COVID-19 and inequities in the Americas: lessons learned and implications for essential health services

Strategies and challenges for maintaining the continuity of essential health services during a pandemic: a scoping review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on health systems worldwide, resulting in disruptions to essential health service delivery, such as routine immunizations, maternal and child health, and treatment for communicable and noncommunicable diseases. These services have been disrupted due to the diversion of resources towards the COVID-19 response. Therefore, the objective of this scoping review was to identify the strategies and challenges associated with maintaining the continuity of essential health services during a pandemic.

METHODS

This scoping review study was conducted in 2023 using the proposed Arksey and O'Malley framework. We conducted searches on PubMed, Scopus, ProQuest, and Web of Science using relevant keywords. Additionally, we searched Google Scholar, hand-searched reference lists of included studies, and reviewed organizational reports, websites, and other sources of information. Content analysis was employed to summarize the themes from the selected articles.

RESULTS

Our search of major databases yielded 3,732 results. After the screening process, 47 articles were included in the scoping review. The extracted interventions were classified into six groups based on the building blocks of the World Health Organization health system: leadership and governance, access to essential medicines, health systems financing, the health workforce, health service delivery, and health information systems.

CONCLUSIONS

The implementation of effective strategies and interventions can help ensure the provision of essential health services during a pandemic. These strategies include leveraging technology for remote care, ensuring the safety of healthcare workers and patients, strengthening supply chains, and establishing flexible and adaptive healthcare systems.

Disruption to diabetes and hypertension care during the COVID-19 pandemic in Latin America and the Caribbean and mitigation approaches: a scoping review

BACKGROUND

The COVID-19 pandemic disrupted care for non-communicable diseases globally. This study synthesizes evidence on disruptions to primary care, focusing on hypertension and diabetes care and mitigation approaches taken during the pandemic in Latin America and the Caribbean (LAC).

METHODS

We conducted a scoping review, searching nine electronic databases for studies from January 2020 to December 2022 on COVID-19-related primary care disruptions and interventions, including studies on hospital-based interventions given their relevance to the pandemic response in LAC. We adapted the Primary Health Care Performance Initiative framework to develop our search strategy and synthesize data. For studies reporting interventions, we included studies conducted outside of LAC.

RESULTS

Of 33,510 references screened, 388 studies were included (259 reported disruptions in LAC, 61 interventions in LAC, 63 interventions outside LAC, and five interventions from countries within and outside LAC), with three-quarters presenting data from Brazil, Argentina, Mexico, and Peru; few studies focused on rural areas. Additionally, the few studies that adequately quantified care disruptions reported a reduction in hypertension and diabetes control during the pandemic (e.g., hypertension control rate decreased from 68 to 55% in Mexico). Frequently reported causes of disruption included burnout and mental health challenges among healthcare workers (with disproportionate effects by type of worker), reduced medication supplies, and reduced frequency of clinic visits by patients (e.g., due to financial constraints). The most reported interventions included remote care strategies (e.g., smartphone applications, virtual meeting platforms) and mental health programs for healthcare workers. Remote care strategies were deemed feasible for care delivery, triaging, and clinical support for non-physicians. Patients were generally satisfied with telemedicine, whereas providers had mixed perceptions. Robust evidence on the effectiveness of remote care strategies for diabetes and hypertension care was unavailable in LAC.

CONCLUSION

Hypertension and diabetes control appeared to worsen in LAC during the pandemic. Major reported causes of care disruptions were workforce issues, reduced medication supply, and changes in patient perceptions of seeking and receiving primary healthcare. Remote care strategies were feasible for various purposes and were well received by patients. However, the lack of data on intervention effectiveness underscores the importance of strengthening research capacity to generate robust evidence during future pandemics. Developing resilient healthcare systems able to provide care for hypertension and diabetes during future pandemics will depend on investment in the healthcare workforce, medical supply chain, health data and research infrastructure, and technology readiness.

Socioecology and Prevalence of SARS-CoV-2 Infection in Quilombolas Living in the Brazilian Amazon

OBJECTIVES

This cross-sectional study presents socioecological, epidemiological aspects, and the seroprevalence of immunoglobulin G (IgG) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a group of quilombola (afro-derived) communities in the states of Pará and Tocantins, in the Brazilian Amazon, to evaluate the impact of SARS-CoV-2 prevalence among them.

METHODS

A total of 551 individuals participated. The detection of anti-SARS-CoV-2 antibodies was performed using an enzyme immunoassay. Socioeconomic and ecological data was collected from all participants 7 years of age or older who were not previously vaccinated.

RESULTS

The seroprevalence of antibodies in both states was 40.7% and was associated with factors such as age group, contact with infected individuals, and being in lockdown inside the quilombos. In Pará, a statistically significant association was observed between seroprevalence and females, and the age group of 12-18 years. In addition, seroprevalence in Pará was higher than in Tocantins, and the reported use of masks was a protective factor, while in Tocantins, the reported use of masks was associated with the presence of antibodies. There was no association between the prevalence of antibodies and the presence of COVID-19 symptoms in Pará. However, in Tocantins, diarrhea and loss of taste were associated with infection.

CONCLUSIONS

Quilombola are highly vulnerable groups due to the long history of enslavement in Brazil. This is the first investigation of SARS-CoV-2 seroprevalence and its impact in these groups in the Amazon. The study helps us to understand the relationship of socioecological differences, behavioral characteristics, and the dynamics of viral transmission associated with the risk of infection by SARS-CoV-2 among traditional populations, and can be useful to the planning of more culturally adequate public health policies for future epidemics.

Exploring women's postpartum experiences during the COVID-19 pandemic: A mixed-method analysis

PROBLEM

While studies across the United States have explored how the perinatal period was affected by COVID-19, most studies have focused on pregnancy and delivery rather than on women's postpartum experiences.

BACKGROUND

Postpartum is a critical period of development for mothers and newborns, with factors such as maternal mental health and quality of mother-infant bonding playing instrumental roles in children's socioemotional outcomes. Yet, COVID-19 served as a significant stressor for many women and acted as a barrier to receiving postpartum supports.

AIM

The current mixed-method analysis further elucidates women's postpartum experiences during COVID-19.

METHOD

New mothers (N = 20) completed interviews on how the pandemic impacted their postpartum experience, as well as a survey about mental health and mother-infant bonding.

FINDINGS

Thematic analysis of interview data identified four themes: Uncertainty surrounding medical care and hospital policies; Lack of connection with social supports; Increased family bonding; Access to community resources. Survey data indicated 57.9 % of participants experienced anxiety symptoms, 68.4 % experienced depressive symptoms, and 36.8 % experienced some bonding difficulty. When evaluated together, it was found that women who endorsed time away from children during hospital stays had significantly lower postpartum anxiety and less difficulty bonding compared to women who did not endorse this subtheme, while women who reported isolation from leisure activities had significantly greater difficulty with bonding.

CONCLUSION

The study highlights the importance of information sharing around community resources and indicates a need for further exploration of how various forms of social support (e.g., immediate family vs. broader networks) impact the wellbeing of postpartum women.

Association between SARS-CoV-2 viral load and serum biomarkers with mortality in Mexican patients

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has resulted in high mortality among hospitalized patients; thus, identifying mortality markers in treating these patients is essential. To evaluate the association between viral load and serum biomarkers with mortality among hospitalized patients with COVID-19.

MATERIALS AND METHODS

A retrospective cohort study was conducted among 198 inpatient records from a tertiary hospital in Mexico City between January and April 2021. The association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and serum biomarkers with death due to COVID-19 was assessed using Cox regression models.

RESULTS

The median age was 54.9 years, and 61.6% were males. The mortality rate was 43.4%. After adjusting for potential confounders, patients with higher viral load [adjusted hazard ratio (aHR) = 1.56; 95% confidence interval (95% CI) = 1.01, 2.42; P value = 0.041]; and higher concentrations of BUN (aHR = 4.87;95% CI = 2.70, 8.79; P value = 0.001), creatinine (aHR = 1.60;95% CI = 1.01, 2.54; P value = 0.043), osmolality (aHR = 4.37;95% CI = 2.34, 8.14; P value = 0.001), and glucose (aHR = 2.41;95% CI = 1.40, 4.18; P value = 0.001) were more likely to have a fatal prognosis. Conversely, mortality risk was lower among patients with high concentrations of lymphocytes (aHR = 0.47;95% CI = 0.30, 0.72; P value = 0.001).

CONCLUSION

SARS-CoV-2 viral load and serum biomarkers such as BUN, creatinine, glucose, osmolarity, and lymphocytes could help physicians identify individuals who require closer monitoring.

A Population-Based Epidemiologic Study of Symptomatic SARS-CoV-2 Infections and Fatalities in Brazilian Children over 3 Years

OBJECTIVE

To provide a comprehensive overview of the epidemiologic characteristics, outcomes, and risk factors of COVID-19-related deaths in children and adolescents in Brazil.

STUDY DESIGN

We conducted a population-based, retrospective cohort study that included all patients aged <18 years with laboratory-confirmed, symptomatic SARS-CoV-2 infection as registered in official Brazilian national surveillance systems for COVID-19 between February 2020 and February 2023. The primary outcome was COVID-19-related deaths. Odds ratios (ORs) of risk factors associated with death were estimated using multivariable logistic regression.

RESULTS

Over a 3-year period, 2 855 704 pediatric patients with symptomatic SARS-CoV-2 infection were registered in Brazil. Of these, 59 179 (2.1%) were hospitalized, 13 844 (0.48%) were admitted to the intensive care unit, and 4943 (0.17%) received mechanical ventilation. A total of 4740 (0.17%) patients had fatal outcomes. The case fatality rate increased to 7.9% among patients who required hospitalization; 2102 (44.3%) patients who died did not receive advanced critical support. Notably, 2 (65%, 95% CI 58-71) or 3 doses (86%, 95% CI 81-89) of the vaccine provided strong protection against death. The following adjusted covariates were significantly associated with increased odds of death: age (0-4 and 11-17 years), ethnicity (Brown and Indigenous), region (Northeast or North), dyspnea, nosocomial infection, and comorbidities. Conversely, living in the South or Central-West regions, admission in the later period of the pandemic, and receiving a vaccine were all associated with protection against death.

CONCLUSIONS

Our findings suggest that a complex interplay between individual factors and social inequities has shaped the impact of COVID-19 on Brazilian children and adolescents.

La equidad en la campaña de vacunación COVID de la Provincia de Buenos Aires (Argentina): un análisis del Municipio de Quilmes

INTRODUCCIÓN

la pandemia de la COVID-19 ha acentuado las desigualdades sociales, económicas y relacionadas con la salud, afectando desproporcionadamente a las personas en situación de vulnerabilidad y perpetuando la inequidad en salud. En Argentina se implementó una campaña nacional gratuita de vacunación contra la COVID-19 con una perspectiva de equidad.

OBJETIVO

identificar desigualdades territoriales en el acceso a la vacunación contra la COVID-19 en Quilmes.

MÉTODOS

se analizó la información referida a la vacunación contra la COVID-19 de personas residentes en el Municipio. Se efectuó la georreferenciación de cada vacunatorio y de cada persona a partir del domicilio declarado en el momento de la vacunación. Para caracterizar el grado de vulnerabilidad de las personas vacunadas, a cada una se le asignó el índice de carencias múltiples (ICM) correspondiente al radio censal de residencia.

RESULTADOS

al menos el 82 % de la población completó el esquema primario de vacunación (dosis 1 y dosis 2), porcentaje que alcanzó el 97 % en los mayores de 65 años. Analizando la media de dosis aplicadas se observa algo similar con un gradiente hacia los quintiles más altos pero con una mínima diferencia entre sí, situación que también se corrobora en todos los grupos etarios.

DISCUSIÓN

no se observaron brechas significativas entre los diferentes niveles socioeconómicos. Si bien se observó un mínimo gradiente en el promedio de dosis recibidas, el tiempo de acceso a las diferentes vacunas y el porcentaje de esquemas primarios completos recibidos, las mismas tienen escasa relevancia clínica y sanitaria.

Effectiveness and Implementation of a Text Messaging mHealth Intervention to Prevent Childhood Obesity in Mexico in the COVID-19 Context: Mixed Methods Study

BACKGROUND

Promoting physical activity (PA) and healthy feeding (HF) is crucial to address the alarming increase in obesity rates in developing countries. Leveraging mobile phones for behavior change communication to encourage infant PA and promote HF is particularly significant within the Mexican context.

OBJECTIVE

This study aims to explore the effectiveness and feasibility of mHealth interventions aimed at promoting PA and HF among primary caregivers (PCs) of Mexican children under the age of 5 years. Additionally, the study aims to disseminate insights gained from intervention implementation amidst the COVID-19 pandemic and assess the potential of behavior change mHealth interventions on a broader population scale.

METHODS

NUTRES, an mHealth intervention, underwent an effectiveness-implementation hybrid trial. Over 36 weeks, participants in the intervention group (IG), totaling 230 individuals, received approximately 108 SMS text messages tailored to their children's age. These messages covered topics such as PA and HF and emphasized the significance of proper child nutrition amidst the COVID-19 pandemic. NUTRES participants were recruited from both urban and rural health units across 2 states in Mexico. Given the COVID-19 context, both baseline and follow-up surveys were conducted via mobile or fixed telephone. The evaluation of effectiveness and implementation used a mixed methods approach. Qualitative analysis delved into participants' experiences with NUTRES and various implementation indicators, including acceptance, relevance, and coverage. Grounded theory was used for coding and analysis. Furthermore, difference-in-differences regression models were used to discern disparities between groups (comparison group [CG] versus IG) concerning knowledge and practices pertaining to infant PA and HF.

RESULTS

Of the total 494 PCs enrolled in NUTRES, 334 persisted until the end of the study, accounting for 67.6% (334/494) participation across both groups. A majority of PCs (43/141, 30.5%, always; and 97/141, 68.8%, sometimes) used the SMS text message information. Satisfaction and acceptability toward NUTRES were notably high, reaching 98% (96/98), with respondents expressing that NUTRES was "good," "useful," and "helpful" for enhancing child nutrition. Significant differences after the intervention were observed in PA knowledge, with social interaction favored (CG: 8/135, 5.9% vs IG: 20/137, 14.6%; P=.048), as well as in HF practice knowledge. Notably, sweetened beverage consumption, associated with the development of chronic diseases, showed divergence (CG: 92/157, 58.6% vs IG: 110/145, 75.9%; P=.003). In the difference-in-differences model, a notable increase of 0.03 in knowledge regarding the benefits of PA was observed (CG: mean 0.13, SD 0.10 vs IG: mean 0.16, SD 0.11; P=.02). PCs expressed feeling accompanied and supported, particularly amidst the disruption of routine health care services during the COVID-19 pandemic.

CONCLUSIONS

While NUTRES exhibited a restricted impact on targeted knowledge and behaviors, the SMS text messages functioned effectively as both a reminder and a source of new knowledge for PCs of Mexican children under 5 years of age. The key lessons learned were as follows: mHealth intervention strategies can effectively maintain communication with individuals during emergencies, such as the COVID-19 pandemic; methodological and implementation barriers can constrain the effectiveness of mHealth interventions; and using mixed methods approaches ensures the complementary nature of results. The findings contribute valuable evidence regarding the opportunities and constraints associated with using mobile phones to enhance knowledge and practices concerning PA and HF among PCs of children under 5 years old.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04250896; https://clinicaltrials.gov/ct2/show/NCT04250896.

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity

BACKGROUND

The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala's public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals.

METHODS

Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic's onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of "Reach, Effectiveness, Adoption, Implementation and Maintenance," RE-AIM (Reach, Implementation delivery + adaptations), and "Practical Robust Implementation and Sustainability Model," PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019-July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations.

RESULTS

Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability.

CONCLUSIONS

Recognition of an EBI's benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation.

TRIAL REGISTRATION

NCT03504124.

Disruption of diabetes and hypertension care during the COVID-19 pandemic and recovery approaches in the Latin America and Caribbean region: a scoping review protocol

INTRODUCTION

The COVID-19 pandemic significantly disrupted primary healthcare globally, with particular impacts on diabetes and hypertension care. This review will examine the impact of pandemic disruptions of diabetes and hypertension care services and the evidence for interventions to mitigate or reverse pandemic disruptions in the Latin America and Caribbean (LAC) region.

METHODS AND ANALYSES

This scoping review will examine care delivery disruption and approaches for recovery of primary healthcare in the LAC region during the COVID-19 pandemic, focusing on diabetes and hypertension awareness, detection, treatment and control. Guided by Arksey and O'Malley's scoping review methodology framework, this protocol adheres to the Joanna Briggs Institute guidelines for scoping review protocols and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for protocol development and scoping reviews. We searched MEDLINE, CINAHL, Global Health, Embase, Cochrane, Scopus, Web of Science and LILACS for peer-reviewed literature published from 2020 to 12 December 2022 in English, Spanish or Portuguese. Studies will be considered eligible if reporting data on pandemic disruptions to primary care services within LAC, or interventions implemented to mitigate or reverse pandemic disruptions globally. Studies on COVID-19 or acute care will be excluded. Two reviewers will independently screen each title/abstract for eligibility, screen full texts of titles/abstracts deemed relevant and extract data from eligible full-text publications. Conflicts will be resolved through discussion and with the help of a third reviewer. Appropriate analytical techniques will be employed to synthesise the data, for example, frequency counts and descriptive statistics. Quality will be assessed using the Newcastle Ottawa Quality Assessment Scale.

ETHICS AND DISSEMINATION

No ethics approval was needed as this is a scoping review of published literature. Results will be disseminated in a report to the World Bank and the Pan American Health Organization, in peer-reviewed scientific journals, and at national and international conferences.

Bottom-up innovative responses to COVID-19 in Latin America and the Caribbean: addressing deprioritized populations

Objective

To identify and describe innovative initiatives implemented as a response to the interruption of health services during the COVID-19 pandemic in Latin America and the Caribbean (LAC).

Methods

This was a descriptive study that reviewed 34 initiatives implemented during the COVID-19 pandemic in LAC to address health services needs among deprioritized groups. The review of initiatives included four phases: a call for submissions of innovative initiatives from LAC countries; a selection of initiatives that had the ability to address health services gaps and that were innovative and effective; systematization and cataloging of the selected initiatives; and a content analysis of the information collected. Data were analyzed from September to October 2021.

Results

The 34 initiatives show important variations regarding the target populations, the stakeholders involved, level of implementation, strategies, scope, and relevance of the innovative initiative. There was also evidence of the emergence of a bottom-up set of actions in the absence of top-down actions.

Conclusion

The findings of this descriptive review of 34 initiatives implemented during the COVID-19 pandemic in LAC suggest that systematizing the strategies and lessons learned has the potential to expand learning for re-establishing and improving post-pandemic health services.

[Multidimensional analysis of the evolution of the COVID-19 pandemic in countries of the AmericasAnálise multidimensional da evolução da pandemia da COVID-19 em países das Américas]

Objective

To evaluate the evolution of the COVID-19 pandemic in countries of the Americas, comparing health system data from before the appearance of the virus in the Region, accumulated cases and deaths before the deployment of public immunization strategies, and the current state of vaccination.

Methods

An HJ-Biplot multivariate analysis and cluster analysis were performed for 28 countries in the Region of the Americas at three points in time: December 2019, December 2020, and December 2021.

Results

In the Americas, heterogeneity was observed in the actions implemented to contain the pandemic, and this was reflected in different groups of countries.

Conclusions

Not all countries in the Region of the Americas had the health conditions necessary to contain COVID-19. At the end of 2019, the United States, Canada, Brazil, and Cuba had advantages over other countries in the Region; however, actions implemented during 2020 to contain the pandemic created different groups of countries in terms of the prevalence of infections and deaths. At the end of 2020, Bolivia, Ecuador, and Mexico had critical levels of mortality. At the end of 2021, after the implementation of vaccination plans, more than 60% of the population of Argentina, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Panama, the United States, and Uruguay had completed the vaccination schedule.

Intimate Partner Violence in the COVID-19 Era: A Health, Psychological, Forensic and Legal Perspective

This commentary aims to provide a multidisciplinary framework on intimate partner violence (IPV) during the COVID-19 pandemic (with a specific focus on the most predominant form of gender-based violence, i.e., male violence towards women), commenting on the multiple negative consequences of the pandemic on gender violence and providing elements of effective practice. We searched literature for reports/studies on the issue of IPV during the COVID-19 pandemic, focusing on health, psychological, forensic, and legal aspects. The combined effects of lockdowns, isolation at home with abusive partners, quarantine, and economic worries/loss of a job could significantly facilitate violence against women and, at the same time, diminish women's chances to seek for help, with a strong negative impact on their life. The continued offer of clinical, psychological, forensic, and legal services for survivors of violence, despite the modifications to the provision of these services due to the new needs related to the COVID-19 pandemic, appears of utmost importance. All actions to support survivors of IPV are expected to be multidisciplinary, including the involvement of social and/or legal services and health systems, and woman-centred. Implementing these measures in the COVID-19 era appears challenging but is of primary importance.

Clinical Characteristics of Children With SARS-CoV-2 Infection in a Hospital in Latin America

OBJECTIVE

COVID-19 infections have shown a different behavior in children than in adults. The objective of this study was to describe the clinical characteristics and severity of SARS-CoV-2 infection in pediatric patients seen at a reference hospital in Colombia.

METHOD

A descriptive, observational study in patients under the age of 18 years with a positive test for SARS-CoV-2 infection (RT-PCR or antigen) between April 2020 and March 2021. Multiple variables were studied, including demographic data, clinical characteristics, lab measurements, treatments administered, intensive care unit admission, and mortality.

RESULTS

A total of 361 patients were included of whom 196 (54%) were males. The median age was 3 years. Of all the patients, 65 (18%) were asymptomatic. The majority of patients had no comorbidities (n = 225, 76%). In those who were symptomatic (n = 296, 82%), the most frequent complaints were fever (n = 178, 60%), nasal congestion (n = 164, 55%) and cough (n = 149, 50%). Chest x-rays were normal in 73 patients (50%). When abnormalities were found, interstitial (29%) and alveolar (12%) patterns were the most prevalent. One hundred and fifty-seven children (53%) required general ward hospitalization, and 24 patients (8%) required pediatric intensive care admission. The global mortality was 0.8% (3 patients).

CONCLUSIONS

The majority of cases were asymptomatic or mild. However, a significant percentage of patients required general ward admission, and some even required intensive care. The main symptom of COVID-19 infections in newborns was apnea. A second COVID-19 RT-PCR may be necessary to detect infections in critically ill patients with a high clinical suspicion of the disease if an initial test was negative.