Clinical characteristics and outcome of pediatric cases managed during the first wave of the Covid-19 pandemic at Ahmadu Bello University Teaching Hospital, Zaria

Maria A Garba; Abdullahi A Mohammed; Aisha J Mohammed; Sani Musa; Hafsat A Rufai

doi:10.4103/njbcs.njbcs_26_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 19 | Issue : 1 | Page : 29-33

Clinical characteristics and outcome of pediatric cases managed during the first wave of the Covid-19 pandemic at Ahmadu Bello University Teaching Hospital, Zaria

Maria A Garba¹, Abdullahi A Mohammed², Aisha J Mohammed¹, Sani Musa¹, Hafsat A Rufai¹
¹ Department of Pediatrics, Ahmadu Bello University/Teaching Hospital, Shika, Zaria, Kaduna, Nigeria
² Department of Medicine, Ahmadu Bello University/Teaching Hospital, Shika, Zaria, Kaduna, Nigeria

Date of Submission	04-Jun-2021
Date of Decision	25-Dec-2021
Date of Acceptance	25-Dec-2021
Date of Web Publication	12-Jul-2022

Correspondence Address:
Dr. Maria A Garba
Department of Pediatrics, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/njbcs.njbcs_26_21

Abstract

Context: Over 161 million cases of COVID-19 have so far been confirmed globally with over 3.3 million deaths. An understanding of the local epidemiological characteristics in the pediatric population is necessary to enable proper planning of mitigation strategies. Aim: To describe the clinical characteristics and outcomes of pediatric patients with COVID-19. Setting and Design: We conducted a retrospective study on cases of COVID-19 diagnosed by the real-time polymerase chain reaction of nasopharyngeal samples and oropharyngeal swabs managed during the first wave of the pandemic at the Ahmadu Bello University Teaching Hospital. The severity of illness was graded based on clinical features as classified by the World Health Organization. Statistical Analysis was carried out using IBM SPSS Version 23 (California, USA). Results: Forty-six children met the above criteria. The median age was 7 yrs (IQR = 3.75-12). There were more females than males with Covid-19 infection (M:F = 1:1.55). A third (32.6%) of children were asymptomatic while half (50%) had only mild symptoms. Although school-aged children aged 6-11 years were the most infected (30.4%), more severe disease was seen in infants (25%) and those with co-morbidities. Nasal discharge, cough, and fever were the most common presentation occurring in 34.8%, 32.6%, and 26.1%, respectively. The case fatality rate was 6.5%, all occurring amongst those with comorbidities. Conclusion: COVID-19 infection in children is largely mild or asymptomatic. Symptoms when present are indistinguishable from symptoms of other common viruses causing upper respiratory tract infections. Severe disease and mortality were observed among infants and children with co-morbidities.

Keywords: Children, clinical features, COVID-19, outcome, severity

How to cite this article:
Garba MA, Mohammed AA, Mohammed AJ, Musa S, Rufai HA. Clinical characteristics and outcome of pediatric cases managed during the first wave of the Covid-19 pandemic at Ahmadu Bello University Teaching Hospital, Zaria. Niger J Basic Clin Sci 2022;19:29-33

How to cite this URL:
Garba MA, Mohammed AA, Mohammed AJ, Musa S, Rufai HA. Clinical characteristics and outcome of pediatric cases managed during the first wave of the Covid-19 pandemic at Ahmadu Bello University Teaching Hospital, Zaria. Niger J Basic Clin Sci [serial online] 2022 [cited 2023 Jun 1];19:29-33. Available from: https://www.njbcs.net/text.asp?2022/19/1/29/350712

Introduction

Coronavirus disease 2019 (COVID-19) is a novel disease that has infected over 167 million persons and caused 3.4 million deaths globally.^[1],[2] This is the 3^rd pandemic of the century caused by a coronavirus, the first two being severe acute respiratory syndrome (SARS) in 2002 and Middle East respiratory syndrome in 2013.^[1] The pandemic has had a significant impact on the human population by straining medical and public health facilities, disrupting education systems as well as causing significant social, economic, and psychological hardships.^[3],[4]

Fewer cases of COVID-19 have been reported from Africa in comparison to Europe and the Americas. Availability of testing kits and the robustness of contact tracing are well-recognized limitations to the diagnosis of the disease. However, despite these limitations, it has been hypothesized that indeed, the fewer cases of the disease reported from Africa could be linked to the continents' younger population, warm climatic conditions, and prior exposures to coronaviruses and parasites.^[5],[6]

Far fewer children than adults have been tested and diagnosed with COVID-19. This age-specific difference has been shown to vary little in different geographic regions. Among 72,314 cases reported by Wu et al.,^[7] persons aged less than 19 years made up only 2% of the disease burden. Children also made up 1.2%, 1.7%, and 0.8%, respectively, of the total numbers of persons infected in Italy, the United States, and Spain.^{[8],[9],[10],[11]}

The manifestation of COVID-19 varies strikingly among individuals, mostly in the adult population who have been the focus of the majority of studies. These range from asymptomatic to mild respiratory symptoms to multi-organ failure. Commonly reported symptoms include cough, nasal congestion, nasal discharge, shortness of breath, anorexia, anosmia, ageusia, diarrhea, and vomiting amongst others.^[12],[13] Outcomes in terms of severity of illness and mortality are more favorable among children due to differing physiology and immunological development.^[14]

To enable proper planning of mitigation strategies, an understanding of the epidemiological characteristics of COVID-19 in this age group is necessary. Thus, the study aimed to describe the clinical characteristics and outcomes of pediatric patients with COVID-19 seen at Ahmadu Bello University Teaching Hospital (ABUTH), Zaria.

Materials and Methods

Kaduna state has 23 local government areas with an estimated population of 9,176,219. There are five COVID-19 designated treatment centers with a total of 236 beds in the state. ABUTH is one of the designated COVID-19 treatment sites. Sick children presenting to the Emergency Pediatric Unit and Pediatric outpatient department who test positive for COVID-19, and those picked on extended screening due to exposure to adults with COVID-19 in line with World Health Organization (WHO) guidelines,^[15],[16] are referred to the ABUTH treatment site for care.

This was a retrospective study. Clinical and demographic data were retrieved from the medical records of all subjects who were seen during the first wave of the pandemic (28^th May 2020 to 29^th September 2020).^[17] Children were categorized to be people in the age of less than 19 years.

The study protocol was approved by the Health and Research Ethics Committee of the Ahmadu Bello University Teaching Hospital, Shika (ABUTHZ/HREC/W48/2020).

The severity of illness was graded [Table 1] based on clinical features as classified by the World Health Organization (WHO).^{[18],[19],[20]}

Table 1: Severity of illness based on clinical features

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Statistical analysis categorical variables were described using percentages and frequencies. Continuous variables were described by means and standard deviations while distributions not normally distributed were expressed as means and IQR. A P value of <0.05 was considered statistically significant. Statistical analysis was carried out using IBM SPSS Version 23 (California, USA, 2015).

Results

Forty-six children with asymptomatic, mild, moderate, severe, or critical illness were managed during this period at ABUTH. The median age was 7 years (IQR = 3.75-12). There were 18 males and 28 females (M: F =1:1.55) as shown in [Table 2] below. [Figure 1] shows disease severity among study subjects. School-aged children aged 6-11 years were the most infected (30.4%), closely followed by those aged 12-16 yrs (23.9%). Infants made up 15.2% while the group least affected were those aged 17 and above (8.7%). No statistically significant relationship was found between age category and symptomatic infection (p = 0.295). [Table 3] shows the distribution of subjects by age and sex. There were more cases of moderate-severe illness among infants compared to other age groups but this was not statistically significant (p = 0.295). The frequency of clinical features among symptomatic study subjects is shown in [Table 4].

Figure 1: Pie chart showing disease severity among study subjects

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Table 2: Distribution of cases by age and gender

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Table 3: Disease severity by age group

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Table 4: Frequency of clinical features observed among Pediatric COVID-19 cases

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Five of the 46 cases had co-morbidities. These include congenital heart disease (2), chronic renal failure (1), sickle cell anemia (1), and systemic lupus erythematosus (1). Of the 46 children managed, 43 were discharged (93.5%) while 3 deaths were recorded (CFR of 6.5%). All deaths that occurred were among children with co-morbidities who also had severe disease. These include a 4-month-old girl with a ventricular septal defect and a 14 years old girl with Libermann Sachs' endocarditis complicated by congestive cardiac failure and arrhythmias (both died within 28 days of illness). The third was a 14-year-old boy with chronic renal failure. There was no statistically significant relationship between duration of hospital stay and severity of illness or mortality.

Discussion

There were 2407 confirmed cases of COVID-19 in Kaduna state within the period of study. Four hundred and thirteen cases (1.7%) occurred in children.^[17] Our cohort comprised 11.13% (46/413) of the pediatric cases diagnosed with COVID-19. The proportion of pediatric COVID-19 cases in comparison to adult COVID-19 is similar to what obtains in Asia, America, and European populations.^{[7],[8],[9],[10],[11],[12]} Contributing to this low figure may be the swift action by the state government to shut down schools, restrict movements, and implement robust contact tracing as measures to curb spread within the week of the first case reported in Kaduna state.^[21] Adedeji et al.^[22] had earlier reported 18% from community surveillance in North-East Nigeria where such measures were delayed.

Since the emergence of COVID-19, investigators had reported the symptomatology to be milder in children as compared to adults.^{[11],[13],[14],[23],[24]} and this have been corroborated by our finding as over 80% of our subjects were asymptomatic or had only mild disease, even though our study population was mainly from family clusters. Theories that have been put forward to explain this apparent “child sparing effect”, which include lower expression of angiotensin-converting enzyme-2 receptors (to which the virus binds to enable its incorporation into tissues) in children in comparison to adults, cross-protection by antibodies through common viral infections,^[25] the lower prevalence of co-morbidities, and higher mucosal colonization by other microorganisms interfering with the replication of COVID-19.^[25] Whether the asymptomatic or mild nature of infection in this group makes them a significant source of disease transmission and propagation is still debatable.

The mean age of infection was 7 years, similar to reports from Europe and China.^{[9],[13],[26]} More girls than boys were diagnosed with Covid-19 in our study. This is in contrast to other reports which showed either a slight male preponderance or no sex difference.^{[13],[23],[26]}

The youngest subject in this study was 3-month-old infant. It is to be noted that infants are at greater risk of exposure to COVID-19 infection. This is due to frequent contact with healthcare workers in the first few weeks of life, dependency on caretakers, and the necessity for close contact during feeding and care that may increase exposure to respiratory secretions of infected persons. According to Dong et al.,^[13] Garrazino et al.,^[23] and Tsabouri et al.^[24] patients are also more likely to have severe disease. We observed this in 25% of infants in our cohort. This is likely due to the immaturity of the immune system and the caliber of their airways which makes them prone to respiratory complications.

We found nasal discharge cough and fever to be the most common presentation while Adedeji^[22] reported nasal discharge, fever, and sneezing to be the three top symptoms. In a systematic review, Perikleous et al.^[26] also, report cough and fever to be the most symptoms in children. Myalgia, anosmia, and ageusia which are frequently reported among adults and may aid in a presumptive diagnosis of COVID-19 was uncommon in our cohort. This may be due to the age-related inability to express the symptoms at a very young. These non-specific features highlight the fact that COVID-19 is indistinguishable from other childhood viral illnesses.

It is not surprising that the case fatality rate (CFR) in this cohort (6.5%) is far higher than the national average of 2% as this was a hospital-based study. It is pertinent to note that all those who died had comorbid conditions. A similarly high rate (11.8%) was reported among hospitalized people less than 20 years old by Nachega et al.^[27] in Congo. These figures are significantly higher than case fatality rates obtainable among hospitalized children in regions where the pandemic has been more devastating but with good health care resources such as the United States of America (2%)^[25] and China (1%).^[13] While the apparent lack of pediatric intensive care units and appropriately trained staff in these regions may have contributed to these higher CFRs, there are emerging reports of increasing cases of COVID-19 related mortality among pediatric subjects in Brazil (BBC).^[28]

It is quite likely that the virus will settle with us like most other viruses and become endemic with the subsequent development of heard immunity among populations. The priority of vaccination programs when vaccines are approved for children should be for children with co-morbidities as they are at the highest risk of mortality.

Conclusion

COVID-19 infection in children is largely mild or asymptomatic. The commonest symptoms include nasal discharge, dry cough, and fever; features which are indistinguishable from symptoms of other common viruses causing upper respiratory tract infections. Severe disease and mortality were observed among infants and children with co-morbidities.

Recommendation

Whereas preventive measures such as mask-wearing, social distancing, and respiratory hygiene should continue to be maintained to curb the spread and protect vulnerable populations, COVID-19 vaccinations for children should be targeted towards infants and those with co-morbidities. The current pandemic underscores the importance of pediatric intensive care units for the management of this vulnerable group of patients.

Limitations

This study had several limitations. There was no exposure to the patients' history and thus incubation periods could not be determined. Due to incomplete data, the laboratory characteristics of the patients were not evaluated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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