Related Factors for Severe, Critical and Death in Children with Healthcare-Associated COVID-19
Authors: Ortega-Riosvelasco F , Moreno-Miranda R , López-Moreno V E , Estrada-Chacón S A , Prado-Galbarro F J , Mejía-Rosales P A , de la Rosa-Zamboni D , Gamiño-Arroyo A E 
Published: November 2023

Abstract

Background
Since the beginning of the pandemic, the American Academy of Pediatrics and the Children′s Hospital Association have reported over 15.4 million cases of COVID-19 in children in the United States (18% of all cases).1 UNICEF on the other hand, has reported more than 288 million cases all over the world and 4.1 million deaths related to COVID-19 in children.2
Healthcare-Associated Infections (HAI) represent a big burden on the health care system, with a subsequent increase in morbidity, hospital stay, medication/procedures, intensive care unit admissions, mortality, etc. Globally there is not enough data of HAI for SARS-CoV-2 in children, specially from low and lower-middle income countries.

Methods
Prognosis study through the description and analysis of an ambispective cohort in children at a tertiary care pediatric hospital [Hospital Infantil de Mexico Federico Gomez: (HIMFG)] in Mexico City from April 2020 to December 2022.
We identified patients &lt;18 years old with probable and definite healthcare-associated (HA) COVID-19 according to the CDC definition:3 symptom onset (or positive test) on day 8 or on, after admission. Independent variables included socio-demographic information, clinical symptoms, laboratory results, among others. Outcome variables measured included severity (severe and critical), and death.4 Chi square and Wilcoxon tests were performed to identify independent risk factors for severity and death. After the bivariate analysis, logistic regression models were used to identify factors associated with patient severity and mortality.

Results
102 patients were included; mean age was 6.4 years (min 0.02, max 17.9) and 57 were male. 32 were asymptomatic, 27 had mild disease, 6 were moderate, 31 severe and 6 critical; of this total, 6 patients died. 98 patients had at least one comorbidity, and 54 had at least 2: 35 with immunosuppression, 28 with cancer, 18 with heart disease, 14 with pulmonary disease and 14 with neurologic disease. 14 patients required admission to a Pediatric Intensive Care Unit.
Mean hospital stay at diagnosis was 35.5 days (min 8, max 143): 24 patients were identified with probable HA-COVID-19 (8-14 days after admission) and 78 with definite HA-COVID-19 (&gt;14 days after admission).

Conclusions
Since the beginning of the COVID-19 pandemic, multiple strategies in infection prevention and control have been implemented at our hospital: universal screening before admission, active surveillance for patients/caretakers/health-care workers with respiratory symptoms and for contacts, universal use of facemasks, isolation of patients with respiratory symptoms, among others. Despite all these measures, a free Hospital from HA-COVID-19 remains a challenge.
Our study found that the sudden onset of symptoms, the presence of fever, irritability and polypnea increases significantly the risk for severity in patients that acquired the disease in the hospital.
On the other hand, patients with an underlying heart disease have 30 times more risk of dying than those who doesn’t. The presence of O2 desaturation and admission to a PICU increases significantly the mortality in patients with HA-COVID-19. Overall, mortality in children with HA-COVID-19 was 5.9% (up to 8.6% if strictly considering only the symptomatic), much more that the one reported globally (1.4%).2

References
1. Cull B HMBLRG. Children and COVID-19 State Date Report. American Academy of Pediatrics. 2022;V. 10/6/22.
2. UNICEF DATA. UNICEF [cited 2022 Oct] Available from: COVID-19 confirmed cases and deaths - UNICEF DATA.
3. Surveillance definitions for COVID-19. European Centre for Disease Prevention and Control. 2021 Mar 21 https://www.ecdc.europa.eu/en/covid-19/surveillance/surveillance-definitions
4. COVID-19. OMS. Enero 2021: Manejo Clínico de la COVID-19. Orientaciones evolutivas; 25 de Enero de 2021. OMS reference number: WHO/2019-nCoV/clinical/2021.1)