Neutrophil-Lymphocyte Ratio (NLR) and Lymphocyte-Monocyte Ratio (LMR) as Covid-19 Screening Parameters Heny Syahrini1.
Trinugroho Heri Fadjari2.
Nadjwa Zamalek Dalimoenthe3 Haematology and Medical Oncology Division.
Internal Medicine Departement.
Universitas Sumatera Utara.
Medan.
Indonesia Haematology and Medical Oncology Division.
Internal Medicine Departement.
Hasan Sadikin Hospital.
Bandung.
Indonesia Clinical Pathology Departement.
Hasan Sadikin Hospital.
Bandung.
Indonesia Correspondence:
Heny Syahrini.
Jln.
Bunga Lau No.
17 Medan North Sumatra.
Indonesia Zip Code: 20136 Email: henylubis01@gmail.
Received: August 21, 2021 Revised: October 23, 2021 Accepted: January 1, 2022 Published: April 28, 2022 DOI: 10.
33086/ijmlst.
Abstract Coronavirus Disease 2019 (COVID-.
diagnosis generally uses RT-PCR as the gold standard to detect coronavirus-2 (SARS-CoV-.
however, this method requires advanced Alternatively.
NeutrophilLymphocyte Ratio (NLR) and Lymphocyte-Monocyte Ratio (LMR) can be used to identify viral infection.
The study aimed: .
to compare each NLR and LMR ratio in patients with and without COVID-19 and .
to test the effectiveness of these ratios in identifying COVID-19.
The study was conducted at the Haji Adam Malik Central General Hospital.
Medan.
Indonesia by acquiring 87 medical records data.
The complete hematologic profile was analyzed from patients with and without COVID-19.
The NLR and LMR ratio accuracy were analyzed as a screening tool for COVID-19.
The AUC of NLR was 0.
638, with cut-off O 2.
49, 47.
sensitivity, and 80% specificity.
therefore, the NLR accuracy as a screening for COVID-19 was defined as not good .
ust sufficien.
because of AUC <0,7.
The AUC of LMR was 0.
661, with cut-off Ou 3.
23, 45.
2% sensitivity, and 2% specificity.
therefore, the LMR accuracy as a screening parameter for COVID-19 is defined as not good .
ust sufficien.
because of AUC <0,7.
There were significant differences in hematologic profile in neutrophil, lymphocyte.
NLR.
LMR between the patients in the COVID-19 group and non-COVID-19 group.
NLR and LMR cannot be used as a screening tool because the Area Under Curve (AUC) is not good enough .
ust sufficien.
in detecting COVID-19.
Keywords COVID-19.
Neutrophil-Lymphocyte Ratio.
LymphocyteMonocyte Ratio.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A2021 by author.
Heny Syahrini, et al.
oropharyngeal and nasal swab of the patient
INTRODUCTION
The world went into chaos around .
However.
RT-PCR often shows late December 2019 when a new virus outbreak results, as it needs complex procedures, many emerged in Wuhan.
China.
This virus spread samples, and a highly advanced laboratory into every corner of the world.
RT-PCR is less efficient to use as World Health Organization (WHO) stated coronavirus diseases 2019 (COVID-.
as a pandemic that is caused by a virus entity remains the gold standard in diagnosing named Severe Acute Respiratory Syndrome COVID if the equipment is adequate .
Neutrophil-Lymphocyte Ratio (NLR) is Corona Virus-2 (SARS-CoV-.
The clinical manifestations of COVID- a ratio of absolute neutrophil count to 19 consisted of mild symptoms .
, fever, absolute lymphocyte count.
This value can be cough, myalgia, fatigue, and diarrhe.
and easily calculated according to findings from life-threatening routine hematology profiles.
It is reported dyspnea, respiratory failure, coagulation that this ratio has an impactful effect on disturbance, headache, loss of consciousness, inflammation in the patient.
Peripherally hemoptysis, multiorgan failures, and even acquired samples of blood also can be used to deat.
Several parameters that describe calculate this ratio.
This ratio is also severe clinical manifestations are respiratory beneficial in determining the cause of the rate >30 times/minute, oxygen saturation infection, such as described in a retrospective below 93%, the ratio of oxygen partial gas
study where a high ratio value indicates a pressure and oxygen inspiration fraction
bacterial infection in a fever of unknown
<300
Lymphocyte-monocyte ratio infiltrates on lung X-ray increasing more than (LMR) can also be used to identify viral 50% in 24 to 48 Hours .
infection in a human.
A ratio < 2 according to .
(PaO2/FiO2 <.
Early detection and screening should be one study can be applied to diagnosing conducted for every patient that needs influenza infection instead of the standard medical attention at every hospital or medical rapid test .
These ratios are even more convenient to probable COVID-19 must undergo gold use in COVID cases as the percentage of Chain leukocytes, lymphocytes, and neutrophils are Reaction (RT-PCR) to detect SARS-CoV-2 greatly affected by the SARS-CoV-2 virus.
virus nucleic acid in the sputum, an Compared to an unaffected person, a person Real-Time Polymerase Ina.
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with COVID-19 has much lower leukocyte this study is patients categorized as probable and lymphocyte counts and much higher of COVID-19.
This study was conducted neutrophil counts.
One study shows that a from April 2020 until June 2020.
The COVID-19 patient may have leucopenia with subjects of this study are patients categorized 2,91 x 109/L, with 70% neutrophils .
as definitive COVID-19 with the positive Another study shows that the NLR ratio is significantly lower in COVID-19 patients.
gathered secondary medical records and The absolute leukocyte, lymphocyte, and collected the hematologic profile of patients monocyte counts are much lower than non- categorized as probable COVID-19.
The COVID-19 patients .
The severity of patients older than 18 and confirmed COVID-19 is also distinguished according to COVID-19 by RT-PCR were included.
the ratio where the NLR ratio is higher in Patients younger than 18 years old and still severe COVID-19, while the LMR ratio is categorized as probable COVID-19 were lower in less severe COVID-19 infection RT-PCR SARS-CoV-2.
Although promising, these ratios have not been fully utilized yet as more precise data are needed to further evaluate the This study used secondary data .
he effectiveness of these ratios as sensitive and specific screening tools for COVID-19.
parameters including the number of medical record of the patient.
with The study aims of this study are to records, age, sex.
RT-PCR result, severity, compare each NLR and LMR ratio in patients primary diagnosis, additional diagnosis, the with COVID-19 and without COVID-19 in endpoint of the patients, full hematologic severe and less severe COVID-19 infection and .
to test these ratiosAo effectiveness in identifying COVID-19.
MATERIALS AND METHODS Study Population The study was conducted at the Haji Medical Record Data Operational Definition Adam Malik Central General Hospital.
Probable COVID-19 is defined as Medan cityt approved by the Research Ethics subjects seeking medical attention with Committee.
Faculty of Medicine.
Universitas symptoms related to COVID-19.
COVID-19
Sumatera Utara (No.
252/TGL/KEPK FK
Confirmed defined as patients with the USU-RSUP HAM/2.
The population of positive result of RT-PCR.
Severe COVIDIna.
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19 is defined as patients confirmed with curve (AUC) from the receiver operating COVID-19 who had one of these criteria:
curve (ROC).
AUC value 0.
9-1 categorized respiratory rate more than 30 times/minute.
as exceedingly accurate, 0.
9 categorized Oxygen saturation < 93%.
PaO2/FiO2 < 300 as highly accurate, 0.
8 categorized as mmHg.
Less Severe COVID-19 is defined as well accurate, 0.
7 categorized as fairly COVID-19 accurate, and < 0.
5 categorized as useful.
COVID-19
Neutrophil Lymphocyte Ratio is the ratio of absolute RESULTS neutrophil count to absolute lymphocyte There were 87 data of medical records count, acquired by analyzing peripheral from patients .
Ae 71 years ol.
included in blood smear prepared on the day of the this study.
There were 52 male patients admission into the hospital.
Lymphocyte and .
8%) and 35 female patients .
2%), 21
Monocyte Ratio is defined as the ratio of female and 21 male in the COVID-19 group, absolute lymphocyte count to absolute and 31 male and 14 female in the non- monocyte count, acquired by analyzing COVID-19 group.
There were no statistically peripheral blood smear, prepared on the day significant differences in the hemoglobin, of the admission into the hospital.
Statistical analyses basophil, neutrophil, and monocyte amount All data were analyzed using SPSS Version Statistics in COVID-19 and non-COVID-19.
However.
Windows the median of the lymphocyte in the COVID- The baseline characteristics of the 19 group .
4%-57.
7%, average: 19.
8%) was higher than lymphocyte in the non-COVID- descriptive distribution tables.
Data are 19 group .
8%-46.
4%, average: 15.
7%), and presented as mean A standard deviation (SD) this was statistically significant with a p- or ycu (%).
value of 0.
<0.
The median of the Data analysis was conducted by unpaired absolute neutrophil count in the COVID-19 T-test if the data had a normal distribution.
the data were unevenly distributed, data 5,471.
was lower than in the non-
analysis was conducted by the Mann-
COVID-19
Whitney test.
To evaluate NLR and LMR average: 7756,.
, and this was statistically ratios as a screening method for COVID-19, significant, with a p-value of 0.
we used parameters sensitivity, specificity, .
<0.
,250.
00Ae14,297.
,170.
78Ae47,329.
There were no significant differences in predictive value (NPV), and area under the severity, endpoint, comorbidity, and duration Ina.
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of complaint in the COVID-19 group statistically significant.
P-value 0.
004 for compared to the non-COVID-19 group.
The fever and 0.
008 for cough.
There were no symptoms of fever and cough were more prevalent in the COVID-19 group than the between the COVID-19 group and the non- non-COVID-19 COVID-19 group.
Table 1.
Baseline Characteristic Variable Age .
Sex Male, n (%) Female, n (%) Hematologic Parameters Hemoglobin Leukocyte Thrombocyte .
Eosinophil (%) Basophil (%) Neutrophil (%) Limphocyte (%) Monocyte (%) Absolute neutrophil
Absolute limphocyte Absolute monocyte Severity Severy Less Severe Endpoint
Death
Cured Comorbidity, n (%) None
ESRD
Sepsis HIV Duration of Complaint O14 days >14 days Symptoms Fever, n (%) Cough, n (%) Dyspneu, n (%) Dysphagia, n (%) Others, n (%) Total .
COVID-19 .
Not COVID-19 .
P-value* 44 .
9,130
,370-49,.
6,232.
,170.
78-47,329.
1,693.
32-5,158.
8-3,145.
8,475
,010-16,.
5,47177
,250-14,297.
1,843.
80-5,158.
9-1,328.
10,060
,370-49,.
7,756.
,170.
78-47,329.
1,377.
32-4,538.
8-3,145.
P-value measured using a Mann Whitney test, b Chi-square test, c Fisher Exact test.
* significant if p <0.
There were 42 patients in the COVID-19 severe COVID-19 group, and 32 patients group, about ten patients categorized as categorized as less severe COVID-19 group Ina.
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(Table .
The median age in the COVID-19 median of thrombocytes .
5 in group was 43 years .
ange: 18 Ae .
, and the the severe COVID-19 group and 295.
5 in the median age in the severe group was 54 .
ange less severe group.
This study showed that 28 Ae .
ange 18-.
in the less patients with severe COVID-19 had a lower median of thrombocyte than less severe significant with P-value of 0.
< 0.
COVID-19 .
-value 0.
(Table .
The The severe COVID-19 group consisted of median of eosinophil was 0.
in older patients.
The hematologic parameters, overall COVID-19 patients, 0 .
in the like hemoglobin, leukocyte, monocyte, had severe COVID-19 group and 1.
in less no significant differences in COVID-19 and severe COVID-19 group.
This study showed non-COVID-19 groups.
that patients with severe COVID-19 had a This However, for other parameters, there are some statistically significant differences.
The lower median of eosinophil than less severe COVID-19, p-value 0.
Table 2.
The Hematologic profile of severe COVID-19 group and not severe COVID-19 group Severity of COVID-19 Variable Total .
Age (Year.
Sex Male, n (%) Female, n (%) Hematologic Parameters Hemoglobin Leukocyte Thrombocyte .
Eosinophil (%) Basophil (%) Neutrophil (%) Limphocyte (%) Severe .
Not Severe .
P-value 43 .
8,475
,010-16,.
10,265
,010-16,.
8,370
,000-16,.
Monocyte (%) 5,471.
6,489.
5,224.
Absolute neutrophil .
,250-14,297.
,845.
4-13,867.
,250-14,297.
1,843.
1,218.
2,219.
Absolute lymphocyte .
8-5,158.
8-2,001.
32-5,158.
Absolute monocyte .
9-1,328.
81-1,159.
9-1,328.
P-value measured using a Mann Whitney test, b Chi-square test, c Fisher Exact test * significant if p <0.
in the severe COVID-19 group and 0.
in overall COVID-19 patients, 0.
in less severe COVID-19 group.
This Ina.
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Heny Syahrini, et al.
study showed that patients with severe absolute lymphocyte count was 1,843.
COVID-19 had a lower median of basophil .
8-5,158.
than less severe COVID-19, p-value 0.
patients, 1,218.
8-2,001.
in the The median of neutrophils was 68.
severe COVID-19 group and 2,219.
in overall COVID-19 patients, 79.
32-5,158.
in less severe COVID-19 .
in the severe COVID-19 group.
This study showed that patients with 1 .
in the less severe severe COVID-19 had a lower median COVID-19 group.
This study showed that absolute lymphocyte count than less severe patients with severe COVID-19 had a higher COVID-19, p-value 0.
median of neutrophil than less severe COVID-19, p-value 0.
COVID-19
The median of NLR in the COVID-19 group .
43, average: 3.
was lower The median of neutrophils was 68.
than the non COVID-19 group .
in overall COVID-19 patients, average: 4.
, and this was stastitically 35 .
in the severe COVID-19 significant with p-value 0.
< 0.
in the less severe (Table .
The median LMR ratio in th COVID-19 group.
This study showed that COVID-19 group .
49, average: 28.
patients with severe COVID-19 had a lower was higher than non COVID-19 group .
median of neutrophil than less severe 9,87, average: 2.
This was statistically COVID-19, p-value 0.
The median of significant with p-value 0.
< 0.
Table 3.
NLR and LMR value in COVID-19 and non COVID-19 Variable Total .
COVID-19 .
Non COVID-19 .
P-value NLR 35 .
LMR
P value calculated using Mann-Whitney test*significant if p-value < 0.
The median NLR ratio in the COVID-19 non-severe COVID-19 group was 2.
group with severe category .
This value was lower than in the non- average: 6.
was lower than in the non- COVID-19 group 4.
, with a p- COVID-19 group .
39, average:
value of 0.
< 0.
P value of less than However, this result was statistically insignificant because of the p-value of 0.
>0.
(Table .
The median NLR in the Ina.
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The median LMR ratio in the severe ratio was 3.
This value was COVID-19 group .
36, average: 1.
lower when compared to the non-COVID-19 was higher than the non-COVID-19 group group compared with control 2.
52, 1.
However, this result is This result was statistically significant defined ad statistically insignificant as the p- with a p-value of 0.
<0.
value is 0.
> 0.
The median LMR Table 4.
The NLR and LMR ratio in COVID-19 patients and non COVID-19 patients based on the severity Severe Cases Not Severe Cases Not COVID-19 COVID-19 .
Variable P-value median .
NLR .
LMR
P-value calculated using Mann-Whitney test*significant if P-value < 0.
COVID-19 .
Not COVID-19 .
P-value The median NLR of the severe COVID- median LMR ratio of the severe COVID-19 19 group was 6.
, higher than group was 1.
, lower than the the less severe COVID-19 group 2.
less severe COVID-19 group 3.
With p-value 0.
< 0.
, this With p-value 0.
< 0.
, this result was statistically significant.
The result was statistically significant (Table .
Table 5.
The NLR and LMR ratio in severe COVID-19 patients and less severe COVID-19 Severity Variable Severe .
Less Severe .
NLR 20 .
LMR
P-value calculated using Mann-Whitney test *significant if p-value < 0.
P value The accuracy of the NLR parameter was 2%, specificity: 82.
2%, the accuracy of defined as not good .
ust sufficien.
because the LMR parameter as a screening for of AUC < 0.
ut-off value O 2.
AUC
COVID-19 cases also defined as not good 638, sensitivity 47.
6%, and specificity .
nly sufficien.
because of AUC < 0.
off LMR Ou 3.
AUC 0.
661, sensitivity:
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DISCUSSION
80%) (Table .
The LMR value, with a cut- Heny Syahrini, et al.
The number of leukocytes in the COVID- .
,370- 4,9.
, p = 0.
This study is in 19 group was lower than in the non-COVID- line with previous studies by Mardani et al.
and Song CY et al.
However, in both of these studies, the difference in However, in this study, the difference was not significant .
,475 .
,010- 16,.
vs 10,060 significant differences.
Tabel 6.
Cut-off of AUC NLR dan LMR ratio as a screening tool for COVID-19
Variable AUC
95% CI
P value Cut-off
NLR
O2.
LMR
552 Ae 0.
>3.
(A)
Sensitivity: 47.
Specificity: 80.
PPV: 69.
NPV: 62.
Sensitivity: 45.
Specificity: 82.
PPV: 70.
NPV: 61.
(B)
Figure 1.
ROC Curve (A) NLR on Covid-19 (B) LMR on Covid-19 This study also found that approximately both in COVID-19 and non-COVID-19 75% of COVID-19 cases were not severe.
Previous with relatively younger age in less severe lymphopenia is often found in COVID-19 cases than severe cases .
edian age 36.
Lymphopenic conditions have been versus 54 year.
discovered to be common, especially in The following baseline characteristic is severe COVID-19 patients, due to a variety the discovery of lymphopenia in both groups, of mechanisms, including direct lymphocyte Ina.
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inflammatory cytokines, the emergence of respiratory tract infections, including clinical lactic acidosis suppression lymphocytes, and progression, response to treatment, healing, attachment of coronavirus to Angiotensin- and recurrence .
Increasing severity is converting enzyme 2 (ACE) 2 receptors on also associated with the presence of lymphocytes .
Thus, if the lymphocytes The count has a normal range, the condition is percentages between the COVID-19 and non- probably associated with less viral load and a COVID-19 (Ou.
significant, with the median lymphocyte Unfortunately, this studyAos SARS-CoV-2 value in the COVID-19 group significantly positive RT-PCR examination did not higher than the non-COVID-19 group include the cycle threshold value.
In addition, .
edian values 19.
in this study, it was found that the RT-PCR .
, p 0.
Although the absolute group of SARS-CoV-2 negative experienced lymphocyte count in the COVID-19 group This condition, characterized was higher than the non-COVID-19 group by a decrease in lymphocyte value, can be .
explained by comorbidities such as diabetes .
, the difference was not mellitus, sepsis, human immunodeficiency statistically significant.
In addition, the cycle virus, and end-stage renal disease .
threshold from the positive RT-PCR SARS The data on baseline characteristics in CoV-2 results might further explain why the this study also showed that the percentage of COVID-19 group has the absolute median neutrophils, absolute neutrophils, monocytes, value of lymphocytes that are still normal and the absolute monocytes in the COVID-19 .
group was lower than that in the non- The SARS CoV-2 positive RT- COVID-19 group, with only the absolute PCR results with high cycle threshold results neutrophils statistically significant .
indicate low viral loads.
The RT-PCR cycle .
threshold O 29 indicates the amount of viral .
, p = 0.
nucleic acid tested is enormous and vice In another study.
Mardani et al.
versa if the cycle threshold value Ou 30 indicates the minimum to moderate amount percentage of neutrophils in the COVID-19 of viral nucleic acid tested .
Viral load group was significantly higher than in the measurements from samples tissue indicate non-COVID-19 group.
Phagocytic cells such an active viral replication.
They can be as dendritic cells, macrophages/monocytes.
Ina.
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and neutrophils play an essential role in the monocytes in this study, the severe COVID- presence of SARS-CoV virus infection.
19 group had a lower absolute monocyte addition to airway epithelial cells and NK value than the non-severe group.
However, cells, it is also said that SARS-CoV-2 can this difference was not significant .
infect monocyte immune cells and circulating .
T lymphocytes in the early stages of the p = 0.
The infection rate in lymphocytes The NLR result in the COVID-19 group 9% and 27.
9% in monocytes.
was lower than the non-COVID-19 group Monocytes and T cells are involved in the .
edian value 3.
innate and adaptive immune systems.
The .
, p = 0.
In the severe destruction of these cells can result in a symptom group, the NLR value was lower in compromised immune response .
The COVID-19 compared to non-COVID-19, but decrease in monocyte value is associated with this difference was not significant .
edian the destruction of these monocyte cells.
, p = The characteristic data also found that the In the moderate symptom group, the types of complaints often found in COVID- NLR value was significantly lower between 19 cases were fever .
%) and cough COVID-19 and non-COVID-19 .
1%),
, p = significantly different from non-COVID-19 This result is inversely proportional to the previous study conducted by Mardani et In this study, between the COVID-19 .
, which showed a higher percentage of group with severe and less severe symptoms, neutrophils and a lower percentage of the percentage of neutrophils and the absolute lymphocytes in the COVID-19 group than in value of neutrophils in the severe group was the non-COVID-19 group so that in the end, higher than in the less severe group.
the NLR value was higher in the COVID-19 However, statistically, the significant value group than in the non-COVID-19 group.
The was only in the percentage of neutrophils NLR results were different in severe and non- .
edian value of 79.
severe COVID-19.
NLR in severe COVID- .
, p = 0.
19 group was significantly higher than those The percentage of monocytes in the study in the moderate-grade group .
was also not significantly different between .
, p = 0.
This the severe and non-severe COVID-19 groups result is in line with the research of Yang Ap .
edian value of 6.
et al.
and Song CY et al.
, who .
, p = 0.
For the absolute value of stated that the NLR in severe COVID-19 was Ina.
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significantly higher than those that were not enough .
nly sufficien.
because of AUC <0.
The LMR value in the COVID-19 group In a previous study.
Song CY et al.
was higher than the non-COVID-19 group.
used a cut-off >5.
8 as one of the This study also compared LMR based on the assessment parameters to determine cases of degree of disease severity between COVID- COVID-19 along with other parameters 19 and non-COVID-19.
In the severely ill made in the form of a COVID-19 early group, there was no significant difference in detection score.
LMR between COVID-19 and non-COVID- A cut-off value of Ou3.
3 indicates a 19 .
COVID-19 patient presenting with less .
, p = 0.
When the LMR ratio of the severe symptoms will develop into a severe less severe COVID-19 group was compared condition as much as 46.
1% within 6.
3 days.
to the non-COVID 19 groups, the LMR ratio Conversely, the cut-off of O3.
3 indicates that was higher in the severe COVID-19 group.
COVID-19 47 .
symptoms will experience improvement and .
, p = 0.
be outpatient within 13.
5 days .
LMR
non-severe AUC was 0.
661, with cut-off Ou3.
23, 45.
comparing the LMR value between the sensitivity, 82.
2% specificity.
therefore, the COVID-19 and non-COVID-19 groups that accuracy of the LMR parameter as a has been published, so the results of this screening for COVID-19 cases is defined as study provide new information for COVID- not good enough .
ust sufficien.
because of 19 cases.
The results of the LMR in this study AUC <0.
There for severe degrees of COVID-19 were Previous
LMR
significantly lower than the non-severe group parameters as filter parameters for COVID- .
, p = 19 is not available.
Previous studies related to LMR
COVID-19
The NLR and LMR values were studied prognostic studies to assess the clinical to find their accuracy as screening parameters outcome of COVID-19 patients.
Yang AP et for COVID-19 cases.
NLR AUC was 0.
explained that the LMR could not with a cut-off of O2.
49, 47.
6% sensitivity, be used as a good prognostic parameter in the and 80% specificity.
therefore, the accuracy case of COVID-19 because the AUC value of the NLR parameter as a screening for obtained is around 0.
265 (AUC <0.
COVID-19 cases is defined as not good Several comorbidities were not excluded Ina.
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The research data obtained only from HS and NZD contributed to the critical one of the hospitals is one of the limitations revision of the manuscript for important of this study.
intellectual content and statistical analysis We recommended that future studies All focus on searching for better and newer acquisition, analysis, or interpretation and COVID-19 reviewed the final manuscript.
sensitivity and specificity, cheap, easy, and non-invasive.
ACKNOWLEDGMENTS
The authors thank colleagues from CONCLUSIONS There were significant differences in Universitas Padjajaran Haematology (Division Medical Oncology.
Faculty of Medicin.
Hasan Sadikin General lymphocyte.
NLR, and LMR between the Hospital.
COVID-19 and non-COVID-19 groups.
(Faculty of Medicin.
, and Haji Adam Malik Nevertheless.
NLR and LMR cannot be used General Hospital for providing insight, as screening tools because the Area Under assistance, and expertise for authors.
Curve (AUC) is not good enough in detecting COVID-19.
Universitas Sumatera Utara We thank Dr.
Rico Andryan Simatupang.
Dr.
Hafiz Syaifullah Siregar.
Dr.
Giovani Christin Purba for assistance during data
AUTHOR CONTRIBUTIONS
HS had full access to all the data and took responsibility for the integrity of the data and the accuracy of the data analysis.
collection and data entry, typing, drafting, and writing the manuscript.
We also thank Mr.
Evan Susandi for his assistance in analyzing the data.
HS and THF contributed to the concept and design of the study CONFLICT OF INTEREST There are no conflicts of interest with 2019 novel coronavirus in Wuhan.
China.
The Lancet.
395: 497-506.
REFERENCES