COVID-19 Prevention Policies Reduce Pediatric Hospital Mortality Due to Community-acquired Pneumonia

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(A) Axial contrast section showing an upper right lobe mass (lung adenocarcinoma) and a mixed lesion (cavity and solid) in the upper left lobe (July 27th, 2018). (B) Axial contrast section showing a progression of the upper right lobe mass after chemotherapy; baseline for the start of the immunotherapy (January 18th, 2019). (C) Axial contrast section showing an abundant right pleural effusion (pleural tuberculosis) and previously described mixed lesion in the upper left lobe (April 30th, 2019). (D) Axial contrast section showing an almost complete tumor response after 28 cycles of immunotherapy (March 23rd, 2021)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Lucile Roussel, Aurélien Brindel, Celsio Pouget, Gauthier Treffel, Yves Billon, Pierre Vaillant, Angelica Tiotiu" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Lucile" "apellidos" => "Roussel" ] 1 => array:2 [ "nombre" => "Aurélien" "apellidos" => "Brindel" ] 2 => array:2 [ "nombre" => "Celsio" "apellidos" => "Pouget" ] 3 => array:2 [ "nombre" => "Gauthier" "apellidos" => "Treffel" ] 4 => array:2 [ "nombre" => "Yves" "apellidos" => "Billon" ] 5 => array:2 [ "nombre" => "Pierre" "apellidos" => "Vaillant" ] 6 => array:2 [ "nombre" => "Angelica" "apellidos" => "Tiotiu" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289621001770?idApp=UINPBA00003Z" "url" => "/03002896/0000005800000002/v4_202209200636/S0300289621001770/v4_202209200636/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "Scientific Letter" "titulo" => "COVID-19 Prevention Policies Reduce Pediatric Hospital Mortality Due to Community-acquired Pneumonia" "tieneTextoCompleto" => true "saludo" => "To the Director:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "197" "paginaFinal" => "199" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carolina F. Dias, Edgar E. Sarria, Camila Scheffel, Laura B. Delatorre, Alexander Sapiro, Marilisa Baldissera, Sabrina Chiapinotto, Helena T. Mocelin, Gilberto B. Fischer, Rita Mattiello" "autores" => array:10 [ 0 => array:3 [ "nombre" => "Carolina F." "apellidos" => "Dias" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Edgar E." "apellidos" => "Sarria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Camila" "apellidos" => "Scheffel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Laura B." 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"apellidos" => "Fischer" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] 2 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 9 => array:4 [ "nombre" => "Rita" "apellidos" => "Mattiello" "email" => array:1 [ 0 => "rita.mattiello@puc.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Pediatric Department, Universidade Federal do Espírito Santo, Vitória, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pediatric Infectious Diseases Section, Hospital Infantil e Maternidade Dr. Alzir Bernardino Alves, Vila Velha, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Postgraduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Pediatrics Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Postgraduate Program in Pediatrics, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 687 "Ancho" => 1333 "Tamanyo" => 72873 ] ] ] ] "textoCompleto" => "Pneumonia remains a leading cause of preventable illness and death in children under five years of age worldwide.<a class="elsevierStyleCrossRef" href="#bib0195">1</a> Globally, pneumonia is associated with between 812,000 and 1.1 million deaths in children annually. In 2017 in Brazil, 2,551,218 hospital admissions occurred among children under five years old and regarding mortality, 3120 deaths due to respiratory disease were registered in the same age range.<a class="elsevierStyleCrossRef" href="#bib0105">2</a>To add to this situation, in 2019 the first cases of COVID-19 were identified. Since then, the number of moderate to severe cases of COVID-19 has increased exponentially in hospitals worldwide, but the disease has consistently behaved benignly in most children compared to adults.<a class="elsevierStyleCrossRef" href="#bib0110">3</a>The World Health Organization and the Centers for Disease Control recommended COVID-19 policies implementation as part of the preemptive and contention measures for COVID-19.<a class="elsevierStyleCrossRef" href="#bib0115">4</a> Since then, studies have shown that, in 2020, there was a reduction in general pediatric care, emergency department visits, and hospital admissions of infants with bronchiolitis.<a class="elsevierStyleCrossRefs" href="#bib0120">5,6</a> The aim of this study is to analyze the impact of those initiatives, originally against COVID-19, on hospitalization mortality due to community-acquired pneumonia in Brazilian children.This ecological study analyzed the data on hospital admissions and deaths due to community-acquired pneumonia in children and adolescents occurring in Brazil from 2019 to 2020. The data were obtained from the database of the Department of Informatics of the Brazilian Public Health System (DATASUS).<a class="elsevierStyleCrossRefs" href="#bib0125">6,7</a>Poisson regression models with robust variance were used to obtain relative risk (incidence of hospitalizations or mortality pre-PCPI/incidence of hospitalizations or mortality with PCPI in place) and the respective 95% CI. The cut-off probability for rejecting the null hypothesis was defined as less than 5%. The statistical analysis was performed using the R software (<a href="http://www.r-project.org/">www.r-project.org/</a>) and the statistical analysis was performed using the IBM SPSS Statistics for Windows, version 21.0.This study does not contain personal or individual data, so it was considered exempt from evaluation by the Research Ethics Committee.From 2019 to 2020, 328,307 hospital admissions and 2383 deaths due to pneumonia were identified in children and adolescents up to 19 years of age. The risk of hospitalization for pneumonia in children in the period when COVID-19 policies implementation measures were implemented to contain de pandemic (2020) was 68% lower compared to 2019 (RR=0.32; 95% CI: 0.29 to 0.37) and that of mortality from pneumonia during hospitalization was 50% lower (RR=0.50; 95% CI: 0.44 to 0.58). Children under the age of 12 months saw the greatest reduction in hospitalizations (RR=0.27; 95% CI: 0.23 to 0.31) and mortality (RR=0.49; 95% CI: 0.40 to 0.59) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The same downward trend, albeit with different magnitudes, was observed in different regions of Brazil. The South region saw the greatest reduction in hospitalizations for pneumonia in all age groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). For mortality, the South region saw the greatest reduction only for the <12 months and the 10–14 years old age groups. Regarding the other age groups, the greatest reduction in mortality in children aged one to four years old was found in the Southeast, for those aged five to nine it was in the Midwest, and for those aged 10–15 it was in the North. When comparing the total incidences between the regions of Brazil, the highest incidence of hospitalizations and mortality was found in the North region (<a class="elsevierStyleCrossRef" href="#fig1">Fig. 1</a>).<elsevierMultimedia ident="fig1"></elsevierMultimedia>The overall cost of hospitalizations for pneumonia in Brazil was 43,552,662.88 dollars in 2019 and 16,200,443.39 dollars in 2020. In other words, Brazil saw a 63% reduction in the cost of hospitalizations for pneumonia when the COVID-19 prevention policies were applied.Our study suggests that the policies for COVID-19 prevention were associated with an important decrease in pediatric hospital mortality in Brazil due to community-acquired pneumonia.We believe that the implementation of policies for supporting COVID-19 prevention was the main reason for this reduction in pediatric pneumonia admissions and mortality during the first year of the COVID-19 pandemic in Brazil. It is not possible or feasible to pinpoint the individual contribution of the different policies for supporting COVID-19 prevention, but studies of the dynamics of their implementation propose that it is the combination of them that has proven to be most useful.<a class="elsevierStyleCrossRef" href="#bib0120">5</a>At the same time, there are reports of an overall decrease in acute respiratory illnesses in children, as well as fewer emergency department visits and fewer pediatric hospital and intensive-care admissions for ARI during the pandemic.<a class="elsevierStyleCrossRefs" href="#bib0120">5–8</a> We did not identify any other studies that reported a decrease in child mortality from pneumonia during hospitalization. A recent study also found a significant decrease in cases of all cause pneumonia in Brazilian children under 14 years during the COVID-19 pandemic.<a class="elsevierStyleCrossRef" href="#bib0140">9</a>For the present study, we performed a nationwide level analysis, and the results showed the same decreasing trend. The Southern region was the one with the greatest overall reduction in the incidence of hospitalizations for pneumonia. For mortality, the Southern region had the greatest reduction only in the age group <12 months.With the COVID-19 pandemic, the main Brazil public health responses have been organized at the state and municipality levels, resulting in different choices and timing regarding the implementation of COVID-19 prevention policies. Social inequality in Brazil is a problem that affects a large part of the population, and the COVID-19 pandemic threatens to increase it even more.A national average adherence of social distancing was <25% was reported, while the WHO believes at least 50% compliance is needed to have a noticeable effect.<a class="elsevierStyleCrossRef" href="#bib0135">8</a> However, we believe that this low adherence applies mainly to adults, since children were subject to greater social distancing while staying at home and out of schools/daycare.<a class="elsevierStyleCrossRef" href="#bib0145">10</a>The promotion of COVID-19 prevention policies needs to be constant and consistent in order to the spreading of viruses in both clinical settings and the community.<a class="elsevierStyleCrossRef" href="#bib0150">11</a> In practical terms, hand hygiene, better space ventilation and even mask wearing during acute respiratory infections, should be included in health education programs.<a class="elsevierStyleCrossRefs" href="#bib0155">12–14</a> These simple strategies are cost-effective and feasible to apply at the different settings, such as schools, public transportation, workplaces and healthcare environments.<a class="elsevierStyleCrossRefs" href="#bib0155">12–19</a> In fact, the overall spending on pneumonia hospitalizations in Brazil was 63% lower during the COVID-19 prevention policies implementation period (2020) compared to 2019.Our study has some limitations. We retrospectively obtained the data from the Brazilian health department registry system. However, this is the official system used to collect and analyze data for public health measures, and it has been effectively in place for more than a decade. We also did not have access to viral identification, which could provide a better picture of the impact the COVID-19 pandemic had on specific respiratory viruses. Nonetheless, pneumonia hospitalizations and mortality showed an important and consistent reduction in all age groups in all Brazilian regions, which suggests that all viruses were similarly affected.Our study found an important reduction in hospitalizations mortality due to pneumonia, as well as in the cost of hospitalizations due to respiratory diseases, because of the implementation of COVID-19 prevention policies initiatives in the public health system. This reinforces the usefulness of prevention policies for decrease pneumonia mortality.Summary of the article's main pointOur study found an important reduction in hospitalizations mortality due to pneumonia, as well as in the cost of hospitalizations due to respiratory diseases, because of the implementation of COVID-19 prevention policies initiatives.FundingThis research has not received specific aid from public sector agencies, commercial sector or non-profit entities.Conflict of interestThe authors declare that they have no conflict of interest directly or indirectly related to the contents of the manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1772368" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Summary of the article's main point" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 4 => array:2 [ "identificador" => "xack626193" "titulo" => "Acknowledgments" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Graphical abstract" "resumen" => "<elsevierMultimedia ident="fig0010"></elsevierMultimedia>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 848 "Ancho" => 2917 "Tamanyo" => 90195 ] ] "descripcion" => array:1 [ "en" => "Incidence of hospitalizations and mortality by year and Brazilian region." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "RR: risk relative, CI: confidence interval." "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hospitalization \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean incidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortality \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean incidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><12 months</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">215.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–4 years</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5–9 years</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–14 years</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15–19 years</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2020 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2019 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Mean annual incidence, relative risk, and 95% confidence interval of hospitalizations and mortality due to pneumonia in Brazilian children by age range." ] ] 2 => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 687 "Ancho" => 1333 "Tamanyo" => 72873 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.A. 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Scientific Letter

COVID-19 Prevention Policies Reduce Pediatric Hospital Mortality Due to Community-acquired Pneumonia

Carolina F. Diasa,b, Edgar E. Sarriac, Camila Scheffeld, Laura B. Delatorred, Alexander Sapirod, Marilisa Baldisserad, Sabrina Chiapinottoe, Helena T. Mocelinc,f, Gilberto B. Fischerc,f,g, Rita Mattiellod,

Corresponding author

rita.mattiello@puc.br

Corresponding author.

a Pediatric Department, Universidade Federal do Espírito Santo, Vitória, Brazil

b Pediatric Infectious Diseases Section, Hospital Infantil e Maternidade Dr. Alzir Bernardino Alves, Vila Velha, Brazil

c Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil

d Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil

e Postgraduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

f Pediatrics Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil

g Postgraduate Program in Pediatrics, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumonia remains a leading cause of preventable illness and death in children under five years of age worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Globally&#44; pneumonia is associated with between 812&#44;000 and 1&#46;1 million deaths in children annually&#46; In 2017 in Brazil&#44; 2&#44;551&#44;218 hospital admissions occurred among children under five years old and regarding mortality&#44; 3120 deaths due to respiratory disease were registered in the same age range&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To add to this situation&#44; in 2019 the first cases of COVID-19 were identified&#46; Since then&#44; the number of moderate to severe cases of COVID-19 has increased exponentially in hospitals worldwide&#44; but the disease has consistently behaved benignly in most children compared to adults&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The World Health Organization and the Centers for Disease Control recommended COVID-19 policies implementation as part of the preemptive and contention measures for COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> Since then&#44; studies have shown that&#44; in 2020&#44; there was a reduction in general pediatric care&#44; emergency department visits&#44; and hospital admissions of infants with bronchiolitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">5&#44;6</span></a> The aim of this study is to analyze the impact of those initiatives&#44; originally against COVID-19&#44; on hospitalization mortality due to community-acquired pneumonia in Brazilian children&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This ecological study analyzed the data on hospital admissions and deaths due to community-acquired pneumonia in children and adolescents occurring in Brazil from 2019 to 2020&#46; The data were obtained from the database of the Department of Informatics of the Brazilian Public Health System &#40;DATASUS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Poisson regression models with robust variance were used to obtain relative risk &#40;incidence of hospitalizations or mortality pre-PCPI&#47;incidence of hospitalizations or mortality with PCPI in place&#41; and the respective 95&#37; CI&#46; The cut-off probability for rejecting the null hypothesis was defined as less than 5&#37;&#46; The statistical analysis was performed using the R software &#40;<a href="http://www.r-project.org/">www&#46;r-project&#46;org&#47;</a>&#41; and the statistical analysis was performed using the IBM SPSS Statistics for Windows&#44; version 21&#46;0&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study does not contain personal or individual data&#44; so it was considered exempt from evaluation by the Research Ethics Committee&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">From 2019 to 2020&#44; 328&#44;307 hospital admissions and 2383 deaths due to pneumonia were identified in children and adolescents up to 19 years of age&#46; The risk of hospitalization for pneumonia in children in the period when COVID-19 policies implementation measures were implemented to contain de pandemic &#40;2020&#41; was 68&#37; lower compared to 2019 &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#59; 95&#37; CI&#58; 0&#46;29 to 0&#46;37&#41; and that of mortality from pneumonia during hospitalization was 50&#37; lower &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;50&#59; 95&#37; CI&#58; 0&#46;44 to 0&#46;58&#41;&#46; Children under the age of 12 months saw the greatest reduction in hospitalizations &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;27&#59; 95&#37; CI&#58; 0&#46;23 to 0&#46;31&#41; and mortality &#40;RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;49&#59; 95&#37; CI&#58; 0&#46;40 to 0&#46;59&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The same downward trend&#44; albeit with different magnitudes&#44; was observed in different regions of Brazil&#46; The South region saw the greatest reduction in hospitalizations for pneumonia in all age groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; For mortality&#44; the South region saw the greatest reduction only for the &#60;12 months and the 10&#8211;14 years old age groups&#46; Regarding the other age groups&#44; the greatest reduction in mortality in children aged one to four years old was found in the Southeast&#44; for those aged five to nine it was in the Midwest&#44; and for those aged 10&#8211;15 it was in the North&#46; When comparing the total incidences between the regions of Brazil&#44; the highest incidence of hospitalizations and mortality was found in the North region &#40;<a class="elsevierStyleCrossRef" href="#fig1">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The overall cost of hospitalizations for pneumonia in Brazil was 43&#44;552&#44;662&#46;88 dollars in 2019 and 16&#44;200&#44;443&#46;39 dollars in 2020&#46; In other words&#44; Brazil saw a 63&#37; reduction in the cost of hospitalizations for pneumonia when the COVID-19 prevention policies were applied&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our study suggests that the policies for COVID-19 prevention were associated with an important decrease in pediatric hospital mortality in Brazil due to community-acquired pneumonia&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We believe that the implementation of policies for supporting COVID-19 prevention was the main reason for this reduction in pediatric pneumonia admissions and mortality during the first year of the COVID-19 pandemic in Brazil&#46; It is not possible or feasible to pinpoint the individual contribution of the different policies for supporting COVID-19 prevention&#44; but studies of the dynamics of their implementation propose that it is the combination of them that has proven to be most useful&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">At the same time&#44; there are reports of an overall decrease in acute respiratory illnesses in children&#44; as well as fewer emergency department visits and fewer pediatric hospital and intensive-care admissions for ARI during the pandemic&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">5&#8211;8</span></a> We did not identify any other studies that reported a decrease in child mortality from pneumonia during hospitalization&#46; A recent study also found a significant decrease in cases of all cause pneumonia in Brazilian children under 14 years during the COVID-19 pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">For the present study&#44; we performed a nationwide level analysis&#44; and the results showed the same decreasing trend&#46; The Southern region was the one with the greatest overall reduction in the incidence of hospitalizations for pneumonia&#46; For mortality&#44; the Southern region had the greatest reduction only in the age group &#60;12 months&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">With the COVID-19 pandemic&#44; the main Brazil public health responses have been organized at the state and municipality levels&#44; resulting in different choices and timing regarding the implementation of COVID-19 prevention policies&#46; Social inequality in Brazil is a problem that affects a large part of the population&#44; and the COVID-19 pandemic threatens to increase it even more&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A national average adherence of social distancing was &#60;25&#37; was reported&#44; while the WHO believes at least 50&#37; compliance is needed to have a noticeable effect&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> However&#44; we believe that this low adherence applies mainly to adults&#44; since children were subject to greater social distancing while staying at home and out of schools&#47;daycare&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The promotion of COVID-19 prevention policies needs to be constant and consistent in order to the spreading of viruses in both clinical settings and the community&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a> In practical terms&#44; hand hygiene&#44; better space ventilation and even mask wearing during acute respiratory infections&#44; should be included in health education programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#8211;14</span></a> These simple strategies are cost-effective and feasible to apply at the different settings&#44; such as schools&#44; public transportation&#44; workplaces and healthcare environments&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#8211;19</span></a> In fact&#44; the overall spending on pneumonia hospitalizations in Brazil was 63&#37; lower during the COVID-19 prevention policies implementation period &#40;2020&#41; compared to 2019&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; We retrospectively obtained the data from the Brazilian health department registry system&#46; However&#44; this is the official system used to collect and analyze data for public health measures&#44; and it has been effectively in place for more than a decade&#46; We also did not have access to viral identification&#44; which could provide a better picture of the impact the COVID-19 pandemic had on specific respiratory viruses&#46; Nonetheless&#44; pneumonia hospitalizations and mortality showed an important and consistent reduction in all age groups in all Brazilian regions&#44; which suggests that all viruses were similarly affected&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our study found an important reduction in hospitalizations mortality due to pneumonia&#44; as well as in the cost of hospitalizations due to respiratory diseases&#44; because of the implementation of COVID-19 prevention policies initiatives in the public health system&#46; This reinforces the usefulness of prevention policies for decrease pneumonia mortality&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Summary of the article&#39;s main point</span><p id="par0095" class="elsevierStylePara elsevierViewall">Our study found an important reduction in hospitalizations mortality due to pneumonia&#44; as well as in the cost of hospitalizations due to respiratory diseases&#44; because of the implementation of COVID-19 prevention policies initiatives&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This research has not received specific aid from public sector agencies&#44; commercial sector or non-profit entities&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest directly or indirectly related to the contents of the manuscript&#46;</p></span></span>"
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Article information

ISSN: 03002896
Original language: English

DOI:10.1016/j.arbres.2021.09.010

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	3	10
2024 October	89	25	114
2024 September	72	19	91
2024 August	92	31	123
2024 July	117	20	137
2024 June	122	27	149
2024 May	112	24	136
2024 April	87	27	114
2024 March	77	15	92
2024 February	69	32	101
2024 January	85	32	117
2023 December	109	19	128
2023 November	219	32	251
2023 October	107	34	141
2023 September	87	33	120
2023 August	65	39	104
2023 July	73	25	98
2023 June	69	12	81
2023 May	61	28	89
2023 April	70	32	102
2023 March	104	22	126
2023 February	91	27	118
2023 January	68	33	101
2022 December	109	44	153
2022 November	119	33	152
2022 October	136	41	177
2022 September	96	43	139
2022 August	80	52	132
2022 July	101	58	159
2022 June	91	46	137
2022 May	103	47	150
2022 April	130	62	192
2022 March	194	90	284
2022 February	209	57	266
2022 January	220	78	298
2021 December	158	33	191
2021 November	218	21	239
2021 October	121	36	157

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