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Association Between Race and COVID-19 Outcomes Among 2.6 Million Children in England

Educational Objective
To investigate the association between race and childhood COVID-19 testing and hospital outcomes.
1 Credit CME
Key Points

Question  Is race associated with COVID-19 testing and hospital outcomes in children in England?

Findings  In this cohort study of 2 576 353 children (0-18 years of age) in England with COVID-19 disease, children who were Black, Asian, or of mixed race had lower proportions of SARS-CoV-2 tests and had higher positive results and COVID-19 hospitalizations compared with White children. These results held after key demographic factors and selected comorbidities were accounted for.

Meaning  These findings suggest that race may play an important role in childhood COVID-19 outcomes, which reinforces the continued need for a race-tailored focus on health system performance and targeted public health interventions.


Importance  Although children mainly experience mild COVID-19 disease, hospitalization rates are increasing, with limited understanding of underlying factors. There is an established association between race and severe COVID-19 outcomes in adults in England; however, whether a similar association exists in children is unclear.

Objective  To investigate the association between race and childhood COVID-19 testing and hospital outcomes.

Design, Setting, Participants  In this cohort study, children (0-18 years of age) from participating family practices in England were identified in the QResearch database between January 24 and November 30, 2020. The QResearch database has individually linked patients with national SARS-CoV-2 testing, hospital admission, and mortality data.

Exposures  The main characteristic of interest is self-reported race. Other exposures were age, sex, deprivation level, geographic region, household size, and comorbidities (asthma; diabetes; and cardiac, neurologic, and hematologic conditions).

Main Outcomes and Measures  The primary outcome was hospital admission with confirmed COVID-19. Secondary outcomes were SARS-CoV-2–positive test result and any hospital attendance with confirmed COVID-19 and intensive care admission.

Results  Of 2 576 353 children (mean [SD] age, 9.23 [5.24] years; 48.8% female), 410 726 (15.9%) were tested for SARS-CoV-2 and 26 322 (6.4%) tested positive. A total of 1853 children (0.07%) with confirmed COVID-19 attended hospital, 343 (0.01%) were admitted to the hospital, and 73 (0.002%) required intensive care. Testing varied across race. White children had the highest proportion of SARS-CoV-2 tests (223 701/1 311 041 [17.1%]), whereas Asian children (33 213/243 545 [13.6%]), Black children (7727/93 620 [8.3%]), and children of mixed or other races (18 971/147 529 [12.9%]) had lower proportions. Compared with White children, Asian children were more likely to have COVID-19 hospital admissions (adjusted odds ratio [OR], 1.62; 95% CI, 1.12-2.36), whereas Black children (adjusted OR, 1.44; 95% CI, 0.90-2.31) and children of mixed or other races (adjusted OR, 1.40; 95% CI, 0.93-2.10) had comparable hospital admissions. Asian children were more likely to be admitted to intensive care (adjusted OR, 2.11; 95% CI, 1.07-4.14), and Black children (adjusted OR, 2.31; 95% CI, 1.08-4.94) and children of mixed or other races (adjusted OR, 2.14; 95% CI, 1.25-3.65) had longer hospital admissions (≥36 hours).

Conclusions and Relevance  In this large population-based study exploring the association between race and childhood COVID-19 testing and hospital outcomes, several race-specific disparities were observed in severe COVID-19 outcomes. However, ascertainment bias and residual confounding in this cohort study should be considered before drawing any further conclusions. Overall, findings of this study have important public health implications internationally.

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Article Information

Accepted for Publication: April 14, 2021.

Published Online: June 21, 2021. doi:10.1001/jamapediatrics.2021.1685

Corresponding Author: Defne Saatci, MD, Primary Care Epidemiology, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, United Kingdom (

Author Contributions: Drs Saatci and Hippisley-Cox had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Saatci, Garriga, Clift, Tan, Harnden, Griffin, Khunti, Dambha-Miller, Hippisley-Cox.

Acquisition, analysis, or interpretation of data: Saatci, Ranger, Garriga, Clift, Zaccardi, Tan, Patone, Coupland, Griffin, Dambha-Miller, Hippisley-Cox.

Drafting of the manuscript: Saatci, Ranger, Garriga, Hippisley-Cox.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Saatci, Ranger, Garriga, Clift, Patone, Coupland, Hippisley-Cox.

Obtained funding: Griffin, Khunti, Dambha-Miller, Hippisley-Cox.

Administrative, technical, or material support: Saatci, Ranger, Zaccardi, Tan, Hippisley-Cox.

Supervision: Ranger, Harnden, Griffin, Hippisley-Cox.

Conflict of Interest Disclosures: Dr Tan reported receiving personal fees from AstraZeneca and Duke-NUS outside the submitted work. Dr Griffin reported receiving grants from the Medical Research Council during the conduct of the study. Dr Khunti reported serving as chair of the Ethnicity Subgroup and as a member of the Scientific Advisory Group for Emergencies. Dr Hippisley-Cox reported receiving grants from the Medical Research Council, Wellcome Trust, Health Data Research UK, Cancer Research UK, the John Fell Fund, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre; receiving nonfinancial support from EMIS Health during the conduct of the study; and serving as director of the QResearch database, a not-for-profit collaboration between EMIS Health (commercial supplier of GP Systems) and Oxford University. No other disclosures were reported.

Funding/Support: Dr Khunti is supported by the NIHR Applied Research Collaboration East Midlands and the NIHR Leicester Biomedical Research Centre. Dr Griffin is supported by the Medical Research Council. The University of Cambridge has received salary support in respect of Dr Griffin from the National Health Service (NHS) in the East of England through the Clinical Academic Reserve.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: EMIS Practices contributed to QResearch, and EMIS Health, the University of Nottingham, and the University of Oxford provided expertise in establishing, developing, or supporting the QResearch database.

Additional Information: This project involves data derived from patient-level information collected by the NHS as part of the care and support of patients with cancer. The COVID-19 test data are collated, maintained, and quality assured by Public Health England (PHE). Access to the data was facilitated by the PHE Office for Data Release. The Hospital Episode Statistics and mortality data used in this analysis are reused with permission of NHS Digital, which retains copyright of those data. NHS Digital and PHE bear no responsibility for the analysis or interpretation of the data.

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