AGE AND GENDER RELATED MORTALITY AND OUTCOME OF COVID 19 POSITIVE PATIENTS

Background : This study was aimed to evaluate the age and gender related mortality and outcome of covid 19 positive patients in order to further strengthen the management of covid 19 patients as the insights from these data will be useful in determining preventive measures and treatment policies of covid 19 patients. Methodology : This was a retrospective observational study done in adult covid positive patients admitted in Tertiary Care Hospital from first May 2020 to 30 June 2021.The age related mortality and outcome in these patients was analyzed. Results : A total of 816 adult covid -19 positive patients were admitted in a Tertiary care hospital,GMC Anantnag from May 2020 to June 2021. Among the patients, 53.55 % were males and 46.44 % were females. The mean of the age involved was 57.96 years. The most common presenting symptom was fever (85%) followed by cough (70%) and shortness of breath (40%). Approximately 20% of patients presented with nonspecific complaints (including generalized aches, pains, body aches, myalgias etc). All age groups were affected equally

On the basis of a suggestive clinical history and the detection of SARS-CoV-2 RNA in respiratory secretions, Diagnosis of Covid-19 can be established. Chest radiography should be performed and bilateral consolidations or ground-glass opacities are commonly seen. 15 The Definition for Epidemiologic purposes in Severe Covid-19 in adults is dyspnea, a respiratory rate of 30 or more breaths per minute, a blood oxygen saturation of 93% or less, a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (Pao2:Fio2) of less than 300 mm Hg, or infiltrates in more than 50% of the lung field 16 Renal failure and thrombosis are well-recognized complications of severe Covid-19. Dexamethasones, Remdesivir, Endotraceal intubation have a role in Management 4 In patients with covid-19 disease, the prevalence of mortality among hospitalized patients varies from 6.3 to 26.85% in different parts of the world 17. For Critical conditions, early identification of risk factors is urgently needed, not only to identify the defining epidemiological and clinical characteristics with greater precision, but also to provide and facilitate the appropriate supportive care and prompt access to the intensive care unit (ICU) if needed. For higher severity and mortality in patients with COVID-19, gender is a risk factor independent of age and susceptibility 18 However, the age-related pattern of COVID-19 fatality is different from that of other respiratory viral infections. As in covid-19 positive patients, the severity pattern is often described as a U-shaped curve;the morbidity and mortality are concentrated at extreme age groups (younger children and the elderly). Population-based studies of seasonal influenza have typically shown this type of mortality distribution according to age 19 During the pandemic, one of the most critical issues dealt by public health and clinical professionals is the spectrum of illness severity. This really affects the triage, diagnostic decision making, therapeutic decision making and prognostic expectations. Therefore, understanding COVID-19 associated morbidity and mortality with relation to age is important 20 As there is paucity of studies regarding gender and age related mortality in covid positive patients, so we conducted this study to provide data to further strenghthen the management of covid-19 positive patients.

Methodology:-
This was an observational retrospective study of covid 19 positive patients. It included patients who were admitted in the Tertiary Care Hospital, GMC Anantnag from ist May 2020 to 30 June 2021. The data was collected from online portal which was maintained by computer section of Department of Medicine. The data was updated each day regarding outcome of the admitted patients. The data was analysed by statistician. All the patients admitted were moderate to severe confirmed COVID-19 patients whose real-time reverse-transcription polymerase chain reaction assay findings for nasal or pharyngeal swab specimens were positive.
Moderate Illness: Clinical or radiographic evidence of lower respiratory tract disease; oxygen saturation ≥94%. Diagnostic testing 21 .

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Data related to age related mortality and outcome of all the patients who were admitted during the study period was collected from their electronic medical records, daily progress charts, nursing notes of the patients. Patients' age, sex, complaints at the time of presentation was noted and analyzed. Total of 816 covid-19 positive patients were admitted. Adult patients were further divided into age-groups of 15 to 50, 51 to 65, and 66-100 and their age related mortality and outcome was seen. Mortality was calculated until patients were hospitalised or discharged from the hospital. This study did not include post discharge mortality in long covid syndrome patients.   Table 3 suggests that the mortality among 816 admitted covid positive patients was about 20% (165). Maximum 599 (73%)of patients were discharged. Only 52 (6.37%) were reffered.    Table 6 depicts that fever was the main presenting symptom (85%) followed by cough (70%). About 42% were having shortness of breath . Approximatekly 20 % of patients were having non specific complaints like generalised pains, bodyaches, myalgias.  In our study, Males and females were of almost equal proportion among admitted covid positive patients. This is in contrast to study 3 where 60% of all admitted patients were males and in contrast to other studies where male predisposition was found for this disease across various ethnic and racial groups 28,29,30

Results:-
In our study, fever was the main presenting symptom followed by cough , shortness of breath. This is similar to study 16 In our study, 29.16 % were of age-group of 15-50 years, 37.25% in the age-group 51-65 years and only about 33.57% were above 65 years age-group. This is in contrast to study 3 where 42.1% were of age-group of 18-50 years, 35% in the age-group 51-64 years, and only about 23% were above 65 years age-group. But similar to the studies from other parts of the world where most of the nonsurvivors were also from a much older age-group 29,30,31 The ICU mortality of COVID-19 patients varies from 8.0 to 66.7% in different studies 32 .In study 3 , the hospital mortality was 18.2% and ICU mortality was 36.1. In our study, the hospital mortality was 20%. Similar mortality rates have been reported in other studies from US, Spain, Italy, and few studies from China 28,29,33 . However, from China, there are other studies which depict lower overall mortality rates 34 Association between age and mortality in covid positive patients was seen in elderly age group in our study. And the results are highly significant. This is similar to the studies 20,35,36,37,7 . Elderly patients have a higher mortality rate due to high CFR and symptomatic infection rate among covid -19 positive patients 37,7 Several studies have reported old age to be a significant risk factor for COVID-19 mortality 37, 7 . In patients with age of more than 70 yrs and more or equal to 60 yrs in Korea and Italy respectively, approximately 80% and 90% of deaths have occurred in them respectively 35, 36 . In an animal study, SARS-CoV-2 infection caused more severe interstitial pneumonia and viral replication in tissues of lungs of old monkeys than in those of young monkeys 38 . Vulnerability to an infection in the elderly is usually explained by immunosenescence and chronic subclinical systemic inflammation also known as inflammaging in immunopathology 39, 40 . Some scientists have claimed that there is the biologically plausible pathomechanism that explains the difference in vulnerability to SARS-CoV-2 infection and this is called antibodydependent enhancement (ADE) 41,42,43,44 . ADE is a well-known cascade of events by which viruses may infect susceptible cells through interactions between virions complexed with antibodies and Fc receptors, where they are more extensively endocytosed and eventually replicated more efficiently 45 The antibodies that bind to virions could be neutralizing or non-neutralizing antibodies, which were previously formed in response to SARS-CoV-2 or other coronaviruses with similar antigenicity to that of SARS-CoV-2. There was also the fact that the seroprevalence of community-acquired coronaviruses among adults was very high (90 -100%) but not in pediatrics which was further presented as an evidence 46,47 .There are several other factors related to aging that could be reasons for higher mortality and morbidity in the elderly in addition to the aging immunity or ADE. Further, The average number of comorbid conditions steadily increased with age. Because of the chronic illnesses and the impact of congregate housing in older adults living in long-term care facilities, they are at the highest risk 48,49 In our study, mortality is same in covid positive males and females. But this is in contrast to the study done by JIN JM et al 18 where male mortality is more as compared to female mortality and Men with COVID-19 are more at risk for worse outcomes and death, independent of age.

Conclusion:-
Overall, there was no sex prediliction. Fever was the main presenting symptom. All age groups were affected equally but mortality was more in elderly age group. Further, mortality is same in male and female covid positive patients with no gender predilection. Age was more determinantal factor for mortality than sex. The above study gives an important clue about the triage and management of covid 19 patients. Even mild to moderate covid disease in elderly warrants critical care in ICU admission. It also downcourages the homebased isolation and management of elderlycovid19 patients.