COVID-19 Fatality Rate Among Children in England

Dawn O'Shea

November 16, 2021

The fatality rate for COVID-19 in children and adolescents in England was five per 100,000 during the first year of the pandemic, however this increased to almost 90 per 100,000 among children with life-limiting neuro-disabilities.

The figures were revealed through an in depth study published in Nature Medicine which used detailed clinical data in the National Child Mortality Database (NCMD) to quantify the number of Children and Young People (CYP) who died from COVID-19 and the number who died of an alternative cause with a coincidental positive SARS-CoV-2 test.

The data showed that between March 2020 and February 2021, 61 of 3105 CYP in England who died of all causes had a positive SARS-CoV-2 test.

Clinical records of the 61 CYP were reviewed to identify if COVID-19 contributed to death, based on whether it was listed as the direct cause of death on the death certificate and whether the clinical course described was typical of SARS-CoV-2 infection. If the role of SARS-CoV-2 in death was not clear, the case was reviewed by independent senior clinical experts in general paediatrics, neonatology, and paediatric intensive care.

It was concluded that only 25 (41%) of the 61 test-positive CYP died from COVID-19, including 22 with acute COVID-19 and three with paediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV-2 (PIMS-TS). In the other 36 test-positive cases, it was concluded that COVID-19 did not contribute to death.

Based on the estimation that 469,982 CYP in England were infected with SARS-CoV-2 between March 2020 and February 2021, the number of deaths attributed to COVID-19 in this study translates to a fatality rate of 5 per 100,000 CYP (0.005%) and, based on a population of 12,023,568, a mortality rate of 2 per million CYP (0.0002%). However, it must be noted that the data relate to a period when the primary strains circulating were the wild type and the Alpha variant, before the Delta variant became the predominant strain in circulation.

Eighteen of the 25 (72%) young people who died of COVID-19 were ≥10 years old. All three children who died of PIMS-TS were aged 10-14 years. There were eight deaths in young people aged 12-15 years.

The proportion of deaths was higher in Asian and Black ethnicities, although the absolute risk of death was still extremely low at 0.6 and 0.8 per 100,000, respectively.

More than three-quarters (76%) of the children and adolescents who died from COVID-19 had a chronic underlying health condition and 60% had a life-limiting condition. Sixteen (64%) had comorbidities in two or more body systems. Neurological conditions were the most common comorbidity in these children (52%).

The estimated mortality rate for CYP with a life-limiting condition was 11.5 per 100,000, while the rate in those with a life-limiting neuro-disability was 88.9 per 100,000.

There were no deaths in patients with an isolated respiratory condition, including cystic fibrosis and asthma. There were also no deaths in CYP with type 1 diabetes, trisomy 21, isolated diagnosis of epilepsy, or a mental health disorder that caused or contributed to death.

The figures presented in the study translate to 2 deaths per million across the CYP population in England, giving a fatality rate of 5 per 100,000, indicating that more than 99.995% of CYP infected with SARS-CoV-2 recovered.

The findings emphasise the importance of underlying comorbidities as the main risk factor for death. However, new research from Public Health England shows that a substantial number of very high-risk children in England remained unvaccinated for at least nine months, despite the Joint Committee on Vaccination and Immunisation December 2020 recommendation that children aged ≥12 years with severe neuro-disabilities should be vaccinated as a priority group.

The study, published in Archives of Disease in Childhood, analysed COVID-19 vaccination data from the National Immunisation Management System (NIMS) in children aged <16 years during December 2020-June 2021. Questionnaires were sent to GPs of 748 children recorded to have been vaccinated in NIMS to confirm their vaccination status, date and brand of vaccine, reason for vaccination, medical attendance post-vaccination and previous SARS-CoV-2 infection status. A total of 598 (80%) returned the questionnaire, and 533 children were confirmed as receiving ≥1 COVID-19 vaccine dose. The median age of vaccinated children was 15 years.

The data revealed that only 47% of the 533 children were appropriately vaccinated according to national recommendations. 10% were vaccinated because they were immunosuppressed or they were household contacts of a vulnerable individual, even though this recommendation was not made until 19 July 2021, while 20% had comorbidities that were not eligible for vaccination.

There are around 15,000 children aged 12-15 years in England living with life-limiting conditions. The authors say that, based on their findings, a large number of these very high-risk children were left unprotected for at least nine months.

The researchers speculate that possible reasons for this could include clinicians or parents being cautious about prescribing an unauthorised vaccine or, alternatively, there may have been operational difficulties in arranging vaccination for children with appropriately trained staff at COVID-19 vaccine centres set up primarily for adult vaccination.

They advise that a multidisciplinary approach, including flexible vaccination services with appropriately trained staff, will be critical for ensuring high vaccine uptake in children with complex needs.

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 (2021). https://doi.org/10.1038/s41591-021-01578-1.

Aiano F, Campbell C, Saliba V, Ramsay ME, Ladhani SN. COVID-19 vaccine given to children with comorbidities in England, December 2020-June 2021. Arch Dis Child. 2021 Nov 5:archdischild-2021-323162. doi: 10.1136/archdischild-2021-323162. Epub ahead of print. PMID: 34740880

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