Do young people from households with low incomes have a higher risk of COVID-19 hospitalization compared with their more affluent counterparts, and if so, what factors are associated with this difference?
In this cohort study of 688 705 children and adolescents, elevated odds of a COVID-19 hospitalization were observed among children and adolescents from households with unemployed parents and who were living in areas with lower median incomes. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.
These findings suggest that greater attention must be paid to a possible severe course of disease in children from families with lower socioeconomic status and closer monitoring should be considered.
Adults in disadvantaged socioeconomic positions have elevated risks of a severe course of COVID-19, but it is unclear whether this holds true for children.
To investigate whether young people from disadvantaged households have a higher risk of COVID-19 hospitalization and whether differences were associated with comorbidities that predispose children to severe courses.
Design, Setting, and Participants
This population-based cohort study included all children and adolescents (aged 0-18 years) who were enrolled in a statutory health insurance carrier in Germany during the observation period of January 1, 2020, to July 13, 2021. Logistic regressions were calculated to compare children from households with and without an indication of poverty. Age, sex, days under observation, nationality, and comorbidities (eg, obesity, diabetes) were controlled for to account for explanatory factors.
Disadvantage on the household level was assessed by the employment status of the insurance holder (ie, employed, long- or short-term unemployed, low-wage employment, economically inactive). Socioeconomic characteristics of the area of residence were also assessed.
Main Outcomes and Measures
Daily hospital diagnoses of COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 and U07.2) were recorded. Comorbidities were assessed using inpatient and outpatient diagnoses contained in the insurance records.
A total of 688 075 children and adolescents were included, with a mean (SD) age of 8.3 (5.8) years and 333 489 (48.4%) female participants. COVID-19 hospital diagnosis was a rare event (1637 participants [0.2%]). Children whose parents were long-term unemployed were 1.36 (95% CI, 1.22-1.51) times more likely than those with employed parents to be hospitalized. Elevated odds were also found for children whose parents had low-wage employment (odds ratio, 1.29; 95% CI, 1.05-1.58). Those living in low-income areas had 3.02 (95% CI, 1.73-5.28) times higher odds of hospitalization than those in less deprived areas. Comorbidities were associated with hospitalization, but their adjustment did not change main estimates for deprivation.
Conclusions and Relevance
In this cohort study, children who had parents who were unemployed and those who lived in low-income areas were at higher risk of COVID-19 hospitalization. This finding suggests that attention must be paid to children with SARS-CoV-2 from vulnerable families and closer monitoring should be considered. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: July 29, 2022.
Published: October 3, 2022. doi:10.1001/jamanetworkopen.2022.34319
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Dragano N et al. JAMA Network Open.
Corresponding Author: Nico Dragano, PhD, Institute of Medical Sociology, Centre for Health and Society, University Hospital and Medical Faculty, Heinrich Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany (firstname.lastname@example.org).
Author Contributions: Mss Dortmann and Scheider had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Dragano, Mayatepek, Wahrendorf.
Acquisition, analysis, or interpretation of data: Dragano, Dortmann, Timm, Mohrmann, Wehner, Rupprecht, Scheider, Mayatepek.
Drafting of the manuscript: Dragano, Rupprecht, Mayatepek, Wahrendorf.
Critical revision of the manuscript for important intellectual content: Dortmann, Timm, Mohrmann, Wehner, Scheider, Mayatepek.
Statistical analysis: Dragano, Dortmann.
Obtained funding: Rupprecht.
Administrative, technical, or material support: Timm.
Supervision: Dragano, Rupprecht, Mayatepek.
Conflict of Interest Disclosures: Dr Dragano reported receiving grants from the Federal Ministry of Education and Research and the Federal Agency for Occupational Safety and Occupational Medicine outside the submitted work. No other disclosures were reported.
Additional Information: This study was conducted in accordance with the German Data Protection legislation. In order to protect the privacy of insurants of the mandatory health insurance carrier, the availability of register data is restricted to internal research (the calculations were made by Mss Dortmann and Scheider) and by law, original data is not allowed to be transferred to third parties. However, the authors can provide aggregated data on request. Requests should be addressed to the corresponding author.
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