Background: As COVID19 pandemic is an emerging global problem, there is a gap in the knowledge regarding epidemiological and clinical spectrum of the diseases in Yemen. The importance of this study is to describe the clinical presentation of COVID 19 from the surveillance data that means clinical description of patients at the time of identification and measure the outcomes from epidemiological perspective.
Methodology: This is a retrospective analysis of the available surveillance data form 10th April to 31st May 2020; it include data of 419 confirmed COVID19 cases
Results: A total of 419 confirmed COVID19 cases out of 979 suspected cases (42.8%) were reported. The most common symptoms reported were fever (91.4%), cough (85.2%), difficulty of breathing (60.6%), sore throat (59.9%) and muscle and joint pain (49.4%). A total of 59 cases out of 419 patients (14.1%) were admitted to intensive care units (ICU) and 25 patients (6%) were treated under respiratory ventilators. Only 6.2% of patients have cardiovascular diseases, 7.9% have hypertension, 5.3% have chronic lung diseases but 11% of patients have diabetes mellitus (DM). The high burden of cardiovascular diseases, hypertension and DM were among COVID 19 old patients (60+ years of age) as 11.5%, 16.3% and 14.5% respectively. The highest rate of admission to ICU were among elder patients (16.3%) followed by the age group of 30-44 years (14.8%) and age group 45-59 years (12.2%). The treatment rate under ventilator was higher among elder patients (8.6%) followed by age group of 45-59 years (6.5%) and age group of 30-44 years (4%). 
A total of 95 patients died giving the case fatality rate (CFR%) to 22.7%. The high age specific death rate were among elder patients (31.7%) followed by age group of 45-59 years (28%) and age group of 30-44 years (14.8%).
Conclusions: The most common symptoms are consistent with what were reported in the international literature. Cardiovascular diseases, hypertension and DM are the most chronic diseases associated with COVID19 especially among elder patients, highest rate of admission to ICU were among COVID19 elder patients who be at high risk to death.
 

Bin Ghouth AS, Al-Waleedy AA (2020) Epidemiological and Clinical Aspects of 419 COVID19 Confirmed Cases in Yemen up To 31 May 2020: Analysis of Surveillance Data. J Family Med Community Health 7(2): 1175.

•    COVID19
•    Pandemic
•    Yemen
 

Since December 2019, when corona virus disease 2019 emerged in Wuhan city, China [1] and rapidly spread throughout world, data have been needed on the clinical characteristics of the affected patients. Given the rapidly emerging pandemic associated with the novel severe acute respiratory syndrome corona virus 2 causing corona virus disease 2019 which is later nominated as COVID19, it is important to review the clinical presentation associated with viral pneumonia in poor resource country like Yemen where data about the pandemic may be limited due to deteriorated health system and weak surveillance performance.

Symptoms of viral pneumonia were reported elsewhere, it include common respiratory tract infection symptoms of cough, fever, and shortness of breath [2]. Data are emerging from retrospective clinical studies conducted in Wuhan, China, showing the symptoms and characteristics of COVID-19 caused by severe acute respiratory virus corona virus 2 (SARS-CoV-2) infection, including fever, cough, and shortness of breath[3].

Due to the general susceptibility of new corona viruses, a lot of questions are raising about what are the common clinical presentation of COVID19, are there difference from country to another due to susceptibility and immunity variations; are there difference due to age variations for example the clinical characteristics and outcomes of elderly and young patients may be different.

In Yemen, the first case was reported in 10th April 2020 in Hadramout region at eastern part; then cases spreads in Aden since 28Th April 2020 till now (31st May 2020), [4] cases still increasing, but this paper presented the available data till 31st May2020.

The importance of this study is to describe the clinical presentation of COVID 19 from the surveillance data that means clinical description of patients at the time of identification and measure the outcomes from epidemiological perspective.

This is a retrospective analysis of the available surveillance data form 10th April to 31st May 2020; it includes data of 194 confirmed COVID19 cases.

In Yemen; the southern and eastern governorates was controlled by the Yemeni government which include 12 governorates including the capital Aden. A specialized COVID surveillance system was developing supported by the rapid response teams to follow the contacts. The diagnostic capacity is based on four new polymerase chain reaction units (PCR units in four main cities (Aden, Taiz at the South and Mukalla and Syoun at the east). All the suspected cases identified by the surveillance system were investigated by PCR units. After confirmation the surveillance officer of each governorate sent the epidemiological, clinical and laboratory data to the central level where trained data entry personnel manage the data and sent to the higher emergency committee to announce the daily epidemiological report.

The research team is able to extract data regarding 419 patients with laboratory-confirmed Covid-19 from April 10, 2020 to May31, 2020. Data were entered to SSPS version 23, and analyzed using the descriptive statistics tools.

A total of 419 confirmed COVID19 cases out of 979 suspected cases (42.8%) were reported in the southern and eastern governorates of Yemen from the period of 10th April 2020 to 31st May 2020.

The mean age of the confirmed cases was 45.4 years (±16.9 years), the median age was 45 years and the range from one year to 115 years. The high proportion of the COVID19 cases were among the age group of 45-59 years (33.2%) followed by age group of 30-44 years (29.1%) then the group of 60+years (24.4%. Males were more affected (75%) than females (25%). The high burden of the pandemic was in Aden (31.7%), Hadramout (26.2%) and Taiz (15.8%). Unfortunately only 6% of patients had history of travel from epidemic country and only 5.4% had history of contact with suspected or confirmed cases (Table 1).

The most common symptoms reported were fever (91.4%), cough (85.2%), difficulty of breathing (60.6%), sore throat (59.9%) and muscle and joint pain (49.4%). The least common symptom was rinnhorea (21%). A total of 59 cases out of 419 patients (14.1%) were admitted to intensive care units (ICU) and 25 patients (6%) were treated under respiratory ventilators. A total of 95 patients died giving the case fatality rate (CFR %) to 22.7% (Table 2).

The role of chronic diseases

Only 6.2% of patients have cardiovascular diseases, 7.9% have hypertension, 5.3% have chronic lung diseases but 11% of patients have diabetes mellitus (DM). Liver diseases (1.7%) or kidney diseases (2.4%) were the less chronic diseases associated with COVID19 patients (Table 3).

The role of the age

The high burden of cardiovascular diseases, hypertension and DM were among COVID 19 old patients ( 60+ years of age) as 11.5%, 16.3% and 14.5% respectively. Chronic lung diseases are more prevalent among the age group 45-59 years (8.6%), DM also was prevalent in this age group (14.5%). The highest rate of admission to ICU were among elder patients (16.3%) followed by the age group of 30-44 years (14.8%) and age group 45-59 years (12.2%). The treatment rate under ventilator was higher among elder patients (8.6%) followed by age group of 45-59 years (6.5% and age group of 30-44 years (4%) (Table 4).

Table 1: Epidemiological characteristics of COVID19 in Yemen (N=419 confirmed cases).

Table 2: Clinical presentation of COVID 19 in 419 confirmed cases.

Table 3: Co-morbidity with chronic diseases.

Although COVID 19 pandemic start in Yemen later than the other counties in the world that giving an opportunity to establish the new PCR units that make the country be able to diagnose the disease. In this study the research team analyzed the surveillance data of the available 419 confirmed COVID cases till 31st May 2020. The median age of the confirmed cases was 45, The high proportion of the COVID19 cases were among the age group of 45-59 years (33.2%) followed by age group of 30-44 years (29.1%) then the group of 60+years (24.4%. Males were more affected (75%) than females (25%). The same age and gender distribution were observed in different countries; In China, the median age of the patients was 47 years; 41.9% of the patients were female [5,6].

The high burden of the pandemic was in Aden (31.7%), Hadramout (26.2%) and Taiz (15.8%). Geographical variation was due to the size of the population movements, those three regions are the most attractive centers for trade activities that attractive population movement.

Unfortunately only 6% of patients had history of travel from epidemic country and only 5.4% had history of contact with suspected or confirmed cases. One study from wahan, China observed that among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city [7].

Low detection of COVID 19 among close contacts or among the comers from other epidemic country due to the limited diagnostic capacity and poor performance of the COVID19 surveillance at the entry point s of Yemen.

Clinically; the symptoms are usually fever, cough, sore throat, breathlessness, fatigue, malaise among. The disease is mild in most people; in some (usually the elderly and those with comorbidities), it may progress to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction[8,9].

While different literatures presented the same findings; other studies reported unusual presentation. Severe acute respiratory illness with fever and respiratory symptoms, such as cough and shortness of breath, comprise the working case definition used to select people for viral testing. This strategy captures typical symptomatic presentation, but imperfectly identifies unusual manifestations, such as patients without respiratory symptoms or only very mild symptoms. One widely cited modeling study concluded that up to 86% of cases might have been missed in China, [10] and reports of patients with unusual presenting symptoms are rising worldwide.11 Case series report gastrointestinal symptoms in 2-40% of patients [12,13] and diarrhoea can be the initial manifestation of infection [14]. Whether SARS-CoV-2 leads to such symptoms directly by infecting the gastrointestinal tract, indirectly by neurological involvement [15]. In this study, The high burden of cardiovascular diseases, hypertension and DM were among COVID 19 old patients ( 60+ years of age) while DM and Chronic lung diseases are more prevalent among the age group 45-59 years, the highest rate of admission to ICU were among elder patients. The same findings were reported elsewhere; Patients who have required critical care have tended to be older (median age ≈60 years), and 40% have had comorbid conditions, commonly diabetes and cardiac disease [16].

At the same time the least prevalence of liver diseases and kidney diseases among COVID19 cases especially elder patients, these finding in consistent with a Meta analysis study conducted in 2020, it was reported that The meta-analysis revealed no correlation between increased risk of COVID-19 and liver disease, malignancy, or renal disease. Hypertension, diabetes, COPD, cardiovascular disease, and cerebrovascular disease are major risk factors for patients with COVID-19[17].

Table 4: Age specific Prevalence rate of chronic diseases among confirmed COVID 19 cases.

The most common symptoms are consistent with what were reported in the international literature. Cardiovascular diseases, hypertension and DM are the most chronic diseases associated with COVID19 especially among elder patients, highest rate of admission to ICU were among COVID19 elder patients who be at high risk to death.

1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020; 382: 1708-1720.

2. Darden DB, Hawkins RB, Larson SD, Iovine NM, Prough DS, Efron PA. The Clinical Presentation and Immunology of Viral Pneumonia and Implications for Management of Coronavirus Disease 2019. Crit Care Explor. 2020; 2: e0109.

3. Miller R, Englund K. Clinical presentation and course of COVID-19. Cleveland Clinic Journal of Medicine. 2020.

4. The higher emergency committee (Yemen). The official daily reports. 2020.

5. Guan W, Zheng-yi Ni ZY, Hu Y, Liang WH, Ou CO, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020; 382: 1708-1720.

6. Chaolin Huang, Yeming Wang, Xingwang Li, Lili Ren, Jianping Zhao, Yi Hu, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 2020; 395: 497-506.

7. Singhal T. A Review of Coronavirus Disease-2019 (COVID-19). Indian J Pediatr. 2020; 87: 281-286.

8. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infect Dis Poverty. 2020; 9: 29.

9. 11. Vetter P, Lan Vu D, L’Huillier A, Schibler M, Kaiser L, Jacquerioz F, et al. Clinical features of covid-19. BMJ. 2020; 369.

10.12. Guan WJ, Ni ZY, Hu Y, Liang W, Ou C, He J, et al. China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382: 1708- 1720.

11.13. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020; 368: 489-493.

12.14. Song Y, Liu P, Shi XL, Chu YL, Zhang J, Xai J, et al. SARS-CoV-2 induced diarrhoea as onset symptom in patient with COVID-19. 2020; 69: 1143-1144.

13.15. Li YC, Bai WZ, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol. 2020.

14.16. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020; 323: 1061-1069.

15.17. Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY). 2020; 12: 6049-6057