More than a year into the pandemic, deaths in Brazil are now at their peak. But, says a BBC News report, despite the overwhelming evidence that COVID-19 rarely kills young children, in Brazil 1,300 babies have died from the virus. One doctor refused to test Jessika Ricarte's one-year-old son for COVID, saying his symptoms did not fit the profile of the virus. Two months later he died of complications from the disease.
There is a misconception that children are at zero risk for COVID, says Dr Fatima Marinho, who is also a senior adviser to the international health NGO Vital Strategies in the BBC News report. Marinho's research has found that a shockingly high number of children and babies have been affected by the virus.
Between February 2020 and 15 March 2021, COVID-19 killed at least 852 of Brazil's children up to the age of nine, including 518 babies under one year old, according to figures from the Brazilian Ministry of Health. But, BBC News reports, Marinho estimates that more than twice this number of children died of COVID. A serious problem of underreporting due to lack of COVID testing is bringing the numbers down, she says.
Marinho calculated the excess of deaths by unspecified acute respiratory syndrome during the pandemic, and found that there were 10 times more deaths by unexplained respiratory syndrome than in previous years. By adding these numbers, she estimates that the virus in fact killed 2,060 children under nine years old, including 1,302 babies.
Experts say the sheer number of COVID cases in the country – the second-highest number in the world – have increased the likelihood that Brazil's babies and young children are affected.
"Of course, the more cases we have and, as a result, the more hospitalisations, the greater the number of deaths in all age groups, including children. But if the pandemic were controlled, this scenario could evidently be minimised," says Renato Kfouri, president of the scientific department of immunisations of the Brazilian Society of Paediatrics.
BBC News reports that such a high infection rate has overwhelmed Brazil's entire health care system. Across the country, oxygen supplies are dwindling, there is a shortage of basic medicines and in many ICUs across the country there are simply no more beds.
Brazilian President Jair Bolsonaro continues to oppose lockdowns and the infection rate is being driven by a variant called P.1 which emerged in Manaus, in northern Brazil, last year, and is thought to be much more contagious. Twice the number of people died last month than in any other month of the pandemic, and the upward trend is continuing.
Another problem driving the high rates in children is a lack of testing, BBC News reports.
Marinho says that for children often the COVID diagnosis comes too late, when they are already seriously ill. "We have a serious problem detecting cases. We don't have enough tests for the general population, even fewer for children. Because there is a delay in the diagnosis, there is a delay in care for the child," she says.
This is not just because there is little testing capacity, but also because it is easier to miss, or misdiagnose, the symptoms of children suffering from COVID-19, as the disease tends to present differently in younger people.
"A child has a lot more diarrhoea, a lot more abdominal pain, and chest pain, than the classic COVID picture. Because there is a delay in diagnosis, when the child arrives at the hospital they are in a serious condition and can end up complicating – and dying," she says.
But it's also about poverty and access to health care.
BBC News reports that an observational study of 5,857 COVID-19 patients under the age of 20, carried out by Brazilian paediatricians led by Braian Sousa from the University of São Paolo School of Medicine, identified both comorbidities and socio-economic vulnerabilities as risk factors for the worst outcome of COVID-19 in children.
Marinho agrees this is an important factor. "Most vulnerable are black children, and those from very poor families, as they have the most difficulty accessing help. These are the children most at risk of death." She says this is because crowded housing conditions make it impossible to socially distance when infected, and because poorer communities do not have access to a local ICU.
These children are also at risk of malnutrition, which is "terrible for the immune response", Marinho is quoted in the BBC News report as saying. When COVID payments stopped, millions were plunged back into poverty. "We went from 7m to 21m people below the poverty line in one year. So people are also going hungry. All of this is impacting mortality."
Study details
Noncommunicable Diseases, Sociodemographic Vulnerability, and the Risk of Mortality in Hospitalized Children and Adolescents with COVID-19 in Brazil: A Syndemic in Play
Braian Lucas Aguiar Sousa, Alexandra Valeria Maria Brentani, Cecilia Claudia Costa Ribeiro, Marisa Dolhnikoff, Sandra Josefina Ferraz Ellero Grisi, Ana Paula Scoleze Ferrer, Alexandre Archanjo Ferraro
Published in medRxiv in February 2021
Abstract
Background
Although many studies identify the presence of comorbidities and socioeconomic vulnerabilities as risk factors for worse COVID-19 outcomes, few have addressed this issue in children. We aimed to study how these factors have impacted COVID-19 mortality in Brazilian children and adolescents.
Methods
This is an observational study using publicly available data from the Brazilian Ministry of Health. We studied 5,857 patients younger than 20 years old, all of them hospitalized with laboratory-confirmed COVID-19. We used multilevel mixed-effects generalized linear models to study mortality, stratifying the analysis by age, region of the country, presence of noncommunicable diseases, ethnicity, and socioeconomic development.
Findings
Individually, most of the comorbidities included were risk factors. Having more than one comorbidity increased almost tenfold the risk of death (OR 9·67 95%CI 6·89-13·57). Compared to White children, Indigenous, Pardo (mixed), and East Asian had a significantly higher risk of mortality. We also found a regional effect (higher mortality in the North), and a socioeconomic effect (higher mortality among children from less socioeconomically developed municipalities).
Interpretation
Besides the impact of comorbidities, we identified ethnic, regional, and socioeconomic effects shaping the mortality of children hospitalized with COVID-19 in Brazil. Putting these findings together, we propose that there is a syndemic among COVID-19 and noncommunicable diseases, driven and fostered by large-scale sociodemographic inequalities. Facing COVID-19 in Brazil must also include addressing these structural issues. Our findings also identify risk groups among children that should be prioritized for public health measures, such as vaccination.