Deaths in Children and Adolescents Associated With COVID-19 and MIS-C in the United States.

Abstract

Objective To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a SARS-CoV-2-associated death. Methods We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12–July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records and entered them into an electronic database. Results We included 112 SARS-CoV-2 associated deaths from 25 participating jurisdictions. The median age was 17 years (interquartile range 8.5-19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least one underlying condition; obesity (47/112, 42%), asthma (33/112, 29%), and developmental disorders (25/112, 22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (45/60, 75%), acute respiratory failure (51/62, 82%), and acute renal failure (21/62, 34%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, gender, and race/ethnicity to decedents without MIS-C, and 11/16 (69%) had at least one underlying condition. Conclusion SARS-CoV-2-associated deaths among persons <21 years of age during February–July 2020 occurred predominantly among Black (non-Hispanic) and Hispanic persons, males, and older adolescents of all races/ethnicities. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with COVID-19 disease were more likely than those with MIS-C to have underlying medical conditions. by guest on September 2, 2021 www.aappublications.org/news Downloaded from Prepublication Release Introduction In previously healthy individuals <21 years of age, infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is typically asymptomatic or mild, with recovery expected within 1-2 weeks.1,2 An estimated 7% of children with COVID-19 are hospitalized3, and 28-33% of hospitalized children require intensive care.3–6 While individuals <21 years of age made up less than 2% of reported COVID-19 cases, as of April 13, 2021, more than 2.8 million cases and 377 deaths associated with SARS-CoV-2 in U.S. children <18 years were reported to the United States Centers for Disease Control and Prevention (CDC).7 Risk factors for death associated with COVID-19 among children are not well described.8,9 In adults, risk factors include older age, male sex, and underlying medical conditions, including obesity, immunosuppression, chronic lung disease, cardiovascular disease, neurologic disorders, and diabetes.10 In hospitalized children, the presence of underlying medical conditions increases the risk for severe illness from COVID-19.4,11 In addition, children infected with SARS-CoV-2 can develop multi-system inflammatory syndrome (MIS-C), which predominantly affects previously healthy school-aged children.12 Given the low number of SARS-CoV-2–associated deaths among persons <21 years of age compared with adult deaths, limited information exists about the clinical course and underlying medical conditions among pediatric decedents. With the ongoing pandemic and increasing cases13 and hospitalizations14 in persons <21 years of age, we conducted an expanded review of data from an earlier study15 to describe the demographics, clinical characteristics, and complications seen in children and adolescents with SARS-CoV-2 who died in the United States during February 12–July 31, 2020. by guest on September 2, 2021 www.aappublications.org/news Downloaded from Prepublication Release Methods Case definition: We defined a SARS-CoV-2–associated pediatric death as a death occurring in a person <21 years of age with confirmed or probable COVID-19 and/or MIS-C and who died during February 12--July 31, 2020. The interim COVID-19 case definition published by the Council of State and Territorial Epidemiologists on August 5, 2020 was used to classify cases as confirmed or probable.16 Briefly, a case was classified as confirmed COVID-19 if there was a documented positive SARS-CoV-2 molecular amplification detection test, and classified as probable COVID-19 if the decedent 1) met clinical criteria and had epidemiologic evidence without confirmatory laboratory testing; 2) met presumptive laboratory evidence and either clinical or epidemiologic criteria; or 3) met vital records criteria without confirmatory lab testing performed. Cases met MIS-C criteria if they fulfilled the case definition published in the CDC Health Alert Network Health Advisory on May 14, 2020.17 Case Ascertainment, Data Collection, and Data Entry: State and local health departments report confirmed or probable COVID-19 cases16 to CDC as an element of the integrated national pandemic response. We examined case-based data for persons <21 years of age with confirmed or probable COVID-19 and/or MIS-C who died during the study period. We contacted health departments in all 50 states, New York City, the District of Columbia, Puerto Rico, Guam, and the US Virgin Islands (n = 55) to review the identified deaths and to invite jurisdictions with at least one identified SARS-CoV-2-associated pediatric death to participate in this study (Figure 1). Classification of cases as SARS-CoV-2-associated deaths was determined by the individual