COVID-19 among Patients Visiting the Department of Emergency of a Tertiary Care Centre: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Because of the unbridled transmissibility of the SARS-CoV-2 worldwide, researchers and healthcare professionals have set a common goal for timely diagnosis and future prevention of the disease. The aim of this study was to find out the prevalence of COVID-19 among patients visiting the Department of Emergency of a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among the individuals suspected COVID-19 who had visited the Department of Emergency of a tertiary care centre between 11 January 2021 and 29 December 2021. Ethical approval was taken from Ethical Review Board (Reference number: 2768). Socio-demographic details, clinical symptoms, and two nasopharyngeal swab samples (one in viral transport medium to run RT-PCR and the other for Ag-RDT) were collected from each individual. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among the 232 patients, COVID-19 was detected in 108 (46.55%) (40.13-52.97, 95% CI) by Ag-RDT. A total of 44 (39.63%) of age groups 31-40 years were predominantly infected with SARS-CoV-2. The mean age was 32.13±10.80 years and was mostly males 73 (65.77%). Fever was present in 57 (51.35%) and dry cough was present in 50 (45.05%) COVID-19 patients. Conclusions: The prevalence of COVID-19 among hospitalized individuals in this study was higher than in previous studies conducted in similar settings.


INTRODUCTION
As of 25 th June 2022, 5,749,355 reverse transcriptasepolymerase chain reaction (RT-PCR) tests have been performed in Nepal and among them, 979,489 tests have diagnosed coronavirus disease of 2019 (COVID-19). 1 RT-PCR assay although deemed to be the most sensitive and reliable gold standard tool to diagnose SARS-CoV-2 infection in individuals as mentioned by the WHO, is a package of complex laboratory procedures, involving increased cost, prolonged report time, and the need for sophisticated laboratory setup. 2,3The immunological diagnosis of COVID-19 by SARS-CoV-2 antigen-based rapid diagnostic test (Ag-RDT) can be the economic and swift alternative to chain the disease.While some international studies Free Full Text Articles are Available at www.jnma.com.nphave reported high percentages of sensitivity (92.80-98.3%)and specificity (100%) of SARS-CoV-2 Ag-RDT, 4 several studies have reported lower sensitivity (57.6-81.8%)and specificity (98.7-99.5%)too. 5,6However, only a handful of such studies have been published in Nepal.
The aim of this study was to find out the prevalence of COVID-19 among patients visiting the Department of Emergency of a tertiary care centre.

METHODS
A descriptive cross-sectional study was conducted among COVID-19 suspected symptomatic and asymptomatic individuals, irrespective of age and gender, who had visited the Department of Emergency Services of Nepal Armed Police Force Hospital (NAPFH), Balambu, Kathmandu, Nepal, between 11 January 2021 and 29 December 2021.Ethical approval was taken from the Ethical Review Board (Reference number: 2768).Written informed consent either from study participants (or their relatives) was obtained.
Those individuals, who were recent foreign returnees, or had a travel history to local endemic areas within the past 7 days and who presented a history of contact with COVID-19-confirmed patients, health workers who were directly involved in treating the COVID-19-positive cases were included in the study.Individuals with traumatic injuries that have affected the nasopharyngeal swab collection anatomical region were excluded.Convenience sampling method was used.The sample size was calculated using the following formula: n= Z 2 x p x q e 2 = 1.96

DISCUSSION
Ever since the first case of COVID-19 caused pneumonia due to SARS-CoV-2, an enveloped RNA beta Coronavirus was reported in Wuhan, Hubei Province, China, in December 2019, 10 the viral infection spread rapidly around the world and subsequently reached the pandemic level, 11 as declared by the World Health Organization (WHO) on March 11, 2020. 12As of June 25, 2022, there were over 548 million confirmed cases of COVID-19 with more than 6 million deaths, across 228 countries and territories worldwide. 13 this study, the SARS-CoV-2 Ag-RDT assay showed the prevalence of COVID-19 in a tertiary care hospital to be 46.55% by Ag-RDT and 47.84% by RT-PCR.Although several studies conducted in developed nations have reported an alternative test to diagnose COVID-19, preferably with the use of SARS-CoV-2 Ag-RDT, and shed light on the diagnostic value of such a test, these studies are markedly limited in developing countries, including Nepal.Moreover, there exist differences in diagnostic accuracy among the kits, which could be attributed to several factors, including manufacturer incorporation of a well-characterized sample set for which the results are known, manufacturer inclusion of a large fraction of specimens displaying high viral loads, test conductance by highly trained personnel, who often have been involved in test development and are well aware of potential pitfalls (weak bands or other forms of ambiguous results), and variations in the quality of the nasopharyngeal swabs samples, as they were collected by different health care workers in a turbulent environment. 14,15is study found that COVID-19 patients aged 31-40 years (39.63%) were at a higher risk of COVID-19 infection, which was discordant with the findings of several other research. 16,17While WHO and the Center for Disease Control and Prevention (CDC) mention a higher risk for older people to contract SARS-CoV-2 infection, a higher prevalence of COVID-19 among adults in our study could be attributable to their inability to dictate their workplace and the infeasibility of adherence to distancing and quarantine guidelines in their workplace and other communal settings. 18,19he mean age of COVID-19 patients (32 years) in our study was comparable with the findings from other studies. 20,21Several studies have discussed the different mean age groups in COVID-19 patients, ranging from 32.5 to 76 years. 21,22In this study, as many as twice the number of SARS-CoV-2 infections, was seen in males, which was consistent with the findings of one of the studies. 23The lower prevalence of SARS-CoV-2 infection in females in this study might be attributed to the adaptive immune system of females, who have higher numbers of CD4+ T cells, more robust CD8+ T cell cytotoxic activity, and increased B cell production of immunoglobulin as compared to males. 24e clinical course of COVID-19 is often unpredictable and is characterized by oligosymptomatic forms of the disease, presenting itself as an asymptomatic or mild case (30-60%) to a moderate or severe/critical case, which is often characterized by pneumonia (6%). 25In this study, 16.67% of the patients diagnosed with COVID-19 were asymptomatic.This study showed symptomatic Free Full Text Articles are Available at www.jnma.com.npCOVID-19 patients to be frequently associated with the presence of multiple symptoms at presentation (29.63-37.96%),including fever (52.78%), dry cough (46.30%), myalgia (36.11%), headache (22.22%) and rhinorrhea (15.74%) as chief clinical complaints.The observed signs and symptoms from this study were comparable to a systematic review and meta-analysis that showed fever (88.7%), cough (57.6%), and dyspnea (45.6%) as the most prevalent symptoms in COVID-19 patients. 26pendency on the viral load concentration is a limitation associated with this serological method, as the viral load in patients gradually changes with the severity or less severity of the disease.

Table 1
7hroat, headache, myalgia, diarrhoea, rashes, or discolouration of the skin, and red irritated eyes were considered to be having less common symptoms for COVID-19.Individuals presenting lower oxygen saturation (SpO 2 <95%) with fingertip pulse oximeter were suspected to be infected.7Apair of nasopharyngeal secretions swab samples was collected from each of the patients following the standard operating procedure (SOP) of the National Public Health Laboratory (NPHL) of Nepal.A swab for RT-PCR was inserted in a 3 ml viral transport media (VTM), and the other swab for SARS-CoV-2 Ag-RDT was inserted in a dedicated extraction tube provided with the kit.Samples and patient information sheets of each patient were packed separately in plastic zip-lock bags and were transported aseptically by maintaining a cold chain to the molecular laboratory of the hospital.
9onsidered to be having serious COVID-19 symptoms; fever more than 38ºC (100.4ºF),cough,tiredness,loss of smell or taste were considered to be having common symptoms; sore SARS-CoV-2 viral nucleic acid extraction was performed with spin column membrane-based purification and the amplification was performed by a multiplex RT-PCR kit for the open reading frame (ORF) lab and the N gene.An endogenous control probe labelled with a specific dye targeting the human RNase P gene was incorporated for specimen integrity, nucleic acid isolation, amplification, and detection in the reagent mixture.As the fluorescence signal changed the computer-controlled RT-PCR, the thermal cycler device drew an amplification curve such that the fluorescence produced was directly proportional to the quantity of DNA formed and fluorophore released, in each cycle continued till the end cycle for all-optical channels.thekitand the antigen-gold nanoparticle-antibody complex formed would flow to the other site where this complex would be captured by capture antibody to give a visible coloured band.9FreeFull Text Articles are Available at www.jnma.com.np