Abstract

Subsequent to our investigations on the novel coronavirus, the possible existence of a “second wave” of COVID-19 and its attributes was explored. Identification of nations exhibiting aberrant clinical characteristics was disclosed. The prior classification of the countries scrutinized into A, B, and C groups, is validated herewith, by aligning them in an expending order of mortality per one million inhabitants.  The data uncovered at the beginning of our study (22.03.2020), and about three months later (06.07.2020), illustrated a comparison between the first and the second period of the pandemic. Seventeen nations were investigated, highlighting three categories of states. In three countries, a notable disparity of clinical parameters was displayed. A divergence was exhibited with the rate of recovery, the frequency of molecular exams and the number of critical patients, a propensity towards deterioration in the patients’ status, noted at the end of the follow up. The three countries concerned, include the USA, Brazil and Israel. The identity of the first two is far from taking one aback, while the latter might mean for some, an eye-opener.

Keywords: COVID-19; evolution; mortality; recovery; critical patients; deviation; divergence

Introduction

Evidence of a “second wave” of COVID-19, may have followed, at least for some countries, the break succeeding the first outburst. The analysis of a collection of 17 countries reported with COVID-19 in two separate days, spaced out by about a three month-period. In order to realize this goal, a classification of the diverse nations, as introduced previously [1] was readjusted to the present situation. Moreover, the index of states was ranked separately, based on the death rate per one million residents [2].

The objective was to highlight a second period in the pandemic, and the means by which it affects several countries of the planet. In addition, identification of states which departed by two or more parameters from the usual characteristics, was looked for [1]. The changes, ensuing the pause, were tinted by the relaxation in the strict attitude towards the epidemiological precepts, observed during the quarantine periods and by the certitude that the novel coronavirus had been overwhelmed. Moreover, some states did not reach a pause at all, but most participated in the feasts of the “deconfinement” freedom.

It is expected, therefore, that a comparison between a daily occurrence in the first outburst, with what seems to represent the transition era or even, for some nations, the second wave or outburst, might disclose significant intelligence.

Materials and Methods

The countries selected, adding up to 17, most of which had been studied previously [1–3], included South Eastern Asian nations which had been involved at an early stage of the pandemic; Western European countries, that were hurt severely; and the USA and Brazil, both huge territories.

The data retrieved included the total number of infected patients; the number and proportion of severe-critical patients; the death rate and the number and percent of recovering individuals. Moreover, the number of RT-PCR tests performed in one million inhabitants was noted; death rate per one million residents and the total number of inhabitants in each country. The data were noted twice: once for the date 22.03.2020 and the second for 06.07.2020. Classification in the A, B, C, states groups was adapted from Tables 1–3 in reference [1]. The variables were ranked accordingly and the first period was compared with that obtained at the end of the follow up. The 17 nations were distributed in an increasing order of the death rate per one million residents and the relevant parameters.

Results

Seven nations were classified in group A during the first wave. They displayed limited parameters, including low levels of recovery. In the second part of the follow up, the variables remained low, except for recovery, which was elevated, justifying the state assignation to group C (Table 1).

Table 1: Country group C: Clinical features on March 22^nd and on July 6^th.

/1M – per one million inhabitants.

Six states were sorted as group B. This was due to their disclosing a high rate of morbidity and mortality. As a rule, two parameters were rated 6% each or more. The second part of the course underlines countries with high death rates, but corresponds to a low number of critical patients. Again, recovery is prominent. While Brazil and Iran were transformed into group C countries, the remainder has persisted as group B countries (Table 2).

Table 2: Country group A – clinical features in two terms.

Four nations only have been categorized as C group. They are mostly South Eastern-Asian countries, to which Iceland has been added. In the first period, all the variables presented restricted values, except for the healing parameter. In the more recent period, the death rate correlated with the state group: when elevated, it was linked with group B (Table 3).

Table 3: Country group B – clinical features in two periods.

In Table 4, the countries are listed in a growing order of mortality per one million inhabitants. The segregation of table 4 into three subgroups highlights a complete correlation is low mortality rate with a state group C (first category); a near absolute association of an intermediary mortality grade with a country group A (second category), and a strong relation between very high mortality level and the state group B (third category).

Table 4: Assortments of countries – clinical correlations based on mortality per 1M residents, on two terms.

Table 4, further compares the recovery levels, the PCR tests ratio and the alteration in the number of severe to critical patients, as it relates with the two periods. In a few cases, the percent recovery was low, or it had not been evaluated at all. In several instances, the number of critical patients displayed an inverse trend, from a low to a high value. When consideration was given to two or more aberrations in the same case, three countries were underlined, the USA, Brazil and Israel which might be expected for the first two territories, but not necessarily so with regard to Israel.

In contrast, China displays different results: its mortality rate is the lowest, and is markedly restrained. RT-PCR tests were not reported; is it because they were not performed? Moreover, only 5 severe-critical patients were reported in the second part of the pandemic. Could it be an indication that by July, 2020, China had already overcome the pandemic?

Discussion

The present analysis highlights five divergent parameters of the pandemic, displayed by 17 countries which describe a range of features in the course of COVID-19 [1, 2]. Thus, a high mortality per one million inhabitants correlated with country group B, in addition to one or more of three variants with digressive qualities. These variables encompassed either a low rate of recuperation; absence of data on recovery; reduced rate of RT-PCR tests, or an inverse level of critical patients. It is through the integration of two or more of these variables, in a given nation, that an increased risk for a more severe illness is disclosed [3].

Among the divergent factors mentioned, part displays an obvious association with a poor outcome malady. A link between a relatively low rate of healing, or between a growing number of severe-to-critical patients, and a grave ailment is evident and self- explanatory. The association of the rate of tests per million residents, with the illness severity, requires a more elaborate justification. It is of note, that regarding the USA and Brazil, a low range of PCR tests must have contributed to a mediocre disease outcome. Pending their being representative, such low levels of exams may reflect a suboptimal care of the authorities to the involvement of their subjects in the pandemic.

The distribution of the parameters in our limited cohort has rendered the confirmation of our classification of countries, relevant. This was made possible by putting in order the 17 states according to the increasing rate of mortality per million individuals. The analysis displayed an association between the mortality and our classification into state group C (low mortality); country group A (intermediate mortality) and nation group B (high mortality). It is suggested that the group C countries, especially those from South East Asia, had been involved with COVID-19, at least for one - one and a half month before the other countries. This may explain a higher degree of maturity in the evolution of the disease, and thus, a milder and more lenient form of the ailment [4]. The consistency in the ranking of the groups of nations and their stable relationship with the proportional mortality, are possibly suggestive of an association with the virus behavior. The restriction of one country group at a given localization may meet the proposed evidence of certain SARS-CoV-2 mutations to certain countries. It is advanced, that group C or B will represent a mutation, or a group of mutations; and evidence that group A may be preferentially transformed into a group C country, while B progresses to a group B, may be consistent with this principle. Thus, the features of COVID-19 in a given land will tend to differ from that of another, consideration being given to the fact that the genetic aspect of a virus is only one determinant of the illness characteristics.

The remaining variables were scrutinized in a combined manner [5]. A special attention was given to states which cumulated two or more aberrations in the parameters studied. Moreover, it seems that China stands out for the lowest value of mortality of our collection; for a lack of mention of the RT-PCR exams; and for the drift, at the last follow up, to the lowest number of critical patients [6]. This may reflect the high degree of recuperation, underlined in Table 1, concerning this country.

Israel displays a moderate-to-low rate of recuperation, when compared to the collection. In addition, a rise in the number of critical patients became evident within 3 months. An association between the deviation of both these parameters and the rigorous status of COVID-19 in Israel may come as a surprise to some observers.

Brazil discloses several divergences: a high level of mortality; transformation from territory group B to C; a low level of healing; a low degree of RT-PCR tests; and a reverse trend in the severity of the illness at last follow up. The five elements mentioned above with their deviation, might have contributed directly or indirectly, to the tragic medical condition prevailing in July 2020 in that huge country.

The USA displayed a departure from the remaining countries involved, by five sets of deviations in the clinical parameters. For one, its classification is unique, and includes periodically, the three groups (A, B, and C). Moreover, its level of recuperation is the lowest ever and PCR exams were relatively scarce. These breaks from normality might be part of the causes of the persistently growing deterioration in the condition of COVID-19 in the USA.

Regarding the divergences noted with the five parameters, notably in the four deviant countries, one wonders whether they might represent possible mechanisms leading to failure in preventing the virus progression. A further query would be whether an inverse relationship prevails between deviation in the five parameters and the adherence to the facial mask, to social distancing, and to hygiene. In Israel, notorious departures from the three health precepts, on religious, cultural, social and political grounds, are recurrently reported, and might be blown up at the gates of the international airport, by highly questionable quarantine observances.

This study assesses possible avenues, by which a lack of adherence to the epidemiological principles of behavior, might be translated into divergence of COVID-19 through its different clinical components.

References

1. Benharroch D, Benharroch YB, Goshen I (2020) Recovery from COVID-19 and evolution, 03.22.2020. J Human Virol Retrovirol 8: 110–113. [View]
2. Benharroch D, Benharroch YB (2020) SARS-CoV-2 evolves through constitutive adjustments or else via executive, medical and social struggle. Schol J Applied Med Sci 8: 1–3. [View]
3. Goshen I, Benharroch A, Benharroch D (2020) Tribulations of the SARS-CoV-2 over the globe. Schol J Applied Med Sci 8: 1170–73. [View]
4. Guo YR, Cao QD, Hong ZS, et al. (2020) The origins, transmission, and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res 7: 1–10. [View]
5. Yuen KS, Ye ZW, Fung SY, et al. (2020) SARS-CoV-2 and COVID-19: the most important research questions. Cell Biosci 10: 1–5. [View]
6. Paraskevis D, Kostaki EG, Magiorkinis G, et al. (2020) Full genome evolutionary analysis of the novel coronavirus (2019-nCoV) rejects the hypothesis of emergence as a result of a recent recombinant event. Infect Genet Evol 79: 104212. [View]