Clinical Outcome of COVID 19 Patients After Hospitalization: Observational Study from a Tertiary Care Hospital, PAKISTAN

Sadia Ishaque (  sadiamir70@gmail.com ) LIAQUAT NATIONAL HOSPITAL Beenish Syed Sindh institute of infectious diseases hospital and research center Saima Akhter Liaquat National Hospital and Medical College Talha Safeer Liaquat National Hospital and Medical College Atif Hashmi Liaquat National Hospital and Medical College Yousra Mansoor Liaquat National Hospital and Medical College Shahroz khawaja Liaquat National Hospital and Medical College Noureen Durrani Liaquat National Hospital and Medical College


Introduction
The outbreak of novel Corona virus (COVID-19) is a public health emergency that caused disastrous outcomes in more than 100 countries (1). The rst con rmed case of COVID 19 in Pakistan was reported on 26th February 2020. As of 23rd October 2020, there have been about 326,216 con rmed cases with 309,646 recoveries and 6,715 deaths in the country (2). Karachi, the economical hub of Pakistan has maximum number of reported cases due to its dense population (3). Since then the number of cases, linear trend and deaths are increased, which is an alarming situation for a developing country, like Pakistan.
Globally, numerous studies have been conducted about this pandemic, many of them observed the course of disease during hospitalization (4)(5)(6). However, the number of recovered and discharged COVID-19 patients kept increasing worldwide and the de nite clinical outcomes of the patients with COVID-19 after discharge were scarcely described in the literature (4,7).
To author's best knowledge, no data from Pakistan has been published or available to describe the clinical outcome of COVID 19 patients after discharge from hospital. This study will help present the data regarding clinical symptoms, and outcomes of COVID 19 patients after discharge which in turn will not Results only help to unravel the long term complications of COVID 19 but also help in the better management of COVID 19 patients.
The aim of this study was to track the course of clinical outcomes of COVID 19 patients after discharge from one of the biggest and busiest tertiary care hospital in Karachi, Pakistan.

Methodology
This prospective cohort study was done at Liaquat National Hospital, a tertiary care almost 700 bed hospital. Data from May 2020 till August 2020 was collected. Patients above the age of 18 years with con rmed COVID PCR were selected, patients were discharged from the hospital if afebrile for at least 3 days in the hospital or signi cant improvement of respiratory symptoms and radiological abnormalities on chest radiograph were included in the study. Those who either couldn't be contacted (i.e. lost to follow up after 2 weeks even after reminder calls) after discharge or refused to participate in the study were excluded from the study. The duration of data collection was from May 1st 2020 to August 31st 2020.
The approval of the study was taken from institutional review board (IRB) and ethical review committee (ERC) of Liaquat National Hospital.
In-hospital data collection on the proforma was done at the time of discharge, in which demographic data, symptoms and complete blood count, in ammatory makers and chest x ray at the time of discharge were noted. Post hospitalization data was obtained by weekly follow up for 2 weeks, and then week 3 and 4 data was obtained via phone calls and recorded on the proforma.
All the data of continuous variables were tested for normality using Shapiro-Wilk test. Based on normality, mean or median ranks were calculated. Categorical data were presented as percentages.
Data Analysis: The collected data were entered in Statistical Package for Social Sciences (Version 26.0, IBM Inc., Armonk, USA) for statistical analysis. Categorical variables were expressed in frequency and percentages.
Continuous variables were presented as mean ± standard deviation or median with range as appropriate. Normality of the data was assessed using Shapiro-Wilk test with p-value > 0.05 was considered as normally distributed. Decrease in proportion of patients with speci c symptoms from discharge to fourth week of post-discharge was determined using Cochrane Q-test. Dunn's test was applied for post-hoc pairwise comparison. Participants' characteristics and laboratory investigations were compared among symptomatic and asymptomatic patients and those with persistent and resolved symptoms. Mann-Whitney U test for ratio variables and Chi-square test for categorical variables were used. Wilcoxon signtest was also applied to compare number of symptoms among symptomatic patients at the time of discharge and 4th week of discharge. McNemar's test was applied to assess difference in proportion of patients with improved x-ray on discharge day and a week after discharge. Two tailed p-value less than 0.05 was de ned as statistically signi cant.

Discussion
We systematically tracked the post hospitalization symptoms of the COVID 19 patients up till 4 weeks to see their pace of recovery.
Like other studies all patients were on a course of recovery (4,(7)(8)(9). Similar to Car et al our patient's age ranged from 52.9-58.1 years with male predominance (7,9). The commonest co morbid in our cluster was diabetes; however unlike Balachander et al, we found no association of co-morbidities with presence of symptoms at the time of discharge (10). Most of the discharged patients were initially admitted to ward. The average length of stay in the hospital in our study was 8 days, while in a prospective cohort study done by Wang et al and Car et al showed longer hospital stay (9,11). The most common symptoms at the time of discharge were fatigue and shortness of breath.
There were 77 patients who had improved symptoms at the time of discharge while 19 were completely asymptomatic. There was no statistical difference in the age, length of hospital stay, co morbidities, and laboratory nding among patients who were symptomatic and asymptomatic at the time of discharge. As observed in studies done by Luo et al and Wang et al in china and, in our study most of the patients from symptomatic group (64.9%) became asymptomatic at the end of 4th week (4,7,8).while Garrigues et al showed persistent of post hospitalization symptoms for longer period of time (8). The most common symptoms that persisted at 4th week were fatigue and shortness of breath, this is inline with other studies which have also reported the commonest symptoms post hospitalization were fatigue and shortness of breath (8,9).
Like other studies, there was a signi cant improvement in chest radiological ndings in most the patients (4,7).
At the end of the 4th week most of the patients had returned to their normal life activity.
This observational study is so far the only study from Pakistan regarding the post hospitalization features of COVID 19.
Limitations of our study includes, small sample size from single center, follow up data up to 4 weeks only and limited data on quality of post COVID life.

Conclusion
In our follow up study, we found the statistically signi cant recovery in most of the COVID 19 survivors after discharge, con rmed by reduction in the symptoms and radiological improvement. There is not statistically signi cant difference in the age, length of hospital stay, co morbidities, and laboratory ndings among patients who were symptomatic and asymptomatic at the time of discharge.
Longer follow up with objective assessment of symptoms perseverance and quality of life scores is necessary to elucidate the physiological and psychological effects of COVID 19 on recovered patients. This will help us to design and improve rehabilitation system to boost COVID 19 survivor's morale and help them to return to normalcy.

Declarations
Ethics approval and consent to participate The approval of the study was taken from institutional review board (IRB) and ethical review committee (ERC) of Liaquat National Hospital.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request

Competing interests
The Authors declare no Con ict of Interest.   Pattern of speci c symptom persistence in symptomatic patients Pattern of speci c symptom persistence in symptomatic patients Pattern of symptoms resolution from discharge day to fourth week Pattern of symptoms resolution from discharge day to fourth week