¹Primary Care Epidemiology, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
²Cancer Research UK Oxford Centre, Department of Oncology, University of Oxford, Oxford, United Kingdom
³Leicester Real World Evidence Unit, Leicester Diabetes Centre, University of Leicester, Leicester, United Kingdom
⁴Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
⁵Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
⁶MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
⁷Primary Care Research Centre, University of Southampton, Southampton, United Kingdom

Read article on JAMA Network

Read Article Take Quiz

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.

Abstract

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.

Take Quiz

Buy This Activity

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 (defne.saatci@phc.ox.ac.uk).

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.

References

Centers for Disease Control and Prevention. CDC COVID Data Tracker. Accessed December 20, 2020. https://covid.cdc.gov/covid-data-tracker/#demographics

European Centre for Disease Prevention and Control. COVID-19 in children and the role of school settings in COVID-19 transmission: first update. Accessed December 20, 2020. https://www.ecdc.europa.eu/en/publications-data/children-and-school-settings-covid-19-transmission

Kim L , Whitaker M , O’Halloran A , et al; COVID-NET Surveillance Team. Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19—COVID-NET, 14 States, March 1-July 25, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1081-1088. doi:10.15585/mmwr.mm6932e3 PubMed Google Scholar Crossref

Swann OV , Holden KA , Turtle L , et al; ISARIC4C Investigators. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. 2020;370:m3249. doi:10.1136/bmj.m3249 PubMed Google Scholar

Bailey LC , Razzaghi H , Burrows EK , et al. Assessment of 135794 pediatric patients tested for severe acute respiratory syndrome coronavirus 2 across the United States. JAMA Pediatr. 2021;175(2):176-184. doi:10.1001/jamapediatrics.2020.5052 PubMed Google Scholar

Parri N , Lenge M , Buonsenso D ; Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group. Children with Covid-19 in pediatric emergency departments in Italy. N Engl J Med. 2020;383(2):187-190. doi:10.1056/NEJMc2007617 PubMed Google Scholar Crossref

Garazzino S , Montagnani C , Donà D , et al; Italian SITIP-SIP Pediatric Infection Study Group; Italian SITIP-SIP SARS-CoV-2 Paediatric Infection Study Group. Multicentre Italian study of SARS-CoV-2 infection in children and adolescents, preliminary data as of 10 April 2020. Euro Surveill. 2020;25(18):2000600. doi:10.2807/1560-7917.ES.2020.25.18.2000600 PubMed Google Scholar

Dong Y , Mo X , Hu Y , et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;145(6):e20200702. doi:10.1542/peds.2020-0702 PubMed Google Scholar

Rankin DA , Talj R , Howard LM , Halasa NB . Epidemiologic trends and characteristics of SARS-CoV-2 infections among children in the United States. Curr Opin Pediatr. 2021;33(1):114-121. doi:10.1097/MOP.0000000000000971 PubMed Google Scholar

10.

Loomba RS , Villarreal EG , Farias JS , Bronicki RA , Flores S . Pediatric intensive care unit admissions for COVID-19: insights using state-level data. Int J Pediatr. 2020;2020:9680905. doi:10.1155/2020/9680905 PubMed Google Scholar

11.

Götzinger F , Santiago-García B , Noguera-Julián A , et al; ptbnet COVID-19 Study Group. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health. 2020;4(9):653-661. doi:10.1016/S2352-4642(20)30177-2 PubMed Google Scholar Crossref

12.

Ludvigsson JF , Engerstrom L , Nordenhall C , Larsson E . Open schools, Covid-19, and child and teacher morbidity in Sweden. N Engl J Med. 2021;384(7):669-671. doi:10.1056/NEJMc2026670 Google Scholar

13.

Williamson EJ , Walker AJ , Bhaskaran K , et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-436. doi:10.1038/s41586-020-2521-4 PubMed Google Scholar Crossref

14.

Office for National Statistics. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales. Published 2020. Accessed December 12, 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020

15.

Hippisley-Cox J , Young D , Coupland C , et al. Risk of severe COVID-19 disease with ACE inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people. Heart. 2020;106(19):1503-1511. doi:10.1136/heartjnl-2020-317393 PubMed Google Scholar Crossref

16.

Clift AK , Coupland CAC , Keogh RH , et al. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. BMJ. 2020;371:m3731. doi:10.1136/bmj.m3731 PubMed Google Scholar

17.

Sze S , Pan D , Nevill CR , et al. Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-analysis. EClinicalMedicine. 2020;29:100630. doi:10.1016/j.eclinm.2020.100630 PubMed Google Scholar

18.

Harman K , Verma A , Cook J , et al. Ethnicity and COVID-19 in children with comorbidities. Lancet Child Adolesc Health. 2020;4(7):e24-e25. doi:10.1016/S2352-4642(20)30167-X PubMed Google Scholar Crossref

19.

QResearch. QResearch. Accessed December 20, 2020. https://www.qresearch.org/

20.

EMIS Health. Products. Accessed December 20, 2020. https://www.emishealth.com/products/emis-web/

21.

Hippisley-Cox J , Coupland C , Robson J , Brindle P . Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ. 2010;341:c6624. doi:10.1136/bmj.c6624 PubMed Google Scholar Crossref

22.

Vinogradova Y , Coupland C , Hippisley-Cox J . Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020;371:m3873. doi:10.1136/bmj.m3873 PubMed Google Scholar

23.

Clift AK , Coupland CAC , Keogh RH , Hemingway H , Hippisley-Cox J . COVID-19 mortality risk in Down syndrome: results from a cohort study of 8 million adults. Ann Intern Med. 2021;174(4):572-576. doi:10.7326/M20-4986 PubMed Google Scholar

24.

Jack RH , Hollis C , Coupland C , et al. Incidence and prevalence of primary care antidepressant prescribing in children and young people in England, 1998-2017: a population-based cohort study. PLoS Med. 2020;17(7):e1003215. doi:10.1371/journal.pmed.1003215 PubMed Google Scholar

25.

von Elm E , Altman DG , Egger M , Pocock SJ , Gøtzsche PC , Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X PubMed Google Scholar Crossref

26.

Langan SM , Schmidt SA , Wing K , et al. The reporting of studies conducted using observational routinely collected health data statement for pharmacoepidemiology (RECORD-PE). BMJ. 2018;363:k3532. doi:10.1136/bmj.k3532 PubMed Google Scholar

27.

NHS Digital. About NHS Digital. Accessed December 20, 2020. https://digital.nhs.uk/about-nhs-digital

28.

Office for National Statistics. Births, deaths, and marriages. Accessed December 28, 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages

29.

UK Department of Health and Social Care. Sources of COVID-19 surveillance systems. Accessed December 22, 2020. https://www.gov.uk/government/publications/national-covid-19-surveillance-reports/sources-of-covid-19-systems

30.

UK Department of Health and Social Care. COVID-19 testing data: methodology note. Accessed December 28, 2020. https://www.gov.uk/government/publications/coronavirus-covid-19-testing-data-methodology/covid-19-testing-data-methodology-note

31.

University of Nottingham. Accessed March 7, 2021. http://eprints.nottingham.ac.uk/3153/

32.

NHS England: COVID-19 hospital activity. Accessed December 28, 2020. https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2020/12/Publication-definitions-1.pdf

33.

Heys M , Rajan M , Blair M . Length of paediatric inpatient stay, socio-economic status and hospital configuration: a retrospective cohort study. BMC Health Serv Res. 2017;17(1):274. doi:10.1186/s12913-017-2171-x PubMed Google Scholar Crossref

34.

Nuffield Trust and The Health Foundation. Quality Watch Report. Focus on: emergency hospital care for children and young people. Accessed December 27, 2020. https://www.nuffieldtrust.org.uk/qualitywatch

35.

Office for National Statistics. 2011 Census. Accessed December 22, 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/articles/2011censusanalysisethnicityandreligionofthenonukbornpopulationinenglandandwales/2015-06-18

36.

Townsend P, Davidson N. Inequalities in Health: The Black Report. Dept of Health and Social Security; 1982.

37.

Netuveli G , Hurwitz B , Levy M , et al. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005;365(9456):312-317. doi:10.1016/S0140-6736(05)17785-X PubMed Google Scholar Crossref

38.

Oldroyd J , Banerjee M , Heald A , Cruickshank K . Diabetes and ethnic minorities. Postgrad Med J. 2005;81(958):486-490. doi:10.1136/pgmj.2004.029124 PubMed Google Scholar Crossref

39.

Public Health England. Differences in child obesity by ethnic group. Accessed December 22, 2020. https://www.gov.uk/government/publications/differences-in-child-obesity-by-ethnic-group/differences-in-child-obesity-by-ethnic-group#references

40.

Knowles RL , Ridout D , Crowe S , et al. Ethnic and socioeconomic variation in incidence of congenital heart defects. Arch Dis Child. 2017;102(6):496-502. doi:10.1136/archdischild-2016-311143 PubMed Google Scholar Crossref

41.

Sinha G , Corry P , Subesinghe D , Wild J , Levene MI . Prevalence and type of cerebral palsy in a British ethnic community: the role of consanguinity. Dev Med Child Neurol. 1997;39(4):259-262. doi:10.1111/j.1469-8749.1997.tb07422.x PubMed Google Scholar Crossref

42.

Hickman M , Modell B , Greengross P , et al. Mapping the prevalence of sickle cell and beta thalassaemia in England: estimating and validating ethnic-specific rates. Br J Haematol. 1999;104(4):860-867. doi:10.1046/j.1365-2141.1999.01275.x PubMed Google Scholar Crossref

43.

StataCorp. Stata Statistical Software. Release 16. StataCorp; 2019.

44.

Office for National Statistics. UK Population by Ethnicity. Accessed December 22, 2020. https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/national-and-regional-populations/population-of-england-and-wales/latest

45.

Millett GA , Jones AT , Benkeser D , et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37-44. doi:10.1016/j.annepidem.2020.05.003 PubMed Google Scholar Crossref

46.

Rentsch CT, Kidwai-Khan F, Tate JP, et al. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: a nationwide cohort study. PLoS Med. 2020;17(9):e1003379. doi:10.1371/journal.pmed.1003379

47.

Marlow LA , Waller J , Wardle J . Barriers to cervical cancer screening among ethnic minority women: a qualitative study. J Fam Plann Reprod Health Care. 2015;41(4):248-254. doi:10.1136/jfprhc-2014-101082 PubMed Google Scholar Crossref

48.

Alvarez-del Arco D , Monge S , Azcoaga A , et al. HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur J Public Health. 2013;23(6):1039-1045. doi:10.1093/eurpub/cks130 PubMed Google Scholar Crossref

49.

Fisher KA , Bloomstone SJ , Walder J , Crawford S , Fouayzi H , Mazor KM . Attitudes toward a potential SARS-CoV-2 vaccine: a survey of U.S. adults. Ann Intern Med. 2020;173(12):964-973. doi:10.7326/M20-3569 PubMed Google Scholar Crossref

50.

Royal Society for Public Health: New poll finds BAME groups less likely to want COVID vaccine. Accessed December 27, 2020. https://www.rsph.org.uk/about-us/news/new-poll-finds-bame-groups-less-likely-to-want-covid-vaccine.html

51.

Dodds C , Fakoya I . Covid-19: ensuring equality of access to testing for ethnic minorities. BMJ. 2020;369:m2122. doi:10.1136/bmj.m2122 PubMed Google Scholar

52.

Mathur R, Rentsch CT, Morton CE, et al. Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform. Lancet. 2021;397(10286):1711-1724. doi:10.1016/S0140-6736(21)00634-6

53.

Rozenfeld Y, Beam J, Maier H, et al. A model of disparities: risk factors associated with COVID-19 infection. Int J Equity Health. 2020;19(1):126. doi:10.1186/s12939-020-01242-z

54.

Lee EH , Kepler KL , Geevarughese A , et al. Race/Ethnicity among children with COVID-19-associated multisystem inflammatory syndrome. JAMA Netw Open. 2020;3(11):e2030280. doi:10.1001/jamanetworkopen.2020.30280 PubMed Google Scholar

55.

Godfred-Cato S , Bryant B , Leung J , et al; California MIS-C Response Team. COVID-19-associated multisystem inflammatory syndrome in children: United States, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1074-1080. doi:10.15585/mmwr.mm6932e2 PubMed Google Scholar Crossref

56.

Iwane MK , Edwards KM , Szilagyi PG , et al; New Vaccine Surveillance Network. Population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children. Pediatrics. 2004;113(6):1758-1764. doi:10.1542/peds.113.6.1758 PubMed Google Scholar Crossref

57.

Swann OV, Holden KA, Turtle L, et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. 2020;370:m3249. doi:10.1136/bmj.m3249

58.

Seidu S , Gillies C , Zaccardi F , et al. The impact of obesity on severe disease and mortality in people with SARS-CoV-2: a systematic review and meta-analysis. Endocrinol Diabetes Metab. 2020;e00176. doi:10.1002/edm2.176 PubMed Google Scholar

59.

Families and Households Dataset. Published 2020. Accessed June 1, 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/datasets/familiesandhouseholdsfamiliesandhouseholds

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

Pediatric COVID-19 Disparities and Prioritizing Equity—Children Are Not Spared

See More About

If you are not a JN Learning subscriber, you can either:

A subscription to JN Learning (CME from JAMA Network) provides:

Sign in to access

If you are not a JN Learning subscriber, you can either:

Sign in to customize your interests

With a personal account, you can:

Name Your Search

Sign in to save your search

With a personal account, you can:

Lookup An Activity

My Saved Searches

Sign in to customize your interests

With a personal account, you can:

Purchase access