By Al-Zuabi, H; Kamel, MI; El-Shazly, MK; Al-Kandari, W; Mandani, G; Hamadah, G; Nasser, AH (2022).
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Greener Journal of Medical Sciences
Vol. 12(2), pp. 161-171, 2022
ISSN: 2276-7797
Copyright ©2022, the copyright of this article
is retained by the author(s)
https://gjournals.org/GJMS
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Gender differences among hospitalized COVID-19 patients.
Homoud Al-Zuabi1,
Mohamed I Kamel2, Medhat K El-Shazly3, Wafaa Al-Kandari4,
Ghaidaa Mandani5, Ghazlan
Hamadah6, Ahmed H Nasser7
1 MRCGP, Consultant Family
Medicine, Head of Chronic Diseases Clinic Team, Head of the Department of
Non-communicable Disease, MOH, Kuwait.
2 MD, Consultant of Public Health,
Department of Occupational Medicine, Ministry of Health, Kuwait & Professor
of Community Medicine, Faculty of Medicine, Alexandria University, Egypt.
3 MD, Consultant of Public Health, Department of Planning,
MOH, Kuwait & Professor of Health Statistics, Medical Research Institute,
Alexandria University, Egypt.
4 MRCGP, Consultant Family Medicine, Member of Chronic
Diseases Clinic Team, Head of Jaber Hospital Quarantine Center and Director of
School Health Administration, MOH, Kuwait.
5 MRCGP, Family Medicine Senior Specialist, Jaber Hospital
Quarantine & School Health Administration MOH, Kuwait.
6 Kuwait Board (AGD), RCSI Dublin (AGD). Advanced General
Dentist Specialist, Jaber Hospital Quarantine & PHC, Kuwait.
7.General Nursing
Diploma, Registered Nurse, Farwaniya Hospital, MOH,
Kuwait.
Correspondence to:
Prof. Dr. Medhat
Shazly
Department Medical Statistics,
Medical Research Institute,
Alexandria University, Egypt
Tel: + 965 24620622
Mobile: + 965 739 3758
E-mail: medshaz@
yahoo. com
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ARTICLE INFO
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ABSTRACT
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Article No.: 102522087
Type: Research
Full Text: PDF, HTML, PHP, EPUB
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Background: A growing body of evidence indicates gender difference in the
severity of COVID-19.
Objectives: The aim of the present study is to highlight gender difference
regarding symptoms, laboratory investigations, complications, and outcome
parameters of COVID-19 in admitted cases during the first wave of the
disease.
Methods: A cross sectional retrospective descriptive epidemiological approach
was carried out using electronic patients’ records review.
Results: One thousand and one hundred fifty males (77.6%) and 332 females
(22.4%) cases for COVOD-19 were subjected to the final analysis. The
proportions of general body ache, loss of smell and sore throat were
significantly higher among females (13.9%, 2.7% and 15.7%) than males (9.9%,
0.3% and 11.0%), whereas shortness of breath was significantly higher in
males than females. A significantly higher proportion of women were more
likely to suffer from low ferritin level than men, whereas men were more
likely to suffer from a low lymphocytic count. Also, a higher proportion of
males suffered from high levels of creatinine than females. No significant
difference between males and females regarding COVID-19 complications except
for respiratory complications that were more significantly encountered among
males than females. Not only more
males (11.9%) tended to use oxygen therapy than females (7.2%) but they used
it through nasal masks (54% compared with 29.2%) and at a higher flow rate
(26.3% compared with 8.3% at a flow rate more than 10 L/min). A higher
percentage of male cases then females required to be admitted to the ICU
significantly (p < 0.001) as 9.7% of males needed care in the intensive
care units (ICU) compared with only 3.3% of females.
Conclusions: There is a difference of COVID-19 presentation, severity, and
hospitalization, between men and women. Overall, this renders males to be at
a higher risk for severe forms of the COVID-19 disease especially with regard
to respiratory complications.
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Accepted: 27/10/2022
Published:
05/11/2022
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*Corresponding Author
Prof. Dr. Medhat Shazly
E-mail: medshaz@ yahoo. com
Phone: + 965 24620622
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Keywords:
gender-difference,
admitted cases, Covid-19.
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Introduction:
Coronavirus disease (COVID-19) was first described in
China in December 2019 as a severe form of acute respiratory syndrome, and
since then has spread worldwide to be announced by the World Health
Organization (WHO) in July 2020 as an out-of-control global pandemic. By May
2021, the number of confirmed infections reached over 169 million with more
than 3.5 million deaths reported to the WHO.(1) COVID-19 virus is one of the
seven coronaviruses that cause infections in humans, it became an epidemic in a
brief period and had a considerable impact on a global scale.(2) Whenever a new
infectious disease emerges, knowledge regarding clinical features, diagnostic
tools and treatment options is critical.(3) A growing body of evidence
indicates gender difference in the clinical outcomes of COVID-19.(4, 5)
Men are consistently over-represented in COVID-19 severe
outcomes, including higher fatality rates. There is a difference in the
perceived symptoms between males and females where evidence suggested that
female patients significantly experienced fatigue, anosmia, headache, sore
throat, and nasal obstruction more than male patients. However, male patients
significantly experienced other symptoms as cough and fever. (6) Apart from
chronic medical conditions and old age (>65years), male gender was
associated with more severe forms of the disease. Although the number of
recorded confirmed cases is similar in males and females, however the mortality
rate tends to be higher in males. (7) The severity of COVID-19, as measured by hospitalisation, admission to intensive care units,
intubation for mechanical ventilation, and death, has consistently been 1.5 to
2 times greater for men than for women around the world.(8-10)
These differences are likely due to gender-specific
behaviors, genetic and hormonal factors, and sex differences in biological
pathways related to COVID-19 infection. Several social, behavioral, and
comorbid factors are implicated in the generally worse outcomes in men compared
with women. (11)
Essential for the success of clinical care is awareness
by clinicians that the diseases they are treating, are characterised
by differences between women and men in epidemiology, pathophysiology, clinical
manifestations, psychological effects, progression, and response to treatment. (12)
It is important to identify the degree to which COVID-19 affects males and
females differently to understand the disease consequences and explore the
prognostic factors for individualized assessment. (11)
This study aimed at exploring
gender difference perceived symptoms, laboratory investigations, complications,
and outcome parameters of COVID-19 in admitted cases during the first wave of
the disease.
Subjects and methods
Setting:
This study
was conducted in Jaber Al-Ahmed hospital. The
time interval of the study was set as four months from April to July 2021.
Study design:
A cross sectional retrospective descriptive
epidemiological approach was carried out using electronic patients’ records
review, aiming at highlighting gender difference among hospitalized COVID-19
patients in Jaber hospital in Kuwait regarding personal characteristics,
presenting manifestations, investigations, vital signs on admission, associated
chronic diseases, COVID-19 complications, and outcome parameters.
Sampling:
A time sample (four months) was set for this study
starting from February to May 2019. All admitted cases during this period were
included in the study. This period was
chosen as during that time all positive cases for COVID-19 (both Kuwaiti and non-Kuwaiti)
across all health governorates were referred to this hospital. After this
period, only Kuwaiti patients were admitted to this hospital.
Research
tools:
A
pre-designed structured questionnaire was designated for data collections. It
included the following domains:
-
Personal characteristics as age, gender, nationality, Smoking,
weight, and height.
-
Associated co-morbid conditions mainly hypertension,
cardiovascular and respiratory diseases, diabetes, dyslipidemia, and endocrine
insufficiency.
-
Presenting symptoms
mainly general, respiratory and gastrointestinal symptoms.
-
Investigations and
vital signs on admission as systolic blood pressure (SBP) (mmHg), diastolic
blood pressure (DBP) (mmHg), heart rate (PPM), respiratory rate (BPM), blood
oxygen saturation (SpO2) (%), D-Dimer (ng/mL), CRP (mg/L), LDH (IU/L), troponin
(ng/L), ferritin (ng/mL), lymphocytic count, serum creatinine (µmol/L), blood
sugar (mmol/L), glycated Hb (HbA1c) (mmol/mol).
-
COVID-19
complications as respiratory, infection, and others complications
-
Outcome
parameters as oxygen therapy, duration of hospital stay, admission to the ICU,
need of intensive ventilation and outcome on discharge
Normal blood oxygen level is defined as 95-100% when
measured with a pulse oximeter. (13) Normal level of serum ferritin is
considered as 20 to 250 ng/mL
for adult males, and 10 to 120 ng/mL for adult females 18 to 39 years and 12 to
263 ng/mL for females 40 years and older. (14, 15) A
normal level of serum creatinine is defined as 61.9 to 114.9 µmol/L for men and
53 to 97.2 µmol/L for women. (16)
All the necessary approvals for carrying out
the research were obtained. The Ethical Committee of the Kuwaiti Ministry of
Health approved the research. The permission of the Deputy Ministry of Health in Kuwait as well as
head of Jaber hospital were obtained. The researchers were trained on skills
required to carry this research efficiently in terms of how to review patient’s
medical record for abstracting the rquired data and to enter these data into
the pre designed file. A pilot study was
carried out on 20 cases.
Data management:
The data collected was logged in the google form directly. Daily revision of the completed data was routinely
carried out. After completing data collection through google forms, this data
was red on an Excel sheet that was in turn changed into an SPSS file
(Statistical Package for Social Science, version 22) for the analysis.
Data cleaning was
performed through checking possible mistakes by a serried range, minimum and
maximum values as well as frequency distribution and cross tabulations to
ensure that all questions had valid codes and values.
Categorical variables are presented as frequencies (number
and percentages) and continuous variables as means (with SDs) or medians (with
interquartile ranges [IQRs]). Simple descriptive statistics were used. Comparison
between groups were performed using Chi square or Fisher’ Exact tests for
categorical data and student t-test or Wilcoxon rank sum test for
qualitative variables.
Results
Reviewing the medical
records of the cases admitted to the selected hospital during the defined
period resulted in inclusion of 1482 positive cases for COVID-19. One thousand
and one hundred fifty males (77.6%) and 332 females (22.4%) were subjected to
the final analysis.
Table 1 describes the
gender differences regarding personal characteristics of the included patients.
The mean age of females (44.1±14.6) was insignificantly higher than that of
males (43.0±14.6) (t = 1.82, P=0.07). Cases in the age group
≥ 60 years represented 18.7% of females and 11.6% of males. There was a
significant difference between male and female cases regarding nationality (χ2
= 194.0, P<0.001). Just less than half of male cases were Indian (46.0%)
while 48.5% of female cases were Kuwaiti, whereas the least proportion were
noticed in Bengali both in males (10.1%) and females (3.3%). The least governorates
that presented in both males and females were Al-Jahra
and Mubarak Al-Kabeer, while 31.6% of male cases were
residents of Farwaniya and 27.1% of female cases were
from Hawalli (χ2 = 25.76,
P<0.001). The BMI was significantly higher in females (29±6.3) than males
(27.0±4.8), (t = 3.81, P<0.001). Smoking was rarely reported in both
males and females, in spite being significantly more presented in males than
females.
Discussion
It is important to
reveal the extent to which COVID-19 affects both sexes to elucidate the disease
outcome and investigate the prognostic factors for individualized assessment. (11)
The available literature dealing with the impact of sex on the outcome and
severity of COVID-19 have rarely linked this relationship with the preventive
and clinical settings. The current study included 1482 hospitalized COVID-19
patients to study clinical, laboratory and outcome differences between males
and females. The overall male/female ratio was 3.46 (1150 males/332 females).
This high male/female ratio may have multiple explanations. This may reflect
the nature of Kuwait as an attracting country of immigrant workers with a higher
proportion of males in the middle age groups. Also, several hospital-based
studies revealed an androgen-mediated condition that may have a role in the
progression of COVID-19 disease. (17, 18)
The most common perceived manifestations by both males
and females were cough (33.3%), fever (27.3%), sore throat (12.1%), body aches
(10.8%) and shortness of breath (10.4%). Loss of both smell and taste were
significantly more commonly prevalent among females (2.7% and 2.1%) than males
(0.3% and 0.7%), while shortness of breath was significantly more common among
males (11.3%) than females (7.2%). Also, a significantly higher proportion of
females (15.7%) suffered from sore throat than males (11.3%). A retrospective
study revealed similar results to the current one regarding loss of taste,
smell and sore throat. (19) However, other main manifestations such as cough
and fever were more common among males while they did not show any significant
difference in the current study. Another study conducted in 2020 revealed that
loss of smell and headache were more frequent in female (20) while another
study revealed that gastrointestinal manifestations including nausea, vomiting
and diarrhea were significantly more frequent in women than men. (21) The
differences between these studies might be attributed to both the design and
setting of the studies as well as the sex ratio where males were more common in
the current study. Also, the dominance of gastrointestinal manifestations
differed from one wave of the disease to another. (19)
Laboratory investigations provide valuable information
about both the clinical status and severity of hospitalized COVID-19 patients.
Consistent with other studies, the current research revealed significant
differences among multiple laboratory investigations between males and females.
(21, 22) A significantly higher proportion of women (34.77%) were more likely
to suffer from low ferritin level than men (1.47%). However, men were more
likely to suffer from a low lymphocytic count with a median of 1.7 compared
with a median of 2.0 for women. Also, a higher proportion of males (7.0%)
suffered from high levels of creatinine than females (3.9%). Lymphopenia and
low ferritin levels were also demonstrated among males in other studies. (21, 22)
Other laboratory findings such as thrombocytopenia, elevated levels of
calcitonin, aspartate and alanine transferase, total bilirubin, C-reactive
protein and venous lactate were demonstrated among male hospitalized COVID-19
cases. (22) These findings, on hospital admission, may render males more
susceptible for a worse outcome than females.
Results from observational studies revealed that COVID-19
males tended to have a higher risk of both morbidity and mortality impacts. (8,
23, 24) Participants of the current study suffered from multiple complications.
The most common ones were the respiratory complications mainly acute
respiratory failure (ARF), pneumonia and acute respiratory distress syndrome
(ARDS) which all were significantly more frequently encountered among males
(15.0%, 4.5%, 4.5% respectively) than females (9.6%, 1.8%, 1.8% respectively).
This might be attributed to the higher proportion of smoking among men revealed
in this study. Higher smoking rate in males may explain the cause of COVID-19
severity Smoking negatively affects the lung, making the individual susceptible
to multiple respiratory system related diseases. Also, smoking was revealed to
reduce immunity against viruses causing a high risk of repeated multiple respiratory
diseases especially repeated respiratory infections. (25, 26)
This high rate of respiratory complications among males
was reflected upon the need to use oxygen therapy as well as its pattern and
flow rate. Not only more males (11.9%) tended to use oxygen therapy than
females (7.2%) but they used it through nasal masks (54% compared with 29.2%)
and at a higher flow rate (26.3% compared with 8.3% at a flow rate more than 10
L/min).
Several studies revealed that more male COVID-19 patients
needed admission to the intensive care units. (8, 9, 27, 28) Data from five
European countries (France, Italy, Spain, Switzerland, and Germany) highlight
this difference, with men 50% more likely to be admitted to ICU than women. (11)
The findings of the current study are consistent with these studies, as 9.7% of
males needed care in the intensive care units (ICU) compared with only 3.3% of
females however. The duration of admission was more or less similar for both
sexes. The higher respiratory complications might be behind the high rate of
ICU admission among males while the similar duration of care may be attributed
to both the pattern and quality of care inside these units. Another factor to
be considered is the ratio of males/females of this study (3.46) which reflects
a high rate of hospitalization of men than women.
International data from several countries showed a
male/female case fatality ratio ranging from 1.6 to 2.8. (29) Data from China,
South Korea, Italy, and autopsy findings from Germany have illustrated that
males formed 59–75% of COVID-19 deaths. (5, 30 – 32) A large study from the
United Kingdom, dealt with more than 17 million COVID-19 patients, identified
that males have a 59% increase in risk of death in comparison to females. (31) The
current study also revealed a ratio of hospitalized male/female mortality of
1.79 (4.3% compared with 2.4%). However, this difference is not statistically
significant. The higher mortality among males of the current study can be
attributed to the significantly higher respiratory complications among males. Again,
respiratory failure was stated as the main cause of mortality among COVID-19
patients. (33)
In general, sex disparity of COVID-19 mortality can be
explained by a both biological (chromosomes, reproductive organs, and related
sex hormones) and gender factors (social and cultural behaviors and
activities). (11)
Men have higher age-adjusted rates of pre-existing
co-morbidities associated with poor COVID-19 prognosis, including hypertension,
cardiovascular disease (CVD), and chronic obstructive pulmonary disease (COPD).
(9, 24, 28, 34) Even after adjustment for age, the effect of co-morbidities on
COVID-19 mortality was greater for men than women. (5) Klein in 2012 reported
that after virus infection, females have been observed to mount more robust
humoral and adaptive immune responses than males. As a result of heightened
immunity to viruses, both the intensity and prevalence of viral infections are
often lower for females than males. (7) Other factors that may explain the
gender difference in COVID-19 prognosis are the immune suppressive effect of
testosterone, the immune enhancing effect of estrogen, (35, 36)
The main limitation
of the current study is being hospital based and depending mainly on secondary
data (records of hospitalized patients). However, the large number of recruited
cases and a selection of the only specialized hospital to deal with COVID-19
cases from all districts of Kuwait can provide both power and advantage for
carrying out this study.
Conclusions
This study demonstrates a difference of COVID-19
presentation, severity, and hospitalization, between men and women. Overall,
this renders males to be at a higher risk for severe forms of the COVID-19
disease especially with regard to respiratory complications. Hospital
physicians should be aware of these differences to guide the diagnosis and
subsequent management decisions. These results would help in developing
specific and effective management strategies.
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