This retrospective study reports the demographics, clinical symptoms, and the results of laboratory tests findings of 2204 patients with confirmed COVID-19 infected, who were treated at Shahid Mostafa Khomeini Hospital, (Ilam, Iran).
Although the number of infected men was more than women, this difference was not significant. In a meta-analysis study, Hannah Packham et al reported that there was no difference in the proportion of men and women with COVID-19 (13). However, George M. Bwire reported that biological and lifestyle differences have led to reports in various studies that men are more likely to be infected than women. Of course, women are more likely than men to take preventive measures, such as the use of face masks and frequent hand washing (14).
The average age of the patients was 56.67 years but most deaths occur at an average age of 64.16 years. Previous studies reported a broadly similar age distribution (15-17). Mortality was significantly higher in people over 40 years of age, which is almost in the age range reported by the study of M. Nikpouraghdam et al in Iran (18). Based on these results, old age can be considered as a risk factor for death.
The frequency of blood groups A+/_, O+/_, B+/_ and AB+/_ among patients was estimated as 40.5/1.4%, 29.1/3.7%, 16.3/1.4% and 6.5/0.6% respectively. The frequency of blood groups A+/_, O+/_, B+/_ and AB+/_ among individuals who died of this infection was estimated as 48.4/3.2%, 29.3/3.2%, 9.7/1.6% and 8.1/0.0% respectively. This study confirmed the relationship between ABO blood groups and COVID-19 sensitivity in patients. Patients with blood type A had a higher frequency compared to non-blood type A and patients with blood type AB had a much lower frequency compared to non-blood type AB.
In the meta-analysis performed by Liu, blood groups A and B were significantly more at risk for COVID-19, whereas this was not the case for blood group AB, people with blood type O were not susceptible to the disease (19). The researchers found that in people with blood type O, the production of natural anti-A and anti-B antibodies could potentially prevent viral attachment to host cells, a mechanism that could explain their lower risk of infection compared to other blood groups (20).
However, in this study, blood group O along with blood group A are more common among patients, which may be due to the fact that blood group O (36.49%) and A (32.09%) are the most blood common group among Iranians (21).
The most common symptoms in patients referred to the hospital were pneumonia (96.8%), dyspnea (87.7%); cough (75.4%); myalgia (54.2%); fever (53.6%); and shiver (48.7%). Other symptoms at illness onset were malaise (35%); nausea (29.5%); vomiting (22.7%); headache (25.7%). The proportion of patients who developed dyspnea in our analysis (87.7%) was more than that reported from meta-analysis done in China and other countries, where over 33.9% of the patients examined had dyspnea (22). As stated in other studies on the clinical signs of COVID-19, few patients had prominent upper respiratory tract signs and symptoms (runny nose (5.9%) or sore throat (19.5%)), indicating that the target cells might be located in the lower airway, furthermore, COVID-19patients rarely developed gastrointestinal signs and symptoms (diarrhea (8.8%), eg) (8).
In this study, patients with severe illness developed ARDS (7.9%), required ICU admission (23.1%), intubation (13.7%), mechanical intubation (13.7) and oxygen therapy (96.1%). Among those who died, 99% needed oxygen, 89% needed incubation, and 71% needed mechanical incubation. The need for invasive mechanical ventilation in this patient population was less than that in Italy (88%) (23), but it was more than China (47% and 42%) (24, 25), and equal to Washington State (71%) (26). The mortality rate in patients who required ICU and mechanical intubation was statistically significantly higher than patients who did not require ICU and mechanical intubation.
According to our results, a total of 54.7% of patients had at least one underling disease in line with that reported by Grasselli (68%)(23) and Wang et al (72.2%)(24): HTN (31.2%), diabetes (22.8%), heart disease (21.9). As with other studies (18, 27), our results it also showed that having co-morbidities can have a statistically significant effect on mortality. Compared to the two groups, only the presence of cancer and COPD was statistically significant.
Based on our data, most abnormal radiologic findings consisted of bilateral pneumonia, multiple mottling and ground-glass opacity, bilateral patchy shadowing, and pleural effusion. As with other publications, our data show that CT scans can play an important role in diagnosing and assessing the severity of the disease (28). Many studies have referred to bilateral pneumonia and bilateral ground-glass opacities on CT scans of people with COVID-19, which have also been seen in our study (24, 29, 30). These symptoms were more common in the deceased patients than in the survivors.
Among laboratory findings, WBC, absolute neutrophil count, Na+, BUN and ESR were higher among in the deceased patients in comparison to the survivors, and the results are in accordance with the previous studies (31). According to the results of a meta-analysis study, patients with Covid-19 with lymphopenia are more likely to develop severe disease (32). In the present study, the number of lymphocytes decreased in people who died compared to those who survived. Contact with infected people has played an important role in the spread of the disease, according to past studies (33, 34).
In this study, the history of occupational contact, contact with suspected cases and referral to medical centers during the two weeks before hospitalization were significantly higher in people who died than in other patients. In Brazil, a total of 34.4% patients had a recent international travel history and 61.1% patients had a history of close contact either with a positive or suspected case of COVID-19 (35). In the study of Xi-Min Qiao et al 53.33% of patients had the history of travel to Wuhan, 26.67% of patients had close contact with confirmed patients, and 6.67% of patient had close contact with suspected patients (36).
In the study of Nopsopon T et al no participants with a history of travel to the high-risk area or close contact with PCR-confirmed COVID-19 case developed SARS-CoV-2 antibodies. No association between history of travel to a high-risk area and close contact with PCR-confirmed or suspected COVID-19 case, was found (37).
Some people believe that alcohol consumption is beneficial for the prevention and treatment of COVID-19 (38). Among patients, 11 (0.5%) patients consumed alcohol and 82 (3.70%) were current smokers; also 41 (1.9%) patients were addicted. No relationship was found between severity of COVID-19 and smoking, and drinking alcohol in this study. The prevalence of low alcohol consumption in our study is probably due to the fact that in Iran, like many Muslim majority countries where alcohol consumption is prohibited (39). Mengyuan Dai's findings indicated that COVID-19 patients with a history of cigarette smoking tend to have more severe outcomes than non-smoking patients. However, alcohol consumption did not reveal significant effects on neither development of severe illness nor death rates in COVID-19 patients (40). In the study of Jin-jin Zhang et al, current smokers (1.4%) were rare (41).
In the study of Suman Saurabh et al, alcohol use was found to increase the risk of symptomatic disease as compared with asymptomatic infection. Current tobacco smoking but not smokeless tobacco use appeared to reduce the risk of symptomatic disease (42). The smoking and drinking chewing rates in Rui Zhong,s study were 15.4 and 26.4%, respectively. The chi-square test showed no statistical significance with the classification of COVID-19. The smoking rate of COVID-19 patients was lower than that the general population (43). The studies of Zhang J. J. et al, 2020 in China on COVID-19 and smoking showed that only 12.6% of patients were smokers, Which was more than the smoking rate in our study (2.8%) (43).
Two groups of drugs were used to manage COVID-19 based on Iranian treatment protocols and disease severity in individual (12). Group one included Oseltamivir, Hydroxychloroquine, Ribavirin and lopinavir/ritonavir. There was no significant difference between the group of survivors and the deceased patients used this drug group. A clinical trial was conducted in United Kingdom, to investigate various drug candidates or therapies including Hydroxychloroquine against severe COVID-19 (44). The result demonstrated no efficacy of Hydroxychloroquine against COVID-19 (44). In this study, there was no significant difference between the group of survivors and the deceased patients used Hydroxychloroquine and Oseltamivir. But in the second group, which included Recigen and Zifron as interferon-β1b, Vit D and Remdesivir, there was a significant difference between the survivors and the deceased patients.
Getu Zhaori et al, found that among the reports on monotherapies, only remdesivir, and among combined antiviral agents, only the combined regimen with interferon-β1b, lopinavir-ritonavir and ribavirin were effective and safe based on evidences from RCTs (45). In the study of Pan H et al, remdesivir, Hydroxychloroquine, lopinavir, and interferon regimens had little or no effect on hospitalized patients with COVID-19, as indicated by overall mortality, initiation of ventilation, and duration of hospital stay (46).
Data from John H. Beigel et al show that Remdesivir was superior to placebo in shortening the time to recovery in adults who were hospitalized with Covid-19 and had evidence of lower respiratory tract infection (47). Hensley et al reported that IFN-β-1a could be an effective therapeutic agent for SARS-CoV infections. In that study, IFN-β-1a demonstrated potent antiviral activity and acceptable safety profiles, suggesting its efficacy in coronavirus treatment (48). The results of the Pooya P et al study are also in favor of using Interferon beta-1a in addition to recommended antiviral treatment in COVID-19 patients (49).
These data suggest that mortality was associated with older age, multiple co-morbidities, abnormal CT scans at admission, direct admission to the ICU, low lymphocyte count, history of suspected exposure, and intubation. Also, drugs including interferon beta (Recigen or Zifron) and Remdesivir are also effective in reducing mortality.