Characteristics of Children Hospitalized for Pandemic (H1N1) 2009, Malaysia

To determine effects of pandemic (H1N1) 2009 on children in the tropics, we examined characteristics of children hospitalized for this disease in Malaysia. Of 1,362 children, 51 (3.7%) died, 46 of whom were in an intensive care unit. Although disease was usually mild, >1 concurrent conditions were associated with higher death rates.

T ransmission of pandemic (H1N1) 2009 in the Northern and Southern Hemispheres has been well documented (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). These reports described a relatively mild and selflimited clinical illness for most cases. However, data on disease prevalence and severity in children in the tropics are scarce. Malaysia has 132 public and 214 private hospitals. We examined the demographics, clinical presentation, and outcomes of children hospitalized for pandemic (H1N1) 2009 in 68 Ministry of Health-affi liated public hospitals in Malaysia that offered pediatric services. These 68 hospitals provide 3,757 beds for children and 101 beds in pediatric intensive care units; each year they serve ≈7,898,700 children <12 years of age. During the pandemic (H1N1) 2009 containment phase, May-July 2009, the Ministry of Health mandated that all patients with infl uenza-like illness (ILI) be admitted to government (public) hospitals for observation and management. During the mitigation phase from August 2009 on, only patients with moderate to severe cases of ILI were hospitalized (13). Infl uenza vaccine is used in the private sector only, and during the study period, only health care workers were vaccinated against pandemic (H1N1) 2009.

The Study
We enrolled children <12 years of age who were hospitalized for ILI from June 18, 2009, through March 1, 2010, and for whom pandemic (H1N1) 2009 infection was confi rmed by real-time reverse transcription-PCR. This study was reviewed and approved by the Malaysian Research and Ethics Committee. Informed consent was provided for patients with confi rmed diagnoses.
During the study period, 1,362 children were hospitalized for ILI. The fi rst case was diagnosed and confi rmed as pandemic (H1N1) 2009 during the third week of June 2009; the number of cases peaked at week 33 and declined until week 43 of 2009 and weeks 1-9 of 2010 ( Figure). The rapid decline of cases after week 33 may have resulted from a change in hospitalization criteria recommendations. From June 18 through July 2009, hospitalization rates among children <12 years, <5 years, and <2 years of age were 1.4, 1.0, and 1.1 per 100,000 children in each age group, respectively. From August 2009 through February 2010, corresponding hospitalization rates were 15.9, 23.8, and 33 per 100,000 children, respectively.
Overall median age of the hospitalized children was 3 years (interquartile range [IQR] 1-6 years); 861 (63.2%) were <5 years and 536 (39.4%) were <2 years of age. Among those who died, median age at time of death was 2 years (IQR 0-6 years). Other demographic characteristics of the cohort are shown in Table 1.
A total of 602 (44.2%) children were admitted to hospital within 48 hours of onset of clinical signs. Median interval from onset of signs to hospitalization was 3 days (IQR 1-5 days) for the overall cohort, 3 days (IQR 1-5 days) for those who survived, and 4 days (IQR 2-6 days) for those who died. Among 120 (8.8%) children whose clinical condition worsened during hospitalization, deterioration occurred within the fi rst 24 hours after admission for 67 (55.9%). Among 657 (48.2%) patients for whom blood cultures were performed, results were positive for only 29 (4.4%). The most common pathogen isolated was Streptococcus pneumoniae (n = 6), followed by coagulase-negative  Among the 1,352 children for whom follow-up data were available, 1,285 (95%) recovered fully and had no sequelae at time of hospital discharge, and 12 (0.9%) recovered but had sequalae (5 pulmonary, 4 neurologic, 2 renal, and 1 pulmonary and neurologic). The mortality rate for children who were <12, <5, and <2 years of age during June-July 2009 was 0.1 death per 100,000 children. Corresponding rates for August 2009-February 2010 were 0.6, 0.9, and 1.3 per 100,000 children, respectively.

Conclusions
In the tropics, pandemic (H1N1) 2009 is a relatively mild illness in children who have no concurrent condition.
Serious complications such as shock and acute respiratory distress syndrome were relatively rare. However, among the small proportion for whom disease was severe, progression was rapid and death occurred within a short period. The case-fatality rate for the hospitalized cohort reported here was 3.7%, comparable to the rates of 0.1%- §Inflammation of brain or degeneration of brain function. (4,9,14). Hospitalization and mortality rates were proportionally higher for children <2 years of age than for children in other age groups. Severe disease leading to death was more likely for patients who had >1 concurrent condition. Other studies have demonstrated similar fi ndings (3,4,7,11). Data on concurrent conditions can help identify and prioritize patients who need prompt antiviral drug therapy and vaccination in countries with limited resources. Our fi nding that early administration of an antiviral drug was associated with a lower risk for death concurs with fi ndings of other studies (3). Study limitations include the facts that patients with mild cases may not seek (or be brought for) medical attention and that not all cases of ILI were laboratory confi rmed as pandemic (H1N1) 2009. Early initiation of antiviral therapy, especially for children with concurrent conditions, may improve outcomes.