In this study which covered the period from March 2020 to October 2021, there were forty-one children and adolescent COVID-19 patients less than 20 years out of six hundred and sixty-four patients 41/664(6.2%) who were treated for the COVID-19 at Gulu Regional Referral Hospital (Table 1, Table 2, and Figure 1). The most significant findings were that no mortality was reported among COVID-19 patients less than 20 years 0/41(0.0%), but the mortality rate among the adult population in this study cohort was 32/623(5.1%). The commonest morbidity observed among patients below 20-years was pneumonia 1(3.3%) and acute live injury 1(3.3%), and this was lower compared to the adult population at 256/623(41.1%) (Table 3, Table 4, and Table 5).
Nearly one-third of the patients were asymptomatic (identified using contact tracing approach and self-referrals to the hospital), and the symptomatic cases presented with mild symptoms with dry cough 17(41.5%) and headache 13(31.7%) (Table 3).
The severe COVID-19 disease is usually shown by extreme difficulty in breathing and low oxygen saturation at admission. The severe form was not observed among the children and adolescents below 20 years in this cohort (Table 3). This may explain the low rate of complications observed among this study population (Table 5). This finding has implications on how the Ugandan Ministry of Health could use this information to plan the response to the COVID-19 pandemic while preserving lives and at the same time saving the Ugandan economy [20,21]. For a long time, scholars and academicians in Uganda have argued for a complete re-opening of the economy, which has been affected by the lockdown measures instituted in March 2020 [20,21]. The current economic situation in Uganda following the two-year lockdown is worrying, and authors argue it should be lifted in a phased manner but quickly [20,21]. The population should be allowed to get back to work to rebuild the economy, evidently struggling [20,21].
Also, this study demonstrated that children and adolescents below 20 years with COVID-19 treated at Gulu Regional Referral Hospital had very mild disease, with few complications and no mortality (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, and Table 7). Authors suggest that although there are many uncertainties about the mid-term and long-term consequences of the infection with the coronavirus, it would be desirable that the government opens its economy so that it does not get into more economic downfall. This finding is also suitable for Uganda because most Ugandans are young, below 30 years, and are the least affected by the COVID-19 [22]. Children and adolescents below 20 years who get infected with the virus develop a mild form and recover from the illness quickly (Figure 1 and Figure 2).
The Authors have raised concerns about the short and long-term effects of COVID-19 on school performance and learning and suggest a formal and comprehensive study to determine this [23]. Authors were concerned that most COVID-19 patients below 20 years were school-going children. Fears raised by many scholars and academicians on the impact of the disease on children’s education are genuine. They should be addressed in a formal study so that proper guidance based on evidence is provided to the Government of Uganda.
In addition, the most productive age group of the Ugandan population are those below 30 years, and the virus largely spares this group, as seen by the low prevalence of the disease in this age group (Figure 1 and Table 1). In this, authors have re-considered the rationale for the prolonged lockdown measures imposed on the most productive age group of the Ugandan population as counterproductive, leading to more economic turmoil. Instead, authors have suggested the “enhanced shielding approach” where the most vulnerable people (the elderly and those with comorbidities are isolated) as the most optimum approach for handling the COVID-19 situation in Uganda [21,22].
Authors have also urged the Ugandan government to stick to its model of managing the COVID-19; for example, maintaining strong leadership and simultaneous application of multiple public health measures as the best approach for handling the COVID-19 pandemic in Uganda now and in the future [24]. In addition, a regional approach to the containment of the virus should be enhanced and promoted whereby working closely with the East African regional leaders ensures that the virus is not spread from one country to another [24].
Also, most clinical presentations of the illness among children and adolescents below 20 years were mild and short, between 1-7 days 17(41.5%) and with low symptom burden (Table 1 and Table 2) (Figure 2 and Figure 3). Similarly, their hospital stay was shorter than adults in the overall study population [18].
Prolonged illness was observed but was very infrequent 1/41(3.3%) and lower than for adults 86/601 (14.3%) (Table 2). The Authors found age not to correlate with illness duration overall among children and adolescents in this cohort (Table 6 and Table 7). In this study population, children and adolescents with an illness duration of 28 days or more were few and contrasted with previous findings in adults in the United Kingdom [25]. This has implications on the duration patients spent in the hospital (hospital stay), which was usually short and allowed bed space for others to receive services at the COVID-19 treatment center. This information is essential as many hospitals in Uganda rarely experienced the exponential rise in the number of cases beyond the ability of the health systems to handle. The Ugandan health system's COVID-19 curve remained manageable, which was commendable for the Ugandan health managers.
In addition, a small percentage of the patients less than 20 years had comorbidities (Table 4, Table 6, Table 7). The low prevalence of diabetes mellitus, cardiovascular diseases, and chronic obstructive pulmonary diseases had perhaps influenced treatment outcomes among this age group. This is important for the country because this age group could engage unrestrictedly in economic activities to allow the country’s economy to remain afloat.
Additionally, more public health approaches, vaccination, and reduction in congregate settings could be applied to ensure that the spread of the virus is limited in the Ugandan populations. Authors have argued that extreme care should shield elders and those with comorbidities from the general population. This is also in line with the findings that about one-fourth of the children and adolescents with COVD-19 were asymptomatic (Table 1). This implies their interaction with those at high risks, such as the elderly and those with comorbidities, should be limited in the Ugandan settings.
Authors suggest that the Ugandan Ministry of Health should design a strategy to have the young people continue their economic activity and, at the same time, reduce the chances of spreading the COVID-19 infection to the high-risk groups. A formal and comprehensive analysis of the home set up in Uganda and how young people below 20 years could be prevented from spreading the virus to the elderly may be an ideal approach from now on.
Most COVID-19 patients below 20 years of age in our cohort were females (Table 1). However, there was no statistically significant gender difference in the occurrence of the coronavirus in this study population (Table 3). The finding is different in the adult population in our previous study, where a statistically significant gender difference and more mortality were observed among females [18]. More females had more comorbidities, such as HIV and AIDS, cardiovascular diseases, and chronic obstructive pulmonary diseases, compared to males. These were thought to be the driving factors in the higher mortality rates among females than males in the study population [18].
The absence of gender difference among the under 20-year-old perhaps underpins the importance of the age factor in guaranteeing gender uniformity among the COVID-19 patients below 20 years (Table 3). In addition, the low prevalence of comorbidities among this age group may partly explain the observation among the cohort since there was no substantial gender difference among this age group (Table 6).
Furthermore, the authors found that in contrast to other respiratory viruses, children have less severe symptoms when infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [26,27,28]. In a literature review, authors have been persuaded by arguments on the proposed hypotheses for the age-related differences in the severity of coronavirus disease 2019 (COVID-19). Factors proposed to explain the difference in the severity of COVID-19 in children and adults include those that put adults at higher risk and those that protect children. These include: (i) age-related increase in endothelial damage and changes in clotting function; (ii) higher density, increased affinity, and different distribution of angiotensin-converting enzyme two receptors and transmembrane serine protease 2; (iii) pre-existing coronavirus antibodies (including antibody-dependent enhancement) and T cells; (iv) immunosenescence and inflammation, including the effects of chronic cytomegalovirus infection; (v) a higher prevalence of comorbidities associated with severe COVID-19 and (vi) lower levels of vitamin D in adults compared to children and adolescents [26,27,28].
It is further proposed that factors that might protect children include the following: (i) differences in innate and adaptive immunity; (ii) more frequent recurrent and concurrent infections; (iii) pre-existing immunity to coronaviruses; (iv) differences in microbiota; (v) higher levels of melatonin; (vi) protective off-target effects of live vaccines and (vii) lower intensity of exposure to SARS-CoV-2 [26,27,28].
In summary, the authors argue that the low prevalence, morbidity, symptoms burden, complications, comorbidities, and mortality of COVID-19 among children and adolescents below 20 years in Northern Uganda is a blessing for the country. The Uganda Bureau of Statistics reports shows that 52.6% of the Ugandan population is below 20 years [22]. This is the most productive age group that could help drive the Ugandan economy forward after the lockdown if limited restrictions on their economic activities were accorded.
Strengths and limitations of this study: This study was a retrospective review of datasets from the COVID-19 medical records of Gulu Regional Referral Hospital. The period of the evaluation was from March 2020 to October 2021. The study has limitations on how Gulu Regional Referral Hospital handled records and record keeping. In addition, vital information, for example, weight, height, and BMI of COVID-19 patients, was not recorded due to the emergency handling of the cases at the beginning of the pandemic in March 2020. The missing variables in the Gulu Hospital HMIS records excluded some files from participating in this study. In this, authors have suggested a need for a prospective or longitudinal assessment of the COVID-19 cases in the future, ensuring that all data were measured and recorded accordingly.
This data is vital as it is one of the well-documented completed data for over 664 cases of COVID-19 treated in a Regional Referral Hospital in Uganda. In this cohort, forty-one were children and adolescents below twenty years, with no reported mortality and very few morbidities. Findings from this study show tremendous and good clinical practices at Gulu Regional Referral Hospital despite the challenges faced during the pandemic.
Generalization of the data from this study: These findings should be cautiously interpreted and generalized only to Regional Referral Hospitals in Uganda. However, this data could be similarly observed in many hospitals in African countries with low-resource settings.