Demographics and co morbidities for seventy nine (79) COVID 19 infections, who were admitted at World Citi Medical Center were included for analysis. Clinical characteristics are summarized in table 2 and ferritin results are presented in table 1.

Fourteen (17.7%) patients did not survive the thirty (30) days hospitalization. At the time of hospital admission, their baseline characteristics and differences were monitored in correlation with ferritin levels between patients who died and those who survived and discharged, including age 48 (19 - 65) vs 49 (24-64), with mean ferrin level for non survivor (FLNS) of 1399.10ng/ml vs among ferritin level of survivors (FLS) 1300.4 ng/ml respectively, OR 0.14; 95%( CI 3.87 to 26.77; p=0.9823), sex 71.40% vs 55.38% males, with mean FLNS of 1645.75ng/ml vs 823.5 FLS respectively, OR 1.29 95% (CI 1.4 to 1.8; p=0.0001), 28.57% vs 44.62 % females, with mean FLNS of 1069ng/ml vs 823.15ng/ml FLS respectively, OR 1.59 95% (2.2 to 3.5; p=<0.0001) and smokers 21.43% vs 23.08, with FLNS of 1523.5ng/ml vs 1489.6ng/ml FLS, OR 1.08 95% (CI 4.33 to 4.67 p=0.9132); non-smokers 78.57% vs 76.92%, with mean FLNS 823.5ng/ml vs 820.5 ng/ml FLS, OR 0.98 95% (CI 1.27 to 1.3 p=0.916) (table 2).

Specific comorbidities were also correlated to serum ferritin level. (Table 3), such as Hypertensive atherosclerotic cardiovascular disease (HASCVD) with mean ferritin level of 1187.78 ng/ml, five (5) patients out of eighteen (18) patients in this group did not survived with FLNS 1532.2ng/ml vs 623.5ng/ml FLS respectively with p value of <0.0001. Type 2 Diabetes mellitus with mean ferritin level of 1261.75 ng/ml, three (3) patients out of sixteen (16) patients did not survived with FLNS 1543ng/ml vs 1023.2 FLS with p value of <0.0001. Chronic Kidney Disease (with or without maintainance dialysis)with mean ferritin level of 1247.2 ng/ml, four (4) patients out of five (5) patients did not survived with FLNS of 1343.33ng/ml vs 1103ng/ml FLS respectively with p value of <0.0001. These top three co morbidities gave a significant impact to thirty (30) days in hospital mortality.

According to our results, consistent with previously published studies related to this paper, ferritin is associated with in hospital mortality as it is higher at the baseline admission of non-survivor patients and maintains significance after multivariable adjustment. With ferritin level of 1437.07ng/ml, poor clinical outcome and possible in hospital mortality was considered. (Table 1). We also observed that demographics and co morbidities of patients in this study were significant to predict thirty (30) days in hospital mortality. Further sub-analysis of co morbidities, HASCVD, Type 2 Diabetes Mellitus, Chronic kidney disease, Liver disease, Chronic Obstructive Pulmonary Disease and Cerebrovascular disease showed poor outcome which were directly related to ferritin levels with p value of <0.0001. (Table 3).

At present, the pathophysiology, disease evolution, diagnosis and prognosis of patients with COVID 19 pneumonia are still unclear. In one study Dahan, et al,7 they concluded that elevated ferritin levels were shown to correlate with disease severity in 39 patients from Israel with confirmed COVID 19 infection. Severe patients had significantly higher level of ferritin (2817.6ng/ml) compared to non-severe patient (708.6ng/ml) p=0.02. In another released study of Moudhi et al,11 they concluded that elevated ferritin level >1000 were found to be an independent predictor of in hospital mortality. In one study of Zhoe et al,9 with 20 COVID -`19 patients, it was found that individuals with severe and very severe COVID-19 exhibited increase serum ferritin level, being serum ferritin the very severe COVID 19 group significantly higher than in the severe COVID -19 group (1006.16 ng/ml (IQR: 408.265-1988.25) vs 291.13ng/ml (IQR:102.1-648.42), respectively). In our study, we focused more on mortality outcomes to prognosticate patient during their admissions based on the ferritin levels. In this study, we were able to correlate the ferritin mean levels of survivors to non survivors (Table 1). At ferritin level of 1437.07 ng/ml, the prognosis of in hospital mortality may be predicted. Ferritin levels and prognostication of in hospital mortality may differ based on the co - morbidities at the time of admission (Table 3). Hypertensive Atherosclerosis Cardiovascular disease, Chronic kidney disease and Type 2 Diabetes Mellitus were the top three diseases that affect the mortality of the patient. Among other diseases listed in this table (Table 3), these three mentioned diseases got the higher levels of ferritin aside from acute coronary syndrome and cerebrovascular disease. In light of this data, we postulated that ferritin levels can be used as prognostic factor for in-hospital mortality. In plasma, ferritin circulates as apoferritin, a non-iron containing molecule. The plasma level generally reflects overall iron storage, with 1ng of ferritin per ml indicating approximately 10mg of total iron stores5. Due to its crucial role in cellular iron hemostasis, it is not surprising that ferritin synthesis is tightly regulated6. It has been well established that elevated serum ferritin levels may suggest not only the presence of an iron overload state but is also a marker for inflammatory, autoimmune, infectious or malignant conditions.7. The pathogenicity of the novel SARSCoV-2 and its effects on the immune system has yet not been completely understood. However, some studies with evidence suggest that severe progressive COVID-19 disease is associated with uncontrolled inflammation and massive cytokine release 7. It is also associated with immunological abnormalities, including cytokine storm and hyperferritinemia. 8. In agreement with this, another study revealed that in patients who died by COVID -19, ferritin levels were high upon hospital admission and throughout the hospital stay10. From these collected data, we postulated that ferritin level on the day of admission, can be used as prognostic marker of hospital mortality of COVID 19 pneumonia. .12