COVID-19 Clinical Manifestations & Concerns among the Kingdom of Saudi Arabia ' s 937 Health Hotline Callers in Jeddah

The on-going COVID-19 pandemic has highlighted telehealth as a crucial tool in delivering high quality healthcare with increased efficiency. In the Kingdom of Saudi Arabia this has been evidently clear with the establishment of the robust Ministry of Health 937 COVID-19 hotline. The objectives of our study are to describe the clinical patterns of COVID-19, identify the most common concerns of the 937 hotline callers and to identify the associations between the clinical presentation of COVID-19 and risk factors of the patients.through an Analytic Cross-Sectional study design. Results : The average age was 36.8 ± 15.7 years, 61.1% were males and 38.9% were females. 69.3% were Saudi and 30.7% were non-Saudis. 82.5% employed, whilst 17.5% were unemployed.The most commonly reported symptoms were fever, followed by fatigue and cough respectively. With 41.8%, 28.2% and 23.2% of participants reporting those symptoms respectively. The most significant predictors of developing shortness of breath due to COVID-19 was chronic lung disease OR=5.7pvalue >0.01, chronic kidney disease, OR = 4.8 p value >0.02 and immunocompromised state OR = 19 >0.01. 82% of all calls to the hotline were related to COVIDOriginal Research Article Moammer and Mandoura; JPRI, 33(48A): 46-56, 2021; Article no.JPRI.76407 47 19 testing, and 11% of all calls resulted in the caller receiving medical counselling and/or treatment without having to make a physical visit to a healthcare provider. Conclusion : A well-designed telehealth program can mitigate the need for a physical visit to the emergency room or clinic and as such reduce the load on front-line healthcare workers, reducing transmission and improving outcomes during infectious disease epidemics. It can also provide valuable insights into the presentation and risk factors of a new disease to aid in the prevention, diagnosis, management and control of the disease.

testing, and 11% of all calls resulted in the caller receiving medical counselling and/or treatment without having to make a physical visit to a healthcare provider. Conclusion : A well-designed telehealth program can mitigate the need for a physical visit to the emergency room or clinic and as such reduce the load on front-line healthcare workers, reducing transmission and improving outcomes during infectious disease epidemics. It can also provide valuable insights into the presentation and risk factors of a new disease to aid in the prevention, diagnosis, management and control of the disease.

INTRODUCTION
The COVID-19 pandemicis an ongoing global health crisis caused by the SARS-CoV-2 virus [1]. COVID-19 was first identified in Wuhan China in December of 2019 [2]. It has since been declared a Public Health Emergency of International Concern on the 30 th of January, 2020 [3] and officially designated a pandemic on the 11 th of March in 2020 [4]. Telehealth played and continues to play an instrumental role in the on-going fight against the COVID-19 Pandemic globally, especially in the United States, the United Kingdom, France and China where the approach has been widely implemented to reduce the risk of transmission [5]. The pivotal role of the 937 hotline during this Covid-19 pandemic makes it an invaluable source of data to study the clinical manifestations of Covid-19 in Jeddah's population as well as better understand their needs and concerns to help address those needs and deliver high quality healthcare. In the Kingdom of Saudi Arabia, the ministry of health 937 hotline plays an instrumental role in our country's on-going fight against the Covid-19 Pandemic with more than 10 million calls received as of 2020 July 7 since the beginning of the Pandemic [6]. The hotline employs a comprehensive national health action plan to aid Covid-19 patients, contacts and healthy individuals in receiving medical treatment, testing, counseling, health education, as well as coordinate with different healthcare institutions to deliver timely and high quality patient care [7]. Despite the hotline's widespread renown and instrumental role in the backbone of the Kingdom of Saudi Arabia's healthcare services, especially during the COVID-19 pandemic, there are no published scientific studies in this area which represents a major gap in the current scientific literature. The first comprehensive large-scale study of the clinical and epidemiological picture of COVID-19 emerged in February from the Chinese CDC which analyzed 72,314 case records. 62% of these were confirmed cases and 1% of these cases were asymptomatic. The study illustrated that the clinical manifestations of the disease can be categorized by their severity to mild, severe and critical disease as such: Mild disease: non-pneumonia and mild pneumonia; 81% of cases.
Subsequent reports indicate that asymptomatic to mild disease constitute 70% of cases [9]. Whilst one independent study estimated that completely asymptomatic cases were estimated to be 30% [10].
In China, at the height of the epidemic, a peak of 625 hotlines existed simultaneously, 420 of which operated 24/7, primarily to address the psychological needs of residents [11].
Australia has also highlighted the importance of the role of telehealth during the COVID-19 pandemic, primarily to address the associated psychological distress of the population [12].
Researchers from the University of Copenhagen's Faculty of Health and Medical Sciences in Denmark conducted a review of the telehealth services provided around the globe, but particularly in Europe, and found 38 different providers offering services during the COVID-19 pandemic in Denmark, Finland, The United Kingdom, The Netherlands, Sweden, France, Norway, The united States, China, Singapore, and The United Arab Emirates ranging from patient communication, training, screening and triage to critical care and patient monitoring [13].
Regionally speaking, in Egypt telemedicine services were experimentally utilized to deliver dermatological consultations and neurosurgical post-operative care to reduce the risk of COVID-19 transmission with high degrees of success [14][15].
In the United Arab Emirates telehealth services were deployed during the surge of COVID-19 cases in April for surveillance as well as teleconsultations [16]. Additionally, telemedicine services were experimentally employed for renal transplant recipients to reduce the risk of COVID-19 transmission due to their high risk for complications and it resulted in fewer COVID-19 infections [17].

Aim
This study can play a role in helping decision makers to address the needs of 937 hotline callers and continue to deliver high quality healthcare.

METHODOLOGY
The study design is Analytic Cross-Sectional carried out in Jeddah city, which is one of the largest cities in The Kingdom of Saudi Arabia, it is located in the western province and considered as the main seaport for the kingdom and the main entry port for the two holy Mosques. Additionally, it considered as the economic and tourism capital of the country.

Inclusion criteria
All adult Ministry of Health hotline callers who are residents of Jeddah, Saudi Arabia whose purpose of the call was related to COVID-19 between March 1 st and June 30 th 2020 were eligible to be entered in this study. Additionally, only callers with laboratory-confirmed COVID-19 by nasopharyngeal swab using a Reverse Transcription-Polymerase Chain Reaction test for Severe Acute Respiratory Syndrome Coronavirus-2 (RT-PCR SARS-CoV-2) were included in our analysis of the clinical manifestations of COVID-19.

Sample size
This study targets a confidence level of 95%, Z value of 1.96 and a P Value of 0.05. The was calculated using the Cochran formula and the latest CDC guidelines for Cross-Sectional studies [19]. We also assumed a prevalence of symptomatic to asymptomatic COVID-19 patients of 50%, which gave us the maximum variability and the largest sample size required for our study using the Cochran Formula.
Sample size calculation : ((Z) 2 (Prevalence) (1-Prevalence)) / (Target P Value) 2 = Sample size ((1.96) 2 (0.5) (0.5)) / (0.05) 2 = 385 However, following the completion of a pilot of our study we recognized a number of risk factors key to our research were not prevalent enough to yield statistically significant results at a 385 sample size and as such we increased the sample size to 3000. The risk factors in question are immunocompromised state, chronic kidney disease and chronic liver disease.

Sampling technique
A systematic random technique was used until we reached our sample size of 3000.Sampling occurred over a period of four months spread out evenly on the odd days of every month, to ensure a representative sample for the whole month. All callers to the hotline were entred into an excel sheet for every odd day of the month.
To reach our sample size over four months we calculated the number needed to sample for each day as 3000/60 = 50 per day. As such, before every daily sample collection, the total number of callers for the day were divided by 50. The resulting number was used as an interval at which a study participant was selected from the list. In cases where the sampled participant did not meet our inclusion criteria or did not wish to participate, we jumped to the following caller in the list whilst keeping the interval intact.

Example
Assuming we had 1000 callers on Day 1 and our determined sampling interval is 50, then callers numbered 50, 100, 150 and so on were selected. In case caller number 150 did not meet our inclusion criteria then caller number 151 would have been selected whilst the sampling interval would continue on from 150 at the same interval of 50.

Data Collection Tool
A constructed questionnaire validated by two Preventive Medicine Consultants was used, containing the primary reason for the call or the caller's primary concern, followed by a section for clinical symptoms identified by the WHO as COVID-19 symptoms [20] and key risk factors which have been linked to increased disease morbidity among COVID-19 patients [21].

Data Collection Technique
The questionnaires were electronically filled via short phone interviews of each study participant, at Jeddah's Ministry of Health 937 hotline center.
The most commonly repeated concerns of the callers were aggregated into determined categories to be used as a quantitative approach. The categories are Testing appointment: Where the caller requests an appointment for a nasopharyngeal swab and a (RT-PCR SARS-CoV-2) test.
Testing result: Where the caller inquires about the result of a previous test. Health education: Where the caller seeks education regarding COIVD-19 precautions and information regarding mode of transmission and distancing guidelines.
Medical treatment: where the caller seeks direct medical treatment, either at a medical facility or at home for COVID-19.
Medical transfer: Where a COVID-19 positive caller seeks to transfer themselves or a COVID-19 positive relative to a different medical facility to continue receiveng care and maintain isolation.
Requesting admission: where the caller seeks hospital admission to receive treatment and/or isolation.

Data Entry and Analysis
The data was Inputted into Microsoft's Excel 2013 software then coded and analyzed using Statistical Package for Social Sciences (SPSS) Version 25.
To describe our data we used frequencies and percentages for categorical data and the means and standard deviation for age. To test for associations between risk factors and symptoms, we initially used chi-square and fisher's exact tests. Which were employed with the assumption of a normally distributed data-set. For nonparametric data we instead used Welch's t-test for two group means as an alternative. Furthermore, we constructed a Binary Logistic Regression Model (BLRM) with Backward Conditional Elimination, Enter Criteria=0.05 and Elimination=0.10, to identify any significant predictor for any given dependent variable in our study with a 95% confidence interval.. A p-value of <0.05 was the criteria to reject the null hypothesis in this study.

RESULTS
Our sample size n=2749is comprised only of confirmed COVID-19 cases with PCR at the command and control center in Jeddah, Saudi Arabia between March 1 st and June 30 th of 2020.. The average age of our sample is 36.8 ± 15.7 years, the youngest being 18 years of age and oldest being 106 years of age. Demographically, 61.1% of our sample are males and 38.9% are females. 69.3% of our participants were Saudi and 30.7% were non-Saudis. 82.5% of study participants were employed, whilst 17.5% were unemployed.
The most commonly reported symptoms by the study participants were fever, followed by fatigue and cough respectively. With 41.8%, 28.2% and 23.2% of participants reporting those symptoms respectively.
Other commonly reported symptoms included sore throat and loss of taste or smell, both at 17.1% each. Whilst 14.6% reported having runny nose and 12.6% reported the loss of the sense of taste or smell. The least reported symptom was diarrhea with only 6.6% reporting having experienced it. The second least reported symptoms was shortness of breath, at 9.1%. 33% of our study participants did not report any symptoms at all.
The most commonly reported risk factor was smoking, with 16.8% of participants identifying as being smokers. 5.8% reported diabetes as a preexisting condition, 4.5% reported hypertension, 3.1% reported chronic lung disease and only 1.3% reported a BMI of more than 35. Cardiovascular disease, chronic lung disease, chronic kidney disease, chronic liver disease and immunocompromised status represented ≤ 1% each. Logistic regression analysis was also conducted to identify associations between risk factors and loss of taste or smell.
Smokers were 1.39 times as likely as non smokers to lose the sense of taste or smell, p value <0.02. Patients with severe obesity were 2.78 times as likely to lose the sense of taste or smell, p value <0.01.
Those with chronic liver disease were 7.97 times as likely to lose the sense of taste or smell, p value <0.04. And finally, immunocompromised patients were 9.78 times as likely to lose the sense of taste or smell as those with a competent immune system, p value <0.02.

DISCUSSION
The aim of this study was to identify the clinical patterns of COVID-19 among Jeddah's population, as well as to find associations between the clinical symptoms of the disease and a set of well-established risk factors. Additionally, we aimed to identify the most common needs and concerns of the 937 hotline callers. As such this multi-center, analytical, cross-sectional study was designed to reach those aims. 81.3% of all calls made to the 937 hotline were related to COVID-19 testing, either to book an appointment or to inquire about the result of a previously conducted test. The remaining 17.7% of calls were related to either COVID-19 prevention or management. Approximately 11% of calls resulted in the caller receiving medical counseling and/or treatment, remotely, at home or through coordinating This was achieved by reducing patient loads at emergency departments through providing telehealth services and multi-sector coordination. Furthermore, with an average age of 36.8, a 3:2 male to female ratio and a 7:3 Saudi to non-Saudi ratio, the demographic characteristics of our sample is similar reflects that of the nation, which is highly skewed to a younger working population due to a large sub-population of migrant male workers [22]. Indicating that the health hotline was equally tapped by all demographic levels of the Kingdom of Saudi Arabia. However the demographic make up of the Kingdom of Saudi Arabia differs materially from that of the European Union and North America, who have much older populations with a more equal gender distribution, but is still substantially similar to its neighboring gulf countries [23][24][25].
When it comes to the clinical presentation of COVID-19 among Jeddah residents, our results indicate that a majority of our study sample was symptomatic rather than asymptomatic. This is likely because the hotline callers were alerted to their condition by experiencing symptoms first, or coming in contact with a symptomatic person which prompted them to contact the hotline.
Smoking, severe obesity, chronic kidney, lung and or liver disease as well as the immunocomprised status -defined as individuals active on-going immunosuppressive therapies -displayed strong and statistically significant associations with the development of two clinically important COVID-19 symptoms, shortness of breath and loss of taste or smell. Which is in accordance with the established literature around increased risk for mortality in patients with chronic kidney disease, chronic lung disease and patients with an immunocomrpomised state such as organ transplant recipients or those receiving immunosupressive cancer therapies [26][27][28][29]. The WHO and CDC and their respective guidelines for COVID-19 signs and symptoms group anosmia and ageusia under one common symptomatic presentation with either the loss of taste or smell and as such those guidelines were followed for this study. The former for the significant morbidity associated with it and the latter for its high specificity to COVID-19 [30].
When it come sto the clinical presentation of COVID-19, approximately one third of all study participants were completely asymptomatic. Which is in line with the 40-45% estimated prevalence of asymptomatic COVID-19 worldwide [31]. Whilst two thirds experienced symptoms. Most commonly fever (41.8%), fatigue (28.2%) and cough (23.2%) this is notably different from a previous retrospective national study in the Kingdom of Saudi Arabia conducted in early 2020 on a sample size of 1519, which found only 9.3% were asymptomatic, whilst the most common symptoms were cough (89.4%), fever (85.6%), and sore throat (81.6%) and notably a hospitalization rate of 71.6% [32].
In contrast, because our study focused on hotline callers, which is expected to reflect more outpatient cases, undiscovered cases and fewer hospitalized cases -only 1.7% of all study participants were hospitalized --the clinical presentation has also been reflective of fewer severe cases, more asymptomatic cases and fewer reported symptoms overall.

CONCLUSIONS AND RECOMMENDATIONS
Fever is the most commonly reported symptom of COVID-19 among the residents of Jeddah.
Smoking, severe obesity, chronic lung disease, chronic kidney disease, chronic liver disease and immunocompromised state are the most significant risk factors for COVID-19 associated morbidity. Four fifths of all 937 COVID-19 related calls were related to COVID-19 testing and one fifth of all calls was related to COVID-19 prevention and treatment. One tenth of all calls resulted in the caller receiving medical counseling and/or treatment without having to make a physical visit to a healthcare provider. Therefore, developing and implementing a welldesigned telehealth program can mitigate the need for a physical visit to the emergency room or clinic and as such reduce the load on front-line healthcare workers, reducing transmission and improving outcomes during infectious disease epidemics.

LIMITATIONS
There appears to be significant under-reporting of pre-existing medical conditions by COVID-19 patients. As the prevalence of several key risk factors, including Hypertension, diabetes and cardiovascular disease in the general population is higher than what is reported by patients in our study [33]. This could be due to the fact that our sample size only included those who called the Kingdom of Saudi Arabia's health hotline which may under-represent hospitalized COVID-19 patients, whom are more likely to have preexisting conditions and more risk factors. Because only 937 hotline callers were part of this study it may not be fully generalizable to all COVID-19 patients, including those that did not seek care or those that sought care directly without calling the hotline. in the study after explanation of the study objectives and health benefit, stressing on the anonymity of the collected data; their approval will be considered as consent. 1.4 The collected data was kept confidential by ensuring anonymity of the participants, the data was stored in personal computer secured by password. All data was not be disclosed except for the study purpose.

FUNDING
The study is self-funded.