APRIL 2021

Prevalence of Risk Factors for
Severe COVID-19 Disease

Implications for Children and Youth
with Special Health Care Needs

Authors: Jay G. Berry, MD, MPH, Jonathan Rodean, MPP, Anna Desmarais, BS,
Alyssa Teves, RN, Troy Yang, MS, Lynne Ferrari, MD

 

havens Hee (iy. S%. Lucile Packard Foundati
Boston Children’s Hospital cvsuc ly: De Chileno Foundation

Where the world comes for answers

 

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About the Authors

 

€:) Boston Children's Hospital cvsue (ls):
JAY G. BERRY, MD, MPH, Complex Care, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital; Harvard
Medical School, Boston, Massachusetts

JONATHAN RODEAN, MPP, Children’s Hospital Association, Lenexa, Kansas

ANNA DESMARAIS, BS, Complex Care, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital
ALYSSA TEVES, RN, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital

TROY YANG, MS, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital

LYNNE FERRARI, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital; Harvard Medical
School, Boston, Massachusetts

CORRESPONDING AUTHOR

Jay G. Berry, MD, MPH

Division of General Pediatrics, Boston Children’s Hospital
Harvard Medical School, 300 Longwood Ave, Boston, MA 02115.
E-mail: jay.berry@childrens.harvard.edu

AUTHORSHIP CRITERIA AND CONTRIBUTIONS
Dr. Berry takes responsibility for the integrity of the work as a whole, from inception to the published report.

Dr. Berry, Dr. Ferrari, Ms. Teves, Ms. Desmarais, Mr. Rodean, and Mr. Yang all made substantial contributions to conception or design
of the work; interpreted the data for the work; drafted the work and revised it critically for important intellectual content; gave final
approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to
the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Mr. Yang and Mr. Rodean had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of
the data analysis.

ACKNOWLEDGEMENTS
The authors have no conflicts of interest to disclose, including relevant financial interests, activities, relationships, and affiliations.

Dr. Berry and Mr. Rodean were supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) under UA6MC31101 Children and Youth with Special Health Care Needs Research Network. This
information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor
should any endorsements be inferred by HRSA, HHS, and the U.S. Government. The funder had no role in the design and conduct of
the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.

 

SG Lucile Packard Foundation
ZS for Children’s Health

THE LUCILE PACKARD FOUNDATION FOR CHILDREN’S HEALTH is a public charity, founded in 1997. Its mission is to elevate the priority
of children’s health, and to increase the quality and accessibility of children’s health care through leadership and direct investment.
The Foundation works in alignment with Lucile Packard Children’s Hospital Stanford and the child health programs of Stanford University.
Through its Program for Children with Special Health Care Needs, the Foundation supports development of a high-quality health care
system that results in better health outcomes for children and enhanced quality of life for families. The views presented here are those
of the authors and not necessarily those of the Foundation or its directors, officers, or staff. Learn more at: lpfch.org/CSHCN

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 2
 

Introduction

March 2021 marked the one-year anniversary of the outbreak of Coronavirus 2019 (COVID-19) in the U.S. To date, there have been
over 29 million COVID-19 cases, 1.8 million hospitalizations, and 527,000 deaths confirmed in the U.S.1 Adults have experienced the
majority of the COVID-19 illness burden; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been substantially less
prevalent in children and youth. Nevertheless, many children and youth with special health care needs (CYSHCN) are at risk for severe
COVID-19 illness.” Herein, we report on the at-risk health conditions in these children, including how the conditions are being used to
prioritize vaccine distribution, how to identify the conditions using health care claims, and how estimating the prevalence of these
conditions can help ensure that children and youth receive the care they need during the pandemic.

 

Many of the CDC conditions that are associated with severe COVID-19 illness originate in childhood and,
most of the conditions apply to CYSHCN.

 

COVID-19 Vaccine

Optimism about overcoming the COVID-19 pandemic has increased as state governments, public health departments, hospitals, and
other entities continue to distribute coronavirus 2019 (COVID-19) vaccines to the U.S. populace.’ Phases of distribution for COVID-19
vaccination using target groups have been designed to first protect the most vulnerable individuals and to maintain capacity of health
care system personnel and other essential workers.’ Although most vaccine distribution plans across the U.S. have focused on elderly
individuals and other at-risk adult populations, deliberations continue on the value, safety, and approach for vaccination programs in
children and youth.’ As of March 2021, the Pfizer/BioNTech COVID-19 vaccine is approved for individuals ages 16 years and older. Mod-
erna and Johnson and Johnson vaccines are approved for individuals age 18 years and older. Pfizer and BioNTech recently requested
that the Food and Drug Administration expand emergency use authorization for their vaccine to children ages 12-to-15 years.”°

Risk Factors for Severe COVID-19 Illness

The World Health Organization and Centers for Disease Control and Prevention (CDC) encourage priority of vaccination to individuals
who have a high risk for severe COVID-19 illness due to underlying medical conditions.*"* The CDC stewards lists of health conditions
that associate with severe COVID-19 illness, resulting in hospitalization, admission to the intensive care unit, intubation and mechanical
ventilation, or death.*"3 These lists, derived from comprehensive reviews of published research studies, include condition-specific
underlying diseases (e.g., sickle cell anemia), broad categories of disease (e.g., neurologic conditions), and behaviors (e.g., cigarette
smoking). Although most of the supporting evidence on these conditions arises from research on adult patients, many of the CDC
conditions that are associated with severe COVID-19 illness originate in childhood. And, most of the conditions apply to CYSHCN.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 3
 

Risk Factors for Severe COVID-19 Illness and
Vaccine Distribution

Many U.S. states include the CDC conditions in plans for COVID-19 vaccine distribution, highlighting the conditions that are supported
by the strongest evidence of risk for severe COVID-19 illness.1*** The CDC categorizes conditions associated with severe COVID-19 illness
in tiers of evidence defined by types of study designs: (1) meta-analysis/systematic review, (2) cohort, case-control, or cross-sectional
studies, (3) case series, case reports or, if other study design, the sample size is small (and no systematic review or meta-analysis were
available to review), and (4) mixed evidence.”

The evidence on risk factors for severe COVID-19 illness in children and youth is especially limited because of (1) the short amount of
time that scientists have had to understand the relationship between COVID-19 and pediatric chronic conditions; (2) the heterogeneity
and low prevalence of pediatric chronic conditions; and (3) the small number of children and youth who have experienced severe
COVID-19 illness. In this context, the absence of a specific condition on a CDC list may indicate that the condition has not been evalu-
ated for severe COVID-19 illness, even though an actual association may exist. The CDC aggregates many childhood chronic conditions
into a pediatric category. This category includes conditions that are distinguished as risk factors in other, higher-grade evidence categories on
the CDC lists (e.g., asthma) as well as conditions that are not listed elsewhere (e.g., congenital heart disease and use of feeding tube).1”?

There has been variation across U.S. states (and counties) in the conditions that are given higher priority for COVID-19 vaccination. For
example, some areas prioritize Down syndrome, cystic fibrosis, and type | diabetes, whereas other areas do not.®2 Moreover, some states
prioritize vaccination to individuals with two or more CDC conditions, since there is stronger evidence to suggest that these patients
will experience a more severe case of COVID-19 disease.* This variation has contributed to the challenges and confusion experienced
by individuals with risk factors for severe COVID-19 illness in their attempt to receive the vaccine.

 

Estimating the prevalence of these risk factors in adolescents and young adults will (1) assist states,
public health departments, Medicaid programs, health plans, hospitals, and other health care entities
with vaccine allocation and administration; and (2) help ensure that the most vulnerable adolescents
and young adults receive the health care services and supports needed to optimize their health and
well-being throughout the pandemic.

 

Importance of Population Assessment of Risk Factors for
Severe COVID-19 Illness in Children and Youth

Identifying CYSHCN with risk factors for severe COVID-19 illness is paramount to assist strategic planning efforts for vaccine distribution.
Estimating the prevalence of these risk factors in adolescents and young adults will (1) assist states, public health departments, Med-
icaid programs, health plans, hospitals, and other health care entities with vaccine allocation and administration; and (2) help ensure
that the most vulnerable adolescents and young adults receive the health care services and supports needed to optimize their health
and well-being throughout the pandemic.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 4
 

Health Care Claims and Risk Factors for
Severe COVID-19 Illness

Health care claims are positioned to help identify health conditions that have been distinguished as risk factors for severe COVID-19
illness. A health care claim is the charge that health care providers and entities submit to payers for payment of health services deliv-
ered to a patient. These claims can include International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
diagnosis codes. The diagnosis codes contain valuable information on acute and chronic health conditions that patients experience.
Most CDC conditions that are associated with severe COVID-19 illness can be distinguished with ICD-10-CM diagnosis codes.

Development and Testing of an Approach to Assess Risk
Factors for Severe COVID-19 Illness Using Health Care Claims

We applied the Agency for Healthcare Research and Quality’s open-source Chronic Condition Indicator (CCI) and Clinical Classification
System (CCS) to match ICD-10-CM diagnosis codes with the CDC risk factors for severe COVID-19 illness (ICD diagnosis codes available
upon request to the study team). CCI distinguishes chronic from non-chronic health conditions and CCS categorizes the conditions into
a distinct diagnosis and affected body system.***° Some CDC conditions are a single diagnosis (e.g., type 1 diabetes mellitus) whereas
others encompass an entire organ system (e.g., neurologic chronic conditions).

We tested this system with two analytical cohorts of adolescents and young adults age 12-to-21 years. Cohort one included 1,820,176
enrollees in 12 U.S. state Medicaid programs from January 1 to December 31, 2018, that contributed data to the IBM Watson Market-
scan Medicaid Database. Cohort two included 103,906 patients who received outpatient, inpatient, or emergency department care
between January 1 and December 31, 2018, in a tertiary, freestanding U.S. children’s hospital. We arrayed claims across patients’
health care encounters (e.g., inpatient, outpatient, emergency department) to identify those with a CDC condition. The conditions
were categorized by CDC tiers of evidence based on study designs as well as by the number of conditions.

Prevalence of Risk Factors for Severe COVID-19 Illness in
Adolescents and Young Adults

The prevalence of CDC conditions associated with severe COVID-19 illness was 21.3% and 31.8% in the Medicaid and children’s
hospital cohorts, respectively (Table 1). Prevalence was slightly higher in individuals age 16 years and older vs. 12-to-15 years [24.8%
vs. 17.6% (Medicaid); 33.5% vs. 29.9% (children’s hospital)]. Of individuals with a condition, most had only one of them (72.4% Medicaid;
67.9% children’s hospital). The prevalence of conditions with the strongest evidence of severe COVID-19 illness was 7.8% (Medicaid)
and 7.2% (children’s hospital). Across both cohorts, the most common conditions were asthma (8.7%, Medicaid; 8.1% children’s
hospital) and neurologic condition (2.6%, Medicaid; 9.4% children’s hospital) (Table 2). Epilepsy and cerebral palsy were among the
most common neurologic conditions in both cohorts.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 5
 

Among pediatric adolescents and young adults, one in five in the Medicaid cohort and one in three in the
children’s hospital cohort had an underlying CDC condition associated with severe COVID-19 illness.

 

Interpretation and Implications of Results

Among pediatric adolescents and young adults, one in five in the Medicaid cohort and one in three in the children’s hospital cohort
had an underlying CDC condition associated with severe COVID-19 illness. Compared with existing literature, the most common types
of risk factors were different in adolescents and young adults (i.e., asthma and neurologic conditions) than in older adults (i.e., hyper-
tension and obesity).*” And, older adults have a higher prevalence of multiple risk factors.?

The current work has several limitations to consider. Health conditions reported by patients and also abstracted from health records
are more accurate than conditions identified with health care claims. There is variation in sensitivity and specificity across ICD-10-CM
diagnosis codes. Some of the codes (e.g., smoking and obesity) may be underused more than others, therefore generating lower
estimates of prevalence. The National Health and Nutrition Examination Survey reports that the prevalence of obesity and severe
obesity in children are 19% and 6%, respectively, which are much higher than our estimates using ICD-10-CM diagnosis codes.®* We
did not measure the COVID-19 risk factor for chronic use of a corticosteroid or immunosuppressive medication. There is collinearity of
this use with multiple other COVID-19 risk factors, including cancer, digestive, immunologic, and respiratory conditions. New evidence
is emerging on risk factors for severe COVID-19 illness, which could necessitate revision of the CDC condition lists and therefore lead
to new findings on prevalence. New findings on vaccine safety and effectiveness in younger children may warrant replication of the
current work in additional pediatric populations.

 

Medicaid programs may use the prevalence findings to advocate for vaccination in vulnerable patient
populations, especially CYSHCN with economic and/or disability challenges.

 

Conclusions

Although the impact of COVID-19 illness has been less in children and youth than adults, most risk factors for severe COVID-19 illness
apply to CYSHCN. The prevalence of these risk factors is high in adolescents and young adults who are enrolled in Medicaid and who
use children’s hospitals. Although review of individuals’ health histories, as well as health records, is warranted for verification, use
of health care claims should be considered with screening efforts to identify children and youth across populations with underlying
conditions associated with severe COVID-19 illness.

The findings from the current work can be used by U.S. states, hospitals, and other health care entities for preparation of vaccination in
younger individuals. Medicaid programs may use the prevalence findings to advocate for vaccination in vulnerable patient populations,
especially CYSHCN with economic and/or disability challenges. In their role as regional referral centers that span large geographic

catchment areas children’s hospitals may be positioned to enable vaccination uptake in adolescents and young adults with risk factors.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 6
 

Table 1.

Prevalence of Risk Factors for Severe COVID-19 Illness in
Adolescents and Young Adults.

Medicaid Cohort

Children’s Hospital Cohort

 

Attribute
All
(N=1,820,176)
COVID-19 Risk Factor
Any 387,331 (21.3%)
One 280,436 (15.4%)
Two or more 106,895 (5.9%)
Evidence Category’

Meta-analysis/
Systematic
Review

Cohort, Case-
Control, or
Cross-Sectional
Studies

Case Series, Case
Reports or, if
Other Study
Design, Sample
Size is Small

Mixed Evidence

 

141,379 (7.8%)

160,237 (8.8%)

1,352 (0.1%)

182,443 (10.0%)

 

12-to-15 years
(N=891,720)

157,238 (17.6%)

127,921 (14.3%)

29,317 (3.3%)

31,502 (3.5%)

56,484 (6.3%)

565 (0.1%)

94,499 (10.6%)

 

16 years and
older
(N=928,456)

230,093 (24.8%)

152,515 (16.4%)

77,578 (8.4%)

109,877 (11.8%)

103,753 (11.2%)

787 (0.1%)

87,944 (9.5%)

 

All
(N=103,472)

33,072 (31.8%)

22,444 (21.6%)

10,628 (10.2%)

7,435 (7.2%)

23,339 (22.5%)

375 (0.4%)

11,541 (11.1%)

 

12-to-15 years
(N=48,205)

14,394 (29.9%)

10,084 (21.0%)

4,310 (9.0%)

2,679 (5.6%)

10,136 (21.1%)

139 (0.3%)

5,160 (10.7%)

‘Informed by the Centers for Disease Control and Prevention (CDC) study design categories for existing evidence:

* Meta-analysis/systematic review: Defined as having a significant association in at least one meta-analysis or systematic review.

 

16 years and
older
(N=55,267)

18,678 (33.5%)

12,360 (22.2%)

6,318 (11.3%)

4,756 (8.5%)

13,203 (23.7%)

236 (0.4%)

6,381 (11.4%)

» Cohort, case-control, or cross-sectional studies: Defined as having an association in cohort, case-control or cross-sectional studies; may include
systematic review or meta-analysis that represents one condition in a larger group of conditions (for example, kidney transplant under the category
of solid organ or blood stem cell transplantation).

» Case series, case reports or, if other study design, the sample size is small (and no systematic review or meta-analysis were available to
review): Defined as having an association in one or more case series studies. If there are cohort or case-control studies, sample sizes were small.
Conditions included may be rare.

» Mixed evidence: Defined as having an association in at least one meta-analysis or systematic review and additional studies or reviews that reached
different conclusions about risk associated with a condition.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs
 

Table 2.

Types of Risk Factors for Severe COVID-19 Illness in
Adolescents and Young Adults.

 

Medicaid Cohort Children’s Hospital Cohort
Risk Factor?
16 years and 16 years and
All 12-to-15 years older All 12-to-15 years older

Asthma | 159,141 (8.7%) 87,622 (9.8%) 71,519 (7.7%) 8400 (8.1%) 4033 (8.4%) 4367 (7.8%)
Immune 4,325 (0.2%) 1,741 (0.2%) 2,584 (0.3%) 2,083 (2.0%) 884 (1.8%) 1,199 (2.2%)
Deficiencies
Hypertension 21,170 (1.2%) 5,722 (0.6%) 15,448 (1.7%) 1,510 (1.5%) 452 (0.9%) 1,058 (1.9%)
Liver Disease 5,860 (0.3%) 2,013 (0.2%) 3,847 (0.4%) 727 (0.7%) 257 (0.5%) 470 (0.8%)

Cystic Fibrosis 651 (0.0%) 290 (0.0%) 361 (0.0%) 232 (0.2%) TT (0.2%) 155 (0.3%)

Thalassemia 701 (0.0%) 275 (0.0%) 426 (0.0%) 143 (0.1%) 62 (0.1%) 81 (0.2%)

Children with

Certain Underlying | 40,932 (2.2%) 16,476 (1.8%) 24,456 (2.6%) 10,808 (10.4%) 4,514 (9.4%) 6,294 (11.3%)
Conditions?
Congenitalheart | 10,943 (0.6%) 5,248 (0.6%) 5,695 (0.6%) 7,571 (7.3%) 3,162 (6.6%) 4,409 (7.9%)
Hematologic | 23,918 (1.3%) 8,549 (1.0%) 15,369 (1.7%) 2,288 (2.2%) 848 (1.8%) 1,440 (2.6%)
Genetic/ | 5 592 (0.2%) 1,662 (0.2%) 1,630 (0.2%) 1,687 (1.6%) 832 (1.7%) 855 (1.5%)
chromosomal , ? ; ?
Feedingtube | 3,248 (0.2%) 1,477 (0.2%) 1,771 (0.2%) 811 (0.8%) 367 (0.8%) 444 (0.8%)
Congenital | 70 (0.1%) 779 (0.1%) 1,491 (0.2%) 718 (0.7%) 346 (0.7%) 372 (0.7%)
anomaly
Prematurity 146 (0.0%) 57 (0.0%) 89 (0.0%) 107 (0.1%) 58 (0.1%) 49 (0.1%)
Neurologic 9 ° 9 ° 5 °
Condition | 27980 (2.6%) 19,879 (2.2%) 28,101 (3.0%) 9,790 (9.4%) 4,378 (9.1%) 5,412 (9.7%)
Other Lung
Diseases? 25,660 (1.4%) 12,785 (1.4%) 12,875 (1.4%) 3,238 (3.1%) 1,651 (3.4%) 1,587 (2.9%)
Overweight’ | 31,432 (1.7%) 16,588 (1.9%) 14,844 (1.6%) 2,620 (2.5%) 1,171 (2.4%) 1,449 (2.6%)

 

 

 

 

 

 

(Table 2. Continued on next page)

 

Ce

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs
 

Medicaid Cohort Children’s Hospital Cohort

Risk Factor’

 

16 years and 16 years and
All 12-to-15 years older All 12-to-15 years older

Cohort, Case-Control, or Cross-Sectional Studies (Continued)

Substance Use [| 55 596 (3.3%) 11,543 (1.3%) 48,053 (5.2%) 1,182 (1.1%) 243 (0.5%) 939 (1.7%)
Disorders
Solid organ or
Blood Stem Cell 1,475 (0.1%) 571 (0.1%) 904 (0.1%) 578 (0.6%) 234 (0.5%) 344 (0.6%)
Transplantation
Down Syndrome 3,178 (0.2%) 1,417 (0.2%) 1,761 (0.2%) 551 (0.5%) 268 (0.6%) 283 (0.5%)
see cee 4,494 (0.2%) 1,751 (0.2%) 2,743 (0.3%) 227 (0.2%) 104 (0.2%) 123 (0.2%)
HIV 824 (0.0%) 154 (0.0%) 670 (0.1%) 36 (0.0%) 8 (0.0%) 28 (0.1%)

 

 

 

 

 

 

Meta-analysis/Systematic Review

 

 

 

 

Diabetes
0, 0, 0, 0, 0, 0,
Mellitus type 1 | 547 (0.5%) 3,438 (0.4%) 5,109 (0.6%) 1,712 (1.7%) 613 (1.3%) 1,099 (2.0%)
Chronic Kidney > ° ° > > °
Dicence, | 9787 (0.3%) 2,187 (0.2%) 3,600 (0.4%) 1,708 (1.6%) 781 (1.6%) 927 (1.7%)
Cancer | 3,873 (0.2%) 1,561 (0.2%) 2,312 (0.2%) 1,512 (1.5%) 593 (1.2%) 919 (1.7%)
Heart Conditions’ | _ 2,328 (0.1%) 740 (0.1%) 1,588 (0.2%) 1,220 (1.2%) 434 (0.9%) 786 (1.4%)
Obesity* | 13,235 (0.7%) 908 (0.1%) 12,327 (1.3%) 630 (0.6%) 33 (0.1%) 597 (1.1%)
y » >
Diabetes | 11 018 (0.6%) 3,253 (0.4%) 7,765 (0.8%) 512 (0.5%) 151 (0.3%) 361 (0.7%)
Mellitus Type 2 , -6% ' 4% ; 8% 5% 3% 7%,
Chronic Obstruc-
tive Pulmonary | _ 1,340 (0.1%) 523 (0.1%) 817 (0.1%) 303 (0.3%) 111 (0.2%) 192 (0.3%)
Disease
Cerebrovascular | 344 (0.1%) 1,378 (0.2%) 966 (0.1%) 257 (0.3%) 112 (0.2%) 145 (0.3%)
Disease
Smoking, current | 65 736 (3.6%) 18,859 (2.1%) 46,927 (5.1%) 255 (0.3%) 93 (0.2%) 162 (0.3%)
or former
Pregnancy | 52,586 (2.9%) 1,281 (0.1%) 51,305 (5.5%) 204 (0.2%) 30 (0.1%) 174 (0.3%)

 

 

1Risk factors were derived from sources reported by the Centers for Disease Control and Prevention (CDC):
(1) https: i i -with-medical-conditions.html; and

 

To avoid double counting of individuals, the conditions reported in this Pediatrics category are limited to those that have not been distinguished in
other areas of the CDC lists. For example, the CDC includes asthma in both the Pediatrics category and also in a stand-alone category for asthma (under
mixed evidence), All adolescents and young adults in the analytical cohort are represented in the stand-alone category for asthma.

3Other lung diseases include interstitial lung disease, pulmonary fibrosis, and pulmonary hypertension:
‘The CDC defines weight categories as the following: overweight (BMI >25 kg/m2 but <30 kg/m2) and obesity (BMI 230 kg/mz2).

5Heart conditions consist of heart failure, coronary artery disease, cardiomyopathies, pulmonary hypertension.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 9
 

References

1. COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/
covid-data/covidview/index.html. Published 2021. Updated March 12, 2021. Accessed March 1, 2021.

2. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem
Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. Jama. 2021;325(11):1074-1087.

3. COVID-19 Vaccine Distribution: The Process. US Department of Health and Human Services. https://www.hhs.gov/coronavirus/
covid-19-vaccines/distribution/index.html#allocation. Published 2020. Accessed February 13, 2021.

4. COVID-19 ACIP Vaccine Recommendations. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-
recs/vacc-specific/covid-19.html. Published 2020. Updated December 22, 2020. Accessed December, 23, 2020.

5. Klass P, Ratner AJ. Vaccinating Children against Covid-19 - The Lessons of Measles. The New England Journal of Medicine. 2021.

6. Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. The New England Journal of
Medicine. 2020;383(27):2603-2615.

7. Federation for Children with Special Needs. Federation for Children with Special Needs: Informing, Educating, Empowering Fami-

lies. http://fcsn.org/index.php. Accessed May 15, 2009.
8. Pfizer and BioNTech requested the F.D.A.’s authorization to use their vaccine in 12- to 15-year-olds. New York Times. https://www.
nytimes.com/2021/04/09/world/pfizer-covid-vaccine-young-teens.html. Published April 9th, 2021. Accessed April 11th, 2021.

9. Study to Describe the Safety, Tolerability, Immunogenicity, and Efficacy of RNA Vaccine Candidates Against COVID-19 in Healthy
Individuals. Pfizer BioNTech SE. https:
er&draw=2&rank=5. Published 2020. Updated February 10, 2021. Accessed February 12, 2021.

 

10. Stone BL, Murphy NA, Mundorff MB, Parker HB, Peterson PR, Srivastava R. Children with chronic complex medical illnesses: Is inpa-
tient care family-centered? Journal of pediatric rehabilitation medicine. 2008;1(3):237-243.

11.WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination. World Health Organization. https://www.
who.int/news/item/16-09-2020-who-sage-values-framework-for-the-allocation-and-prioritization-of-covid-19-vaccination.

 

Published 2020, Accessed February 10th, 2021.

12. People with Certain Medical Conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/
need-extra-precautions/people-with-medical-conditions.html. Published 2020. Updated March 29, 2021. Accessed April 2, 2021.

13. Scientific Evidence for Conditions that Increase Risk of Severe Illness. Centers for Disease Control and Prevention. https://www.cdc.

gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html. Published 2020. Updated March 29, 2021. Accessed
March 29, 2021.

14. State Plans for Vaccinating their Populations against COVID-19. Centers for Disease Control and Prevention and the US Dept. of
Health and Human Services. https://www.nash i . Published
2021. Accessed March 16, 2021.

 

15. Ivory D, Harmon A. How America’s Vaccine System Makes People With Health Problems Fight for a Place in Line. New York Times.
March 9, 2021, 2021.

16. State COVID-19 Vaccine Priority Populations. Kaiser Family Foundation. https://www.kff.org/other/state-indica-

 

tion%22,%22sort%22:%22asc%22%7D. Published 2021. Updated March 15, 2021. Accessed March 18, 2021.

 

17.Alsaied T, Aboulhosn JA, Cotts TB, et al. Coronavirus Disease 2019 (COVID-19) Pandemic Implications in Pediatric and Adult
Congenital Heart Disease. J Am Heart Assoc. 2020;9(12):e017224.

18. Sanna G, Serrau G, Bassareo PP, Neroni P, Fanos V, Marcialis MA. Children’s heart and COVID-19: Up-to-date evidence in the form of a
systematic review. Eur J Pediatr. 2020;179(7):1079-1087.

 

Prevalence of Risk Factors for Severe COVID-19 Disease: Implications for Children and Youth with Special Health Care Needs 10
 

19. Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019
(COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. 2020;174(9):868-873.

20. Sabatino J, Ferrero P, Chessa M, et al. COVID-19 and Congenital Heart Disease: Results from a Nationwide Survey. J Clin Med.
2020;9(6).

21. Bellino S, Punzo O, Rota MC, et al. COVID-19 Disease Severity Risk Factors for Pediatric Patients in Italy. Pediatrics. 2020;146(4).
22.Parri N, Lenge M, Buonsenso D. Children with Covid-19 in Pediatric Emergency Departments in Italy. N Engl J Med. 2020;383(2):187-190.

23.DeBiasi RL, Song X, Delaney M, et al. Severe Coronavirus Disease-2019 in Children and Young Adults in the Washington, DC,
Metropolitan Region. J Pediatr. 2020;223:199-203.e191.

24. Chao JY, Derespina KR, Herold BC, et al. Clinical Characteristics and Outcomes of Hospitalized and Critically Ill Children and
Adolescents with Coronavirus Disease 2019 at a Tertiary Care Medical Center in New York City. J Pediatr. 2020;223:14-19.e12.

25.Kim L, Whitaker M, O’Halloran A, et al. Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with
Laboratory-Confirmed COVID-19 - COVID-NET, 14 States, March 1-July 25, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1081-1088.

26. Gonzalez-Dambrauskas S, Vasquez-Hoyos P, Camporesi A, et al. Pediatric Critical Care and COVID-19. Pediatrics. 2020;146(3).

27. Gétzinger F, Santiago-Garcia B, Noguera-Julian A, et al. COVID-19 in children and adolescents in Europe: a multinational,
multicentre cohort study. Lancet Child Adolesc Health. 2020;4(9):653-661.

28. Zachariah P, Johnson CL, Halabi KC, et al. Epidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus
Disease 2019 (COVID-19) in a Children’s Hospital in New York City, New York. JAMA Pediatr. 2020;174(10):e202430.

29.Verma S, Lumba R, Dapul HM, et al. Characteristics of Hospitalized Children With SARS-CoV-2 in the New York City Metropolitan Area.
Hosp Pediatr. 2020.

30. Leon-Abarca JA. Obesity and immunodeficiencies are the main pre-existing conditions associated with mild to moderate COVID-19
in children. Pediatr Obes. 2020;15(12):e12713.

31. Oualha M, Bendavid M, Berteloot L, et al. Severe and fatal forms of COVID-19 in children. Arch Pediatr. 2020;27(5):235-238.

32. Heilbronner C, Berteloot L, Tremolieres P, et al. Patients with sickle cell disease and suspected COVID-19 in a paediatric intensive
care unit. Br J Haematol. 2020;190(1):e21-e24.

33. Burke BL, Robbins JM, Bird TM, Hobbs CA, Nesmith C, Tilford JM. Trends in hospitalizations for neonatal jaundice and kernicterus in
the United States, 1988-2005. Pediatrics. 2009;123(2):524-532.

34. Certain medical conditions for Phase 2 groups. Massachusetts Department of Public Health. https://www.mass.gov/info-details/
certain-medical-conditions-for-phase-2-groups. Published 2020. Accessed February 10, 2021.

35. Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of Children With Multiple Chronic Conditions to Pediatric
Hospitalizations in the United States: A Retrospective Cohort Analysis. Hosp Pediatr. 2017;7(7):365-372.

36. Chronic Condition Indicators for ICD-10-CM (beta version). Agency for Healthcare Research and Quality. https://www.hcup-us.ahrg.
gov/toolssoftware/chronic_icd10/chronic_icd10.jsp, Published 2020. Accessed December 15, 2020.

37. Pang R, Zhao J, Gan Z, et al. Evolution of COVID-19 in patients with autoimmune rheumatic diseases. Aging. 2020;12(23):
23427-23435,

38. Cheryl D. Fryar MSPH, Margaret D. Carroll MSPH, Joseph Afful MS, Surveys DoHaNE. Prevalence of overweight, obesity, and severe
obesity among children and adolescents aged 2-19 years: United States, 1963-1965 through 2017-2018. NCHS Health E-Stats.
Published 2020. Accessed March 23, 2021.

 

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