key: cord-1047058-qerpma1a authors: Maruo, Yuji; Ishikawa, Shinichi; Oura, Kazumi; Shiraishi, Haruki; Sato, Norio; Suganuma, Takashi; Mikawa, Makoto; Sato, Tomonobu title: The impact of COVID‐19 pandemic on pediatric hospitalization in Kitami, Japan date: 2021-07-29 journal: Pediatr Int DOI: 10.1111/ped.14937 sha: de34b286d29f564382fba4dfdf9a49a47bb36104 doc_id: 1047058 cord_uid: qerpma1a BACKGROUND: Coronavirus disease 2019 (COVID‐19) has drastically changed the recommended activities and environment of patients worldwide. Our aim was to assess the impact of COVID‐19 on pediatric hospitalizations in Kitami, Japan. METHODS: A retrospective, single‐center study was conducted on hospitalized patients aged 0–14 years at the Japanese Red Cross Kitami Hospital. We compared the incidence of pediatric patients hospitalized in 2020 with those in 2017–2019. RESULTS: The number of pediatric hospitalized patients dropped significantly in 2020 compared to that in 2017–2019 (median 43.0 vs. 78.5 per month, p < 0.001). The age was significantly older in 2020 (4.3 vs. 3.4 years, p < 0.001). Hospitalization from respiratory (8.5 vs. 30.5, p < 0.001) and gastrointestinal infections (3.0 vs. 6.0, p = 0.004) significantly decreased. Admission due to respiratory syncytial virus (0.0 vs. 4.0, p < 0.001), human metapneumovirus (0.0 vs. 1.0, p = 0.005), influenza (0.0 vs. 0.0, p = 0.009), adenovirus (0.0 vs. 1.0, p = 0.003), and rotavirus infection (0.0 vs. 0.0, p = 0.025) also decreased significantly. The <1–5 age groups significantly decreased (< 1 year old, 6.5 vs. 12.5, p < 0.001; 1–3 years old, 13.0 vs. 29.5, p < 0.001; 4–5 years old, 5.5 vs. 11.5, p < 0.001). Hospitalization due to foreign body ingestions increased significantly in 2020 (1.0 vs. 0.0, p = 0.010). CONCLUSIONS: The COVID‐19 control measures inadvertently reduced the number of hospitalized pediatric patients, especially in younger children with respiratory and gastrointestinal infections. The coronavirus disease 2019 (COVID-19) outbreak caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan, China towards the end of the year 2019. 1 COVID-19 spread worldwide and was declared a pandemic on March 11, 2020 by the World Health Organization. 2 As a disease that is transmitted by close contact, this pandemic has drastically changed the recommended activities and environment of patients worldwide. Japan had the first case of COVID-19 on This article is protected by copyright. All rights reserved Kitami is a city in Japan with a population of approximately 120,000, and the prevalence of children 0-14 years old is 11%-12%. The Japanese Red Cross Kitami Hospital has a total of 490 beds, and the number of beds in the pediatric ward is 30. There are eight pediatricians in our hospital. Our hospital is the only hospital in Kitami where children can be hospitalized, providing primary, secondary, and tertiary care. Therefore, the number of hospitalizations in this hospital is reflective of the entire pediatric population in Kitami City and its surrounding municipalities. In this study, we aimed to describe the impact of COVID-19 on the number of pediatric hospitalizations in Kitami, Japan, to obtain a better understanding of the epidemiological changes to pediatric hospitalization during the COVID-19 pandemic. A retrospective, single-center study was conducted on pediatric hospitalized patients aged 0-14 years at the Japanese Red Cross Kitami Hospital, Japan. We compared the frequency of pediatric hospitalized patients admitted in our institution in 2020 with that in This article is protected by copyright. All rights reserved 2017-2019. The number of pediatricians was eight or nine, depending on the year. Hospital open days per week did not change during the study period. Our institution did not impose hospitalization restrictions for pediatric patients during the COVID-19 pandemic. We collected the following information from medical records: age, sex, date of hospitalization, duration of hospitalization, background to hospitalization, diagnosis, and infectious disease pathogens. Infections were classified as respiratory, gastrointestinal, or other infections. Newborns admitted to the neonatal intensive care unit or growing care unit were excluded from this study. The following test kit was used for rapid antigen testing: ALSONIC RSV (Alfresa Pharma Corp., Osaka, Japan) for respiratory syncytial (RS) virus, ImunoAce hMPV (TAUNS Laboratories, Shizuoka, Japan) for human metapneumovirus, ImunoAce Flu (TAUNS Laboratories, Shizuoka, Japan) for influenza, ALSONIC Adeno (Alfresa Pharma Corp., This article is protected by copyright. All rights reserved Osaka, Japan) for nasopharyngeal adenovirus, QuickNavi TM -Norovirus2 (Denka Company Limited, Tokyo, Japan) for fecal norovirus, and Quick Chaser Rota/Adeno (MIZUHO MEDY Corp., Saga, Japan) for fecal rotavirus and adenovirus. Streptococcus pyogenes Infection was diagnosed when it was detected in pharyngeal culture. If the antigen test or pharyngeal culture was positive, we diagnosed this as an infection caused by that antigen. If the antigen was already identified by the previous doctor, we diagnosed this as an infection caused by that antigen according to the test result of the previous doctor, and the antigen test was not repeated at our hospital. Each antigen test was performed at the discretion of the attending physician. ImunoAce hMPV (TAUNS Laboratories, Shizuoka, Japan) for human metapneumovirus was available from August 2017. TRCReady SARS CoV-2 (Tosoh Corp., Yamaguchi, Japan) was used for the polymerase chain reaction test of SARS-CoV-2 since May 2020 in our hospital. Other available tests or the policy did not change during the study period. Statistical analyses were performed with EZR (Saitama Medical Center, Jichi This article is protected by copyright. All rights reserved Medical University, Saitama, Japan), which is a graphical user interface for R 4.0.3 (The R Foundation for Statistical Computing, Vienna, Austria). 8 More precisely, it is a modified version of R commander (version 2.7-1) designed to incorporate statistical functions frequently used in biostatistics. Categorical variables were described as numbers and percentages, while continuous variables were described as the median and interquartile range (IQR). The Mann-Whitney test was used to compare two groups of independent, non-parametric numerical data. The chi-square test was used to compare the proportions for categorical variables. Statistical significance was set at a two-sided p-value of < 0.05. Ethical approval was obtained from the Japanese Red Cross Kitami Hospital Ethics Committee in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki). Patient demographics are shown in Table 1 Table 2 ). The number of hospitalized pediatric patients at each age is shown in Figure 2a . In 2020, the number of hospitalized patients in infants (< 1 year old), toddlers (1-3 years old), and preschoolers (4-5 years old) was significantly decreased (infants, median 6.5 vs. 12.5 per month, p < 0.001; toddlers, median 13.0 vs. 29.5 per month, p < 0.001; preschoolers, This article is protected by copyright. All rights reserved (Figure 2b ). In this study, we aimed to assess the impact of COVID-19 on the number of pediatric hospitalizations in a single-center institution from Kitami, Japan. According to reports from the National Institute of Infectious Diseases, the number of reported cases of respiratory syncytial virus, human metapneumovirus, influenza, adenovirus, Streptococcus This article is protected by copyright. All rights reserved pyogenes, norovirus, and rotavirus dropped sharply after the COVID-19 pandemic in Japan. 9 We observed that pediatric hospitalizations for infectious, gastrointestinal, and respiratory etiologies significantly decreased during the pandemic in Kitami. These changes were similar to those reported in other countries. 4 Thorough infection control in nursery schools and kindergartens may have contributed to its decrease. Refraining from using these facilities and the high hygienic preventive measures of guardians against infectious diseases may also have been a factor in preventing the spread of the infection. Standard precautions may have reduced parent-to-child transmission at This article is protected by copyright. All rights reserved home. Second, community-level quarantine measures, such as school closures, may have suppressed the spread of infectious diseases. However, in our study, hospitalization in children > 8 years did not decrease after the COVID-19 pandemic. This is probably because children > 8 years are less likely to be hospitalized from infection due to the usually milder presentation than those aged < 7 years. Third, infections during this period may be underreported since non-severe cases are managed at home. Some patients who were eligible for hospitalization may have improved spontaneously at home after avoiding hospital consultations. In Kitami City, the first COVID-19 patient was reported on February 22, 2020. 14 A total of 17 SARS-CoV-2-positive cases, including adult cases, were reported in Kitami City in 2020. 14 SARS-CoV-2-positive cases were reported in February (n = 7), March (n = 6), November (n = 2), and December (n = 2), but no positive cases were reported from April to October. 14 The higher surge of COVID-19 infection during the early quarter of 2020 may have encouraged more stringent infection control measures within the community, which may have contributed to the decline in pediatric hospitalized patients from March (Figure 2a ). This article is protected by copyright. All rights reserved with another viral microorganism within the same host. [15] [16] [17] Viral interference may also occur in COVID-19, 17 which may have resulted in the decrease in the incidence of other infectious diseases. The COVID-19 outbreak was well-controlled in Kitami with a relatively small incidence. Therefore, viral interference by COVID-19 may not be the primary cause of decreased hospitalization in Kitami from other infectious diseases. In our study, asthma and Kawasaki disease also decreased significantly in Kitami after the COVID-19 pandemic. The reduction in the number of asthma hospitalizations after the COVID-19 pandemic was consistent with a previous report in Japan. 18 The reduction of exposure to respiratory infections and allergens from the increased hygiene practices may have reduced asthma attacks. It has been previously reported that epidemiological data strongly suggest an infectious etiology for Kawasaki disease. 19 Although an infectious etiology for Kawasaki disease remains unclear, the concomitant decrease in respiratory and gastrointestinal infections may have likewise led to a decrease in Kawasaki disease cases. Chong et al. reported that trauma-related complaints in the emergency department decreased during the lockdown in Singapore. 4 However, trauma-related hospitalization in the pediatric population did not decrease in Kitami in 2020. Most trauma-related hospitalized This article is protected by copyright. All rights reserved patients had fractures that occurred outside their homes. This may be because strict measures such as lockdowns were not enforced in Japan. On the other hand, accidental ingestion of foreign bodies has increased significantly in 2020. All foreign body ingestions from 2017 to 2020 occurred at home. Increased time spent at home may have contributed to this increase. Thus, it is important to inform the community about the risks of accidental foreign body ingestion while staying at home. There are some limitations in this study. Since our study was a retrospective single-center study, our findings require corroboration from other facilities for generalization. In addition, the decision to perform antigen testing depended on the physician's decision. Antigen testing was not performed on all infectious cases, thus, there may be cases in which the pathogen has not been determined. In conclusion, we demonstrated changes to the epidemiological patterns of pediatric hospitalizations in Kitami. COVID-19 infection control measures that focused on proper hygiene practices and social distancing reduced the number of pediatric patients hospitalized for other diseases, especially in infants, toddlers, and preschoolers with respiratory A pneumonia outbreak associated with a new coronavirus of probable bat origin World Health Organization Director-General's opening remarks at the media briefing on COVID-19 -11 COVID-19 related reduction in pediatric emergency healthcare utilization -a concerning trend Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore Outbreak of aseptic meningitis caused by echovirus 30 in Kushiro, Japan in 2017 Kitami City [homepage on the Internet Viral Interference: The Case of Influenza Viruses