The differences of clinical characteristics and outcomes between imported and local patients of COVID-19 in Hunan: A two-center retrospective study

doi:10.21203/rs.3.rs-23247/v1

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The differences of clinical characteristics and outcomes between imported and local patients of COVID-19 in Hunan: A two-center retrospective study

https://doi.org/10.21203/rs.3.rs-23247/v1

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published 26 Nov, 2020

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Background: The clinical characteristics and outcomes of 2019 novel coronavirus (COVID-19) pneumonia are different in Hubei and out of Hubei in China. But there are few comparative studies on the imported and local patients.

Methods: We investigated 169 patients of COVID-19 pneumonia in two centers in Hunan Province, and divided into two groups according to epidemiology history, aiming to analyze the difference of clinical characteristics and outcomes in the two groups. All the epidemiological, clinical, imaging, and laboratory data were analyzed and contrasted.

Results: The incidence of fever on admission in imported patients was significantly higher than local patients. The proportion of abnormal pulmonary signs was also significantly higher in imported patients. There was a significantly higher proportion of hypokelamia, hyponatremia in imported patients than that in local patients. Compared with local patients, the imported patients using antibiotics, glucocorticoids and gamma globulin were significantly higher. The moderate type was more common in local patients, and the severe type are more frequent in imported patients. In addition, the median duration of viral clearance was longer in imported patients.

Conclusions: In summary, we found that imported patients more likely developed into severe patients than local patients and required more powerful treatments.

Trial registration: We registered 21 March, 2020, and this study has been approved by the Medical Ethics Committee (Approved Number. 2020017).

Infectious Diseases

COVID-19

SARS-CoV-2

clinical characteristics

outcomes

virulence

Since December 2019, with the outbreak of COVID-19 pneumonia, the World Health Organization declared 2019-nCoV epidemic as a Public Health Emergency of International Concern on January 30^th[1]. As of March 12, 2020, China has confirmed 80,981 patients and 3123 deaths. Among them, 1018 patients were confirmed and 4 patients died in Hunan[2]. The pathogen that caused the outbreak now is officially named SARS-CoV-2, which is a member of the coronavirus family[3].

Compared with the studies in Wuhan and other provinces and cities, we found that Wuhan has a higher rate of severe patients, higher mortality and longer hospitalization time[4-6]. Previous studies suggest that most viruses will co-evolve with their hosts, and intermediate virulence maximizes pathogen fitness, which is called a trade-off between virulence and transmission[7]. Excluding the influence of environmental factors, has the virulence of the SARS-CoV-2 been reduced in the process of transmission? Regretfully, few studies focus on this area at present, which is conducive to our comprehensive understanding of the clinical and epidemiological characteristics of COVID-19.

Hunan is geographically adjacent to Hubei, and a large number of people have escaped into Hunan before Wuhan closed its city borders[8], which may lead to a large number of potentially infected patients. Since it is relatively difficult to distinguish the generations of patients clinically, we adopted two classifications: "imported patients " refers to patient with a clear history of travel in Wuhan within 14 days before onset, while " local patients” refers to local resident without recent history of travel in Wuhan.

In this study, we collected data from 169 adult COVID-19 pneumonia patients from two centers in Hunan Province. All patients were divided into imported patients and local patients according to epidemiology history. We made a comprehensive comparison and analysis of their clinical features and outcomes in order to explore the differences between the two groups.

Study Design and Participants

This is a two-center, retrospective study. We enrolled 169 adult patients of COVID-19 pneumonia admitted to hospital in Changsha and Xiangtan, Hunan Province from January 21, 2020 to February 21, 2020. Considering the physiological differences between children and adults, and the fact that the differences in clinical characteristics between children and adults COVID-19 pneumonia patients had been confirmed[9], we abandoned the inclusion of underage patients. The enrolled patients included 134 patients from Changsha Public Health Treatment Center and 35 patients from Xiangtan Central Hospital. Both hospitals are the only designated hospitals to treat COVID-19 pneumonia patients in Changsha and Xiangtan respectively. All patients were diagnosed as COVID-19 pneumonia according to the guidelines issued by National Health Commission of PRC[10] and divided into imported patients (74 patients) and local patients (95 patients) according to their epidemiological history. We collected all of the clinical data separately up to March 2, 2020 (include a start date).

Procedures

All patients were diagnosed according to the guidelines of National Health Commission of PRC[10], patients diagnosed as suspected patients were tested for nasal/pharyngeal swab RT-PCR immediately. If the nucleic acid test was positive, patient would be confirmed. If negative, the nucleic acid tests would be taken again the next day.

We collected the basic information (gender, age, epidemiological history, underlying diseases, etc.), clinical characteristics or signs (fever, respiratory symptoms, gastrointestinal symptoms and respiratory frequency, fatigue, etc.), laboratory data (blood routine, blood biochemistry, coagulation function, blood gas analysis, liver and kidney function assessment, infection-related biomarkers, etc.), imaging results (Ground-glass opacity, consolidation, involved scope, pleural effusion, etc.), treatment measures (respiratory support, antiviral drugs, antibiotics, hormones, etc.) from the hospital medical records. The data were as of March 2, 2020. If the important data were missing or clarification was needed, we obtained the data by communicating with the attending clinicians. For imaging data, we used two commercial multi-detector CT scanner (LightSpeed, GE Medical Systems, USA; SOMATOM, Siemens Medical, Germany) to perform chest CT scans in all patients. CT images were collected during one or two breath holds. Imaging features include the type and distribution of lesions, the number of lesions and the lobes involved. All CT images were read by two radiologists with more than 10 years' experience, and If differences arose, a third radiologist was added for analysis.

Before the data were collected, the attending clinicians had classified all patients into four categories: mild, moderate, severe and critical type according to the guidelines of National Health Commission of PRC[10]. We followed the attending clinicians' classification.

Outcomes

The primary outcome was death. And the secondary outcomes included the incidence of serious complications, utilization rate of mechanical ventilation and the duration to negative RT-PCR tests.

Definitions

Confirmed standard:

Nasal / Pharyngeal swabs or other samples were positive for viral nucleic acid tested by reverse transcription polymerase chain reaction (RT-PCR);
The sequencing of virus gene was highly homologous to the known novel coronavirus.

Clinical classification standard:

Mild: Clinical symptoms are slight, and no pneumonia manifestations can be seen on imaging;
Moderate type: With symptoms such as fever and breathing, and pneumonia manifestations can be seen on imaging;
Severe: Shortness of breath, RR> 30 beats/min, or oxygen saturation <93% at rest, or arterial blood oxygen partial pressure (Pa0₂)/oxygen concentration (Fi0₂) <300mmHg, or lung radiology imaging shows that the lesions progress more than 50% within 24-48 hours;
Critical: Respiratory failure and requiring mechanical ventilation, or shock, or combined organ failure and requiring ICU monitoring treatment.

Statistical analysis

For continuous variable, we expressed it as mean(SD) or median (IQR). We assessed the differences by two-sample T-test or Mann-Whitney test. Categorical variable was expressed as counts (%), and differences were tested by χ2 or Fisher exact tests, if appropriate. For the laboratory results, we also evaluate whether the values were beyond the normal range. We used SPSS (version 26.0) for all analyses, p <0.1 is considered statistically significant, for the population is not big.

Demographics, baseline and clinical characteristics of COVID-19 pneumonia patients (table 1)

In our study, 74 (43.7%) patients had a clear history of living in Wuhan before the onset of the disease, including Wuhan locals and those working, studying, traveling or working in Wuhan. These patients who were infected with the virus in Wuhan were regarded as imported patients, while the rest were regarded as local patients. There was no medical staff in our patients.

The median age of all patients was 45 years (interquartile range, 34.5 to 55). The median age of imported patients was 45 years, and local patients was 43 years. The age of the patients was mainly between 19 and 49 years old (67.6% of imported patients and 58.9% of local patients). The proportion of local patients over 50 years old (41%) was slightly higher than that of imported patients (32.5%). There is no significant difference in gender between two groups. The male-to-female ratio of all patients was close to 1/1, which was consistent with the study of Wu et al[11].

On admission, body temperature in most of patients (62.2% VS 77.9%) was lower than 37.3 ℃. Among the fevers, most of them were slight fever, and only 1 case had high fever (＞40℃). The incidence of fever in imported patients (37.9%) was significantly higher than that in local patients (22.1%). P=0.065.

The abnormal physical signs of pulmonary auscultation were mainly crackles or mixed crackles and stridor. The proportion of abnormal pulmonary signs was significantly higher in imported patients (10.9% VS 4.2%). And only 3 of imported patients were complicated with mixed crackles and stridor, while none of local did.

Among all of the patients, 31.4% had at least one complication. Compared with local patients, more patients with underlying disease in imported patients (35.8% VS 25.7%), but no statistically significant was found. The top three underlying diseases were hypertension (8.1% VS 13.7%), diabetes (5.4% VS 9.5%), and cardiovascular and cerebrovascular diseases (2.7% VS 8.4%).

In this study, cough (86.5% VS 75.8%), fever (78.4% VS 68.4%) and fatigue (both 43.2%) were still the three most common clinical symptoms of COVID-19 pneumonia. However, the proportion of gastrointestinal symptoms (such as nausea, vomiting, diarrhea, etc.) was also close to 1/3 (29.7% VS 32.6%), which is not as low as the previous study[6]. But no significant was observed between two groups.

In addition, the median onset-visit interval of both imported and local patients was 3 days, and there was no significant difference.

Radiographic findings of COVID-19 patients (table 2)

On admission, radiographs results showed that 130 of the 166 patients (78.3% VS 78.1%) had ground-glass opacity (GGO), and 21 of the 166 patients (13.7% VS 11.8%) had mixed GGO and consolidation. Only 1 patient had consolidation only. Besides, the proportion of bilateral pneumonia was higher in imported patients (84.9% VS 79.6%) while the proportion of unilateral pneumonia was higher in local patients (8.2% VS 14.0%). However, no significant difference was observed.

After a period of treatment, the proportion of patients with only GGO decreased (54.2% VS 46.2%), while the proportion of mixed GGO and consolidation patients increased (29.2% VS 35.2%), which conform natural outcome of lung imaging performance.

Laboratory results of COVID-19 patients (table 3)

The leukopenia accounted for 22.6% (25.7% VS 20.2%), lymphocytopenia 47.6% (48.6 VS 46.8%), Hemoglobinopenia 24.4% (20.3% VS 27.7%), thrombocytopenia 14.3% (16.2% VS 12.8%), but there was no significant difference between two groups at admission.

The proportion of APTT (median 12.1s) shortening in imported patients was significantly lower than that in local patients (median 11.7s). On the contrary, the proportion of increased D-dimer in imported patients was significantly higher (35.1% VS 25.8%)，P values＜0.1.

The results of blood gas analysis in the two groups were similar. 68.6% of the patients had alkalosis, while 28.3% of the patients had a decrease in PaO2 and 37.1% had a decrease in PaCO2. No significant difference was found.

Most patients had hypoalbuminemia (62.2% VS 51.6%), of which the albumin level of imported patients (median 37.87g/L) is lower than that of local patients (median 39.64g/L). The prevalence of abnormal serum ALT and AST was about 23%, while that of CK and CK-MB was less than 10%, but there was still no significant difference.

There was a significant difference in hyponatremia (25.7% VS 11.6%) and p value is 0.025. Besides, the median serum potassium and median serum sodium of imported patients (3.95mmol/L and 137.0mmol/L) were significantly lower than those of local patients (4.15mmol/L and 137.8mmol/L), while the proportion of blood glucose rise was significantly higher than that of local patients (50% VS 34%)，p＜0.1。

In addition, CRP was elevated in more than half of the patients (58.1% VS 50.5%). The median CRP of imported patients was 12.71mg/L, while the median CRP of local patients was 9.92mg/L, but there was no statistical difference. Surprisingly, only 3 patients had increased PCT.

Complications, treatments and clinical outcomes of COVID-19 patients (table 4)

The moderate type was the most common (70.3% VS 82.1%), followed by severe, mild, and critically type. The proportion of severe type of imported patients (20.3%) was significantly higher than that of local patients (9.3%), while the proportion of moderate type was significantly lower (70.3% VS 81.4%), p＜0.1.

During the hospitalization, 18 patients had severe complications, such as ARDS, Shock, AKI, and MODS. The incidence of ARDS (12.2% VS 7.4%) in imported patients was higher than that in local patients. Shock only occurred in imported patients (2.7%). 20 patients were admitted to the ICU, of which 13.5% were imported patients and 10.5% were local patients. Oxygen therapy was administered in about 95% patient in both two groups, and only 2 patients were treated with ECMO, and 1 case was treated with continuous renal replacement therapy, all of which were imported patients. No statistically significant difference was observed.

All patients received antiviral therapy during hospitalization, with about 1/4 using a single drug and 3/4 using a combination. The most commonly used antiviral drugs were Lopinavir/Ritonavir, interferon and Arbidol.

Using antibiotics, glucocorticoids, and gamma globulin were significantly higher in imported patients than in local patients (60.8% VS 44.2%, 36.5% VS 17.9%, 36.5% VS 17.9% respectively), P ＜0.05. The type of glucocorticoid was methylprednisolone, with the usual initial dose of 40mg, and the maximum dose of 80mg. Glucocorticoids and gamma globulin were not used unless a panel discussion by experts considered necessary (e.g., ARDS). The median course of treatment of the glucocorticoid was 7 days, while the median course of gamma globulin was 6 days. Besides, the median viral clearance duration in imported patients was significantly longer than that in local patients (11 days VS 9 days), p is 0.080.

As of March 2, 2020, a total of 154 patients were discharged, 1 died (imported case), and 14 (1 imported case and 13 local patients) were still in hospital. Since Wuhan was closured on 23 Jan., there were no more imported patients after 5 Feb., so the patients admitted to the hospital at the later stages were local patients. The median length of hospital stay was 13 days.

This is a retrospective study to explore whether there is a difference between imported patients and local patients. We included 169 patients from Changsha and Xiangtan, and divided them into imported patients and local patients according to their epidemiology history. Most patients had fever during the course of disease, predominantly slightly fever, but might present with no fever at admission. Therefore, our early screening should not be limited to symptoms such as fever, otherwise many early patients with asymptomatic or mild symptoms would be missed. In addition, there was a higher proportion of fever and abnormal pulmonary auscultation in imported patients. In addition, the results showed that the proportion of patients with early imaging changes was higher than that of patients with early symptoms and signs, suggesting that CT may be more sensitive in the early stage, which is helpful for an early diagnosis. However, lacking of specificity, so it needs to be diagnosed in combination with clinical manifestations and epidemiological history.

In terms of laboratory tests, there was a higher proportion of hypoproteinemia, lymphocytopenia, elevated CRP, prolonged PT, elevated D-dimer and elevated LDH in imported patients, which were the most common clinical biochemical abnormalities in COVID-19 pneumonia[6]. And in the aspect of clinical classification, the proportion of severe type of imported patients was higher, while the proportion of moderate type was lower, indicating that imported patients had more severe clinical manifestations than local patients. In addition, in imported patients, the proportion of hypokalemia, hyponatremia and hyperglycemia was higher, too, which may also be related to the more serious disturbance of internal environment caused by infection. These findings illustrate that imported patients are more likely to progress to severe type.

Another finding in this study was that more antibiotics were used in imported patients. The most commonly used antibiotic was moxifloxacin, which is a broad-spectrum antibiotic, suggesting that the imported patients may have more bacterial infection compared to local patients. In addition, the proportions of using glucocorticoids and gamma globulins in imported patients were also larger, suggesting that the incidence of inflammatory storms is higher and the infection is more serious in imported patients.

In this study, the viral clearance duration was longer in imported patients. The median viral clearance duration was 11 days in imported patients and 9 days in local patients, which was close to that of Chen et al[12]. And Chen et al had confirmed that the viral clearance duration in patients admitted in ICU was longer than that in patients not admitted in ICU. In other words, the median viral clearance duration may take longer in the more severe patients. We speculate that the time of nucleic acid turning negative may be related to the viral load of patients, and Dr. Liu and his colleagues had pointed out that the viral load is positively correlated with the clinical manifestations and biochemical indicators of patients[13], which may explain to some extent why imported patients are more serious than local patients.

Based on the above analysis, our results indicated that the clinical manifestations of imported patients are more severe than that of local patients, and the ratio of requiring special treatment is higher. A recent study has shown that the incubation period of SARS-CoV-2 in tertiary patients is longer than that in imported patients and secondary patients, and the viral load is lower, so the infectivity of SARS-CoV-2 in tertiary patients may gradually decrease[14]. It also mentioned that there were no significant differences in early clinical symptoms and signs between imported patients, secondary patients, and tertiary patients, which are consistent with the results of ours. Another study presented a linear correlation between viral load and severity of lung injury[13]. Therefore, we speculate that the virulence of SARS-CoV-2 may have decreased during the infection of local patients. For the clinical characteristics of imported and local patients are not significantly different in the early stages, but since the disease progression, the imported patients may tend to develop more serious than local patients, so we needs to pay more attention of imported patients at initiation.

Compared with the study in Wuhan[15], the mortality of COVID-19 pneumonia patients in Hunan was 0.5%, and the proportion of severe and critical type was 16.9%, which was significantly lower than that in Wuhan, but conform with the data of other provinces out of Hubei[4, 5], lots of factors may play important role except for the virulence of SARS-CoV-2 decreasing. For the outbreak of COVID-19 pneumonia, medical resources in Hubei were relatively scarce, and mild patients could not be admitted to the hospital, which led the proportion of severe patients much higher. What’s more, the psychological problems also very grievous not only in patients, but also in medical workers[16].

Psychological problems may be another important factor that cause the difference between the imported and local patients. Lima et al. found that patients are prone to mental health problems during this epidemic, especially in Wuhan[17]. Hence, during the epidemic, all people associated with Wuhan were easily regarded as "black sheep" and suffered discrimination[18]. The imported patients in this study represent the situation of local patients in Wuhan in some extent, so they are more likely to suffer prejudice from surrounding people, leading to psychological problems, which is harmful for their condition. Therefore, early prevention and treatment for psychology trauma to medical workers and the general public in severely affected areas are very necessary, which will contribute to build confidence and have a positive effect on fighting against the epidemic.

There are several limitations in our study. First of all, the sample size is small, which leads to no statistically difference compared to other data. Secondly, the mechanism of SARS-CoV-2 virulence decrease still need to study further. Thirdly, we did not have a long-term follow-up that could not evaluate the long-term prognosis of patients. In addition, we only included two centers in Hunan Province, so large-scale multicenter studies are needed to verify our findings.

We found that imported COVID-19 pneumonia patients more tended to develop into severe type than local patients, and need more aggressive treatments. In view of the fact that SARS-CoV-2 has become a global epidemic[19], as there is no effective medicine and treatment, we’d better to pay more attention to the imported populations and quarantine for a while to prevent external spread. On the other hand, the government should increase support for medical resources in epidemic areas to prevent medical runs and even the collapse of the medical system in epidemic areas.

COVID-19, 2019 novel coronavirus disease

SARS-CoV, severe acute respiratory syndrome-related coronavirus

SARS-CoV-2, severe acute respiratory syndrome-related coronavirus-2

CT, computed tomographic

IQR, interquartile ranges

GGO, ground-glass opacity

CK, Creatine kinase

CK-MB, Creatine kinase-MB

AKI, Acute kidney injury

MODS, Multiple organ dysfunction syndrome

ARDS, Acute respiratory distress syndrome

ICU, intensive care unit

ECMO, Extracorporeal membrane oxygenation

ALT, Alanine aminotransferase

AST, Aspartate aminotransferase

PCT, Procalcitonin

CRP, C-reactive protein

PT, Prothrombin time

LDH, Lactate dehydrogenase

APTT, Activated partial thromboplastin time

Ethics approval and consent to participate：This study has been approved by the Medical Ethics Committee (Approved Number. 2020017). Given the urgent need to collect data, we abandoned this retrospective study to obtain written informed consent from patients, referring to the CIOMS guidelines.

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare no conflict of interest.

Funding: This research was funded by The National Natural Science Foundation of China, grant number: 81900661.

Author Contributions: Conceptualization：Chang Wang，Lizhi Zhou and Xiangyu Chen; Data curation, Juan Chen, Yong Yang and Tianlong Huang; Formal analysis, Lizhi Zhou; Funding acquisition, Chang Wang; Supervision, Xiangyu Chen; Writing – original draft, Lizhi Zhou; Writing – review & editing, Chang Wang.

Acknowledgments: Hongzhuan Tan and Jia Zhou from Xiangya School of Public Health of Central South University provided guidance on statistical methods. Mu Li and Sydney Lipu contribute to english editing equally.

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Table 1. Demographics, baseline and clinical characteristics of COVID-19 pneumonia patients.

Variables			All cases (n=169)	imported cases (n=74)	local cases (n=95)	P Value
Age (yr)
	Median (IQR)		45 (34.5-55)	45 (35-53.5)	43 (34-57)	0.872
	Range
		19-49	106 (62.7)	50 (67.6)	56 (58.9)	0.392
		50-64	38 (22.5)	13 (17.6)	25 (26.3)
		≥65	25 (14.8)	11 (14.9)	14 (14.7)
Sex
		Male	86 (50.9)	40 (54.1)	46 (48.4)	0.536
		Female	83 (49.1)	34 (45.9)	49 (51.6)	0.536
Temperature on admission (℃)
	Median (IQR)		36.8 (36.5-37.4)	37.0 (36.6-37.5)	36.8 (36.5-37.2)	0.076
	Range
		＜37.3	120 (71.0)	46 (62.2)	74 (77.9)	0.065
		37.3-38.0	37 (21.9)	21 (28.4)	16 (16.8)
		38.1-39.0	11 (6.5)	7 (9.5)	4 (4.2)
		＞39	1 (0.6)	0 (0)	1 (1.1)
Pulmonary auscultation on admission
		Crackles	9 (5.3)	5 (6.8)	4 (4.2)	0.507
		Stridor	0 (0)	0(0)	0 (0)	1.000
		Both	3 (1.8)	3 (4.1)	0 (0)	0.082
Complication
	Not less than 1		53 (31.4)	19 (25.7)	34 (35.8)	0.183
		Recurrent respiratory infections	4 (2.4)	1 (1.4)	3 (3.2)	0.632
		Hypertension	19 (11.2)	6 (8.1)	13 (13.7)	0.329
		Diabetes	13 (7.7)	4 (5.4)	9 (9.5)	0.393
		Immunodeficiency	2 (1.2)	0 (0)	2 (2.1)	0.505
		Chronic obstructive pulmonary disease	3 (1.8)	1 (1.4)	2 (2.1)	1.000
		Cancer	2 (1.2)	1 (1.4)	1 (1.1)	1.000
		Cardiovascular and cerebrovascular diseases	10 (5.9)	2 (2.7)	8 (8.4)	0.189
Symptoms or signs
		Fever	123 (72.8)	58 (78.4)	65 (68.4)	0.167
		Cough	136 (80.5)	64 (86.5)	72 (75.8)	0.117
		Expectoration	71 (42.0)	28 (37.8)	43 (45.3)	0.350
		Hemoptysis	4 (2.4)	3 (4.1)	1 (1.1)	0.320
		Nasal congestion	3 (1.8)	1 (1.4)	2 (2.1)	1.000
		Headache	23 (13.6)	7 (9.5)	16 (16.8)	0.183
		Shortness of breath	37 (21.9)	20 (27.0)	17 (17.9)	0.190
		Muscle soreness	11 (6.5)	3 (4.1)	8 (8.4)	0.351
		Fatigue	73 (43.2)	32 (43.2)	41 (43.2)	1.000
		Gastrointestinal symptoms	53 (31.4)	22 (29.7)	31 (32.6)	0.740
Onset-visit interval(days)
	Median (IQR)		3 (1-6)	3 (1-6)	3 (1-6)	0.711

Data are n (%) or median (IQR), unless otherwise specified.

Table 2. Radiographic findings of COVID-19 patients.

Variables		All cases (n=169)	imported cases (n=74)	local cases (n=95)	P Value
CT findings on admission¹
	Ground-glass opacity（GGO）only	130/166 (78.3)	57/73 (78.1)	73/93 (78.5)	1.000
	Consolidation only	1/166 (0.6)	0/73 (0)	1/93 (1.1)	1.000
	Mixed GGO and consolidation	21/166 (12.7)	10/73 (13.7)	11/93 (11.8)	0.815
Involved scope¹
	Unilateral pneumonia	19/166 (11.4)	6/73 (8.2)	13/93 (14.0)	0.328
	Bilateral pneumonia	136/166 (81.9)	62/73 (84.9)	74/93 (79.6)	0.421
CT findings after treatment¹
	Ground-glass opacity（GGO）only	81/163 (49.7)	39/72 (54.2)	42/91 (46.2)	0.346
	Consolidation only	1/163 (0.6)	0/72 (0)	1/91 (1.1)	1.000
	Mixed GGO and consolidation	53/163 (32.5)	21/72 (29.2)	32/91 (35.2)	0.501

Data are n (%), n/N (%) or median (IQR), unless otherwise specified.

¹Data were missing for the item in several cases.

Table 3. Laboratory results of COVID-19 patients.

Variables			Normal range	All cases (n=169)	imported cases (n=74)	local cases (n=95)	P Value
Blood routine
	Leucocytes¹(×10⁹/L)		3.5-9.5	4.62 (3.63-5.89)	4.61 (3.44-5.99)	4.62 (3.64-5.87)	0.844
		Increased		4/168 (2.4)	1 (1.4)	3/94 (3.2)	0.631
		Decreased		38/168 (22.6)	19 (25.7)	19/94 (20.2)	0.459
	Neutrophils¹(×10⁹/L)		1.8-6.3	2.89 (2.30-3.67)	2.80 (2.26-3.56)	2.93 (2.30-3.77)	0.693
		Increased		9/168 (5.4)	4 (5.4)	5/94 (5.3)	1.000
		Decreased		17/168 (10.1)	6 (8.1)	11/94 (11.7)	0.608
	Lymphocytes¹(×10⁹/L)		1.1-3.2	1.13 (0.81-1.55)	1.11 (0.81-1.53)	1.18 (0.81-1.60)	0.666
		Increased		2/168 (1.2)	0 (0)	2/94 (2.1)	0.504
		Decreased		80/168 (47.6)	36 (48.6)	44/94 (46.8)	0.877
	Hemoglobin¹(g/L)		120-160	130.5 (120.0-141.8)	132.0 (121.0-143.0)	129.0 (117.8-141.0)	0.150
		Decreased		41/168 (24.4)	15 (20.3)	26/94 (27.7)	0.284
	Platelets¹(×10⁹/L)		125-350	175.5 (145.0-227.0)	172.5 (139.0-228.0)	181.5 (145.8-227.3)	0.699
		Increased		3/168 (1.8)	1 (1.4)	2/94 (2.1)	1.000
		Decreased		24/168 (14.3)	12 (16.2)	12/94 (12.8)	0.658
Coagulation Function
	Prothrombin time¹ (s)		9.4-12.5	11.8 (11.0-12.7)	12.1 (11.2-12.7)	11.7 (10.8-12.5)	0.099
		Increased		44/167 (26.3)	22 (29.7)	22/93 (23.7)	0.384
	Activated partial thromboplastin time¹(s)		25.1-36.5	33.1 (30.4-36.1)	32.9 (31.0-35.6)	33.3 (30.2-36.8)	0.943
		Increased		40/167 (24.0)	15 (20.3)	25/93 (26.9)	0.364
		Decreased		5/167 (3.0)	0 (0)	5/93 (5.4)	0.067
	D-dimer¹(mg/L)		0.0-0.5	0.31 (0.15-0.57)	0.36 (0.19-0.59)	0.26 (0.13-0.53)	0.072
		Increased		50/167 (29.9)	26 (35.1)	24/93 (25.8)	0.234
Blood gas analysis
	pH¹		7.35-7.45	7.47 (7.45-7.50)	7.47 (7.44-7.51)	7.48 (7.45-7.50)	0.785
		Increased		109/159 (68.6)	45/70 (64.3)	64/89 (71.9)	0.309
		Decreased		1/159 (0.6)	0/70 (0)	1/89 (1.1)	1.000
	PaO₂¹ (mmHg)		75-105	87.4 (71.6-109.0)	90.7 (70.8-109.4)	86.0 (72.0-108.4)	0.429
		Decreased		45/159 (28.3)	19/70 (27.1)	26/89 (29.2)	0.860
	PaCO₂¹ (mmHg)		35-46	37.0 (32.9-40.6)	36.6 (33.6-39.7)	37.5 (32.8-41.3)	0.718
		Increased		8/159 (5.0)	4/70 (5.7)	4/89 (4.5)	0.732
		Decreased		59/159 (37.1)	26/70 (37.1)	33/89 (37.1)	1.000
Blood biochemistry
	Albumin (g/L)		40.0-55.0	38.8 (35.6-42.7)	37.87 (35.43-42.36)	39.64 (36.30-43.30)	0.133
		Decreased		95 (56.2)	46 (62.2)	49 (51.6)	0.211
	Alanine aminotransferase (U/L)		9-50	19.9 (13.9-29.3)	20.9 (13.6-30.5)	19.7 (14.0-28.3)	0.611
		Increased		18 (10.7)	10 (13.5)	8 (8.4)	0.322
	Aspartate aminotransferase (U/L)		15-40	22.5 (17.3-28.6)	23.2 (16.0-29.1)	21.9 (17.5-28.2)	0.837
		Increased		20 (11.8)	10 (13.5)	10 (10.5)	0.634
	Creatine kinase (U/L)		＜171	68.5 (40.9-103.9)	72.0 (39.9-108.6)	65.0 (41.0-90.5)	0.712
		Increased		17 (10.1)	9 (12.2)	8 (8.4)	0.450
	Creatine kinase-MB (U/L)		＜25	9.8 (6.3-12.3)	10.3 (6.1-13.1)	9.7 (6.4-12.9)	0.947
		Increased		10 (5.9)	4 (5.4)	6 (6.3)	1.000
	Total bilirubin (μmol/L)		3.4-17.1	10.7 (7.8-15.3)	11.5 (7.8-17.8)	10.1 (7.6-14.3)	0.128
		Increased		38 (22.5)	20 (27.0)	18 (18.9)	0.266
	Serum potassium (mmol/L)		3.5-5.5	4.10 (3.69-4.44)	3.95 (3.63-4.40)	4.15 (3.85-4.48)	0.058
		Increased		2 (1.2)	1 (1.4)	1 (1.1)	1.000
		Decreased		18 (10.7)	10 (13.5)	8 (8.4)	0.322
	Serum sodium (mmol/L)		135-145	137.5 (135.6-139.8)	137.0 (134.8-139.8)	137.8 (136.1-139.9)	0.088
		Increased		1 (0.6)	1 (1.4)	0 (0)	0.438
		Decreased		30 (17.8)	19 (25.7)	11 (11.6)	0.025
	Blood urea nitrogen (mmol/L)		2.8-7.5	4.26 (3.42-5.30)	4.38 (3.36-5.33)	4.13 (3.45-5.30)	0.560
		Increased		14 (8.3)	6 (8.1)	8 (8.4)	1.000
	Serum creatinine (μmol/L)		57.0-111.0	53.68 (41.48-68.00)	51.94 (40.30-66.23)	55.00 (44.98-72.90)	0.156
		Increased		5 (3.0)	1 (1.4)	4 (4.2)	0.387
	Lactate dehydrogenase (U/L)		120-250	169.0 (140.1-216.1)	176.6 (137.7-226.8)	160.1 (141.4-207.5)	0.264
		Increased		23 (13.6)	13 (17.6)	10 (10.5)	0.258
	Glucose¹ (mmol/L)		3.9-6.1	5.63 (4.95-7.44)	6.10 (5.07-7.75)	5.41 (4.86-6.95)	0.049
		Increased		69/168 (41.1)	37 (50.0)	32/94 (34.0)	0.041
Infection-related biomarkers
	C-reactive protein (mg/L)		＜10	12.23 (3.25-26.06)	12.71 (4.25-28.52)	10.30 (2.30-25.37)	0.225
		Increased		91 (53.8)	43 (58.1)	48 (50.5)	0.354
	Procalcitonin¹ (ng/ml)		＜0.5	—²	—²	—²	—²
		Increased		3/168 (1.8)	2/73 (2.7)	1/95 (1.1)	0.581

Data are n (%), n/N (%) or median (IQR), unless otherwise specified.

¹Data were missing for the item in several cases.

²Not all data were collected by quantitative data

Table 4. Complications, treatments and clinical outcomes of COVID-19 patients.

Variables			All cases (n=169)	imported cases (n=74)	local cases (n=95)	P Value
Clinical classification
	Mild type		10 (5.9)	5 (6.8)	5 (5.3)	0.750
	Moderate type		130 (76.9)	52 (70.3)	78 (82.1)	0.097
	Severe type		24 (14.2)	15 (20.3)	9 (9.5)	0.074
	Critical type		5 (3.0)	2 (2.7)	3 (3.2)	1.000
Severe complication
	Acute respiratory distress syndrome		16 (9.5)	9 (12.2)	7 (7.4)	0.304
	Shock		2 (1.2)	2 (2.7)	0 (0)	0.190
	Acute kidney injury		4 (2.4)	1 (1.4)	3 (3.2)	0.632
	Multiple organ dysfunction syndrome		3 (1.8)	1 (1.4)	2 (2.1)	1.000
Treatments
	Admitted in ICU		20 (11.8)	10 (13.5)	10 (10.5)	0.634
	Oxygen therapy		162 (95.9)	71 (95.9)	91 (95.8)	1.000
	High-flow nasal cannula oxygen therapy		14 (8.3)	7 (9.5)	7 (7.4)	0.780
	Prone Positioning		4 (2.4)	2 (2.7)	2 (2.1)	1.000
	non-invasive positive pressure ventilation		7 (4.1)	3 (4.1)	4 (4.2)	1.000
	Invasive positive pressure ventilation		3 (1.8)	2 (2.7)	1 (1.1)	0.582
	Extracorporeal membrane oxygenation		2 (1.2)	2 (2.7)	0 (0)	0.190
	Continuous renal replacement therapy		1 (0.6)	1 (1.4)	0 (0)	0.438
	Antiviral treatment
		Single drug	41 (24.3)	16 (21.6)	25 (26.3)	0.588
		Concomitant drugs	128 (75.7)	58 (78.4)	70 (73.7)	0.588
	Antibiotic treatment		87 (51.5)	45 (60.8)	43 (44.2)	0.043
	Glucocorticoids		44 (26.0)	27 (36.5)	17 (17.9)	0.008
		Course of treatment (days) -Median (IQR)	7 (5-9)	7 (5-10)	6 (4-8.5)	0.259
	Gamma globulin		44 (26.0)	27 (36.5)	17 (17.9)	0.008
		Course of treatment (days) -Median (IQR)	6 (4-8)	6 (4-7)	6 (3.5-8.5)	0.913
Clinical outcome
	Discharged frome hospital		154 (91.1)	72 (97.3)	82 (86.3)	0.002
	Death		1 (0.6)	1 (1.4)	0 (0)
	Hospitalization		14 (8.3)	1 (1.4)	13 (13.7)
		Length of hospital stay (days)	13 (11.0-18.0)	13 (11.0-17.8)	13 (10.0-19.0)	0.916
Viral clearance duration (days)¹
	Median (IQR)		10 (8-15)	11 (8-15)	9 (7-15)	0.080

Data are n (%), or median (IQR), unless otherwise specified.

¹ patients without symptoms before onset were excluded

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The differences of clinical characteristics and outcomes between imported and local patients of COVID-19 in Hunan: A two-center retrospective study

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