When Yale researchers began studying cases of COVID-19 among children, they expected that they would find that the disease afflicted Black and Hispanic children at higher rates, just as it had in the adult population.
It turns out the unequal burden borne by minority children was even greater than they expected.
In an analysis of 281 pediatric patients across eight hospitals in New York, New Jersey, and Connecticut, scientists from Yale and other pediatric centers found that three out of four children hospitalized with severe cases of COVID-19 were Black or Hispanic (23.3% Black and 51% Hispanic). In comparison, only 38% of adults aged 65 or over who were hospitalized were from a minority group (27% Black and 11% Hispanic), according to U.S. COVID data.
Although the hospitals serve diverse sociodemographic populations — with many having a predominantly non-Hispanic white population — nearly all the sites reported that the majority of patients diagnosed with the coronavirus that causes COVID-19 were Hispanic and/or Black.
The researchers also discovered a sharp difference in the forms the virus took in these young patients depending on their race. The majority of COVID-19 patients presenting with severe respiratory issues were Hispanic teenagers with underlying health issues. On the other hand, nearly all of the youths presenting with multisystem inflammatory syndrome (MIS-C) — which appears two to four weeks after COVID-19 infection — were 7 to 9 years old and had no preexisting conditions. Black children and youth were more likely to present with MIS-C than respiratory COVID-19, they found.
The findings appear in the Nov. 13 online edition of the Journal of Pediatrics.
“It was not what we expected,” said lead author Dr. Carlos Oliveira, assistant professor of pediatrics (infectious disease) and director of Congenital Infectious Diseases at Yale New Haven Children’s Hospital. “It was almost like two different diseases. We have a lot more work to do to untangle race and ethnicity from socioeconomic factors.”
The U.S. recently surpassed over 1 million children infected with COVID-19. Based on recent spikes in adult cases, scientists now expect a new rise in pediatric MIS-C cases to follow. In the case of MIS-C, Oliveira said, children typically have asymptomatic cases of COVID at first. But for reasons that are not fully understood, their immune responses don’t properly shut down.
In this respect, the disease has been likened to Kawasaki disease, which causes similar swelling and inflammation in young children. But, said Oliveira, “we might see a handful of Kawasaki disease at Yale New Haven Children’s Hospital every year. To date, we have seen 20 to 30 with MIS-C in our system, and they are largely of African American descent. This is about more than genetic predisposition.”
Children presenting with MIS-C rarely have respiratory symptoms, he said. Instead, they tend to have diarrhea and vomiting that become increasingly worse over time, along with fevers, rash, and red eyes. In contrast, those with severe respiratory COVID-19 are usually older adolescents, Oliveira said, and often have preexisting conditions such as obesity and asthma.
Among the 281 patients in the study, 143 (51%) presented with respiratory disease, and 69 (25%) with MIS-C. Sixty-nine patients (25%) were diagnosed with another acute SARS-CoV-2-related clinical syndrome or condition, such as gastrointestinal symptoms or neurologic disease. Nearly 58% of those with the severe respiratory form of COVID were Hispanic and 35% of those with MIS-C were Black.
Researchers will continue to study these and new pediatric patients with COVID-19 to better understand these inequities and the two distinct clinical manifestations of the virus, Oliveira said.
However, socioeconomic status (SES) appears to be one important indicator, he said; 31% of those hospitalized with SARS-CoV-2 were considered as “low SES.” As the study notes, poverty is associated with poor health outcomes and higher rates of pediatric ICU admissions in general.
Oliveira said that many of these youths are likely getting COVID-19 from parents who are considered essential workers. “The first COVID-19 patient I took care of was a Hispanic teenager with respiratory disease,” he said. “As we were about to intubate him, we learned that his father, who was in his late 30s, was placed on a ventilator a few hours prior, and his mother was just beginning to show signs of COVID-19.”
The child has since recovered, Oliveira said, but the example illustrates the challenges of treating children in sick families.
“We will be following them all for some time” in order to track outcomes, he said. Oliveira noted that about 40 children have been hospitalized with COVID at YNHH, and about one-third of them ended up in the intensive care unit. Nearly all pediatric patients did recover and were discharged, regardless of race, ethnicity, or socioeconomic status.