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

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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 (Table). 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 (Figure 1). 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) (Figure 2).

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.

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

¹CDC 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.

References

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Abbreviations: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network; ICU = intensive care unit; IQR = interquartile range.
* Includes persons admitted to a hospital with an admission date between January 1, 2021 and March 31, 2021. Counties included in COVID-NET surveillance: California (Alameda, Contra Costa, and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson counties); Connecticut (Middlesex and New Haven counties); Georgia (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Montgomery, Prince George’s, Queen Anne’s, St. Mary’s, Somerset, Talbot, Washington, Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties); New Mexico (Bernalillo, Chaves, Doña Ana, Grant, Luna, San Juan, and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe, Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne, and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison, Morrow, Perry, Pickaway and Union counties); Oregon (Clackamas, Multnomah, and Washington counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner, Williamson, and Wilson counties); and Utah (Salt Lake County).
^† Data are missing for <5 percent of observations for all variables.
^§ If ethnicity was unknown, non-Hispanic ethnicity was assumed.
^¶ Includes non-Hispanic persons reported as other or multiple races.
** Unknown residence types are those which have not yet been ascertained from the medical chart but have not been determined to be missing.
^†† COVID-19-related symptoms included respiratory symptoms (congested/runny nose, cough, hemoptysis/bloody sputum, shortness of breath/respiratory distress, sore throat, upper respiratory infection, influenza-like illness, wheezing) and non-respiratory symptoms (abdominal pain, altered mental status/confusion, anosmia/decreased smell, chest pain, conjunctivitis, diarrhea, dysgeusia/decreased taste, fatigue, fever/chills, headache, muscle aches/myalgias, nausea/vomiting, rash, seizures). Symptoms are abstracted from the medical chart and might not be complete.
^§§ ICU admission and invasive mechanical ventilation are not mutually exclusive categories, and patients could have received both. Of the 31 patients whose primary reason for admission was not COVID-19-related but who were admitted to the ICU or received invasive mechanical intervention, nine (29.0%) were admitted because of trauma and 14 (45.2%) were admitted for a psychiatric admission requiring medical care, including suicide attempts or overdoses.
^¶¶ Defined as ≥1 of the following: chronic lung disease, chronic metabolic disease, blood disorder/hemoglobinopathy, cardiovascular disease, neurologic disorder, immunocompromised condition, renal disease, gastrointestinal/liver disease, rheumatologic/autoimmune/inflammatory condition, obesity, feeding tube dependency, wheelchair dependency, or pregnancy.
*** Obesity is defined as body mass index (kg/m²) ≥95th percentile for age and sex based on CDC growth charts among children, a discharge diagnosis of obesity indicated by International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) codes, or obesity is indicated as an underlying condition on the COVID-NET case report form for adolescents who were not pregnant at the time of admission.

FIGURE 1. Three-week moving average COVID-19–associated hospitalization rates* among children and adolescents aged <18 years, by age group — COVID-NET, 14 states,^† March 1, 2020–April 24, 2021

Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network.

* Number of patients with laboratory-confirmed COVID-19–associated hospitalizations per 100,000 population.

^† COVID-NET sites are in the following 14 states: California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah.

FIGURE 2. Cumulative rates for COVID-19–associated hospitalizations* compared with influenza-associated hospitalizations^† among adolescents aged 12–17 years, by surveillance week^§ — COVID-NET^¶ and FluSurv-NET,** 14 states,^†† 2017–2021^§§

Abbreviations: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network; FluSurv-NET = Influenza Hospitalization Surveillance Network.

* Number of patients with laboratory-confirmed COVID-19-associated hospitalizations per 100,000 population.

^† Number of patients with laboratory-confirmed influenza-associated hospitalizations per 100,000 population.

^§ Surveillance week is based on the epidemiologic week for disease reporting and lasts Sundays through Saturdays. MMWR week numbering is sequential beginning with 1 and incrementing with each week to a maximum of 52 or 53. The three influenza seasons had no surveillance week 53, so values from surveillance week 52 were imputed to surveillance week 53. https://wwwn.cdc.gov/nndss/document/MMWR_week_overview.pdf

^¶ COVID-NET is a population-based surveillance system of laboratory-confirmed COVID-19–associated hospitalizations in 99 counties across 14 states. COVID-19–associated hospitalizations among residents in a predefined surveillance catchment area who received a positive test for SARS-CoV-2 (the virus that causes COVID-19) during hospitalization or ≤14 days before admission are included in surveillance.

** FluSurv-NET is a population-based surveillance system of laboratory-confirmed influenza-associated hospitalizations in 81 counties across 13 states (for the period included) and is conducted annually during October 1–April 30. Influenza-associated hospitalizations among residents in a predefined surveillance catchment area who received a positive test for influenza during hospitalization or ≤14 days before admission are included in surveillance.

^†† COVID-NET and FluSurv-NET sites were in the following 14 states for the period shown: California, Colorado, Connecticut, Georgia, Iowa (COVID-NET only), Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah.

^§§ Cumulative COVID-19–associated hospitalization rates among adolescents aged 12–17 years during October 1, 2020–April 24, 2021, were compared with influenza-associated hospitalization rates in the same age group during October 1–April 30 across three seasons (2017–18, 2018–19, and 2019–20) using data from FluSurv-NET.