Clinical characteristics and factors associated with COVID-19-related mortality and hospital admission during the first two epidemic waves in 5 rural provinces in Indonesia: a retrospective cohort study

Background Data on coronavirus disease 2019 (COVID-19) clinical characteristics and severity from resource-limited settings are limited. This study examined clinical characteristics and factors associated with COVID-19 mortality and hospitalisation in rural settings of Indonesia, from 1 January to 31 July, 2021. Methods This retrospective cohort included individuals diagnosed with COVID-19 based on polymerase chain reaction or rapid antigen diagnostic test, from five rural provinces in Indonesia. We extracted demographic and clinical data, including hospitalisation and mortality from a new piloted COVID-19 information system named Sistem Informasi Surveilans Epidemiologi (SISUGI). We used mixed-effect logistic regression to examine factors associated with COVID-19-related mortality and hospitalisation. Results Of 6,583 confirmed cases, 205 (3.1%) died and 1,727 (26.2%) were hospitalised. The median age was 37 years (Interquartile range 26-51), with 825 (12.6%) under 20 years, and 3,371 (51.2%) females. Most cases were symptomatic (4,533; 68.9%); 319 (4.9%) had a clinical diagnosis of pneumonia and 945 (14.3%) presented with at least one pre-existing comorbidity. Age-specific mortality rates were 0.9% (2/215) for 0-4 years; 0% (0/112) for 5-9 years; 0% (1/498) for 10-19 years; 0.8% (11/1,385) for 20-29 years; 0.9% (12/1,382) for 30-39 years; 2.1% (23/1,095) for 40-49 years; 5.4% (57/1,064) for 50-59 years; 10.8% (62/576) for 60-69 years; 15.9% (37/232) for ≥70 years. Older age, pre-existing diabetes, chronic kidney disease, liver diseases, malignancy, and pneumonia were associated with higher risk of mortality and hospitalisation. Pre-existing hypertension, cardiac diseases, COPD, and immunocompromised condition were associated with risk of hospitalisation but not with mortality. There was no association between province-level density of healthcare workers with mortality and hospitalisation. Conclusion The risk of COVID-19-related mortality and hospitalisation was associated with higher age, pre-existing chronic comorbidities, and clinical pneumonia. The findings highlight the need for prioritising enhanced context-specific public health action to reduce mortality and hospitalisation risk among older and comorbid rural populations.