Child Healthcare and Immunizations in Sub-Saharan Africa During the COVID-19 Pandemic

To the Editor: On February 20, 2020, the incidence of Covid-19 began to rapidly escalate in Italy. By March 25, Italy had the second highest number of Covid-19 infections worldwide and the greatest number of deaths. 1 Children younger than 18 years of age who had Covid-19 composed only 1% of the total number of patients; 11% of these children were hospitalized, and none died. 2 The Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) study involved a cohort of 100 Italian children younger than 18 years of age with Covid-19 confirmed by reverse-transcriptase–polymerase-chain-reaction testing of nasal or nasopharyngeal swabs who were assessed between March 3 and March 27 in 17 pediatric emergency departments. Here, we describe the results of the CONFIDENCE study and compare them with those from three cohorts in previously published analyses. 3-5 The median age of the children was 3.3 years (Table 1). Exposure to SARS-CoV-2 from an unknown source or from a source outside the child’s family accounted for 55% of the cases of infection. A total of 12% of the children appeared ill, and 54% had a temperature of at least 37.6°C. Common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%); the latter symptom occurred more often in children younger than 21 months of age. Fever, cough, or shortness of breath occurred in 28 of 54 of febrile patients (52%) (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). A total of 4% of the children had oxygen saturation values (as measured by pulse oximetry) of less than 95%; all these patients also had imaging evidence of lung involvement. Of the 9 patients who received respiratory support (Table S2), 6 had coexisting conditions. Laboratory and imaging findings are provided in Tables S3 and S4. According to the categories described by Dong et al., 4 21% of the patients were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease, and 1% were in critical condition (Table S5). Most of the infants presented with mild disease. Severe and critical cases were diagnosed in patients with coexisting conditions. No deaths were reported. A total of 38% of the patients were admitted to the hospital because of symptoms, irrespective of the severity of disease (Table 1). 4 Among our patients, the incidence of transmission through apparent exposure to a family cluster was lower than that in other cohorts, possibly because of the late lockdown in Italy. As compared with the other cohorts, fewer patients in our cohort had moderate-to-severe disease, possibly because chest radiography was predominantly used and chest computed tomography was rarely used. Thus, fewer cases of diagnosed (subclinical) pneumonia may have been identified. Bedside lung ultrasonography by experienced sonographers was performed in only 10% of the patients, 90% of whom received a diagnosis of lung interstitial syndrome without further radiographic imaging.

The coronavirus disease 2019 (COVID-19) pandemic will have a large impact in low-resource settings (LRS). 20% of COVID-19 patients become critically ill with hypoxia or respiratory failure (figure ). 1 Critical illness, describing any acute life-threatening condition, is receiving increased attention in global health because of its large disease burden and population impact. 2 Before the COVID-19 pandemic, growing evidence suggested that the care of critical illness was overlooked in LRS—hospitals cannot, or do not, prioritise emergency and critical care. 3 Most critically ill patients are cared for in emergency units and general wards and do not have access to advanced care in intensive care units (ICUs). Data from hospital wards in Malawi showed that 89% of hypoxic patients (oxygen saturation <90%) were not receiving oxygen, and 53% of unconscious patients (Glasgow Coma Scale <9) were being nursed supine without a protected airway (unpublished data). Figure Severity profile of coronavirus disease 2019 Data source: Wu et al (2020). 1 The COVID-19 pandemic will lead to a surge in the number of critically ill patients. 4 Hospitals throughout the world will become overwhelmed, and care will be provided at a lower resource level than usual. Along with preventive measures and infection control, the clinical care of these patients will be a fundamental determinant of the pandemic's overall impact. Unfortunately, the headline figures of ICU requirements for COVID-19 patients in resource-rich settings are masking the need for essential care. Attention is directed towards expensive, high-tech equipment that demands highly trained providers while neglecting low-cost essential care. To avoid this neglect, we recommend a primary policy focus on basic, effective actions with potential population impact. A conceptual framework has recently been proposed that illustrates the need for hospital readiness and good quality clinical practice for the dual aspects of identification and care of critically ill patients (appendix). 5 Hospitals should establish effective systems for triage and essential care in emergency units and wards, including patient separation and staff safety. User-friendly, concise protocols should be developed, disseminated, and implemented for good quality and feasible clinical care, with WHO's leadership and through national authorities. Simple physiological signs have been shown to identify critical illness, and single-parameter systems might be easier to use than compound scores. The central role of oxygen therapy should be emphasised, oxygen supplies and delivery systems secured, and guidelines for sustainable and appropriate use issued. Other essential care includes a head-up patient position, suction, and simple chest physiotherapy. When human resources are limited, such care can be implemented by less trained health workers or vital-signs assistants through a protocolised approach and task sharing. Quality essential care of critical illness could have a large positive effect on mortality even without ICUs. It would ameliorate the fatalism and passivity that arises from an absence of high-resource treatment options. Moreover, provision of essential care could prevent progression to multi-organ failure, reducing the burden on limited ICU capacity. The ability of health services in LRS and throughout the world to provide good quality essential care of critical illness must be greatly and urgently increased.