Association of Area Deprivation Index With Severity of COVID-19 in Pediatric Patients: A Multisite Study of Racially and Ethnically Diverse Children : The Pediatric Infectious Disease Journal

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Association of Area Deprivation Index With Severity of COVID-19 in Pediatric Patients: A Multisite Study of Racially and Ethnically Diverse Children

Acosta, Sebastian PhD*; Suresh, Srinivasan MD; Ettinger, Anna K. PhD; Savorgnan, Fabio MD*; Annapragada, Ananth PhD§; Kannikeswaran, Nirupama MD; Sethuraman, Usha MD

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The Pediatric Infectious Disease Journal 42(6):p e197-e200, June 2023. | DOI: 10.1097/INF.0000000000003888
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Socioeconomic factors drive a host of health-related outcomes and socioeconomic deprivation can set children on a trajectory of health inequities if experienced early in life.1 The area deprivation index (ADI) is a validated metric that ranks neighborhoods by socioeconomic disadvantage.2 The ADI is a factor-based composite measure of socioeconomic deprivation constructed from 17 variables in the domains of income, education, employment, and housing quality from the American Community Survey 5-year estimates aggregated to US Census block groups, proxies for neighborhoods. Recent studies in adults have reported neighborhood-level deprivation as a predictor of coronavirus disease 2019 (COVID-19) risk and outcomes.3,4

Children represent approximately 17% of all reported cases of COVID-19.5 and a fraction develops severe disease, including multisystem inflammatory syndrome in children (MIS-C).6 Previous studies have highlighted the role of demographic and physical characteristics such as age, race, ethnicity and body mass index for COVID-19 disease severity and outcomes in children.3,7,8 However, studies that adjusted for the deprivation level found comparable COVID-19 severity across various races and suggested socioeconomic status as a mediator of the association between race and hospitalization.3,7 For example, Savorgnan et al in a study of a large cohort of children in Texas, found an increase in odds of severe MIS-C by 21% for each decile increase in ADI.9 However, this study was limited due to being conducted in a single state and included only those COVID-19 patients with a diagnosis of MIS-C. Hence the study results are not generalizable to other populations and the entire range of severe COVID-19 infections.

Our study objectives were to determine the relationship of ADI with severity of COVID-19 in a large cohort of children evaluated in geographically distinct areas of the USA and to identify social and demographic risk factors correlated with severe illness.


Study Design and Sites

This was a prospective study of a sample of children who were evaluated for symptoms related to SARS-CoV-2 infection between March 29, 2021, and December 31, 2021, at 3 sites (A. Children’s Hospital of Michigan, B. UPMC Children’s Hospital of Pittsburgh, and C. Texas Children’s Hospital). Sites A and B are tertiary pediatric centers located in the Midwest and Northeast regions of the United States, respectively, while site C is a quaternary pediatric hospital located in the Southwest region of the United States. The study included children of age <18 years with SARS-CoV-2 infection.

Study Definitions and Measures

SARS-CoV-2 infection: Defined by a positive reverse transcription polymerase chain reaction (RT-PCR) test, serology or antigen test. The patients were categorized as having “severe” disease if they required noninvasive respiratory support including high flow oxygen >6 L, bilevel positive airway pressure (BiPAP), continuous positive airway pressure, or mechanical ventilation, and/or inotropic/vasoactive support, extracorporeal membrane oxygenation (ECMO) or if the infection resulted in death. Otherwise, the patients were categorized as having “mild” disease. The outcome variable is disease severity, and the explanatory variables are the ADI score which ranges from 1 to 100 at the national level, with higher values indicating higher deprivation, sex, age, race/ethnicity and weight status.

Study Data

Information on demographic data, final diagnosis and treatment given were entered into a database by trained research assistants. Clinical data were obtained from the electronic medical records of the participating sites. The reference distributions for race/ethnicity, sex, age and weight were obtained from the CDC database as the population-adjusted averages of Texas, Michigan and Pennsylvania.10 Using home addresses, the 9-digit postal codes were obtained through a secure application programming interface with the US Post Office. Subsequently, the 9-digit postal codes were linked to ADI scores using the 2020 version of the Neighborhood Atlas database.2 The postal codes and all personal identifiers were then removed from the working database to avoid sharing PHI data. In the combined multisite database, subjects were fully de-identified. The study was reviewed and approved by the Institutional Review Boards of all sites.

Statistical Analysis

Continuous variables were discretized by their median and interquartile range (IQR). Categorical variables were mapped to frequencies and proportions and compared by the Fisher exact test and the Binomial test. The association between multiple covariates and severity of disease was established using a multivariate logistic regression. All statistical analyses were conducted using the statsmodels v0.13.2 package in the Python 3.8.3 environment. A P value of <0.05 was considered statistically significant and all tests were 2-sided.


Data on a total of 3434 children were included in the final analysis. The median age of the cohort was 8.6 years (IQR: 2.0–14.4 years), 52% were recorded as male. The median ADI was 64 (IQR: 43–81). Of the total, two-thirds of the cohort (67%) had an ADI classification > US national median. See Figure 1 for a graphical comparison of the ADI and weight distributions of the cohort and the US general population. The demographics and ADI classification of this cohort as compared with the reference population of children are provided in Table 1. Our sample was significantly different from the reference 3-state population in age, race, weight and ADI distributions. There was a larger proportion of younger children (<6 years old), a smaller proportion of children with healthy weight, and a larger proportion of children lived in areas with a higher ADI score in our cohort compared with the reference population.

TABLE 1. - Comparison Between the Entire COVID-19 Pediatric Cohort and Reference Population in the United States, and Also Between “Mild” and “Severe” Subgroups
Variables Entire Cohort Reference, % Binomial Test, P Mild Severe Fisher’s Exact Test, P
Total 3434 (100%) n/a n/a 2926 (85%) 508 (15%) n/a
 Female 1664 (48%) 49 0.573 1434 (49%) 230 (45%) 0.124
 Male 1770 (52%) 51 0.573 1492 (51%) 278 (55%) 0.124
 <6 y 1411 (41%) 31 <0.001 1219 (42%) 192 (38%) 0.107
 6–12 y 764 (22%) 32 <0.001 669 (23%) 95 (19%) 0.038
 >12 y 1259 (37%) 37 0.448 1038 (35%) 221 (44%) <0.001
 Underweight 323 (9%) 5 <0.001 243 (8%) 80 (16%) <0.001
 Healthy weight 1878 (55%) 80 <0.001 1662 (57%) 216 (43%) <0.001
 Overweight 407 (12%) 10 <0.001 363 (12%) 44 (9%) 0.017
 Obese 826 (24%) 5 <0.001 658 (22%) 168 (33%) <0.001
 Low (≤ 50th) 1144 (33%) 50 <0.001 995 (34%) 149 (29%) 0.041
 High (> 50th) 2290 (67%) 50 <0.001 1931 (66%) 359 (71%) 0.041
 Hispanic 1572 (46%) 35 <0.001 1354 (46%) 218 (43%) 0.162
 Non-Hispanic White 823 (24%) 46 <0.001 706 (24%) 117 (23%) 0.613
 Non-Hispanic Black 817 (24%) 13 <0.001 682 (23%) 135 (27%) 0.114
 Non-Hispanic Asian 97 (3%) 5 <0.001 77 (3%) 20 (4%) 0.110
 Other/Unknown 125 (4%) n/a n/a 107 (4%) 18 (4%) 1.000
The reference in race/ethnicity, sex, age and weight distributions were obtained from the population-adjusted average of the study sites’ states (Texas, Michigan and Pennsylvania).
n/a indicates not applicable.

Comparison between the COVID19 pediatric cohort and the general population. Histograms of the cohort ADI (A) and age- and sex-adjusted weight (B) compared with the US national distributions as reference.

Five hundred eight children (15%) had severe disease. Based on univariable analysis, we found that children of age >12 years (P < 0.001), with underweight and obese status (P < 0.001), or high ADI score (P = 0.041) had a higher proportion of severe cases. A multivariable logistic regression revealed that non-Hispanic Asians in reference to non-Hispanic White (odds ratio [OR] = 1.77, P = 0.039), both underweight (OR = 2.51, P < 0.001) and obese (OR = 1.84, P < 0.001) in reference to healthy weight, ages >12 years in reference to 6–12 years (OR = 1.45, P = 0.006) and higher ADI (OR = 1.06 per each 10-point increase, P = 0.008) were independently associated with severe disease while also controlling for child sex. See details in Table 2.

TABLE 2. - Multivariable Logistic Regression of COVID-19 Severity (N = 3434)
Covariables Coef. OR (95% CI) P
Intercept −2.65 n/a <0.001
 Male (ref: female) 0.18 1.20 (0.99–1.45) 0.068
 Hispanic (ref: Non-Hispanic White) −0.13 0.88 (0.68–1.13) 0.300
 Non-Hispanic Black (ref: Non-Hispanic White) 0.09 1.09 (0.82–1.44) 0.542
 Non-Hispanic Asian (ref: Non-Hispanic White) 0.57 1.77 (1.03–3.03) 0.039
 Other/unknown (ref: Non-Hispanic White) −0.04 0.96 (0.56–1.66) 0.890
 0–6 y (ref: 6–12 y) 0.14 1.15 (0.88–1.51) 0.311
 12–18 y (ref: 6–12 y) 0.37 1.45 (1.12–1.89) 0.006
 Underweight (ref: healthy weight) 0.92 2.51 (1.87–3.35) <0.001
 Overweight (ref: healthy weight) −0.09 0.91 (0.64–1.29) 0.603
 Obese (ref: healthy weight) 0.61 1.84 (1.46–2.33) <0.001
 Ten-point increase in ADI score 0.06 1.06 (1.01–1.11) 0.008
CI indicates confidence interval; OR, odds ratio.


Our study highlights the impact of race and ethnicity, body habitus and social economic factors on severity of COVID-19 in children living in the Southwest, Midwest and Northeast regions of the United States. Overall, the study cohort of COVID-19 pediatric patients was found to be heavily skewed toward high disadvantage. Moreover, Non-Hispanic Asians, underweight and obese children and those living in areas with even higher deprivation index were significantly more likely to have severe disease.

Our findings are aligned with other related studies confirming that social constructs (socioeconomic status and race/ethnicity) have an impact on prevalence, hospitalization and death rates in COVID-19.3,4,8 In fact, our cohort contains a larger proportion of Hispanic and non-Hispanic Black subjects, smaller proportion of subjects with healthy weight, and higher ADI scores compared with the reference population (Table 1). Disease severity, ADI, race/ethnicity and weight status are mutually associated among the subjects in our cohort. Hence, to quantify the effect of ADI on disease severity, it is important to control for race/ethnicity and weight as covariables in the logistic regression analysis. Savorgnan et al studied 206 children with MIS-C in Texas and determined that Non-Hispanic Black race and high ADI to be associated with severe MIS-C.9 While our study had similar results about the influence of socioeconomic factors on severe disease, we found only non-Hispanic Asian race (in reference to non-Hispanic White) to be associated with severe disease. One of the reasons for this noted discrepancy could be the small number of non-Hispanic Asians in our cohort which may have impacted our results.

It is well known that overweight and obese status is a significant risk factor for the incidence and severity of COVID-19 in adult patients. See Wu et al11 and references therein. However, an additional interesting finding in our study is the association of underweight status with severe COVID-19 in pediatric patients. Previous studies in adults have reported this association.11,12 Stridsman et al in their study of a cohort of adults with chronic obstructive pulmonary disease from a Swedish registry found underweight status among others to be a predictor of severe COVID-19.12 Wu et al found that in adults, underweight was associated with a 2.85-fold higher risk of death secondary to COVID-19 after adjusting for potential confounders.11 Although the exact reasons for this association are unclear, we propose that poor nutritional status could result in impaired immune response thus making the host more vulnerable to severe disease.

Our study was limited to 3 large health centers with their satellites across 3 states only and hence may not be generalizable. While ADI is an acceptable indicator of social status, it does not provide granular information for each individual/family regarding social risks and determinants of health. Hence, it is possible that there are several other family-level factors that may exist which could not be captured by the ADI. Another limitation due to the nature of this retrospective study is the lack of a complete record of comorbidities and risk factors for the cohort of patients.


Race/ethnicity, underweight and obesity and high ADI levels are predictors of severe disease in pediatric COVID-19. Further large-scale studies are required to confirm our findings so that populations and social determinants of health can be targeted for appropriate interventions.


1. American Psychological Association. Children, youth, families & socioeconomic status. August 2022. [Online]. Available at: Accessed January 6, 2023.
2. Kind A, Buckingham W. Making neighborhood-disadvantage metrics accessible- the Neighborhood Atlas. N Engl J Med. 2018;378:2456–2458.
3. Adjei-Fremah S, Lara N, Anwar A, et al. The effects of race/ethnicity, age, and area deprivation index (ADI) on COVID-19 disease early dynamics [published online ahead of print February 15, 2022]. J Racial Ethn Health Disparities. doi: 10.1007/s40615-022-01238-1.
4. M KC, Oral E, Straif-Bourgeois S, et al. The effect of area deprivation on COVID-19 risk in Louisiana. PLoS One. 2020;15:e0243028.
5. CDC Data. Analytics and visualization task force, “COVID-19 case surveillance public use data,”. 2022. [Online]. Available at: Accessed January 6, 2023.
6. Lee EH, Kepler KL, Geevarughese A, et al. Race/ethnicity among children with COVID-19–associated multisystem inflammatory syndrome. JAMA Netw Open. 2020;3:e2030280–e2030280.
7. Gershengorn HB, Patel S, Shukla B, et al. Association of race and ethnicity with COVID-19 test positivity and hospitalization is mediated by socioeconomic factors. Ann Am Thorac Soc. 2021;18:1326–1334.
8. Muñoz-Price L, Nattinger A, Rivera F, et al. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open. 2020;3:e2021892.
9. Savorgnan F, Acosta S, Alali A, et al. Social and demographic disparities in the severity of multisystem inflammatory syndrome in children. Pediatr Infect Dis J. 2022;41:e256–e258.
10. CDC. “Percentile Data Files with LMS,” Centers for Disease Control and Prevention, [Online]. Available at: Accessed April 1, 2022.
11. Wu X, Li C, Chen S, et al. Association of body mass index with severity and mortality of COVID-19 pneumonia: a two-center, retrospective cohort study from Wuhan, China. Aging (Milano). 2021;13:7767–7780.
12. Stridsman C, Vanfleteren L, Konradsen J, et al. Predictors of severe COVID-19 in a registry-based Swedish cohort of patients with COPD. Eur Respir J. 2021;58:2101920.

COVID-19; socioeconomic; race; ethnicity; area deprivation index; SARS-CoV-2

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