Comorbidity and Risk Factors for COVID-19 Confirmed Patients in Wasit Province, IRAQ

1 www. jkmc.uobaghdad.edu.iq Al-Kindy College Medical Journal 2020:16 [suppl] ABSTRACT Background: Coronavirus disease 2019 (COVID-19) is one of the updated challenges facing the whole world. Objective: To identify the characteristics risk factors that present in humans to be more liable to get an infection than others. Methods: A cross-sectional study was conducted for positively confirmed 35 patients with polymerase chain reaction in Wasit province at AL-Zahraa Teaching Hospital from the period of March 13 till April 20. All of them full a questionnaire regarded by risk factors and other comorbidities. Data were analyzed by SPSS version 23 using frequency tables and percentage. For numerical data, the median, and interquartile range (IQR) were used. Differences between categorical groups were performed by fissure exact test. Results: The median age of the patients was 43 years old and interquartile range (25-56 years). Majority of the patients were female (60%) and (51%) of them were from the same region (AL-ezza). The dominant blood group among patients was (O) (40%). About 11.4% of patients had a travel history especially to Islamic Republic of Iran, while (77.1%) had contact with positive cases. The highest percentage of comorbidities among patients was hypertension (40%), and the most presenting symptoms were cough and fever. About 51% of patients were with mild symptoms. Diabetes, coronary heart diseases, and chronic renal diseases were significantly related to disease severity (P-value=0.02, 0.001, 0.01 respectively). Conclusion: Being a female, overweight or obese, and with blood group (O) are the major risk factors among patients. Comorbidities can play an important role in the severity of disease especially hypertension, diabetes, coronary heart diseases, and chronic renal diseases.


INTRODUCTION
Novel coronavirus (SARS-CoV-2) infection or COVID-19 disease considers as a major health concern that affecting 213 countries and areas worldwide starting from December 2019 (1) . On April 12, 2020, there were about 1,781,432 confirmed cases with 108,883 related deaths all over the world (2) . The disease started in China in December 2019 and identified by physicians as a series of pneumonia cases which is similar to severe acute respiratory syndrome (SARS) (3) . The disease began in Wuhan, then it is rapidly spread into different regions of China. Many factors were responsible for this rapid and widespread of the virus to different clusters like people susceptibility, various infection routes, and virus virulence (4) . It is reported that about 75,465 cases were confirmed in china until February 20, 2020 (5) . The World health organization (WHO) announced COVID-19 as a global pandemic on March 11, 2020 (6) . The United States ranks number one around the world with all 50 states reported different levels of infected cases and the CDC mentioned that the USA is in the acceleration phase of the pandemic (7) . In Iraq, the risk of the disease was raised due to borders with the neighbouring country, the Islamic Republic of Iran which becomes the eighth highest region with confirmed and dead cases reported (  . As of April 12, Iraq confirmed cases was 1,318 with 601 recovering and only 72 deaths (8) . Wasit is one of the Iraqi provinces that have close contact and sharing borders with the Islamic Republic of Iran which made the governorates authorities to start early measures for prevention and control that include school closure, movement restrictions, and increase population awareness. According to previous studies, the most important risk factors were age, gender, and co-existing diseases. A review study found that older people were more liable to get the infection than younger age groups. The mortality among males was significantly higher compared to females with no approval of susceptibility to infection among two genders. The presence of pre-existing and any condition that weakens the immune system can be a risk factor for infection with COVID-19 (9) . As the definite treatment and vaccine for this disease have not yet discovered, it is so important to identify risk factors to design suitable plans for the prevention of infection transmission for highly susceptible people. The current study aimed to identify the major risk factors and comorbidities identified among COVID-19 patients in Wasit province, Iraq.

METHODOLOGY
Study design and setting: This is a cross-sectional study done in Wasit province, one of the Iraqi governorates situated in the eastern border of Iraq with Iran with a total population of approximately 1,450,000. Data collection and analysis was continuous for about two months from 1 st of March until the end of April. Sample, Group definition: The sample involved in this study was all patients confirmed with COVID-19 infection by real-time reverse transcriptasepolymerase chain reaction test (RT-PCR) obtained from public health laboratory in the capital (Baghdad) using patients' nasal and pharyngeal swabs. All 35 Cases registered and admitted to AL-Zahraa Teaching Hospital for March 3 rd (first diagnosed case in Wasit) until April 20 th , 2020 were included in the study. There are no exclusion criteria for the sample collection. The case definition for COVID-19 confirmed patients include all patients test positive by (RT-PCR) regardless of the presence of any sign and symptoms. The patients presenting sign and symptoms were classified according to the Chinese center for disease control and prevention into mild, moderate, severe, and critical (10) . This classification was the same as to that approved by the Ministry of Health in Iraq. Ethical approval: An official approval was obtained from Wasit Health Directorate for data usage. All patients signed the consent form before starting the research. Study Tool: (Questionnaire): A structured questionnaire previously prepared by two experts specialist in internal medicine and community health was used for data collection. The questionnaires consist of 3 parts mainly part A regarding demographic data such as age, gender, educational level, employment, place of living, and blood group. Part B was about risk factors such as smoking, travelling history, and contact with a positive case. Part C regarding symptoms of present illness and also past medical history like hypertension, diabetes, coronary heart diseases, chronic renal diseases, and others. Statistical Methods: Data analysis was performed using SPSS version 23. Frequency and percentage were used to present categorical data, while numerical data were presented by a median, and interquartile range (IQR). Differences between categorical groups were performed by fissure exact test. Level of statistical significance considered as P < 0.05.

RESULT
The median age of patients was 43 years old (IQR 25-56 years). The minimum age was 2 years, while the maximum was 74 years old. Table 1 shows the demographic distribution of patients. The females were higher than males in getting the infection with (60%) women. More than one third (34.3%) of patients never had any education including children. Near half (48.6%) of them were unemployed including retired and housewives. The majority of the patients were overweight (40%) and obese (37.1%). Majority of patients (51.4%) were living in Al-ezaa city.  In table 2, about two-thirds of patients (68.7%) were having a history of chronic diseases. Hypertension was the most common pre-existing disease with (58.3%) followed by diabetes and coronary heart diseases with (12.5%) respectively. Only one female patient had a history of breast cancer.

DISCUSSION
Even that COVID-19 is considered as a pandemic disease worldwide, Iraq reported a relatively low incidence rate of disease. In Wasit province, there were only 35 cases until April 20 th with only 2 death recorded. People who positively diagnosed as COVID-19 showed a different distribution among different age groups. Children were less likely to get the infection, while the majority of cases were belonging to the younger age groups (16-60) years old, with only 5 out of 35 patients were above 60 years old. The reason may be because the Iraqi population consisted of more than 58% of these age groups (15-65) years (11) . The median age of the infected patients was 43 years. Other studies showed different values of age distribution among patients as was mentioned in a review study that median age of patients was 47-59 years with a very small percentage of children (2%) (12) . Different age distribution was mentioned in previous studies like in China, Wuhan found that the median age for patients was from 41 to 58 years old with no children and adolescents infected patients (13) . While  found the IQR for age was (35-58) years and only 0.9% below 15 years old (14) . Even, in China, outside Wuhan the median age was 34 years (IQR=34-48 years), only (3%) of patients were under 15 years old and 3% above 65 years (15) . There are a lot of studies that found slightly similar results regarding age distribution among patients like in Zhejiang province among 62 patients with COVID-19 who all express human to human transmission of the disease (16) . Females have a higher percentage of infection compared to males. According to the history taken from infected women, it was obvious that the higher percentage of them were attending the same consolation where the super-spreader was present (17) . Men tend to be more exposed to get the virus in other studies as their jobs outside the home and being more socially active (12)(13)(14)(15)(16) . Males still reported higher mortality rates from the disease which was obvious in this study as the two deaths were males, maybe due to genetic, behavioural or biological factors related to females (9) . Obesity, in general, has an important role in disease pathogenesis especially diabetes and hypertension which is, in turn, lead to an increased risk for COVID-19. This study shows the high distribution of the disease among obese and overweight which may be explained by the presence of pre-existing chronic diseases. According to previous studies, obesity was mentioned as a risk factor for disease severity. Obese patients are more difficult to intubate and obtaining a diagnostic image especially when a prone position is needed (18) . Kassir (2020)  inhibitors 2 (ACE2) receptors. The ACE2 expression is present at a higher level in adipose tissue (19) . Place of living was related to the disease with more than half of patients coming from one region (Ezaa) where most of the women attending the consolation and spread the infection to their families by family clusters pattern (20) . It was obvious that blood groups play an important role as a risk factor for infection. In this study, patients with blood group O were represented by 40%, followed by B group patients. This may be due to blood group distribution among the Iraqi population. It was found that group O was the most common blood group among Iraqis followed by A, B, and AB (21) . This result was in contrast to other nonpeer-reviewed studies in China, that found blood group A were the most affected group by the virus with fewer percentages of patients among blood group type O (22)(23) . Only 4 out of 35 patients had travel history outside Iraq during the last 2 months, exactly to the Islamic Republic of Iran where the disease was highly spread. This may be related to limit travelling and transportation during this period in population due to protests or school examinations. Even so, the majority picked the infection by contacting a positive case which may indicate the higher activity of the virus transmission within this region. In China,  found that contact and travelling history among patients who living outside Wuhan were 72.3% and 31.3% respectively (14) . Although smoking is a major risk factor for many respiratory illnesses, this study shows only 4 out of 35 patients had smoking habits. This may be due to the social perspective about smoking, especially among females. Other studies also showing a low level of smoking among patients as in Zhou et al.
(2020) study showed only 6% while in Zhang et al.
(2020) study it was mentioned that only 3.4% of patients were current smokers (24)(25) . Although smoking does not prove to be a risk factor for COVID-19, it may be considered as a risk for disease severity because smoking can suppress lung immune function and increase the risk of the acute respiratory syndrome(ARS) (26)(27) . Regarding symptoms, the common symptoms presented by the majority of patients were cough and fever, while gastrointestinal symptoms like vomiting and diarrhoea were the least. The same results were reported in other studies that give an idea about the differences of viral tropism from other coronavirus species, absence of fever doesn't mean the absence of COVID-19 (12,(14)(15)(16) . The most common pre-existing chronic diseases among patients were hypertension(40%), diabetes and coronary heart diseases (8.6%), chronic renal diseases (5.7%), cancer (2.9%), and hydrocephaly (2.9%). previous studies found that diabetes was the most common among COVID-19 patients followed by hypertension, and cardiovascular diseases (13) while Wei-jie  found that hypertension was the highest comorbidity (16.9%), followed by diabetes (8.2%) among 1590 Chinese patients (28) . In the US population, the presence of comorbidities was found in more than 70% of severe cases. Diabetes mellitus is the commonest followed by chronic lung disease, and then cardiac disease (29) . Although diabetes and other comorbidities significantly related to the severity of the infection in this study and this may be due to its relation to older age groups and lower immunity, it is found that only (8.6%) of COVID-19 patients were diabetic. Our results were supported by previous research that gives the reason that sharing the same receptors between the virus and some types of drugs that are dipeptidyl peptidase-4 (DPP-4) inhibitors used commonly in diabetes treatment (12) .

CONCLUSION
The clinical picture of COVID-19 in Wasit province was showing an increase in infection among younger age groups, female, overweighted, or obese with more infection rates among blood group type O. Being in contact with infected persons mainly increases the risk of infection. Diabetes, coronary heart diseases and chronic renal diseases were significantly associated with disease severity. More promotion and early detection are needed to tackle infected people as early as possible, especially those with contact with positive COVID-19 patients. More researches are needed especially in other Iraqi Provinces.

Acknowledgement:
To all infected patients and all healthcare workers who represented the first line of defence against the disease. Funding: No funding.

Conflict of interest:
No conflict of interest was mentioned in this study.