key: cord-0968655-2nx7qyza
authors: Alotaibi, Abdullah Rashid; Ezzeldin, Tarek; Siddiqui, Intisar Ahmed; Alzahrani, Mosa Saeed; Alghamdi, Mohammed Ahmed; Alotaibi, Wijdan Hasan; Almutairi, Malik Zwaid; Alqannas, Naif Khalid
title: Correlation of Racial Effect with Severity of Disease and In‐Hospital Outcome in Individuals Diagnosed with COVID‐19
date: 2021-05-22
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14383
sha: 67033ab3814d43e047040bf807851549679c0bdb
doc_id: 968655
cord_uid: 2nx7qyza

INTRODUCTION: Many countries have diverse population and hence, studies have been conducted to find the relation between ethnic or racial groups within a society and incidence or mortality due to COVID‐19. OBJECTIVES: Aim of the study was to evaluate the racial effect on severity of disease and in‐hospital outcome in individuals diagnosed with COVID‐19. MATERIAL AND METHODS: This retrospective study based on records of 804 tested positive COVID‐19 patients presented at Dammam Medical Complex and Braira quarantine during March to May 2020 was conducted after approval from the ethical board. Patient’s records included the routine patient’s consent statement about explanation of all the investigations and procedures prior to be performed. Data were retrieved included in analysis were age, gender, country of origin, racial background (Arab, Caucasian, Asian, Black, Latin, and Hispanic), severity of COVID‐19 and outcome. RESULTS: Out of total 804 confirmed patients of covid‐19, there were 647 (80.5%) males and 157 (19.5%) females (M: F ratio = 4.1: 1). Male preponderance was seen in all racial groups, and significantly higher in Asian than the Middle Eastern race (91.2% vs. 70.3%, p=0.000). Mean age of Asians was significantly higher than the mean age of the Middle Eastern and Black & Caucasian races (42.8±10.0 vs. 39.6±16.3 vs. 37.0±10.3, p=0.003). proportion of deaths was significantly high among Asians (5.4%) compare to Middle Eastern patients (1.2%) (p‐value 0.001). CONCLUSION: Severity and in‐hospital outcome were varying significantly among the racial groups. East & South Asian COVID‐19 patients had more severe symptoms and less recovery rate compare to other groups, late presentation may be a contributory reason.

In the present literature, severity of novel corona virus infection covid-19 has been evaluated from many aspects including demographic characteristics, comorbidity, presenting symptoms and other clinical factors except racial effect which may be a potential confounding factor as Saudi Arabia is a country with a large number of skilled workers and laborers from variant country of origin, so this study will add correlation of various racial groups with the severity of covid-19 disease.

Racial diversity in Saudi Arabia may be potential confounding factor with regards to patient's adaptation, family history, life style and community norms. Hence, severity of novel corona virus covid-19 was evaluated in relation to the various racial groups along with demographic characteristics and other risk factors.

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Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) was announced as public health emergency of international concern on 8 th January 2020 (1) . It was started from Wuhan, Hubei Province, China and has subsequently spread around the globe. It is also considered the greatest challenge the world has faced since World War II, since it's emergence in Asia in December, the virus had spread all over the world infecting around half a million people every day.

Since the outbreak of the disease, numerous studies have been conducted to explore relation between the current pandemic with socio-demographic status, health status and other factors have also been studies and it is reported that age is one of the leading risk factors and severity of disease increases in the presences of comorbidities, such as heart and lung disease (2) (3) (4) . Many countries have diverse population and hence, studies have been conducted to find the relation between ethnic or racial groups within a society and incidence or mortality due to COVID-19.

According to 2011 census, proportion of ethnic minority in UK was 13% (5). Therefore, study was conducted to study the incidence or outcome of COVID-19 patients in the ethnic groups in UK (6) . CDC and COVID-19 associated hospitalization surveillance network examined that COVID-19 patients with race/ethnicity data found that 45% were Caucasian, 33% African American, 8% Hispanic, 5% Asian, <1% American Indian/Alaskan Native and 7.9% were of other or unknown race (7) . Similarly, other studies have also reported the emerging impact of the pandemic across ethnicities in various settings including in UK (8-10), USA (11) and Norway (12) .

Saudi Arabia has also various ethnic minorities. In the mid-2016, total population of Saudi Arabia was 31.79 million in which population of ethnic minorities was 11.71 million which contributed 36.8% of the total population of the country (13) . Although, proportion of ethnic minorities are high in Saudi Arabia however, to the authors' best knowledge, literature is unable to provide any study conducted in Saudi Arabia which studied the severity and outcome of the COVID-19 tested positive patients among racial groups. Hence, present study was designed to evaluate the correlation of racial effect with severity of disease and in-hospital outcome in individuals diagnosed with COVID-19.

This article is protected by copyright. All rights reserved The inclusion criteria were 1) COVID-19 should be confirmed positive on PCR, LAB findings and CT, 2) All age groups and both genders. Patients who were suspected for COVID-19 but tested negative on PCR, CT and LAB findings were excluded from the sample.

All the medical records of confirmed COVID-19 cases diagnosed based on LAB findings, PCR and CT findings reviewed to document the following features as anticipated outcomes of study:

age, gender, country of origin, racial background (Arab, Caucasian, Asian, Black, Latin, and Hispanic). Severity of COVID-19: mild, moderate, or severe is defined at the time of admission according to the British Thoracic Society guidelines (CURB-65) for the assessment of severity of pneumonia. In-hospital poor outcome of COVID-19 is defined as either need for ICU admission or expired.

Statistical data were analyzed by using SPSS-20.0, IBM product of Chicago (USA). Numeric response variable age was presented as Mean±SD. The categorical variables including gender, race, country of origin, comorbidities, symptoms, course of disease and in-hospital outcome of patients were presented by frequencies and percentages. Chi-square test was applied to compare racial effect in relation to patients' characteristics, severity of disease and in-hospital outcome of COVID-19. Logistic regression analysis was applied to calculate odd ratios of all predictive variables including gender, age, racial background, comorbid and severity of COVID-19 by taking in-hospital outcome poor or good outcome as binary variable. P-value ≤0.05 was considered statistically significant result.

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Out of total 804 confirmed patients of covid-19, there were 647 (80.5%) males and 157 (19.5%) females (M: F ratio = 4.1: 1). Mean age of patients was 41.1±13.7 (ranging from 5 to 100) years, and the commonest age group was 31-45 years in which nearer half of the patients (47.4%) were seen. Fifty percent patients were belonging to the Middle Eastern race followed by 388 (48.3%) Asian, 8 (1%) black and only 1 (0.12%) Caucasian. Black and Caucasian races were merged due to shorter number of patients in order to evaluate racial effect on patients characteristics and outcomes.

Male preponderance was seen in all racial groups, and significantly higher in Asian than the (Table-1 

This article is protected by copyright. All rights reserved Total eleven factors were evaluated to identify the predictors leading towards severity of disease and in-hospital death occurred due to Covid-19. The males as compared to females were about 7 times more likely to have a poor outcome. The age groups 31-45 years and 46-60 years had more likely poor outcomes respectively by 4 times and 3 times than the younger age groups. Asian race had 4.36 times more likely to appear with poor in-hospital outcome than the Middle Eastern race (p=0.000). However, involvement of various comorbidities did not show any significance except diabetes mellitus 2.43 times more likely to expose a poor outcome. Severe symptoms as compared to moderate symptoms have shown 10 times more likely poor outcome. Course of disease 7-14 days and above than 14 days as compared to below 7 days were equally high contributory factors of in-hospital poor outcome i.e. OR=5.58 and OR=4.35 respectively (Table- 3).

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After the distribution of sampled population according to their race it was found high proportion of COVID-19 positive patients belonged to the East and South Asia. Furthermore, average age above 40 years, prevalence of comorbidities, appearance of moderate/severe symptoms and poor outcome was also found dominating in this group. Studies reported that those in younger age group (14), be women (15) , and have fewer comorbidities (16) had higher chances to survive in case if they got the virus. A study conducted in 14 different states of USA and reported that COVID-19 related hospitalization was higher among males compare to females (5.1 vs 4.1 per 100,000 population (17) . In addition, current data also suggested that minority groups may also be more suspectable of getting infected from COVID-19 (17) . Furthermore, the educational barrier made them less aware about this current pandemic, precautions need to be taken, how they can prevent themselves, etc. These could be the possible reasons of what we found in analysis that patients in Asian group had more prevalence of comorbidities, having moderate to severe symptoms and even poor outcome.

In the Middle Eastern racial group, 276 were Saudis out of 407 which showed majority were nationals and very less were foreigners, secondly the countries in this group had same language which is Arabic. Whereas in East and South Asian group had 388 patients and all were foreigners and non-Arabic. Hence, it meant Asian group had high proportion of foreigners than other groups. Hence, due to these differences in two groups, health seeking behavior may vary between the groups. Late presentation to hospital could be an important factor associated with hospital outcome (21) however authors of the present study were not able to consider this variable as part of the collected data.

Socioeconomic status of the COVID-19 patients included in the study was not included and it was one of the study limitations. Access of the health care facilities, language barrier and literacy rate could also be contributing factors which were not recorded in this study.

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Prevalence of COVID-19 among different racial groups residing in Saudi Arabia was significantly different. Furthermore, males and aged people were found more infected from virus which in quite in line what had been reported in literature. Educating those are in low socioeconomic status and less educated could help to practice preventive measures in more effective way as well as can help to identify COVID-19 symptoms early which perhaps help to reduce the severity rate.

There is no conflict of interest of participants and no any involvement of funding in this study. This article is protected by copyright. All rights reserved 

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Values given in parentheses in 2 nd & 3 rd columns are percentages. *Shows significantly higher proportions at 5% level of significance

Complex, for providing us patient's files and notes.

Authors' contribution: All authors participated in this study and placed authorship as per their contribution in initiating the idea and proposal development, data collection, analysis, manuscript writing and review of manuscript.

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