COVID-19 Comorbidity and Non-Communicable Diseases (NCDs) General Reference Hospital (HGR), Niamey, Niger

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Introduction
Noncommunicable diseases (NCDs) are emerging diseases that pose a major threat to the world's population, especially in developing countries 1 .According to the World Health Organization (WHO), NCDs are responsible for more than 70% of deaths and 63% of the global burden of disease 2 .Persons with existing non-communicable diseases (NCDs) are more vulnerable to health risks due to emergencies and disasters than their counterparts free of any noncommunicable diseases 3,4 .Those with chronic diseases, such as cardiovascular disease, chronic lung disease, and diabetes have higher vulnerability to disaster induced disruption and stress and significant proportion of mortality in post-disaster phases results from the failure of health care services to cater to the needs of patients with chronic diseases 5 .
The Corona Virus 19 (COVID-19) pandemic has worsened this already precarious situation.NCDs are a risk factor for the occurrence of COVIS-19 on the one hand and a complication of this disease on the other.Literature show that people with NCDs are at greater risk of severe forms and death from COVID-19 6 .There appears to be a link between the causative agent of COVID-19, hypertension and its cardiovascular complications 7 .Some studies indicate a high prevalence of hypertension in patients hospitalized for COVID-19, regardless of the geographical focus of the epidemic ranging from 15 to more than 50% in the literature [8][9][10] .Other studies have also showed the increased risk of this association.
The impact of COVID-19 on NCD management has recently constituted a major source of concerns, among public health managers globally.The World Health Organization has begun the development of guidelines and recommended actions for people with NCDs during this pandemic 11 .However, research on the status and disease management of NCD patients in the context of COVID-19 remains very limited in most developing countries 3 .In Niger there is no data on the extent of NCDs before and during the outbreak of COVID-19.There has also been no research on the coexistence of NCD and COVID-19.The paper therefore examined NCD and COVID-19 comorbidity in order to improve the management of COVID-19 patients in general and those living with one or more NCDs.

Methods
This was a cross-sectional study that made it possible to collect data from patient files and the epidemiological file of COVID-19 patients hospitalized from March 19 to June 3, 2020 in the various care services (Resuscitation and Medicine) of the Niamey General Reference Hospital (GRH).Included were the records of COVID-19 patients treated at the GRH during the period from March 19 to June 03, 2020.The variables studied were epidemiological data: sex, marital status, level of education; clinical characteristics, various associated comorbidities, course, treatment, blood pressure, obesity, glycemia.The diagnosis of COVID -19 infection was made using the PCR test on a nasopharyngeal swab carried out by the Center for Medical Research in Health (CERMES) in Niamey.The severity has been assessed according to the WHO COVID-19 severity criteria 8 .Patients were classified according to their age, clinical status, paraclinical and presence of NCD and the severity of symptoms (mild, moderate, severe or critical) 12 .
The data was collected from patient hospital records, the GRH, COVID-19 database.Telephone calls also made it possible to complete certain missing information in the files.The duration of the study was 6 months (June 30 to December 31, 2020).
The data collected was entered and processed using Word, Excel 2016 and SPSS software in version 23 after making an input mask.For the comparison of the results, the statistical tests used were the chi2 considered significant if the probability p <0.05.To carry out this investigation, the agreement of the General Management of the GRH was obtained.Confidentiality was guaranteed and respected during the presentation of results on all survey forms.Informed consent from living patients and families of deceased patients was obtained for further information by telephone and / or interview.

Epidemiological characteristics
During the period of the study from March 19 to June 3, 2020 considered as the first wave of the epidemic in Niger, 273 patients were hospitalized in the various care services of the GRH in Niamey, including 58 patients, i.e.21, 25% in the intensive care unit and 215 patients or 78.75% in the medical services.The highest number of admissions of COVID-19 cases was observed between April 08 and 12, 2020 with a peak on April 10, 2020.Regarding morbidity, the period from March 31 to April 04, 2020 recorded more of cases with a peak on April 2, 2020 (Figure 1).Over thirty-eight percent (38.6%) of the 273 COVID-19 infected persons were health workers.This was followed by other civil servants (13.1%) and retirees (12.5%).Others were traders (11.9%),Housekeepers (6.8%), military officers (5.1%), workers in beauty salons (4.0%), teachers (3.4%), farmers (2.3%), students (1.7%) and drivers (0.6%).Ninety-seven patients (34.79%) presented one or more co-morbidities associated with COVID-19 and patients (65.20%) who did not present any co-morbidity.
Sixty-seven of the COVID-19 patients with NCDs had arterial hypertension.This was followed 49 patients with diabetes, and 10 with respiratory diseases.Another nine had other diseases, including heart disease, obesity, dyslipidemia, gout, leukemia, Chronic renal failure patients.At least 37% of the COVID-19 patients had at least one NCD with comorbidity.See Figure 2.
The overall distribution of patients by sex shows that men represented 72.52% (198 patients) and women

Clinical and paraclinical aspects
The average time to see COVID-19 patients was 3.77 days after first symptoms with a range one to eight days.In co-morbid patients, the clinical symptoms characterizing the two main NCDs, hypertension and diabetes, were similar.These were mainly cough, fever, chills, sore throat and rhinorrhea.See Figure 4.
Information according to the clinical criteria for classification of the severity of COVID-19 established by WHO was not provided on 62 cases (22.71%).However, on the 211 files (77.29%) which were completed, revealed that in 16.11% (34 patients) the clinical signs were severe and in 83% (177 patients), they were moderate.The analysis showed that there is a significant correlation between the clinical severity of the disease with the age of the patients (over 50 years) and with the association of NCD with COVID-19 (Table 1).
It emerges from this analysis that adulthood and the presence of comorbidity are statistically associated significantly and have a negative impact on the classification of COVID-19 patients with a p less than 0.05.However, our study does not show a statically significant association between gender and the severity of COVID-19.

Therapeutic and evolutionary aspects
A total of 35.8% were hospitalized in intensive care in the NCD group and 14.6% in the NCD group (p <0.01).The average length of hospital stay was 6.87 days overall.This hospital stay was 7 days in intensive care.In 61.7% of cases, the hospital stay was longer than 4 days.The overall death

Discussion
Niger's first COVID-19 patient was registered on March 19 at the GRH in Niamey.Since then, the incidence has steadily increased.The highest number of cases was recorded between 08 and 12 April 2020 with a peak on 10 April 2020.NCDs were therefore the subject of special attention.The prevalence of this combination of COVID-19 and MNT was 34.8% in patients hospitalized at the GRH from March 19 to June 03, considered as the 1st Wave.The results obtained corroborate with the data in the literature.In fact, the studies currently available show a high prevalence of NCDs and COVID-19 13,14 .In Kenya, around half of COVID-19 deaths have occurred in people with NCDs while in the Democratic Republic of Congo, 85% of COVID-19 deaths have occurred in patients with one or more NCDs 15 .The prevalence of hypertension was 24% in our series.According to the data in the literature, it varies from 15% to more than 50% [15][16][17][18][19] .This prevalence was the highest among all the comorbidities in our sample.It seems to be higher in the European series, probably due to an older population.The overrepresentation of hypertension in patients hospitalized for COVID-19 remains very marked in patients hospitalized in intensive care (58%) and among non-survivors (25-38%) [15][16][17][18][19] .
South Africa, which records nearly half of the cases and deaths on the continent, found that 61% of COVID-19 patients in hospitals had high blood pressure and 52% had diabetes 16 .Diabetes was the second most frequently recorded comorbidity in patients with COVID-19 with 17.9% in this population.Data from a study published by the US Center for Disease Control and Prevention (CDC) in the United States shows a prevalence of diabetes of 6% in outpatient COVID-19 patients, 24% in inpatients without intensive care and 32% among hospitalized patients with intensive care 20 .Based on a meta-analysis of a total of 1382 patient records, it was concluded that people with diabetes were at increased risk for intensive care unit (ICU) admission (OR, 2.79; 95% CI, 1.85-4.22)and mortality (OR, 3.21; 95% CI, 1.82-5.64) 21.The higher vulnerability may be explained by the presence of co-morbidities, including cardiovascular disease, and by a reduced immune response to infection 22,23 .
Age, gender, ethnicity, co-morbidities such as hypertension, diabetes and cardiovascular disease, obesity all probably contribute to the risk of a worse prognosis 24,25 .People of any age can contract COVID-19, but the elderly (60 years and older) are most affected.In our study, the mean age of patients with NCDs was 55.78 years.Men were more affected than women in our context, which is like the data in the literature 25 .In a large epidemiological survey in China with 72,314 cases, 51.0% of patients were men 26 .In a recent report about 1,590 patients hospitalized for COVID-19 in China 27 , the male gender was 57.3%, and it was 51.3% in the study by Huoshenshan from New York in the United States.USA with 1,780 hospitalized cases.Men represented 72.52% of cases in our study.This finding was indirectly proven by an Italian study of 1591 patients admitted to intensive care units (ICU), of which men represented 82.0% 28 .
People with NCDs are more likely to have severe symptoms of COVID-19 requiring admission to an ICU 28 .However, there is no difference in symptoms between hypertensive patients and diabetics.While most COVID-19 patients presented only a mild (40%) or moderate (40%) form of the disease 13 , it worsens in about 15% of patients, requiring an intake of oxygen, and 5% of patients had a clinically critical condition associated with complications, such as respiratory failure, acute respiratory distress syndrome, septic shock, thromboembolism, and / or multiple organ failure, including acute renal and heart failure 29 .Old age, smoking 30,31 and the presence of underlying NCDs, such as diabetes, hypertension, heart disease, chronic lung disease and cancer, have been described as risk factors for COVID -19 severe and death.In patients with comorbidity, the clinical symptomatology characterizing the two main NCDs (hypertension and diabetes) was similar.These are mainly cough, fever, chills, sore throat and rhinorrhea.However, the initial symptomatology of COVID-19 appears to be more frustrating in the diabetic patient.
In fact, fever is less present in this group of patients, which could induce diagnostic delay 16 .In our study, 211 of the 273 files contained information relating to the clinical criteria for the severity of COVID-19 established by the WHO 13 .According to this classification, the distribution revealed that 34 patients or 16.11% were severe and 177 patients or 83% moderate.Known risk factors for rapid deterioration, severe disease and / or increased mortality were: advanced age (> 60 years) and NCDs, such as cardiovascular disease, diabetes, chronic lung disease, cancer and vascular disease cerebral 32 .
The average length of hospital stay was 6.87 days, almost identical to that of intensive care patients, which is 7 days.There is an excess mortality in the group suffering from NCD (22.1%) compared to the non-NCD group (7.3%) (p <0.01).According to Chinese data covering more than 70,000 cases, the overall mortality from COVID-19 was 2.3% while it was 7.3% in diabetic patients 33,34 .Diabetic patients therefore appear to be at greater risk of death from COVID-19.Male patients, over the age of 65, appear to be at greater risk not only to COVID-19 but also at a higher risk of developing a critical or fatal clinical condition.Comorbidities such as hypertension, diabetes, cardiovascular disease and respiratory disease could also negatively impact the prognosis of COVID-19 patients 35 .
The limitations of this study were related to incomplete records and insufficient certain clinical data, medication and anthropometric measurements such as weight and height in order to assess the patients' BMI.

Conclusion
The COVID-19 pandemic, although recent, has changed the outlook for the management of certain conditions, including NCDs.The combination of COVID-19 and NCD is not only increasing the length of hospital stays, but also the rate of ICU admissions and deaths.In our study, 90.6% of registered deaths occurred in intensive care.To this end, the COVID-19 case management services require capacity building to cope with the management of the second wave started in November 2020 and which seems more intensive.In order to better document this second wave, data collection and analysis is continuing for the prospective part of this study relating to the COVID-19 and NCD comorbidity in Niger.

Figure 1 :
Figure 1: Daily evolution of recorded cases and deaths of COVID-19 at GRH Niamey from March 19 to June 03, 2020

Table 1 :
Distribution of COVID-19 cases by severity and selected background characteristicsFigure 4: Distribution of COVID-19 patients by symptoms in the group with hypertension and diabetesrate among COVID-19 patients hospitalized at GRH was 12.45% or 34 patients.There were more deaths (22.1%) in the NCD group and 7.3% in the COVID-19 without NCD group (p <0.001).In total 90.6% of patients had died in intensive care.According to NCD, the lethality was 45.8% in hypertensive patients and 54.2% in diabetics.