Author ORCID Identifier

https://orcid.org/0000-0002-8980-3330

Date of Award

8-9-2022

Degree Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

Public Health

First Advisor

Therese Decampo Pigott, PhD

Second Advisor

Jennifer Gander, PhD

Abstract

INTRODUCTION: Since the SARS-CoV-2 emergence in 2019, the subsequent disease COVID-19 has become a global public health emergency. While substantial research has been done regarding the acute phase of this disease, little is known about the long-term health implications of COVID-19, including the biological mechanisms leading to the development of persistent symptoms following infection known as “long-COVID”. One suggested causal pathway is that the immune response induced by SARS-CoV-2 causes dysregulation of iron homeostasis, hemolysis, and/or erythropoiesis, resulting in abnormally low Hgb levels and insufficient O2 transfer. Developing a better understanding of these mechanisms is key to treating and preventing the long-term health implications linked to COVID-19.

AIM: The aim of this study is to evaluate the prevalence of anemia 180-days post-COVID diagnosis and assess potential risk factors including patient demographics, comorbidities, and hospitalization (COVID severity) status.

METHODS: The sample was obtained from KPGA’s CURE Cohort and EMR. Individuals aged ≥18 at COVID-19 diagnosis, alive as of February 2022, and with Hgb labs taken pre- and 180-days post- COVID19 diagnosis ±30-days were included in the study. Anemia was defined as blood hemoglobin (Hgb) levels <12.0g/dL for females and <13.0g/dL for males. Unadjusted univariate and adjusted multivariable logistic regression were used to calculate odds ratios and assess the association between anemia and exposures of interest.

RESULTS: We found the prevalence of anemia at 180-days post-COVID to be 34.1%. Univariate analysis showed that age (≥65) (OR=1.40, 95% CI: 1.00, 1.97), Black/African American race (OR=2.46, 95% CI: 1.98, 3.05), obesity (OR=1.33 95% CI: 1.08, 1.64), kidney disease (OR=2.48, 95% CI: 1.91, 3.22), diabetes (OR=2.14, 95% CI: 1.72, 2.68), hypertension (OR=1.44, 95% CI: 1.16, 1.78), malignant cancer (OR=1.70, 95% CI: 1.28, 2.27), heart disease (OR=1.55, 95% CI: 1.25, 1.93), hospitalization (COVID-severity) (OR=2.46, 95% CI: 1.89, 3.21), and pre-COVID anemia (OR=13.71, 95% CI: 10.57, 17.77) were significantly associated with post-COVID anemia. The final fitted multivariable logistic regression model showed that Black/African American race (OR=1.74, 95% CI: 1.34, 2.26), diabetes (OR=1.53, 95% CI: 1.14, 2.05), malignant cancer (OR=1.47, 95% CI: 1.02, 2.13), hospitalization (COVID-severity) (OR=1.92, 95% CI: 1.37, 2.70), and pre-COVID anemia (OR=11.58, 95%CI: 8.85, 15.17) were significantly associated with post-COVID anemia. In a sensitivity analysis using our final fitted multivariable logistic regression, hospitalization was treated as an effect modifier. Among individuals not hospitalized for COVID-19, Black/African American race (OR=2.03, 95% CI:1.52, 2.72) was significantly associated with increased risk of having post-COVID anemia.

DISCUSSION: The findings of this study show that individuals diagnosed with diabetes, cancer, and anemia pre-COVID are at increased risk of post-COVID anemia. Additionally, individuals identifying as Black or African American had significantly higher risk of post-COVID anemia, specifically in the outpatient (non-severe COVID-19) population. There was significant overlap with post-COVID anemia risk factors identified in both the adjusted/unadjusted analysis and known risk factors for long-COVID. Future research should look to further examine the causal link between anemic Hgb levels post-COVID infection and the development of long-COVID.

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