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5 junio, 2021

Hospitalization of Adolescents Aged 12–17 Years with Laboratory-Confirmed COVID-19 COVID-NET, 14 States, March 1, 2020 April 24, 2021

Summary

What is already known about this topic?

Most COVID-19–associated hospitalizations occur in adults, but severe disease occurs in all age groups, including adolescents aged 12–17 years.

What is added by this report?

COVID-19 adolescent hospitalization rates from COVID-NET peaked at 2.1 per 100,000 in early January 2021, declined to 0.6 in mid-March, and rose to 1.3 in April. Among hospitalized adolescents, nearly one third required intensive care unit admission, and 5% required invasive mechanical ventilation; no associated deaths occurred.

What are the implications for public health practice?

Recent increased hospitalization rates in spring 2021 and potential for severe disease reinforce the importance of continued COVID-19 prevention measures, including vaccination and correct and consistent mask wearing among persons not fully vaccinated or when required.

Most COVID-19–associated hospitalizations occur in older adults, but severe disease that requires hospitalization occurs in all age groups, including adolescents aged 12–17 years (1). On May 10, 2021, the Food and Drug Administration expanded the Emergency Use Authorization for Pfizer-BioNTech COVID-19 vaccine to include persons aged 12–15 years, and CDC’s Advisory Committee on Immunization Practices recommended it for this age group on May 12, 2021.* Before that time, COVID-19 vaccines had been available only to persons aged ≥16 years. Understanding and describing the epidemiology of COVID-19–associated hospitalizations in adolescents and comparing it with adolescent hospitalizations associated with other vaccine-preventable respiratory viruses, such as influenza, offers evidence of the benefits of expanding the recommended age range for vaccination and provides a baseline and context from which to assess vaccination impact. Using the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), CDC examined COVID-19–associated hospitalizations among adolescents aged 12–17 years, including demographic and clinical characteristics of adolescents admitted during January 1–March 31, 2021, and hospitalization rates (hospitalizations per 100,000 persons) among adolescents during March 1, 2020–April 24, 2021. Among 204 adolescents who were likely hospitalized primarily for COVID-19 during January 1–March 31, 2021, 31.4% were admitted to an intensive care unit (ICU), and 4.9% required invasive mechanical ventilation; there were no associated deaths. During March 1, 2020–April 24, 2021, weekly adolescent hospitalization rates peaked at 2.1 per 100,000 in early January 2021, declined to 0.6 in mid-March, and then rose to 1.3 in April. Cumulative COVID-19–associated hospitalization rates during October 1, 2020–April 24, 2021, were 2.5–3.0 times higher than were influenza-associated hospitalization rates from three recent influenza seasons (2017–18, 2018–19, and 2019–20) obtained from the Influenza Hospitalization Surveillance Network (FluSurv-NET). Recent increased COVID-19–associated hospitalization rates in March and April 2021 and the potential for severe disease in adolescents reinforce the importance of continued COVID-19 prevention measures, including vaccination and correct and consistent wearing of masks by persons not yet fully vaccinated or when required by laws, rules, or regulations.

COVID-NET is a population-based surveillance system of laboratory-confirmed COVID-19–associated hospitalizations in 99 counties across 14 states,§ covering approximately 10% of the U.S. population. Included in surveillance are COVID-19–associated hospitalizations among residents in a predefined surveillance catchment area who had a positive real-time reverse transcription–polymerase chain reaction or rapid antigen detection test result for SARS-CoV-2 (the virus that causes COVID-19) during hospitalization or ≤14 days before admission (2). Clinical and demographic data, updated monthly, were analyzed for adolescents aged 12–17 years hospitalized during January 1–March 31, 2021. Clinical and demographic characteristics were analyzed separately for patients whose primary reason for admission was likely COVID-19 and those whose primary reason for admission might not have been primarily related to COVID-19, despite receiving a positive SARS-CoV-2 laboratory test result.** Hospitalization rate data, updated weekly, were analyzed during March 1, 2020–April 24, 2021, to describe cumulative COVID-19–associated hospitalization rates in adolescents aged 12–17 years and adults aged ≥18 years and weekly COVID-19–associated hospitalization rates in children aged 0–4 years and 5–11 years and adolescents aged 12–17 years. In addition, cumulative COVID-19–associated hospitalization rates among adolescents aged 12–17 years during October 1, 2020–April 24, 2021 (covering most of the typical October 1–April 30 season for influenza-associated hospitalization surveillance), were compared with influenza-associated hospitalization rates in the same age group across three influenza seasons (2017–18, 2018–19, and 2019–20) using data from FluSurv-NET†† (3). Rate calculations are unadjusted and include all persons meeting the case definition (2). SAS statistical software (version 9.4; SAS Institute) was used for analyses. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§§

Among 376 adolescents hospitalized during January 1–March 31, 2021, who received a positive SARS-CoV-2 laboratory test result, 172 (45.7%) were analyzed separately because their primary reason for admission might not have been directly COVID-19–related. Among the 204 patients who were likely admitted primarily for COVID-19–related illness, 52.5% were female, 31.4% were Hispanic or Latino (Hispanic), and 35.8% were non-Hispanic Black. Overall, 70.6% had one or more underlying medical conditions, the most common of which were obesity (35.8%), chronic lung disease, including asthma (30.9%), and neurologic disorders (14.2%); 31.4% of patients required ICU admission and 4.9% required invasive mechanical ventilation, but there were no associated deaths.

During March 1, 2020–April 24, 2021, the cumulative COVID-19–associated adolescent hospitalization rate (49.9) was 12.5 times lower than that in adults aged ≥18 years (675.6). Weekly COVID-19–associated adolescent hospitalization rates (3-week moving average) were comparable to rates among those aged 0–4 years, but higher than rates among children aged 5–11 years. Weekly adolescent hospitalization rates peaked at 2.1 per 100,000 during the week ending January 9, 2021, declined to 0.6 during the week ending March 13, 2021, then increased to 1.3 and 1.2 for the weeks ending April 17 and 24, 2021, respectively. Rates among adolescents in two of 14 sites (Maryland and Michigan) were highest during April 2021 compared with all other weeks within their respective sites since surveillance began on March 1, 2020. Cumulative COVID-19–associated hospitalization rates during October 1, 2020–April 24, 2021, were 2.5–3.0 times higher than seasonal influenza-associated hospitalization rates during three recent influenza seasons (October 1–April 30).

Discussion

COVID-NET data indicate that COVID-19–associated hospitalization rates were lower in adolescents aged 12–17 years compared with those in adults but exceeded those among children aged 5–11 years during March 1, 2020–April 24, 2021. Moreover, COVID-19–associated hospitalization rates among adolescents increased during March–April 2021, and nearly one third of 204 recently hospitalized adolescents required ICU admission. Rates of COVID-19–associated hospitalization among adolescents also exceeded historical rates of seasonal influenza-associated hospitalization during comparable periods. Recent increased hospitalization rates and the potential for severe disease reinforce the importance of continued COVID-19 prevention measures among adolescents, including vaccination and correct and consistent wearing of masks.

After declines in January and February 2021, weekly population-based rates of COVID-19–associated hospitalization among adolescents increased during March and April, and in two COVID-NET sites (Maryland and Michigan) the highest adolescent COVID-19–associated hospitalization rates in their respective sites since the start of the COVID-19 pandemic occurred during this period. This trend contrasts with hospitalization rates among persons aged ≥65 years, the group with the highest COVID-19 vaccination coverage, among whom hospitalization rates in COVID-NET stabilized during the same period.¶¶ Increased hospitalization rates among adolescents might be related, in part, to circulation of particularly transmissible SARS-CoV-2 variants,*** the larger numbers of children returning to school or other in-person indoor activities, and changes in physical distancing, wearing masks, and other COVID-19 prevention behaviors (4). SARS-CoV-2 transmission occurs more easily in high schools than in elementary schools (4), and outbreaks have been associated with high school extracurricular activities (5). Vaccination of adolescents is expected to reduce the risk for COVID-19 in these settings.

Population-based COVID-19–associated hospitalization rates among adolescents were lower than were those in adults, a finding consistent with studies showing that illness is generally milder in children than in adults (6). Nevertheless, severe disease does occur, including that requiring ICU admission and invasive mechanical ventilation. Most (70.6%) adolescents in this study whose primary reason for hospitalization was COVID-19–associated illness had at least one underlying medical condition, which is lower than the percentage of hospitalized adults with an underlying medical condition (92%) (7). Nearly 30% of these adolescents had no reported underlying medical condition, indicating that healthy adolescents are also at risk for severe COVID-19–associated disease. In addition, approximately two thirds of adolescents hospitalized with COVID-19 were Hispanic or non-Hispanic Black persons, consistent with studies showing an increased incidence of COVID-19 among racial and ethnic minority populations and signifying an urgent need to ensure equitable access to vaccines for these groups (8). Vaccination is effective in preventing hospitalization among adults (9); similarly, widespread vaccination of adolescents will likely reduce COVID-19–associated hospitalizations, and potential sequelae from COVID-19 in adolescents, including multisystem inflammatory syndrome in children (MIS-C), a rare but serious complication of COVID-19 (10).

During a comparable period, adolescent hospitalization rates associated with COVID-19 exceeded those for seasonal influenza, another respiratory virus that can cause hospitalization and death in adolescents and for which a vaccine is recommended in this age group.††† This widespread circulation of SARS-CoV-2 occurred despite containment measures such as school closures, wearing masks, and physical distancing, none of which had been enacted during the historical influenza seasons. Without these containment measures, the rates of COVID-19–associated hospitalization might have been substantially higher.

The findings in this report are subject to at least five limitations. First, the primary reason for hospital admission was not always clear, and some (45.7%) adolescents who met the COVID-NET case definition were hospitalized for reasons that might not have been primarily related to COVID-19, despite a positive SARS-CoV-2 laboratory test result; these hospitalizations were included in rate calculations. Thus, rates of hospitalizations for COVID-19 might be overestimated. Second, laboratory confirmation depends on clinician-ordered testing and hospital testing policies for SARS-CoV-2 (COVID-NET) and influenza (FluSurv-NET); consequently, hospitalization rates might also be underestimated. Given more widespread testing for SARS-CoV-2 compared with influenza, the lack of adjustment for testing practices likely disproportionately affects influenza rates compared with COVID-19 rates. Third, adolescents hospitalized with MIS-C might not be identified if testing occurred >14 days before admission, potentially leading to an underestimate of severe COVID-19–associated disease. Fourth, the Pfizer-BioNTech COVID-19 vaccine had been approved for and administered to adolescents aged 16–17 years during this study period; therefore, rates of COVID-19–associated hospitalization in adolescents aged 16–17 years might differ from those in adolescents aged 12–15 years who were not previously eligible for vaccination, and could affect the overall hospitalization rate for all adolescents. Finally, hospitalization rates are preliminary and might change as additional data are reported.

Recent increases in COVID-19–associated hospitalization rates and the potential for severe disease requiring ICU admission, including invasive mechanical ventilation, among adolescents indicate an urgent need for vaccination in combination with correct and consistent mask wearing by persons not yet fully vaccinated or when required by laws, rules, or regulations. Highly effective COVID-19 vaccines are now available to adolescents as an additional evidence-based prevention measure (9); expansion of COVID-19 vaccination of adolescents, with particular attention to racial and ethnic minority groups disproportionately affected by severe COVID-19, is expected to reduce COVID-19–associated morbidity within this age group.

Acknowledgments

Joelle Nadel, Jeremy Roland, Brooke Heidenga, Roxanne Archer, Monica Napoles, Susan Brooks, California Emerging Infections Program; Linda Niccolai, Connecticut Emerging Infections Program, Yale School of Public Health; Elisabeth Vaeth, Cindy Zerrlaut, David Blythe, Maryland Department of Health; Rachel Park, Michelle Wilson, Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health; Jim Collins, Sam Hawkins, Justin Henderson, Shannon Johnson, Val Tellez Nunez, Sue Kim, Lauren Leegwater, Sierra Peguies-Khan, Chloe Brown, Michigan Department of Health and Human Services; Austin Bell, Kalyla Bilski, Emma Contestabile, Kristen Ehresmann, Claire Henrichsen, Emily Holodick, Lisa Nguyen, Katherine Schleiss, Samantha Siebman, Julie Hottinger, Amanda Gordon, Minnesota Department of Health; Kerianne Engesser, Suzanne McGuire, Adam Rowe, New York State Department of Health; Kathy Billings, Katie Dyer, Anise Elie, Karen Leib, Terri McMinn, Danielle Ndi, Manideepthi Pemmaraju, John Ujwok, Vanderbilt University Medical Center; Ilene Risk, Mary Hill, Salt Lake County Health Department; Keegan McCaffrey, Utah Department of Health; Mimi Huynh, Council of State and Territorial Epidemiologists; Sonja Mali Nti-Berko, Susan Conner Gantt, Alissa O’Halloran, Charisse Cummings, Rachel Holstein, Carrie Reed, CDC.

COVID-NET Surveillance Team

Gretchen Rothrock, California Emerging Infections Program, Oakland, California; Arthur Reingold, University of California; Millen Tsegaye, Colorado Department of Public Health & Environment; Sarah McLafferty, Colorado Department of Public Health & Environment; Amber Maslar, , Connecticut Emerging Infections Program; Paula Clogher, Connecticut Emerging Infections Program; Adam Misiorski, Connecticut Emerging Infections Program; Christina Parisi, Connecticut Emerging Infections Program; Maria Correa, Connecticut Emerging Infections Program; Tessa Carter, Connecticut Emerging Infections Program; Carol Lyons, Connecticut Emerging Infections Program; Daewi Kim, Connecticut Emerging Infections Program; Gaggan Brar, Connecticut Emerging Infections Program; Emily Fawcett, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Allison Roebling, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Katelyn Ward, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Jana Manning, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Asmith Joseph, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Chandler Surell, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Daniel Pizarro, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Jeremiah Williams, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Rayna Ceaser, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Stephanie Lehman, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Taylor Eisenstein, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Gracie Chambers, Georgia Emerging Infections Program, Georgia Department of Public Health, Veterans Affairs Medical Center, Foundation for Veterans Education and Research; Grayson Kallas, Division of Infectious Diseases, School of Medicine, Emory University, Emerging Infections Program, Georgia Department of Health; Lauren Russell, Division of Infectious Diseases, School of Medicine, Emory University, Emerging Infections Program, Georgia Department of Health; Suzanne Segler, Division of Infectious Diseases, School of Medicine, Emory University, Emerging Infections Program, Georgia Department of Health; David Blythe, Maryland Department of Health; Alicia Brooks, Maryland Department of Health; Erica Bye, Minnesota Department of Health; Richard Danila, Minnesota Department of Health; Cory Cline, New Mexico Department of Health; Susan Ropp, New Mexico Department of Health; Chad Smelser, New Mexico Department of Health; Daniel Sosin, New Mexico Department of Health; Salina Torres, New Mexico Department of Health; Kathy Angeles, New Mexico Emerging Infections Program; Melissa Christian, New Mexico Emerging Infections Program; Nancy Eisenberg, New Mexico Emerging Infections Program; Kristina Flores, New Mexico Emerging Infections Program; Caroline Habrun, New Mexico Emerging Infections Program; Emily Hancock, New Mexico Emerging Infections Program; Sarah Khanlian, New Mexico Emerging Infections Program; Meaghan Novi, New Mexico Emerging Infections Program; Erin Phipps, New Mexico Emerging Infections Program; Dominic Rudin, New Mexico Emerging Infections Program; Yadira Salazar-Sanchez, New Mexico Emerging Infections Program; Judith Segall, New Mexico Emerging Infections Program; Sarah Shrum Davis, New Mexico Emerging Infections Program; Grant Barney, New York State Department of Health; Christina Felsen, University of Rochester School of Medicine and Dentistry, Rochester, New York; Sophrena Bushey, University of Rochester School of Medicine and Dentistry, Rochester, New York; Kevin Popham, University of Rochester School of Medicine and Dentistry, Rochester, New York; Virginia Cafferky, University of Rochester School of Medicine and Dentistry, Rochester, New York; Christine Long, University of Rochester School of Medicine and Dentistry, Rochester, New York; RaeAnne Kurtz, University of Rochester School of Medicine and Dentistry, Rochester, New York; Nicole West, Public Health Division, Oregon Health Authority; Ama Owusu-Dommey, Public Health Division, Oregon Health Authority; Breanna McArdle, Public Health Division, Oregon Health Authority; Emily Youngers, Public Health Division, Oregon Health Authority; Kylie Seeley, Oregon Health & Science University School of Medicine, Portland, Oregon; Tiffanie Markus, Vanderbilt University Medical Center; Amanda Carter, Salt Lake County Health Department, Utah; Andrea Price, Salt Lake County Health Department, Utah; Andrew Haraghey, Salt Lake County Health Department, Utah; Ashley Swain, Salt Lake County Health Department, Utah; Caitlin Shaw, Salt Lake County Health Department, Utah; Ian Buchta, Salt Lake County Health Department, Utah; Jake Ortega, Salt Lake County Health Department, Utah; Laine McCullough, Salt Lake County Health Department, Utah; Ryan Chatelain, Salt Lake County Health Department, Utah; Tyler Riedesel, Salt Lake County Health Department, Utah

Corresponding author: Fiona P. Havers, fhavers@cdc.gov.

CDC COVID-19 Response Team; 2California Emerging Infections Program, Oakland, California; 3Career Epidemiology Field Officer Program, CDC; 4Colorado Department of Public Health and Environment, 5Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut; 6Departments of Medicine and Pediatrics, Emory University School of Medicine, Atlanta, Georgia; 7Georgia Emerging Infections Program, Georgia Department of Public Health; 8Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; 9Division of Infectious Diseases, School of Medicine, Emory University, Atlanta Georgia; 10Iowa Department of Public Health; 11Maryland Department of Health; 12Michigan Department of Health and Human Services; 13Minnesota Department of Health; 14New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico; 15New Mexico Emerging Infections Program, New Mexico Department of Health; 16New York State Department of Health; 17University of Rochester School of Medicine and Dentistry, Rochester, New York; 18Ohio Department of Health; 19Public Health Division, Oregon Health Authority; 20Vanderbilt University Medical Center, Nashville, Tennessee; 21Salt Lake County Health Department, Salt Lake City, Utah; 22General Dynamics Information Technology, Atlanta, Georgia; 23Influenza Division, National Center for Immunization and Respiratory Diseases, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Andrea George, Laurie M. Billing, Libby Reeg, Alexander Kohrman, Andrew Weigel, Kenzie Teno, and Jess Shiltz report grant funding from the Council of State and Territorial Epidemiologists. William Schaffner reports personal fees from VBI Vaccines. Evan J. Anderson reports grants for clinical trials from Pfizer, Merck, PaxVax, Micron, Sanofi-Pasteur, Janssen, MedImmune and GSK, and personal fees for consulting from Sanofi-Pasteur, Pfizer, and Medscape, and for data safety monitoring board service from Kentucky Bioprocessing, Inc. and Sanofi-Pasteur; and funding from the National Institutes of Health to conduct clinical trials of Moderna and Janssen COVID-19 vaccines. No other potential conflicts of interest were disclosed.


Créditos: Comité científico Covid

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