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\begin{document}

\title{Waiting for the next winter. Outpatient pediatric visits for respiratory
infections before, during and after the COVID-19 pandemic in the city of
Buenos Aires}



\author[1]{Fernando Ferrero}%
\author[1]{Paula Gonzalez Pannia}%
\author[1]{Fernando Torres}%
\author[2]{Manuel Rodriguez Tablado}%
\affil[1]{Hospital General de Ninos Pedro de Elizalde}%
\affil[2]{Buenos Aires Ciudad}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Introduction:} During the COVID-19 pandemic, pediatric visits
due to acute lower respiratory infections (ALRIs) decreased, but most
reports are from hospitalized patients. There is little information on
this phenomenon in outpatients, who are the majority in IRABs. We
evaluated the impact of the COVID-19 pandemic on ALRIs related
outpatient visits in the City of Buenos Aires. \textbf{Methods:}
Observational study including all outpatient visits of children under 2
years of age to the public health system of the City of Buenos Aires,
between Jan 01, 2018 and Dec 31, 2022. We estimated the total number
visits and the ALRIs-related visits, and their distribution throughout
the study period. \textbf{Results:} A total of 704,426 visits were
registered, 7.38\% of them due to ALRIs. ALRIs-related visits decreased
from the implementation of a national lockdown (2020) and increased
again as the restriction measures decreased, particularly the return to
full school attendance (2021). In general, the proportion of
ALRIs-related vists was significantly higher in the cold months than in
the warm ones (9.8\% vs. 5.5\%; OR: 1.76, 95\%CI: 1.73-1.79;
p\textless{}0.001). This difference was observed before (2018, 2019) and
after the pandemic (2022), but not in 2020-2021. The peak of
ALRIs-related visits occurred in the cold months in pre-pandemic years
(2018-2019), did not appear in 2020, reappeared delayed in 2021 and
recovered seasonality in 2022. \textbf{Conclusion:} Outpatient
ALRIs-related visits decreased significantly in the city of Buenos Aires
during the COVID-19 pandemic and currently seem to have recovered their
magnitude and seasonality.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Acute lower respiratory infections (ALRIs) are the main cause of illness
and hospitalization in children, and their most frequent etiology is
viral (1). During the COVID-19 pandemic, a decrease in pediatric visits
for respiratory causes was observed (2,3), probably because the
nonpharmacological mitigation measures used to face the pandemic altered
the circulation of the most common respiratory viruses.

However, many of the reports refer to a specific disease (bronchiolitis)
or to a particular virus (respiratory syncytial virus (RSV) and
influenza), include data from one or a few centers, or refer to
hospitalized patients (4,5,6). In contrast, there is little information
on the magnitude of this phenomenon in larger populations, especially in
relation to less seriously affected patients, who tend to be the
majority in the case of ALRIs. Unfortunately, recording the reasons for
health facility visit due to ALRIs can be confusing (7). Despite the
different coding systems used, there is still difficulty in identifying
ALRI-related visits (8). We recently developed an algorithm that showed
acceptable precision in the identification of ALRI-related visits in
electronic health records, based not only on the reasons for
consultation or identified diseases but also on terms used by
professionals in the text of the registry (9). The public health system
of the City of Buenos Aires has electronic health records for ambulatory
care areas before the pandemic, allowing a precise evaluation of the
impact of the pandemic on outpatient visits for different causes in a
large urban population.

Our objective was to evaluate the impact of the COVID-19 pandemic on
outpatient visits for acute respiratory infections in the city of Buenos
Aires.

\textbf{Methods}

This was an observational study that included all visits at health
facilities of the public health system of the City of Buenos Aires
(Gobierno de la Ciudad de Buenos Aires - GCABA) for children under 2
years of age, registered in the GCABA electronic health records, between
January 1, 2018, and December 31, 2022. The visits occurred at one of
the hospitals or primary care centers of the system (10).

To identify the visits in the GCABA health database, a validated
algorithm was (9).

The total number of visits and ALRIs-related visits and their
distribution throughout the study period, by year and by season (cold
months - autumn/winter: April, May, June, July, August and September -,
and warm months - spring/summer: October, November, December, January,
February and March) were evaluated.

The proportion of ALRIs-related visits was calculated (percentage with
95\% CI). The proportion of ALRIs-related visits was compared between
different years (chi square for trend) and seasons (chi square). The
analysis was carried out using IBM-SSPS Statistics 22.0. Data were
conveniently anonymized. Approval by the Institutional Ethics Committee
was requested and obtained (GCABA public research registry number
7141/2022).\textbf{Results\emph{}}In the period under study, 704,426
outpatient visits were registered for children under 2 years of age in
hospitals and primary care centers of the GCABA. The average age of the
patients was 0.8 \selectlanguage{ngerman}± 0.5 months, and 48\% were male. Of the total number
of visits, 51,975 (7.38\%; 95\% CI 7.32-7.44) were ALRIs-related. The
total number of visits, particularly those ALRIs-related, decreased
significantly during 2020 (p\textless{}0.001) (Table 1). In general, the
proportion of ALRIs-related visits was significantly higher in cold
months than in warm months (9.8\% vs. 5.5\%; OR: 1.76 95\% CI:
1.73-1.79; p \textless{}0.001). This distribution was clearly observed
before (2018, 2019) and after the pandemic (2022); during 2020, it was
reversed (more ALRI in warm months), and in 2021, no difference was
observed (Table 2). A peak of ALRI-related visits occurred in the
cold-month period in the prepandemic years (2018-2019); there was no
peak in 2020; and the peak was delayed in 2021, with a recovery of
prepandemic seasonality in 2022 (Figure 1). Visits for ALRIs decreased
after a strict lockdown was imposed (March 2020) and increased again
when the restrictions decreased, in particular with the return to full
school attendance (July 2021) (Figure 1).\textbf{Discussion\emph{}}In
countries with a temperate climate, ALRIs usually have a seasonal
pattern with an increase in cold months, following the circulation of
the main viruses responsible for such infections (RSV and influenza
virus); this pattern is observed both in the Northern Hemisphere and in
the Southern Hemisphere (11,12). In our study, in 2018 and 2019, we
verified this pattern in the city of Buenos Aires, with cases of ALRI
appearing in the cold months and peaking in June, the beginning of the
southern winter. During the first year of the COVID-19 pandemic, a
drastic decrease was observed in health visits in general, and in visits
for respiratory infections in particular, for the pediatric population
around the world (13,14). This decrease was fundamentally attributed to
the nonpharmacological mitigation measures that adopted to reduce the
risk of SARS-CoV-2 infection: the use of face masks, frequent hand
washing and social distancing measures, including school closings and
public circulation limitations (15). In this study, in 2020, the number
of cases of ALRIs decreased after the establishment of a national-wide
lockdown at the end of the summer (16), remaining very low during the
rest of the year, without showing a characteristic winter peak. This
phenomenon is similar to that reported in other countries in the
Southern Hemisphere, such as Brazil (17) and Australia (18), where there
was a decrease in cases of bronchiolitis and hospitalizations for
respiratory causes among the pediatric population in that period. In the
Northern Hemisphere, during the first pandemic winter (2020-2021) and
with mitigation measures still in force, similar findings were
described: in cities in northern Italy (19) and in England (20), a
decrease was observed in the number of pediatric hospitalizations and,
particularly, in the incidence of RSV bronchiolitis between October 2020
and March 2021. During 2021, mitigation measures gradually decreased,
and the circulation of common respiratory viruses reappeared (21). In
this study, the cases of ALRIs increased in winter 2021 but later and
with a somewhat lower intensity than in the prepandemic years
(2018-2019). This phenomenon was also reported in relation to cases of
RSV infection in pediatric hospitals in Buenos Aires (22,23). A similar
delay in the onset of respiratory infections was observed in the
Northern Hemisphere in the winter of 2021-2022 (24,25). In 2022, the
winter increase in ALRIs cases occurred earlier and with greater
intensity than in 2021, approaching prepandemic values. Something
similar was observed in the Northern Hemisphere (2022-2023), with the
seasonal cycle of RSV circulation moving toward prepandemic patterns
(25). As mentioned above, most of the studies on the impact of the
pandemic on pediatric respiratory infections include hospitalized
patients and/or those affected by RSV or influenza. As the spectrum of
viruses responsible for ALRIs in outpatients may be different (including
rhinoviruses and parainfluenza viruses) (26), the impact could have been
different in these patients. However, our study, which included only
outpatient visits, showed similar results, indicating that the impact of
the pandemic was similar for all viruses responsible for ALRIs. During
the pandemic, the circulation of respiratory viruses was greatly
altered, and there were questions regarding whether the usual pattern
would re-emerge (27). This study provides evidence that a return to the
usual seasonal patterns of viral circulation is occurring. The pandemic
highlighted, on several occasions, the need to be prudent in
forecasting. In particular, children were affected by the pandemic in an
indirect way (not related to the SARS-Cov2 virus) but to a much greater
extent (domestic violence, eating disorders, anxiety, etc.) (28).
Although there is a return of the circulation of common respiratory
viruses to prepandemic patterns, it is unknown whether the immunological
debt (29) of children has been fully settled or if a different pattern
will emerge next winter.\textbf{Conclusion}Outpatient visits for ALRIs
decreased significantly in the city of Buenos Aires during the COVID-19
pandemic and currently seem to have recovered their magnitude and
seasonality.

\textbf{References}

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\end{enumerate}

\textbf{Table 1. Distribution of visits according to cause, by year}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Year} & \vtop{\hbox{\strut \textbf{ALRIs}}\hbox{\strut n (\%)}}
& \vtop{\hbox{\strut \textbf{Other}}\hbox{\strut n (\%)}} &
\textbf{Total}\tabularnewline
\textbf{2018} & 14,683 (11.3\%) & 115,434 (88.7\%) &
130,117\tabularnewline
\textbf{2019} & 18,327 (9.7\%) & 170,575 (90.3\%) &
188,902\tabularnewline
\textbf{2020} & 2,441 (2.1\%) & 118,944 (98.1\%) &
121,385\tabularnewline
\textbf{2021} & 5,998 (4.5\%) & 127,175 (95.5\%) &
133,173\tabularnewline
\textbf{2022} & 10,526 (8.1\%) & 120,323 (92.1\%) &
130,849\tabularnewline
\textbf{Total} & 51,975 (7.4\%) & 652,451 (92.6\%) &
704,426\tabularnewline
\bottomrule
\end{longtable}

\textbf{ALRIs:} Acute lower respiratory infections\textbf{Table 2.
Distribution of ALRIs-related visits according to seson, by year}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Year}\\
\textbf{(Total n*)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Cold months}\\
\textbf{n (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Warm months}\\
\textbf{n (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{OR (IC 95\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2018}\\
(n = 130,117)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
8,742 (15.3)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
5,491 (8.2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1.86 (1.81-1.91)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2019}\\
(n = 188,902)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
11,349 (13.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
6,978 (6.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2.1 (2.01-2.12)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{2020}\\
(n = 121,649)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
475 (1.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1,966 (2.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.4 (0.38-0.47)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2021}\\
(n = 133,173)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
2,713 (4.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
3,285 (4.4)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1.04 (0.99-1.09)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.09\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2022}\\
(n = 130,849)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
6,645 (10.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
3,881 (5.7)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1.8 (1.78-1.92)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{Total}\\
(n = 704,426)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
29,924 (9.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
22,051 (5.5)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1.76 (1.73-1.79)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{ALRIs:} Acute lower respiratory infections\textbf{*Total n:}
ALRI-related visits + other cause visits

\textbf{Figure 1. Monthly distribution of ALRIs-related vists during the
study period}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

(The shaded boxes indicate the ''cold months'' period -autumn/winter-)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig-1-12may/Fig-1-12may}

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