Factors associated with COVID-19 length of hospitalization and mortality during four epidemic waves, March 2020–November 2021, Suriname

ABSTRACT

Objectives.

To determine the sociodemographic risk factors associated with coronavirus disease 2019 (COVID-19) mortality in Suriname.

Methods.

This was a retrospective cohort study. All registered deaths from COVID-19 in Suriname (n=1112) between March 13, 2020 and November 11, 2021 were included. Data were collected from medical records and included demographic variables and hospitalization duration of patients who died. Descriptive statistics, chi-squared tests, ANOVA models, and logistic regression analyses were used to determine associations between sociodemographic variables, length of hospitalization, and mortality during four epidemic waves.

Results.

The case fatality rate over the study period was 22 per 1 000 population. The first epidemic wave was from July to August 2020, the second from December 2020 to January 2021, the third from May to June 2021, and the fourth from August to September 2021. Significant differences were found in the number of deaths and hospitalization duration by wave (p<0.001). Patients were more likely to have a longer hospitalization during the first (OR 1.66; 95% CI: 0.98, 2.82) and third waves (OR 2.37; 95% CI: 1.71, 3.28) compared with the fourth wave. Significant differences in mortality were also seen between ethnicities by wave (p=0.010). Compared with the mixed and other group, people of Creole ethnicity (OR 2.7; 95% CI: 1.33, 5.29) and Tribal people (OR 2.8; 95% CI: 1.12, 7.02) were more likely to die during the fourth wave than the third wave.

Conclusions.

Tailored interventions are needed for males, people of Creole descent, Tribal and Indigenous peoples, and people older than 65 years.

Globally, the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affected the social and economic landscape (1), and greatly affected the Caribbean region (2).

Recent data (December 2022) show that 639 572 819 confirmed cases of COVID-19 and 6 615 258 deaths occurred worldwide (3). Most deaths were reported in elderly people, who were more likely to develop acute respiratory distress syndrome and require mechanical ventilation. Studies in China and Brazil show that most deaths were in men, people aged 65 years and older, and those with with comorbidities (4, 5). This higher mortality rate in men was also observed in Ecuador (6). Other studies found racial differences in the proportion of cases and death rates, such as in Black and Hispanic people living in the USA. Higher mortality rates appear to be related to income, poverty, and working in the health care and essential service sector (7).

From the start of the COVID-19 pandemic, many epidemic waves have been recorded. Studies have shown that the different epidemic waves were largely related to the different circulating variants of SARS-CoV-2, which led to variability in morbidity and mortality. In Israel and Malaysia, the third COVID-19 wave had more confirmed cases and deaths compared with the first and second waves (8, 9). In Japan, the overall severity in the fourth wave was higher than the first three waves; however this did not result in a significant difference in mortality (10). In most countries, the total number of deaths in waves three and four were similar or higher than in wave two (11). In general, the delta variant was the dominant variant in epidemic waves three and four.

Suriname is a middle-income Caribbean country. Similar to other countries in this region (12), pressure on the health care system has far-reaching consequences, making public health planning and hospital management particularly important. Suriname is among the countries in the Caribbean region with the highest mortality rate from COVID-19 (206.07 deaths per 100 000 inhabitants), higher than Ecuador (193.97 per 100 000 inhabitants), Guyana (136.69 per 100 000 inhabitants), and Uruguay (178.87 per 100 000 inhabitants) (12). Suriname had its first COVID-19 death in April 2020. From the start of the epidemic in Suriname in March 2020 until November 2021, four different COVID-19 waves occurred, which resulted in 1 166 registered deaths and 50 760 COVID-19 cases up to November 30, 2021 (13). While the COVID-19 epidemic placed a heavy burden on the already fragile health care system and hence required rigorous health planning, no studies have yet been conducted on COVID-19 morbidity and mortality in Suriname. The objective of this study therefore was to identify sociodemographic risk factors for death from COVID-19 in Suriname.

METHODS

Our study was a retrospective cohort design. All people who died of COVID-19 in Suriname (n=1 112) between March 13, 2020 (epidemiological week 14) and November 11, 2021 (epidemiological week 46) were included in this study. This was regardless of nationality, residency or legal status. For hospital deaths, data were obtained from the records of all hospitals in Suriname, namely: the Academic Hospital Paramaribo; Diakonessenhuis Hospital; Medical Mungra Centre; Regional Hospital Wanica; ‘s Lands Hospital; and St Vincentius Hospital (Figure 1). The non-hospital deaths were patients who died at home or at a primary health care clinic (Regional Health Services clinic or Medical Mission Primary Health Care Suriname clinic). The diagnosis of COVID-19 was confirmed by a positive result for SARS-CoV-2 based on a polymerase chain reaction test. Patients with a positive COVID-19 diagnosis who were hospitalized or admitted to a primary health care clinic were included in the study.

FIGURE 1. Diagram of COVID-19 deaths in Suriname.

COVID-19, coronaviruse disease 2019; ICU, intensive care unit.

Source: prepared by authors from results taken from published data.

The data collected included demographic variables (age, sex, ethnicity, and place of residence) and information on the date of admission and death. The duration of hospitalization was defined as the period between the date of admission and date of death. Ethnicity was self-reported and categorized as follows: Chinese, Creole (of African descent mixed with any other race), Hindustani, Indigenous, Javanese, Tribal (of African descent), and other (mixed, Caucasians). Region was categorized as: urban (Paramaribo and Wanica); rural (Nickerie, Coronie, Saramacca, Commewijne, and Para); and Hinterlands of Suriname (Marowijne, Brokopondo, and Sipaliwini). The classification of region is according to the General Bureau of Statistics (14). The mortality rate by age, sex, and ethnicity was expressed per 10 000 people with the latest census data from 2012 from the Bureau of Statistics (14).

During the study period, four epidemic waves were identified in Suriname by the Ministry of Health (15), based on number of people with positive COVID-19 tests. The first wave was from July to August 2020, the second wave from December 2020 to January 2021, the third from May to June 2021 and the fourth from August to September 2021. For this study, we distinguished waves based on mortality and called these fatality waves.

Statistical analysis

Data were analyzed using SPSS, version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics include absolute values, relative frequencies, and mortality rates per 10 000 inhabitants. The one-sample chi-squared test was used to determine differences in the number of deaths per wave for each independent variable. Bivariate logistic regression analysis was used to determine an association between duration of hospitalization and wave. Chi-squared tests and ANOVA models were used to examine differences between the independent variables during the four waves. A multivariable logistic regression analysis was used to estimate the magnitude of the relationship between ethnicity and mortality in the second, third and fourth waves compared with the first COVID-19 wave. Odds ratios (OR) and 95% confidence intervals (CI) are given. A p-value ≤0.05 was considered statistically significant. The case fatality rate was calculated by dividing the number of confirmed deaths by the number of confirmed cases during the study period (3).

Ethical considerations

This study was approved by the Medical Ethical Commission of Suriname’s Ministry of Health. Consent was waived because the study was a secondary analysis of de-identified data.

RESULTS

Table 1 shows the demographic characteristics of the the people who died from COVID-19. The median age was 66 years (interquartile range 56.0–75.5 years), with a range of 17–100 years. Of the people who died, 52.6% were aged ≥65 years, 56.2% were males, and 29.0% were of Creole ethnicity, followed by 26.8% of Hindustani ethnicity. Most of the patients lived in urban areas (76.8%). The highest mortality rates were among the Indigenous peoples and people of Creole ethnicity, both 34 deaths per 10 000, followed by people of Javanese ethnicity (24 deaths per 10 000).

TABLE 1. Deaths from COVID-19 and mortality rate by sociodemographic characteristics, Suriname.

Characteristic (n=1112)	n (%)	Population, N	Mortality rate (deaths per 10 000)
Age, in yearsa
15–24	9 (0.9)	93 950	1
25–34	35 (3.5)	85 000	4
35–44	59 (5.8)	75 530	8
45–54	129 (12.7)	59 870	22
55–64	248 (24.5)	39 400	63
65–74	260 (25.7)	22 490	116
≥70	273 (26.9)	12 250	223
Missing	99 (–)	NA	NA
Sex
Male	574 (56.2)	27 2690	21
Female	447 (43.8)	26 7220	17
Missing	91 (–)	NA	NA
Ethnicity
Creole	291 (29.0)	84 933	34
Hindustani	269 (26.8)	148 443	18
Indigenous	70 (7.0)	20 344	34
Javanese	181 (18.0)	73 975	24
Tribal	75 (7.5)	117 567	6
Mixed and other	117 (11.7)	87 391	13
Missing	109 (–)	NA	NA
Region
Urban	514 (76.8)	361 736	14
Rural	129 (19.3)	111 224	12
Interior	26 (3.9)	71 268	4
Missing	443 (–)	NA	NA

COVID-19, coronaviruse disease 2019; NA, not applicable.

^aMedian age was 66 years.

Source: Prepared by authors from the results, based on published data.

Figure 2 shows the epidemic waves based on confirmed cases and the fatality waves from March 2020 until November 2021. The overall case fatality rate of COVID-19 was 22 per 1 000 positive COVID-19 cases. The number of deaths in each wave (and as a proportion of all deaths during the study period) is as follows: 74 (6.7%, first wave), 38 (3.4%, second wave), 391 (35.2%, third wave), and 304 (27.3%, fourth wave). The number of deaths per wave differed significantly (p<0.001).

FIGURE 2. Trend in COVID-19 cases and deaths during the four epidemic waves, March 2020–November 2021, Suriname.

COVID-19, coronaviruse disease 2019.

Source: prepared by authors from results taken from published data.

Table 2 shows the sociodemographic characteristics of hospitalized patients who died in the four waves. The median age of patients in these waves varied between 65 and 70 years. The median duration of hospitalization differed significantly by the fatality wave (p<0.001). Patients were more likely to have a longer hospitalization duration (above the median) during the first (OR 1.66; 95% CI: 0.98, 2.82) and third fatality waves (OR 2.37; 95% CI: 1.71, 3.28) compared with the fourth wave. Although not significant, more male patients died of COVID-19 than female patients during each fatality wave. A significant association was seen between the different ethnicities and the four fatality waves (p=0.010). When compared with the mixed and other groups, patients of Creole ethnicity (OR 2.7; 95% CI: 1.33, 5.290; p=0.006) and Tribal people (OR 2.8; 95% CI: 1.12, 7.02; p=0.028) were more likely to die during the fourth wave than the third wave.

TABLE 2. Sociodemographic characteristics of hospitalized patients who died from COVID-19 by epidemic wave, Suriname.

Characteristic	Wave				p-value
	One (week 31–37, 2020)	Two (week 2–6, 2021)	Three (week 17–28, 2021)	Four (week 35–42, 2021)
Median age, in years	66	70	65	66	0.437
Median duration of hospitalization, in days	7.0	3.5	6.0	3.0	0.001
Sex, n (%)					0.294
Male	48 (64.9)	24 (63.2)	209 (54.3)	143 (55.0)
Female	26 (35.1)	14 (36.8)	176 (45.7)	117 (45.0)
Ethnicity, n (%)					0.010
Creole	16 (22.5)	8 (22.9)	106 (28.3)	100 (38.5)
Hindustani	14 (19.7)	9 (25.7)	100 (26.7)	68 (26.2)
Indigenous	11 (15.5)	4 (11.4)	18 (4.8)	16 (6.2)
Javanese	13 (18.3)	6 (17.1)	80 (21.3)	36 (13.8)
Tribal	7 (9.9)	3 (8.6)	21 (5.6)	17 (6.5)
Others	10 (14.1)	5 (14.3)	50 (13.3)	23 (8.8)
Region, n (%)					0.846
Urban	36 (80.0)	13 (81.2)	(162 (77.9)	155 (76.7)
Rural	6 (13.3)	3 (18.8)	39 (18.8)	40 (19.8)
Interior	3 (6.7)	0 (0.0)	7 (3.4)	7 (3.5)

COVID-19, coronaviruse disease 2019.

Source: Prepared by authors from the results, based on published data.

DISCUSSION

This study examined the COVID-19 mortality rate and its associated sociodemographic determinants, as well as hospitalization duration, between the COVID-19 epidemic waves in Suriname. As expected, the so-called fatality waves closely followed the epidemic waves in time and distribution. The case fatality rate of COVID-19 in Suriname was 22 per 1 000 cases. This rate was 0.018 deaths per 1 000 in Paraguay (16). Notably, our study showed that more deaths were recorded in the third and fourth waves. A possible explanation for this may be the different variants that emerged after the second epidemic wave, potentially causing higher mortality in Suriname. The P1, B1.1.7, and B1.351 variants were confirmed during these epidemic waves, as well as the delta variant during the third epidemic wave in Suriname (17, 18). The COVID-19 variants were assessed through genomic surveillance.

Proportionally more people of Creole descent and Indigenous peoples died of COVID-19 in Suriname. These higher rates are in line with other studies showing higher mortality rates in Black people and Indigenous populations (7, 19). Significantly more people of Creole descent and Tribal peoples died than people of mixed and other ethnicity during the fourth fatality wave compared with the third fatality wave. Underlying factors may relate to a lack of access to or use of health care services, social determinants such as poor work safety, poverty, and crowded housing (20, 21), as well as pre-existing health conditions and biological susceptibilities (22, 23).

Most of the people who died were men, a finding that concurs with other studies (5, 6). However, it should be noted that an increase in the number of women who died was seen in the third and fourth fatality waves. This finding may be related to the type of variants that were circulating during the corresponding epidemic waves. We also found that mortality was highest in patients 65 years and older, which is consistent with other studies (4, 5). Our study showed a significantly longer duration of hospitalization during the first and third waves, compared with the second wave. These differences may be explained by the changed virulence and pathogenicity of the circulating variants.

A strength of our study is that it included all registered deaths from COVID-19, from the start of the epidemic in Suriname until November 2021. Another strength is that the data were retrospectively collected in a short period of time using the hospital databases. We were therefore able to analyze the most recent data. Since almost 90% of the COVID-19 deaths occurred in hospitals, our results can be seen as representative of the Surinamese population. A limitation of our study was that data on all people in Suriname who tested positive for COVID-19 were not available. Therefore, we could not compare our results with the demographic variables of all confirmed cases or the waves as defined by the Ministry of Health. While most of the data were readily available, there was a backlog in entry of some data, such as on comorbidities. This was due to the effects of the epidemic on personnel with more sick leave and higher workloads. It should be noted that an important proportion of people may have had COVID-19 but were asymptomatic. Our study focused on hospitalized and thus symptomatic patients; hence asymptomatic people were not included.

Conclusion

This study showed that important sociodemographic differences in COVID-19 mortality rates exist in Suriname. Based on our findings, groups that can be identified as vulnerable are: men; people aged 65 years and older; people of Creole descent; and Tribal and Indigenous peoples. These groups require tailored interventions. The duration of hospitalization related to the different waves and circulating variants during the COVID-19 epidemic in Suriname also highlights that close monitoring of variants can help inform health planning. To gain further insight into the spread and effect of COVID-19 in Suriname, future studies should assess knowledge, attitudes, and behaviors of the Surinamese population regarding COVID-19, and include other sociodemographic factors, such as income, comorbidities, and vaccination status.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.