Between March 2020 and February 2021, 3105 CYP in England died of all causes. Of these, 61 CYP had a positive SARS-CoV-2 test (5 deaths every 30 days) and 3044 died from all other causes (250 deaths every 30 days).
Clinical records of the 61 CYP who died with a positive SARS-CoV-2 test were reviewed to identify if SARS-CoV-2 contributed to death. 25 (41%) of the 61 CYP died of SARS-CoV-2 (2 deaths every 30 days), including 22 with acute COVID-19 and three with PIMS-TS. The other 36 (59%) of the 61 CYP were categorised as SARS-CoV-2 did not contribute to death (Table 1, Figure 1, Figure 2).
There were an estimated 469,982 CYP infected with SARS-CoV-2 in England from March 2020 to February 2021, giving an infection fatality rate of 5 per 100,000 CYP (0·005%) and, based on a population of 12,023,568, a mortality rate of 2 per million CYP (0·0002%).
Demographics (Table 1, Figures 3 and 4)
CYP who died of SARS-CoV-2 (n=25) were older than those who died from all other causes (n=3080) in the same time period (Figure 3). 18/25 (72%) young people who died of SARS-CoV-2 were aged 10 years or over, compared to 19% in the deaths from all other causes (chi2 59·7, p <0·001). All three deaths in CYP who died of PIMS-TS were aged 10-14 years. The sex distribution was equally split between males and females (12 (48%) and 13 (52%) respectively) and did not differ from the deaths from all other causes (chi2 0·64, p=0·28). A greater proportion of CYP from an Asian (36% cf 16%) and Black (20% cf 8%) ethnicity died of SARS-CoV-2 compared to deaths from all other causes (chi2 17·9, p<0·001). There was no significant difference in the deprivation categories between CYP who died of SARS-CoV-2 and deaths from all other causes (chi2 0·35, p=0·99) although more CYP from more deprived areas died in both groups.
The mortality rate in CYP who died of SARS-CoV-2 was 0·2 per 100,000 (95%CI 0·1-0·3) compared to 25·5 per 100,000 (95%CI 24·7-26·5) for all other causes of death. Although the proportion of CYP from Asian and Black ethnic groups who died of SARS-CoV-2 was higher, their absolute risk of death from SARS-CoV-2 was still extremely low at 0·6 per 100,000 (95%CI 0·3-1·1) and 0·8 per 100,000 (95%CI 0·3-1·8) respectively. Similarly the proportion of CYP aged 10-14 years and 15-17 years who died of SARS-CoV-2 was higher, however their absolute risk of death from SARS-CoV-2 was still extremely low at 0·3 per 100,000 (95%CI 0·1-0·5) and 0·5 (95%CI 0·2-0·9) per 100,000 respectively.
Co-morbidities (Table 2, Table 3)
A similar proportion of the 25 CYP who died of SARS-CoV-2 (n=19, 76%) and the 3080 deaths from all other causes (n=2267, 74%) (chi2 0·004, p=0·60) had a chronic underlying health condition. Significantly more CYP who died of SARS-CoV-2 had a life-limiting condition (n=15, 60%) compared to deaths from all other causes (n=988, 32%) (chi2 8·5, p=0·005). 64% (n=16) of the 25 CYP who died of SARS-CoV-2 had comorbidities in two or more body systems compared to 45% (n=1373) of the CYP who died from all other causes (chi2 5·5, p=0·14).
Six (24%) of the 25 CYP who died of SARS-CoV-2 appeared to have no underlying health conditions similar to 24% (729 of the 3080 CYP) who died of all other causes.
Neurological conditions were the commonest comorbidity in both the CYP who died of SARS-CoV-2 (n=13/25, 52%) and the CYP who died of all other causes (n=1218/3080, 40%; chi2 1·6, p=0·29). All 13 CYP who died of SARS-COV-2 with neurological comorbidity had complex neurodisability due to a combination of an underlying genetic or metabolic condition, hypoxic ischaemic events or prematurity. Eight (32%) of the 13 CYP who had a neurological comorbidity also had a respiratory comorbidity, including five who required home respiratory support; four with non-invasive ventilation or high flow oxygen and one with low flow oxygen. There were zero CYP who died of SARS-CoV-2 that were invasively home ventilated. There was one death in a young person with a tracheostomy required for airway patency.
Amongst the 25 CYP who died of SARS-CoV-2 there was one child with each of the following comorbidities; congenital cardiac, oncological, haematological, obesity, endocrinology and complications of prematurity.
There were no deaths in CYP with the following conditions:
- An isolated respiratory condition e.g. cystic fibrosis or asthma (three of the CYP with complex neurodisability had a historic diagnosis of asthma, however the asthma diagnosis was not considered to contribute to death.)
- Type 1 diabetes
- Trisomy 21
- Isolated diagnosis of epilepsy
The estimated mortality rate for CYP who died of SARS-CoV-2 with a life-limiting condition was 11·5 per 100,000 (95%CI 5·6-21·2) compared to 1,124 per 100,000 (95%CI 1054-1197) for all other causes of death. Although the proportion of CYP with life-limiting neurodisability who died of SARS-CoV-2 was higher, their absolute risk of death was 88·9 per 100,000 (95%CI 47·3-152) compared to 2,441 per 100,000 (95% CI 2,194-2,707) in CYP with life-limiting neurodisability who died of all other causes.
Place of death
Nine (36%) of the 25 CYP who died of SARS-CoV-2, died within a Paediatric Intensive Care Unit and four died on a hospital ward. The remaining 12 CYP died either at home (unexpected (n=6) or expected (n=2)) or in the Emergency Department (n=4). There were five deaths in CYP with advance care plans in place to provide hospital ward level care rather than escalate to intensive care.