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Association of Household Deprivation, Comorbidities, and COVID-19 Hospitalization in Children in Germany, January 2020 to July 2021

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To identify the key insights or developments described in this article
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Key Points

Question  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?

Findings  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.

Meaning  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.


Importance  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.

Objective  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.

Exposures  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.

Results  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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Article Information

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 (dragano@med.uni-duesseldorf.de).

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.

Monod  M , Blenkinsop  A , Xi  X ,  et al; Imperial College COVID-19 Response Team.  Age groups that sustain resurging COVID-19 epidemics in the United States.   Science. 2021;371(6536):eabe8372. doi:10.1126/science.abe8372PubMedGoogle ScholarCrossref
Viner  RM , Mytton  OT , Bonell  C ,  et al.  Susceptibility to SARS-CoV-2 infection among children and adolescents compared with adults: a systematic review and meta-analysis.   JAMA Pediatr. 2021;175(2):143-156. doi:10.1001/jamapediatrics.2020.4573PubMedGoogle ScholarCrossref
American Academy of Paediatrics. Children and COVID-19: state data report. February 3, 2022. Accessed February 8, 2022. https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%202.3.22%20FINAL.pdf
Levin  AT , Hanage  WP , Owusu-Boaitey  N , Cochran  KB , Walsh  SP , Meyerowitz-Katz  G .  Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications.   Eur J Epidemiol. 2020;35(12):1123-1138. doi:10.1007/s10654-020-00698-1PubMedGoogle ScholarCrossref
O’Driscoll  M , Ribeiro Dos Santos  G , Wang  L ,  et al.  Age-specific mortality and immunity patterns of SARS-CoV-2.   Nature. 2021;590(7844):140-145. doi:10.1038/s41586-020-2918-0PubMedGoogle ScholarCrossref
Chang  S , Pierson  E , Koh  PW ,  et al.  Mobility network models of COVID-19 explain inequities and inform reopening.   Nature. 2020;589(7840):82-87. doi:10.1038/s41586-020-2923-3PubMedGoogle ScholarCrossref
Magesh  S , John  D , Li  WT ,  et al.  Disparities in COVID-19 outcomes by race, ethnicity, and socioeconomic status: a systematic-review and meta-analysis.   JAMA Netw Open. 2021;4(11):e2134147. doi:10.1001/jamanetworkopen.2021.34147PubMedGoogle ScholarCrossref
Muhsen  K , Na’aminh  W , Lapidot  Y ,  et al.  A nationwide analysis of population group differences in the COVID-19 epidemic in Israel, February 2020-February 2021.   Lancet Reg Health Eur. 2021;7:100130. doi:10.1016/j.lanepe.2021.100130PubMedGoogle ScholarCrossref
Mena  GE , Martinez  PP , Mahmud  AS , Marquet  PA , Buckee  CO , Santillana  M .  Socioeconomic status determines COVID-19 incidence and related mortality in Santiago, Chile.   Science. 2021;372(6545):eabg5298. doi:10.1126/science.abg5298PubMedGoogle ScholarCrossref
Ginsburgh  V , Magerman  G , Natali  I .  COVID-19 and the role of inequality in French regional departments.   Eur J Health Econ. 2021;22(2):311-327. doi:10.1007/s10198-020-01254-0PubMedGoogle ScholarCrossref
Green  MA , García-Fiñana  M , Barr  B ,  et al.  Evaluating social and spatial inequalities of large scale rapid lateral flow SARS-CoV-2 antigen testing in COVID-19 management: an observational study of Liverpool, UK (November 2020 to January 2021).   Lancet Reg Health Eur. 2021;6:100107. doi:10.1016/j.lanepe.2021.100107PubMedGoogle ScholarCrossref
Chadeau-Hyam  M , Bodinier  B , Elliott  J ,  et al.  Risk factors for positive and negative COVID-19 tests: a cautious and in-depth analysis of UK Biobank data.   Int J Epidemiol. 2020;49(5):1454-1467. doi:10.1093/ije/dyaa134PubMedGoogle ScholarCrossref
McQueenie  R , Foster  HME , Jani  BD ,  et al.  Multimorbidity, polypharmacy, and COVID-19 infection within the UK Biobank cohort.   PLoS One. 2020;15(8):e0238091. doi:10.1371/journal.pone.0238091PubMedGoogle ScholarCrossref
Bergman  J , Ballin  M , Nordström  A , Nordström  P .  Risk factors for COVID-19 diagnosis, hospitalization, and subsequent all-cause mortality in Sweden: a nationwide study.   Eur J Epidemiol. 2021;36(3):287-298. doi:10.1007/s10654-021-00732-wPubMedGoogle ScholarCrossref
Batty  GD , Deary  IJ , Luciano  M , Altschul  DM , Kivimäki  M , Gale  CR .  Psychosocial factors and hospitalisations for COVID-19: prospective cohort study based on a community sample.   Brain Behav Immun. 2020;89:569-578. doi:10.1016/j.bbi.2020.06.021PubMedGoogle ScholarCrossref
Patel  AP , Paranjpe  MD , Kathiresan  NP , Rivas  MA , Khera  AV .  Race, socioeconomic deprivation, and hospitalization for COVID-19 in English participants of a national biobank.   Int J Equity Health. 2020;19(1):114. doi:10.1186/s12939-020-01227-yPubMedGoogle ScholarCrossref
Brandén  M , Aradhya  S , Kolk  M ,  et al.  Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data.   Lancet Healthy Longev. 2020;1(2):e80-e88. doi:10.1016/S2666-7568(20)30016-7PubMedGoogle ScholarCrossref
Elliott  J , Bodinier  B , Whitaker  M ,  et al.  COVID-19 mortality in the UK Biobank cohort: revisiting and evaluating risk factors.   Eur J Epidemiol. 2021;36(3):299-309. doi:10.1007/s10654-021-00722-yPubMedGoogle ScholarCrossref
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/s41586-020-2521-4PubMedGoogle ScholarCrossref
Ambrose  AJH .  Inequities during COVID-19.   Pediatrics. 2020;146(2):e20201501. doi:10.1542/peds.2020-1501PubMedGoogle ScholarCrossref
Dennis-Heyward  EA , Shah  SN .  Pediatric COVID-19 disparities and prioritizing equity—children are not spared.   JAMA Pediatr. 2021;175(9):898-900. doi:10.1001/jamapediatrics.2021.1682PubMedGoogle ScholarCrossref
Angelidou  A , Sullivan  K , Melvin  PR ,  et al.  Association of maternal perinatal SARS-CoV-2 infection with neonatal outcomes during the COVID-19 pandemic in Massachusetts.   JAMA Netw Open. 2021;4(4):e217523. doi:10.1001/jamanetworkopen.2021.7523PubMedGoogle ScholarCrossref
Goyal  MK , Simpson  JN , Boyle  MD ,  et al.  Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children.   Pediatrics. 2020;146(4):e2020009951. doi:10.1542/peds.2020-009951PubMedGoogle ScholarCrossref
Saatci  D , Ranger  TA , Garriga  C ,  et al.  Association between race and COVID-19 outcomes among 2.6 million children in England.   JAMA Pediatr. 2021;175(9):928-938. doi:10.1001/jamapediatrics.2021.1685PubMedGoogle ScholarCrossref
Javalkar  K , Robson  VK , Gaffney  L ,  et al.  Socioeconomic and racial and/or ethnic disparities in multisystem inflammatory syndrome.   Pediatrics. 2021;147(5):e2020039933. doi:10.1542/peds.2020-039933PubMedGoogle ScholarCrossref
Fernandes  DM , Oliveira  CR , Guerguis  S ,  et al; Tri-State Pediatric COVID-19 Research Consortium.  Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth.   J Pediatr. 2021;230:23-31.e10. doi:10.1016/j.jpeds.2020.11.016PubMedGoogle ScholarCrossref
Ward  JL , Harwood  R , Smith  C ,  et al.  Risk factors for PICU admission and death among children and young people hospitalized with COVID-19 and PIMS-TS in England during the first pandemic year.   Nat Med. 2022;28(1):193-200. doi:10.1038/s41591-021-01627-9PubMedGoogle ScholarCrossref
Martins-Filho  PR , Quintans-Júnior  LJ , de Souza Araújo  AA ,  et al.  Socio-economic inequalities and COVID-19 incidence and mortality in Brazilian children: a nationwide register-based study.   Public Health. 2021;190:4-6. doi:10.1016/j.puhe.2020.11.005PubMedGoogle ScholarCrossref
Nabity  SA , Han  E , Lowenthal  P ,  et al.  Sociodemographic characteristics, comorbidities, and mortality among persons diagnosed with tuberculosis and COVID-19 in close succession in California, 2020.   JAMA Netw Open. 2021;4(12):e2136853. doi:10.1001/jamanetworkopen.2021.36853PubMedGoogle ScholarCrossref
Nafilyan  V , Pawelek  P , Ayoubkhani  D ,  et al.  Occupation and COVID-19 mortality in England: a national linked data study of 14.3 million adults.   Occup Environ Med. 2022;79(7):433-441. doi:10.1101/2021.05.12.21257123PubMedGoogle Scholar
Kompaniyets  L , Agathis  NT , Nelson  JM ,  et al.  Underlying medical conditions associated with severe COVID-19 illness among children.   JAMA Netw Open. 2021;4(6):e2111182. doi:10.1001/jamanetworkopen.2021.11182PubMedGoogle ScholarCrossref
Tsankov  BK , Allaire  JM , Irvine  MA ,  et al.  Severe COVID-19 infection and pediatric comorbidities: a systematic review and meta-analysis.   Int J Infect Dis. 2021;103:246-256. doi:10.1016/j.ijid.2020.11.163PubMedGoogle ScholarCrossref
Bann  D , Johnson  W , Li  L , Kuh  D , Hardy  R .  Socioeconomic inequalities in childhood and adolescent body-mass index, weight, and height from 1953 to 2015: an analysis of four longitudinal, observational, British birth cohort studies.   Lancet Public Health. 2018;3(4):e194-e203. doi:10.1016/S2468-2667(18)30045-8PubMedGoogle ScholarCrossref
Sullivan  K , Thakur  N .  Structural and social determinants of health in asthma in developed economies: a scoping review of literature published between 2014 and 2019.   Curr Allergy Asthma Rep. 2020;20(2):5. doi:10.1007/s11882-020-0899-6PubMedGoogle ScholarCrossref
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053Google ScholarCrossref
Brandmueller  T , Schäfer  G , Ekkehard  P , Müller  O , Angelova-Tosheva  V .  Territorial indicators for policy purposes: NUTS regions and beyond.   Reg Stat. 2017;7(1):78-89. doi:10.15196/RS07105Google ScholarCrossref
Hoebel  J , Michalski  N , Diercke  M ,  et al.  Emerging socio-economic disparities in COVID-19-related deaths during the second pandemic wave in Germany.   Int J Infect Dis. 2021;113:344-346. doi:10.1016/j.ijid.2021.10.037PubMedGoogle ScholarCrossref
González-Rábago  Y , Cabezas-Rodríguez  A , Martín  U .  Social inequalities in health determinants in Spanish children during the COVID-19 lockdown.   Int J Environ Res Public Health. 2021;18(8):4087. doi:10.3390/ijerph18084087PubMedGoogle ScholarCrossref
Pullano  G , Valdano  E , Scarpa  N , Rubrichi  S , Colizza  V .  Evaluating the effect of demographic factors, socioeconomic factors, and risk aversion on mobility during the COVID-19 epidemic in France under lockdown: a population-based study.   Lancet Digit Health. 2020;2(12):e638-e649. doi:10.1016/S2589-7500(20)30243-0PubMedGoogle ScholarCrossref
Evans  GW .  The environment of childhood poverty.   Am Psychol. 2004;59(2):77-92. doi:10.1037/0003-066X.59.2.77PubMedGoogle ScholarCrossref
Ahmad  K , Erqou  S , Shah  N ,  et al.  Association of poor housing conditions with COVID-19 incidence and mortality across US counties.   PLoS One. 2020;15(11):e0241327. doi:10.1371/journal.pone.0241327PubMedGoogle ScholarCrossref
Rod  NH , Bengtsson  J , Elsenburg  LK , Taylor-Robinson  D , Rieckmann  A .  Hospitalisation patterns among children exposed to childhood adversity: a population-based cohort study of half a million children.   Lancet Public Health. 2021;6(11):e826-e835. doi:10.1016/S2468-2667(21)00158-4PubMedGoogle ScholarCrossref
Mukkada  S , Bhakta  N , Chantada  GL ,  et al; Global Registry of COVID-19 in Childhood Cancer.  Global characteristics and outcomes of SARS-CoV-2 infection in children and adolescents with cancer (GRCCC): a cohort study.   Lancet Oncol. 2021;22(10):1416-1426. doi:10.1016/S1470-2045(21)00454-XPubMedGoogle ScholarCrossref
Singh  P , Attri  K , Mahto  D ,  et al.  Clinical profile of COVID-19 illness in children-experience from a tertiary care hospital.   Indian J Pediatr. 2022;89(1):45-51. doi:10.1007/s12098-021-03822-5PubMedGoogle ScholarCrossref
Smith  C , Odd  D , Harwood  R ,  et al.  Deaths in children and young people in England after SARS-CoV-2 infection during the first pandemic year.   Nat Med. 2022;28(1):185-192. doi:10.1038/s41591-021-01578-1PubMedGoogle ScholarCrossref
Erdmann  F , Feychting  M , Mogensen  H , Schmiegelow  K , Zeeb  H .  Social inequalities along the childhood cancer continuum: an overview of evidence and a conceptual framework to identify underlying mechanisms and pathways.   Front Public Health. 2019;7:84. doi:10.3389/fpubh.2019.00084PubMedGoogle ScholarCrossref
Marques  AH , Bjørke-Monsen  A-L , Teixeira  AL , Silverman  MN .  Maternal stress, nutrition and physical activity: impact on immune function, CNS development and psychopathology.   Brain Res. 2015;1617:28-46. doi:10.1016/j.brainres.2014.10.051PubMedGoogle ScholarCrossref
Austin  MK , Chen  E , Ross  KM ,  et al.  Early-life socioeconomic disadvantage, not current, predicts accelerated epigenetic aging of monocytes.   Psychoneuroendocrinology. 2018;97:131-134. doi:10.1016/j.psyneuen.2018.07.00PubMedGoogle Scholar
Hoebel  J , Grabka  MM , Schröder  C ,  et al.  Socioeconomic position and SARS-CoV-2 infections: seroepidemiological findings from a German nationwide dynamic cohort.   J Epidemiol Community Health. 2022;76(4):350-353. doi:10.1136/jech-2021-217653PubMedGoogle ScholarCrossref
Zhu  Y , Duan  M-J , Dijk  HH , Freriks  RD , Dekker  LH , Mierau  JO ; Lifelines Corona Research initiative.  Association between socioeconomic status and self-reported, tested and diagnosed COVID-19 status during the first wave in the Northern Netherlands: a general population-based cohort from 49 474 adults.   BMJ Open. 2021;11(3):e048020. doi:10.1136/bmjopen-2020-048020PubMedGoogle ScholarCrossref
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