A multi-center observational study published in JAMA Pediatrics has identified associations between economic instability and adverse social conditions and an elevated risk of long COVID in school-aged children and adolescents. The research, drawing data from the federally funded RECOVER (Researching COVID to Enhance Recovery) Initiative, found that factors such as food insecurity, difficulty covering expenses, and high levels of discrimination correlated with a higher likelihood of prolonged SARS-CoV-2 symptoms in pediatric populations. Conversely, food security was linked to a reduced risk of developing long COVID.
Study Methodology
The study was conducted by investigators including those from Mass General Brigham. It utilized data from the RECOVER-Pediatrics study, recruiting participants from 52 sites across the United States. The research included 4,584 participants, comprising 903 children aged 6 to 11 years and 3,681 adolescents aged 12 to 17 years. All participants had a history of SARS-CoV-2 infection between 2022 and 2024.
Participant demographics included:
- 51% identified as male at birth.
- 54% were White non-Hispanic, and 25% were Hispanic, Latino, or Spanish.
- 59% were recruited from existing non–COVID-19 research or clinical cohorts.
- 53% had been infected prior to the widespread appearance of the Omicron variant.
- 39% of participants were fully vaccinated, and 37% were not eligible for vaccination.
- Caregivers, predominantly mothers (91%), provided data through long COVID symptom surveys.
Researchers analyzed 24 distinct social risk factors, categorizing them into five primary social determinants of health (SDOH) domains: economic stability, social and community context, caregiver education access and quality, neighborhood and built environment, and health care access and quality. Latent classes were used in regression models to examine the correlation between these domains and long COVID.
Key Findings
The analysis indicated that economic instability and adverse social and community circumstances were associated with an increased probability of developing long COVID in children and adolescents.
Specific associations included:
- Economic Instability: Participants in certain latent classes for economic stability showed unadjusted odds ratios (OR) for long COVID ranging from 2.96 to 2.52 in adjusted models. A combined analysis found a 57% higher risk of long COVID when considering economic instability characterized by difficulty covering expenses, poverty, receipt of government assistance, and food insecurity (Adjusted OR [AOR], 1.57; 95% CI, 1.18-2.09). Food security was identified as a protective factor.
- Social and Community Context: Participants in certain latent classes had unadjusted ORs of 3.13, with adjusted ORs ranging from 2.17 to 2.18. A combined analysis showed a 117% higher risk in contexts of high discrimination and low social support (AOR, 2.17; 95% CI, 1.77-2.66).
- Caregiver Education Access and Quality: Unadjusted OR of 1.44, with adjusted ORs ranging from 1.12 to 1.18.
- Health Care Access and Quality: Unadjusted OR of 2.09, with adjusted ORs ranging from 1.14 to 1.20 (adjusted risks were not significantly elevated in all models).
- Neighborhood and Built Environment: Unadjusted OR of 1.23, though adjusted risks were not significantly elevated.
Researchers hypothesize that healthy diets may contribute to a decrease in inflammation, which could offer protection against the development of long COVID symptoms.
Long COVID Characteristics
Long COVID is characterized by post-acute chronic symptoms that persist for at least three months. Common symptoms reported include loss of smell or taste, muscle or joint pain, fatigue, postexertional malaise, cognitive issues, and mood changes. The study authors propose that adverse social determinants of health may function as chronic stressors, potentially activating physiological responses that modulate cardiovascular activity, metabolic function, cognitive and emotional responses, and immune function.
Limitations and Implications
The study acknowledged several limitations, including potential selection bias, possible reduced enrollment by families more affected by SDOH, data collection primarily in English and Spanish, potential symptom miscategorization, and the absence of objective neighborhood-level data, which may affect the generalizability of the findings.
The authors concluded that economic instability and adverse social and community circumstances are associated with an increased probability of developing long COVID in children. This finding aligns with associations previously noted by the American Academy of Pediatrics in 2021. The study suggests that the combination of a viral infection and adverse social conditions may elevate risk, as chronic stress can lead to abnormal cortisol responses and immunological dysregulation. Public health interventions targeting social risk factors are considered important in efforts to mitigate the burden of long COVID in children. Further research is recommended to investigate whether addressing these identified adverse social factors can effectively reduce future disease risk.