Social Determinants of Health in Children with Severe and Non-severe sars-cov-2 Infection

Background: The COVID-19 pandemic has been shown to have a compounding effect on families across various social and healthcare needs. However, the impact of social determinants of health (SDOH) on COVID-19 disease severity in children is unknown. Our objectives were to describe the SDOH in children with SARS-CoV-2 infection and determine their association with severity of the infection

Methods: This prospective observational study was supported by the National Institutes of Health RADx program and conducted in the emergency department (ED) of two large children’s hospitals. Children ≤ 18 years of age with symptoms due to SARS-CoV-2 infection (positive RT PCR test, serology or epidemiological link) were enrolled between 03/29/2021 and 05/30/2021. Data collected from electronic medical records included demographics, clinical features, treatment, disposition, and outcomes. Severe cases were defined as the following within 30 days of test positivity: diagnosis of Multisystem inflammatory syndrome in children or Kawasaki disease, requirement for oxygen > 2L, inotropes, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death. Following informed consent, caregivers were surveyed via an electronic device on previously validated PhenX questions. Aligned with the Healthy People 2020 SDOH framework, caregivers reported on economic stability, education, social and community context, health and health care, and neighborhood and built environment. Stata was used to analyze descriptive statistics, and unadjusted comparisons between groups were assessed using two sample t-tests for continuous variables and Fisher’s exact test for categorical variables due to small sizes.

Results: A total of 107 children (mean age 6.9 (±5.9) years, 44.9% males), with SARS-CoV-2 infection were enrolled, and 85 caregivers (79.4%) completed the survey (71.4% Black). In this sample, 97% of children were RT PCR positive, 3% had an epidemiological link, and 23 (27.1%) were categorized as severe. Almost half of caregivers (47.6%) reported employment or income loss due to COVID-19. The three most common SDOH needs identified were that of childcare (22.0%), housing instability (22.0%), and food insecurity (21.7%). Children with severe COVID-19 were significantly more likely to have a caregiver who was single, including never married, separated/divorced, and widowed (82.6% vs. 52.5%; Table 1). Although not statistically significant, children with severe COVID-19 tended to have higher levels of social needs including housing instability, poor caregiver mental health, and lower levels of social support compared to children with non-severe infection (Table 2).

Conclusion: Our preliminary data on SDOH suggest that among children with SARS-CoV-2 infection, housing instability, food insecurity and childcare needs are particularly prevalent. Children with severe SARS-CoV-2 infection were more likely to have single caregivers. Family structure may influence severe COVID-19 in children and programming and supports for single parent households should be considered. Larger studies in the ED setting will help confirm these findings and to direct resources to address these social needs.