Non-communicable diseases, sociodemographic vulnerability and the risk of mortality in hospitalised children and adolescents with COVID-19 in Brazil: a cross-sectional observational study

Abstract

Objectives: To analyse how previous comorbidities, ethnicity, regionality and socioeconomic development are associated with COVID-19 mortality in hospitalised children and adolescents.

Design: Cross-sectional observational study using publicly available data from the Brazilian Ministry of Health.

Setting: Nationwide.

Participants: 5857 patients younger than 20 years old, all of them hospitalised with laboratory-confirmed COVID-19, from 1 January 2020 to 7 December 2020.

Main outcome measure: We used multilevel mixed-effects generalised linear models to study in-hospital mortality, stratifying the analysis by age, region of the country, presence of non-communicable diseases, ethnicity and socioeconomic development.

Results: Individually, most of the included comorbidities were risk factors for mortality. Notably, asthma was a protective factor (OR 0.4, 95% CI 0.24 to 0.67). Having more than one comorbidity increased almost tenfold the odds of death (OR 9.67, 95% CI 6.89 to 13.57). Compared with white children, Indigenous, Pardo (mixed) and East Asian had significantly higher odds of mortality (OR 5.83, 95% CI 2.43 to 14.02; OR 1.93, 95% CI 1.48 to 2.51; OR 2.98, 95% CI 1.02 to 8.71, respectively). We also found a regional influence (higher mortality in the North-OR 3.4, 95% CI 2.48 to 4.65) and a socioeconomic association (lower mortality among children from more socioeconomically developed municipalities-OR 0.26, 95% CI 0.17 to 0.38) CONCLUSIONS: Besides the association with comorbidities, we found ethnic, regional and socioeconomic factors shaping the mortality of children hospitalised with COVID-19 in Brazil. Our findings identify risk groups among children that should be prioritised for public health measures, such as vaccination.

Keywords: epidemiology; paediatric infectious disease & immunisation; paediatrics.

Figure 1

Flow chart of the patients included in this study.

Figure 2

Distribution of COVID-19 paediatric hospitalisations in absolute numbers (A), proportional to population (B) and death rate (C) by state. N=5857. Bars are coloured by state macroregion: blue for Southeast; yellow for Northeast; grey for South; green for North; orange for Centre west. AC, Acre; AL, Alagoas; AM, Amazonas; AP, Amapá; BA, Bahia; CE, Ceará; DF, Distrito Federal; ES, Espírito Santo; GO, Goiás; MA, Maranhão; MG, Minas Gerais; MS, Mato Grosso do Sul; MT, Mato Grosso; PA, Pará; PB, Paraíba; PE, Pernambuco; PI, Piauí; PR, Paraná; RJ, Rio de Janeiro; RN, Rio Grande do Norte; RO, Rondônia; RR, Roraima; RS, Rio Grande do Sul; SC, Santa Catarina; SE, Sergipe; SP, São Paulo; TO, Tocantins.

Figure 3

Risk of mortality for clinical features in multilevel mixed-effects generalised linear models, assuming municipalities and hospitals as random effects. Error bars represent 95% CIs, N=5857. For each individual condition, the reference group was patients without such condition. The groups ‘1 comorbidity’ and ‘>1 comorbidities’ includes all the aforementioned, Down syndrome and conditions disclosed as ‘other comorbidities’. Both categories exclude asthma, as asthma seems to has a protective association. The reference group for them was patients without comorbidities.

Figure 4

Risk of mortality for sociodemographic features in multilevel mixed-effects generalised linear models, assuming municipalities and hospitals as random effects. Error bars represent 95% CIs. N=4472 for ethnicity (1385 missing), 5857 for region and 5691 for socioeconomic development (166 missing). ‘Pardo’ means a wide range of mixed or diverse ethnic backgrounds. ‘North’ refers to both North and Northeast Brazilian macroregions. Socioeconomic development categorised by GeoSES terciles. Reference groups were ‘white’ for ethnicity, ‘South’ for region and low GeoSES tercile for socioeconomic development. SES, socioeconomic status.

Figure 5

Frequency of children without NCDs for each sociodemographic category, both in the general hospitalised population and among the dead. Bars in red represent the general rate for each group, while the other bars represent the rate among the dead. ‘Pardo’ means a wide range of mixed or diverse ethnic backgrounds. ‘North’ refers to both North and Northeast Brazilian macroregions. Socioeconomic development categorised by GeoSES terciles. NCDs, non-communicable diseases; SES, socioeconomic status.