Study indicates an increased likelihood of COVID-19-associated hospitalization among children living in rural areas

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

In a recent study on the medRxiv* preprint server, researchers in the United States investigated characteristics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections related to pediatric hospitalizations.

Study: Younger and Rural Children are More Likely to be Hospitalized for SARS-CoV-2 Infections. Image Credit: GroundPicture/Shutterstock


COVID-19 has caused unprecedented morbidity and mortality across the globe. The continual evolution of SARS-CoV-2 has given rise to several variants, differing in their transmissibility, immune evasiveness, and virulence.

The risks of COVID-19 severity outcomes, such as hospitalizations and deaths, vary with the causative variant of concern (VOC).

Most studies assessing SARS-CoV-2 VOC-wise COVID-19 outcomes comprised adults, warranting further research on the impact of SARS-CoV-2 infections in the pediatric population. Previous studies reported mild COVID-19 among children.

On the contrary, in children, recent studies have indicated an increase in COVID-19 incidence and severity during the SARS-CoV-2 Omicron VOC wave.

About the study

In the present cross-sectional study, researchers investigated whether specific clinical and demographic factors would elevate the risk of hospitalization among SARS-CoV-2-infected children. They also evaluated if the differences in hospitalization risks were SARS-CoV-2 VOC-specific in the pediatric population.

SARS-CoV-2-infected children visiting the Arkansas children’s hospital emergency department or those hospitalized from 27 May 2020 to 28 April 2022 for COVID-19-associated diagnoses were recruited. This was based on the international classification of diseases, the tenth revision (ICD-10) codes, and the pediatric hospital information system (PHIS) database data.

The team compared different VOC dominant periods for the differences in hospitalization risks for patients with different clinical and demographic characteristics.

PHIS data included participants’ gender, age, ethnicity/race according to the equity race category (ERC) classification, residence according to the rural-urban commuting area (RUCA) codes, type of visit (observation, inpatient, or ED), intensive care unit (ICU) admissions, duration of stay, complex medical conditions, mortality, disposition, and diagnosis.

Multivariable logistic regression modeling was performed to calculate the odds ratios (OR) for characteristics that increased the probability of being hospitalized. Risk estimators are the VOC wave, age, sex, ERC-based ethnicity/race, RUCA-based urban/rural status, complex medical conditions, and the payor type.

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PHIS reports were cross-referenced with the infection prevention department data and the Arkansas University’s medical sciences department’s pediatric section on infectious diseases for multisystem inflammatory syndrome in children (MIS-C) data.

Cases were allocated to the VOC dominant at the time using sequencing data. The period between 27 May 2020 and 1 May 2021 was considered the pre-Delta VOC dominant period. The Delta dominant period was between 1 June 2021 and 15 November 2021. Finally, between 16 December 2021 and 31 March 2022 was considered the period of Omicron dominance.


In total, 2,410 COVID-19 cases visiting the emergency department, hospitalized, or kept under observation were identified, among whom the mean age was six years, and 662 (28%) were aged <1.0 years.

Among the participants, 1,141 (47%) were females, 2,019 individuals (84%) resided in urban regions, and 303 (13%) had complex medical conditions.

In total, 681, 673, and 970 pre-Delta VOC cases, Delta VOC cases, and Omicron VOC cases were analyzed, among whom 400 (17%) were hospitalized. Among the participants, 21% (n=142), 19% (n=130), and 12% (n=116) were hospitalized during pre-Delta VOC, Delta VOC, and Omicron VOC predominance, respectively.

The number of non-Hispanic Blacks during the corresponding waves was 35%, 31%, and 27%, respectively, and the proportions of Hispanics were 28%, 17%, and 25%, respectively.

The proportions of Whites in the pre-Delta, Delta, and Omicron waves were 33%, 43%, and 40%, respectively, and those of other ethnicities were five percent, ten percent, and nine percent, respectively.

Compared to children with Omicron VOC infections, those with pre-Delta VOC (odds ratio 2.20) and Delta VOC infections (OR 2.0) showed a 2.0-fold greater likelihood of hospitalization.

Infants aged <1.0 years were thrice as likely to be admitted to the hospital as those aged 5.0 to 14.0 years, irrespective of the SARS-CoV-2 VOC infection (OR 3.4).

Rural children had a 3.0-fold greater likelihood of being hospitalized across different COVID-19 waves than urban children (OR 2.7). The likelihood of hospitalization was greater among children having complex conditions 15-fold (OR 15).

Children hospitalized during pre-Delta VOC, Delta VOC, and Omicron VOC predominance had mean hospitalization durations of 0.9 days, 0.5 days, and 1.4 days, respectively.


Overall, the study findings showed that children diagnosed with pre-Delta VOC and Delta VOC infections were more likely to be hospitalized than children diagnosed with Omicron infections.

Rural and younger patients showed greater odds of hospitalization, irrespective of the VOC infection.

Lower rates of COVID-19 vaccination and greater distances from healthcare facilities may have impacted hospitalization rates.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:
  • Preliminary scientific report.

    Cantu, R. et al. (2023) "Younger and Rural Children are More Likely to be Hospitalized for SARS-CoV-2 Infections". medRxiv., doi: 10.1101/2023.03.29.23287924.

Posted in: Child Health News | Medical Science News | Medical Research News | Disease/Infection News | Healthcare News

Tags: Children, Coronavirus, Coronavirus Disease COVID-19, covid-19, Evolution, Healthcare, Hospital, Infectious Diseases, Intensive Care, International Classification of Diseases, Mortality, Omicron, Research, Respiratory, SARS, SARS-CoV-2, Severe Acute Respiratory, Severe Acute Respiratory Syndrome, Syndrome

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Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.

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