|Year : 2020 | Volume
| Issue : 6 | Page : 183-187
An epidemiological study of laboratory confirmed COVID-19 cases admitted in a tertiary care hospital of Pune, Maharashtra
Muralidhar Parashuram Tambe1, Malangori A Parande2, Vinay S Tapare2, Pradip S Borle3, Rajesh N Lakde2, Sangita C Shelke2, BJMC COVID Epidemiology group4
1 Dean and Professor and Head, B.J. Govt. Medical College, Pune, Maharashtra, India
2 Associate Professor, B.J. Govt. Medical College, Pune, Maharashtra, India
3 Statistician-cum-Assistant Professor, Department of Community Medicine, B.J. Govt. Medical College, Pune, Maharashtra, India
|Date of Submission||05-May-2020|
|Date of Decision||12-May-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||2-Jun-2020|
Muralidhar Parashuram Tambe
Department of Community Medicine, B.J. Govt. Medical College, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: India has reported more than 70,000 cases and 2000 deaths. Pune is the second city in the Maharashtra state after Mumbai to breach the 1000 cases. Total deaths reported from Pune were 158 with a mortality of 5.7%. To plan health services, it is important to learn lessons from early stage of the outbreak on course of the disease in a hospital setting. Objectives: To describe the epidemiological characteristics of the outbreak of COVID-19 in India from a tertiary care hospital. Methods: This was a hospital-based cross-sectional study which included all admitted laboratory confirmed COVID19 cases from March 31, to April 24, 2020. The information was collected in a predesigned pro forma which included sociodemographic data, duration of stay, family background, outcome, etc., by trained staff after ethics approval. Epi Info7 was used for data analysis. Results: Out of the total 197 cases, majority cases were between the ages of 31–60 years with slight male preponderance. Majority of these cases were from the slums. Breathlessness was the main presenting symptom followed by fever and cough. More than 1/5th of patients were asymptomatic from exposure to admission. The case fatality rate among the admitted cases was 29.4%. Comorbidity was one of the significant risk factors for the progression of disease and death (odds ratio [OR] = 16.8, 95% confidence interval [CI] = 7.0 − 40.1, P < 0.0001). Conclusion: Mortality was higher than the national average of 3.2%; comorbidity was associated with bad prognosis.
Keywords: COVID-19, epidemiology, tertiary care hospital
|How to cite this article:|
Tambe MP, Parande MA, Tapare VS, Borle PS, Lakde RN, Shelke SC, BJMC COVID Epidemiology group. An epidemiological study of laboratory confirmed COVID-19 cases admitted in a tertiary care hospital of Pune, Maharashtra. Indian J Public Health 2020;64, Suppl S2:183-7
|How to cite this URL:|
Tambe MP, Parande MA, Tapare VS, Borle PS, Lakde RN, Shelke SC, BJMC COVID Epidemiology group. An epidemiological study of laboratory confirmed COVID-19 cases admitted in a tertiary care hospital of Pune, Maharashtra. Indian J Public Health [serial online] 2020 [cited 2020 Jul 13];64, Suppl S2:183-7. Available from: http://www.ijph.in/text.asp?2020/64/6/183/285630
BJMC COVID Epidemiology group
Yallapa Jadhav, Kendre Varashrani Vithalrao, Vikas Kshirsagar,
Nandkumar Salunke, Atul Jagtap, Kunhipurayil Kavita Kurunan,
Swati Fulambarkar, Uzma Shaikh, Ganesh Jagdale, Amit Patil, Apeksha
Paunikar, Pradnya Shinde, Kalyani Ekre,Namrata Mule, Amol Bangar,
Minal Hatanapure, Priyanka Salunke, Pawan Chavan, Department of
Community Medicine, B.J. Govt. Medical College, Pune, Maharashtra, India
| Introduction|| |
The 2019 novel coronavirus (SARS-cov2) or COVID-19 as it is now called is rapidly spreading worldwide from its place of origin in Wuhan City of Hubei Province of China. Up to April 25, 2020, COVID-19 had affected 210 countries and territories around the world and globally around 2,870,862 confirmed cases of COVID-19 and more than 200,000 confirmed deaths have been reported. The first case in India was reported on January 30, 2020, 100th case on March 17, 1000th case on 30 March, and 10,000th case on 14 April and total cases were 24,642 and 779 deaths with a case fatality rate of 3.2%. Maharashtra has reported the highest number of cases in India with 6817 total cases and 310 total deaths on 25th April with a mortality of 4.4%. Pune is the second city in the Maharashtra state after Mumbai to breach the 1000. It took 47 days for Pune to cross 1000 cases since it reports its first two cases on March 9, 2020. Total deaths reported from Pune were 158 with a mortality of 5.7%.
Even though the virus is causing mild disease in many, the course of illness may be severe, leading to hospitalization and even death in elderly or those with comorbid conditions. Many of the epidemiological features vary from countries to countries or are not known. Therefore, there is need to generate evidence on this aspect. This study has been planned to describe the epidemiological characteristics at an early stage of the outbreak in India from a tertiary care setting in India used for isolation of suspected cases and management of COVID-19-positive patients.
| Materials and Methods|| |
Sassoon General Hospital is a tertiary care hospital in Pune and has been designated for isolation and management of suspected cases of COVID-19 as dedicated COVID hospital. This center started admitting the patients of COVID-19 from March 31, 2020. The current study was a hospital-based cross-sectional descriptive study of epidemiological features of COVID-19-positive patients who presented themselves to this center during the outbreak from March 31, to April 24, 2020.
We followed the NCDC/ICMR guidelines for defining suspect cases., This included patients with acute respiratory illness, AND a history of travel to or residence in a country/area or territory reporting local transmission; a patient/health-care worker with any acute respiratory illness AND having been in contact with a confirmed COVID-19 case in the last 14 days prior to onset of symptoms; all hospitalized patients with severe acute respiratory illness (fever and cough and/or shortness of breath); all asymptomatic direct and high-risk contacts of a confirmed case tested once between days 5 and day 14 of coming in his/her contact and a positive swab report; and a case for whom testing for COVID-19 is inconclusive.
Laboratory confirmed case
A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.
Patients with suspected COVID-19 were admitted and quarantined in this tertiary care hospital. Nasopharyngeal swab samples were collected and tested for the presence of SARS-CoV-2 using a reverse transcriptase–polymerase chain reaction (RT-PCR) test. Once patients were confirmed as COVID-19 positive by the RT-PCR, they were shifted to isolation ward. All laboratory-confirmed cases were eligible for inclusion in this study and the epidemiological data was prospectively collected by person-to-person interview with a predesigned pro forma and also from the patient records available from the ward. The predesigned pro forma included sociodemographic data, duration of stay, family background, outcome etc., The interviews were conducted by the trained staff of department of Community Medicine after taking informed consent. Outcome of patient was recorded as recovery and discharge, absconded, discharge-against-medical-advice, transferred-out, still-admitted and death.
Permission of Institute Ethics Committee (IEC) was taken (IEC Ref No.BJGMC/IEC/Pharmac/ND-Dept 0420062-062). All participants were informed about the objectives and their right whether to choose to participate or not in the study. A written informed consent was obtained from all participants or their relatives. In case the study subject was less than 18 years, informed consent was taken from the parents/guardian and assent was taken from the subject. Full confidentiality of respondent's information was maintained and information was used only for research purpose.
The data were analyzed by EPI INFO™ version 7 Epi Info™ website (http://wwwn.cdc.gov/epiinfo/). Descriptive Statistics, Chi-square tests were done and significance of tests was decided at P = 0.05.
| Results|| |
A total of 2154 subjects were screened during the study period for COVID-19; out of which 197 (9.1%) were confirmed as COVID-19 cases Majority i.e., 109 (55.4%) were between the age group of 31-60 years; mean age was 45.8 ± 17.3 years; ranging from 4 months to 85 years. There was a slight male preponderance with M:F ratio of 1: 1.2.
Out of 197 patients, only one patient (0.51%) had history of foreign travel while 57 (29.1%) were exposed to a laboratory confirmed COVID-19 case; out of which 47 (23.8%) cases had exposure within their family and 10 (5.0%) had exposure at work place.
Ward-wise distribution of cases in Pune city who reported to this center [Figure 1] showed that around 2/3rd of admitted cases i.e., 137 (65.4%) were from the Bhavanipeth, Kasbapeth, Yerawada, and Kondhwa area.
|Figure 1: Ward-wise distribution of admitted COVID-19 cases in Pune city as per area of residence.|
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The presenting symptoms of these patients are described in [Figure 2]. On admission, the most common symptom was breathlessness 92 (46.7%), followed by cough 86 (43.5%) and fever 84 (42.6%). The other symptoms included cold 11 (5.6%), weakness 10 (5.1%), nausea and vomiting 10 (5.1%), pain in lower extremities 8 (4.1%), chest pain 7 (3.5%), body ache 7 (3.5%), headache 5 (2.5%), loss of appetite 4 (2.0%), and other symptoms such as dizziness 3 (1.5%), difficulty in urination, loose motions, and palpitation in 2 (1.0%) individuals each, while one patient had myalgia as a symptom at the time of admission. Forty-five out of 197 (22.8%) patients were asymptomatic from exposure to admission.
Among the 152 symptomatic cases, duration from onset of symptoms to admission ranged from 1 day to 21 days with average time of 3.5 days; 17 (8.6%) cases reported on same day of illness while maximum 71 (36.0%) cases reported between 1 and 3 days, while 9 (4.6%) cases reported beyond one week.
Out of the 197 cases admitted, 58 cases died giving a case fatality rate of 29.4%, out of which 3 patients were brought dead. Out of the 139 remaining patients, 74 (37.6%) recovered and were discharged after two consecutive negative samples; 37 (18.9%) patients who had mild/very mild disease were transferred to COVID care center, while 5 (2.5%) patients took discharge against medical advice and were transferred out to other dedicated COVID hospital and 23 (11.7%) patients were still admitted in the hospital.
Out of 197 patients [Table 1], 104 (52.8%) had no history of any comorbidity while 93 (47.2%) reported one or the other comorbidity; hypertension being the most common one followed by diabetes. Out of the 93 COVID-19 cases with reported comorbidity, 37 (18.7%) patients had two comorbidities, of which 29 (14.7%) had both hypertension and diabetes; 6 (3.0%) patients reported three comorbidities and one patient reported 4 comorbidities.
|Table 1: Association of comorbidity and outcome of admitted COVID-19 patients (*multiple responses)|
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Out of 58 patients who died due to COVID-19, comorbidity was one of the significant risk factor for death (odds ratio [OR] = 16.8, 95% confidence interval [CI] = 7.0 − 40.1, P < 0.0001). The most common risk factor among the dead patients was hypertension followed by diabetes. Out of 58 patients who died, 18 (9.1%) patients had dual comorbidity of hypertension and diabetes, three more patients had dual comorbidity; two patients had three comorbidities and one patient had four comorbidities.
Majority of the deaths were in age group of 51–60 years followed by 61–70 years; no deaths were seen in age group of 0–20 years. Highest death rate of 45.4% was seen in age group 71–80 years followed by age group 51–60 years 41.6%. Overall male preponderance was seen among deaths.
It was seen that 6 (12%) cases were admitted on the same day as the onset of illness, while 22 (46%) cases were admitted between 1 and 3 days, 19 (38%) cases between 4-6 days, and 3 cases were admitted after ≥1 week of onset of illness.
Among the patients who died, it was observed that majority had survived more than 24 hrs after getting admitted to the hospital. Within 1–3 days of admission, 22 (37.9%) died, while 13 (22.4%) died between 4-6 days, while ten (17.2%) patients survived 7 days before succumbing to death [Table 2].
| Discussion|| |
During March 31, 2020 to April 24, 2020, a total of 197 cases were admitted to this tertiary care center, which is recognized as dedicated COVID hospital. This study presents the epidemiological characteristics of COVID-19 admitted patients. The infection was observed mainly (55.4%) in the age group of 31–60 years. There was a slight male preponderance which may be related to their outdoor activities and travel. Similar results were observed in a study conducted in New Delhi. In this study, only one patient had a history of foreign travel while 29.1% were exposed to a laboratory-confirmed COVID-19; out of which 23.8% cases had family exposure and 5.0% had exposure at work place which was mainly health care setting. Majority of the cases reported no history of travel or history of contact which suggests that local and to small extent community transmission is going on in this city. Ward-wise distribution of cases in Pune city [Figure 1] showed that around 2/3rd of admitted cases were from the Bhavanipeth, Kasbapeth, Yerawada, and Kondhwa area. The first three areas were declared as hotspot areas in this city in addition to five other and containment activities such as rigorous contact tracing, dedicated COVID care booth, door to door check-up, extensive sanitization were strengthened in these areas by the municipal health authorities. These areas consist of mainly slums with population density of about 70,000/km2, thereby making these areas as most densely populated area. There were no separate toilets and bathrooms. With this scenario, and such high population density, social distancing measures are hard to practice.
The most common symptom of presentation was breathlessness followed by cough and fever. These findings are in contrast to findings of a case series study by Nitesh Gupta et al. who found fever as the most common symptom. This might be due to the fact that this is tertiary level institute recognized as dedicated COVID hospital, where majority patients came with serious signs and symptoms. Forty-five (22.8%) patients were asymptomatic at the time of admission. These were the high-risk contacts of the COVID-positive cases; tested due to exposure without symptoms and detected as positive. Diarrhea and loss of appetite were atypical symptoms of low incidence in COVID-19 patients. Similar results were seen in various studies., Although it was unclear whether there was a definite link between diarrhea and COVID-19, both studies raise a question concerning whether the gastrointestinal tract might be another site of viral replication, indicating the possibility of faecooral transmission.
Among the symptomatic 152 cases, duration from onset of symptoms to admission ranged from 1 day to 21 days with an average time of 3.5 days; 4.6% cases reported beyond one week.
The case fatality rate among the admitted cases was 29.4% which is quite higher than the national average figure of 3.2% (2293/70795 till May 12, 2020). This might be due to the fact that this hospital being a tertiary care public hospital, all serious cases were referred by other hospitals or those patients who came on their own had serious types of symptoms like breathlessness. Three patients were brought dead and were suspected; later on, they turned out to be positive for COVID-19. Mortality rate among diagnosed cases (case fatality rate) has a variable range; true overall mortality rate is uncertain, as the total number of cases (including undiagnosed persons with milder illness) is unknown. Not much literature is published yet on this aspect of COVID-19 as far as Indian situation is concerned. This disease is causing rapid respiratory failure in a handful of people, but that, handful can mean a lot to deal with in terms of logistics and resources when we look at from the national perspective.
Among the admitted patients, 52.8% had no history of any comorbidity while 47.2% reported one or the other comorbidity; hypertension being the most common one followed by diabetes. Comorbidity was one the significant risk-factors for the progression of disease and death (OR = 16.8, 95% CI - 7.0 − 40.1, P < 0.0001). The most common risk factor among the dead patients was hypertension followed by diabetes. Out of 58 patients who died, 24 (41.3%) patients had two or more comorbidities. Majority of the death were in age group of 51–60 years; no deaths were seen in young age group of 0–20 years, while the highest death rate of 45.4% was seen in age group 71–80 years followed by age group 51-60 years (41.6%). Overall male preponderance was seen in deaths. These findings suggest that older adults have elevated rates of COVID-19–associated hospitalization and the majority of persons hospitalized with COVID-19 have underlying medical conditions.,, Among laboratory-confirmed cases of COVID-19, patients with any comorbidity yielded poorer clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomes.
Among patients who died, when we compare the onset of illness to hospital-admission, it is seen that 6 (12%) cases were admitted the same day, while three cases admitted ≥1 week period. It was seen that earlier the admission better was the prognosis.
| Conclusion|| |
Among the hospitalized patients in this tertiary level hospital, breathlessness was the main presenting symptom followed by fever and cough. Majority of these cases were from the slums with poor social distancing practices. The case fatality rate among the admitted cases was quite higher than the national figures. Comorbidity is one of the significant risk factors for the progression of disease to death.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]