Addressing Racial and Ethnic Disparities in COVID-19 Among School-Aged Children: Are We Doing Enough?

Arica White, PhD, MPH; Leandris C. Liburd, PhD; Fátima Coronado, MD, MPH


Prev Chronic Dis. 2021;18(6):e55 

In This Article

Disparities in Underlying Medical Conditions and Social Determinants of Health

As of May 2021, the US continues to experience substantial levels of SARS-CoV-2 transmission. Although less common than in adults, children and teens are still at risk of developing severe illness and complications from COVID-19; approximately 1 in 3 children hospitalized with COVID-19 were admitted to the intensive care unit, similar to the rate among adults.[4] Although evidence on which medical conditions in children are associated with increased risk is limited, children with the following conditions might be at increased risk for severe COVID-19: obesity, diabetes, asthma, other chronic lung disease, congenital heart disease, medical complexity, severe genetic disorders, sickle cell disease, chronic kidney disease, severe neurologic disorders, inherited metabolic disorders, and immunosuppression due to malignancy or immune-weakening medications.[21]

Serious racial and ethnic health and health care inequities persist for children with chronic health conditions.[22] National estimates indicate significant disparities in the prevalence of chronic disease conditions that may place some children and teens at increased risk for severe illness from COVID-19 (Table 1). Nearly 1 in 5 children aged 2–19 years (19.3) in the United States have obesity.[24] The prevalence of obesity among Mexican American (26.9), Hispanic (25.6), and non-Hispanic Black (NHB; 24.2) children was higher than among non-Hispanic White (NHW; 16.1) and non-Hispanic Asian (8.7) children during 2017–2018. Children who have obesity are more likely to have risk factors for adult cardiovascular disease,[27] including high blood pressure and high cholesterol, increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes, as well as asthma[28] and sleep apnea.[29] Racial and ethnic disparities also are evident in asthma, diabetes, and cardiovascular disease. In 2018, the prevalence of current asthma among NHB (14.2), Hispanic overall (8.0), and Mexican American (7.0) children was higher than among NHW (5.6) children younger than 18 years (Table 1).

The SEARCH for Diabetes in Youth Study has reported disparities in the incidence of type 2 diabetes per 100,000 among children aged 10–19 years. During 2014–2015, NHB (37.8), American Indian (32.8), Hispanic (20.9), and Asian/Pacific Islander (11.9) children had higher incidence rates of type 2 diabetes than NHW (4.5) children (Table 1).[25] Additionally, using 2013–2016 data from the National Health and Nutrition Examination Survey (NHANES), Jackson et al reported that among children aged 12–19 years, the estimated prevalence of hypertension (≥130/80 mm Hg) was 4.2. However, the prevalence for NHB (6.3) and Mexican American (4.9) children was higher than among NHW children (3.0).[26] According to Lopez et al, mortality rates resulting from congenital heart disease significantly declined during 1999–2017 among all races/ethnicities, although disparities in mortality rates persisted among NHB children in comparison with NHW children; the highest mortality rate was in infants (<1 year) of all races/ethnicities.[30] Improvements in cardiovascular health have not been equally shared by US children aged 12–19 years of varying socioeconomic status. A study using NHANES data reported increases in the prevalence of obesity among only adolescents from low-income (18.1–21.7) and middle-income (17.1–26.0) households from 1999 to 2014. During 2011–2014, significant disparities in prevalence of obesity were observed between adolescents from low-income and high-income households (21.7 vs 14.6). Although no significant disparities were observed in children aged 12–19 years in the prevalence of prediabetes, diabetes, hypertension, or hypercholesterolemia, the prevalence of prediabetes and diabetes increased (21.4–28.0) among adolescents from low-income households during 1999–2014.[31]

Approximately 42 of children hospitalized with COVID-19 during March 1 through July 25, 2020, had 1 or more underlying medical conditions.[4] The most prevalent conditions among these children were obesity (37.8) and chronic lung disease, including asthma (18.0). For hospitalized children aged 5–17 years, Hispanic (42.3) and NHB (32.4) children had a higher prevalence of underlying conditions compared with NHW children (14.1); Hispanic (47.2) and NHB (31.8) children also had higher hospitalization rates than NHW children (12.6).[4]

The families of children experiencing systemic disadvantage likely share similar COVID-associated health risks and, therefore, may be more likely to be hospitalized or die if they contract COVID-19.[2,32] As of November 30, 2020, compared with NHW individuals, hospitalization rate ratios were 4 times higher among non-Hispanic American Indian or Alaska Native people and Hispanic or Latino people, and 3.7 times higher among NHB or African American people.[32] Likewise, deaths were 2.8 times higher for NHB or African American people and Hispanic or Latino people, and 2.6 times higher for non-Hispanic American Indian or Alaska Native people compared with NHW people.[32] Family and household members may be at increased risk of exposure to COVID-19 through their occupation.[33] Parents then play an important role in ensuring strict adherence to established mitigation measures by everyone in the household.[34]