A multidisciplinary study led by two University of Pretoria (UP) researchers has found that Tshwane District hospitals were under immense pressure to provide clinical services in the face of an influx of paediatric patients (under 19 years old) during the early stages of the COVID-19 Omicron wave in November and December 2021. 

The study provides data to assist with the worldwide preparation for the impact of the Omicron variant among children.

It describes the rapid rise in paediatric COVID-19-associated hospitalisations in the Tshwane District (which has a population of 3 552 452 and a population density of 527 people/km²), one of the first known epicentres of the Omicron variant. The study showed that there had been an increase in infections among paediatric patients, starting from mid-November 2021 onwards.  

Professor Ute Feucht – Director of the Centre for Maternal, Fetal, Newborn and Child Health Care Strategies in UP’s Faculty of Health Sciences – and Adjunct Professor and paediatrician Jeané Cloete of Steve Biko Academic Hospital (UP’s main teaching hospital) headed up the study. They collaborated with Dr George Mukhari Academic Hospital, Tshwane District Health Services, the Gauteng Department of Health, the National Institute for Communicable Diseases, district officials and other scientists.

The study – titled ‘Paediatric hospitalisations due to COVID-19 during the first SARS-CoV-2 Omicron (B.1.1.529) variant wave in South Africa: a multicentre observational study’ – was published in The Lancet Child & Adolescent Health, and was conducted over a six-week period in which 6 287 paediatric COVID-19 cases were recorded in Tshwane. 

According to the scientists, 462 (7.3%) paediatric patients were admitted to 38 hospitals, making up 18% of overall admissions. “This was in stark contrast to the number of paediatric cases in the previous three waves, uncharacteristically preceding adult hospitalisations, thus raising the alarm about the readiness of hospitals, which have generally focused on adult patients,” they said. 

The relevant data was extracted from various sources, including COVID-19 line lists for contact tracing activities; SARS-CoV-2 testing data collated by the National Institute for Communicable Diseases; and SARS-CoV-2 genomic sequencing data from specimens obtained within the district through UP’s Zoonotic Arbo- and Respiratory Virus research group. 

“Information obtained during the study revealed that young children (0–4 years) were most affected,” the researchers explained. “Symptoms included fever (61%), coughing (57%), shortness of breath (31%), seizures (31%), vomiting (26%) and diarrhoea (25%). The length of hospital stay was short, averaging 3.2 days, and in 45% of cases, COVID-19 was the primary diagnosis.” 

Most children received standard ward care (92%), with 27 (23%) receiving oxygen therapy. Seven children (6%) were ventilated; four died as a result of additional illnesses that were the main cause of death. However, no child died primarily due to the COVID-19 virus.

Prof Cloete said the fourth COVID-19 wave started from a low base, with evidence in Tshwane District communities of low transmission levels; there were very low numbers of COVID-19 infections documented in Tshwane despite continued testing. 

She added that the wave started earlier than expected, with paediatric hospital wards noticing marked increases in admissions of COVID-19-infected children from mid-November 2021, at much higher levels than during the previous three COVID-19 waves and uncharacteristically ahead of adult COVID-19-related admissions. 

“The increased numbers of paediatric admissions, and rapid upward trajectory thereof, created logistical issues locally, as few paediatric COVID-19 hospital beds were available,” Prof Cloete said. “Coupled with acute staff shortages due to COVID-19-related isolation and quarantine, this created a challenging environment in which to admit the unexpectedly large number of COVID-19 paediatric patients.”

“Most of the admitted COVID-19 paediatric patients had mild-to-moderate symptoms and had been discharged after only a few days in hospital,” Prof Feucht said. “The clinical picture is mixed with other childhood illnesses – children were presenting with childhood diseases at different times of the year compared to the pre-COVID 19 waves.” She added that many COVID-19 diagnoses were incidental in that children presented with trauma or injury before being diagnosed with COVID-19. 

“What happened in Tshwane was unexpected – it seemed to have come out of nowhere. For genomic sequencing, the clinical specimens were used from public sector health facilities, showing that the Omicron variant was causing this fourth COVID-19 wave. The lessons would provide insight into other parts of South Africa that experienced a surge, and Europe and the US, which are contending with escalating numbers.” 
The scientists said that district-based research must continue to include research around the impact of COVID-19 on children and how this affects the healthcare system. This is critical in the long term in order to save the lives of children by ensuring that they get the same treatment as adults.