Bakshi A. S, Sharma N, Singh j, Batish S, Sehgal v. To Study Demographics as Risk Factor for Mortality Associated with COVID-19 : A retrospective cohort study. Biomed Pharmacol J 2021;14(3)

---

Manuscript received on :14-04-2021
Manuscript accepted on :26-07-2021
Published online on: 28-07-2021

---

Plagiarism Check: Yes
Reviewed by: Dr. Rajesh K. Sahu  
Second Review by: Dr. Salman Ahmed  
Final Approval by: Dr. Ayush Dogra

---

How to Citeclose    |   Publication History close

 Views: (Visited 331 times, 1 visits today)    PDF Downloads: 320

Amandeep Singh Bakshi¹, Neetu Sharma^2*, Jasbir Singh², Sandeep Batish³, Vijay Sehgal¹

¹Department of Orthopedics, Govt. Medical College , Patiala. India

²Department of Pharmacology, Govt. Medical College , Patiala. India

³Deputy Civil Surgeon , Kaithal , Haryana. India.

Corresponding Author E-mail: drneetusharma1975@gmail.com

DOI : https://dx.doi.org/10.13005/bpj/2253

Abstract

Objectives : Novel coronavirus disease COVID-19  has emerged as a pandemic, claiming over 1,431,513  lives ( till Nov. 27,2020 ) worldwide involving 191 countries . The objective of the study is to evaluate age and gender as a risk factor for COVID -19 related mortality . Material and Methods : It is a retrospective cohort study , where the database of indoor COVID-19 positive patients was assessed for the study. Evaluation of the role of age and gender in mortality of COVID infection by comparing dataset of 2,142 indoor COVID positive patients with two outcome groups namely ,death and discharged groups was done. Results: The  age comparison between two groups namely, death and discharged groups  showed a median age of 60 years (IQR 50-70) for patients who died and 52 years (IQR 36–62) for the patients who recovered from COVID (p value-<0.001). There were 9 (0.65%) pediatric patients (<12 yrs) in the group of patients who recovered .For gender analysis (n=2129), COVID patients who died were 32.5%( n=692) ,out of which 63.6%(n=440) were males and 36.4%(n=252) were females. COVID positive patients in discharged group were 67.5%(n=1437),out of which 61.2%(n=880) were males and 38.8%(n=557) were females. There was no statistical difference between the two groups for mortality risk based on gender for COVID -19 infection (chi square value of 1.09, p value=.296) and the relative risk of death in males and females who died of COVID was 1.052 (95% CI=0.92-1.204). Conclusion: COVID-19 infection is showing predilection for male gender in both death and discharged group but the males and females are equally susceptible to the risk of death .

Keywords

COVID-19; Demographics; Mortality risk; risk factors

Introduction

Novel corona virus disease COVID-19  has emerged as a pandemic, claiming over 1,431,513  lives ( till Nov. 27,2020 ) worldwide involving 191 countries .^[1] More than 1,35,715 deaths( till Nov. 27,2020 )  have been reported from India . Out of these 4,710 deaths ( till Nov.  27,2020 )  have been reported from Punjab.^[2]

Corona viruses are a family of enveloped, single stranded, zoonotic  RNA viruses which can rapidly mutate and recombine, leading to novel viruses that can spread from animals to humans^[3] These RNA viruses have  glycoprotein spikes that give them a crown like appearance.^[4]

The mode of disease spread is by droplets generated by infected people during sneezing and coughing. ^[5,6] Incubation period varies from 2-14 days with a median of 5 days. The severity and fatality are higher in the elderly, especially above the age of 60 and those with comorbidities like heart disease, hypertension, diabetes etc. ^[7]

In this study, we will investigate the associations between various  factors like age and gender as risk factors for  COVID-19-related mortality in patients admitted to the hospital. However, little data on the prognostic factors of COVID-19 have been reported. This is the first regional study evaluating the role of age and gender in mortality of COVID infection by comparing huge data set of thousands of people with two outcome groups namely ,death and discharged groups.

Material and Methods

Study  Design

It is a record based retrospective cohort study .For the COVID-19 cohort in this study, database of Covid hospital, Rajindra hospital Patiala for COVID-19 ,from july 1 to November 30, 2020, was assessed . The information used in this study is anonymous and covers only age and gender data. In the first group named Death group data of COVID positive patients who died was analysed and in the second group named Discharged group , the data of COVID positive patients who recovered and were discharged from the hospital was included. The study protocol was approved by the Institutional Ethics Committee.

Sample size

Database of COVID-19 positive patients  hospitalized between the months of July 2020 and November 2020 was included for analysis in this study. Sample size for age analysis was data of 2,142 indoor covid positive patients out of which 705 died  and 1437 recovered and discharged from the hospital  . Sample size for various variables analysis differed by ± 25 because of some missing values in the database.

Statistical analysis

Continuous variables were described using mean ± standard deviation and categorical variables were presented as frequency rates and percentages. We used independent group t tests to compare means for continuous variables when the data were normally distributed.In the case of age group analysis Levene’s test was significant (p < .05), suggesting a violation of the equal variance assumption,but seeing the sample size of thousands instead of using another option of Mann Whitney U test the results of students t test with highly significant difference were found permissible in this case . For categorical variables, we used the Chi square test, to compare differences between the dead and discharged  patients groups where appropriate. The two sided  p value of <0.05 was considered statistically significant and p value of <0.01 was considered as statistically highly significant . The data was subjected to statistical analysis using JASP software 0.14 version of the license.

Results

A database of 2308 COVID-19 positive  patients who were hospitalised between July 1 and Nov 30, 2020,was screened for inclusion in this retrospective cohort study . Out of this, data of 161(6.98%) indoor COVID-19 positive patients was excluded due to various reasons of referral to other hospital (n=129) , brought dead (n=1) and missing values of the variables(n=36) .Data of total of 2142  patients hospitalized for COVID -19 was included in the analysis in this study.[Table 1]

Table 1: Flow Chart of Data Disposition in tha study. Click here to view figure

The data analysis  of patients hospitalised for COVID-19 for the  age comparison between two groups based on the outcome showed a median age of 60 years (IQR 50-70) for patients who died because of COVID-19  and 52 years (IQR 36–62) for the patients who recovered from COVID and were discharged from the hospital (p value-<0.001).[Table 2] There were 9 (0.65%) pediatric patients (<12 yrs) in the group of patients who recovered and were discharged from hospital.

Table 2: Analysis of data for age as risk factor for COVID -19 related mortality.

For gender analysis (n=2129), COVID patients who died were 32.5%( n=692) ,out of which 63.6%(n=440) were males and 36.4%(n=252) were females. COVID positive patients who recovered and were discharged from the hospital were 67.5%(n=1437),out of which 61.2%(n=880) were males and 38.8%(n=557) were females.On comparing the two outcome groups for gender males were more affected with COVID in death and discharged both groups . Mean age of males and females in the death group was 57.9±14.7 and 59.5±13.7 respectively. Mean age of males and females in the discharged group was 50.4±15.6 and 49.0±18.1 respectively. Ages were comparable between men and women in both patients who deceased and survived.[Table 3]Of the 692  patients in the death group,63.6% were men and 36.4 % were women. The number of men was 1.74 times that of women in the death group.It was evident from the results where  male gender is showing clear cut predilection for COVID infection compared to females in both death and discharged group. There was no statistical difference between the two groups for mortality risk based on gender for COVID -19 infection (chi square value of 1.09, p value=.296).[Table 4] The relative risk of death in males and females in death group was 1.052 (95% CI=0.92-1.204). as this confidence interval includes value of 1, so the risk ratio shows that incidence of risk of death in  death group amongst males and females is same.

Table 3: Independent Samples T-Test.

Note:Student’s t-test.Levene’s test is significant (p < .05), suggesting a violation of the equal variance assumption

Table 4: Analysis of data for Gender as risk factor for COVID -19 related mortality.

Discussion

As the novel corona virus continues to evolve, there are still many lacunae  to our knowledge regarding the risk factors affecting the mortality caused by this deadly virus. Older  age adults are more affected by this disease. However, little data on the prognostic factors of COVID-19 have been reported. This is the first regional study evaluating the role of age and gender in mortality of COVID infection by comparing huge data set of thousands of people with two outcome groups namely ,death and discharged groups.In the first group named Death group data of COVID positive patients who died was analysed and in the second group named Discharged group , the data of COVID positive patients who recovered and were discharged from the hospital was included.

In this study  of COVID-19, consistent with previous studies older age patients of median age 60 years (IQR 50-70) were died compared to median age 52 years (IQR 36–62) in the patients who recovered from COVID. According to the CDC, 8 out of 10 deaths reported in the USA occurred in adults 65 years old and above.^[8]The age-dependent defects in T-cell and B-cell function, and the excess production of type 2 cytokines could lead to a viral replication control deficiency and more prolonged pro-inflammatory responses, potentially causing poor outcomes.^[9]

On comparing the two outcome groups (Death vs Discharged) for gender, males were more affected than females with COVID in death and discharged both groups( 63.6% vs 36.4% ;61.2% vs 38.8%) . Mean age of males and females in the death group was 57.9±14.7 and 59.5±13.7 respectively .Mean age of males and females in the discharged group was 50.4±15.6 and 49.0±18.1 respectively.

Ages were comparable between men and women within the group in both patients who deceased and survived while higher age people were more prone  to succumb to death by COVID-19 infection showing that age is an independent risk factor for mortality leaving aside the gender. That means both males and females of higher age are at the risk  of increased mortality independent of their gender( chi square ,p value=0.296).Both males and females are equally susceptible to the risk of death in death group (RR=1.053; 95%CI=0.92-1.204).The  risk ratio shows that incidence of risk of death in  death group amongst males and females is same enclosing value of 1 .

In a study done by Jian-Min Jin et al in china Gender Differences in Patients With COVID-19 with the Focus on Severity and Mortality they concluded that Age was comparable between men and women in all data sets . In the case series, however, men’s cases tended to be more serious than women’s (P = 0.035)while in the public data set, the number of men who died from COVID-19 was 2.4 times that of women (70.3 vs. 29.7%, P = 0.016).^[10] Thereby showing that  the gender role in mortality was also observed. The percentage of males were higher in the deceased group than in the survived group (P = 0.015).Nevertheless, in our study based on Indian patients although COVID-19 infection is showing predilection for male gender in both death and discharged group ( 63.6% vs 36.4% ;61.2% vs 38.8%) but the males and females are equally susceptible to the risk of death in death group (RR=1.053; 95%CI=0.92-1.204).

Conclusion

The patients with COVID-19 infection requiring hospitalization are showing predilection for male gender in both death and discharged group. Ages were comparable between men and women within the group in both patients who deceased and survived while higher age people were more prone  to succumb to death by COVID-19 infection showing that age is an independent risk factor for mortality leaving aside the gender.That means both males and females of higher age are at the risk  of increased mortality independent of their gender.

Labour force surveys conducted by National Sample Survey Office (NSSO), Ministry of Statistics and Programme Implementation ,Government of Indiathe estimated female Worker Population Ratio (%) on usual status basis in the country during 2009-10 and 2011-12 are 26.6% and 23.7% respectively.^[11] The male predilection of COVID-19 infection could be due to more outdoor exposure compared to females.

Conflict of interest

None

Funding source

None

References

1. COVID-19 Map [Internet]. Johns Hopkins Coronavirus Resource Center. [cited 2020 Nov 27]. Available from: https://coronavirus.jhu.edu/map.html.
2. Ministry of health and family welfare .COVID -19 status. [cited 2020 Nov 27]. Available from: https:// www.mohfw.gov.in/;2020.
3. Zimmermann P, Curtis N. Coronavirus Infections in Children Including COVID-19. PIDJ. 2020 Mar 12. [Epub ahead of print] Available from: https://journals.lwww.com/ pidj/Abstract/onlinefirst/ Coronavirus_Infections_inChildren _Including. 96251. aspx.Accessed on April 06,2020.
4. Singhal T. A Review of Coronavirus Disease-2019 (COVID-19). Indian. J. Pediatr. 2020;87:281-6.
   CrossRef
5. Tang B, Bragazzi  N.L, Li Q, Tang S, Xiao Y, Wu J. An updated estimation of the risk of transmission of the novel coronavirus (2019-nCov). Infect. Dis. Model. 2020;5:248-55.
   CrossRef
6. Chawla D, Chirla D, Dalwai S, et al. Perinatal-Neonatal Management of COVID-19 Infection — Guidelines of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP). Indian. Pediatr. 2020 Jun;57(6):536–48.
   CrossRef
7. Zheng X, Chen J, Deng L, Fang Z, Chen G, Ye D, et al. Risk factors for the COVID-19 severity and its correlation with viral shedding: A retrospective cohort study. Journal of Medical Virology [Internet]. [cited 2020 Nov 27];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.26367
   CrossRef
8. CDC. Coronavirus (COVID-19): symptoms of coronavirus.Centers for Disease Control and Prevention. 2020. [Accessed Oct18 ,2020] ,Available from: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html].
9. Opal S.M , Girard T.D , Ely E.W . The immunopathogenesis of sepsis in elderly patients. Clin.Infect. Dis. 2005; 41 (suppl 7):S504–12.
   CrossRef
10. Frontiers | Gender Differences in Patients With COVID-19: Focus on Severity and Mortality | Public Health [Internet]. [cited 2021 Feb 12]. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2020.00152/full?filter_by=popular7&utm_ content =117588489&utm_medium=social&utm_source=facebook&hss_channel=fbp-225612270801893&fbclid=IwAR2rZLOpUzkpn-NCWIyqWpjsFc_5Vtzk66- _0faTHA o1sA tiUx26cbEsHlp
11. Female Employment Rate [Internet]. [cited 2021 Feb 12]. Available from: https://pib.gov.in/Pressreleaseshare.aspx?PRID=1540619