key: cord-0695466-cu9166c8 authors: Gavish, Rachel; Levinsky, Yoel; Dizitzer, Yotam; Bilavsky, Efraim; Livni, Gilat; Pirogovsky, Avinoam; Scheuerman, Oded; Krause, Irit title: The COVID‐19 pandemic dramatically reduced admissions of children with and without chronic conditions to general paediatric wards date: 2021-02-10 journal: Acta Paediatr DOI: 10.1111/apa.15792 sha: 7300934b65b890e70d86bbdf41d0d3db2594ef15 doc_id: 695466 cord_uid: cu9166c8 AIM: We examined the impact of the COVID‐19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted. METHODS: Israel declared COVID‐19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID‐19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre‐existing conditions, with 638 children hospitalised during the same period in 2019. RESULTS: The mean number of daily hospitalisations during the COVID‐19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID‐19. There was a significant decrease in the number of patients admitted with infectious (74%) and non‐infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre‐existing medical conditions. CONCLUSION: The Israeli COVID‐19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital. and their consequences, have been described in past pandemics 6 and are now being reported during the present one. [7] [8] [9] [10] Another interesting aspect is the potential influence of the COVID-19 outbreak on the incidence of other medical conditions. 11 Like many other countries, the Israeli Government has imposed numerous restrictions on the population. From 12 to 14 March 2020, all educational institutions were closed, including kindergartens and schools. Then, on 19 March a national state of emergency was declared and citizens were instructed to go into lockdown and refrain from leaving their house, except for urgent reasons. The main restrictions included forbidding group gatherings, closing all leisure venues and non-essential stores, mandatory masks and total quarantine during a national holiday. These restrictions led to a marked decrease in physical contact between children, which could have reduced the spread of infectious diseases. As a result, we could have expected a decrease in infection-related morbidity in Israel, in line with the reductions described by Kadambari et al in a paper on the pandemic. 12 The aim of this study was to investigate the impact of the COVID-19 pandemic lockdown in Israel on the number of children hospitalised in three general paediatric wards and the nature of those admissions. We performed a retrospective cohort study in the largest tertiary paediatric hospital in Israel, the Schneider Children's Medical Center of Israel in Petah Tiqva, which is about 10 kilometres from Tel Aviv. The data were obtained from the hospital's electronic database. All hospitalisations in the three general paediatric wards between 1 February and 18 April during 2018, 2019 and 2020 were studied. Hospitalisations that listed COVID-19 as a main cause of admission (total of 20 admissions) were excluded, since the purpose of our study was to evaluate the impact of the pandemic on hospitalisations of patients with conditions other than COVID-19 disease. The primary outcome was a comparison between the number of daily hospitalisations during the COVID-19 lockdown period of 20 March to 18 April and the three periods. The secondary outcome was to compare the reasons for the admissions and the medical backgrounds of the patients between the COVID-19 period and the corresponding four-week period in 2019. All analyses were performed using SPSS statistics software, version 17.0 (IBM Corp.), and a p value of <0.05 was considered statistically significant. We used negative binominal regression to examine the effect of the COVID-19 pandemic on the number of daily hospitalisations. This model was chosen because of the over dispersed nature of the dependent variable, which was the number of daily hospitalisations. To analyse the impact of the COVID-19 pandemic on the number of hospitalisations for each admission category, we carried out a separate model for the causes of admission, which were organised into groups. Using the model, we calculated the incidence rate ratios (IRR) that represented the ratio of the number of patients hospitalised during the COVID-19 period and compared that with the corresponding period in 2019. The chi-square test was used to compare patients with, and without, chronic conditions. For descriptive purposes, the number of daily hospitalisations was plotted during the different research periods. • Mean daily admissions to Israel's largest paediatric hospital were 59% lower in the 4 weeks after the Government declared a national emergency due to COVID-19. • The rates of hospitalisations in three general paediatric wards were compared with the immediate pre-pandemic lockdown period and data for 2018 and 2019. • There were significant decreases in patients admitted with infectious and non-infectious diseases and with and without pre-existing medical conditions. When we analysed the patients' medical backgrounds, we found a significant decrease in the number of patients admitted with (58%), and without (55%), existing conditions. There was no significant difference in the number of chronic patients hospitalised, as the percentages of total admissions, between the COVID-19 period and the corresponding four-week period in 2019: 44% versus 46%, respectively, p = 0.61. Our study showed that there was a drop in the total number of admissions to the three general paediatric wards of Israel's largest tertiary paediatric hospital in the four weeks after the Government declared COVID-19 a national emergency. The overall number of hospital admissions decreased by almost 60% during the pandemic study period, and this finding was consistent with previous reports of significant decreases in emergency department presentations. 13 The reduction in hospitalisation numbers during the COVID-19 pandemic appears to be much greater than the lower numbers observed during the severe acute respiratory syndrome outbreak in 2009. For example, a Canadian study by Michael et al reported a reduction of only 10%-12% in the total number of admissions at that time. 14 Our findings can be explained by several factors. People were concerned about visiting hospitals because they saw them as sites where they could be exposed to COVID-19. This stopped parents from entering hospitals and minimised referrals from primary care physicians. In addition, medical insurance companies encouraged the general public to find alternative ways to receive medical care, such as telemedicine. 15 This increased concerns about the role of 13 Another interesting finding was the lack of any significant difference between the percentages of patients with and without chronic diseases. We expected to find that a larger percentage of chronic patients had been admitted, because many of them cannot be treated in outpatient settings. One of the most common causes of deterioration in patients with chronic conditions is developing an infectious disease. Therefore, the reduction in the prevalence of infectious diseases might be explained by the decreased need for hospitalisation in this population. Another explanation is that these high-risk patients avoided being hospitalised because of considerable concerns about acquiring the virus that causes COVID-19. Our study had several limitations. First, it was conducted in a single, urban, paediatric tertiary hospital and this means that the generalisability of these findings is limited to comparable institutions. Second, we only observed a short period, which covered the first four weeks at the start of the pandemic in Israel, and it may not reflect the real long-term impact of the COVID-19 outbreak. Lastly, we lacked information about patients who did not seek medical help or were not referred to our hospital. This additional information might have provided greater clarity about all the factors that drove the decrease in the number of hospitalisations during the COVID-19 pandemic period. Our results show that the first four weeks of the COVID-19 pandemic in Israel led to a dramatic reduction in the number of patients admitted to the general paediatric wards of the country's largest paediatric hospital. It also had an impact on the distribution of the reasons for those admissions. Further studies are needed to identify the factors that may have affected this trend, which has also been reported in other countries. There is a need to re-examine the indications for hospitalisation and to find out whether reduced admissions are damaging the health of paediatric patients due to late diagnoses and referrals. 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