Abstract
BACKGROUND:
The coronavirus disease 2019 (COVID-19) pandemic resulted in a huge burden on healthcare systems and necessitated a risk assessment of patients and an update of the treatment protocol to include home isolation for low-risk patients. The primary objective was to describe the outcome of home isolation and the characteristics of patients at higher risk of admission. The secondary objectives were to determine the proportion of patients with pneumonia and hypoxemia and the correlation between cycle of the threshold (CT) value and severity of the disease.
MATERIALS AND METHODS:
For this study, 394 patients were randomly selected from a total of 8000 home-isolated COVID-19 patients during July to October 2020, and were followed by Bahrain International Hospital (BIH). All data were obtained from a live Excel sheet completed by physicians covering BIH during the study period. Data analysis included Chi-square test to determine significant association between categorical variable, Pearson correlation, and logistic regression analysis.
RESULTS:
Of the 394 home-isolated patients followed, 18 patients with missing data were excluded. The overall admission rate was 50% for ≥50 age group compared to 13.3% for 18–49 age group, while only 2.8% in <18 age group. Moreover, Intensive Care Unit (ICU) admissions were significantly higher in the older age group: 15.2% for ≥50 age group (P < 0.001). About 14% of the patients with comorbidities needed ICU admission, compared with 1.8% of those without comorbidities (P < 0.001). Of the home-isolated patients, 6.3% were diagnosed with pneumonia and 9.9% of those presenting had low oxygen saturation. The CT value was significantly correlated with the severity of symptoms and the need for admission.
CONCLUSION:
Home isolation of low-risk patients with monitoring and follow-up was a safe and necessary step in dealing with the COVID-19 pandemic.
Keywords: Coronavirus disease 2019, home isolation, pandemic
Introduction
Coronavirus disease 2019 (COVID-19) was first identified in Wuhan city, the capital of Hubei province, China, in December 2019 after several atypical pneumonia cases linked to the seafood market were observed.[1] The causative agent is called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[2] It is an RNA-enveloped, single-stranded virus that belongs to the family of Coronaviridae, genus Betacoronavirus.[3] The virus is transmitted mainly via respiratory droplets and invades human cells by binding to the angiotensin-converting enzyme 2 receptor.[4,5] The clinical spectrum ranges from mild upper respiratory tract symptoms and gastrointestinal symptoms to severe pneumonia, acute respiratory distress syndrome (ARDS), and death.[6]
When the number of infected cases began to rise, the World Health Organization (WHO) made a number of decisions. In January 2020, the WHO appealed for more information on the reported cases in China and activated the Incident Management Support Team. Based on the information received, the WHO announced advisory precautions for countries related to the outbreak. On March 11, 2020, the WHO assessed the situation globally and declared that COVID-19 infection is a pandemic.[7]
Bahrain is one of many countries affected by this pandemic.[8] In response, the National Taskforce for Combating the COVID-19 Committee was established and the Bahrain COVID-19 national protocols were released based on the available evidence on the best practices in caring for COVID-19-infected individuals. The first protocol released in February 2020 recommended isolating patients who did not require medical treatment in designated governmental places or in treatment facilities. It did not include home isolation.[9] The protocol was updated according to the available data and best evidence. A section on home isolation added on July 1, 2020, included all patients who were asymptomatic, aged below 60 years, and with no comorbidities.[10] Therefore, the COVID-19 treatment center in Bahrain International Hospital (BIH) was established officially in July 2020, to take care of all the home-isolated patients who needed treatment. From July 2020 to September 2020, any patient who needed admission with an oxygen saturation (SpO2) of <93% was admitted to the intensive care unit (ICU). The protocol was updated for home isolation in October 2020 to take care of all asymptomatic patients regardless of their age or comorbidities. BIH was run by physicians, who received the cases from three sources: Be Aware app, 444 hotline, and primary care health centers.
Be Aware and 444 are the two main pathways that were introduced by the Bahraini government to allow patients to connect easily and effectively with the healthcare authorities. The former was a mobile-based application, while the latter was a 24-h hotline. Both of those systems were introduced by the Bahraini government to make it easy for patients to ask for help 24/7.
Our national laboratories were using quantitative real-time polymerase chain reaction (RT-PCR) to detect the virus in nasal swabs. The cycle of the threshold (CT) value was measured in all positive RT-PCR cases. Simply stated, the CT value is the number of cycles needed for the machine to detect the viral RNA. The lower the number, the higher the viral load.
The primary objective of this study was to determine the outcomes of home-isolated COVID-19 patients who were followed up through BIH from July to October 2020 and the characteristics of patients who were admitted. The outcomes of those patients were either discharge, admission to general wards, or ICU. Our secondary objectives were to identify the proportion of pneumonia and hypoxia in those who were followed up and determine the correlation with the severity of the disease and the need for admission.
Materials and Methods
It was a single-center retrospective study of home-isolated patients followed by BIH. Based on the target population size and margin of error of 5%, the calculated sample size was determined with the following formula:
where N=8000 is the population of COVID-19 home-isolated patients from July 2020 to October 2020, and e denotes the allowed probability of committing an error in selecting a sample from the population and was assumed to be 0.05. Therefore, the sample size was:
A simple random sample of 394 subjects was selected using IBM SPSS statistics for Windows, Version 26 (IBM Corp., Armonk, NY, USA) from the population. Ethical approval was obtained from the Ethics Committee of Royal Medical Services in Bahrain vide letter no.CRT-COVID2020-109 dated 31/12/2020, with a waiver of informed written consent since no human subjects were directly involved in this study.
The data were obtained from a live sheet retrospectively (from July 2020 to October 2020) of the home-isolated patients who were followed up by the BIH physicians and referred by the three sources: Be Aware app, 444 hotline, and primary care health centers. The live sheets were completed by BIH physicians for those who were referred from the three referral sources, after assessing and examining the patients and checking their vitals and chest X-rays (CXRs). The sheet had the following variables: age, gender, comorbidities, symptoms, duration of symptoms, SpO2, CXR findings, day of presentation at BIH, the need for admission, length of stay at the hospital, the need for oxygen, and the place of admission if decided (ICU vs. non-ICU admission).
All home-isolated patients were supplied with a set of pulse oximetry, thermometer, N95 masks, and sanitizers. Hence, they had to check their SpO2 and temperature at home.
The patients were evaluated originally by Be Aware application from a questionnaire filled out by the patients, 444 hotlines by a physician who answers patient calls, and by local health centers by calling all positive cases registered with them through teleclinic. All cases from the above resources who had concerning symptoms based on the phone assessment were referred to the BIH center to be examined and evaluated by the assigned physician to determine their need for admission or continuation of home isolation. Then, those who were advised to continue with home isolation were followed up by the BIH physician by phone on a daily basis to follow their progress until the end of their isolation period. It is worth mentioning that patients who were followed by the local health centers who did not need a referral to the BIH were followed by the same local health center physicians.
An automated labeling system in Be Aware application classifies the respondents into three categories (red, orange, and green) based on their symptoms and vitals. The red category included those who had shortness of breath, chest pain, or SpO2 ≤93% on room air. The orange category included those with a fever of more than 38.5°C and a cough. The green category included those who did not have any of the red or orange signs or symptoms. All the patients who were labeled by Be Aware as red or orange were contacted by BIH physicians for further assessment to determine their need for admission. The other two resources of referral (444 hotline and primary health centers) used the same criteria to determine the need to refer to BIH for further evaluation.
In BIH, all those with moderate-to-severe symptoms, defined as fever >38, dyspnea, chest pain, change in mental status, respiratory rate >30, saturation ≤93% on room air, changes suggestive of pneumonia in the CXR, and the presence of the following risk factors (obesity, cardiac diseases, chronic lung diseases, coagulopathies, and sickle cell anemia) even if symptoms were mild were admitted. The RT-PCR for the COVID specimens in Bahrain was done in two accredited laboratories in public health. The assays were standardized in both laboratories.
SPSS 26 was used for data entry and analysis. Initial analysis included calculating mean and standard deviation (SD) for quantitative variable, and frequencies and percentages categorical variables. Chi-square test or Fisher’s exact test, as appropriate, used to determine whether there was a significant relationship between two categorical variables. Binary logistic regression was used to explore the risk factors that affected the outcome. In all statistical tests, P < 0.05 was considered statistically significant.
Results
The study included 394 patients, the mean age of the study subjects was 33.5 years (SD=13.2) years (Range 1-82 years). Majority (77.4%) were 18-19 year old, 48.2% were males, 84% were Bahrainis [Table 1].
Table 1.
Demographic characteristics of home-isolated COVID-19 disease patients in Bahrain (n=394)
| N (%) | |
|---|---|
| Gender | |
| Male | 190 (48.2) |
| Female | 204 (51.8) |
| Age (years)* | |
| <18 | 40 (10.2) |
| 18–49 | 305 (77.4) |
| ≥50 | 49 (12.4) |
| Nationality | |
| Bahraini | 331 (84) |
| Non-Bahraini | 63 (16) |
*The mean age is 33.5±13.2 years with minimum of 1 year and maximum of 82 years
Regarding referral of the patients, 79.8% were referred through Be Aware App, 10.95% were referred by 444 COVID-19 hotline, and 9.3% were referred from health centers. Of the 308 patients who were referred through Be Aware application, 18.5% were labeled red and 81.5% were labeled orange.
Fifty-three patients were found to have comorbidities; 32.1% of these had diabetes mellitus, 22.6% had hypertension, 5.7% were obese, while 39.6% had various other comorbidities, such as hypothyroidism, bronchial asthma, rheumatoid arthritis, sickle cell disease, and pregnancy [Table 2].
Table 2.
Clinical characteristics of home-isolated COVID-19 patients in Bahrain followed by BIH (n=394)
| N (%) | |
|---|---|
| Referral | |
| Be Aware App | 308 (79.8) |
| Label red | 57 (18.5%) |
| Label orange | 251 (81.5%) |
| 444 Hotline | 42 (10.9) |
| Health centers | 36 (9.3) |
| Missing | 8 |
| Comorbidities | |
| Diabetes mellitus | 17 (4.3) |
| Hypertension | 12 (3) |
| Obese | 3 (0.8) |
| Hypothyroid | 8 (2) |
| Bronchial asthma | 5 (1.3) |
| Multiple sclerosis | 1 (0.3) |
| Rheumatoid arthritis | 1 (0.3) |
| Dyslipidemia | 4 (1) |
| Pregnant | 2 (0.5) |
| Sickle cell trait | 1 (0.3) |
| Diagnosis | |
| Pneumonia | 25 (6.3) |
| No pneumonia | 369 (93.7) |
| Cough | |
| Yes | 215 (54.6) |
| No | 179 (45.4) |
| Shortness of breath | |
| Yes | 27 (6.9) |
| No | 367 (93.1) |
| Fever | |
| Yes | 47 (11.9) |
| No | 347 (88.1) |
| Oxygen saturation | |
| Normal | 146 (90.1) |
| Abnormal | 16 (9.9) |
| Missing | 232 |
A few cases were diagnosed with pneumonia (6.3%), while 54.6% presented with a cough, 6.9% with dyspnea, and 11.9% with fevers. Of the 162 patients for whom SpO2 was registered (41.1%), 146 (90.1%) had normal SpO2 of ≥94%, while only 16 patients (9.9%) had abnormal saturation levels [Table 2].
It was found that the patients who did not need further treatment were in the majority (43.6%). Those who needed primary healthcare management were 156 (39.8 %), while those who needed secondary healthcare were 37 (9.4%), but the remaining patients (7.1%) either refused the referral or did not show up.
Regarding the destination, 11 patients only needed ICU admission (2.9%) and 52 (13.8%) were admitted to non-ICU facilities, while the majority continued to be home isolated (83%). One patient refused admission (0.3%). He was an 82-year-old male, and his family refused the admission advised by the doctors at BIH. Regarding the need for admission, 90.7% were released home, 9% needed admission, and 1 (0.3%) passed away [Table 3].
Table 3.
Action label, destination, intensive care unit care, and outcome of home-isolated COVID-19 patients in Bahrain followed by BIH (n=394)
| N (%) | |
|---|---|
| Action label | |
| No further action needed | 171 (43.6) |
| Primary care management | 156 (39.8) |
| Referred to secondary care | 37 (9.4) |
| Others | 28 (7.1) |
| Missing | 2 |
| Destination | |
| Home isolation | 312 (83) |
| ICU admission | 11 (2.9) |
| Non-ICU admission | 52 (13.8) |
| Refused admission | 1 (0.3) |
| Missing | 18 |
| Need for admission | |
| Free | 353 (90.7) |
| Discharged | 35 (9) |
| Died | 1 (0.3) |
| Missing | 5 |
ICU: Intensive care unit
There was a statistically significant association between age and comorbidities (P < 0.001); as age rose, the comorbidities increased. Pneumonia was found to be more common in males than in females (P = 0.014), and it was higher in patients who were ≥50 years of age (P = 0.004). ICU admissions were found to be higher for the elderly ≥50 years of age, and home isolation was more common in young adults and middle-aged patients (P < 0.001). The need for admission was much lower among young adults and middle-aged patients (P < 0.001) [Table 4].
Table 4.
Association between demographic characteristics and comorbidities, diagnosis, symptoms, destination, and need for admission among home-isolated COVID-19 patients in Bahrain followed by BIH (n=394)
| Gender | Age | Nationality | |||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Male N (%) | Female N (%) | <18 years N (%) | 18-49 years N (%) | ≥50 N (%) | Bahraini N (%) | Non.Bahraini N (%) | |
| Comorbidities | |||||||
| Yes | 17 (8.9) | 20 (9.8) | 0 | 23 (7.5) | 14 (28.6) | 36 (10.9) | 1 (1.6) |
| No | 173 (91.1) | 184 (90.2) | 40 (100) | 282 (92.5) | 35 (71.4) | 295 (89.1) | 62 (98.4) |
| P-value* | 0.771 | <0.001 | 0.021 | ||||
| Diagnosis | |||||||
| Pneumonia | 18 (9.5) | 7 (3.4) | 0 | 17 (5.6) | 8 (16.3) | 22 (6.6) | 3 (4.8) |
| No pneumonia | 172 (90.5) | 197 (96.6) | 40 (100) | 288 (94.4) | 41 (83.7) | 309 (93.4) | 60 (95.2) |
| P-value | 0.014 | 0.004 | 0.780a | ||||
| Symptoms | |||||||
| Yes | 112 (58.9) | 134 (65.7) | 26 (65) | 193 (63.3) | 27 (55.1) | 209 (63.1) | 37 (58.7) |
| No | 78 (41.1) | 70 (34.3) | 14 (35) | 112 (36.7) | 22 (44.9) | 122 (36.9) | 26 (41.3) |
| P-value | 0.168 | 0.515 | 0.507 | ||||
| Destination† | |||||||
| Home isolation | 144 (80.4) | 168 (85.7) | 35 (97.2) | 254 (86.7) | 23 (50) | 266 (84.2) | 46 (78) |
| ICU admission | 7 (3.9) | 4 (2) | 0 | 4 (1.4) | 7 (15.2) | 8 (2.5) | 3 (5.1) |
| Non-ICU admission | 28 (15.6) | 24 (12.2) | 1 (2.8) | 35 (11.9) | 16 (34.8) | 42 (13.3) | 10 (16.9) |
| P-value | 0.332 | <0.001 | 0.404 | ||||
| Need for admission‡ | |||||||
| Free | 167 (90.8) | 186 (91.2) | 39 (97.5) | 281 (92.4) | 33 (75) | 297 (91.1) | 56 (90.3) |
| Discharged | 17 (9.2) | 18 (8.8) | 1 (2.5) | 23 (7.6) | 11 (25) | 29 (8.9) | 6 (9.7) |
| P-value | 0.887 | <0.001 | 0.844 | ||||
*Chi-square test, aFisher’s exact test, †Number of missing is 19, ‡Number of missing is 6. ICU: Intensive care unit
It was found that those with comorbidities presented with lower oxygen levels (P = 0.011) and were in need of ICU admission compared to those without comorbidities (P = 0.001). No other significant associations were found [Table 5].
Table 5.
Relationship between comorbidities and each of diagnosis, symptoms, oxygen saturation, and need for admission for home-isolated COVID-19 patients in Bahrain followed by BIH (n=394)
| Comorbidities | P-value* | ||
|---|---|---|---|
|
| |||
| Yes N (%) | No N (%) | ||
| Diagnosis | |||
| Pneumonia | 5 (13.5) | 20 (5.6) | 0.073 |
| No pneumonia | 32 (86.5) | 337 (94.4) | |
| Symptoms | |||
| Yes | 23 (62.2) | 223 (62.5) | 0.971a |
| No | 14 (37.8) | 134 (37.5) | |
| Oxygen saturation† | |||
| Normal | 11 (68.8) | 135 (92.5) | 0.011 |
| Abnormal | 5 (31.3) | 11 (7.5) | |
| Destination‡ | |||
| Home isolation | 21 (58.3) | 291 (85.8) | |
| ICU admission | 5 (13.9) | 6 (1.8) | <0.001 |
| Non-ICU admission | 10 (27.8) | 42 (12.4) | |
| Need for admission§ | |||
| Free | 28 (82.4) | 325 (91.8) | 0.106 |
| Discharged | 6 (17.6) | 29 (8.2) | |
*Fisher’s exact test, aChi-square test, †Number of missing data is 232, ‡Number of missing data is 19, §Number of missing data is 6. ICU: Intensive care unit
It was found that there was a significant correlation between the source of referral and symptoms (P < 0.001) as well as the need for admission either in ICU or non-ICU admission (P = 0.007). Of the 54 patients who were labeled red, 40 of them (74.1%) continued home isolation, while 14 patients (25.9%) needed hospital admission. Of those admitted, only 4 patients were admitted to the ICU. No mortality was registered in this category. Orange-labeled patients were lower in terms of admissions in comparison to those labeled red, 444, and health center referrals as 218 (87.9%) continued home isolation while only 3 (1.2%) needed ICU admission and 27 (10.9%) non-ICU admission.
Finally, the correlation between the source of referrals and comorbidities, diagnosis (pneumonia vs. no pneumonia), and SpO2 was found to be nonsignificant [Table 6]. Mann–Whitney and Kruskal–Wallis tests were done to see if there was any correlation between the CT value and gender, age, nationality, comorbidities, diagnosis, symptoms, and the need for admission. All the correlations were statistically not significant.
Table 6.
Relationship between source of referrals and each of comorbidities, diagnosis, symptoms, oxygen saturation, destination, and need for admission among home-isolated COVID-19 patients in Bahrain followed by BIH (n=394)
| Source of referrals | P-value* | ||||
|---|---|---|---|---|---|
|
| |||||
| Be Aware App Label Red N (%) | Be Aware App Label Orange N (%) | 444 Hotline N (%) | Health centers N (%) | ||
| Comorbidities† | |||||
| Yes | 9 (15.8) | 25 (10) | 3 (7.1) | 0 | 0.083 |
| No | 48 (84.2) | 226 (90) | 39 (92.9) | 36 (100) | |
| Diagnosis† | |||||
| Pneumonia | 4 (7) | 12 (4.8) | 4 (9.5) | 5 (13.9) | 0.163 |
| No pneumonia | 53 (93) | 239 (95.2) | 38 (90.5) | 31 (86.1) | |
| Symptoms† | |||||
| Yes | 32 (56.1) | 179 (71.3) | 15 (35.7) | 19 (52.8) | <0.001 |
| No | 25 (43.9) | 72 (28.7) | 27 (64.3) | 17 (47.2) | |
| Oxygen saturation‡ | |||||
| Normal | 28 (87.5) | 102 (92.7) | 8 (80) | 8 (80) | 0.329 |
| Abnormal | 4 (12.5) | 8 (7.3) | 2 (20) | 2 (20) | |
| Destination§ | |||||
| Home isolation | 40 (74.1) | 218 (87.9) | 27 (73) | 23 (71.9) | 0.007 |
| ICU admission | 4 (7.4) | 3 (1.2) | 3 (8.1) | 1 (3.1) | |
| Non-ICU admission | 10 (18.5) | 27 (10.9) | 7 (18.9) | 8 (25) | |
| Need for admission|| | |||||
| Free | 44 (81.5) | 230 (92) | 36 (87.8) | 35 (100) | 0.018 |
| Discharged | 10 (18.5) | 20 (8) | 5 (12.2) | 0 | |
*Chi-square test, †Number of missing data is 8, ‡Number of missing data is 232, §Number of missing data is 23, ||Number of missing data is 14
Binary logistic regression analysis, to determine factors associated with need for admission, showed that only age and labels were significant. Patients aged ≥50 years were 15.588 times more likely to be admitted than patients aged <18 years, with 95% confidence interval [CI] of 1.790, 135.747. Furthermore, patients with red labels were 2.974 times more likely to be admitted than patient labeled orange, with 95% CI of 1.258, 7.032 [Table 7].
Table 7.
Logistic regression analysis: Risk factors for need to admission in the hospital for home-isolated COVID-19 patients in Bahrain
| OR (95% CI for OR) | P-value | |
|---|---|---|
| Gender | ||
| Male (Reference) | ||
| Female | 1.035 (0.492–2.179) | 0.928 |
| Age (year) | ||
| <18 (Reference) | ||
| 18–49 | 3.073 (0.393–24.018) | 0.285 |
| ≥50 | 15.588 (1.790–135.747) | 0.013 |
| Nationality | ||
| Bahraini (Reference) | ||
| Non-Bahraini | 1.231 (0.459–3.298) | 0.680 |
| Label | ||
| Orange (Reference) | ||
| Red | 2.974 (1.258–7.032) | 0.013 |
| 444 | 1.232 (0.406–3.741) | 0.713 |
| Comorbidities | ||
| No (Reference) | ||
| Yes | 1.265 (0.443–3.613) | 0.661 |
Discussion
As the number of COVID-19 patients drastically grew in the Kingdom of Bahrain as it did globally and the demand on healthcare system increased, it was mandatory to adopt certain strategies and measures to deal with cases. Home isolation of low-risk patients was one of the measures taken in the Kingdom of Bahrain starting on July 1, 2020, before which all the positive COVID-19 cases were admitted to designate governmental healthcare facilities. All home-isolated patients had access to BIH, which was a COVID-19 governmental hospital responsible for follow-up, treatment, and triaging of home-isolated patients. This study evaluated the outcome and epidemiology of these home-isolated patients.
Regarding the source of referral, it was found that there was no statistically significant correlation between the source of referral and comorbidities, pneumonia presentation, or low SpO2. The lack of correlation between the source of referral and SpO2 can be explained by the large missing data of SpO2 recordings in the live sheet since the patient evaluation sheet did not initially include SpO2 but was added later after the COVID-19 protocol was updated in October 2020. Moreover, it has been found that increasing age had a significant correlation with the diagnosis of pneumonia and the need for admission. Furthermore, those with comorbidities had lower SpO2 and were at higher risk for ICU admission, which was statistically significant. Consequently, age and comorbidities should be included in labeling patients’ categories in Be Aware applications.
It was also found that there was no relationship between CT value and each of the demographical characteristics, comorbidities, diagnosis, symptoms, and need for admission. This was supported by a prospective cohort study on 321 patients by Salto-Alejandre et al., which found that nasopharyngeal SARS-CoV-2 viral load on admission was generally high in patients with COVID-19, regardless of illness severity, but it could not be used as an independent predictor of unfavorable clinical outcome.[11] On the other hand, a study done by Maltezou et al., to evaluate upper respiratory tract viral load, measured by PCR CT value, and outcome, found that patients with high viral load were older, had more often comorbidities, developed symptomatic disease, were intubated, and died; in addition, patients with high viral load had a longer stay in ICU and longer intubation compared to patients with low viral load.[12] Based on the above findings, we think that further studies are needed to determine the significance of the CT value in predicting patient outcomes.
From the data above, it is evident that age was the major factor in determining ICU admission and diagnosis of pneumonia. Furthermore, we found that comorbidities that increase with age were associated with the need for ICU admission. These findings are well supported by multiple other studies done worldwide. A prospective cohort study done in New York in 2020, by Petrilli et al., to determine factors associated with hospital admission and critical care of patients with coronavirus disease, found that the strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% CI 26.1–56.0) for ages 75 years and older.[13] Another study done in China found that COVID-19 patients with ARDS were older and had a higher proportion of comorbidities, including hypertension and diabetes.[14]
In our study, gender was not found to have a role in determining admission. This is supported by a study done in China which found no difference in the proportion of men and women between ICU patients and non-ICU patients.[6] Furthermore, a study done in India to determine clinical outcomes among asymptomatic or mildly symptomatic COVID-19 patients in an isolation facility found that gender did not play a role in disease progression.[15] These findings contradict some of the studies which found that men were infected more commonly than women.[16] Another study done by Bienvenu et al., demonstrated that male patients with COVID-19 were more symptomatic and exhibited increased disease severity, higher complication rates, and mortality.[17]
The introduction of home isolation for low-risk confirmed COVID-19 cases with monitoring and follow up as well as taking measures to prevent the spread of infection was a safe and necessary strategy adopted by Bahrain National Team to combat COVID-19 virus. It helped to avoid unnecessary admissions, decrease the burden on the healthcare system and staff, and preserve the hospital beds for those in greater need. In our study of home-isolated patients, 17% needed admission but the majority (83%) continued with home isolation. A study done in Saudi Arabia for a COVID-19 home monitoring program found that of the total of 5368 COVID-19 patients who were referred to the home isolation/monitoring program, 5% only required hospital admission, the majority (94%) continued in the home monitoring program till recovery, while the remaining (1%) were admitted in intermediate healthcare facility (quarantine centers for the homeless patients).[18] Another retrospective study done in Georgia, USA, using a telemedicine risk assessment tool to predict the risk of hospitalization of 496 outpatients with COVID-19, found that the overall hospitalization rate in this outpatient cohort was 7%.[19] The rate of admission was slightly higher in our study (17%) compared to the other studies mentioned (5% in Saudi Arabia and 7% in the USA), probably as a result of the low threshold for admission at the beginning of applying the home isolation protocol.
Our study has a number of limitations. There are missing data for a few patients as a result of human factors. For instance, physicians did not complete the evaluation forms, possibly because of their workload during the peak of the COVID-19 pandemic. Furthermore, in the initial period of our study, all patients with comorbidities were excluded from home isolation, but the home isolation section was updated in the last month of our study (October) to include those with comorbidities and those who were asymptomatic. Consequently, the number of patients with chronic illness was limited. We had difficulty in accessing patients’ data in some of the COVID-19 centers, which contributed to a number of missing data and loss of follow-up for some patients. Besides, some of the home-isolated patients did not quite comprehend the labeling system as there were disparities between some patients’ labels and the clinical presentation to the hospital evaluated later.
Conclusion
With continuous monitoring and follow-up, home isolation of low-risk patients and those who were asymptomatic or had mild symptoms was safe and effective and was an important step owing to the increasing demand on the healthcare system. We recommend further prospective studies to evaluate the safety of home isolation for low-risk patients or those with mild symptoms. The labeling system did not include age and comorbidities in triaging home-isolated patients, and as found in our study, these contributed the most in determining the need for admission.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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