Factors associated with disease severity amongst children admitted with SARS-COV-2 infection in Gauteng and KwaZulu-Natal, 2020 to 2022

Abstract

Background Understanding the risk factors associated with severe disease, including mortality, in children infected with SARS-CoV-2 is crucial for guiding public health interventions and clinical management. Methods We conducted a retrospective analysis of paediatric patients (<18 years) admitted with SARS-CoV-2 infection between April 2020 and March 2022 in Gauteng and KwaZulu- Natal. We examined demographic and clinical characteristics associated with mortality and severe disease, using multivariable logistic regression models to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results Among 13,577 children admitted, 1,569 (11.6%) developed severe COVID-19. Newborns had the highest odds of severe disease (aOR: 4.7, 95% CI: 3.4–6.5, p<0.001), followed by infants aged 1–11 months (aOR: 2.0, 95% CI: 1.6–2.5, p<0.001). Males had a slightly increased risk (aOR: 1.2, 95% CI: 1.1–1.4, p=0.013). Comorbid conditions significantly contributed to severity, with diabetes (aOR: 3.6, 95% CI: 2.3–5.5, p<0.001) and HIV- positive status (aOR: 1.6, 95% CI: 1.0–2.6, p=0.043) being key predictors. Hospital stays exceeding 15 days were strongly associated with severe disease (aOR: 6.0, 95% CI: 4.8– 7.6, p<0.001). v Among 320 paediatric deaths, infants (<1 year) accounted for the highest proportion (43.1%), with newborns at the greatest risk (aOR: 3.2, 95% CI: 2.1–4.8, p<0.001). Adolescents (13–17 years) also had an increased mortality risk (aOR: 1.6, 95% CI: 1.1– 2.3, p=0.016). Patients admitted to high-care and intensive care units had markedly higher odds of death (aOR: 2.4 and 8.2, respectively, p<0.001). Conclusion Younger age (especially newborns), male sex, prolonged hospitalization, and underlying comorbidities significantly increased the risk of severe disease (including mortality) in paediatric COVID-19 patients. These findings emphasize the need for targeted interventions to protect high-risk children and optimize clinical management strategies.