Investigation of the Association between COVID 19 Infection, Gastrointestinal Manifestations, Parasitic Diseases and Antiparasitic Treatment: An Electronic Data Compilation

and can attenuate the severity of disease presentation. Methods: A cross-sectional analytical study was done to investigate the possible association between COVID-19 syndrome, gastrointestinal manifestations, parasitic diseases and antiparasitic treatment. A non-probability convenient sampling technique was used to recruit participants, through electronic data collection. Results: The mean age of the survey respondents reporting a positive history of COVID 19 infection was 35.69±12.24 years. Study participants with a positive COVID 19 history have reported a positive history of gastrointestinal disorders in 40.9% of 93 patients responding to that question. Twenty-six out of 95 (27.4%) participants reporting a positive history of COVID 19 also reported a previous history of parasitic infection, while 22 (15.6%) subjects out of 141 individuals with a negative history of COVID 19 infection had a past experience of parasitic infection (P=0.028) Among the parasitic infections stated was amoebiasis, giardiasis and enterobiasis. Conclusions : The higher incidence recorded of parasitic infections among subjects with a positive history of COVID-19 suggests that parasite co-infection 3 may lead predispose to a high incidence of COVID-19, which conflicts with other literature data reporting a protective effect of parasitosis against SARS CoV-2 infection. More extensive survey studies targeting larger populations are of crucial importance, especially in developing countries.


INTRODUCTION
Viral infections are important causative agents of epidemics and pandemics that have burdened humanity throughout history. Viral agents causing such health burdens include coronaviruses, such as the severe acute respiratory syndrome coronavirus (SARS-CoV), the Middle East respiratory syndrome coronavirus (MERS-CoV) and most recently, the SARS CoV-2 virus (Piret and Biovin, 2021). The most recent of these pandemics is the coronavirus disease of 2019 (COVID 19) caused by the SARS CoV-2 virus. Despite the various vaccination campaigns, COVID 19 continues to challenge national and international health organizations. Rapid research and investigation strategies are required to keep pace with the rapid spread of this pandemic. Survey studies are valuable research tools that can provide rapid information over a wide base of respondents with different backgrounds (Geldsetzer 2020).
The SARS CoV-2 virus enters epithelial cells by binding to the angiotensin-converting enzyme-2 (ACE-2) receptor. Viral entry and fusion with the host cell membrane are facilitated by the transmembrane serine protease (TMPRSS2). This enzyme serves to cleave the viral S protein, allowing the virus to release its fusion peptide. In addition to the respiratory tract, expression sites of both ACE-2 receptors and TMPRSS2 include the esophagus and the enterocytes of the small and large intestine, which renders the gastrointestinal tract (GI) a target for SARS CoV-2 entry .
One of the challenges of COVID 19 is the diversity of clinical manifestations, since it may present with a variety of GI symptoms such as diarrhea, nausea, vomiting and gustatory dysfunction Tong et al., 2020). Fecal shedding of the SARS CoV-2 virus has been was reported to persist even after respiratory tract samples became negative (Parasa et al., 2020) GI symptoms among COVID-19 patients could be attributed either to the direct binding of the virus to the ACE-2 receptors present in the intestinal epithelial cells (Hunt et al., 2021), or to the association of SARS COV-2 infection with other GI conditions, such as parasitic infections (Hillyer, 2020). Chronic and/or persistent parasitic infections are common in low and medium-income countries (LIMCs). Such chronic infections were shown to alter the clinical outcomes to other infections possibly by modulating the host's immunity. Hence, pre-existing parasitic infections may also impact the host's immune response to infection with SARS-CoV-2, which could result in beneficial and detrimental effects (Woldaya et al., 2021).
Antiparasitic drugs such as chloroquine and ivermectin have been included in various anti-COVID drug regimens. However, till now there is no clinical evidence that any therapy possesses prospective outcomes in suspected or confirmed COVID-19 patients. There are more than 300 clinical treatment and prophylactic trials underway (Caly., et al., 2020).
Our study aimed to investigate the possible association between the COVID-19 manifestations and management, gastrointestinal manifestations (GI) and parasitic infections in Middle Eastern countries, particularly Egypt.
The present study aimed at exploring the prevalence of COVID 19 among the study participants and the possible association with GI manifestations, with special reference to parasitic diseases and anti-parasitic drugs.

MATERIALS AND METHODS 1-Study Type:
A cross-sectional analytical study was done to investigate the possible association between COVID-19 syndrome, gastrointestinal manifestations severity, frequency, and parasitic diseases. The study

4-Study Population and Setting:
The study was conducted on all people willing to participate in this study (1 to 70 years) from different Egyptian Governorates. Surveys from children were filled by their guardians after consenting to their participation.

5-Inclusion Criteria:
All persons, who could access the internet and who approved participating in the study, were recruited.

6-Exclusion Criteria:
Persons who refused to participate in this study or couldn't access the internet or could not complete the questionnaire were excluded.

7-Data Collection Tool:
A self-administered structured questionnaire composed of 60 questions was designed. Questions were presented in the Arabic language. Content and face validity was checked by the authors. An online data collection method was used in line with lockdown measures conducted in Egypt and neighboring countries to achieve social distancing. A Google form was created, and participants were requested to complete and submit it. A questionnaire link was shared with groups on social media forums (Facebook, Twitter, and WhatsApp). Furthermore, the authors shared the link personally in their network areas.

8-Ethical Consideration:
The objectives of the study were explained to the participants (by a statement before the initiation of the online survey) and they were completely free to accept or refuse. Participants who refused were excluded from the study results and online consent was taken from those who accepted to participate. Strict confidentiality about participants' personal data (this was secured by the questionnaire being anonymous) was maintained throughout data collection, entry and analysis (according to the Helsinki declaration, and approved by the Research Ethics Committee for at the Faculty of Pharmacy, Modern University for Technology and Information, Egypt and Family Medicine Department Council, Faculty of Medicine, Cairo University.

9-Data Analysis:
The data were coded and exported on a data sheet prepared on Microsoft Excel program, version 2013. The statistical package for social science (SPSS) version 24 was used for data analysis. Simple descriptive statistics were used for the summary of quantitative data and frequencies used for qualitative data. The bivariate relationship was displayed in cross-tabulations, and a comparison of proportions was performed using the chisquare and Fisher's exact tests where appropriate. Independent T-test and oneway ANOVA were used to compare normally distributed quantitative data. The level of significance was set at probability P-value <0.05.

RESULTS Personal History:
The mean age of the survey respondents reporting a positive history of COVID 19 infection was 35.69±12.24 years, the minimum age being 1 year and the maximum being 70 years. Five individuals were under 18 years of age (5.3%), 71 individuals were between the ages of 18 and 40 years (74.7%), 14 persons were in the age group between 41 and 60 years (14.7%), and 5 persons were above 60 years of age (5.3%). The mean age among COVID 19 negative subjects was 35.27±14.25 years. No significant difference was found between the two age groups (P=0.812).
Among the study subjects, 95 (40.25%) have reported a positive history of COVID 19 infection. Among these 95 participants, 10 (10.53%) have reported having contracted repeated infections. History of contact with a COVID 19 case was reported by 35 (38.5%) out of 91 persons, while 4 persons did not respond to that question.

Fig. 2:
Bar chart representing the number of COVID 19 positive subjects (X-axis) according to their presentation with general and respiratory symptoms (Y-axis) during infection.

Relation Between Clinical Presentation of COVID 19 and Population Characteristics:
Analysis of the relation between gender and clinical presentation of COVID 19 infection revealed that male patients were more prone to develop loss of taste and smell and loss of weight than female patients (Table 2). A significant association was also found between smoking and loss of taste and smell, where 16 out of 17 smokers (94.1%) reported suffering from this symptom as compared to 33 out of 70 non-smokers (47.1%) who also reported losing smell and taste during the COVID 19 attack (P<0.001, Pearson's Chi-square test).
Fever was more commonly found among children and young adults and elderly individuals (Table 3).
Management strategies of individuals with a COVID 19 history are summarized in Table 4.

Association of Digestive Disorders with COVID 19 Infection:
Study participants that had previously suffered from COVID 19 infection have reported a positive history of digestive disorders in 40.9% of 93 patients responding to that question. Nausea and heartburn were significantly more common among subjects with a positive COVID 19 history (P=0.004 and P=0.002, respectively) (Table 5). Twenty-five patients have reported an increase in the intensity of the whole spectrum of GIT symptoms after acquiring COVID 19 infection. In comparison, 10 participants have reported a decrease in GI disturbance, mainly diarrhea.

History of Parasitic Infection In Relation to the COVID 19 Infection Status Among Study Participants:
Twenty-six out of 95 (27.4%) participants reporting a positive history of COVID 19 also reported a previous history of parasitic infection, while 22 (15.6%) subjects out of 141 individuals with a negative history of COVID 19 infection had a past experience of parasitic infection (P=0.028) (figure 3). Among the parasitic infections stated were amoebiasis (9 cases among COVID 19 positive patients and 8 cases among negative patients), enterobiasis (6 cases among COVID 19 positive patients and 1 case among negative patients) and giardiasis (5 cases in each study group).
Helicobacter pylori infection was also reported in 8 COVID 19 positive patients and 15 negative patients. Six patients suffered from COVID 19 simultaneously with the occurrence of parasitic infection, the most common being amoebiasis in 3 patients, while one participant suffered from giardiasis and another one from enterobiasis along with the COVID 19 attack. In addition, one respondent reported having been infected with both Entamoeba spp and Enterobius vermicularis along with the SARS CoV-2 virus. These patients were treated with metronidazole (4 patients), nifuroxazide (1 patient), and nitazoxanide (1 patient).

DISCUSSION
Population studies in the middle eastern region and developing countries are still short of providing satisfactory data on the characteristics of COVID 19 in these regions. We have therefore designed a cross-sectional online survey targeting participants in the Middle East, particularly Egypt. This region is of special research interest, due to the high prevalence of gastrointestinal disorders and parasitic diseases, which affect the immunity of the host, thus modulating the immune response to various pathogens, including viruses (Maizels et al., 2018).
The mortality rates due to COVID 19 are higher among older patients. Levin et al. (2020) reported an infection fatality rate of 0.002% in patients 10 years of age as compared to 15% in patients 85% years of age. While this age susceptibility is evident in developed countries, higher death reports have been reported among younger patients in low-income countries. This could probably be attributed to the higher incidence of infection and decreased management quality (Chauvin et al., 2020). In our study, the mean age of participants with an appositive history of SARS CoV-2 infection was 35.69±12.24 years. The majority of patients were between 18 and 40 years of age (74.7%). Only five patients required ICU admission, all of whom were between the ages of 27 to 37 years. Jin et al. (2020) investigated gender differences in susceptibility to SARS CoV-2 infection and severity of disease presentation. Among 1,019 survivors of COVID 19 infection, the susceptibility among male and female patients was similar. However, data from hospitalized and deceased patients revealed that male patients were more prone to severe infection and also increased mortality rates.
In the current study, there was no significant difference between the susceptibility to COVID 19 infection among male and female patients. It was observed, however, that male patients reported a higher incidence of loss of taste and smell. The abundance of ACE 2 receptors in the tongue and nasal mucosa can explain the distortion of taste and smell sensations secondary to viral binding to these receptors (Vaira et al., 2020). In the study at hand, we also observed a higher incidence of loss of taste and smell among smokers. There is conflicting data on the susceptibility of smokers to COVID 19, since some studies have reported a protective effect of smoking due to the inhibition of pro-inflammatory cytokine production by nicotine (Korzeniowska et al., 2021). In opposition, other studies suggested an increased risk of COVID 19 among smokers due to the increased expression of ACE 2 receptors in lung cells (Maggi et al., 2021).
Loss of taste and smell was the most frequently reported symptom (89.3%) in our study. Additionally, participants also suffered from fever (77.4%), difficulty in breathing (78.7%), sore throat and difficulty in swallowing (71.2%), musculoskeletal pain (86.7%), loss of weight 77.8%) and diarrhea and abdominal pain (75.0%). COVID 19, although notorious for its respiratory manifestations, has also well-recognized gastro-intestinal symptoms (Pola et al, 2021). These can be attributed to the immune response against viral infection or even the direct action of the virus. This is evidenced by the fact that intranasal inoculation of SARS CoV-2 leads to faecal shedding of viral RNA, while intragastric inoculation leads to lung pathology (Pola et al., 2021). In a study by Tian et al. (2020), case reports and retrospective clinical studies were evaluated to analyze the nature of GIT disturbance during COVID 19 infection. Symptoms reported in these studies included anorexia, nausea, vomiting, diarrhea, abdominal pain and GI bleeding.
Diarrhea was more frequently found in adults and children.
GIT manifestations during viral infections might also be due to underlying intestinal disorders. Parasites are major contributors to intestinal disturbances and cause a wide spectrum of upper and lower intestinal tract symptoms. Crossroads between parasitic infections and SARS CoV-2 infection are of particular research interest, due to the wide prevalence of coinfection and the impact of parasitic infections on immune modulation. In the study at hand, the incidence of past parasitic infection was significantly higher among patients with SARS CoV-2 infection history. Six survey respondents had simultaneous SARS CoV-2 and parasitic infection including amoebiasis, enterobiasis and giardiasis. Abdoli (2020) suggested that helminthic infection can increase the susceptibility to intracellular pathogens including viruses by potentiating a T-helper 2 immune response. However, several studies have suggested a protective effect of parasitic infections against SARS CoV-2 infection (Abott, 2018;Desai et al., 2021). One of the potential contributors to such a protective effect is the eosinophilia commonly present with parasitosis (Rosenberg and Foster, 2021). Eosinophils are suggested to play a protective role in SARS CoV-2 infection since patients with low eosinophil count were more likely to develop severe symptomatology and fatal outcome (Yan et al, 2021). Eosinophils are also potential markers for past SARS CoV-2 infection among COVID-19 patients (Li et al., 2021). Further research on the molecular mechanisms of parasite-virus interactions is certainly recommended and can open valuable insights to explain gastrointestinal pathogenesis of microbial co-infection. For example, human galectins 1 and 3 (Gal-1 and Gal-3) were found to be increased during Entamoeba histolytica (Petropolis, 2014). These pro-inflammatory mediators inhibit viral adhesion and are potential targets for antiviral therapy (Pourrajab, 2021). Another approach to antiviral therapy is arginine deprivation since arginine is essential for viral replication. Infection with Giardia lamblia causes arginine depletion by consumption of host arginine and metabolism by arginine deaminase thus disturbing the enterocyte cell cycle (Buret et al., 2015).
Another important crossing point between SARS CoV-2 and parasitic infections is the observation that certain anti-parasitic drugs have proven to improve the clinical outcome of COVID-19. In the current study, participants reported using hydroxychloroquine (57.8%) and ivermectin (3.6%) as part of the drug regimen against COVID 19, which also included anti-inflammatory drugs, anticoagulants and immune stimulants. The antimalarial drug hydroxychloroquine was one of the earliest agents to be included in the anti-COVID regimen by several countries. It was found to protect against the development of severe attacks, especially if given early in the disease (Prodromos and Rumschlag, 2020;Weston et al., 2020). Another famous anti-parasitic agent included in the anti-COVID regimen is the macrocyclic lactone ivermectin (Heidary and Gharebaghi, 2020). While its antiparasitic activity is contributed to its action as a glutamate-gated chloride channel blocker, its anti-viral activity is mediated by interfering with SARS CoV-2 protein transport into the nucleus of the host (Caly et al., 2020). Another antiparasitic drug that has been investigated for its potential benefit in SARS CoV-2 infection is nitazoxanide, which inhibits viral replication and potentiates interferon-alpha and beta production (Filho et al., 2020).

Limitations and Recommendations:
The study was conducted before the implementation of widespread vaccination campaigns, so the effect of vaccination on both COVID 19 and digestive disturbances remains uncovered. Repetition of the survey questionnaire with emphasis on the response to vaccination and its possible impact on co-existing intestinal infections is strongly recommended. In addition, middle eastern and developing countries merit more extensive population studies to explore the effect of endemic parasitic diseases on emerging viral infections and the value of therapeutic repurposing of antiparasitic drugs in the management of parasite-virus co-infection.

Conclusions
The COVID 19 pandemic is considered to be the highest health crisis worldwide and constitutes an augmented health burden in middle and low-income countries. The current study investigated the association between GIT disturbances, particularly parasitic infections and COVID-19. The higher incidence of parasitic infections among subjects with a positive history of COVID-19 could suggest that parasite co-infection may lead to a high incidence of COVID-19, which conflicts with other literature data reporting a protective effect of parasitosis against SARS CoV-2 infection. In addition, respondents were asked about the treatment regimen against COVID 19 and the inclusion of the antiparasitic drugs hydroxychloroquine and ivermectin. Additionally, other lines of therapy were reported.
These included immunomodulatory agents which could be an alternative treatment option under the situation of the lacking of effective antiviral therapy, their high side effects and low patient compliance. However, more experimental and clinical trials are needed to yield sufficient evidence concerning the correlations of COVID-19 and other GIT infections along with the convenient effective therapy. In addition, more extensive survey studies targeting larger populations are of crucial importance, especially in developing countries, to determine the impact of parasitic diseases on SARS CoV-2 infection and the degree of public awareness on common symptomatology and management strategies between these health burdens.