Complete Blood Cells Findings Among Covıd-19 In-Patients at Covıd-19 Reference Hospitals, West Nusa Tenggara

Covid-19 virus still attacks various worldwide sectors, especially health. The current problem is that the Covid-19 vaccine is still in progress, so the best strategy to deal with this problem is to prevent this disease's spread. In the laboratory sector, complete blood cells tend to use as a screening method for disease, especially infectious disease. This study describes the CBCs findings among Covid-19 patients at Covid-19 reference hospitals in West Nusa Tenggara. This study will enhance the data to provide early diagnosis for patients with Covid-19. This was a retrospective study conducted from Mei to July 2020. A total of four hospitals have access to 85 medical records of Covid-19 patients. The patient’s data included in this study should have (1) initials; (2) Gender; (3) Age; (4) Patients' disease other than Covid-19; and (5) The results of the first CBCs examination. Incomplete data excluded from the study. The CBCs data collected from Hospital Management Information Systems (HMIS) and Laboratory Information Systems (LIS). The data were analyzed descriptively. The results showed that 5.88% of patients with comorbidities or another disease reported abnormal CBCs results. In comparison, another 94.12% of patients without another disease than Covid-19 tend to present normal results. In conclusion, most of the CBC's findings among Covid-19 patients in West Nusa Tenggara show normal value among patients with no disease other than Covid-19. Keyword: Covid-19; complete blood cells; hospital management information systems; laboratory information systems INTRODUCTION In recorded human history, the latest Covid-19 is the third coronaviral (CoV) outbreak (Yi et al., 2020). The world has faced highly pathogenic human CoVs, i.e., Severe Acute Respiratory Syndrome (SARS-CoV) and Middle East Respiratory Syndrome (MERS-CoV), which initially triggered an outbreak in China and Saudi Arabia in 2003 and 2012, respectively. The virus spread and reaches quickly worldwide, with horrible morbidity and mortality (Paules et al., 2020). The Covid-19 infection symptoms begin to appear after a five to six-day incubation period (Qun Li et al., 2020). The time between the onset of COVID-19 symptoms to death ranges from 6-41 days, with a median of 14 days (Wang et al., 2020). As the symptoms, fever is often occurring among Covid-19 cases, which can be accompanied by no symptom. Dry cough, shortness of breath, dizziness, muscle ache, sore throat, rhinorrhea, headache, diarrhea, chest pain, vomiting, and nausea are other symptoms of Covid-19 infection. Sometimes, patients had no fever, and several had no irregular radiological findings (Guan et al., 2020). A covid-19 pandemic occurs to be an issue to the world. All health professionals have attempted to find out how to prevent, manage, and cure this pandemic. CovidMedical Laboratory Technology Journal Available online at : http://ejurnal-analiskesehatan.web.id ISSN 2461-0879 Received 2020-20-10; Revised 2020-29-10; Accepted 2020-05-11 6 (2), 2020, 152-162


INTRODUCTION
In recorded human history, the latest Covid-19 is the third coronaviral (CoV) outbreak . The world has faced highly pathogenic human CoVs, i.e., Severe Acute Respiratory Syndrome (SARS-CoV) and Middle East Respiratory Syndrome (MERS-CoV), which initially triggered an outbreak in China and Saudi Arabia in 2003 and 2012, respectively. The virus spread and reaches quickly worldwide, with horrible morbidity and mortality (Paules et al., 2020). The Covid-19 infection symptoms begin to appear after a five to six-day incubation period (Qun . The time between the onset of COVID-19 symptoms to death ranges from 6-41 days, with a median of 14 days .
As the symptoms, fever is often occurring among Covid-19 cases, which can be accompanied by no symptom. Dry cough, shortness of breath, dizziness, muscle ache, sore throat, rhinorrhea, headache, diarrhea, chest pain, vomiting, and nausea are other symptoms of Covid-19 infection. Sometimes, patients had no fever, and several had no irregular radiological findings .
A covid-19 pandemic occurs to be an issue to the world. All health professionals have attempted to find out how to prevent, manage, and cure this pandemic. Covid-

Medical Laboratory Technology Journal
Available online at : http://ejurnal-analiskesehatan.web.id ISSN 2461-0879 19 patients with and without symptoms or abnormalities should be screened for the virus for early diagnosis . Besides, many studies have reported improvements in the laboratory detection data of Covid-19 patients, and studies have usually concentrated on one or more hematology parameters Terpos et al., 2020).
Infected patients with COVID-19, whether hospitalized or outpatient, are at high risk for venous thromboembolism (Terpos et al., 2020). Thrombocytosis, lymphopenia, and increased C-reactive protein were typical laboratory findings, although the majority of Covid-19 patients . Another study from  reported that older age, lymphopenia, and raised lactate dehydrogenase (LDH) were associated with intensive care unit admissions. Patients who transferred to the intensive care unit had a deeper nadir absolute lymphocyte count (ALC), absolute monocyte count (AMC), hemoglobin, and a higher peak of absolute neutrophil count (ANC) and LDH than patients who did not need ICU stay.
The most widely conducted hematological laboratory test worldwide is a CBC, and most routine laboratories fitted with a hematology analyzer. Some of the studies reported a variety of abnormal changes in CBCs parameters among Covid-19 patients. There is a lack of a summary of the data and the geographical variety, so it is essential to conduct this study to describe the CDCs findings among Covid-19 patients at Covid-19 reference hospitals in West Nusa Tenggara, Indonesia.

MATERIALS AND METHOD
This research was conducted in May-July 2020 at the Mataram City Hospital, Bhayangkara Hospital, Patuh Patut Patju Hospital, and North Lombok Regional Hospital. This study's ethical feasibility comes from the Ethics Committee of the Faculty of Medicine, Al-Azhar Islamic University, with number: 19/EC/FK-06/UNIZAR/ V/2020. The 85 patients' data used in this study was the first result of patients' CBCs since confirmed positive for Covid-19. The data included in this study should have (1) initials; (2) Gender; (3) Age; (4) Patients' disease other than and (5) The results of the first CBCs examination. Incomplete data excluded from the study. The variables studied were gender, age, hemoglobin, hematocrit, number of leukocytes, number of platelet cells, number of erythrocyte cells, erythrocyte index (MCV, MCH, MCHC), leukocyte count (absolute and percentage), red cell distribution width (RDW-CV), and neutrophils-lymphocytes ratio.
Data collection started from the Hospital Management Information Systems (HIMS) to see the medical record number, initial, gender, age, and comorbidities of Covid-19 patients. Some hospitals had HIMS that integrated with the Laboratory Information System (LIS) so that patient data and CBCs results can be accessed more easily. In another hospital, researchers must continue with patient data from HIMS to obtain CBCs of patients in the laboratory if HIMS and LIS are not integrated. The data obtained grouping by age to the study variables, computerized, and then presented in tabular form.

RESULTS AND DISCUSSION
This study conducted using 85 data from the medical record. The data calculated, and the result shows that female patients (64%) with positive Covid-19 status were more than male patients (36%) (Figure 1).    The results from 80 positive Covid-19 patients show mostly normal conditions on all parameters from the first CBC examination (at first admission) ( Table 1). The standard value of assessing the low, high, and normal value of each parameter is based on clinical data interpretation guidelines by the Indonesian Ministry of Health (2011). Fan et al. (2020) reported that most Singapore patients had normal CBC (normal Hb, WBC, and platelet count). There were no patients with moderate to severe thrombocytopenia, commonly seen in other viral diseases, such as dengue fever, prevalent in Indonesia. Normal or low hemoglobin levels cannot be used as a diagnostic parameter for Covid-19 infection but can be used as a supporting parameter in determining the P a g e | 157 Copyright © 2020, MLTJ, ISSN 2461-0879 severity or recovery of patients during treatment Lippi & Plebani, 2020).
In general, the white blood cell count appears normal or decreased in Covid-19 patients at first admission . The same findings were observed in asymptomatic patients . Also, age dependence has been reported to be associated with disease severity, and a higher WBC count has been observed in elderly patients than younger adults with Covid-19 .
The 80 samples showed a tendency for the patient's platelet count to be normal because most patients did not have comorbidities, so that the severity of this disease was thought to be low.  reported that as many as 8% of patients requiring Intensive Care Unit (ICU) care had a low platelet count compared to 4% of patients who did not require ICU care.  Table 2 shows a total of five positive Covid-19 patients with another disease reported. Most of them were elderly people. There were only three patients with comorbid disease of Covid-19 (i.e., chronic kidney disease + hypertension stage 2; chronic obstructive pulmonary disease; and pulmonary tuberculosis + chronic kidney disease). CBC parameters in this data were most abnormal in the neutrophil percentage, neutrophil absolute, neutrophil-lymphocyte ratio (NLR), and platelet lymphocyte ratio (PLR).  reported that there was variability within the severe group, with 87.5% of critically ill patients having neutrophilia. Other investigators have also reported neutrophilia in some elderly patients after admission . The likelihood of neutrophilia being a predictor of disease severity has been further supported by other investigators who investigated 82 deaths in Covid-19 patients and demonstrated that neutrophilia was present in 74.3% of cases after admission and increased to 100% in the last 24 hours before death (Zheng et al., 2020) A study in Wuhan with a sample of 40 people consisting of 15 men (37.5%) and 25 women (62.5%) stated that absolute neutrophil levels were significantly higher in severe cases of Covid-19 than in severe cases .
Increased NLR and age were significantly associated with disease severity. The binary logistic analysis identified increased NLR as an independent factor for poor clinical outcome of Covid-19 (Yang et al., 2020). Increased NLR is a risk factor for death not only in infectious diseases but also in malignancies, acute coronary syndromes, intracerebral hemorrhage, polymyositis, and dermatomyositis (Azab et al., 2010;Giede-Jeppe et al., 2017;Guthrie et al., 2013;Ha et al., 2018). Qu et al. (2020) proposed PLR as an indicator reflecting the severity of inflammation in the treatment process by comparing the PLR changes during treatment. It was found that the higher the PLR cut-off point, the longer patient stays in the hospital. Therefore, the investigators speculate that changes in the platelet/lymphocyte ratio in the blood during treatment may reflect disease progression and Covid-19 patients' prognosis. This disparity in numbers may, in part, represent the extent of the epidemiological data available. The limitation of this study is that the data still limit to 85 patients. A higher number of data can enhance the study. Another limitation is that CBCs cannot be used as a determining indicator of the presence of the Covid-19 virus in a patient's blood. This complete blood count is more precisely used as a supporting parameter in determining the patient's severity or recovery during the treatment period. Careful evaluation of whole blood parameters at the start and during the disease can help clinicians formulate a tailored treatment approach and promptly provide intensive care to patients who are most in need.