key: cord-0976116-b8iyyymr authors: Samrah, Shaher M.; W Al-Mistarehi, Abdel-Hameed; Ibnian, Ali M.; Raffee, Liqaa A.; Momany, Suleiman M.; Al-Ali, Musa; Hayajneh, Wail A.; Yusef, Dawood H.; Awad, Samah M.; Khassawneh, Basheer Y. title: COVID-19 outbreak in Jordan: Epidemiological features, clinical characteristics, and laboratory findings date: 2020-07-18 journal: Ann Med Surg (Lond) DOI: 10.1016/j.amsu.2020.07.020 sha: 34cff8c80366fe0e0da6a2338246e95cf7ab0d6c doc_id: 976116 cord_uid: b8iyyymr BACKGROUND: In March 2020, an outbreak of coronavirus 19 (COVID-19) was detected in the North of Jordan. This retrospective study is the first from Jordan to report the epidemiologic, clinical, laboratory, and radiologic characteristics of COVID-19 infected patients. METHODS: All patients with laboratory-confirmed COVID-19 infection by RT-PCR in the North of Jordan admitted between March 15 and April 2, 2020 were included. The clinical features, radiological, and laboratory findings were reviewed. RESULTS: Of 81 patients affected, 79 (97.5%) shared a common exposure to four recent travelers from endemic areas. The mean age was 40.0 years. Although about half (44 [54.3%]) were females, symptomatic patients were mostly females (75%). The most common presenting symptoms were nasal congestion, sore throat and dry cough. Less than one-third (31%) had chronic diseases. Although 84% of patients reported receiving Bacille Calmette-Guérin (BCG) vaccination, more asymptomatic patients had BCG than symptomatic (p = 0.017). Almost all patients (97.5%) had an elevated D-dimer level. Erythrocyte sedimentation rate (ERS) and c-reactive protein were elevated in 50% and 42.7% of patients, respectively. High ESR found to be the predictor of abnormal chest radiograph observed in 13 (16%) patients with OR of 14.26 (95% CI 1.37–147.97, p = 0.026). CONCLUSIONS: An outbreak of COVID-19 infection in northern Jordan affected more females and relatively young individuals and caused mainly mild illnesses. The strict outbreak response measures probably contributed to the lenient nature of this outbreak, but the contribution of other factors to such variability in COVID-19 presentation is yet to be explained. In a study from Singapore, mild respiratory tract infection was the main complaint in 38 patients with COVID-19, and a few patients required supplemental oxygen (8) . with the assay developed by the CDC, targeting the N1 and N2 genes (9) . Clinical charts, nursing records, laboratory findings, and chest x-rays of all 75 patients with laboratory-confirmed COVID-19 infection were retrospectively reviewed. Demographic data, medical and exposure history, underlying comorbidities, 77 laboratory results, and radiological findings were extracted. Data, that was not comparable ethical standards (10) . This work has been reporting based on STROCSS 89 2019 guidelines (Strengthening the Reporting of cohort studies in surgery) (11) . The from an endemic area (13) . Two patients were from the nursing staff at KAUH. The 113 majority of patients were relatively young; 43 (53.1%) were aged 18-39 years, 32 114 (39.5%) were aged 40-64 and 6 (7.4%) were older than 64 years. The mean ± SD 115 age of the patients was 40.0 ± 16.6 years (range 18-80) and 54.3% were females. About one third were cigarette smokers, 35.5% were obese (BMI ≥ 30 kg/m2), and 117 31% had chronic illnesses such as ischemic heart disease, hypertension, 118 dyslipidemia, diabetes mellitus, and malignancy. Four female patients were pregnant. The majority of the patients (84%) received BCG vaccination. The demographic and 120 clinical characteristics are shown in Table 1 . On admission about half of the patients (45.7%) were asymptomatic. The most 122 common presenting symptoms in the symptomatic patients were upper respiratory 123 tract symptoms, manifested as sore throat, and/or nasal congestion (40%), followed Abnormal chest radiographic findings were seen more in patients older than 50 148 years, obese patients, and those with higher acute phase reactants (CRP, and ESR), In this study, only 12.4% of the patients were older than 60 years, which is lower 162 than what has been described in Asia and Europe (4, 5, 6, 7, 8) . This reflects the demographic nature of the Jordanian population; 5.5% of the population is ≥ 60 years 164 old and 62.9% < 30 years old (14) . All patients presented in our study had either mild or no symptoms. Mild upper 166 respiratory tract infection symptoms were the most common presenting symptoms 167 followed by a dry cough. Fever was an uncommon presenting symptom. Besides, 168 females were significantly more symptomatic than males, unlike what has been 169 reported in the literature (15, 16) . In regard to the laboratory findings, CRP and ESR were elevated in 43% and 171 50% of patients, respectively but ESR was significantly higher in symptomatic Many studies reported normal chest radiographs in early or mild disease. In a 178 retrospective study of 64 patients in Hong Kong, 20% of patients did not have any 179 abnormalities on chest radiographs at any point during the illness (18) . In our study, 17% had infiltrates in chest radiographs and were significantly more common in 181 symptomatic patients. Obese patients, patients > 50 years old, and those with 182 elevated ESR and CRP had a higher incidence of lung infiltrates. Patients with 183 comorbidities such as Diabetes Mellitus and hypertension had a higher incidence of 184 abnormal chest radiograph but without statistical significance (p=0.053). Several studies described varying degrees of illness and severity: mild, severe, or 186 critical (19, 20) . In Singapore, among the first 18 cases of COIVD-19, mild respiratory 187 tract infection was the most common presentation with some patients requiring 188 supplemental oxygen (8) . A study from the Chinese Center for Disease Control and 189 Prevention with more than 44,000 confirmed cases has reported no or mild 190 pneumonia in 81%, while 19% were considered severe or critical with an overall case fatality rate (CFR) of 2.3% (19) . CFR reported worldwide is variable, probably related 192 to the population demographic features (such as age distribution of the population), 193 with as high as 5.8% in Italy (21) to 0.7% in South Korea (22) . Our results showed a mild spectrum of severity in the clinical presentation of this 195 outbreak. Similar presentations have been described as an initial trend of COVID-19 196 outbreak presentation in countries like Singapore and New Delhi, (6, 8, 23, 24, 25) (Table 197 6). The mildness of this outbreak might be explained by the including of 198 asymptomatic cases and the fact that the majority of our cases (97.5%) shared a 199 common source of exposure, an index case who lives in Spain and traveled to 200 Jordan which resulted in a local outbreak of COVID-19 (13) . Sharing the same COVID- There is no clear evidence that BCG immunization has a positive impact on 210 COVID-19 morbidity and mortality at the present time (26) . Two studies have 211 suggested that BCG immunization, given routinely after birth and at school age in 212 countries with a higher incidence of tuberculosis (TB) to primarily prevent TB 213 meningitis, induces a nonspecific-immune response that may have protective effects 214 against viral infections (27, 28) . Although few studies suggested a trend toward a 215 protective effect of BCG vaccination, these studies were prone to significant bias 216 from many variables, including differences in national demographics and disease 217 burden, testing rates for coronavirus infections, and the stage of the pandemic in 218 each country. (29, 30, 31) . BCG vaccination policy is adopted as part of the national immunization program of Jordan in 1970. Since 1983, children with no vaccination 220 scar were vaccinated at school age. Although patients who received BCG 221 immunization in our study were found to have a higher chance of being 222 asymptomatic, the small cohort size and cluster nature of our study population 223 cannot be representative to conclude a protective effect of BCG immunization on the 224 severity or lower incidence of COVID-19 infection. World Health Organization (WHO) 225 recommends BCG vaccination not to be used for prevention or lessening the severity 226 of COVID-19, pending further data (32) . The outbreak response measures, that were adopted and strictly applied by the While studies are being conducted to determine the benefits of several drugs against 245 COVID-19 such as antiviral protease inhibitors, and immunosuppressants (33, 34) , we 246 recommend to come up with restricted guidelines for isolation, and triage of these 247 patients as well as perform restrict outbreak response measures as early as possible. Our study has several notable limitations including the small cohort size. First, 249 most of our cases were mild cases with limited exposure to a critically ill spectrum of 250 disease. Second, BCG immunization was obtained by questioning the patients 251 rather than having documented medical records as most were patients who were 252 seen for the first time at our hospital. Third, some cases had incomplete 253 documentation of clinical symptoms and were missing laboratory testing or both. Laboratory data are reported as percent of patients with abnormalities defined according to the local reference ranges. URT Gupta et al. (23) Chen et al. (6) Young et al. (8) Saleemi et al. (24) Khamis et al. (25) Location of study • A COVID-19 outbreak in Northern Jordan caused asymptomatic or mild illness presentation. • Most of the cases in the outbreak shared a common exposure. • Young individuals and females were mainly affected in this outbreak. • The majority and more of the asymptomatic patients, reported receiving BCG immunization. • Inflammatory markers were elevated in most cases and Elevated ESR was a predictor to abnormal chest radiograph findings. • The strict outbreak response measures followed at early stages significantly limited the spread of COVID-19 pandemic in Jordan and probably contributed to the lenient nature of this outbreak. 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All authors were involved in project design, data collection, analysis, statistical analysis, data interpretation and writing the manuscript. All authors presented substantial contributions to the article and participated of correction and final approval of the version to be submitted. In accordance with the Declaration of Helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. Please enter the name of the registry and the unique identifying number (UIN) of your study. We gratefully acknowledge all health-care workers involved in the diagnosis and treatment of patients in KAUH. We thank Ali Banni Issa, Enas Bataienh, Heba Al Zamel, and Reem Qudisat for their assistance on data collection for patients with 2019-nCoV infection.