The differential impact of pediatric COVID-19 between high-income countries and low- and middle-income countries: A systematic review of fatality and ICU admission in children worldwide

Abstract

Background: The overall global impact of COVID-19 in children and regional variability in pediatric outcomes are presently unknown.

Methods: To evaluate the magnitude of global COVID-19 death and intensive care unit (ICU) admission in children aged 0-19 years, a systematic review was conducted for articles and national reports as of December 7, 2020. This systematic review is registered with PROSPERO (registration number: CRD42020179696).

Results: We reviewed 16,027 articles as well as 225 national reports from 216 countries. Among the 3,788 global pediatric COVID-19 deaths, 3,394 (91.5%) deaths were reported from low- and middle-income countries (LMIC), while 83.5% of pediatric population from all included countries were from LMIC. The pediatric deaths/1,000,000 children and case fatality rate (CFR) were significantly higher in LMIC than in high-income countries (HIC) (2.77 in LMIC vs 1.32 in HIC; p < 0.001 and 0.24% in LMIC vs 0.01% in HIC; p < 0.001, respectively). The ICU admission/1,000,000 children was 18.80 and 1.48 in HIC and LMIC, respectively (p < 0.001). The highest deaths/1,000,000 children and CFR were in infants < 1 year old (10.03 and 0.58% in the world, 5.39 and 0.07% in HIC and 10.98 and 1.30% in LMIC, respectively).

Conclusions: The study highlights that there may be a larger impact of pediatric COVID-19 fatality in LMICs compared to HICs.

Fig 1. PRISMA flowchart.

^a Included two manually extracted article. ^b No national data from North Korea and Turkmenistan was identified. ^c Aggregated data from more than one eligible reports identified, screened, and included for data analysis/synthesis for 6 countries (Estonia, Namibia, Romania, Rwanda, United Kingdom, and the United States of America). ^d National reports from 8 countries (Burkina Faso, Cyprus, Guinea, Kazakhstan, Kenya, Oman, Pakistan, and Trinidad Tobago) were not included into primary analysis because they were reported more than 2 months before the date of final search (Dec 7, 2020), but they are included into the sensitivity analysis. MIS-C: Multisystem inflammatory syndrome in children.

Fig 2. World map of national pediatric COVID-19 deaths (/1,000,000 children).

The map was built with the geographic information system QGIS (v3.10, https://qgis.org) and the World Bank Official Boundaries Data Set (https://datacatalog.worldbank.org/dataset/world-bank-official-boundaries). Deaths are presented per million children. Countries of no pediatric case reported includes the country clearly report that there was no confirmed case in children in the national report as of December 7, 2020. National reports published more than 2 months before December 7 were included, if the countries were CDC COVID-19 Level 1 (low transmission) since the date of report.

Fig 3. Pediatric COVID-19 deaths (/1,000,000 children) by country income.

The ranges are presented by 95% confidence intervals of each proportion. Global includes all countries defined by World income. Abbreviations: HICs, high-income countries; LMICs, low- and middle-income countries; MICs, middle-income countries; LICs, low-income countries.

Fig 4. Age-specific deaths and ICU admissions (/1,000,000 children).

A. Age-specific deaths (/1,000,000 children). B. Age-specific ICU admissions (1,000,000 children). Age-specific national data with up to one year difference of age buckets were included. For example, age-specific national data reporting outcomes of 1–5 years and 10–15 years were included in our calculation of 1–4 years and 10–14 years. Abbreviations: y, years.