Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak

Abstract

Objective: The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge.

Background: Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children.

Study design: We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation.

Results: Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29-3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ± 39 vs 47 ± 27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2.

Conclusions: Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

FIGURE 1

Perforation rates for appendicitis treated by quarter. Across the control period, there is natural variability against the 65-month overall perforation rate (dashed vertical line). None of the 22 quarters comprising the control period demonstrated any statistical differences in their individual perforation rates when compared back to the 27% overall control perforation rate (P values provided for each quarter). Perforation rates observed during the COVID-19 era represent a statistical outlier.

FIGURE 2

Distribution of pediatric acute appendicitis by week during the initial COVID-19 surge in the NYC area. The total number of appendicitis cases for each week during the COVID-19 study period is represented by the vertical bars, with designation of nonperforated and perforated cases. The dashed line represents the total COVID-19 hospital admissions (adult and pediatric) for the institutions included in the study.