Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes
Ashok K Pannu, Mohan Kumar, Pranjal Singh, Alan Shaji, Arnab Ghosh, Ashish Behera, Saurabh C Sharda, Mandeep Bhatia, Neeraj Singla, Mini P Singh, Atul Saroch
COVID-19, SARS-CoV-2, Severe acute respiratory infection, Severity, Surveillance
Citation Information :
Pannu AK, Kumar M, Singh P, Shaji A, Ghosh A, Behera A, Sharda SC, Bhatia M, Singla N, Singh MP, Saroch A. Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes. Indian J Crit Care Med 2021; 25 (7):761-767.
Introduction: World Health Organization proposes severe acute respiratory infection (SARI) case definition for coronavirus disease 2019 (COVID-19) surveillance; however, early differentiation between SARI etiologies remains challenging. We aimed to investigate the spectrum and outcome of SARI and compare COVID-19 to non-COVID-19 causes.
Patients and methods: A prospective cohort study was conducted between March 15, 2020, to August 15, 2020, at an adult medical emergency in North India. SARI was diagnosed using a “modified” case definition—febrile respiratory symptoms or radiographic evidence of pneumonia or acute respiratory distress syndrome of ≤14 days duration, along with a need for hospitalization and in the absence of an alternative etiology that fully explains the illness. COVID-19 was diagnosed with reverse transcription-polymerase chain reaction testing.
Results: In total, 95/212 (44.8%) cases had COVID-19. Community-acquired pneumonia (n = 57), exacerbation of chronic lung disease (n = 11), heart failure (n = 11), tropical febrile illnesses (n = 10), and influenza A (n = 5) were common non-COVID-19 causes. No between-group differences were apparent in age >60 years, comorbidities, oxygenation, leukocytosis, lymphopenia, acute physiology and chronic health evaluation (APACHE)-II score, CURB-65 score, and ventilator requirement at 24-hour. Bilateral lung distribution and middle-lower zones involvement in radiography predicted COVID-19. The median hospital stay was longer with COVID-19 (12 versus 5 days, p = 0.000); however, mortality was similar (31.6% versus 28.2%, p = 0.593). Independent mortality predictors were higher mean APACHE II in COVID-19 and early ventilator requirement in non-COVID-19 cases.
Conclusions: COVID-19 has similar severity and mortality as non-COVID-19 SARI but requires an extended hospital stay. Including radiography in the SARI definition might improve COVID-19 surveillance.
World Health Organization. WHO surveillance case definitions for ILI and SARI: case definitions for influenza surveillance. Geneva: World Health Organization; 2014. Available at: https://www.who.int/influenza/surveillance_monitoring/ili_sari_surveillance_case_definition/en/ (accessed March 30, 2021).
Fitzner J, Qasmieh S, Mounts AW, Alexander B, Besselaar T, Briand S, et al. Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection. Bull World Health Organ 2018;96(2):122–128. DOI: 10.2471/BLT.17.194514.
World Health Organization. Pandemic influenza risk management: a WHO guide to inform & harmonize national & international pandemic preparedness and response. Geneva: World Health Organization (WHO); 2017. Available at: https://apps.who.int/iris/handle/10665/259893. Accessed November 16, 2019.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382(8):727–733. DOI: 10.1056/NEJMoa2001017.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497–506. DOI: 10.1016/S0140-6736(20)30183-5.
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(18):1708–1720. DOI: 10.1056/NEJMoa2002032.
Gandhi RT, Lynch JB, Del Rio C. Mild or moderate Covid-19. N Engl J Med 2020;383:1757–1766. DOI: 10.1056/NEJMcp2009249.
Berlin DA, Gulick RM, Martinez FJ. Severe Covid-19. N Engl J Med 2020;383:2451–2460. DOI: 10.1056/NEJMcp2009575.
World Health Organization. Global surveillance for COVID-19 caused by human infection with COVID-19 virus: interim guidance. Geneva: World Health Organization; 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/331506/WHO-2019-nCoV-SurveillanceGuidance-2020.6-eng.pdf?sequence=1&isAllowed=y. Accessed March 30, 2021.
Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fryet AM, et al. Clinical practice guidelines by the infectious diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenzaa. Clin Infect Dis 2019;68(6):895–902. DOI: 10.1093/cid/ciy866.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13(10):818–829. Available at: https://pubmed.ncbi.nlm.nih.gov/3928249/
Vincent JL, Moreno R, Takala J, Mendonça AD, Bruining H, Reinhart CK, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22:707–710. DOI: 10.1007/BF01709751.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 2016;315:801–810. DOI: 10.1001/jama.2016.0287.
Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Jeune IL, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64(suppl 3): iii1–iii55. DOI: 10.1136/thx.2009.121434.
Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, Cheng VC, et al. Infectious diseases society of america guidelines on the treatment and management of patients with COVID-19. Clin Infect Dis 2020;2020:ciaa478. DOI: 10.1093/cid/ciaa478.
World Health Organization. Clinical management of COVID-19: interim guidance. Geneva: World Health Organization; 2020. Available at: https://www.who.int/publications/i/item/clinical-management-of-severe-acute respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed May 30, 2020.
Ministry of health & family Welfare, Government of India. Guidelines on Clinical Management of COVID - 19. New Delhi: Directorate General of Health Services. Ministry of Health and Family Welfare; 2020. Available at: https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19dated27062020.pdf. Accessed June 28, 2020.
Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med 2019;200(7):e45–e67. DOI: 10.1164/rccm.201908-1581ST.
Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. Am J Respir Crit Care Med 2017;195(5):557–582. DOI: 10.1164/rccm.201701-0218PP.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;136(6):e137–e161. DOI: 10.1161/CIR.0000000000000509.
Central TB Division, Ministry of Health & Family Welfare, Government of India. Guidelines: technical and operational guidelines for TB control in India 2016. New Delhi: Central TB Division, Ministry of Health and Family Welfare, Government of India; 2018. Available at: https://tbcindia.gov.in/index1.php?sublinkid=4573&level=2&lid=3177&lang=1. Accessed May 3, 2019.
Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study BMJ 2020;369:m1985. DOI: 10.1136/bmj.m1985.
Menni, C, Valdes AM, Freidin MB, Sudre CH, Nguyen LH, Drew DA, et al. Real-time tracking of self-reported symptoms to predict potential COVID-19. Nat Med 2020;26:1037–1040. DOI: 10.1038/s41591-020-0916-2.
Parasa S, Desai M, Thoguluva CV, Patel HK, Kennedy KF, Roesch T, et al. Prevalence of gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: a systematic review and meta-analysis. JAMA Netw Open 2020;3(6):e2011335. DOI: 10.1001/jamanetworkopen.2020.11335.
Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al. The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner society. Chest 2020;158(1):106–116. DOI: 10.1016/j.chest.2020.04.003.
Korevaar DA, Kootte RS, Smits LP, van den Aardweg JG, Bonta PI, Schinkel J, et al. Added value of chest computed tomography in suspected COVID-19: an analysis of 239 patients. Eur Respir J 2020;56(2):2001377. DOI: 10.1183/13993003.01377-2020.
Rees EM, Nightingale ES, Jafari Y, Waterlow NR, Clifford S, Pearson CAB, et al. COVID-19 length of hospital stay: a systematic review and data synthesis. BMC Med 2020;18(1):270. DOI: 10.1186/s12916-020-01726-3.
Sprung CL, Joynt GM, Christian MD, Truog RD, Rello J, Nates JL, et al. Adult ICU triage during the coronavirus disease 2019 pandemic: who will live and who will die? Recommendations to improve survival. Crit Care Med 2020;48(8):1196–1202. DOI: 10.1097/CCM.0000000000004410.
Lewnard JA, Liu VX, Jackson ML, Schmidt MA, Jewell BL, Flores JP, et al. Incidence, clinical outcomes, and transmission dynamics of severe coronavirus disease 2019 in California and Washington: prospective cohort study. BMJ 2020;369:m1923. DOI: 10.1136/bmj.m1923.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180(7):934–943. DOI: 10.1001/jamainternmed.2020.0994.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020;5(7):802–810. DOI: 10.1001/jamacardio.2020.0950.