It is commonly accepted, at least for now, that children and adolescents (0-19 years) have been largely spared the direct epidemiological effects of the COVID-19 crisis on their own health and survival. This narrative is based predominantly on early data from the first affected countries of the virus, notably from China (Wuhan Province) and Italy in early 2020, and also other high-income countries including the United States and some European nations.
This narrative has conditioned subsequent screening and testing of COVID-19 cases in children and adolescents, which have been notably lower than for other age cohorts. But demographic dynamics differs widely among countries, and assumptions and narrative made on evidence taken from ageing societies and mainly from high income countries may not hold for more youthful and growing populations (Figure 1). For this reason, we began to investigate the burden of COVID-19 cases for children and adolescents globally. And what we have found so far, despite major data limitations, suggest that children worldwide may be more affected by COVID-19 than the dominant narrative so far suggests.
The narrative [that children have been spared] is based predominantly on early data from the first affected countries of the virus, notably China and Italy and other high-income countries including the United States and some European nations.
The dataset we have compiled from websites of 42 countries with available disaggregated data shows that the average of COVID-19 reported cases among children and adolescents under 20 years as a percentage of total cases is 8.1 per cent. There is an incredibly broad spread among the proportions, ranging from Paraguay, where under-20s account for about 23 per cent of the national COVID case load on 14 June 2020, to Spain, where they represented just 0.82 per cent by 4 June 2020. (Figure 2).
A pattern of the child and adolescent burden of reported COVID-19 cases emerges when countries are aggregated along income levels and geographic locations. Using the World Bank income categorization, the share of COVID-19 cases among under-20s in the total reported burden is around 10 per cent for low- and middle-income countries (LMICS) including China compared to 7 per cent for high-income countries (Figure 1). When China is excluded, the share of COVID-19 cases among under-20s in the total national burden is around 11 percent. What is perhaps more disturbing, however, is that for some of the high-burden child and adolescent mortality countries – including Brazil, India and Nigeria – the proportion of cases among under 20s to the total national COVID-19 cases is in double digits.
One reason that children may be neglected as sufferers from COVID-19 derives from the way the virus affects them. Children confirmed with COVID-19 generally have fewer symptoms than adults, including fever and cough, and much less dyspnoea (shortness of breath) than adults. Consistent with less severe disease, laboratory findings in children with COVID-19 are less abnormal than in adults, and they are less likely to require ICU or significant treatments. However, the emerging multi-system inflammatory syndrome (MISS or MIS-C) in children reported in Western countries is of great concern and calls for increased vigilance. Early detection is key to prevent unintended consequences for children.
Much of the difficulty of drawing definitive conclusions from the available data is related to the fact that there is just too little of child specific data. From our search of diverse sources, we were only able to draw on data by age from 42 countries out of the 188 countries and territories that have confirmed cases of COVID-19, which represents about 20 per cent of these countries. It is even harder to obtain disaggregated data to evaluate proportional representation by age among children and adolescents with COVID-19. This omission requires rapid rectification if the full direct effects of the virus on children and adolescents – and indeed other stratifiers such as gender and race/ethnicity — are to be better understood.
While understanding the additional burden the accurate age reporting may place on already overstretched health systems, particularly in countries with weak health system capacity, experience from some low-and-middle-income countries proved that it is possible for much more age disaggregated data to be made available in a readily accessible format. This will not only benefit children and adolescents but the wider understanding of the impact of COVID-19 on all age cohorts. The same argument can and is being made for disaggregation by sex.
It is imperative to have standardized age data to enable a comprehensive and timely understanding of the patterns of vulnerability across ages, geography, co-morbidities and vulnerabilities, thus enabling better programme strategies and policy adoption that are context specific. At the end of the day, the pandemic is about people in different parts of the world, so invoking the SDG principle of leaving no one behind, and universal health coverage, we need to pay attention to everyone including children and adolescents, who are often the silent victims. Children are without a voice or platform and are among the most vulnerable. It is the responsibility of all governments and parties to make sure they are not left behind in this epidemic due to lack of data, research and testing.
The pandemic has currently appeared to hit men and the elderly hardest, particularly in high income countries. But data emerging from the US and elsewhere points alarmingly to COVID-19 disease becoming an equity issue, with certain ethnicities and income groups much more likely to die from it than others
In addition, a further call by the authors is for the continuous monitoring of age- and sex-disaggregated data for COVID-19 by governments and major international agencies. The pandemic has currently appeared to hit men and the elderly hardest, particularly in high income countries. But data emerging from the US and elsewhere points alarmingly to COVID-19 disease becoming an equity issue, with certain ethnicities and income groups much more likely to die from it than others, even when controlling for pre-existing health conditions, age, and other socio-demographic factors. Like polio before it, unless we continue to monitor its socio-demographic spread, COVID-19 may start out being a disease that first affects more affluent communities and countries but could end up lasting longest and deepest among the world’s poorest countries and communities.
In the HIV crisis, age-disaggregated data appeared long after the aggregate numbers or even the sex-disaggregated, leaving child prevention, detection and treatment lagging well behind that of adults. Until it did, children were assumed to be affected largely by its secondary effects on their parents, caregivers and family members. The disaggregated figures showed that children were also primary victims of the crisis, as well as secondary ones, but by the time this happened, it was too late to stop this momentum. We must not make the same mistakes with the COVID-19 crisis.
Priscilla Idele is Deputy Director of UNICEF Innocenti. David Anthony is Chief of Strategic Planning and Convening at UNICEF Innocenti. Kaku Attah Damoah, is a Research Consultant at UNICEF Innocenti working on poverty reduction. Danzhen You is Sr. Advisor, Statistics and Monitoring at UNICEF.