Jordanian health authority policy regarding management of COVID-19 pandemic was to admit every patient with positive PCR COVID-19 regardless of symptoms or clinical condition. Many individuals were tested for COVID-19 only because they were in close contact with COVID-19 patients. Therefore most patients were asymptomatic. This also explains why the laboratory tests on admission for most patients were within normal range. Most patients did not require more than paracetamol as treatment. This is different from other countries such as China and Italy.
Wuhan's results demonstrate that hypertension (30%), diabetes (22%), and coronary artery disease (22%), all of which are more prevalent in people with obesity, were the most common co morbidities in patients needing hospitalization 22. The percentage of these co-morbidities was lower by about 50% in our cohort of patients: with hypertension (17%), diabetes (11%), cardiac disease (6%). However, the ICU patient prevalence of the above mentioned co-morbidities was higher: hypertension (100%), diabetic (58%) and cardiac disease (42%).
BMI positively and strongly correlates with ICU admission increasing the risk of severe COVID-19 illness to around 300 folds. This is consistent with other published results 23–25. Additionally, the presence of hepatic steatosis increased the risk of severe COVID-19 illness to around 17 folds. The presence of hepatic steatosis among obese patient increased the risk to over 300 folds.
A large New York City cohort report revealed that obesity (BMI 30–40) is strongly correlated with a progression to serious illness with a relatively increased odds ratio than any cardiovascular or pulmonary condition 4. Another study in the early days of the Italian epidemic demonstrated that the Case-fatality rate of patients hospitalized with COVID-19 was about 20%. Older age, obesity and disease severity upon admission were factors related with increased risk of death 26.
Even after adjustment for other possibly confounding factors such as age, gender, race and troponin levels, obesity was reported to be associated with significantly higher levels of ICU admission and mortality in hospitals 27–30. Higher demand for assisted ventilation beyond pure oxygen support (Invasive Mechanical Ventilation or Non-Invasive Ventilation) and increased admission to intensive or semi-intensive care units has been identified in patients in overweight and obesity 31.
While other literature does not provide data about steatosis and its correlation with severity of COVID-19, our study provides valuable evidence about this correlation. On the other hand, there was rather a weak correlation between FIB-4 and ICU admission. Additional studies are needed to confirm these findings and to better understand the underlying mechanisms for why the association is greater in those with obesity.
The total number of COVID-19 positive patients in Jordan from March until July 2020 was about 1200 and only 10 of them died (0.8%). Our cohort (230 patients) represents about 19% of the total COVID-19 patients in Jordan. Our cohort contained 9 of the 10 patients who died and 90% of all patients admitted to ICU. Most mortalities occurred in the first cohort of patients (300) that were diagnosed in Jordan. Only one mortality occurred in the following cohort of patients (900) that were not included in our study.
Several reports indicate that obesity may be a very significant consideration in younger people 32–34. A report of 3,615 New York patients revealed that obesity was strongly correlated with hospital and ICU admittance for patients under 60 years of age 32. Another study showed that hospitalized patients younger than 50 with morbid obesity are more likely to die from COVID-19. This is particularly relevant in the western world where obesity rates are high. In the same context, the findings of another study found a greater prevalence of obesity in younger hospitalized patients 33;34.
This is similar to what is suggested by literature. data suggests a longer viral shedding time + 5 days & abnormal liver function x7 folds in patients with (MAFLD) 12;16. There is an increased risk of symptomatic infection in MALFD patients 35.
No mortalities occurred among children in Jordan. The youngest patient who died was 44 years old and had hypertension, diabetes and cardiac disease.
The Hashemite kingdom of Jordan managed to keep the COVID-19 pandemic under control. Jordan followed an early and strict lockdown strategy and all infected cases were admitted to hospital regardless of symptoms. COVID-19 did not widely spread in Jordan, which has a population of about 10 million. COVID-19 was only found in 1200 patients over 4 months, which is (0.012%).
Most Jordanian patients did not have symptoms. Most patients did not require treatment or antiviral medication. Therefore this could be the reason for the generally unaltered liver function enzymes.
Some limitations of this study should be recognized. While the liver was assessed by CT scan for severe steatosis, patients included in our study did not undergo liver biopsy, thus COVID-19 severity in relation to liver histology could not be assessed.
Another common characteristic of obesity is vitamin D deficiency, which raises the risk of bacterial infections and impairs the immunity response 36. Vitamin D has several mechanisms by which it eliminates the chance of microbial infection and death according to an analysis of the role of vitamin D in lowering the risk of common cold, which divides these mechanisms into three groups: physical barrier, cellular natural immunity and adaptive immunity 37. Level of Vitamin D was not tested in patients in this study.
In addition, patients were mostly of Arab ethnicity and thus the applicability of the results to other ethnic groups is uncertain.