Why the Coronavirus More Often Strikes Children of Color

One of the notable features of the new coronavirus, evident early in the pandemic, was that it largely spared children. Some become severely ill, but deaths have been few, compared to adults.

But people of color have been disproportionately affected by Covid-19, the illness caused by the coronavirus, and recent studies have renewed concern about the susceptibility of children in these communities.

They are infected at higher rates than white children, and hospitalized at rates five to eight times that of white children. Children of color make up the overwhelming majority of those who develop a life-threatening complication called multisystem inflammatory syndrome, or MIS-C.

Of more than 180,000 Americans who have died of Covid-19, fewer than 100 are children, according to the Centers for Disease Control and Prevention. But children of color comprise the majority of those who have died of Covid-19.

The deaths include 41 Hispanic children, 24 Black children, 19 white children, three Asian-American children, three American Indian/Alaska Native children, and two multiracial children.

The unique vulnerabilities of these youngsters are coming to light even as the number of infections in children is rising and schools and parents around the country are grappling with nettlesome decisions about reopening safely.

The susceptibility of minority children to the disease is not unique to the United States. Black children hospitalized in the United Kingdom were more likely than whites to be transferred to critical care and to develop MIS-C, according to a study published last week in the journal BMJ.

“Children don’t exist in a vacuum,” said Dr. Monika K. Goyal, a pediatric emergency medicine specialist at Children’s National Hospital in Washington.

Among 1,000 children tested for Covid-19 at a site in Washington in March and April, nearly half of the Hispanic children and nearly one-third of the Black children were positive for the coronavirus, Dr. Goyal found in a recent study.

“They live in homes where their parent or caregiver doesn’t have the luxury of telecommuting, so they are at increased risk of exposure,” she added. “They are also more likely to live in multigenerational households. It’s all connected.”

Poverty also is linked to a higher risk of infection, and Dr. Goyal’s research, published on Tuesday in the journal Pediatrics, found that children from low-income families were much more likely to become infected than those with the most affluent parents.

The higher infection rates appear to be driven by greater exposure to the virus, Dr. Goyal said: “There’s nothing to indicate that there’s some sort of genetic predisposition to Covid based on race or ethnicity.”

Dr. Yvonne Maldonado, a professor of pediatrics at Stanford, agreed: “I know exactly what’s happening to those kids. Their parents are frontline, blue-collar or essential workers.”

Dr. Maldonado said she had frequently treated adult patients with the coronavirus who said their partners or children were sick, as well.

Researchers at Harvard have documented higher infection rates in Massachusetts communities with high proportions of immigrants, high numbers of food service workers and high numbers of people living in large, shared households.

Immigrants may hesitate to seek medical care, and employees who work in the food service industry often lack adequate paid sick leave, said Jose Figueroa, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health.

“What you have is the perfect recipe for fast transmission of Covid-19 in the Latino community,” he said. “Working adults who keep going to work because they need to put food on the table and pay the rent, and who often have young children.”

While restaurant patrons worry about the distances between tables and wonder whether to dine outdoors, “someone is preparing the food in the back, and they don’t have the luxury of being outdoors,” Dr. Figueroa said. “They’re in small kitchens cooking the food, and even if they’re wearing masks, they’re often in small, confined spaces.”

The true number of children who have been infected with the coronavirus may not be known, as young children tend to have milder courses of the disease and have never been routinely tested in the United States.

A mother in the Bronx, who asked to be identified only as Darlene to protect her child’s privacy, said her son was sick for months during the spring peak of the coronavirus outbreak in New York City. But health providers in the Bronx deflected her repeated requests to have the 3-year-old tested in March and through much of April, because he did not have a fever and was not having difficulty breathing, she said.

When she managed to get him tested in April, the result was negative. But her son was lethargic, complained of a stomach ache, had persistent diarrhea and often woke up wailing in the middle of the night.

Ordinarily an active and playful toddler, he had difficulty walking and fell a number of times, Darlene said: “I knew something was wrong — this was not my baby.”

Finally, in June, as his symptoms were resolving, Darlene was able to take him to his regular doctor at Mount Sinai Hospital in Manhattan, who tested him for antibodies to the virus. The result was positive, indicating he had indeed been infected. (Other family members tested negative for antibodies).

Dr. Goyal’s study reported that Hispanic children were six times more likely to test positive for the coronavirus than white children who came to the testing site in Washington. Black children were twice as likely to test positive as white children.

Two other reports by the C.D.C. last month underscored the heightened risk of poor outcomes for children of color.

Hispanic children were at greatest risk of severe disease: they were hospitalized at a rate nearly eight times that of white children, according to the C.D.C. Black children were hospitalized at a rate five times that of white children.

The C.D.C. study, which looked at 576 children under the age of 18 who had been hospitalized in 14 states between March 1 and July 25, found that nearly half had at least one underlying health condition. The most common was obesity, followed by chronic lung disease and premature birth.

Among the hospitalized children whose race and ethnicity were known, nearly half were Hispanic, and 29 percent were Black. Hispanic and Black children also had higher rates of underlying health conditions: 45 percent and 29 percent, respectively. Among white children, 15 percent had underlying health problems.

Another C.D.C. paper looked at 570 children with MIS-C in 40 states, the District of Columbia and New York City, between March 2 and July 18. Of those whose race was known, only 13 percent were white; 40 percent were Hispanic, and 33 percent were Black.

Just under 3 percent were Asian, and about 10 percent were listed as “other” or multiracial. Fewer than 1 percent of the children were American Indian/Alaskan Native or Native Hawaiian/Pacific Islander.

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Two-thirds of the children had no pre-existing medical conditions before the onset of MIS-C, though the proportion of those who were obese was slightly higher than in the general population. The most common symptoms were abdominal pain, vomiting, a skin rash and diarrhea.

While children over all have been less severely affected by the disease, there was a 21 percent increase in confirmed infections among children between the second and third weeks of August, according to the American Academy of Pediatrics.

The academy estimates children represent 9.5 percent of all cases in states that have reported positive tests by age, with 476,439 confirmed infections in children, among the six million Covid-19 cases in the United States. (The definition of child varies from state to state, but is usually 18 and under, or under 18.)

Since the vast majority of children infected with the virus have a mild or asymptomatic illness, many cases may have been missed earlier this year, when testing was scarce and limited to the very ill, said Dr. Alefiyah Malbari, an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai in New York.

When parents called their pediatricians and said their children had symptoms, “Our line was, ‘This could be Covid — quarantine yourself as if you had Covid,’” Dr. Malbari said. “Even the playgrounds were closed, so it was easy to do.”

Now, with schools opening and testing more widely available, “we have to take these symptoms really, really seriously.”