Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 152 No. 1920 (2022)

Sex disparities in patients with suspected COVID-19 presenting at an emergency department in Switzerland

  • Ketina Arslani
  • Ceylan Eken
  • Sarah Tschudin-Sutter
  • Caroline E. Gebhard
  • Nuria Zellweger
  • Stefano Bassetti
  • Roland Bingisser
  • Maurin Lampart
  • Stefan Osswald
  • Gabriela M. Kuster
  • Raphael Twerenbold
DOI
https://doi.org/10.4414/SMW.2022.w30167
Cite this as:
Swiss Med Wkly. 2022;152:w30167
Published
20.05.2022

Summary

AIMS OF THE STUDY: In the global COVID-19 pandemic, female sex is associated with comparable infection rates but better outcome. However, most studies lacked appropriate controls. We investigated whether these sex disparity findings are specific to patients with COVID-19 or generalizable to patients presenting to the emergency room (ER) with similar symptoms but no COVID-19.

METHODS: In this prospective cohort study, consecutive patients presenting with symptoms suggestive of COVID-19 were recruited at the ER of the University Hospital Basel, Switzerland from March to June 2020. Patients were categorized as SARS-CoV-2 positive (cases) or negative (controls) based on nasopharyngeal PCR swab tests. The final clinical diagnosis was determined for all patients. The primary outcome was a composite of intensive care admission, rehospitalization for respiratory distress and all-cause death within 30 days. We used Kaplan–Meier curves and Cox proportional hazards models to explore associations between sex and outcomes.

RESULTS: Among 1,081 consecutive ER patients, 191 (18%) tested positive for SARS-CoV-2, with an even sex distribution (17.9% female vs. 17.5% male, p = 0.855). In COVID-19 patients, female sex was associated with lower risk of hospitalization (51% vs. 66%, p = 0.034), lower necessity of haemodynamic support (8% vs. 20%, p = 0.029), lower rates of intubation (10% vs. 21%, p = 0.037) and the primary outcome (18% vs. 31%, p = 0.045; age-adjusted HR 0.536, 95%CI 0.290–0.989, p = 0.046) compared with male sex. Sex disparities were most prominent in patients ≥55 years (HR for composite primary outcome in women 0.415, 95%CI 0.201–0.855, p = 0.017). In contrast to the COVID-19 patients, no sex-specific differences in outcomes were observed in the unselected overall control group (age-adjusted HR 0.844, 95%CI 0.560–1.273, p = 0.419) or in a subgroup of controls with upper respiratory tract infections or pneumonia (age-adjusted HR 0.840, 95%CI 0.418–1.688, p = 0.624).

CONCLUSION: In this unselected, consecutive cohort study at a tertiary hospital in Switzerland, female sex is associated with better outcome in patients presenting to the ER with COVID-19. These sex disparities seem to be at least partly specific to COVID-19, as they were not observed in comparable controls.

References

  1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708-20. Epub 2020/02/29. doi: https://doi.org/10.1056/NEJMoa2002032. PubMed PMID: 32109013; PubMed Central PMCID: PMCPMC7092819.
  2. Gebhard C, Regitz-Zagrosek V, Neuhauser HK, Morgan R, Klein SL. Impact of sex and gender on COVID-19 outcomes in Europe. Biol Sex Differ. 2020;11(1):29. Epub 2020/05/27. doi: https://doi.org/10.1186/s13293-020-00304-9. PubMed PMID: 32450906; PubMed Central PMCID: PMCPMC7247289.
  3. Abate BB, Kassie AM, Kassaw MW, Aragie TG, Masresha SA. Sex difference in coronavirus disease (COVID-19): a systematic review and meta-analysis. BMJ Open. 2020;10(10):e040129. Epub 2020/10/09. doi: https://doi.org/10.1136/bmjopen-2020-040129. PubMed PMID: 33028563; PubMed Central PMCID: PMCPMC7539579.
  4. Jin JM, Bai P, He W, Wu F, Liu XF, Han DM, et al. Gender Differences in Patients With COVID-19: Focus on Severity and Mortality. Front Public Health. 2020;8:152. Epub 2020/05/16. doi: https://doi.org/10.3389/fpubh.2020.00152. PubMed PMID: 32411652; PubMed Central PMCID: PMCPMC7201103.
  5. Iaccarino G, Grassi G, Borghi C, Carugo S, Fallo F, Ferri C, et al. Gender differences in predictors of intensive care units admission among COVID-19 patients: The results of the SARS-RAS study of the Italian Society of Hypertension. PLoS One. 2020;15(10):e0237297. Epub 2020/10/07. doi: https://doi.org/10.1371/journal.pone.0237297. PubMed PMID: 33022004; PubMed Central PMCID: PMCPMC7537902.
  6. Sex gaC-GH. [13 March, 2021]. Available from: https://globalhealth5050.org/the-sex-gender-and-covid-19-project/
  7. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014 Dec;12(12):1495–9. https://doi.org/10.1016/j.ijsu.2014.07.013
  8. Zhu D, Chung HF, Dobson AJ, Pandeya N, Giles GG, Bruinsma F, et al. Age at natural menopause and risk of incident cardiovascular disease: a pooled analysis of individual patient data. Lancet Public Health. 2019;4(11):e553-e64. Epub 2019/10/08. doi: https://doi.org/10.1016/s2468-2667(19)30155-0. PubMed PMID: 31588031; PubMed Central PMCID: PMCPMC7118366. https://doi.org/10.1016/S2468-2667(19)30155-0
  9. Muller B, Harbarth S, Stolz D, Bingisser R, Mueller C, Leuppi J, et al. Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia. BMC Infect Dis. 2007;7:10. Epub 2007/03/06. doi: https://doi.org/10.1186/1471-2334-7-10. PubMed PMID: 17335562; PubMed Central PMCID: PMCPMC1821031.
  10. Suleyman G, Fadel RA, Malette KM, Hammond C, Abdulla H, Entz A, et al. Clinical Characteristics and Morbidity Associated With Coronavirus Disease 2019 in a Series of Patients in Metropolitan Detroit. JAMA Netw Open. 2020;3(6):e2012270. Epub 2020/06/17. doi: https://doi.org/10.1001/jamanetworkopen.2020.12270. PubMed PMID: 32543702; PubMed Central PMCID: PMCPMC7298606.
  11. Tolia VM, Chan TC, Castillo EM. Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency Department. West J Emerg Med. 2020;21(3):503-6. Epub 2020/04/01. doi: https://doi.org/10.5811/westjem.2020.3.47348. PubMed PMID: 32223871; PubMed Central PMCID: PMCPMC7234708.
  12. Grasselli G, Greco M, Zanella A, Albano G, Antonelli M, Bellani G, et al. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy. JAMA Intern Med. 2020;180(10):1345-55. Epub 2020/07/16. doi: https://doi.org/10.1001/jamainternmed.2020.3539. PubMed PMID: 32667669; PubMed Central PMCID: PMCPMC7364371.
  13. Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect. 2020;81(2):e16-e25. Epub 2020/04/27. doi: https://doi.org/10.1016/j.jinf.2020.04.021. PubMed PMID: 32335169; PubMed Central PMCID: PMCPMC7177098.
  14. Lakbar I, Luque-Paz D, Mege JL, Einav S, Leone M. COVID-19 gender susceptibility and outcomes: A systematic review. PLoS One. 2020;15(11):e0241827. Epub 2020/11/04. doi: https://doi.org/10.1371/journal.pone.0241827. PubMed PMID: 33141872; PubMed Central PMCID: PMCPMC7608911 speaker for MSD, Pfizer and as consultant for Amomed, Aguettant and Gilead. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
  15. Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol. 2016 Oct;16(10):626–38. https://doi.org/10.1038/nri.2016.90
  16. Scully EP, Haverfield J, Ursin RL, Tannenbaum C, Klein SL. Considering how biological sex impacts immune responses and COVID-19 outcomes. Nat Rev Immunol. 2020;20(7):442-7. Epub 2020/06/13. doi: https://doi.org/10.1038/s41577-020-0348-8. PubMed PMID: 32528136; PubMed Central PMCID: PMCPMC7288618.
  17. Maleki Dana P, Sadoughi F, Hallajzadeh J, Asemi Z, Mansournia MA, Yousefi B, et al. An Insight into the Sex Differences in COVID-19 Patients: What are the Possible Causes? Prehosp Disaster Med. 2020;35(4):438-41. Epub 2020/07/01. doi: https://doi.org/10.1017/s1049023x20000837. PubMed PMID: 32600476; PubMed Central PMCID: PMCPMC7327162. https://doi.org/10.1017/S1049023X20000837
  18. Potluri T, Fink AL, Sylvia KE, Dhakal S, Vermillion MS, Vom Steeg L, et al. Age-associated changes in the impact of sex steroids on influenza vaccine responses in males and females. NPJ Vaccines. 2019;4:29. Epub 2019/07/18. doi: https://doi.org/10.1038/s41541-019-0124-6. PubMed PMID: 31312529; PubMed Central PMCID: PMCPMC6626024.
  19. Gemmati D, Bramanti B, Serino ML, Secchiero P, Zauli G, Tisato V. COVID-19 and Individual Genetic Susceptibility/Receptivity: Role of ACE1/ACE2 Genes, Immunity, Inflammation and Coagulation. Might the Double X-chromosome in Females Be Protective against SARS-CoV-2 Compared to the Single X-Chromosome in Males? Int J Mol Sci. 2020;21(10). Epub 2020/05/20. doi: https://doi.org/10.3390/ijms21103474. PubMed PMID: 32423094; PubMed Central PMCID: PMCPMC7278991.
  20. Palaiodimos L, Kokkinidis DG, Li W, Karamanis D, Ognibene J, Arora S, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism. 2020;108:154262. Epub 2020/05/19. doi: https://doi.org/10.1016/j.metabol.2020.154262. PubMed PMID: 32422233; PubMed Central PMCID: PMCPMC7228874.
  21. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. Epub 2020/03/15. doi: https://doi.org/10.1016/S0140-6736(20)30566-3. PubMed PMID: 32171076; PubMed Central PMCID: PMCPMC7270627.

Most read articles by the same author(s)

<< < 1 2 3 4 5 6 7 > >>