Hospitalizations of Children and Adolescents With Laboratory-Confirmed COVID-19

COVID-NET, 14 States, July 2021-January 2022

Kristin J. Marks, PhD; Michael Whitaker, MPH; Onika Anglin, MPH; Jennifer Milucky, MSPH; Kadam Patel, MPH; Huong Pham, MPH; Shua J. Chai, MD; Pam Daily Kirley, MPH; Isaac Armistead, MD; Sarah McLafferty, MPH; James Meek, MPH; Kimberly Yousey-Hindes, MPH; Evan J. Anderson, MD; Kyle P. Openo, DrPH; Andy Weigel, MSW; Justin Henderson, MPH; Val Tellez Nunez, MPH; Kathryn Como-Sabetti, MPH; Ruth Lynfield, MD; Susan L. Ropp, PhD; Chad Smelser, MD; Grant R. Barney, MPH; Alison Muse, MPH; Nancy M. Bennett, MD; Sophrena Bushey, MHS; Laurie M. Billing, MPH; Eli Shiltz, MPH; Nasreen Abdullah, MD; Melissa Sutton, MD; William Schaffner, MD; H. Keipp Talbot, MD; Ryan Chatelain, MPH; Andrea George, MPH; Christopher A. Taylor, PhD; Meredith L. McMorrow, MD; Cria G. Perrine, PhD; Fiona P. Havers, MD


Morbidity and Mortality Weekly Report. 2022;71(7):271-278. 

In This Article

Abstract and Introduction


The first U.S. case of COVID-19 attributed to the Omicron variant of SARS-CoV-2 (the virus that causes COVID-19) was reported on December 1, 2021,[1] and by the week ending December 25, 2021, Omicron was the predominant circulating variant in the United States.* Although COVID-19–associated hospitalizations are more frequent among adults, COVID-19 can lead to severe outcomes in children and adolescents.[2] This report analyzes data from the Coronavirus Disease 19–Associated Hospitalization Surveillance Network (COVID-NET)§ to describe COVID-19–associated hospitalizations among U.S. children (aged 0–11 years) and adolescents (aged 12–17 years) during periods of Delta (July 1–December 18, 2021) and Omicron (December 19, 2021–January 22, 2022) predominance. During the Delta- and Omicron-predominant periods, rates of weekly COVID-19–associated hospitalizations per 100,000 children and adolescents peaked during the weeks ending September 11, 2021, and January 8, 2022, respectively. The Omicron variant peak (7.1 per 100,000) was four times that of the Delta variant peak (1.8), with the largest increase observed among children aged 0–4 years. During December 2021, the monthly hospitalization rate among unvaccinated adolescents aged 12–17 years (23.5) was six times that among fully vaccinated adolescents (3.8). Strategies to prevent COVID-19 among children and adolescents, including vaccination of eligible persons, are critical.**

COVID-NET conducts population-based surveillance for laboratory-confirmed COVID-19–associated hospitalizations in 99 counties across 14 states.†† Among residents of a predefined surveillance catchment area, COVID-19–associated hospitalizations are defined as receipt of a positive SARS-CoV-2 real-time reverse transcription–polymerase chain reaction (RT-PCR) or rapid antigen detection test result during hospitalization or during the 14 days before admission. This analysis describes weekly hospitalization rates during the weeks ending July 3, 2021–January 22, 2022, to coincide with a period during which detailed clinical data (e.g., intensive care unit [ICU] admission) were available (monthly, July 1–December 31, 2021). Unadjusted weekly COVID-19–associated hospitalization rates were calculated by dividing the total number of hospitalized patients by the population estimates within each age group for the counties included in the surveillance catchment area.§§ ICU admission rates were similarly calculated using 2-week periods. All rates were estimated per 100,000 population for children, adolescents, or both.

Among adolescents aged 12–17 years, hospitalization rates were calculated by COVID-19 vaccination status, which was determined both for hospitalized patients and the catchment population using linkage to state immunization information systems data.¶¶ Monthly incidence was calculated by summing the total number of hospitalized adolescents who were fully vaccinated (≥14 days after final dose in primary series) for each day of the month and dividing by the sum of fully vaccinated adolescents in the underlying population for each day of the month; the same method was used to calculate incidence in unvaccinated adolescents.*** Rate ratios (RRs) and 95% CIs were calculated.

Trained surveillance staff members conducted medical chart abstractions for all pediatric COVID-NET patients using a standardized case report form through November 2021. Because of the large number of cases during December 2021, some sites examined clinical outcome data on a representative sample of hospitalized children.††† Data on indicators of severe disease were collected (i.e., hospital length of stay, ICU admission, use of invasive mechanical ventilation [IMV],§§§ and in-hospital death), as were data on primary reason for admission¶¶¶ and symptoms that were present when the patient was admitted****.[3] Proportions were compared between periods of Delta predominance (July 1–December 18, 2021) and Omicron predominance (December 19–31, 2021); a variant that accounted for >50% of sequenced isolates was considered to be predominant.†††† A similar analysis was completed by vaccination status among adolescents, the only pediatric age group for whom a COVID-19 vaccine had been approved throughout the surveillance period. Wilcoxon rank-sum tests were used to compare medians, and chi-square or Fisher's exact tests were used to compare proportions; p-values <0.05 were considered statistically significant. Percentages were weighted to account for the probability of selection for sampled cases and further adjusted to account for nonresponse (defined as an incomplete chart review). Data were analyzed using SAS (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§§§

During the Delta- and Omicron-predominant periods, pediatric weekly hospitalization rates peaked during the weeks ending September 11, 2021, and January 8, 2022, respectively; the Omicron variant peak (7.1 per 100,000 children and adolescents) was four times that of the Delta variant peak (1.8). Hospitalization rates among children aged 0–4 years were approximately five times as high during the peak week of the Omicron period (15.6) than during the Delta period (2.9) (RR = 5.4; 95% CI = 4.0–7.2) (Figure); RRs were also increased among children aged 5–11 years (Delta = 1.1; Omicron = 2.4; RR = 2.3; 95% CI = 1.5–3.6) and adolescents aged 12–17 years (Delta = 1.7; Omicron = 5.9; RR = 3.5; 95% CI = 2.5–5.0). Peak ICU admission rates for children and adolescents were 1.4 times higher during Omicron predominance (2-week period ending December 31, 2021 [1.5]) than during Delta predominance (2-week period ending September 11, 2021 [1.1]). During December 2021, when both variants were circulating, the rates of hospitalization were 23.5 and 3.8 per 100,000 among unvaccinated and fully vaccinated adolescents, respectively (RR = 6.3; 95% CI = 4.4–8.6).


Weekly COVID-19–associated hospitalization rates* among children and adolescents aged 0–17 years, by age group — COVID-NET, 14 states, July 3, 2021–January 22, 2022
Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network.
*Number of patients with laboratory-confirmed COVID-19–associated hospitalizations per 100,000 population; rates are subject to change as additional data are reported.
COVID-NET sites are in the following 14 states: California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. Starting the week ending December 4, 2021, Maryland data are removed from weekly rate calculations.

Complete clinical data were available for 1,834¶¶¶¶ and 266***** hospitalized children and adolescents in the Delta-predominant (July 1–December 18, 2021) and Omicron-predominant (December 19, 2021–December 31, 2021) periods, respectively. The proportions of hospitalized children and adolescents requiring ICU admission (Delta = 27.8%; Omicron = 20.2%) or IMV (Delta = 6.3%; Omicron = 2.3%) were significantly lower during the Omicron period (Table 1). No significant difference was detected between the Delta- and Omicron-predominant periods in the proportion of patients with COVID-19–related symptoms recorded at admission (87.7% versus 86.9%) or with COVID-19 as the primary reason for admission (81.3% versus 81.6%).

The proportion of hospitalized adolescents who were fully vaccinated was significantly lower during the Delta-predominant period (8.3%) than during the Omicron-predominant period (22.2%) (Table 1), consistent with increasing adolescent vaccination coverage during the surveillance period. During July 1–December 31, 2021, 42.4% of hospitalized unvaccinated adolescents were non-Hispanic Black adolescents (Table 2). A higher proportion of unvaccinated adolescents (70.3%) than fully vaccinated adolescents (40.8%) had COVID-19 as a primary reason for admission. A significantly higher proportion of unvaccinated adolescents were admitted to the ICU (30.3%) than were those who were vaccinated (15.5%).

COVID-NET hospitalization data are preliminary and subject to change as more data become available. In particular, case counts and rates for recent hospital admissions are subject to lag.
††California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah.
§§Rates are calculated using the National Center for Health Statistics vintage 2020 bridged-race postcensal population estimates for the counties included in surveillance (
¶¶The Food and Drug Administration granted emergency use authorization for the Pfizer-BioNTech COVID-19 vaccine for adolescents aged 12–15 years on May 10, 2021. The earliest date that adolescents in this age group could have met the definition for being a fully vaccinated COVID-19 patient was June 14, 2021.
***Fully vaccinated adolescents with COVID-19–associated hospitalizations were defined as those who had received the final dose in their primary series ≥14 days before receiving a positive SARS-CoV-2 test result associated with their hospitalization. Adolescents who received only 1 vaccine dose ≥14 days before the SARS-CoV-2 test date or had received a single dose of vaccine <14 days before the positive SARS-CoV-2 test results were considered partially vaccinated; they were not included in rates and were grouped with unvaccinated adolescents in other analyses. Unvaccinated adolescents were defined as those who did not meet the criteria for being fully or partially vaccinated. Additional COVID-NET methods for determining vaccination status have been described previously (
†††Colorado, Georgia, New Mexico, and Utah sampled 50% of patients during the month of December. All other sites included 100% of cases. To produce random samples of hospitalized patients for medical record abstraction, random numbers (1–100) are automatically generated and assigned to each patient as their data are entered into the surveillance database. Percentages are weighted to account for the probability of selection for sampled patients.
§§§ICU admission and IMV are not mutually exclusive categories, and patients could have received both.
¶¶¶Among sampled patients, COVID-NET collects data on the primary reason for admission to differentiate hospitalizations of patients with laboratory-confirmed SARS-CoV-2 infection who are likely admitted primarily for COVID-19 illness rather than for other reasons. During chart review, if the surveillance officer finds that the chief complaint or history of present illness mentions fever/respiratory illness, COVID-19-like illness, or a suspicion for COVID-19, then the case is categorized as COVID-19 related illness as the primary reason for admission.
****COVID-19–related symptoms included respiratory symptoms (congestion or runny nose, cough, hemoptysis or bloody sputum, shortness of breath or respiratory distress, sore throat, upper respiratory infection, influenza-like illness, and wheezing) and nonrespiratory symptoms (abdominal pain, altered mental status or confusion, anosmia or decreased smell, chest pain, conjunctivitis, diarrhea, dysgeusia or decreased taste, fatigue, fever or chills, headache, muscle aches or myalgias, nausea or vomiting, rash, and seizures), and among those aged <2 years, included apnea, cyanosis, decreased vocalization or stridor, dehydration, hypothermia, inability to eat or poor feeding, and lethargy. Symptoms are abstracted from the medical chart and might not be complete.
††††Delta became the predominant (>50%) variant circulating in the United States the week ending July 3, 2021. By the week ending December 18, 2021, Omicron accounted for 38% of circulating variants; Omicron became the predominant variant the week ending December 25 at 74%.
§§§§45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
¶¶¶¶Among the 1,943 sampled children and adolescents with COVID-19–associated hospitalizations during July 1–December 18, 2021, a total of 1,834 (94.4%) had data available on hospital length of stay, ICU admission, receipt of IMV, and in-hospital death at the time of reporting.
*****Among the 281 sampled children and adolescents with COVID-19–associated hospitalizations during December 19–31, 2021, a total of 266 (94.7%) had data available on hospital length of stay, ICU admission, receipt of IMV, and in-hospital death at the time of reporting.