Hospital admissions linked to SARS-CoV-2 infection in children and adolescents: cohort study of 3.2 million first ascertained infections in England

Dynamics of Multisystem Inflammatory Syndrome in Children (MIS-C) associated to COVID-19: steady severity despite declining cases and new SARS-CoV-2 variants-a single-center cohort study

Multisystem Inflammatory Syndrome in Children (MIS-C) is a serious condition associated with SARS-CoV-2 infection. The relationship between SARS-CoV-2 variants of concern (VOCs) and the occurrence and severity of MIS-C is unknown. We analyzed the dynamics of MIS-C in the Milan metropolitan area (Italy) during the COVID-19 pandemic, focusing on the epidemiologic trends and disease severity in relation to different VOCs in a single-center study. Fifty-seven MIS-C patients (mean 8.3 ± 3.8 years) admitted to the Pediatric Department of Buzzi Children's Hospital in Milan, Italy, between November 2020 and July 2022, were retrospectively included in the study. The SARS-CoV-2 variant was retrospectively identified from serological fingerprinting (profiles of serum antibodies targeting different variants of SARS-CoV-2 obtained by a label-free microarray biosensor) or by the variant of prevalence. Two main periods of MIS-C case accumulation were observed. The peak of MIS-C cases rate in December 2020 reached 0.6 cases per day, which is nearly double the rate observed in February 2022, despite the larger number of infected subjects. Although the WT variant exhibited a broader range of severity score values, the score distributions for the different variants do not show statistically relevant differences.

CONCLUSION

The results clearly show a decrease in the incidence of MIS-C in relation to infections, but also support the concept that severity of MIS-C remained essentially unchanged across different virus variants, including Omicron. The course of MIS-C, once initiated, is independent from the characteristics of the triggering variants, although later variants may be considered less likely to induce MIS-C.

WHAT IS KNOWN

• MIS-C is a rare systemic inflammatory disorder that arises as a post-infectious complication temporally related to SARS-CoV-2 infection. • Fluctuations in MIS-C incidence were observed throughout the pandemic, with the latest variants associated with a lower incidence.

WHAT IS NEW

• The SARS-CoV-2 variant of infection can be retrospectively confirmed by serum antibody fingerprinting using a label-free microarray biosensor. • Despite the decreasing incidence, MIS-C severity has remained essentially unchanged across SARS-CoV-2 variants.

Vaccination in pregnancy to protect the newborn

Infectious diseases pose a particular risk to newborns and there is a global need to protect this vulnerable group. Because of the challenges of developing vaccines that are effective in newborns, only the hepatitis B and tuberculosis vaccines are given in the first 28 days of life, and even those vaccines are mainly only offered to high-risk groups. Maternal antibodies cross the placenta and can afford some protection to the newborn, so an alternative strategy is vaccination in pregnancy. This approach has been successfully used to protect newborns against tetanus and pertussis, and vaccines that are primarily offered to protect the mother during pregnancy, such as influenza and COVID-19 vaccines, also provide some protection to newborns. A respiratory syncytial virus vaccine has recently been approved for use in pregnancy to protect newborns, and a new vaccine that will be offered during pregnancy to prevent Group B Streptococcus infection in infants is on the horizon. Here, we discuss the current vaccines that are offered during pregnancy and to newborns, the vaccines in development for future use in these groups and the challenges that remain concerning the delivery and uptake of such vaccines.

Peripandemic outcomes of infants treated for sentinel congenital heart diseases in England and Wales

BACKGROUND

Infants with congenital heart disease (CHD) are clinically vulnerable to cardiac deteriorations and intercurrent infections. We aimed to quantify the impact of health system disruptions during the COVID-19 pandemic, on their clinical outcomes and whether these differed by socioeconomic and ethnic subgroups.

METHODS

In this population-based cohort study, we used linked electronic healthcare datasets from England and Wales to identify infants with nine sentinel CHDs born and undergoing intervention in 2018-2022. The outcomes of cardiac intervention timing, infant mortality and hospital care utilisation, were described by birth eras, and risk factors were explored using multivariable regression.

RESULTS

Of 4900 included infants, 1545 (31.5%) were born prepandemic (reference), 1175 (24.0%) in the transition period, 1375 (28.0%) during restrictions and 810 (16.5%) postrestrictions. The casemix was hypoplastic left heart syndrome (195; 3.9%), functionally univentricular heart (180; 3.7%), transposition (610; 13.5%), pulmonary atresia (290; 5.9%), atrioventricular septal defect (590; 12.1%), tetralogy of Fallot (820; 16.7%), aortic stenosis (225; 4.6%), coarctation (740; 15.1%) and ventricular septal defect (1200; 24.5%).Compared with prepandemic, there was no evidence for delay in treatment procedures in transition, restrictions or postrestrictions eras. Infant mortality increased for those born in the transition period, adjusted OR 1.60 (95% CI 1.06, 2.42) p=0.01, but not in restrictions or postrestrictions. The days spent at home were similar with birth in transition and restrictions, but fewer for postrestrictions, adjusted days difference -2 (95% CI -4, 0), p=0.05.Outcomes did not vary by pandemic birth era according to social characteristics. There was higher infant mortality in the deprived versus non-deprived binary category (adjusted OR 1.56 (95% CI 1.11, 2.18), p=0.004) and there were fewer days spent at home for the most versus least deprived neighbourhood quintile (adjusted difference -4 (95% CI -6, -2), p<0.001).

CONCLUSIONS

Specialist care for infants with CHD during the pandemic, in terms of pathway procedure timing and healthcare contacts, was not compromised. Increased healthcare utilisation postpandemic and heath inequality based on socioeconomic status require further evaluation.

Deaths in children in England from SARS-CoV-2 infection during the first 2 years of the pandemic: a cohort study

OBJECTIVE

The aim of this analysis was to describe the epidemiology, demographics and characteristics of children and young people (CYP) who died of SARS-CoV-2 infection in England during the first 2 years of the pandemic.

DESIGN

The cohort investigated in this study is all CYP, born alive at, or after, 22 weeks of gestation, who died before their 18th birthday between 1 February 2020 and 31 March 2022 in England. All cases were reviewed to identify if SARS-CoV-2 probably, or possibly, contributed to death. Mortality rates were calculated, assuming a Poisson distribution, for the whole population, and split by demographics and patient characteristics.

SETTING

England.

PARTICIPANTS

6389 CYP deaths in England reported to the National Child Mortality Database (NCMD).

MAIN OUTCOME

Risk of death.

RESULTS

88 of the 6389 deaths of CYP were identified as deaths probably due to COVID-19. Thus, COVID-19 was responsible for 1.4% of all deaths of CYP in this 26-month period. Overall mortality rate due to COVID-19 in CYP was 3.59 (2.88-4.42) per 1 000 000 person years, being highest in the youngest (< 5 years; 4.68 (3.16-6.68)) and oldest (16/17 years; 4.83 (2.57-8.26)) CYP. Asian and Black CYP had higher mortality than those from white backgrounds (p<0.001), and mortality rate increased with increasing deprivation. The majority (61/77, 79.2) of CYP who died of COVID had a documented life limiting condition.

CONCLUSIONS

Mortality rates were highest in less than 5 years old. Despite social changes, and shielding of vulnerable CYP, children with life-limiting (but not necessarily life-threatening) conditions, appeared to have the highest mortality rates, similar to that seen in adults with comparable underlying conditions. The risk of death in more deprived neighbourhoods and in those from Asian and Black ethnic backgrounds was increased, and this was not explained by their other demographic characteristics.

Postacute COVID-19 fatigue, dyspnea and reduced activity in children and adolescents

BACKGROUND

This study aimed to quantify fatigue, dyspnea, and physical activity and identify associated factors in children and adolescents with postacute COVID-19 syndrome.

METHODS

A prospective cohort study included 74 participants aged 6-18 years with postacute COVID-19 symptoms and 120 age- and sex-matched controls without SARS-CoV-2 antibodies. Participants completed questionnaires assessing fatigue, dyspnea, and physical activity and underwent pulmonary function tests.

RESULTS

Children with postacute COVID-19 syndrome reported significantly greater fatigue (parent-rated scores: mean 67.9 vs. 82.4, p < 0.001; child-rated scores: 73.7 vs. 83.0, p < 0.001), increased dyspnea (mMRC grades 3-4: 10.9% vs. 4.1%, p = 0.001), and lower physical activity (median 787.8 vs. 1658.5 MET*min/week, p < 0.001) than controls. They also had a higher prevalence of mixed (8.1% vs. 1.7%, p = 0.029) and restrictive lung disease (29.7% vs. 10.8%, p = 0.001). Older age and COVID-19 were identified as risk factors for fatigue and reduced activity. Fatigue correlated with reduced physical activity but not with pulmonary function.

CONCLUSION

Children and adolescents with postacute COVID-19 syndrome, particularly older individuals, experience greater fatigue and reduced physical activity than controls. These findings highlight the importance of quantifying postacute COVID-19 symptoms and their associations with physiological assessments.

IMPACT

This prospective, age- and sex-matched cohort study revealed that children and adolescents with postacute COVID-19 syndrome perceived higher fatigue levels, had higher dyspnea scores, had a greater prevalence of mixed lung and restrictive lung disease, and exhibited less physical activity than their control counterparts. Fatigue correlated with reduced physical activity but was not consistently correlated with pulmonary function test results. This study highlights the importance of quantifying postacute COVID-19 symptoms and exploring the associations between individual symptoms and the impact of coronavirus infection on various systems, including the neurological, musculoskeletal, cardiopulmonary, and immune systems.

COVID-19 vaccine effectiveness and uptake in a national cohort of English children and young people with life-limiting neurodisability

OBJECTIVE

To investigate SARS-CoV-2 vaccine uptake and effectiveness in children and young people (CYP) with life-limiting neurodisability.

DESIGN

We undertook a retrospective cohort study using national hospital data in England from 21 December 2020 to 2 September 2022 to describe SARS-CoV-2 vaccination uptake, and then examined COVID-19 hospitalisation, paediatric intensive care unit (PICU) admission and death following SARS-CoV-2 infection by vaccination status using Cox regression models.

PATIENTS

CYP aged 5-17 with life-limiting neurodisability.

RESULTS

We identified 38 067 CYP with life-limiting neurodisability; 13 311 (35.0%) received at least one SARS-CoV-2 vaccine, with uptake higher among older, white CYP, from less deprived neighbourhoods. Of 8134 CYP followed up after a positive SARS-CoV-2 test, 1547 (19%) were vaccinated. Within 28 days of infection, 309 (4.7%) unvaccinated CYP were hospitalised with COVID-19 compared with 75 (4.8%) vaccinated CYP. 46 (0.7%) unvaccinated CYP were admitted to PICU compared with 10 (0.6%) vaccinated CYP. 20 CYP died within 28 days of SARS-CoV-2 infection, of which 13 were unvaccinated. Overall, adjusted hazard of hospitalisation for COVID-19 or admission to PICU did not vary by vaccination status. When the Alpha-Delta SARS-CoV-2 variants were dominant, hazard of hospitalisation with COVID-19 was significantly lower among vaccinated CYP (HR 0.26 (0.09 to 0.74)), with no difference seen during Omicron (HR 1.16 (0.74 to 1.81)).

CONCLUSIONS

SARS-CoV-2 vaccination was protective of COVID-19 hospitalisation among CYP with life-limiting neurodisability during Alpha-Delta, but not for other SARS-CoV-2 variants. Vaccine uptake was low and varied by ethnicity and deprivation.

Child mortality in England after national lockdowns for COVID-19: An analysis of childhood deaths, 2019-2023

BACKGROUND

During the COVID-19 pandemic children and young people (CYP) mortality in England reduced to the lowest on record, but it is unclear if the mechanisms which facilitated a reduction in mortality had a longer lasting impact, and what impact the pandemic, and its social restrictions, have had on deaths with longer latencies (e.g., malignancies). The aim of this analysis was to quantify the relative rate, and causes, of childhood deaths in England, before, during, and after national lockdowns for COVID-19 and its social changes.

METHODS AND FINDINGS

Deaths of all children (occurring before their 18th birthday) occurring from April 2019 until March 2023 in England were identified. Data were collated by the National Child Mortality Database. Study population size and the underlying population profile was derived from 2021 Office of National Statistics census data Mortality for each analysis year was calculated per 1,000,000 person years. Poisson regression was used to test for an overall trend across the time period and tested if trends differed between April 2019 to March 2021 (Period 1)) and April 2021 to March 2023 (Period 2: after lockdown restrictions). This was then repeated for each category of death and demographic group. Twelve thousand eight hundred twenty-eight deaths were included in the analysis. Around 59.4% of deaths occurred under 1 year of age, 57.0% were male, and 63.9% were of white ethnicity. Mortality rate (per 1,000,000 CYP per year) dropped from 274.2 (95% CI 264.8-283.8) in 2019-2020, to 242.2 (95% CI 233.4-251.2) in 2020-2021, increasing to 296.1 (95% CI 286.3-306.1) in 2022-2023. Overall, death rate reduced across Period 1 (Incidence rate ratio (IRR) 0.96 (95% CI 0.92-0.99)) and then increased across Period 2 (IRR 1.12 (95% CI 1.08-1.16)), and this pattern was also seen for death by Infection and Underlying Disease. In contrast, rate of death after Intrapartum events increased across the first period, followed by a decrease in rate in the second (Period 1 IRR 1.15 (95% CI 1.00-1.34)) versus Period 2 (IRR 0.78 (95% CI 0.68-0.91), pdifference = 0.004). Rates of death from preterm birth, trauma and sudden unexpected deaths in infancy and childhood (SUDIC), increased across the entire 4-year-study period (preterm birth, IRR 1.03 (95% CI 1.00-1.07); trauma IRR 1.12 (95% CI 1.06-1.20); SUDIC IRR 1.09 (95% CI 1.04-1.13)), and there was no change in the rate of death from Malignancy (IRR 1.01 (95% CI 0.95-1.06)). Repeating the analysis, split by child characteristics, suggested that mortality initially dropped and subsequently rose for children between 1 and 4 years old (Period 1 RR 0.85 (95% CI 0.76-0.94) versus Period 2 IRR 1.31 (95% CI 1.19-1.43), pdifference < 0.001. For Asian, black and Other ethnic groups, we observed increased rates of deaths in the period 2021-2023, and a significant change in trajectory of death rates between Periods 1 and 2 (Asian (Period 1 IRR 0.93 (95% CI 0.86-1.01) versus Period 2 IRR 1.28 (95% CI 1.18-1.38), pdifference < 0.001); black (Period 1 IRR 0.97 (95% CI 0.85-1.10) versus Period 2 IRR 1.27 (95% CI 1.14-1.42), pdifference = 0.012); Other (Period 1 IRR 0.84 (95% CI 0.68-1.04) versus Period 2 IRR 1.45 (95% CI 1.20-1.75), pdifference = 0.003). Similar results were observed in CYP in the most deprived areas (Period 1 IRR 0.95 (95% CI 0.89-1.01) versus Period 2 IRR 1.18 (95% CI 1.12-1.25), pdifference < 0.001). There was no change in the trajectory of death rates for children from white (p = 0.601) or mixed (p = 0.823) ethnic backgrounds, or those in the least deprived areas (p = 0.832), between Periods 1 and 2; with evidence of a rise across the whole study period for children from white backgrounds (IRR 1.05 (95% CI 1.03-1.07), p < 0.001) and those in the least deprived areas (IRR 1.06 (95% CI 1.01-1.10), p < 0.001). Limitations include that the population at risk was estimated at a mid-point of the study, and changes may have biased our estimates. In particular, absolute rates should be interpreted with caution. In addition, child death in England is rare, which may further limit interpretation; particularly in the stratified analyses.

CONCLUSIONS

In this study, overall child mortality in England after the national lockdowns was higher than before them. We observed different temporal profiles across the different causes of death, with reassuring trends in deaths from Intrapartum deaths after lockdowns were lifted. However, for all other causes of death, rates are either static, or increasing. In addition, the relative rate of dying for children from non-white backgrounds, compared to white children, is now higher than before or during the lockdowns.

Characteristics of Children Ages 1-17 Who Died of COVID-19 in 2020-2022 in the United States

OBJECTIVES

This study describes characteristics of children ages 1 to 17 years who died of coronavirus disease 2019 (COVID-19) in 2020 to 2022 and whose deaths were reviewed by child death review (CDR) teams across the United States.

METHODS

We used data in the National Fatality Review-Case Reporting System to examine children who died of COVID-19. Deaths were determined because of COVID-19 from death certificates or CDR determinations.

RESULTS

A total of 183 children 1 to 17 years old who died of COVID-19 were reported in the National Fatality Review-Case Reporting System. One-third (33%) were 15- to 17-year-olds, and 26% were 1- to 4-year-olds. Fifty-six percent were reported as male, 54% white, 24% Black, and 18% Hispanic ethnicity. Physicians declared cause of death in at least 82% of deaths. More than two-thirds (68%) had a medical condition (excluding COVID-19) at time of death. The most common conditions were nervous system disorders (19%), congenital disorders (14%), obesity (12%), respiratory disorders (12%), and neurodevelopmental disorders (10%). Of children with an underlying condition, 35% had 3 or more conditions. Less than half (42%) had contact with a health care provider within a month of their death; and three-fourths died within 14 days of exposure.

CONCLUSIONS

This study describes the demographics, death investigation findings, and medical conditions of children who died of COVID-19. The results highlight the short timeline between COVID-19 exposure and death. Pandemic planning that prioritizes prevention efforts and timely access to effective medical care may result in saving children's lives.

The seroprevalence of SARS-CoV-2-specific antibodies in Australian children: A cross-sectional study

BACKGROUND

Following reduction of public health and social measures concurrent with SARS-CoV-2 Omicron emergence in late 2021 in Australia, COVID-19 case notification rates rose rapidly. As rates of direct viral testing and reporting dropped, true infection rates were most likely to be underestimated.

OBJECTIVE

To better understand infection rates and immunity in this population, we aimed to estimate SARS-CoV-2 seroprevalence in Australians aged 0-19 years.

METHODS

We conducted a national cross sectional serosurvey from June 1, 2022, to August 31, 2022, in children aged 0-19 years undergoing an anesthetic procedure at eight tertiary pediatric hospitals. Participant questionnaires were administered, and blood samples tested using the Roche Elecsys Anti-SARS-CoV-2 total spike and nucleocapsid antibody assays. Spike and nucleocapsid seroprevalence adjusted for geographic and socioeconomic imbalances in the participant sample compared to the Australian population was estimated using multilevel regression and poststratification within a Bayesian framework.

RESULTS

Blood was collected from 2,046 participants (median age: 6.6 years). The overall adjusted seroprevalence of spike-antibody was 92.1% (95% credible interval (CrI) 91.0-93.3%) and nucleocapsid-antibody was 67.0% (95% CrI 64.6-69.3). In unvaccinated children spike and nucleocapsid antibody seroprevalences were 84.2% (95% CrI 81.9-86.5) and 67.1% (95%CrI 64.0-69.8), respectively. Seroprevalence was similar across geographic remoteness index and socioeconomic quintiles. Nucleocapsid antibody seroprevalence increased with age while the point seroprevalence of the spike antibody seroprevalence decreased in the first year of life and then increased to 97.8 (95% Crl 96.1-99.2) by 12-15 years of age.

CONCLUSION

Most Australian children and adolescents aged 0-19 years, across all jurisdictions were infected with SARS-CoV-2 by August 2022, suggesting rapid and uniform spread across the population in a very short time period. High seropositivity in unvaccinated children informed COVID-19 vaccine recommendations in Australia.

COVID-19-related hospitalizations among Aotearoa, New Zealand children during the Omicron era of SARS-CoV-2

Objectives

This multicenter cohort study describes Aotearoa New Zealand children hospitalized during the country's first wave of sustained SARS-CoV-2 transmission, Omicron variant.

Methods

Children younger than 16 years, hospitalized for >6 hours with COVID-19 across New Zealand from January to May 2022 were included. Admissions for all Māori and Pacific and every second non-Maori non-Pacific children were selected to support equal explanatory power for ethnic grouping. Attribution of hospital admission, demography, clinical presentation, comorbidity, treatment, and outcome data were collected.

Results

Of 444 hospitalizations of children positive for COVID-19, 292 (65.5%) from 290 children were considered admissions attributable to COVID-19. Of these admissions, 126 (43.4%) were aged under 1; 118 (40.7%), 99 (34.1%), and 87 (30.0%) were children of Māori, Pacific, and non-Maori non-Pacific ethnicity, respectively. Underlying respiratory disease was the most common comorbidity, present in 22 children (7.6%); 16 children (5.5%) were immunosuppressed. Median length of stay was 1 day (interquartile range 0.0-2.0). Four children received antiviral, 69 (24%) antibacterial, and 24 (8%) supplemental oxygen. Although eight children required intensive care, there were no deaths.

Conclusions

Children hospitalized during the first significant wave of SARS-CoV-2 infection in New Zealand presented with a multi-system viral illness and rarely with severe disease.

Have immigrant children been left behind in COVID-19 testing rates? - A quantitative study in the Lisbon metropolitan area between march 2020 and may 2023

Immigrant children often encounter additional barriers in accessing health care than their peers. However, there is a lack of evidence globally regarding how migrant status may have affected access to COVID-19 testing during the pandemic. This study aimed to analyze migrant status as a determinant of COVID-19 testing rates among children in the Lisbon metropolitan area, Portugal. This cross-sequential study included 722 children aged 2-8 years (47% non-immigrants; 53% immigrants). We collected data from a national surveillance system on laboratory-confirmed COVID-19 tests conducted between March 2020 and May 2023 and assessed whether children were ever tested for COVID-19 and testing frequency. We employed robust and standard Poisson regression models to estimate Adjusted Prevalence Ratios and Relative Risks with 95% confidence intervals. A total of 637 tests were performed. Immigrant children had lower testing rates (53% vs. 48%) and fewer tests per child (median: 2 vs. 3). Moreover, they were 17% less likely to be ever tested (PR = 0.83, 95% CI: 0.76-0.89) and performed 26% fewer tests (RR = 0.74, 95% CI: 0.67-0.82) compared to non-immigrant children. Caregiver's age, education, employment status, child's birth weight, and perceived health status were associated factors. Our findings suggest that the COVID-19 pandemic has left immigrant children somewhat behind. We conclude that specific interventions targeting vulnerable populations, such as immigrant children, are needed in future health crises.

Emerging and re-emerging pediatric viral diseases: a continuing global challenge

The twenty-first century has been marked by a surge in viral epidemics and pandemics, highlighting the global health challenge posed by emerging and re-emerging pediatric viral diseases. This review article explores the complex dynamics contributing to this challenge, including climate change, globalization, socio-economic interconnectedness, geopolitical tensions, vaccine hesitancy, misinformation, and disparities in access to healthcare resources. Understanding the interactions between the environment, socioeconomics, and health is crucial for effectively addressing current and future outbreaks. This scoping review focuses on emerging and re-emerging viral infectious diseases, with an emphasis on pediatric vulnerability. It highlights the urgent need for prevention, preparedness, and response efforts, particularly in resource-limited communities disproportionately affected by climate change and spillover events. Adopting a One Health/Planetary Health approach, which integrates human, animal, and ecosystem health, can enhance equity and resilience in global communities. IMPACT: We provide a scoping review of emerging and re-emerging viral threats to global pediatric populations This review provides an update on current pediatric viral threats in the context of the COVID-19 pandemic This review aims to sensitize clinicians, epidemiologists, public health practitioners, and policy stakeholders/decision-makers to the role these viral diseases have in persistent pediatric morbidity and mortality.

Symptom Profiles of Children and Young People 12 Months after SARS-CoV-2 Testing: A National Matched Cohort Study (The CLoCk Study)

BACKGROUND

Although 99% of children and young people have been exposed to SARS-CoV-2, the long-term prevalence of post-COVID-19 symptoms in young people is unclear. The aim of this study is to describe symptom profiles 12 months after SARS-CoV-2 testing.

METHOD

A matched cohort study of a national sample of 20,202 children and young people who took a SARS-CoV-2 PCR test between September 2020 and March 2021.

RESULTS

12 months post-index-test, there was a difference in the number of symptoms reported by initial negatives who never tested positive (NN) compared to the other three groups who had at least one positive test (p < 0.001). Similarly, 10.2% of the NN group described five-plus symptoms at 12 months compared to 15.9-24.0% in the other three groups who had at least one positive test. The most common symptoms were tiredness, sleeping difficulties, shortness of breath, and headaches for all four groups. For all these symptoms, the initial test positives with subsequent reports of re-infection had higher prevalences than other positive groups (p < 0.001). Symptom profiles, mental health, well-being, fatigue, and quality of life did not vary by vaccination status.

CONCLUSIONS

Following the pandemic, many young people, particularly those that have had multiple SARS-CoV-2 positive tests, experience a range of symptoms that warrant consideration and potential investigation and intervention.