PREVALENCE OF COVID-19 AND ASSOCIATED CO-MORBIDITIES AT A TERTIARY HOSPITAL IN EASTERN NEPAL

Introduction: COVID-19 (coronavirus disease) manifests as asymptomatic, mild, or severe pneumonia-like symptoms. COVID-19 patients with diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), hypertension, malignancies, HIV, and other comorbidities could develop a life-threatening condition. 
Objectives: To identify the various comorbid illnesses in COVID-19-positive patients along with its baseline characteristics in a tertiary hospital in eastern Nepal. 
Methodology: A one-month observational study carried out in RT-PCR positive COVID-19 patients in Birat Medical College and Hospital (BMCTH) Molecular Laboratory from June to July 2021. All the data was entered in a pre-structured proforma. The data was then further entered and analyzed by using Microsoft Excel 2014. 
Result: There were 354 (22.77%) RT-PCR positive COVID-19 cases and 1200 (77.22%) RT-PCR negative COVID-19 cases. More than half of the COVID-19 positive patients were males 211(59.60%). The most common symptoms were fever (92.3%), cough (83.5%) and tiredness (81.23%). Psycho-social stress such as anxiety, depression and insomnia 123 (34.74%) were common comorbidities followed by diabetes 91(25.70%) and hypertension 72(20.33%). 
Conclusion: COVID-19 patients were mostly between the 20-30 years of age group. Fever, cough, and throat pain were the commonest presenting symptoms. 


INTRODUCTION
In December 2019, several cases of pneumonia by an unknown causa ve agent, were seen in Wuhan city of Hubei province in China, and was reported to the World Health Organiza on (WHO) by the Health Authority of China on 31 December 2019 and the outbreak was called as New enveloped and have a non-segmented, single-stranded, posi ve-sense ribonucleic acid (ssRNA+) as their nuclear material.On electron microscopy, these viruses show a characteris c appearance that resembles a crown (corona in La n means crown) due to the presence of club-shaped replica on strategy.The RNA group of viruses is classified into three orders that include the order Nidovirales, which is further classified into four families: Coronaviridae, Arteriviridae, Mesoniviridae, and Roniviridae.The family Coronaviridae is further divided into two subfamilies: Coronavirinae and Torovirinae.The Coronavirinae subfamily includes four genera of viruses (Alphacoronaviruses, Betacorona viruses, Gammacoronaviruses, and Deltacorona viruses), which have been grouped primarily based on serology and phylogene c clustering (divisions based on the habitat/gene c relatedness).SARS-CoV-2 is considered and many animal species like birds and mice.The Severe Acute Respiratory Distress Syndrome and Middle East Respiratory Syndrome (MERS) cases were reported to have a very high case fatality rate of 9.5 and 34.4% respec vely.In contrast, the CoVID-19 has a case fatality rate of 2.13%.Also, there are no clear medical countermeasures for these 12 coronaviruses yet.Evidence suggests that COVID-19 and SARS have many similari es.There are approximately 79.5% similari es in the genome sequences of these two viruses that have been reported.The virus is mostly transmi ed from person to 13 14 person via respiratory droplets.Some research suggests that direct contact with infected or contaminated items can 15 also spread this virus.The gastrointes nal system is also involved, and some reports indicate that SARS-CoV-2 is iden fied in feces, implying that fecal-oral pathway transmission 16 is possible.Another study reveals that SARS-CoV-2 can infect 17 conjunc va cells, which could be another route of transmission.CoV-2 primarily affects the respiratory system and can involve both the upper (sinuses, nose, and throat) and lower respiratory tracts (windpipe and lungs).The common symptoms of COVID-19 are fever, dry cough, and redness.The other symptoms include aches and body pains, nasal conges on, headache, conjunc vi s, sore throat, diarrhea and loss of taste or smell, etc.In addi on to respiratory 18 symptoms, and neurological manifesta ons hepa c and 1 9 gastrointes nal involvement have been reported.Analyzing clinical and epidemiological data of COVID-19specific comorbidi es raise the risk of infec on, resul ng in severe lung injury and death.So far, the common comorbidi es reported are hypertension, cardiovascular 20 disease, and diabetes.Also, a high propor on of COVID-19 pa ents being admi ed in ICU suggests comorbidi es as a poten al risk factor for COVID-19 pa ents.Despite this pandemic's increasing number of cases and dura on, our country s ll lacks adequate data on COVID-19 comorbidi es, and various clinical findings.As a result, the purpose of this study was to assess the comorbidi es associated with COVID-19 with respect to age and gender in a ter ary care centre of eastern Nepal.The data from our study will help in bringing awareness about Covid -19 cases and assis ng the government in implemen ng policies to take the appropriate steps to control the pandemic within the country.The extracted template was then added to a master mix (Zybio Nucleic Acid Detec on kit) and analyzed in a Real-Time PCR system, Azure Cielo biosystem.All the data was entered in a pre-structured proforma.The data was then entered and analyzed using Microso Excel 2014.The mean age of pa ents was 42.69 SD ± 18.74 years.This finding is consistent with a study conducted in Bangladesh that found the mean age of the pa ents to be 42.59±14.43(21.75 %).This could be a ributed to the fact that people in this age group are more mobile, produc ve and ac ve resul ng in a higher risk of exposure.Overall, males were infected at a higher rate (59.60%) than females, which is 20,21 consistent with the findings of other studies.Males are generally more dynamic than females and par cipate in more outdoor and risk-taking ac vi es and gatherings, which may have led to male predominance in our study.This could also be related to a gender disparity in female case detec on and social s gma.A systemic review and metaanalysis men oned that underrepor ng of female pa ents even a er infec on due to shyness or social s gma is a challenge to focus on, which could be a possible source of 22 rapid disease transmission.MERS-CoV and SARS-CoV showed a similar pa ern of sex distribu on according to 23,24 other studies.In this study majority of the COVID-19 posi ve cases reported from Morang and Sunsari districts of Province 1 at a rate of (55.93%) and (29.37%) respec vely.This finding is quite obvious as our hospital is one of the largest ter ary care hospitals located in Morang district and close to the neighboring district Sunsari.COVID-19 pa ents are commonly present with fever and respiratory illness.Some pa ents, however, reported GI symptoms such as diarrhea, nausea/vomi ng, and abdominal pain.Fecal-oral transmission of COVID-19 infec on has been confirmed by the fact that the virus can 25 replicate in both the respiratory and diges ve tracts.In our study, the most common symptoms of COVID-19-posi ve pa ents were fever, cough, redness and body aches.Fever is the most common symptom in COVID-19 pa ents, but it 26,27 does not affect all pa entsaccording to a few studies.The fever is an alarming sign of the disease, and vomi ng and fever (above 39 degrees) are usually associated with a more severe illness and a longer hospital stay.COVID-19 fever is 28,29 less common than SARS and MERS.

Out
As a result, more a en on should be paid to COVID-19 pa ents who do not have fever as a source clue of infec on, because if the surveillance system only relies on fever in pa ents, some 30 pa ents will then be missed.In this study fever was seen in (92.3%) of cases, cough in (83.5%) of cases, and fa gue in (81.23%) of cases.Our results are comparable to a Chinese study where the common symptoms of COVID-19-posi ve pa ents were fever (67.4%), dry cough (34.3%), and myalgia 31 (28.5%).Similarly, in an Iranian study fever (63.8%), cough (68.1%), and dyspnea (72.7%) were the most common 26 symptoms of COVID-19-posi ve pa ents.According to a Bangladeshi report (87.8%) of the pa ents were symptoma c, and the most commonly reported symptoms were fever (77%), cough (56.8%), breathlessness (24.3%), 20 myalgia (24.3%), sore throat (21.6%) and fa gue (17.6%).In our study loss of smell and taste sensa on was present in (25.23%) of the pa ents.Breathlessness was present in (52.21%) of pa ents, much higher than WHO suggested 30 prevalence of (31-40%).Among the non-respiratory symptoms diarrhea, myalgia, hemoptysis, and sore throats were the least common symptoms; however, these findings were similar to those obtained for other viruses such as 31 SARS and MERS.This may indicate that COVID-19 is a similar infec on to SARS and MERS, which target the cells in the lower respiratory tract system.Although the nasopharynx is theore cally the first organ to become infected with COVID-19, a recent study found that infected people rarely have upper respiratory symptoms at the onset 32 of the infec on.This suggests that the virus usually targets 33 cells of the lower respiratory tract.The most common comorbidi es found in our study were psychological comorbidity (34.74%) followed by cardiovascular disorders (20.33%) and diabetes (25.70%).The psychological comorbidi es were mostly in the form of anxiety (66.66%) and depression (33.33%) as a result of the outbreak of COVID-19.Out of these (36.58%) of the pa ents had severe anxiety and (15.44%) had severe depression.Our finding is in line with a Bangladeshi study where (60%) and (52.9%) of pa ents had anxiety and depression; among them (21.4%) had severe anxiety and (8.1%) had severe 20 depression.Similarly, another study from China showed that (53.8%) of the pa ents had a psychological impact of moderate or severe degree; (16.5%) with moderate to severe depressive symptoms; (28.8%) with moderate to severe anxiety symptoms, and (8.1%) with moderate to 34 severe stress levels.Various studies have reported diverse prevalence rates for cardiovascular disorders ranging from (11%) to (45%) and for diabetes ranging from (13%) to 26,35 (35%).Cardiovascular disorders (20.33%) and diabetes (25.70%) were the most prevalent co-morbidi es among Covid-19 pa ents in our study.A meta-analysis reported an overall pooled prevalence of (8.4%) for cardiovascular disorders and (9.7%) for diabetes respec vely, while another meta-analysis reported a prevalence of (12%) for 36 cardiovascular disorders and around (8%) for diabetes.Authori es believe that subjects with comorbidi es had a worse disease outcome when infected with the novel 37 coronavirus than pa ents without underlying disease.According to the literature and previous research, underlying diseases increase the mortality rate in COVID-19 pa ents, with cardiac disease and diabetes being the most 38 significant risk factors.

CONCLUSION
COVID-19 pa ents were mostly between the 20-30 years of age group.Most of the pa ents were males.The most common symptoms were fever, cough, and throat pain.Psychological impacts were the most common comorbidity followed by diabetes and hypertension.

1 Coronavirus
Pneumonia (NCP).Originally novel coronavirus 2 was referred to as 2019-nCoV by Chinese researchers.The Interna onal Commi ee on Taxonomy of Viruses (ICTC) named this virus as Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-Cov-2) based on the phylogene c associa on with coronavirus that caused SARS outbreak in 3 2003 and consequently the disease was named as COVID-19.World Health Organiza on (WHO) declared SARS-CoV-2 infec on as a public health emergency of interna onal concern on 30 January, 2020 and later declared it as global pandemic on 11 March, 2020.With the occurrence of first and second wave of this pandemic, there have been more than 192 million cases and more than 4 million deaths 4 worldwide by mid-July, 2021.In Nepal, the first case was found on 23 January 2020, in a 5 man returning from Wuhan.According to the reports published by the Ministry of Health, Nepal, on 25 July, 2021, total cases of Covid-19 ll then were 679017, out of which the total recovered cases were 641565, total deaths were 6 9695 & ac ve cases were 27757.Coronaviruses (CoVs) are members of the Coronaviridae family, the order Nidovirales, and the genus Coronavirus.They are the largest group of viruses causing respiratory and gastrointes nal infec ons.Morphologically, CoVs are enveloped viruses containing a non-segmented posi vesense, single-stranded ribonucleic acid (RNA) They are 7 .
This cross-sec onal study included a total number of 1554 clinically suspected pa ents for COVID-19 who visited different OPD and emergency wards of Birat Medical College and Hospital (BMCTH) from June to July 2021.The study was approved by the Ins tu onal Review Commi ee (Ref.noPA-190/2078-79).The samples were collected from all pa ents under inves ga on for COVID-19 infec on.Only PCRposi ve pa ents were included in the study.The comorbidity was iden fied from the pa ent record file maintained in the COVID-Block of the ins tute.The samples (oropharyngeal and nasopharyngeal swabs) were collected in the Molecular Laboratory of Birat Medical College and Hospital (BMCTH).The oropharyngeal and nasopharyngeal

Table 1 :
Distribu on of cases as per gender Original Research Ar cle ISSN: 2542-2758 (Print) 2542-2804 (Online) 2005 Birat Journal of Health Sciences Vol.8/No.1/Issue20/Jan -April, 2023swabs were collected in Viral Transport Medium (Run Mei) and the cold chain was maintained immediately.In the case of those samples which were not processed on the same day 0 they were stored at -80 C.The samples were processed using the Interim Guidelines for SARS-Cov-2 PCR laboratories laid by Nepal's Na onal Public Health Laboratory Network.RNA was extracted using a fully automated extrac on machine and a Zybio Nucleic Acid Extrac on kit based on the magne c bead technique (Zybio, EXM-3000).