Organ Systems and Substantial Functional Impairment

Collaborators

Affiliations

COVID-19 Outcomes Among US Military Health System Beneficiaries Include Complications Across Multiple Organ Systems and Substantial Functional Impairment

Authors

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Affiliations

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