COVID-19 experience in Kuwait: A high prevalence of asymptomatic cases and increased mortality in smokers

Emerging information adds to our knowledge that may help in dealing with the current pandemic of coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2). In EClinicalMedicine, Almazeedi and Colleagues [1] have reported a retrospective analysis with regards to the patient's characteristics of more than thousand confirmed COVID-19 from a single large hospital of Kuwait, studied over a period of about 2 months. Authors have found that nearly half of patients were of Indian origin working as manual laborer in Kuwait, and one-fourth of them had a history of recent travel from the place where COVID-19 was highly prevalent at that point of time. This study also found nearly half of them were asymptomatic at the time of admission, majority had no signs of any infection on clinical examination, and all were diagnosed during the routine mass screening on behalf of Kuwaiti government. Most of COVID-19 patients were young (mean age 41 year) male, of which 22% were obese and only 30% had comorbidities, of which, hypertension and or diabetes contributed nearly one-third. At admission, 90% had normal white blood cell count including absolute lymphocyte count and two-third had a normal chest X-ray. Multivariable analysis found the risk factors that were significantly associated with an increased risk of severity requiring ICU admission were elevated procalcitonin, C-reactive protein, smoking and older age (>50 years). The risk factors that were significantly associated with an increased risk of death include smoking, elevated procalcitonin and asthma.

Authors must be applauded for reporting the clinical characteristics of COVID-19 patients of a whole country of Kuwait in Middle-East, since all patients were admitted in this only single large COVID-19 hospital, as per governmental law. In addition, this study carries a special importance since one homogeneous protocol was applied for every patient with regards to diagnosis, treatment, prognosis and discharge.

The key finding from this study is disproportionately higher number of COVID-19 patients who were asymptomatic (46%), when compared to the other currently available studies. For example - one longitudinal study from Taiwan [2] and other from USA [3] found approximately 18% of asymptomatic cases, while a Korean study [4] reported only 2% of asymptomatic cases of COVID-19. Although this discordant finding could partly be attributed to the mass screening carried out in the present study, it is also likely that some of asymptomatic cases were detected early in pre-symptomatic stage. Nevertheless, this finding does carry an immense importance to public health, considering that these asymptomatic patients could have silently spread the infection, had they not been diagnosed with COVID-19 and quarantined. Therefore, it is imperative for all the stake holders that testing programs should be made affordable to the public at large to trace, test, identify and quarantine these asymptomatic cases, in order to flatten the pandemic curve. In addition, this also emphasizes the importance of social distancing and mandatory use of mask during the unlock down period, as most of countries have already started.

Another finding of importance includes affliction of migrant people of South-Asian origin in majority. While this has been accounted by the authors to the residential proximity to the two epicenters of Kuwait where majority of these people live in highest concentration and linked to the poor socioeconomic status, this may not necessarily be the exact reason. A higher involvement of migrant South-Asians irrespective of their socioeconomic status and behavioral factors have been recently documented in a study from UK [5]. The reason for ethnic predilection to COVID-19 is not known but surely needs further evaluation [6]. Nonetheless, all efforts should be tried in order to minimize the risk in any such susceptible ethnic groups.

Finally, two important risk factors that have emerged from this study need special attention. Both smokers and patients having high procalcitonin were not only associated with a significant increase in severity but also had significant increase in mortality. This finding is similar in line with recent metanalysis that found smokers are having a >2-fold increase in severe COVID-19 [7]. Interestingly, initial debate that started with the association of smoking with less chance of contracting SARS-CoV-2 and subsequent proposal of nicotine use, no longer remain tenable [8,9]. Notwithstanding, World Health Organization recommends tobacco users to stop smoking [10]. Since high procalcitonin denotes a concomitant bacterial infection and increase in procalcitonin was associated with a poor prognosis, it is desirable to use broad-spectrum antibiotics judiciously, whenever necessary.

Declaration of Competing Interest

Nothing to declare