key: cord-0275431-zs6sjlyn
authors: Omer, S.; Sarwar, M. B.; Roman, M.; Usman, M.; Khan, M. A.; Afzal, N.; Qaiser, T. A.; Yasir, M.; Shahzad, F.; Tahir, R.; Ayub, S.; Akram, J.; Jahan, S.
title: Epidemiology, Clinico-Pathological Characteristics, and Comorbidities of SARS-CoV-2 infected Pakistani Patients
date: 2021-09-27
journal: nan
DOI: 10.1101/2021.09.25.21264111
sha: 0ceb5eb0eea9490ac23d6d980fedc96d715c5fd8
doc_id: 275431
cord_uid: zs6sjlyn

SARS-CoV-2 is a causative agent for COVI-19 disease, initially reported from Wuhan, China. Infected Patients experienced mild to severe symptoms, resulting in several fatalities due to a weak understanding of its pathogenesis, which is the same even to date. This cross-sectional study has been designed on four hundred and fifty-two symptomatic, mild-to-moderate, and severe/critical patients to understand the epidemiology and clinical characteristics of COVID-19 patients with their comorbidities and response to treatment. The mean age of studied patients was (58{+/-}14.42) years, and the overall male to female ratio was 61.7 to 38.2%, respectively. 27.3% of the patients had a history of exposure, 11.9% travel history, while for 60% of patients, the source of infection was unknown. The most prevalent signs and symptoms in ICU patients were dry coughs, myalgias, shortness of breath, gastrointestinal discomfort, and abnormal Chest X-ray (p<0.001), along with the high percentage of hypertension (p=0.007) and COPD (p=0.029) as leading comorbidities. Complete Blood Counts indicators were significantly increased in severe patients, while the Coagulation Profile and D-dimer values were significantly higher in mild-to-moderate (non-ICU) patients (p < 0.001). Serum Creatinine (1.22 umole L-1; p = 0.016) and LDH (619 umol L-1; p < 0.001) indicators were significantly high in non-ICU patients while, raised values of Total Bilirubin (0.91 umol L-1; p = 0.054), CRP (84.68 mg L-1; p = 0.001) and Ferritin (996.81 mg L-1; p < 0.001) were found in ICU patients. Drug Dexamethasone was the leading prescribed and administrated medicine to the COVID-19 patients, followed by Remdesivir, Meropenem, Heparin, and Tocilizumab, respectively. A characteristic pattern of Ground glass opacities (GGO), consolidation, and interlobular septal thickening were prominent in severely infected patients. These findings could be used for future research, control, and prevention of SARS-CoV-2 infected patients.

The novel Coronavirus (2019-nCoV) was first identified, in patients with pneumonia of unknown cause, originating in Wuhan, China, in late December 2019 (Lu, Stratton, and Tang 2020; Zhou et al. 2020) . The virus that caused this infection belongs to the Conronaviridae family (Lvov and Alkhovsky 2020) . Later, this virus was named "Severe Acute Respiratory Syndrome Coronavirus 2" (SARS-CoV-2) by the World Health Organization (WHO) that caused the coronavirus disease 19 (COVID-19) (WHO 2020). In January 2020, WHO declared the COVID-19 outbreak, a Public Health Emergency of International Concern, and a pandemic in March 2020 (J. ).

As of September 2021, WHO has reported 228,8076,631 confirmed cases, with more than 4,697,099 deaths attributed to the ongoing COVID-19 pandemic, while Within Southeast Asia, the confirmed cases have risen 42,594,688 (WHO 2021) .

In Pakistan, the first confirmed case of COVID-19 was reported on February 26, 2020, and until June 17, 3 parts of the country (Nawaz et al. 2020) . Considering the severity of the pandemic, the Government of Pakistan has established the National Command and Operational Centre (NCOC) to synergize and articulate national efforts against COVID-19 (NCOC 2021b) . Measures taken by NCOC to control pandemics were quite effective. NCOC adopted the WHO checklist to exercise travel restrictions, smart lockdowns, workplace hazard controls, and even facility closures to minimize exposure with the carriers (asymptomatic) as preventive measures (NCOC 2021c). As of September 2021, Pakistan's total confirmed COVID count had reached 1,230,238 with 27,374 deaths and 1,140,917 recoveries (NCOC 2021a) . Despite the control measures launched into action, the alarming rise in COVID-19 cases and increasing fatalities in the region have raised multiple concerns regarding the infrastructure of our health system and the overwhelming burden placed on it. Understanding the relationship between COVID-19 and epidemiological features like clinicopathological characteristics and treatment available for mild-to-moderate and severe patients is essential to suggest preventive measures. Epidemiological features include age, sex, race, and comorbidities, which are the most studied parameters not only in COVID-19 but also in other infectious diseases , Sun et al., 2020b , Bi et al., 2020 .

Practically most health workers relied upon clinical signs and symptoms, mainly involving the respiratory and digestive system, associated with fever, fatigue, and lab findings such as raised values of IL-6, D-dimer, Procalcitonin, CBC counts, etc. to assess disease prognosis (Grant et al. 2020; Lechien et al. 2020; Tian et al. 2020 ).

SARS-CoV-2 infected patients showed variable symptoms, ranging from mild to severe illness. It primarily affects the pulmonary system producing symptoms like a sore throat, cough, rhinorrhea, nasal congestion, dyspnea, digestive system causing nausea, vomiting, diarrhea, abdominal pain; associated systemic symptoms like fever, headache, myalgia, arthralgia, generalized body ache, and fatigue. It may affect the nervous system, causing atypical clinical findings, such as anosmia, loss of taste, dizziness, and rarely seizure. The most common symptoms seen were fever, dyspnea, myalgia, etc. One in five patients infected with SARS-CoV-2 did not develop noticeable symptoms, acting as a silent carrier, thereby increasing the chances of further progression of SARS-CoV-2 infection and putting old age patients at risk and those with associated comorbidities like Diabetes, Hypertension, COPD, ARDS, IHD, Chronic Liver Disease, Chronic Kidney Disease. Comorbidities and the nature of pathological findings in the organs and tissues are the leading factors that determine the disease severity and outcome (Gu and Korteweg 2007; Mueller, McNamara, and Sinclair 2020) The mortality ratio of COVID-19 patients depends on viral-host genetic interaction and geographical setting (international and regional spread), as climates differences influence viral transmission via respiratory droplets (Oberemok et al. 2020) . Punjab is the largest and most densely populated province of Pakistan, has a population of 110 million, out of which about 64% reside in the urban areas (GOP 2017). It has a high population density of about 536 persons per square kilometer, increasing susceptibility towards the spread of COVID-19. Out of the total COVID-19 confirmed patients, about 37% were located in the province of Punjab (GOP 2021).

Islamabad is the capital tertiary of Pakistan with more than two million inhabitants, but due to limited area, it has the highest average population density of 2,215 persons per square kilometers (GOP 2017) . The city is the gateway to the country for foreign travelers and provides habitation to people from the whole country. Islamabad had 81,116 confirmed patients of COVID-19 (GOP 2021) . Accordingly, the main referral hospital of Islamabad was also selected for this study.

In Pakistan, limited studies have been conducted to get the epidemiological aspect, clinic pathological parameters, and comorbidities of COVID-19 patients. This study is aimed to expand our knowledge about the COVID-19 pandemic by assessing the symptomatic hospitalized COVID-19 patients based on the epidemiological, clinical, and laboratory characteristics. It is hoped that this study shall contribute to a better understanding of COVID-19 patient risk factors and the assessment of the severity and outcome of disease that would be valuable for preventive interventions, treatment strategies, and overall patient management. The comparative cross-sectional study was conducted in the leading hospitals designated for COVID-19 treatments, i.e., Mayo Hospital Lahore, Jinnah Hospital Lahore, Sheikh Zaid Hospital Lahore, University of Health Sciences, Lahore, Nishtar Hospital Multan, Victoria Hospital Bahawalpur, Pakistan Institute of Medical Sciences (PIMS) Islamabad and Infectious Treatment Centre (IHITC) Islamabad.

A non-probability convenience sampling technique was used for the selection of the study population. qPCR confirmed SARS-CoV-2 positive patients aged >18 years admitted in the isolation wards of the selected hospitals were selected after taking permission from the respective administration. These patients were divided into mild-tomoderate and severe categories using the operational definitions of "Chinese Clinical Guidance for COVID-19

Pneumonia Diagnosis and Treatment," published by the Chinese National Health Commission (Gao, Tian, and Yang 2020) . The patients in the ward meeting the case definition for COVID-19 with and without evidence of viral pneumonia were categorized as mild-to-moderate. Whereas patients in intensive care units with clinical signs of pneumonia (fever, cough, dyspnea, tachypnea), including the following: respiratory rate >30 breaths min -1 ; severe respiratory distress; or oxygen saturation (SpO2) < 90% on room air, were considered as severe. The estimated sample size was ~450 patients using the WHO formula and considering the anticipated population proportion ).

Before entering the isolation wards, guidelines and SOPs of each hospital were adopted. A detailed questionnaire was prepared with the assistance of three medical consultants for the collection of information, which was based on similar studies (Kirchberger et al. 2021; Al Mutair et al. 2020; Yegorov et al. 2021 profile, inflammatory biomarkers for organ function and analysis of immunological responses), and treatment given (antibiotics oral/IV?, antiviral, steroids, I/V fluids, orogastric fluids, antimalarial and any experimental drug), length . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 of hospitalization, and time taken to get the negative result of qPCR for SARS-CoV-2 (1 st qPCR negative Report).

The digital images of the Chest CT scan of COVID-19 patients were obtained from selected hospitals and shared with experienced radiologists for characteristic disease findings.

Data were entered, cleaned, and analyzed using Statistical Package for Social Sciences (SPSS)V.23. The quantitative variables like age and laboratory parameters were presented in mean and standard deviation. In contrast, qualitative data like clinical features, comorbidities, and demography were presented in frequency and percentages.

The relationship between COVID-19 with clinic-pathological parameters and comorbidities among mild-tomoderate and severe patients was assessed using the Chi-square test (p ≤ 0.05). Means were compared using the student's t-test or ANOVA where applicable. Bar and pie diagrams were used to present categorical data where applicable.

Four hundred and fifty-two (452) 

The most common symptoms of illness in the COVID-19 patients were fever (n=364; 80%), followed by dyspnea at rest (n=343; 75%) and cough (n=261; 57%). Small percentage of COVID-19 patients had fatigue (n=138; 30%), pneumonia (n=89; 19%), myalgias and generalized body aches (n=75; 16%). Vomiting (n=61; 13%), headache (n=36: 7.9%), sore throat (n=33; 7.3%), diarrhea (n=33; 7.3%), sputum production (n=19; 4.2%), nausea (n=13; 2.9%), loss of taste (n=12; 2.7%), rhinorrhea (n=12 ; 2.7%), anosmia (n=7; 1.5%), nasal congestion (n=5;

1.1%) and abnormal Chest X-ray n=36 (7.9%) were also observed. Some clinical manifestation differed significantly between mild-to-moderate and severe patients. Symptoms of dyspnea, pneumonia, respiratory distress and abnormal Chest X-ray findings were more pronounced in severe patients as compared to mild-to-moderate cases (p < 0.001).

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On the contrary symptoms of fatigue (p < 0.001) and loss of taste (p = 0.04) were seen in mild/moderate cases…? Tabulated summary of clinical feature of SARS-CoV-2 infected patients are shown in Table 2 .

Compared mild-to-moderate patients, severe patients had underlying co-morbidities such as hypertension (n=104;

48.8%), type 2 diabetes (n=82; 38.5%), ischemic heart disease (n=36; 16.9%). Other diseases included chronic kidney disease (n=10; 4.7%), asthma (n=6; 2.8%), immunocompromised state (n=6; 2.8%), COPD (n=7; 3%), liver disease (n=2; 0.9%) and history of smoking (n=3: 1.4%). The severe patient included a significantly high percentage of hypertension (p=0.007) and COPD (p=0.029). These co-morbidities impact outcome of disease severity and COVID-19 mortality. A comprehensive comparison is shown in Table 3 .

The mean values of Complete Blood Count (CBC) were significantly high in severe patients as compared to mild-to- Table 4 .

The Table 5 summarized the medication given to the SARS-CoV-2 infected patients. Almost all SARS-CoV-2 infected patients, spanning from mild-to-moderate and severe had combination of antiviral, antibacterial, corticosteroid-based medication combined with oxygen therapy. Only two critically ill patients were on invasive ventilators, while others were managed with non-invasive ventilation. As compared mild-to-moderate patients, 

A significant correlation was assessed among laboratory parameters that are summarized in (Table 6) :

i. A highly significant positive correlation was evaluated between ferritin and Hb, WBC, ALT/SGPT, total bilirubin, CRP, and LDH and had a highly negative correlation with lymphocytes.

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The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10. 1101 ii.

D-dimer had a highly positive significant correlation with WBC, INR, procalcitonin, and LDH.

iii. Hb had a highly positive significant correlation with ALT/SGPT and hematocrit. In contrast, it was negatively correlated with CRP and sodium.

iv. WBC had a highly positive significant correlation with neutrophil, LDH, CRP, and INR.

A highly significant positive correlation was assessed between hematocrit and ALT/SGPT.

vi. INR had a highly positive significant correlation with neutrophils.

vii. CRP had a highly positive significant correlation with procalcitonin, neutrophil, and LDH, negatively correlated with potassium.

viii. LDH had a highly positive correlation with neutrophils.

ix. Platelets had a negative correlation with sodium and total bilirubin.

The patients that underwent Chest CT scans were also assessed in this study and summarized in Table 7 and Figure 2 . and Opacities n=2 (6.7%), infiltration (n=2, 6.7%), consolidation (n=1, 3.3%) and cavitation (n=1, 3.3%). Seventeen (57.7%) had five affected lobes, 8 (26.7%) had four affected lobes, 2 (6.7%) had three affected lobes, 2 (6.7%) had two affected lobes, and 1 (3.3%) had one affected lobe Figure 2 .

The number of male patients was high compared to female patients, presumably due to men's increased vulnerability to COVID 19 due to various reasons. It has been attributed that females showed more resistance to COVID-19 infection than men due to differences in sex hormones and lower expression of receptors (ACE-2) (Bwire 2020). Others have reported that men show high mortality from heart disease and diabetes, contributing to sex-based severity from COVID-19 (Pradhan and Olsson 2020; Tian et al. 2020 ). The older aged peoples are at high risk to catch the SARS-CoV-2 due to weak immune system and high prevalence of comorbidities, and this susceptibility has also been concluded in different studies (Amber L. Mueller, Maeve S.McNamara, and David A.

Sinclair 2020; Al Mutair et al. 2020; Yegorov et al. 2021) . The high number of COVID-19 patients in the study belonged to the extended family type, presumably due to crowded living conditions that favored the spread of disease. The same has been concluded in different studies (Noreen et al. 2020; Ramadhana 2020) .

The source of infection was unknown for 60% of COVID-19. It has been reported in other studies that the prevalence of asymptomatic carriers is difficult to determine, requires comprehensive screening. This would provide . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101/2021.09.25.21264111 doi: medRxiv preprint essential information on hidden viral strains circulating in the community, and the rate of such carriers would be different in high-density urban areas (Ahmed, Colebunders, and Siewe Fodjo 2020; Cloutier et al. 2020) . Similarly, it has also been reviewed that the majority of asymptomatic patients appear to have a milder clinical course during hospitalization, but the severity of the symptoms in asymptomatic patients among all confirmed cases varies widely (from 1.95% to 87.9%), according to the study setting and the populations studied (Han et al. 2020) . It was concluded that patients with travel history from abroad (11%) were positive for COVID-19 on the health authorities' investigation. Since Pakistan has a high frequency of travel and trade with China and Iran, it has been reported that the risk of viral transmission across borders increases (Javed et al. 2021; Noreen et al. 2020) .

Furthermore, an inclination to withhold travel history to high-risk epidemic regions also results in unpredictable outcomes . The susceptibility of getting infected while coming in contact with confirmed COVID-19 patients (27%) may be attributed to person-to-person transmission, as reported in several similar studies (Cloutier et al. 2020; Lechien et al. 2020; Martinez-Fierro et al. 2021) . It was concluded that the average number of days spent in the hospital was significantly high in severe patients compared to mild/moderate patients (10 vs. 5 days, p < 0.001).

Symptoms of illness such as fever (80%), shortness of breath (75%), and cough (57%) are most common, predominantly due to the reason that the disease is reported to affect the lower respiratory system. Presumably, due to similar reasons, the symptoms of shortness of breath, pneumonia, and abnormal chest X-ray were significantly high in severe patients. The results coincide with other studies wherein it has been reported that fever, cough, Other symptoms of COVID-19 patients, including myalgia and generalized body aches, vomiting, headaches, etc., were presumably associated symptoms of fever, cough, and shortness of breath. Similar findings were reported in various studies from different regions (P. Weng, Su, and Wang 2021, 2021 ). An alternative diagnosis should also be considered to prevent weak opinion, mainly other infectious diseases like pneumonia of bacterial etiology, bacteremia, and respiratory infections such as exacerbation of COPD, cardiovascular disorders like acute heart failure. Systematic evaluation of heart function should be done in COVID-19 suspected patients.

Ruling out other differentials with similar clinical features prevents extended hospital stay in isolation wards, shortage of beds required for critical COVID-19 patients, thereby reducing the burden on the healthcare system.

The predominance of patients had a longstanding history of hypertension (48.8% vs. 35.9%), type 2 diabetes (38.5%

vs. 31.4%), ischemic heart disease (16.9% vs. 12.5%). In severe COVID-19 patients, these may be linked to multiple factors, among them the significant ones the aged patients, reduced systemic oxygenation intake due to pneumonia, concomitantly increased cardiac demand, and use of ACE inhibitors. The high percentage of hypertension and chronic obstructive pulmonary disease (COPD) in the severe patient may also be linked to similar reasons along with underlying poor lung reserves or increased expression of ACE-2 receptors in small airways. Many studies . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101/2021.09.25.21264111 doi: medRxiv preprint found a high risk of infection in cardiovascular, pulmonary, and renal patients (De Almeida-Pititto et al. 2020; Leung et al. 2020) . Most importantly, studies revealed that high mortality ratios in COVD-19 patients were associated with cardiovascular and renal complications of diabetes and independently with glycemic control and BMI (Dyusupova et al. 2021; Holman et al. 2020; Richardson et al. 2020) .

Complete blood count, coagulation profile, biochemical parameters, and inflammatory mediators predict disease 

A significantly high percentage of severe patients were treated with steroid (Dexamethasone), antiviral (Remdesivir), antibiotic (Meropenem), anticoagulant (Heparin), and immunosuppressive (Tocilizumab) as compared to mild/moderate patients. Dexamethasone helps control inflammation of the lower respiratory tract and its immunosuppressive role (Selvaraj et al. 2020) . patients. Therefore, it has been recommended that early anticoagulation may reduce coagulopathy, microthrombus formation, and the risk of organ damages (Becker 2020; Gozzo et al. 2020; Richardson et al. 2020 ). It has been reported that treatment with Tocilizumab, whether administered intravenously or subcutaneously, might reduce the risk of invasive mechanical ventilation or death in patients with severe COVID-19 pneumonia (Guaraldi et al. 2020) .

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Radiological findings:

Chest X-ray is a valuable tool in assessing disease progression and severity. In COVID-19 patients, it may be normal initially but later may follow a characteristic pattern of progression from bilateral lower predominant zone to upper zones, vertically extend peripheral to diffuse in critical ICU patients showing a picture of ARDS. It has been concluded that in the initial Chest X-ray on admission, involvement of >4 zones have been linked to increased severity and unfavorable outcome.

Non-enhanced Chest CT is a vital component in the diagnosis of patients suspected of COVID-19 infection. The pattern of GGO, GGO, and consolidation, and interlobular septal thickening were the most prominent findings among infected patients of different age groups, gender, and severity. The pattern of findings is somewhat similar to that described in related studies on severe acute respiratory syndrome Pan et al. 2020; Wu et al. 2020 ). In critical patients, honey-combing pattern, traction bronchiectasis, interlobar pleural traction can be appreciated. Follow-up CT after six months may show fibrotic changes in such patients. Combination RT-PCR analysis and Chest CT scan increase the sensitivity and specificity of Covid-19 diagnosis to 88% and 100%, respectively. Semi-quantitative CT Severity Score System (CT-SSS) helps in showing the extent of pulmonary involvement. It is as follow, 0 score = no involvement 1 score = <5% involvement 2 score = 5-25% involvement 3 score = 26-49% involvement 4 score = 50-75% involvement 5 score = >75% involvement Total CT severity score is calculated by summing up the individual lobe score, with a cumulative score ranging from (0-25). CT score > 18 has been correlated with increased severity, mortality, and worse prognosis. In another study, it has been reported that a CT score > 7 has been linked to increased chances of developing the post-covid syndrome.

Older patients, predominantly male was more in number in both groups with comorbidities, mainly hypertension, type 2 diabetes, and ischemic heart. Preventive measures against COVID-19 must be followed, and surveillance for asymptomatic carriers should be increased. Excessive use of antibacterial, antiviral, anticoagulants, and drugs for . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101/2021.09.25.21264111 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 . Correlation is significant at the 0.01 level (2-tailed).

*Correlation is significant at the 0.05 level (2-tailed).

.

It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review) Data are n(%)and mean (S.D.)

.

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(which was not certified by peer review) 

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