African children and adolescents hospitalised with COVID-19 experience substantially higher mortality rates than Europeans or North Americans of the same age, according to the AFREhealth study, which collected data from 25 health facilities across Nigeria, Ghana, Democratic Republic of the Congo, Kenya, South Africa, and Uganda, was published in JAMA Pediatrics. African infants with pre-existing, non-communicable diseases were also more likely to have poorer outcomes, such as requiring intensive care, and death.
The study was conducted by researchers from the Institute of Human Virology (IHV) at the University of Maryland School of Medicine (UMSOM) and the Institute of Human Virology Nigeria (IHVN). Both organisations are members of the Global Virus Network (GVN).
Question What are the clinical outcomes and associated factors among children and adolescents hospitalised with COVID-19 in sub-Saharan Africa?
Findings In this cohort study of 469 children and adolescents hospitalised with COVID-19 in 6 sub-Saharan African countries, morbidity and mortality were substantially higher than reported among those in non-African settings and were independently associated with age younger than 1 year and select noncommunicable disease comorbidities.
Meaning This study’s findings may have implications for clinical practice and health policy regarding paediatric COVID-19 in African countries; given their high risk of adverse outcomes, COVID-19 vaccination and therapeutic interventions are needed for African children and adolescents.
“This study provides important information about COVID-19 among African children, which was not previously available at this scale. We now have evidence from multiple countries to show that these children also experience severe COVID-19; they experience multisystem inflammatory syndrome; some require intensive care; some also die, and at much higher rates than outside Africa,” said Dr Nadia Sam-Agudu, associate professor of paediatrics at the University of Maryland School of Medicine’s (UMSOM) Institute of Human Virology, and Senior Technical Advisor for Paediatric and Adolescent HIV, Institute of Human Virology Nigeria.
Sam-Agudu is a co-first author along with principal investigator Dr Jean Nachega of the University of Pittsburgh and Stellenbosch University in Cape Town, South Africa.
The study included 469 African children and adolescents aged three months to 19 years hospitalised with COVID-19 between March and December 2020. The team reported a high overall mortality rate of 8.3%, compared with 1% or less totalled from Europe and North America. Furthermore, African children under a year old and with pre-existing, non-communicable diseases were more likely to have poorer outcomes, such as requiring intensive care, and death.
Eighteen participants had suspected or confirmed multisystem inflammatory syndrome (also known as MIS-C), and four of these children died.
Sam-Agudu, who led the West Africa team for the study, urged health authorities and policymakers in Nigeria and other African countries to act upon the study findings “to protect children by expanding vaccine approvals and procurements for children specifically, as the variants emerging since our study’s completion have either caused more severe disease and/or more cases overall”.
“We cannot leave children behind in the pandemic response,” added Sam-Agudu, who was recently awarded a 2022 Dr Thomas Hall-Dr Nelson Sewankambo Mid-Career Leadership Award from The Consortium of Universities for Global Health. The award acknowledges outstanding individuals for accomplishments and commitment to contributing to the advancement of global health worldwide.
According to associate professor of Epidemiology and Public Health at the Institute of Human Virology of UMSOM and IHVN Chief Executive Officer Patrick Dakum, MBBS, MPH: “These data from Dr Sam-Agudu and AFREhealth collaborators put science from Nigeria and the rest of Africa squarely on the map for pandemic-responsive research, particularly for young populations. We will continually work towards contributing to research discoveries in Nigeria, West Africa and beyond.”
Alash’le Abimiku, PhD, Professor of Medicine at the UMSOM’s Institute of Human Virology, and executive director of the Institute of Human Virology Nigeria’s International Research Center of Excellence, also noted that, “The high impact paediatric COVID-19 findings of this collaborative research underscore the value of sustained investments in strong research institutions, collaborations, and leadership in Nigeria and across Africa. We can generate rigorous local data to guide local, regional, and international health policy and practice.”
Director-General of the Nigeria Centre for Disease Control, Dr Ifedayo Adetifa, said: “The AFREhealth study findings show that COVID-19 affects children and can cause severe consequences. Thus, we seriously need to factor them into age-disaggregated COVID-19 disease surveillance and reporting, and consider COVID-19 illness when they present to the hospital. Furthermore, the high in-hospital mortality rate reported indicates a need for investments in critical care for children in African settings. We need more of such rigorous multicentre studies to inform evidence-based policy-making in Nigeria and other African countries.”
Assessment of Clinical Outcomes Among Children and Adolescents Hospitalised With COVID-19 in 6 Sub-Saharan African Countries.
Jean B. Nachega, Nadia A. Sam-Agudu, Rhoderick N. Machekano, et al.
Published in JAMA Pediatrics on 19 January 2022.
Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent.
To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalised with COVID-19 in six countries in sub-Saharan Africa.
Design, Setting, and Participants
This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalised patients aged 0 to 19 years with SARS-CoV-2 infection.
Age, sex, preexisting comorbidities, and region of residence.
Main Outcomes and Measures
An ordinal primary outcome scale was used comprising five categories: (1) hospitalisation without oxygen supplementation, (2) hospitalisation with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay.
Among 469 hospitalised children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalised. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge.
Conclusions and Relevance
In this cohort study of children and adolescents hospitalised with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.
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