Clinical characteristics of patients with COVID-19 admitted to the COVID-19 Emergency Field Hospital of Bangkalan, Indonesia

Introduction

Coronavirus disease 2019 (COVID-19) is still a concern worldwide due to its rapid spread and enormous burden in all aspects. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)^1,2. On March 12, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic³. The pandemic has already spread to several nations throughout the world, including Indonesia. Indonesia is a middle-income country with one of the lowest per capita health expenditures in the category⁴. Low- and middle-income countries (LMICs) are predicted to be affected most by the COVID-19 pandemic⁵. Physical distance and lockdown are nearly impossible due to the population's poor socioeconomic standing, which is characterized by congested living circumstances, limited access to daily basic requirements (e.g., food, clean water), and reliance on daily wages. Furthermore, caring for patients with COVID-19 is difficult since already limited health-care resources are soon exhausted.

The first COVID-19 case was reported in Indonesia in 2020, until early December 2021, the total number of cases in Indonesia was approximately 4,256,687 cases with a death rate of 143,840 people⁶. Since March 2020, COVID-19 cases rapidly increased which made East Java, Indonesia’s second most populous province, the epicenter of the pandemic from March to June 2020, where the highest number took place in this hospital area, Bangkalan. In response, the Indonesian government established the COVID-19 Emergency Field Hospital of Bangkalan in collaboration with the East Java Provincial Government, Regional Disaster Management Agency, and Regional Public Hospital Dr. Soetomo. This hospital was the epicenter of COVID-19 in Indonesia since the highest number of cases occurred in Bangkalan. From June 2021, the Emergency Field Hospital of Bangkalan conducted a study about the characteristics of patients with COVID-19 in Indonesia since studies are still limited.

The COVID-19 Emergency Field Hospital of Bangkalan has a total of 242 beds and can accommodate up to a maximum of 500 beds. This facility intended to treat a number of patients with COVID-19 with asymptomatic and mild–moderate symptoms to reduce community transmission. The study regarding the clinical characteristics of patients with COVID-19 in low-resource settings such as emergency field hospitals in Indonesia was limited, and particular studies of patients with COVID-19 in the Bangkalan area had not been established to date. This report will demonstrate the clinical characteristics needed to prevent further transmission of the virus in the Bangkalan area.

Clinical manifestations of COVID-19 are varied. Some patients are asymptomatic or have mild symptoms such as fever, cough, dyspnea, myalgia, and fatigue^7–9. For severe cases, there are manifestations of acute respiratory distress syndrome and a combination of other complications that lead to death^10,11. The characteristics of patients in this kind of emergency hospital in LMIC settings are still largely unknown, especially during the early phase of the pandemic. This study aimed to analyze the clinical characteristics of mild and asymptomatic patients with COVID-19 who have been hospitalized during the pandemic in Indonesia in the COVID-19 Emergency Field Hospital of Bangkalan. The results of this study are expected to aid in risk stratification of patients with COVID-19 infection; thus, further interventions can be given in a timely manner to avoid and reduce disease progression as well as to improve the patient’s outcomes and reduce the mortality rate from COVID-19 in the future.

Methodology

Results

Discussion

Between March and June 2020, Jakarta Special Capital Region Jakarta and East Java Province were the epicenters of COVID-19 cases in Indonesia with the highest number of cases occurring in Bangkalan¹⁴. The rapid rise of COVID-19 cases might be related to the population density in East Java, which was high (851 people per km²). In Bangkalan, where the highest case took place, the population density reached 1,059 people per km²¹⁵. Furthermore, we found patients in adulthood (18–59 years) dominating the data reported, with 40–49 years (31.1%) being the most common age range, followed by 30–39 years (27.1%) and 18–29 years (21.2%), respectively (Table 1). This finding was consistent with the previous study in Indonesia stating that the incidence correlates with adult people being engaged in many daily activities and actively working; therefore, it is easier for them to be infected while not strictly adhering to COVID-19 prevention protocols¹⁶. This may have allowed COVID-19 to spread more greatly contributing to the sudden outbreak in East Java. In this study, the prevalence of COVID-19 was slightly higher in women (51.5%), in concordance with the East Java population where the female population was slightly higher (50.1%) and in contrast to many previous studies in which more men were infected^17–18. Our study found that 99% of patients hospitalized here had a history of traveling abroad. Most of the patients who have a history of traveling abroad are Indonesian immigrant workers, in which 79.9% are women¹⁹. Additionally, the overall population in East Java Province is dominated by women²⁰. This might have affected the sex dominance in our study.

Among 763 patients included in this study, 377 (49.4%) patients were asymptomatic. Moreover, 120 (15.7%) patients complained of productive cough, followed by headache in 117 (15.3%) patients, cold (8.7%), dry cough (5.9%), fever (5.9%), and sore throat (4.7%). Less common symptoms were dyspnea, nausea, abdominal pain, myalgia, diarrhea, vomiting, anosmia, and/or ageusia. These findings support the earlier studies that fever and cough were the dominant symptoms and gastrointestinal symptoms were uncommon^18–22. Anosmia and/or ageusia stated to be the single strongest predictor of COVID-19 infections (by 10.2-fold higher than those with COVID-19-like illness) were found at the least number in our study. For its reliability, this symptom was used as the empiric signal for symptom-based public health surveillance in areas with fewer facilities available; however, several hypothesized that anosmia and/or ageusia mechanisms still require future studies^23,24.

Overall, 172 (22.5%) patients were recorded to have at least one pre-existing comorbidity, 46 (6.0%) patients have two comorbidities, and 4 (0.5%) patients have three comorbidities. The most common comorbidity was grade 1 obesity found in 94 (12.3%) patients, followed by hypertension (11.0%), grade 2 obesity (5.9%), pregnancy (4.7%), diabetes mellitus (1.7%), and others. Previous studies also mentioned risk factors contributing to more severe disease and poorer outcomes with COVID-19 infections such as age >60 years, obesity, hypertension, diabetes, cardiovascular diseases, cerebrovascular diseases, chronic kidney disease, and chronic obstructive pulmonary disease^25,26. This study also collected data on patients’ comorbidities, with obesity becoming the most common (12.3%). Evidence from a previous study involving 4,265 patients with COVID-19 in Jakarta stated that the risk of death across all ages was higher for patients with more than one comorbidity than for those without; the risk among patients <50 years was notably increased by six-fold²⁵. In addition, pregnancy is widely considered as a comorbidity; the most common comorbidity in this study was obesity. It correlates with this study finding since a large number of patients present with fewer comorbidities, mostly asymptomatic, and therefore come with great clinical outcomes.

There is no proven effective treatment against the virus to date approved by WHO, even though several drugs have been repurposed for treating COVID-19²³. Supportive therapy and monitoring remain the mainstay treatment of mild and asymptomatic COVID-19 infections. Suspected or confirmed mild COVID-19 should be isolated, given treatment such as antipyretics for fever and pain, adequate nutrition, appropriate rehydration, without antibiotic therapy or prophylaxis based on the latest WHO clinical management living guidance²⁷. The clinical outcomes of this study showed that 692 (90.1%) patients recovered, 43 (5.6%) patients self-quarantined, 28 (3.7%) patients referred to a more equipped health facility, and no patients died. No patient admitted to this hospital received antiviral, antibiotics, or corticosteroids. A study involving 500 patients observed disadvantages of the use of antiviral drugs for patients with COVID-19 with mild symptoms. The study concluded that antiviral treatment did not provide superior clinical outcomes to supportive care, since patients with mild COVID-19 who had received antiviral medication had significant LOS at the hospital compared with those without²⁸. Approximately 1.3% of patients receive O₂ therapy during their stay in the hospital. This is consistent with a study in Japan where 61.6% of patients did not receive respiratory support during hospitalization²⁹. The clinical outcomes were excellent; 90.1% of patients recovered.

In the current study, there were 753 (98.7%) patients with an LOS of less than 10 days, 3 (0.4%) patients with an LOS of 10 days, and 7 (0.9%) patients with an LOS of more than 10 days. Although the clinical symptoms of patients are similar to the data reported from previous studies^17,18, the mortality rates reported were significantly different (no deaths reported in this study) as most study subjects had either mild or asymptomatic COVID-19 infection, and those with moderate to severe infection were referred to a more equipped health facility.

This study had some limitations. First, recall bias was inevitable based on the nature of the retrospective study. Second, the data were collected from the electronic health record database. This precluded the level of detail possible with a manual medical record review. Third, the subjects either were asymptomatic or had mild symptoms and there was no comparison to patients who had been treated with antiviral therapy. Finally, this was a small study that only covers one area where the majority of patients are Madurese and Javanese, so it falls short to represent the whole country. A further multi-center study covering more areas and patients will give a more comprehensive finding of the characteristics as well as the management of COVID-19 in Indonesia.

Conclusion

Most patients with COVID-19 were asymptomatic with an age range between 40 and 49 years, dominated by women. Most patients had a history of travel abroad and had no comorbidities. Supportive therapy without antibiotics or antivirals was given to patients with an LOS of fewer than 10 days, and most of the cases showed excellent clinical outcomes. Findings from the data reported that our population originated from a single geographic area and may not reflect risk factors associated with clinical outcomes associated with SARS-CoV-2 infection in the general population. Accordingly, our data should be interpreted with caution as the risk factors associated with these health outcomes may differ elsewhere. Our study is a retrospective study based on electronic medical records collected during high surge cases of COVID-19 that are mostly dominated by Indonesian migrant workers. More clinical and basic research for the assessment, risk factors, and treatment of patients with COVID-19 with a wider population is needed in the future.

Data availability