Clinical Characteristics and Treatment Outcomes of COVID-19 Patients at Eka Kotebe General Hospital, Addis Ababa, Ethiopia

ABSTRACT. Data from much of Africa are still scarce on the clinical characteristics, outcomes of treatment, and factors associated with disease severity and mortality of COVID-19. A cross-sectional study was conducted at Eka Kotebe General Hospital, Ethiopia’s first COVID-19 treatment center. All consecutive symptomatic SARS CoV-2 RT-PCR positive individuals, aged 18 and older, admitted to the hospital between March 13 and September 16, 2020, were included. Of the total 463 cases, 319 (68.9%) were male. The median age was 45 years (interquartile range 32–62). The most common three symptoms were cough (69%), shortness of breath (SOB; 44%), and fatigue (37%). Hypertension was the most prevalent comorbidity, followed by diabetes mellitus. The age groups 40 to 59 and ≥ 60 were more likely to have severe disease compared with those < 40 years of age (adjusted odds ratio [aOR] = 3.45, 95% confidence interval [CI]: 1.88–6.31 and aOR = 3.46, 95% CI: 1.91–6.90, respectively). Other factors associated with disease severity included the presence of any malignancy (aOR = 4.64, 95% CI: 1.32–16.33) and SOB (aOR = 3.83, 95% CI: 2.35–6.25). The age group ≥ 60 was significantly associated with greater in-hospital mortality compared with those < 40 years. In addition, the presence of any malignancy, SOB, and vomiting were associated with higher odds of mortality. In Ethiopia, most COVID-19 patients were male and presented with cough, SOB, and fatigue. Older age, any malignancy, and SOB were associated with disease severity; these factors, in addition to vomiting, also predicted mortality.


INTRODUCTION
As of December 2, 2021, there were more than 261 million COVID-19 cases and 5.2 million verified COVID-19 deaths worldwide.In Africa, there were approximately 8.8 million cases and 224,000 deaths.Most who contract the virus are asymptomatic, but the majority of symptomatic patients will have mild to moderate respiratory disease.On the other hand, older individuals and those with comorbidities can become severely ill and require medical attention.][3] In the initial WHO-China Joint Mission on Coronavirus Disease 2019 and according to a comprehensive overview and meta-analysis, the most common disease symptoms are fever, cough, fatigue, sputum, dyspnea, myalgia, chest tightness/pain, sore throat, headache, diarrhea, nasal congestion/rhinorrhea, nausea/vomiting, abdominal discomfort, and hemoptysis.In most individuals, COVID-19-related comorbidities include hypertension (HTN), diabetes mellitus (DM), and cardiovascular disease.0][11][12][13][14][15][16][17][18][19][20] Others have reported risk factors for disease severity to be male gender, low oxygen saturation (SpO 2 ), two or more comorbidities, malignancy, chronic kidney disease (CKD), human immunodeficiency virus (HIV), obesity, smoking, cough, fever, and fatigue. 9,10,17,18,20OVID-19 mortality has been associated with decreased SpO 2 , CKD, malignancy, HIV/AIDS, and fever. 9,15,21Others report male gender, greater sequential organ failure assessment, and previous and current tuberculosis. 15,21,22s of this writing, it has been 1.5 years since the first case was reported in Ethiopia.As of December 2, 2021, 371,272 cases and 6,771 deaths had been reported in the nation. 23,24nly a few studies have been published from Ethiopia on the clinical features, illness severity, treatment, and outcomes.This study aimed to describe the clinical manifestations, treatment, outcomes, and factors related to severity and mortality at Eka Kotebe Hospital, Ethiopia's pioneer COVID-19 treatment facility.

METHODS
Study design and setting.This cross-sectional retrospective study was undertaken in Eka Kotebe General Hospital, the first COVID-19 treatment center in Addis Ababa.It was initially established as an extension of the Amanuel General Hospital until April 2020 when it became a stand-alone federal hospital.It has a bed capacity of approximately 400, with 40 beds dedicated to intensive care services, 16 of which are for patients requiring mechanical ventilation (such as critically sick COVID-19 patients).Patients of all levels of severity (mild to critical COVID-19) were admitted to the hospital.It is staffed by more than 130 nurses, 90 general practitioners, three anesthesiologists, three emergency physicians, two internists, one pulmonary and critical care subspecialist, two obstetrics and gynecology physicians, two surgeons, three psychiatrists, two radiologists, and two pediatricians.Nine of these senior physicians are academic staff at the College of Health Sciences, Addis Ababa University, and they have been working in the hospital since April 2020.
Study period.The study took place from March 13, 2020, through September 16, 2020.
Study population.All consecutive symptomatic SARS CoV-2 Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) positive were included.
Inclusion criteria.Regardless of data completeness, all COVID-19 patients aged 18 and older were included.Only those who were symptomatic and those with positive RT-PCR on admission or who turned positive after admission were included.
Exclusion criteria.Asymptomatic cases and those with SARS CoV-2 RT-PCR-negative test results who were admitted to the hospital early in the pandemic when it was serving as both an isolation and a quarantine center.
Sample size.All cases meeting the inclusion criteria during the study period were included.
Operational definitions.Data collection and quality assurance.A structured questionnaire was used to collect data on demographics, clinical manifestations, comorbidities, laboratory values, inpatient medications, treatments (including invasive mechanical ventilation and kidney replacement therapy), and outcomes (including length of stay, discharge, readmission, and mortality) of the study subjects.Trained physician data clerks collected data from the chart.The questionnaire was tested, and revisions were made before data collection started.

COVID
Data analysis.The collected data were coded, entered into CSPro software, and exported to SPSS version 26 for analysis.Categorical variables were presented using frequency and percentages, whereas continuous variables were reported as medians with interquartile ranges (IQRs).For categorical variables, the chi-square or Fisher exact test for expected frequency , 5 in univariate analysis was used to make a comparison between groups.An independent t test for continuous variables was performed to compare the means of two independent groups for normally distributed and the Mann-Whitney U test for nonnormally distributed numeric data.To determine the predictor of disease severity (nonsevere versus severe) and COVID-19 outcome (alive or dead during hospital stay), a binary logistic regression model was used independently.In the univariate analysis, variables with P , 0.1 were used to identify potential significant factors for the final models.A binary logistic regression model was well fitted to identify predictor variables Hosmer and Lemeshow goodness of fit test P 5 0.126 and P 5 0.055 for disease severity and mortality outcome respectively.Adjusted odds ratio (aOR) with a 95% confidence interval (CI) and P value , 0.05 was used as statistically significant.
Source of funding and ethical consideration.1).
The median age in those who died was older than in those who survived (61 versus 43 years, P , 0.0001), and fewer patients died in the age group below 40 than above 60 years (13.2 versus 60.4%, P , 0.0001).On univariate analysis HTN, DM, the presence of any comorbidity, malignancy, chronic liver disease (CLD), SOB, loss of appetite, vomiting, AST $ 37 u/L were significantly associated with in-hospital mortality whereas headache, loss of appetite and ALC count .1,000/mm 3 were found to decrease mortality (Table 4).

DISCUSSION
This study investigated the clinical manifestations, treatment, outcomes, and factors related to the severity and mortality of COVID 19 in patients admitted to a COVID-19 specialty hospital in Addis Ababa, Ethiopia, in the prevaccine era.In our treatment center, more than two-thirds of participants were male.The median age was 45 years with 30% of study participants $ 60 years of age.Cough, SOB, fatigue/malaise, fever, and headaches were the most common symptoms.HTN, DM, and chronic cardiac diseases were the most frequent comorbidities.Overall, age $ 60 years, malignancy, and SOB were found to be significant predictors of disease severity; these factors, in addition to vomiting, also predicted mortality.
The reported rate of bacterial superinfection has been variable ranging from 8% in earlier clinical studies to 32% from autopsy reports. 25,26A recent more objective study based on bronchoalveolar lavage samples within 48 hours of hospitalization revealed 21% of superinfection. 27However, in our study, three out of five patients received antibiotics.This practice was predicated on the universal recommendation of antibiotic use in moderate to critical disease conditions in the previous national guidelines. 28,29ore than half of the patients received anticoagulants, prophylactic or therapeutic, in accordance with the observed benefit of these medications in COVID-19, particularly those with severe disease. 30Slightly less than a quarter of patients were given corticosteroids, in contrast to current evidence that steroids have a survival advantage in severe to critical COVID-19. 31This underuse of steroids was due, in part, to the discretion of the managing team before publication of the interim report of the RECOVERY trial.
HTN, DM, and chronic cardiac disease were the most prevalent comorbidities.This finding is consistent with results from previous Ethiopian reports 12,32 and other studies done in Africa, China, Brazil, and the United States. 9,14In multivariable analyses, HTN and DM were not associated with disease severity.This is in contrast to most studies.Another local study by Abraha et al. also found no association between HTN and severity of disease.However, DM, was associated with disease severity. 32COVID-19 in-hospital mortality was not associated with HTN or DM in multivariable analyses, similar to previous reports from Ethiopia, Saudi Arabia, Brazil, the U.S.-Mexico border, and the United States. 9,14HTN did not also increase risk for death in the largest COVID registry from United Kingdom. 33Further, HIV/AIDS was not associated with disease severity or mortality in our study.This finding agrees with other Ethiopian published reports 32,34,35 and those from other areas of Africa, Europe, China, and the United States. 9,15,21[35][36][37][38] Proposed explanations include the physiological aging process, particularly the increased prevalence of frailty, age-related decline in lung function, comorbidities, and a weakened immune system. 39,40ore than half of our study participants were , 50 years of age.Our age distribution was similar to other treatment centers in Ethiopia 32,34,35 and data from other sub-Saharan countries, [41][42][43] but younger than study populations reported from Europe, North America, and China. 44This variation could be due to the generally younger population of the African continent and greater hospital admissions in the region early during the pandemic for those with mild COVID-19 disease.
Patients with malignancy had adjusted odds ratio (aOR) 4.6 times greater for severe disease and 9 times greater for mortality compared with nonsevere disease.These findings are consistent with those of another Ethiopian study by Hiluf et al. from Tigray. 32It might be because of weakened immunity from the malignancy itself or from the immunosuppressive drugs used to treat the condition.The presence of SOB was associated with more than 3-fold increased odds of severe disease compared with nonsevere disease, and the risk of death was 2.3 times higher.18,20 It might be because SOB occurs late in the course, usually in the inflammatory stage of the disease when mortality is high.Vomiting was also significantly associated with an increased likelihood of mortality.This is consistent with a report from Iraq that showed a poor prognosis in those with concomitant respiratory symptoms. 45][48] There are several study limitations.The lack of comprehensive laboratory findings prohibited us from including them in the final model as possible predictors of disease outcome.The cross-sectional nature of the study design made it difficult to establish a cause-effect relationship between  In conclusion, in Ethiopia, most COVID-19 patients were male and presented with cough, SOB, and fatigue.Older age, any malignancy, and SOB were associated with disease severity; these factors, in addition to vomiting, also predicted mortality.

5
absolute lymphocyte count; ALT the various factors and disease severity or treatment outcome.Being a single-center and hospital-based study, the findings may not be generalizable.

TABLE 1 Continued
IQR 5 interquartile range.COVID-19 IN ETHIOPIA Critical COVID: A COVID-19 case requiring mechanical ventilation or hemodynamic support.This includes patients with acute respiratory distress syndrome, acute renal failure, and septic shock.Disease severity: Nonsevere COVID-19 (mild to moderate cases) and severe COVID-19 (severe or critical cases).Chronic lung diseases included preexisting COPD and bronchial asthma.

TABLE 2
Laboratory findings and clinical management of study participants in Eka Kotebe Hospital ALC 5 absolute lymphocyte count; ALT 5 alanine transaminase; AST 5 aspartate transaminase; IQR 5 interquartile range.

TABLE 3
Demographic, comorbidity, and symptom characteristics; comparison based on disease severity and factors associated

TABLE 4
Demographic, comorbidity, and symptom characteristics; comparison based on disease outcome and factors associated