key: cord-0976763-u6dnq5ke
authors: Panthee, Bimala; Dhungana, Saraswati; Panthee, Nirmal; Gyawali, Saroj; Paudel, Atmika; Panthee, Suresh
title: Clinical and epidemiological features of COVID-19 deaths in Nepal
date: 2020-10-19
journal: New Microbes New Infect
DOI: 10.1016/j.nmni.2020.100797
sha: 7330ae7c7e0ae66b64c372416263975839133886
doc_id: 976763
cord_uid: u6dnq5ke

COVID-19, caused by a deadly severe acute respiratory syndrome coronavirus (SARS-CoV)-2 has taken more than 0.7 million lives globally. In this manuscript, based on the official media releases of the Government of Nepal, we analyzed the clinical and epidemiological features of the patients who died as a result of COVID-19 infection in Nepal from January 23 to August 10, 2020. We found that nearly half of the deaths were among people less than 50 years of age and being female was highly likely to succumb to death. The majority of the deaths were associated with comorbidities, where most common comorbidities were cardiovascular diseases and diabetes followed by respiratory diseases. With approaching festive season and loosened lockdown, government and citizens need to be more cautious about the severity of the COVID-19 infection and take appropriate action.

COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronaviruses (SARS-CoV) -2. SARS-CoV -2, named in interim as 2019-nCoV[1] is of global concern due to its independent zoonotic transmission and rapid transmission rate. At present, COVID-19 accounts for more than 19 million infections and more than 0.7 million deaths, and 13% of those infections are in South-East Asia [2] . Eight months have passed since the first case of COVID-19 infection appeared in China [3] . Nepal saw its first case in January 23 and beginning March 24, Nepal implemented the national level lockdown [4] which ended on 22 July with a few restrictions in place. Recently, after the easing of national level lockdown, Nepal has seen a rapid increase in COVID-19 cases and deaths. The proper management of a disease requires the knowledge of its severity and mortality. The objective of this research is to analyze the clinical and demographic features of the patients who succumbed to death due to infection based on the official government reports. All data reported in this manuscript are current as of August 10, 2020.

J o u r n a l P r e -p r o o f After the incidence of the second case of COVID-19 in Nepal, Ministry of Health and Population-Nepal started to give regular media briefings [5] . Additionally, the MoHP has been releasing situation reports almost every day since January 28 [6] . The media briefings and situation reports explained the major activities of the government to curb the disease and current status of infections, hospitalization and deaths. By focusing on serious cases including deaths, the data for this research was obtained from those media briefings and situation reports.

Number of confirmed cases, confirmed deaths, and province wise deaths were obtained.

The symptoms reported, demographics of the deaths including age, sex, comorbidities, and diagnosis time were analyzed. When specific parameter was not explicitly mentioned in the media briefings or situation report, the data was reported as 'not sure'. The age of three dead patients was missing which was replaced with the mean data during analysis.

More than 6 months have passed since the detection of first case on January 23.

Although, the Government of Nepal used both Rapid Diagnostic Test (RDT) and real-time reverse transcriptase Polymerase Chain Reaction (RT-PCR) for testing SARS-CoV -2 in early days, Nepal required all the suspected cases to be confirmed with real-time RT-PCR to be counted in the official numbers. So far, Nepal has performed 452,236 RT-PCR tests and seen a total of 23,310 confirmed cases and 79 deaths, including the death of a Chinese national, attributed to COVID-19, with overall case fatality rate of 0.34%. Of the total cases, 16,493 (71%) have already recovered and based on the data reported on July 1 (SitRep#143) by the Government, the early recovery rates among male and female were 27% and 17%, respectively [6] . Recent trend indicates that the number of deaths is increasing faster than number of cases with the most recent doubling time for number of cases and deaths being 44 and 26 days, respectively (Figure 1a ). Since July 29, the MoHP started to release information regarding the number of cases that require ICU and ventilatory support. The recent data shows that the number of cases requiring ICU and ventilatory support is also in increasing trend (Figure 1b (The x-axis shows the number of days since the first reported case in Nepal (January 23), and yaxis shows the cumulative cases, recoveries and deaths and daily deaths in log 10 scale). (b)

Number of cases requiring admission to intensive care unit (ICU) and ventilatory support from J o u r n a l P r e -p r o o f July 29 to August 10. The data is extracted from references [5, 6] . The doubling time was calculated from the most recent data of August 10, by subtracting the day on which the events were half.

The maximum and minimum number of diagnosed cases were in province 2 and province 1 with 6,534 and 1,481 cases, respectively. The maximum number of deaths were also seen in province 2 and lowest deaths were observed in Karnali province. Although the total number of cases identified at Bagmati province is similar to that of Gandaki province, it bears the highest case fatality rate (0.71%) (Figure 2 ). Bagmati province includes the capital city Kathmandu, a medical hub for Nepal, and includes two out of four level 3 hospitals dedicated for COVID-19 treatment[7]. The higher case fatality rate in spite of healthcare preparedness at Bagmati indicates that some severe cases might have been referred from other provinces. in an ascending order. The lowest (0.14%), and the highest (0.71%) case fatality rates were for Sudurpaschim and Bagmati province, respectively. The data is extracted from references [5, 6] .

We found that the mean age of death was 50 years with a range of 0.13 years (49 days) to 85 years and majority of them (72%) were male ( Table 1) . Although female accounted for only 24% of deaths, as the gender-wise distribution of infection among male and female was 5.25 : 1, case fatality rate remained higher among female (0.51%) compared to that of male (0.29%) and

this is consistent with the lower recovery rates among women. Our finding contrast to many reports that indicate being male is highly associated with death due to COVID-19 [8] . Men were at a higher risk of death due to COVID-19 in India [9] , USA [10] , Brazil [11] , and England [8] . [13] .

Nearly half of the deaths occurred in younger population of less than 50 years of age (Table 1) . A nationwide disparity among the deaths attributed to COVID-19 and appears that there is a difference among the developed and developing regions. In developed regions, the elderly people account for higher share of the population, who are at significantly higher risk of dying, if contracted COVID-19. Regions like United States [14] , and Italy [15] have seen a larger proportion of elderly people, with the age more than 80 years, accounting for majority of deaths attributed to COVID-19; whereas the majority of deaths lied around 50 -70 years in countries like India [9] , Bangladesh [16] , Brazil [11] , and Iran [17] . In addition, as the life expectancy at birth in Nepal is about 70 years[18], the result from our analysis of COVID-19 deaths in Nepal is particularly alarming.

We found that only 33% of the cases were presented with definitive symptoms where respiratory difficulties were the most frequently reported symptoms followed by fever ( Table 1) . The reported incidence of symptoms in Nepal is far lower than reported in China [19] and Italy [15] ,

where at least more than 84% and 93% of the deaths had symptoms, respectively. In addition, 61% of the deaths were associated with comorbidities where cardiovascular diseases and diabetes accounted for the majorities of comorbidities (Table 1) . Although, the incidence of comorbidities among deaths is much lower than reported in China [20] , South Korea [20] ,

Italy [15] and Brazil [11] , this data is similar to the one reported from USA [14] . Given the differences among national data, it is very important to consider the region-specific strategic plan in the management of COVID-19. The higher incidence of cardiovascular disease and diabetes among COVID-19 deaths in Nepal is, in fact, similar to those reported in the studies [11, 14, 15, 20] . Recent studies have shown the involvement of angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 in SARS-CoV-2 entry and binding [21, 22] whose expression have been found to have increased in diabetic patients [23] . Thus, being diabetes increases the risk of death due to COVID-19, however, with proper management and controlled sugar level, the outcome of COVID-19 in diabetic patients can be improved [24] .

We further found that more than half of the deaths were diagnosed as COVID-19 positive after the death (Table 1) . A major study covering two states of India found that about 18% of the deaths were reported either ≤ 24 hours before death or posthumously [9] . In Nepal, when the COVID-19 infection was confirmed after death or the data was not available, 71% of the events were reported as without symptoms. We speculate that the posthumous detection of the cases in 

In summary, more than half of the COVID-19 deaths were related to comorbidity and respiratory problems were most frequently observed among them. Although males were vulnerable to infection, we found that, if infected, women were particularly at more risk to succumb to death.

Interestingly, not majority of fatalities were associated among elderlies indicating that younger population also need to be considerate towards the severity of the disease. Although the Nepal government's management appeared to be effective in the beginning, later due to uncontrolled entry of the returnees, lack of ability to conduct massive testing, poorly managed quarantines, and lack of adherence to physical distancing measures among citizens, the number of cases and deaths did not decrease even with the strict measures in place [4] . In conclusion, with loosened lockdown, and upcoming festive seasons, it might be difficult to control the spread of COVID-19. Therefore, Nepal needs to be more prepared to detect, handle, and treat more infection in the coming days before the healthcare system becomes overwhelmed.

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