key: cord-0757036-5g1mebsb
authors: Parvin, Sultana; Islam, Md. Samiul; Majumdar, Touhidul Karim; Ahmed, Faruque
title: Clinicodemographic Profile, ICU Utilization and Mortality Rate Among the COVID-19 Patients Admitted During the Second Wave in Bangladesh
date: 2021-12-03
journal: IJID Regions
DOI: 10.1016/j.ijregi.2021.11.011
sha: c837007200f106c8f073608cd549dc16e2b44c3e
doc_id: 757036
cord_uid: 5g1mebsb

Introduction: The second wave of Coronavirus Disease 2019 (COVID-19) started appearing in August-September 2020 across the Indian subcontinent. The wave arrived in our country in the middle of March 2021. This pilot research from a tertiary care COVID-dedicated hospital observed the clinicodemographic profile, ICU utilization, and mortality rate among the COVID -19 admitted patients during the second wave. Methods: RT-PCR (Reverse Transcription–Polymerase Chain Reaction) or high-resolution computed tomography (HRCT) chest confirmed 972 COVID-19 cases were included in this cross-sectional study from 24th March to 23rd June, 2021, using a convenience sampling technique. Data regarding clinicodemographic profile, ICU utilization, and mortality rate were analyzed. Results: The mean age of the study cohort was 54.47±12.73 years, with most patients (48.3%) in the 41-60 age range and 64.1 % were male. Fever (77.9%) and cough (75.9%) were the two most common symptoms, with hypertension (43.6%) and diabetes (42.15%) being the most common comorbidities. Nearly half of the patients had total lung involvement of 26-50%, and 23.8% required ICU. The overall mortality rate was 16.5%, whereas the mortality rate among ICU admitted patients was 56.1%. The most important predictors of mortality were older age, chronic renal illness, the proportion of lung involvement, and ICU requirement. Conclusions: The current study found a overall higher mortality and ICU utilization rate, as well as a greater total lung involvement in HRCT during the second wave. The mortality rate among the elderly and ICU patients was also higher than earlier.

The severe acute respiratory syndrome coronavirus (SARS-CoV-2)-caused worldwide pandemic began in Wuhan, China, in December 2019 and swiftly spread around the world, culminating in wave after wave of outbreaks. . (Ridruejo and Soza, 2020, Taboada et al., 2021) The World Health Organization (WHO) has designated the new illness as Coronavirus Disease 2019 . (Lippi et al., 2020) Further, on 30th January 2020, WHO proclaimed it a Public Health Emergency of International Concern (PHEIC), and on 11th April 2020, it was declared a pandemic. (Cucinotta and Vanelli, 2020 ) Based on information received from the affected nations, the World Health Organization has already reported a total of 18,52,91,530 laboratory-confirmed cases of the illness, with 40,10,834 deaths as of 9th July 2021. (WHO, 2021) Although more than half of COVID-19 cases are asymptomatic, others develop symptoms ranging from flu-like episodes including fever, cough, myalgia to pneumonia. Age, sex, and co-morbid illness are found to be associated with the severity of the disease that causes multiorgan involvement and death. (Chan et al., 2020 , Soriano et al., 2021 The majority of COVID-19 diseases (about 80%) present in a mild form and may generally be managed without hospitalization. Admission is required in 15-20 % of the patients, and critical care is required in 3-5% of cases, with reported fatality rates ranging from 50 to 97 % in those requiring ventilatory support. (Auld et al., 2020, Wu and McGoogan, 2020) Since the first case was documented at the beginning of March of 2020, 568,706 persons in our nation have been found to be positive for COVID-19, and 8,668 people have already died, resulting in a fatality rate of 1.52% through 20th March 2020. Overall daily case detection began to drop in early December 2020, and in early January 2021, the detection fell below 1000 per day. But, the number of detection and the rate of case referral to hospitals increased again on 16th March 2021, indicating the commencement of the second wave of the pandemic. According to recent studies from other nations, the second wave has much higher infection rates, ICU utilization, and mortality. (Graichen, 2021 , Jain et al., 2021 There is currently paucity of data on the second wave among the people of our nation.

This study would be one of the first to investigate the clinicodemographic profile, ICU utilization, and mortality rate among the COVID-19 admitted cases during the second wave. The research would also provide information on the symptomatology and comorbidity associated with the present wave.

This cross-sectional study was conducted in a tertiary care COVID-19 specialist hospital during the peak of the second wave (from the 24th March, 2021, to the 23rd June, 2021). The 250-bed hospital is located in the country's capital and serves a population of 10.9 million people in the city's northern reaches. Following a convenience sampling technique, 972 confirmed COVID-19 cases were included on the basis of diagnostic RT-PCR (Reverse Transcription-Polymerase Chain Reaction) and or positive chest high-resolution computed tomography (HRCT). Patients under the age of 18 years were excluded. The study was approved by the institutional review board of the COVID-19 dedicated hospital, who waivered the requirement for informed consent in the face of a pandemic scenario.

A pre-formed data sheet containing demographics, symptoms, comorbidity, HRCT findings, ICU utilization, patient vital status, and patient outcome was used to collect the data. A chest HRCT was done if necessary, and all HRCTs were reported by the same specialist radiologist. Each patient's HRCT severity score was calculated based on lung involvement by calculating the percentage of each lobar involvement separately and allocating a number between 1 and 5, with a score of 1 signifying 5% involvement, score 2: 5-25% involvement, score 3: 26-50% involvement, score 4: 51-75% involvement and Score 5: > 75% involvement. The patient's ultimate score was computed out of 25 by adding the individual lobar scores. The total lung involvement was then calculated by multiplying the ultimate score by 4. Finally, the extent of total lung involvement was categorized as follows: Minimal involvement: 1-25% of total lung volume, Mild involvement: 26 to 50 %, moderate involvement: 51-75%, and >75% lung involvement was considered as Severe. (Al-Mosawe et al., 2021 , Francone et al., 2020 SPSS (Statistical Package for the Social Sciences) Statistics software version 23 from IBM Corporation, Armonk, New York, was used for the statistical analysis. Numbers and percentages were used to represent categorical data. The mean and standard deviation were used to present numerical data. The Chi-square test was used to examine qualitative factors, while an unpaired t-test was used to assess quantitative data. The cutoff for statistical significance was determined at p<0.05.

During the research period, 983 patients were admitted to the tertiary care COVID-19 specialty hospital. A total of 972 individuals were included in the research after the exclusion of 11 patients (Three patients were under the age of 18, and eight patients had symptoms but were negative for COVID-19 on both HRCT of the chest and RT-PCR). The average age of the research participants was 54.47±12.73 years, with 64.1% of them being male. Patients aged between 41 to 60 years made up the majority of the study population (48.3%). Most patients had one or more of the following co-morbid conditions: hypertension (HTN) (43.6%), diabetes mellitus (DM) (42.1%), bronchial asthma (BA) (9.7%), ischemic heart disease (IHD) (7.8%), chronic kidney disease (CKD) (4.7%), and cancer (2.2%) cases. 34.1% of participants had no comorbidities, whereas 33.1% had at least one. Fever and cough were the most prevalent complaints of the patients, accounting for 77.9% and 75.9% of all cases, respectively. Shortness of breath (SOB) affected 38.6% of patients; diarrhea affected 19.1% of patients; and body aches affected 15.2% of patients. Only around a total of 12% of the patients had anosmia, lethargy, or chest discomfort [ Table 1 ]. CT was done in more than 65.5% of the study population, 7.2% of them being severe cases. Minimal to mild changes were found in around 68% of cases. A total of 232 (23.8%) patients out of 972 needed critical care support [ Table 2 ]. The overall mortality rate was 16.5% among the individuals who participated in the research [Figure1(a)], and the mortality rate among patients admitted to ICU was 56.1% [ Figure 1(b) ]. The results of a comparison between patients who had not survived and those who had been released revealed older age, male gender, presence of HTN and DM along with CKD, carcinoma, and IBD were significantly associated with mortality. The not survived group had considerably greater percentages of lung involvement and ICU utilization rate [Table3] . There were no significant differences in gender or associated comorbidities between patients admitted to ICU and not admitted to ICU. On the other hand, compared to non-ICU patients, ICU patients were significantly older, with a higher mortality rate and a greater percentage of lung involvement in chest CT [Table4].

The second wave of COVID-19 has had a catastrophic impact on the Indian subcontinent, resulting in much greater infection rates, ICU utilization, and death when compared to the first wave. (Graichen, 2021 , Jain et al., 2021 According to current data, critical care units and mechanical ventilators are only accessible at a rate of 0.1 to 2.5 per 1000,000 persons in low-and middle-income nations like ours. (Lombardi et al., 2020) Furthermore, a recent study found that critically ill patients had a longer hospital stay with a death rate of up to 60%, resulting in a scarcity of critical care resources. (Sang et al., 2021) The objective of this pioneer study was to evaluate the clinicodemographic profile, ICU utilization, and death rate of COVID-19 admitted patients during the second wave in our country.

The average age of the participants in this research was 54.47±12.73 years, with the majority of patients (48.3%) falling into the 41 to 60 years of age. Rahim et al. (2021) and another retrospective research from Germany discovered that the average age and majority age group were comparable. (Brehm et al., 2021 , Rahim et al., 2020 The current study demonstrated older age and male predominance (64.1%) among the COVID-19 patients. Several studies that were performed in our subcontinent and Europe also found similar age and gender predominance. (Ali et al., 2021 , Brehm et al., 2021 , Rahim et al., 2020 It has been proposed that females are more resistant to infections than men and that women have more responsible attitude toward the Covid-19 pandemic than men. (Bwire, 2020 , Kopel et al., 2020 . On the other hand, due to unavoidable physiological changes and possibly underlying comorbid conditions that occur with ageing, older people are more susceptible to infection. (Divo et al., 2014) Our observation revealed that 65.7% of patients had one or more comorbidities that were almost similar to the findings reported from Italy and China, respectively. (Grasselli et al., 2020 , Yu et al., 2020 The most frequent comorbidities in this study were hypertension (43.6%) and DM (42.1%). Likewise, in previous studies done in our nation and other countries, DM and HTN were two most prevalent comorbidities. (Mowla et al., 2020 , Nelson et al., 2020 , Singh et al., 2020 ) Fever (77.9%), cough (75.9%) followed by SOB (38.6%), diarrhoea (19.1%), and body ache (15.2%) were the dominant clinical manifestations. Fever and cough were also found as the most prevalent symptoms of the COVID-19 patient in previous research. (Di Gennaro et al., 2021 , Mowla et al., 2020 In this study, the overall mortality rate was 16.5 %. Earlier statistics from this subcontinent reported a somewhat lower overall mortality rate of 13.72%. (Malhotra et al., 2021) Not survived patients were older and had a greater percentage of diabetes, hypertension, and kidney diseases. In their study, Oliveira et al. (2021) observed that mortality is influenced by older age, CKD, and ICU admission. (Oliveira et al., 2021) The average total lung involvement in HRCT among all hospitalized patients was 44.83±19.87, with nearly half of patients having total lung involvement of 26-50 %, , indicating a larger involvement than earlier study. (Alam et al., 2020) In the present study, out of 972 patients, 232 (23.8%) required intensive care support, and the mortality rate among the ICU patients was 56.1%. Previous studies reported an ICU utilization rate of 19.6% with a case fatality rate of 35%. (Armstrong et al., 2021 , Karaca-Mandic et al., 2020 However, earlier research in our county found that ICU utilization was less than 10%. (Hossain et al., 2020) A higher overall mortality and ICU mortality, increased ICU utilization with greater total lung involvement in the current study indicates that the disease variant is more severe. In their study, Pijls et al. (2021) found that being older is strongly linked with intensive care support and Ahlstrand, et al. reported the CT severity score for COVID-19 patients is a strong predictor of ICU admission. (Ahlstrand et al., 2021 , Pijls et al., 2021 This study had few limitations. It was carried out at a single tertiary care COVID-19 specialized referral facility; therefore, the proportion of critically ill patients may be higher than in other centers or population-based research. Furthermore, this case series were assessed the clinical history while in the hospital without any follow-up data. Therefore, the information on recurrences was not documented. Nevertheless, in our country, this was a pioneer research on the second wave. this was a pioneer study on the second wave in our country. Our findings will serve as a baseline for the upcoming multicentered study as well as a resource for comparison to past or future waves, which we obviously do not want to experience.

The findings of current research are not different from studies performed elsewhere; nevertheless, the investigation identified higher overall mortality and ICU death rates, as well as increased ICU utilization and larger total lung involvement during the current wave. The mortality rate of elderly patients was also higher. That most frequent symptoms to be cough and fever, as well as the most prevalent comorbidities to be diabetes and hypertension. Age, the presence of chronic renal disease, and the need for ICU care were all significant predictors in mortality. The percentage of lung involvement was also higher in the not survived group. Tables   Table 1 Clinicodemographic 3) Values are presented as frequency, percentage, and mean± Standard Deviation (SD), the percentage in the parenthesis. Hypertension (HTN), Diabetes mellitus (DM), Bronchial asthma (BA), ischemic heart disease (IHD), chronic kidney disease (CKD), Inflammatory bowel disease (IBD), Chronic obstructive pulmonary disease (COPD) 

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The authors are grateful for the gracious assistance of the microbiology and radiology departments at the center where the study was done.

The Ethical and Scientific Committee of the tertiary care COVID-19 specialized hospital approved the protocol.

This study received no particular funding from any source.

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