The impact of the COVID-19 pandemic on pediatric acute … – Nature.com

In this analysis of 135,759 pediatric patients diagnosed with acute conjunctivitis between March 2017 to February 2022, we examined pediatric conjunctivitis infection rates before, during, and after the COVID-19 pandemic restriction and assessed the impact of the pandemic and lockdowns on acute infectious conjunctivitis incidence among the pediatric population in southern Israel CHS. To the best of our knowledge, this is the first study to examine the trends of acute infectious conjunctivitis between three pre-COVID-19 pandemic years and the two pandemic years.

Our study demonstrated a stable trend in the incidence of acute conjunctivitis episodes before the COVID-19 pandemic. During the three COVID-19 lockdowns, we observed a shift in normalcy. The number of diagnosed patients decreased among all ages. This decline was statistically significant in a time series approach, even after adjusting for seasonality. When compared to a control group consisting of non-infectious skin diseases, the decline was notably greater in cases of acute conjunctivitis, suggesting the evident declines represents an actual reduction in the incidence of infection, rather than a change in health seeking behaviors or access to healthcare during this period. The pattern of reduced infection rates among the pediatric population during the COVID-19 pandemic lockdowns was described in other communicable diseases2,4,17,18,19,20.

The decline in acute conjunctivitis rates can be attributed to the social and physical distancing mandated by governmental restrictions and lockdowns. The public was required to wear a face mask and stay within a limited home range, 100m limit range on the first lockdown, 500m on the second, and 1000m on the third. All regular educational frameworks were closed, and classes were conducted online during the full lockdowns. In the intervals between full lockdowns, attending school grounds and classrooms was permitted for specific school grades, primarily for children in early school grades, depending on the number of positive COVID-19 cases in the resident district. When school attendance met the requirements, classes were performed in small and invariable teaching capsules and carried out on different timeframes. Youth groups and other afterschool events were canceled during and between the lockdowns21,22,23.

The highly contagious syndrome of infectious conjunctivitis has accounted for many outbreaks in various leisure, healthcare, and educational frameworks. Among the pediatric population, the most common transmission is thought to be through direct contact24. Poor hand hygiene and sharing contaminated objects can also be attributed to the transmission of infectious conjunctivitis8. Hand and personal hygiene campaigns issued by the government, raising awareness for COVID-19 virus transmission, were spread vastly across the country, contributing to lower rates of infectious conjunctivitis. Meticulous hand hygiene practices ability to reduce transmission of other common pathogens among the pediatric population was described before25.

Lockdown end had different outcomes depending on the age group. For the 611 years and 1218 years age groups, the restriction termination resulted in lower conjunctivitis rates than before the pandemic. The decline in conjunctivitis rates among these age groups was statistically significant in a time series analysis, even after adjusting for seasonal variations. The establishment of better hand hygiene practices mentioned earlier might explain the lower rates of conjunctivitis among these groups, even after lifting COVID-19 restrictions. Despite the positive effect hand hygiene might have, another plausible explanation for reduced post-lockdown conjunctivitis rates is rooted in the mental and behavioral effects of the COVID-19 pandemic. Children and teens suffer higher levels of depression and anxiety, influencing their integration capabilities and social skills, resulting in their gravitation toward online social interactions over real-life gatherings26.

Among the younger age groups, 01 and 15, the rates in the post-lockdowns months had begun to return to their pre-pandemic rates. With a slightly non statistically significant increased incidence among the 15 years age group and a subtle decrease among the 01 age group. Since conjunctivitis rates before the COVID-19 pandemic reflect regular everyday activity, the pattern seen among these age groups correlates with the return to the usual routine. This might also be clarified by the immaturity of children at these ages, affecting their abilities to perform hygiene practices and to maintain social awareness of pathogen transmission.

Adenovirus, responsible for most viral conjunctivitis, has been known to facilitate outbreaks in a seasonal pattern, typically contagious in the winter and spring5,7. Interestingly, we found that during post-lockdown months, there was an additional, non-typical peak, which occurred during the end of the spring, lasting through the summer, similar in form to the winter peak, followed by a usual winter seasonal peak. The pattern of seasonal switch was described in a similar study conducted in Israel14. Respiratory syncytial virus (RSV) demonstrated a similar non-typical seasonal pattern in Australia and Israel with unparalleled virus outbreaks during the summer occurring during the pandemic restrictions gradually lifting27,28. The added peak lasting through the summer supports human behavior as the etiology of the seasonality pattern of acute viral conjunctivitis. The fact that individuals spend more time indoors in proximity to others might play a more significant role in the higher incidence of acute conjunctivitis during the winter than the low temperatures considered favorable to some pathogens.

The additional summer peak could also be a non-infectious form of acute conjunctivitis. The lack of exposure to common allergens among children at a young age due to COVID-19 pandemic restrictions, along with over-cleanliness (i.e., Hygiene hypothesis), resulted in higher rates of allergic manifestations of conjunctivitis29. A previous study examined the differential diagnosis and treatment for patients presenting with pink eye to general practitioners and ophthalmologists in nine countries; demonstrated a higher tendency for diagnoses of allergic conjunctivitis among general medical practitioners compared to an ophthalmologist during the spring and summer seasons30. In our study, a large portion of the diagnoses was made by pediatricians and general practitioners, therefore strengthening our results regarding the lower rates of infectious conjunctivitis. Pediatricians tend to diagnose patients with pink eye as allergic conjunctivitis during the spring and summer; the fact that those doctors, who made the majority of the diagnoses gave conjunctivitis diagnoses strengthens our results.

The concept of immunity debt may also underpin the atypical surge in acute conjunctivitis cases post-lockdown. The prolonged isolation during lockdown likely diminished exposure to various pathogens, leading to an accumulation of immunity debt. Once social interactions resumed post-lockdown, heightened susceptibility due to this debt could have contributed to the uncharacteristic summer peak in conjunctivitis cases, as suggested31,32. While this concept may hold true for infectious agents transmitted via the respiratory tract (e.g. meningococcal illness or influenza), its applicability to pathogens transmitted via direct contact such as many causative organisms of conjunctivitis remains questionable and deserves further study.

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