Among children hospitalized for severe respiratory infections in Brazil, those who had COVID-19 were at highest risk for in-hospital death within 30 days, with underlying medical conditions a risk factor for all viral strains, finds a study published today in Pediatrics.
Federal University of Minas Gerais researchers analyzed data from the Brazilian national epidemiologic surveillance system to compare the outcomes of 235,829 children and adolescents aged 0 to 17 years hospitalized with respiratory infections from February 2020 to February 2023 in Brazil.
"The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2020 has had an evident impact on the epidemiology of acute respiratory infections worldwide, underscoring the importance of data that directly compare the burden of SARS-CoV-2 infection and other viral etiologies," the study authors wrote.
6.5% risk of death from COVID, 2.3% for flu
During the study period, 411,400 severe respiratory infections were reported among children and adolescents, 235,829 of whom were included in the study sample. The average patient age was 3.8 years. While a higher proportion of adolescents had COVID-19, respiratory syncytial virus (RSV) cases predominated in infants.
A total of 25.6% of patients were admitted to an intensive care unit (ICU), 50.6% needed noninvasive supplemental oxygen, 8.9% received invasive ventilation, and 3.0% died. Relative to patients with other respiratory illnesses, RSV patients had lower oxygen saturation at admission and needed more ICU care and supplemental oxygen.
A competing-risk survival analysis estimated the odds of in-hospital death by 30 days at 6.5%, 3.4%, 2.9%, 2.3%, 2.1%, and 1.8%, for SARS-CoV-2, coinfection, adenovirus, influenza, other viruses, and RSV, respectively.
COVID-19 patients were at three times the risk of death than non-COVID patients (hazard ratio [HR], 3.3; 95% confidence interval [CI], 3.1 to 3.5). Coinfected patients and those infected with adenovirus were at a significantly increased risk of death (HR, 1.7 [95% CI, 1.2 to 2.4] and HR, 1.4 [95% CI, 1.2 to 1.7], respectively). In contrast, patients with RSV and rhinovirus were at lower risk of death (HR, 0.57 [95% CI, 0.51 to 0.65] and HR, 0.79 [95% CI, 0.69 to 0.94], respectively).
After adjustment, the risk factors for death from all viruses were hospitalization in the poor northeast and north regions of the country, an oxygen saturation less than 95%, and underlying illnesses. Hospitalization after 2021 was increasingly protective against death for COVID-19 patients.
Socioeconomic disparities
The first COVID-19 case in Brazil was confirmed on February 16, 2020, and SARS-CoV-2 became prevalent in all age-groups about the 14th epidemiologic week of 2020, maintaining a prevalence over 80% throughout that year.
Brazil is a middle-income country with significant disparities in the social determinants of health, including differences in access to and quality of public health services, as [well as] a low coverage of ICU in North and Northeast regions.
SARS-CoV-2 remained prevalent in children in 2021, but RSV surpassed it in infants in the 10th epidemiologic week. In 2022, SARS-CoV-2 predominated again after the emergence of the Omicron variant among all children of all ages until the ninth epidemiologic week, when RSV again became the leading virus.
The researchers noted that children and adolescents hospitalized in the poorest regions of Brazil were at higher risk for death than those in the wealthiest region. "Brazil is a middle-income country with significant disparities in the social determinants of health, including differences in access to and quality of public health services, as [well as] a low coverage of ICU in North and Northeast regions," they wrote.
The authors said that little is known about how SARS-CoV-2 will behave in terms of equilibrium dynamics with seasonal viruses. "In this context, our findings highlight the importance of monitoring and understanding viral epidemiology in the post–COVID-19 era to establish timely preventive measures to lessen the severity of upcoming seasonal outbreaks of respiratory viruses," they concluded.
