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. 2022 Mar 1;176(3):e216436.
doi: 10.1001/jamapediatrics.2021.6436. Epub 2022 Mar 7.

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries

Jean B Nachega  1   2   3   4 , Nadia A Sam-Agudu  5   6   7   8 , Rhoderick N Machekano  9 , Helena Rabie  10 , Marieke M van der Zalm  11 , Andrew Redfern  10 , Angela Dramowski  10 , Natasha O'Connell  10 , Michel Tshiasuma Pipo  12   13 , Marc B Tshilanda  13 , Liliane Nsuli Byamungu  14 , Refiloe Masekela  14 , Prakash Mohan Jeena  14 , Ashendri Pillay  14 , Onesmus W Gachuno  15 , John Kinuthia  16 , Daniel Katuashi Ishoso  17 , Emmanuella Amoako  18 , Elizabeth Agyare  19 , Evans K Agbeno  20 , Charles Martyn-Dickens  21 , Justice Sylverken  21   22 , Anthony Enimil  21   22 , Aishatu Mohammed Jibril  23 , Asara M Abdullahi  24 , Oma Amadi  25 , Umar Mohammed Umar  26 , Lovemore Nyasha Sigwadhi  9 , Michel P Hermans  27 , John Otshudiema Otokoye  28 , Placide Mbala-Kingebeni  29 , Jean-Jacques Muyembe-Tamfum  29 , Alimuddin Zumla  30   31 , Nelson K Sewankambo  32 , Hellen Tukamuhebwa Aanyu  33 , Philippa Musoke  34 , Fatima Suleman  35 , Prisca Adejumo  36 , Emilia V Noormahomed  37 , Richard J Deckelbaum  38 , Mary Glenn Fowler  39 , Léon Tshilolo  40   41 , Gerald Smith  42 , Edward J Mills  42   43 , Lawal W Umar  23 , Mark J Siedner  44   45 , Mariana Kruger  10 , Philip J Rosenthal  46 , John W Mellors  47 , Lynne M Mofenson  48 ; African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents
Collaborators, Affiliations

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries

Jean B Nachega et al. JAMA Pediatr. .

Abstract

Importance: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent.

Objective: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 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 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection.

Exposures: Age, sex, preexisting comorbidities, and region of residence.

Main outcomes and measures: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay.

Results: Among 469 hospitalized 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 hospitalized. 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 hospitalized 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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nachega reported receiving grants from the Fogarty International Center at the National Institutes of Health (NIH) during the conduct of the study. Dr Sam-Agudu reported receiving grants from the African Forum for Research and Education in Health (AFREhealth) during the conduct of the study. Dr Rabie reported receiving grants from AFREhealth during the conduct of the study. Dr Byamungu reported receiving grants from the Fogarty International Center at the NIH during the conduct of the study. Dr Amoako reported receiving personal fees from AFREhealth during the conduct of the study. Dr Agbeno reported receiving personal fees from AFREhealth during the conduct of the study. Dr Martyn-Dickens reported receiving grants from AFREhealth during the conduct of the study. Dr Enimil reported receiving personal fees from Komfo Anokye Teaching Hospital during the conduct of the study. Dr Jibril reported receiving personal fees from AFREhealth during the conduct of the study. Dr Abdullahi reported receiving personal fees from AFREhealth during the conduct of the study. Dr Amadi reported receiving grants from AFREhealth during the conduct of the study. Dr U. Umar reported receiving grants from AFREhealth during the conduct of the study. Dr Aanyu reported receiving grants from AFREhealth during the conduct of the study. Dr Musoke reported receiving grants from AFREhealth during the conduct of the study. Dr L. Umar reported receiving grants from AFREhealth during the conduct of the study and grants from the Fogarty International Center at the NIH (directed to AFREhealth via the Makerere University Infectious Disease Institute) outside the submitted work. Dr Mellors reported receiving grants from Gilead Sciences (via the University of Pittsburgh), Janssen Pharmaceuticals (via the University of Pittsburgh), the NIH (via the University of Pittsburgh), and the US Agency for International Development (via the University of Pittsburgh); personal fees from Accelevir Diagnostics, Gilead Sciences, Merck & Co, the University of Pittsburgh, and Yufan Biotechnologies; owning shares in Abound Bio, Cocrystal Pharma, and Infectious Disease Connect; and serving as president and chief executive officer of Abound Bio, a scientific advisory board member of Gilead Sciences, and an advisor for Infectious Disease Connect outside the submitted work. Dr Muyembe-Tamfum reported receiving grants from the National Institute of Biomedical Research, Democratic Republic of the Congo during the conduct of the study and outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Clinical Outcomes Stratified by Initial Intensive Care Unit Admission and Oxygen Supplementation
ICU indicates intensive care unit.
Figure 2.
Figure 2.. Clinical Outcomes of Children and Adolescents With COVID-19 by Region
A total of 26 patients (15.8%) in eastern Africa, 5 patients (15.2%) in central Africa, 18 patients (36.0%) in western Africa, and 94 patients (45.9%) in southern Africa required oxygen supplementation. A total of 15 patients (21.7%) in eastern Africa, 5 patients (7.3%) in central Africa, 3 patients (4.4%) in western Africa, and 46 patients (66.7%) in southern Africa were admitted to the intensive care unit (ICU). A total of 7 patients (20.6%) in eastern Africa, 1 patient (2.9%) in central Africa, 0 patients in western Africa, and 26 patients (76.5%) in southern Africa required invasive mechanical ventilation. A total of 12 patients (7.0%) in eastern Africa, 2 patients (5.3%) in central Africa, 7 patients (14.0%) in western Africa, and 18 patients (8.7%) in southern Africa died.
Figure 3.
Figure 3.. Kaplan-Meier Curves Comparing Survival Differences by Sex, World Health Organization COVID-19 Severity Stage, Number of Comorbidities, and Region
A, The hazard ratio (HR) was 2.77 (95% CI, 1.30-5.88; P = .008) for male patients compared with female patients (reference group). B, The HRs were 3.27 (95% CI, 0.65-16.38; P = .15) for moderate stage disease, 5.90 (95% CI, 1.62-21.49; P = .007) for severe stage disease, and 10.68 (95% CI, 3.18-35.89; P = .001) for critical stage disease compared with mild stage disease (reference group). C, The HRs were 1.37 (95% CI, 0.59-3.15; P = .46) for 1 comorbidity and 2.89 (95% CI, 1.28-6.52; P = .01) for 2 or more comorbidities compared with 0 comorbidities (reference group). D, The HRs were 0.60 (95% CI, 0.13-2.70; P = .50) for central Africa, 1.29 (95% CI, 0.61-2.74; P = .50) for southern Africa, and 2.35 (95% CI, 0.92-6.00; P = .07) for western Africa compared with eastern Africa (reference group). WHO indicates World Health Organization.
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Comment in

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