The reported number of COVID-19 hospitalizations, one of the primary metrics for tracking the severity of the coronavirus pandemic, was grossly inflated for children in California hospitals, two research papers published Wednesday concluded. The papers, both published in the journal Hospital Pediatrics, found that pediatric hospitalizations for COVID-19 were overcounted by at least 40 percent, carrying potential implications for nationwide figures.
Dr. Monica Gandhi, an infectious-diseases specialist at the University of California, San Francisco, and Amy Beck, an associate professor of pediatrics, also at UCSF, wrote a commentary for Hospital Pediatrics that accompanied the two studies. They wrote, “Taken together, these studies underscore the importance of clearly distinguishing between children hospitalized with SARS-CoV-2 found on universal testing versus those hospitalized for COVID-19 disease.” The studies demonstrate, they said, that reported hospitalization rates “greatly overestimate the true burden of COVID-19 disease in children.” Gandhi told Intelligencer that while the studies were both conducted with data from California hospitals, “there is no reason to think these findings would be exclusive to California. This sort of retrospective chart review will likely reveal the same findings across the country.”
The implications of the findings of these two studies are enormously important, as reports of pediatric hospitalizations have regularly made headlines over the past year, greatly affecting public perceptions about risks to children. Untold numbers of parents have kept children home from school or limited playdates and other activities out of fear their children would be infected and fall seriously ill. The hospitalization numbers for children were already extremely low relative to adults — at the pandemic’s peak this winter, it was roughly ten times lower than for 18-to-49-year-olds and 77 times lower than those age 65 and up. But cutting the pediatric numbers by nearly half is a striking difference, making the actual rates vanishingly small. Pediatric hospitalization figures for COVID-19 also influence policy on school openings and guidelines, camp recommendations, and other political decisions. Gandhi and Beck’s commentary noted, “Children have suffered tremendously due to policies that have kept schools and recreational facilities closed to them, and the burden has been greatest on children who are low-income and English-language learners.”
In one study, conducted at a children’s hospital in Northern California, among the 117 pediatric SARS-CoV2-positive patients hospitalized between May 10, 2020, and February 10, 2021, the authors concluded that 53 of them (or 45 percent) “were unlikely to be caused by SARS-CoV-2.” The reasons for hospital admission for these “unlikely” patients included surgeries, cancer treatment, a psychiatric episode, urologic issues, and various infections such as cellulitis, among other diagnoses. The study also found that 46 (or 39.3 percent) of patients coded as SARS-CoV2 positive were asymptomatic. In other words, despite patients’ testing positive for the virus as part of the hospital’s universal screening, COVID-19 symptoms were absent, therefore it was not the reason for the hospitalization. Any instance where the link between a positive SARS-CoV2 test and cause of admission was uncertain the authors erred toward giving a “likely” categorization.
In the second study, at the fifth-largest children’s hospital in the country, out of 146 records listing patients as positive for SARS-CoV-2 from May 1, 2020, to September 30, 2020, the authors classified 58 (40 percent) as having “incidental” diagnosis, meaning there was no documentation of COVID-19 symptoms prior to hospitalization. Like the first study, and as has been typical around the nation, this hospital implemented universal testing of inpatients for SARS-CoV-2. An example of incidentally SARS-CoV-2-positive patients are those who came to the hospital because of fractures. Patients who may have had COVID-19 symptoms but who had a clearly documented alternative reason for them, such as a child with abdominal pain and fever found to be related to an abdominal abscess, were also deemed to have incidental diagnosis. The study categorized 68 patients, or 47 percent, as “potentially symptomatic,” which was defined as when “COVID-19 was not the primary reason for admission for these patients, and COVID-19 alone did not directly require hospitalization without the concomitant condition.” Examples of these patients were those with acute appendicitis, since that condition includes gastrointestinal symptoms that may also present in COVID-19.
To be certain, there are other effects of COVID-19 on children that are separate from hospitalization. But the studies provide a critical retrospective look at how the reported pediatric COVID-19 hospitalization rates amplified the impression of the true extent of the virus’s impact on children. Moreover, the findings arrive as parents have begun vaccinating children under the expedited “emergency-use authorization” against a virus that, these findings suggest, poses a dramatically lower incidence of pediatric hospitalizations than the data have shown thus far. Stefan Baral, an infectious-diseases epidemiologist and physician at Johns Hopkins, wrote in the British Medical Journal about the risk-benefit calculus of vaccinating children against a disease that poses a “very low likelihood of severe outcomes” to them, which, he argued, means it does not meet the definition of an “emergency.” These studies weigh the scales even further toward that conclusion. The findings, Baral told Intelligencer, “reinforce the importance of going through a meaningful process to understand the risks to children.”
Explaining why the official tallies were found to be so far off, Baral said the electronic databases that hospitals use are administrative in purpose, meant for billing, resource management, et cetera. “They were not designed to infer the prevalence and severity of an infectious virus.” We have a desire for instant, accurate data, he said, but validation takes time.
“It is critical that the risks of COVID-19 to children be portrayed accurately,” Gandhi and Beck wrote. “Scientific and media reports that inaccurately portray the risk of COVID-19 to children can do harm by alarming parents and providing justification for ongoing restrictions to in-person education and other programming. Via these studies, parents and policy-makers should be reassured that pediatric hospitalization for severe COVID-19 disease is indeed rare.”
Neither paper addressed the accuracy of pediatric mortality rates attributed to COVID-19, nor that of adult patients categorized as COVID-19 hospitalizations. But, Gandhi and Baral both noted, these findings clearly illustrate the need to perform similar retrospective chart reviews for COVID-19-coded adult hospitalizations and overall mortality.