Of 413 patients admitted to hospitals, 55.5% were male and 38.5% aged more than 50. The mean age of the patients was 45.05±17.38, ranging from 10 to 92 years. Regarding epidemiological characteristics, 9% and 3.9% of patients reported drug use and cigarette smoking, respectively. Patients who traveled to high-risk areas within 14 days before the onset of symptoms were 13.6%. Close contact with a respiratory patient in a medical center, in the family, and the workplace was 5.9%, 9.2%, and 2.7%, respectively. About 4% of patients reported a history of close contact with a COVID19 patient within 14 days before the onset of symptoms. Among patients, 41.4% used mask protection, and 54.7% went to a medical center personally. At admission, 145 (35.10%) patients were in severe and 268 (64.90%) in non-severe conditions. There was a significant relationship between age and severity of COVID-19. The odds of severe disease were 3.38 times greater in patients aged more than 50 years, and it was 2.09 times greater in cases of substance abuse. Patients referred to the hospital by ambulance (OR=3.53) were more likely to be in a severe condition of COVID-19 compared to those who went to the hospital personally. Although wearing a mask decreased the odds of severity (OR=0.38), there was no significant relationship between mask protection and the disease severity. There were 16 (3.9%) cigarette smokers, and smoking was not the predictor of severity among COVID-19 patients (Table 1).
Table 1: Demographic and epidemiological characteristics of COVID-19 severe patients in the southeast of Iran
OR(95% CI)
|
|
Severe
N (%)
|
Total
N (%)
|
Demographics and epidemiological characteristics
|
1.00
|
62 (24.4)
|
254(61.5)
|
Less/equal 50
|
Age (year)
|
3.38 (2.22,5.16)*
|
83 (52.2)
|
159(38.5)
|
More than 50
|
1.00
|
65 (35.3)
|
184(44.5)
|
Female
|
Gender
|
0.98 (0.66,1.48)NS
|
80 (34.9)
|
229(55.5)
|
Male
|
1.00
|
138 (34.8)
|
397(96.1)
|
No
|
Cigarette smoking
|
1.46 (0.53,4.00) NS
|
7 (43.8)
|
16(3.9)
|
Yes
|
1.00
|
126 (33.5)
|
376(91)
|
No
|
Substance abuse
|
2.09 (1.06,4.13) *
|
19 (51.4)
|
37(9)
|
Yes
|
1.00
|
136 (38.1)
|
357(86.4)
|
No
|
Travel to high-risk areas
|
0.31 (0.14,0.65) *
|
9 (16.1)
|
56(13.6)
|
Yes
|
1.00
|
122 (33.7)
|
362(87.6)
|
No
|
Go to the medical care center within 14 days before the onset of symptoms
|
1.62 (0.89,2.92) NS
|
23 (45.1)
|
51(12.4)
|
Yes
|
1.00
|
127 (34.8)
|
365(88.3)
|
No
|
Close contact with a respiratory patient within 14 days before the onset of symptoms
|
1.12 (0.60,2.10) NS
|
18 (37.5)
|
48(11.7)
|
Yes
|
1.00
|
133 (34.2)
|
389(94.1)
|
No
|
Close contact with a respiratory patient within 14 days before the onset of symptoms in medical centers
|
1.93 (0.84,4.40) NS
|
12 (50.0)
|
24(5.9)
|
Yes
|
1.00
|
130 (34.7)
|
375(90.8)
|
No
|
Close contact with a respiratory patient within 14 days before the onset of symptoms in the family
|
1.23 (0.62,2.44) NS
|
15 (39.5)
|
38(9.2)
|
Yes
|
1.00
|
142 (35.3)
|
402(97.3)
|
No
|
Close contact with a respiratory patient within 14 days before the onset of symptoms in the workplace
|
0.69 (0.18,2.63) NS
|
3 (27.3)
|
11(2.7)
|
Yes
|
1.00
|
137 (34.5)
|
397(96.1)
|
No
|
History of close contact with a COVID19 patient within 14 days before the onset of symptoms
|
1.90 (0.70,5.17) NS
|
8 (50.0)
|
16(3.9)
|
Yes
|
1.00
|
106 (43.8)
|
242(58.6)
|
No
|
Using Mask protection
|
0.38 (0.25,0.59) NS
|
39 (22.8)
|
171(41.4)
|
Yes
|
1.00
|
54 (24.2)
|
223(54.4)
|
Personally
|
How transferred to a medical center
|
2.30 (1.40,3.77) *
|
44 (42.3)
|
104(25.3)
|
By others
|
3.53 (2.08,5.99) *
|
44 (53.0)
|
83(20.3)
|
By ambulance
|
1.00
|
142 (35.1)
|
404(97.8)
|
No
|
Distance protection
|
0.92 (0.23,3.74) NS
|
3 (33.3)
|
9(2.2)
|
Yes
|
1.00
|
121 (33.4)
|
362(87.6)
|
More than 1
|
The duration between symptom onset and hospital admission (day)
|
1.77 (0.98,3.20) NS
|
24 (47.1)
|
51(12.4)
|
Less/equal 1
|
NS: Not Significant, *Significant at the level of P<0.05
Regarding clinical symptoms at admission, 37% of patients had a temperature of more than 37.5. The most prevalent symptoms were cough (71.2%), breath shortness (61.2%), fever (32.2%), shiver (29%), and bruising (28.4%). An abnormal CT was found in 94.5%. In univariate analysis, cough, shortness of breath, abdominal pain, lack of appetite, and loss of consciousness were related to the severity of disease among COVID-19 patients. Shortness of breath increased the odds of severe COVID-19 (OR=1.93). The odds of severe COVID-19 was significantly greater in patients with abdominal pain (OR=7.7), seizure (OR=27.1), and loss of consciousness (OR=12.4) (Table 2). Among all patients, 1.4% had a runny nose, and 1.7% had no sign.
In univariate analysis, sepsis, respiratory failure, acute respiratory distress, heart failure, acute kidney, and liver injury were related to the severity of disease among COVID-19 patients. The odds of severe COVID-19 was significantly greater in patients with sepsis (OR=26.3), respiratory failure (OR=39.1), acute respiratory distress syndrome (OR=30.81), heart failure (OR=24.2), acute heart injury (OR=11.5), acute kidney injury (OR=11.7), liver injury (OR=3.7) and acidosis (OR=11.5) (Table 2).
Table 2: Clinical characteristics and signs of COVID-19 severe patients in the southeast of Iran
OR (95% CI)
|
Severe
N(%)
|
Total
N (%)
|
Clinical Characteristics at admission*
|
1.00
|
88 (34.2)
|
257(63)
|
Less/equal 37.5
|
Temperature
|
1.06 (0.66,1.70)NS
|
38 (35.5)
|
107(26.2)
|
37.5-38.5
|
1.21 (0.62,2.34) NS
|
17 (38.6)
|
44(10.8)
|
More than 38.5
|
1.00
|
106 (36.1)
|
294(71)
|
No
|
Shiver
|
0.86 (0.55,1.36) NS
|
39 (32.8)
|
119(29)
|
Yes
|
1.00
|
22 (7.9)
|
280 (67.8)
|
No
|
Fever
|
0.85 (0.35,1.73) NS
|
9 (6.7)
|
133 (32.2)
|
Yes
|
1.00
|
54 (45.4)
|
119(28.8)
|
No
|
Cough
|
0.54 (0.35,0.84) *
|
91 (31.0)
|
294(71.2)
|
Yes
|
1.00
|
42 (26.3)
|
160(38.7)
|
No
|
Shortness of breath
|
1.93 (1.25,2.97)*
|
103 (40.7)
|
253(61.2)
|
Yes
|
1.00
|
117 (33.6)
|
348(84.22)
|
No
|
General weakness
|
1.49 (0.87,2.56) NS
|
28 (43.1)
|
65(15.8)
|
Yes
|
1.00
|
113 (38.2)
|
296(71.6)
|
No
|
Bruising
|
0.61 (0.38,1.08)
|
32 (27.4)
|
117(28.4)
|
Yes
|
1.00
|
140 (36.1)
|
388(93.9)
|
No
|
Sore throat
|
0.44 (0.16,1.21) NS
|
5 (20.0)
|
25(6.1)
|
Yes
|
1.00
|
142 (36.2)
|
392(95)
|
No
|
Diarrhea
|
0.29 (0.09,1.01) NS
|
3 (14.3)
|
21(5)
|
Yes
|
1.00
|
123 (35.7)
|
345(83.5)
|
No
|
Nausea
|
0.86 (0.50,1.50) NS
|
22 (32.4)
|
68(16.5)
|
Yes
|
1.00
|
126 (36.6)
|
344(83.3)
|
No
|
Headache
|
0.66 (0.37,1.16) NS
|
19 (27.5)
|
69(16.7)
|
Yes
|
1.00
|
141 (35.2)
|
401(97)
|
No
|
Chest pain
|
0.92 (0.27,3.12) NS
|
4 (33.3)
|
12(3)
|
Yes
|
1.00
|
137 (34.0)
|
403(97.5)
|
No
|
Abdominal pain
|
7.77 (1.63,37.08)*
|
8 (80.0)
|
10(2.5)
|
Yes
|
1.00
|
141 (35.9)
|
393(95.1)
|
No
|
Joint pain
|
0.45 (0.15,1.36) NS
|
4 (20.0)
|
20(4.9)
|
Yes
|
1.00
|
141 (34.6)
|
408(98.8)
|
No
|
Tachypnea
|
7.57 (0.84,68.41) NS
|
4 (80.0)
|
5(1.2)
|
Yes
|
1.00
|
129 (35.0)
|
369(89.3)
|
No
|
Abnormal lung sounds
|
1.06 (0.56,2.04) NS
|
16 (36.4)
|
44(10.7)
|
Yes
|
1.00
|
6 (26.1)
|
23(5.5)
|
No
|
Abnormal CT
|
1.57 (0.61,4.07) NS
|
139 (35.6)
|
390(94.5)
|
Yes
|
1.00
|
143 (34.9)
|
410(99.2)
|
No
|
Seizure
|
3.73 (0.34,41.54) NS
|
2 (66.7)
|
3(0.8)
|
Yes
|
1.00
|
120 (33.2)
|
361(87.4)
|
No
|
Lack of appetite
|
1.86 (1.04,3.34)*
|
25 (48.1)
|
52(12.6)
|
Yes
|
1.00
|
140 (35.4)
|
395(95.6)
|
No
|
Dizziness
|
0.70 (0.24,2.01) NS
|
5 (27.8)
|
18(4.4)
|
Yes
|
1.00
|
122 (31.6)
|
386(93.4)
|
No
|
Loss of consciousness
|
12.44 (4.21,36.76)*
|
23 (85.2)
|
27(6.6)
|
Yes
|
OR (95% CI)
|
Severe
N(%)
|
Total
N (%)
|
complications created during treatment*
|
1.00
|
121 (31.3)
|
387(93.6)
|
No
|
Sepsis
|
26.38 (6.14,113.41) *
|
24 (92.3)
|
26(6.4)
|
Yes
|
1.00
|
112 (29.6)
|
378 (91.5)
|
No
|
Respiratory failure
|
39.19 (9.24,166.10) *
|
33 (94.3)
|
35(8.5)
|
Yes
|
1.00
|
142 (34.7)
|
409(99)
|
No
|
Coagulopathy
|
5.64 (0.58,54.73)NS
|
3 (75.0)
|
4(1)
|
Yes
|
1.00
|
130 (32.7)
|
397(96.1)
|
No
|
Acute respiratory distress syndrome
|
30.81 (4.03,235.76) *
|
15 (93.8)
|
16(3.9)
|
Yes
|
1.00
|
136 (33.7)
|
403(97.5)
|
No
|
Heart failure
|
24.2(3.33,249.09) *
|
9 (90.0)
|
10(2.5)
|
Yes
|
1.00
|
139 (34.2)
|
406(98.3)
|
No
|
Acute heart injury
|
11.52 (1.37,96.68) *
|
6 (85.7)
|
7(1.7)
|
Yes
|
1.00
|
128 (32.6)
|
393(95.1)
|
No
|
Acute kidney injury
|
11.73 (3.38,40.76) *
|
17 (85.0)
|
20(4.9)
|
Yes
|
1.00
|
143 (34.9)
|
410(99.2)
|
No
|
Acute liver injury
|
3.73 (0.34,41.54) *
|
2 (66.7)
|
3(0.8)
|
Yes
|
1.00
|
139 (34.2)
|
406(98.3)
|
No
|
Acidosis
|
11.52 (1.37,96.68) *
|
6 (85.7)
|
7(1.7)
|
Yes
|
NS: Not Significant, *Significant at the level of P<0.05
The most prevalent underlying disease among COVID-19 patients were hypertension (23.5%), diabetes (17.2%), cardiovascular disease (13.1%), chronic pulmonary disease (9.5%), and asthma (5.1%). Underlying conditions, including cardiovascular disease (OR=2.43), liver disease (OR=5.74), chronic lung disease (OR=3.34), hypertension (OR=1.98), and rheumatologic disease (OR=5.8) increased the odds of severity among COVID-19 patients (Table 3). Congestive heart disease, organ transplant, and malignancy were reported in only 2 (0.5%) patients.
Table 3: Distribution of underlying condition among COVID-19 severe patients in the southeast of Iran
OR (95% CI)
|
Severe
N(%)
|
Total
N (%)
|
Underlying conditions
|
1.00
|
140 (34.9)
|
401(94.8)
|
No
|
Dialysis
|
1.33 (0.42,4.27)NS
|
5 (41.7)
|
12(5.2)
|
Yes
|
1.00
|
116 (32.3)
|
359(86.9)
|
No
|
Cardiovascular disease
|
2.43 (1.36,4.34) *
|
29 (53.7)
|
54(13.1)
|
Yes
|
1.00
|
114 (33.3)
|
342(82.8)
|
No
|
Diabetes
|
1.55 (0.92,2.61) NS
|
31 (43.7)
|
71(17.2)
|
Yes
|
1.00
|
139 (34.3)
|
405(98)
|
No
|
Liver disease
|
5.74 (1.14,28.82) *
|
6 (75.0)
|
8(2)
|
Yes
|
1.00
|
138 (34.5)
|
400(96.8)
|
No
|
Chronic kidney disease
|
2.22 (0.73,6.72) NS
|
7 (53.8)
|
13(3.2)
|
Yes
|
1.00
|
143 (35.4)
|
404(97.8)
|
No
|
Chronic neurological disease
|
0.52 (0.11,2.54) NS
|
2 (22.2)
|
9(2.2)
|
Yes
|
1.00
|
121 (32.4)
|
374(90.5)
|
No
|
Chronic pulmonary disease
|
3.34 (1.69,6.61) *
|
24 (61.5)
|
39(9.5)
|
Yes
|
1.00
|
144 (35.0)
|
411(99.5)
|
No
|
Malignant Disease
|
1.85 (0.12,29.86) NS
|
1 (50.0)
|
2(0.5)
|
Yes
|
1.00
|
99 (31.3)
|
316(76.5)
|
No
|
Hypertension
|
1.98 (1.24,3.14) *
|
46 (47.4)
|
97(23.5)
|
Yes
|
1.00
|
140 (34.7)
|
404(97.8)
|
No
|
Cerebrovascular disease
|
2.36 (0.62,8.92) NS
|
5 (55.6)
|
9(2.2)
|
Yes
|
1.00
|
142 (35.1)
|
405(98)
|
No
|
Chronic blood disease
|
1.11 (0.26,4.72) NS
|
3 (37.5)
|
8(2)
|
Yes
|
1.00
|
136 (34.7)
|
392(94.9)
|
No
|
Asthma
|
1.41 (0.58,3.43) NS
|
9 (42.9)
|
21(5.1)
|
Yes
|
|
143 (34.8)
|
411(99.5)
|
No
|
Congestive heart disease
|
|
2 (100.0)
|
2(0.5)
|
Yes
|
1.00
|
136 (33.9)
|
401(97.1)
|
No
|
Rheumatologic disease
|
5.85 (1.56,21.95)*
|
9 (75.0)
|
12(2.9)
|
Yes
|
|
143 (34.8)
|
411(99.5)
|
No
|
Organ transplant
|
|
2 (100.0)
|
2(0.5)
|
Yes
|
1.00
|
140 (35.0)
|
400(96.8)
|
No
|
Defect immune system
|
1.16 (0.37,3.62) NS
|
5 (38.5)
|
13(3.2)
|
Yes
|
NS: No Significant *Significant at the level of P<0.05.
Among all patients, 37% had an oxygen saturation of more than 0.93, 11.4% were admitted to ICU eventually, and 8.7% received mechanical ventilation. According to oxygen therapy, 90.6% received high flow nasal cannula (HFNC) and 8.2% invasive mechanical ventilation. The odds of severe disease increased significantly in patients admitted to ICU (OR=27.8) and mechanically ventilated patients (OR=84.9). Oxygen saturation of more than 0.93 could prevent the disease severity by 70%. The mean heart rate and respiratory rate were significantly different between the severe and non-severe patients (P<0.001) (Table 4). About 36 (94.7%) of the severe patients were intubated. Most patients took antibiotics (91.5%) and antiviral drugs (97.3%), but their use was not related to severity among COVID-19 patients (P>0.05).
Table 4: Distribution of oxygen therapy and vital sign among COVID-19 severe patients in the southeast of Iran
OR (95% CI)
|
Severe
N(%)
|
Total
N (%)
|
|
|
1.00
|
37 (94.9)
|
39(90.5)
|
No
|
High flow nasal cannula
|
0.02 (0.005,0.093)*
|
108 (28.9)
|
374(9.5)
|
Yes
|
|
137 (33.8)
|
405(98)
|
No
|
Non-Invasive mechanical ventilation
|
|
8 (100.0)
|
8(2)
|
Yes
|
1.00
|
112 (29.6)
|
379(91.7)
|
No
|
Invasive mechanical ventilation
|
78.67 (10.63,582.25) *
|
33 (97.1)
|
34(8.3)
|
Yes
|
1.00
|
102 (27.9)
|
366(88.6)
|
No
|
ICU admission
|
27.82 (9.74,79.49) *
|
43 (91.5)
|
47(11.4)
|
Yes
|
1.00
|
109 (29.1)
|
375(90.8)
|
No
|
Intubation
|
43.93 (10.40,185.63) *
|
36 (94.7)
|
38(9.2)
|
Yes
|
1.00
|
110 (29.2)
|
377(91.3)
|
No
|
Mechanical ventilation
|
84.96 (11.50,627.82) *
|
35 (97.2)
|
36(8.7)
|
Yes
|
1.00
|
30 (19.6)
|
153(37)
|
More than 0.93
|
Oxygen saturation
|
3.25 (2.03,5.18) *
|
114 (44.2)
|
258(63)
|
Less/equal 0.93
|
P
|
Sever / Critically sever
|
Low / Moderate
|
|
Mean ± SD.
|
0.002
|
97.75±18.57
|
92.33±12.94
|
|
Heart rate
|
<0.001
|
22.19±6.53
|
18.92±4.37
|
|
Respiratory rate
|
0.182NS
|
118.36±19.21
|
115.95±16.35
|
|
Systolic blood pressure
|
0.234 NS
|
74.57±11.46
|
73.18±11.14
|
|
Diastolic blood pressure
|
NS: No Significant, *Significant at the level of P<0.05
Multivariate regression showed increased odds of the severity for COVID-19 was associated with older age (OR=3.51), substance abuse (OR=2.22), and having at least one underlying disease (OR= 3.45) (Table 5).
Table 5: Multivariate logistic regression for predictors of severity among COVID-19 patients in the southeast of Iran*
Independent variables
|
B
|
SE of Beta
|
OR (95% CI)
|
P
|
Age
|
>50
≤50**
|
1.25
1
|
.22
|
3.51(2.28, 5.4)
|
.0001
|
Substance abuse
|
Yes
No**
|
.78
1
|
.35
|
2.22(2.05, 5.78)
|
.0002
|
Having underlying disease***
|
Yes
No**
|
1.24
1
|
.26
|
3.45(1.01, 1.32
|
.032
|
* Variables for Table 4 not included in the model,**Reference group,***Having at least one underlying disease according to table 3.