The Association of Latitude and Altitude with COVID-19 Symptoms: A VIRUS: COVID-19 Registry Analysis

Aysun Tekin1, Shahraz Qamar2, Vikas Bansal3, Salim Surani1, 4, *, Romil Singh1, Mayank Sharma1, Allison M. LeMahieu5, Andrew C. Hanson5, Phillip J. Schulte5, Marija Bogojevic3, Neha Deo6, Devang K. Sanghavi7, Rodrigo Cartin-Ceba8, Nitesh K. Jain9, Amy B. Christie10, Uluhan Sili11, Harry L. Anderson12, Joshua L. Denson13, Ashish K. Khanna14, 15, Igor Borisovich Zabolotskikh16, Abigail T. La Nou17, Murtaza Akhter18, Surapaneni Krishna Mohan19, Kenneth W. Dodd20, 21, Lynn Retford22, Karen Boman22, Vishakha K. Kumar22, Allan J. Walkey23, Ognjen Gajic3, Juan Pablo Domecq24, Rahul Kashyap1
1 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
2 Post-baccalaureate Research Education Program, Mayo Clinic College of Medicine and Science, Rochester, MN
3 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
4 Medical Critical Care Services, Texas A&M University, Corpus Christi, TX
5 Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
6 Mayo Clinic Alix School of Medicine, Rochester, MN
7 Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
8 Division of Pulmonary, Department of Medicine and Department of Critical Care Medicine. Mayo Clinic, Scottsdale, AZ
9 Division of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN
10 Department of Critical Care, Atrium Health Navicent, Macon, GA
11 Department of Infectious Diseases and Clinical Microbiology, Marmara University School of Medicine, Istanbul, Turkey
12 Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI
13 Section of Pulmonary, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
14 Wake Forest University School of Medicine; Wake Forest Baptist Health Network, Winston-Salem, NC
15 Outcomes Research Consortium, Cleveland, OH
16 Department of Anesthesiology, Intensive Care Medicine and Transfusiology, Kuban State Medical University with affiliation Territorial Hospital #2, Krasnodar, Russia
17 Division of Critical Care Medicine, Mayo Clinic Health System, Eau Claire, WI
18 Department of Emergency Medicine, University of Arizona College of Medicine–Phoenix, Valleywise Health, Phoenix, AZ
19 Panimalar Medical College Hospital & Research Institute, Varadharajapuram, Poonamallee, Chennai-600 123, Tamil Nadu, India
20 Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL.
21 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN
22 Society of Critical Care Medicine, Mount Prospect, IL
23 Pulmonary Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Evans Center of Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA
24 Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN

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Creative Commons License
© 2022 Tekin et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Medical Critical Care Services, Texas A&M University, Corpus Christi, TX, 78412, USA; E-mail:



Better delineation of COVID-19 presentations in different climatological conditions might assist with prompt diagnosis and isolation of patients.


To study the association of latitude and altitude with COVID-19 symptomatology.


This observational cohort study included 12267 adult COVID-19 patients hospitalized between 03/2020 and 01/2021 at 181 hospitals in 24 countries within the SCCM Discovery VIRUS: COVID-19 Registry. The outcome was symptoms at admission, categorized as respiratory, gastrointestinal, neurological, mucocutaneous, cardiovascular, and constitutional. Other symptoms were grouped as atypical. Multivariable regression modeling was performed, adjusting for baseline characteristics. Models were fitted using generalized estimating equations to account for the clustering.


The median age was 62 years, with 57% males. The median age and percentage of patients with comorbidities increased with higher latitude. Conversely, patients with comorbidities decreased with elevated altitudes. The most common symptoms were respiratory (80%), followed by constitutional (75%). Presentation with respiratory symptoms was not associated with the location. After adjustment, at lower latitudes (<30º), patients presented less commonly with gastrointestinal symptoms (p<.001, odds ratios for 15º, 25º, and 30º: 0.32, 0.81, and 0.98, respectively). Atypical symptoms were present in 21% of the patients and showed an association with altitude (p=.026, odds ratios for 75, 125, 400, and 600 meters above sea level: 0.44, 0.60, 0.84, and 0.77, respectively).


We observed geographic variability in symptoms of COVID-19 patients. Respiratory symptoms were most common but were not associated with the location. Gastrointestinal symptoms were less frequent in lower latitudes. Atypical symptoms were associated with higher altitude.

Keywords: Altitude, COVID-19, Gastrointestinal, Latitude, Respiratory, Symptoms.