Analysis of clinical features of COVID-19 patients admitted in a tertiary care hospital
in Chattogram, Bangladesh
Name: Mohammad Saiful Islam MPH Thesis
One Health Institute Roll No. 0119/04 Registration no:731
Session: 2019-2020
The thesis submitted is in the partial fulfillment of the
requirements for the degree of MPH (One Health)
I hereby declare that I am the sole author of this thesis. I also authorize the Chattogram Veterinary and Animal Sciences University (CVASU) to lend this thesis to other institutions or individuals for the purpose of scholarly research. I further authorize the CVASU to reproduce the thesis by photocopying or by other means, in total or in part, at the request of other institutions or individuals for the purpose of scholarly research. I, the undersigned, and author of this work, declare that the electronic copy of this thesis has been provided to the CVASU Library, is an accurate copy of the print thesis submitted, within the limits of the technology available.
Mohammad Saiful Islam April 2022
in Chattogram, Bangladesh
Name: Mohammad Saiful Islam Roll no: 0119/04
Registration no.: 731 Session: 2019-2020
This is to certify that we have examined the above MPH (One Health) thesis and have found that it is complete and satisfactory in all respects,
and all revisions required by the thesis examination committee have been made.
Professor Dr. A.M.A.M Zonaed Siddiki Supervisor
Dr. Adnan Walid Co-Supervisor
---
Prof. Sharmin Chowdhury, PhD Chairman of the Examination Committee
One Health Institute
Chattogram Veterinary and Animal Sciences University
Acknowledgements
All praises to almighty Allah who gave me the opportunity to be enrolled in the One Health Institute for achieving the degree of Masters in Public Health. I would like to express my gratitude to honorable supervisor Prof A.M.A.M Zonaed Siddiki, Department of Pathology, Chattogram Veterinary and Animal Sciences University (CVASU) for his coherent and articulated instructions. It would not be possible to complete such a laborious task without his scholastic guidelines. It was a beautiful experience for me to work under his supervision. I am also grateful to my co-supervisor Dr. Adnan Walid, Specialist, Department of Pediatric Surgery, Imperial Hospital Limited for his valuable suggestions and inspirations.
I am thankful to the Chairman of Medical Centre Hospital and the staff at the COVID unit for granting me permission to conduct this study and supporting me throughout the study period.
I would like to acknowledge the support and encouragement received during MPH programme from other teachers, technical and non-technical staffs of the One Health Institute, CVASU.
Mohammad Saiful Islam April 2022
2.1 Background ……… 4
2.2 Origin and evolution of coronavirus ……… 5
2.3 Transmission ……….. 6
2.4 Clinical Features ……… 7
2.4.1 Antibody response ………. 7
2.4.2 Cytokine response………. 8
2.4.3 Cellular response ………... 9
2.5 Association of hematological and biochemical markers with COVID-19 infections……….… 11
2.6 Disease burden ………... 12
2.7 Prevention ……….. 13
2.8 Treatment ………... 13
Chapter 3: Materials and Methods……….. 15
3.1 Description of the study area ………. 15
3.2 Ethical consideration ………... 15
3.3 Study Design ………... 15
3.4 Study period ………... 16
3.5 Sample size ……….. 16
3.6 Inclusion and exclusion criteria ……… 16
3.7 Admission criteria of patients ……… 16
3.8 Method of data collection ………... 17
3.9 Variables used ………. 17
3.10 Statistical analysis ……….. 17
Chapter 4: Results………. 19
Chapter 5: Discussion………... 32
Chapter 6: Conclusion………. 37
Chapter 7: Limitations………. 38
Chapter 8: Recommendations………. 39
Abstract………. viii
Chapter 1: Introduction………... 1
Chapter 2: Review of the literature………. 4
List of Tables
Table 4.1 Univariate association with the demographic factors
and adverse patient outcome 19
Table 4.2 Univariate analysis of risk factors associated with
COVID-19 and patient outcome 22
Table 4.3 Association of patient’ s signs and symptoms with
patient outcome 25
Table 4.4 Association of vital signs of patients with patient
outcome (N=306) 27
Table 4.5 Association of serum electrolytes with patient outcome
(n= 176) 28
Table 4.6 Relationship of hematological markers with patient
outcome (N=306) 28
Table 4.7 Relationship of biochemical markers with patient
outcome 29
Table 4.8 Medications used by the study subjects 31
List of Figures
Figure 4.1 Risk factors among the study subjects 21 Figure 4.2 Presenting symptoms of study subjects 23 Figure 4.3 Presenting signs on admission among the study
subjects 24
Figure 4.4 Management given to study subjects based on
requirement 30
Figure 4.5 Outcome of the study subjects 31
SpO2 Oxygen Saturation
GCS Glasgow Coma Scale
ESR Erythrocyte Sedimentation Rate WBC White Blood Cells
PT Prothrombin Time
SGPT/ALT Serum Glutamic-Pyruvic Transaminase/Alanine Aminotransferase SGOT/AST Serum Glutamic-Oxaloacetic Transaminase/ Aspartate Aminotransferase
CS Cytokine Storm
IL Interleukin
FGF Fibroblast Growth Factors
G-CSF Granulocyte Colony Stimulating Factor
GM-CSF Granulocyte Macrophage Colony-Stimulating Factor
IFN-γ Interferon Gamma
MCP Monocyte Chemoattractant Protein MIP Macrophage Inflammatory Proteins PDGF Platelet-Derived Growth Factor
TNF Tumor Necrosis Factor
VEGF Vascular Endothelial Growth Factor CRP C- Reactive Protein
NT Pro BNP N-Terminal Pro B-Type Natriuretic Peptide HFNC High-Flow Nasal Cannula
CPAP Continuous Positive Airway Pressure BiPAP Bi-level Positive Airway Pressure DORB Discharge On Risk Bond
COPD Chronic Obstructive Pulmonary Disease ARDS Acute Respiratory Distress Syndrome
viii viii
Abstract
The coronavirus disease (COVID-19) caused by the RNA virus SARS-CoV-2 has appeared as a devastating pandemic in recent times. Although many studies have been conducted on the clinical features and the complications caused by the disease, the changing variants of the virus has resulted in the disease showing a diversity in illness presentation, from asymptomatic cases to critical illness followed by death. In Bangladesh, few studies are available on the presenting features of patients requiring hospital admissions. Present study was undertaken to confirm the findings stated in previous studies and to report any new observations that were not mentioned before or may have gone unnoticed. The study was conducted at the in-patient department of a COVID-19 dedicated hospital in Chattogram metropolitan area. With necessary consent, a total of 306 patients were followed from the time of admission until the time of discharge from the hospital’ s COVID unit. Among the
admitted adult cases, majority of them were between the 35 to 55 years old age group and the male:female ratio was 7.74:1. Common risk factors observed were hypertension (56.2%), diabetes (45.4%), smoking (33.3%), obesity (29.1%), bronchial asthma (14.4%), chronic kidney disease (10.1%), chronic heart disease (5.9%), cerebrovascular disease (4.9%), chronic obstructive pulmonary disease (3.9%), history of suppressive therapy (2.6%), chronic liver disease (1.6%) and history of surgery (0.7%) and chemotherapy (0.7%). Common symptoms were fever (99.3%), cough (91.8%), fatigue (81.7%), altered smell (81%), altered taste (71.6%), anorexia (56.5%), dyspnea (48.4%), headache (48.4%), generalized body ache (28.4%), sore throat (25.5%), conjunctivitis (23.5%), diarrhea (15%), nasal congestion (14.1%), vomiting (13.1%), and dizziness (11.1%). Common signs were wheezing (31.4%), crackles (21.9%), bronchial breath sounds (20.3%) and cyanosis (2%). In case of clinical management, 119 (38.9%) patients received IV fluids, 47 (15.4%) patients were given medications to support blood pressure and 2 (0.7%) patients had undergone dialysis. For oxygen maintenance, 181 (59.2%) patients received oxygen through a nasal cannula, 42 (13.7%) were given oxygen through High Flow Nasal Cannula, 33 (10.8%) patients were managed with Continuous positive airway pressure, 16 (5.2%) with Bi-Level Positive Airway Pressure and 6 (2%) were given mechanical ventilation.
The most common drugs used for COVID-19 treatment were enoxaparin (76.8%), followed by the dexamethasone (41.5%), Remdesivir (17%), methylprednisolone (7.5%),
the age (p=0.007) and number of affected family members (p=0.046) were significantly associated with adverse patient outcome. Patients with a history of diabetes (p<0.001), hypertension (p= 0.003), bronchial asthma (p= 0.041) and use of suppressive therapy (p=0.024) had a significant association with adverse patient outcome. In case of symptoms, a significant difference was found between mean duration of symptoms for the variables fever (p<0.001), cough (p=0.011), dyspnea (p=0.031), altered taste (p=0.001), fatigue (p=0.009), confusion (0.045) and generalized body ache (p<0.001). In case of signs, a significant difference was observed between mean duration of signs such as crackles (p=0.04), wheezing (p<0.001) and bronchial breath sounds (p=0.033). Patients who expired had a significantly lower SPO2 on admission (p=0.004), lower SPO2 after oxygen therapy (p<0.001), lower Glasgow Coma Scale (p=0.018), lower systolic (p<0.001) and diastolic blood pressure (p<0.001), higher heart rate (p=0.005) and higher respiratory rate (p=0.008). For serum electrolytes, levels of sodium (p=0.002), potassium (p=0.011) and bicarbonate (p=0.001) were significantly low among patients who expired. For hematological markers, patients that expired had a significantly lower hemoglobin level (p<0.001), lymphocyte percentage (p=0.001), and platelet count (p=0.001); and a significantly higher ESR (p=0.013), total WBC (p=0.02), neutrophil percentage (p=0.02) and neutrophil: lymphocyte ratio (p<0.001). For biochemical markers, among expired patients, a significantly lower mean for N-Terminal Pro B-Type Natriuretic Peptide (p=
0.045) and Troponin I (p=0.001) and a significantly higher mean for C - reactive protein (p<0.001), serum ferritin (p<0.001), d- dimer (p<0.001), procalcitonin (p=0.037), random blood sugar (p<0.001), aspartate transaminase (p=0.001) and serum creatinine (p=0.019) were observed. This study adds valuable information to the body of literature on COVID
‐
19 among the Bangladeshi population. On the basis of this study, further research can be
