RETROSPECTIVE STUDY ON THE PREVALENCE OF COVID-19 CONFIRMED CASES AND EVIDENCE OF GENDER BIAS IN LIBYA

Introduction. To stop SARS-CoV-2 from spreading, it's crucial to have a solid understanding of the baseline characteristics of demographic variables, clinical symptoms, and comorbidity so that quarantining and testing protocols can be developed. 
Material and methods. A retrospective study was conducted on COVID-19 Laboratory confirmed cases. Data were collected by using kobo toolbox, demographic variables, clinical symptoms, and Comorbidity was considered. Yates-corrected chi2 tests and Multinomial Logistic Regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) of factors and their impact on COVID-19 prevalence. 
Results. A total of 6302 of which 3536(56.1%) men and 2766 (44%) women with a mean age (±SD) of 44±17.6 years were included within the study.  Clinical symptoms and Comorbidity were significant for both sexes p<0.0001. Multinomial Logistic Regression confirmed that age <55, 3 or more symptoms (OR=1.130 CI95% 1.013-1.261) and 3 or more comorbidities (OR=1.035 Cl95% 0.942-1.137) were a significant risk factor for COVID-19 prevalence in male patients, among women, age 85>/=, 3 or more symptoms (p<0.0001, OR=1.995 CI95% 1.335-2.992) and 3 or more comorbidities (p<0.0001, OR=1.538 Cl95% 1.045-2.640) were significant risk factor for COVID-19 prevalence in females. 
Conclusions. Our study suggests that the prevalence of COVID-19 patients and symptoms was higher in men than women. The high prevalence of smoking could have contributed to the high prevalence of COVID-19 among men. Study also suggests that the presence of at least one or combined comorbidities are risk factors of COVID-19 prevalence and a potential risk factor COVID-19 - related outcomes. More efforts should be exercised to protect patients with one or more comorbidities from being exposed to infection.


INTRODUCTION
On late December, an outbreak of a febrile respiratory illness in Wuhan city, Hubei Province, China (1) caused by the novel coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred. The World Health Organization (WHO) identified this disease as novel coronavirus disease 2019 (COVID- 19) on February 11th, 2020 and declared it a pandemic on March 11th, 2020 (2). As of this writing, the total number of cases documented globally has surpassed 190 million, with over 4 million deaths (3). This fatal infection is spread mostly by large respiratory droplets produced by infected persons when coughing or sneezing, however the virus has also been found in infected people's feces and urine (4). Fever, dry cough, tiredness, nasal congestion, myalgia, sore throat, and diarrhea are the most frequent COVID-19 symptoms, whereas comorbidities include diabetes, hypertension, respiratory illness, cardiovascular disease, cancer, and others (5,6,7). Accordingly, the globe is taking extraordinary efforts to combat the risks presented by the developing pandemic Corona virus . The World Health Organization has declared the coronavirus a global health emergency. As a result, governments and people must take quick action to stop the spread of the illness and safeguard communities. In Libya, the first case diagnosed with COVID-19 (at Tripoli Medical Center) was confirmed by Public Health Reference Laboratory, National Center for Disease Control, Tripoli on March 24th, 2020. Up through December 31st, 2020, the total number of cases has risen by more than 101978 thousand and 1498 Death cases in Libya (8). The knowledge about the characteristics of novel coronavirus is limited, with only few published articles (9, 10). However, surveillance officer and the data management team have made remarkable efforts concerning COVID-19 data. The aim of this study is to determine the prevalence of COVID-19 and the impact of variables such as age, comorbidities, clinical features, the frequency of comorbidities on Gender based disparities. The aim of the study is to assess the Gender based disparities in the prevalence of COVID-19 confirmed cases.

MATERIAL AND METHODS
A retrospective study was conducted on COVID-19 Laboratory confirmed cases to gain insight on positive COVID-19 patients characteristics. Variables included the patients' demographic characteristics, comorbidities and symptoms. The completed data was collected by kobo collect toolbox, obtained from the surveillance team who agreed to participate using the kobo toolbox, covering the period from May 5 to December 2020. To display information on comorbidities, symptoms, and other categorical variables, we created frequency tables. To see whether there are any statistically significant variations in categorical variable between males and females, we used Yatescorrected chi 2 tests for percentages to test gender differences regarding variables. Multinomial Logistic Regression analyses were performed to evaluate the factors associated with confirmed COVID-19 cases, the results were presented as estimated odds ratio (OR) with respective 95% confidence interval (CI) and p values. A two-sided pvalue <0.05 was considered statistically significant. All statistical analyses were performed using Microsoft excel and SPSS version 23 (SPSS Inc., Chicago, IL, USA).

Characteristics of the sample.
A total of 6302 patients with a confirmed diagnosis of COVID-19 were identified. Of these, 2766 (44%) were females and 3536 (56.1%) were males, the mean age of our sample was 44±17.6 years. The 40-59 age group was the most representative ( fig. 1), with a significant difference between men and women (p<0.05) shown in the age groups (10-79) (tab. 1).

DISCUSSIONS
Libya, like many other countries, is going through a challenging time because of the global COVID-19 issue. Furthermore, since the beginning of the war in Libya in early 2011 (11,12,13), the nation has experienced internal security, political, and economic crises, in addition to the looming health catastrophe in 2020. Therefore, the ability to cope with pandemic data and health information was limited.
However, according to this study, the use of a sim ple data collection tool like the kobo gather toolbox aided the surveillance officer in collecting COVID-19 data. In previous research conducted in several countries focusing on patients' demographics, underlying health comorbidities, socioeconomic inequities in healthcare access and quality, and environmental variables including pollution, to identify possible risk factors and susceptible groups, while other researches have looked over the impacts of these domains on COVID-19 dissemination individually, some of them haven't considered the possibly confusing interactions between factors. On the other hand, according to our knowledge there are limitations regarding risk factors related to COVID-19 researches in Libya. However, one study was done to explore the factors that influence in-ICU mortality rate, which revealed that risk factors such as age, BMI, laboratory findings, admission SOFA score, and quick SOFA score were strongly predictive for mortality (9). In this study, we sought to investigate the COVID-19 prevalence and their association with demographical characteristics, clinical manifestation, and comorbidities, we observed that males are more likely to be infected by COVID-19 (with 56.1%) compared to females (44%). A similar conclusion has previously been observed in another research (14,15,16). Men are more vulnerable than women, according to research carried out in Spain (17), because of their careless attitude about the possibility of a COVID-19 pandemic. Another Spanish study found that males and the elderly have a greater severity and case fatality rate (CFR) (18). Furthermore, females have stronger resistance, which might be attributed to female sex hormones, whereas men have lesser resistance owing to the high expression of the ACE2 receptor, which coronavirus easily attaches to (19). Other studies also showed that higher viral load in men has also been linked to ACE2 expression, reduced B cell and NK cell-specific transcripts, male hormones, and enhanced NF-B inhibitor (20,21,22). Results showed that all age groups in both sexes were susceptible to COVID-19, showing a significant difference of p<0.0001, however younger individuals aged between 0-19-70+ showed lower COVID-19 incidence, while higher rate of COVID-19 cases was noticed in age groups over 20 years (aged 20-69). Furthermore this could indicate that during this study period from May to December 2020, the COVID-19 virus had the Wuhan strain, and the susceptibility to contract the virus among men or women may depend on the role of biological profile of a person; as well as their activities, were men are more likely to engage in outside activities, exposing them to conditions such as extreme weather and pollution, which might influence their response to an infection such as COVID-19. Furthermore, men's lifestyles, which include smoking, result in a high viral load and severity (23). In our study, smoking was significant p<0.0001 in male patients, thus our findings were similar to a study which suggested that those current smokers are at greater risk than former smokers or non-smokers (24).
The prevalence of clinical symptoms among 6302 COVID-19 cases, 3896 (62%) were symptomatic and asymptomatic 38.2% and about 25% had one clinical symptom (high temperature, coughing, breathing difficulties, diarrhea, sore throat, loss of smell and taste), 18% with two symptoms and 21% with three or more symptoms. Therefore, our results on the prevalence of symptoms in adults corresponded to the results found in systemic literature review (25,26). The findings show clearly that fever and cough are the most common symptoms, while other symptoms occur at much lower prevalence. However, there was not enough evidence on the prevalence of additional symptoms difference by age in the young and adults.
The presence of comorbidities in 67% of COVID-19 cases; with 33% had no comorbidity, 12.2% reported having at least one comorbidity, 27% had two comorbidities and 28% had reported three or more comorbidities. Furthermore, in the study the prevalence of specific comorbidities for both sexes included diabetes, hypertension, cardiovascular diseases, asthma, and obesity with p<0.0001. In pregnant women the significant value was of p<0.0001, thus the studies suggested that pregnancy has been identified as a risk factor for developing severe complications (27,28). The study findings are consistent with other published studies (29,30). However, few data were available on the frequency of combinations of comorbidities and symptoms (31,32 (25,29,32). Furthermore, our findings suggested that patients with comorbidities are more likely to have poorer well-being. Therefore, proper triage of patients should be implemented by carefully inquiring about their medical history; both the category and number of comorbidities should be considered because it might help iden 2020 tify patients who would be more likely to develop adverse outcomes of COVID-19 and predicting the prognosis in patients with COVID-19. Moreover, better protection should be given to the patients with COIVD-19 who had comorbidities upon confirmation of the diagnosis.
Although this study highlights the prevalence COVID-19-related symptoms, comorbidities limi-tations must be acknowledged. The sample size was small, but most results were consistent with other studies on adults and children's patients with COVID-19. The study did not include data on the recovered COVID-19 patients. Furthermore, this study didn't evaluate the mortality rate in patients with severe COVID-19, thus a larger case series should be considered for further analysis.

CONCLUSIONS
1. Available data indicate that the prevalence of COVID-19 patients is greater in males than in women, and that vulnerability to COVID-19 cases among young and middle-aged people is similar to that of older age groups.
2. The prevalence of COVID-19 symptoms was found to be higher in men than in women. The high prevalence of smokers might contribute to the high prevalence of COVID-19 among men.
3. Our study also suggests that the presence of at least one or combined comorbidities represent risk factors of COVID-19 prevalence and a potential risk factor for COVID-19-related outcomes. More efforts should be implemented to protect patients with one or more comorbidities from being exposed to the infection.