As school districts, teachers, parents, and clinicians weigh reopening schools for in-classroom learning next month, it's not helping that useful data about COVID-19 in children and teens is lacking in many states -- especially since case counts in certain age brackets have been rapidly rising in recent weeks.
Many counties and states, and even the National Center for Health Statistics, lump infants, children, and teens into one or two groupings -- for example, from 0 to 4 and from 5 to 17. Ohio and a few other states don't separate them at all, with a single line for those age 0 to 19.
How each state defines a "child" is all over the map. Alabama, for example, reports that 21.7% of its 58,225 COVID cases so far are in youth, but divides them into two groups, 0-4, which has 1,123 cases, and 5-24, which has 11,493. Some of the latter, perhaps most, are adults by any measure.
Yvonne Maldonado, MD, chair of the Committee on Infectious Diseases for the American Academy of Pediatrics (AAP), which has produced weekly reports on the issue of "substantial" discordance in state-by-state pediatric COVID reporting, said the situation is far from optimal.
"All states should provide more granular data regarding symptomatic and asymptomatic infections in children, as well as age breakdown, number of hospitalizations, and deaths. Exposure history would also be helpful," she said in an e-mail.
"While we would prefer that all states provide a standardized age range for children, we are limited by what the states are making publicly available," Blake Sisk, senior research associate for the AAP and an author of the AAP's reports, told 51˶ in an e-mail.
Few states disclose the setting in which children or adolescents tested positive, what percentage of children were tested, whether they were sick or required hospitalization, or whether they died.
Child COVID Data Essential
Yet some experts say this information is essential to control the spread of SARS-CoV-2 as increasing numbers of reports suggest that not only can children become seriously ill with COVID-19, but they can transmit it to other children, their teachers, and other school support staff and their families. Against the common belief that pediatric infections are of little clinical concern, reports have emerged about multisystem inflammatory syndrome in children, and long-lasting effects on the brain.
To date, 66 children have died in the U.S., issued Monday (which didn't define "children" either). , issued Wednesday by the Coronavirus in Kids Tracking and Education Project, has documented a total of 77 deaths in children and teens in 23 states, as well as 805 COVID-19 admissions to pediatric intensive care units. That report also included an estimate of 1.9 million pediatric coronavirus infections in the U.S., including undiagnosed cases not counted in official data.
In California, for example, the percentage of children and teens infected with COVID has been rapidly increasing. On April 1, the percentage of all children and teens 17 and younger was just 1.1% of all patients diagnosed with COVID-19. By June 1, it was 5.7%. In the 3 weeks beginning July 1, the percentage increased from 8.03% to 8.7% as California broke records on overall case counts and new pediatric cases in one day.
Irwin Redlener, MD, a pediatrician and founding director of the National Center for Disaster Preparedness at Columbia University, called the discordance in COVID-19 reporting of children and teens "a mess, just a mess. The restriction of data, especially around children right now, is a terribly bad idea."
He added that these case reports by age bracket are important: "We actually don't know that much about the disease and the way the virus behaves in children and it would be extremely helpful to have a more precise breakdown."
"It's difficult to understand why states aren't reporting this more precisely, or why they aren't reporting in ways that are consistent across all states," he added.
All Over the Map
One state, Florida, seems to be more transparent than most. Florida breaks down pediatric COVID cases not only into five brackets of ages, but also how many in each bracket were hospitalized and how many died. Its report is updated Fridays.
revealed that 6,373 Florida children and teens were diagnosed with COVID-19 in the previous week -- to -- for a total of 23,170 among children age 0-17 since reporting began -- and that 246 of those children and teens had been sick enough to be hospitalized (33 in the last seven days). The second highest number of hospitalizations, 51, was among infants less than one year old.
Two deaths were reported in 10- to 14-year-olds and two in those ages 15-17. Of the total new cases, 317 were infants younger than 1, for a total of 1,412.
New York was much less forthcoming. Asked for its pediatric COVID data, Evan Frost, a spokesman for the New York Department of Health, provided data only through May 10, in which 15,515 cases of COVID-19 in people under age 21 were reported to the state.
"All the currently available data related to COVID-19 in New York State can be found on the Department of Health's ," Frost said. He advised a reporter wanting more current, granular information to file a freedom of information request: "We do not have any other publicly available data."
Nationally, according to the latest AAP report (prepared with the Children's Hospital Association), case counts are rising rapidly, with a 46% increase during July 2-16, from 165,845 to 241,904. The report also noted that about 80% of new pediatric cases are in states in the South and West. The report is updated every week.
Howard Taras, MD, a pediatrician and advisor for the large San Diego County Unified School District, said more precise data on COVID in children and teens would be helpful. "For example, if elementary schools in one area opened and not in another, it would be great to compare just elementary school age trends between those two areas," he said.
But variation in pediatric COVID reporting has been going on for so long that school officials and pediatricians "just try to follow general trends," Taras said. He noted that "age groups in our buildings are also not clear and consistent," with a variety of different sets of grade levels among schools.
Diagnosed Cases Likely to Be Sick
Since there is little to no systematic testing of these populations, it's likely that children who have been tested were those who developed symptoms severe enough to warrant medical attention.
"We don't have a lot of random testing of children yet because it requires a deep nasal pharyngeal probe, and a lot of kids aren't going to tolerate that, and without their parents there, that's not going to happen," said Redlener.
He said it's logical to assume that the majority of those children were tested either because they developed COVID symptoms, or were exposed to someone who became ill.
Joshua Sharfstein, MD, of the Johns Hopkins Bloomberg School of Public Health, said that while data granularity for children could improve -- Maryland and Baltimore County report pediatric cases from 0 to 9 and 10 to 19, which total 9% of all cases -- "it's probably going to be more important, as more kids get sick, to understand what's going on."
Sharfstein said a key point is whether the children are hospitalized or not, and where, exactly, the outbreaks are occurring.
Many policy makers and educators fear a repeat of , where schools reopened May 17 under a belief the pandemic in their country was over. In the first two weeks of July, a total of 2,026 students, teachers, and staff have contracted COVID-19, and 28,147 are under quarantine.
It's also important to produce better information to inform policy makers, such as Missouri Gov. Mike Parson (R), who recently from the coronavirus.
"And if they do get COVID-19, which they will -- and they will when they go to school -- they're not going to the hospitals," Parson told a radio show host. "They are going to go home and they're going to get over it."
Redlener said what's needed is a uniform reporting system for all states and the CDC to report age-bracketed data the same way.
"So far I don't see how that's going to happen unless there's a federal directive that is telling the schools, you need to do this, you must do this," Redlener said. "But we've had history since February of incompetency and lack of a clear message -- lack of consistent guidelines that would apply to the whole country, and that's why we're in the mess we're currently in."