Delta and Omicron killed far more children than flu ever does.

New data show that Covid-19 is far worse for children than seasonal influenza, as long suspected.

One of the talking points you hear from minimizers—and even some well-meaning amateurs looking for reassurance—is that Covid-19 isn’t a bad disease for children. At the center of the argument against Covid-19 mitigation measures (like masking and using tests to slow down spread) is the ghastly notion that we ought to have used children as human shields to protect the elderly—the idea being that we could have achieved herd immunity by allowing younger healthier people to get Covid.

This was doomed to fail, logistically, if not biologically. But ideologues argued for it anyway, and continue to, in part based on the aspirational belief that for children, Covid-19 is “less dangerous than many other harms, including influenza.” At the time that sentence was written (2020), it already seemed untrue to many of us on the front lines, based on what we had seen in adults, and on some pediatric data. But we really didn’t have the data to say that it was demonstrably false in children.

Now we do.

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[NOTE: In response to questions from readers and colleagues, I've edited the following paragraph. For transparency, you can see the changes below in bold. For a more complete follow up Inside Medicine on this and related issues, click here.]

Covid-19 killed (i.e., appeared on death certificates as either an underlying or contributing cause) 596 (around 600) children in 2021, which is far more than influenza ever kills in any given year. At the peak of Omicron, 158 (156; two more dead children have been added to the dataset) US children died of Covid-19 in a single month (January 2022). In the 10 years leading up to the Covid-19 pandemic, an average of 150 (120) children died of flu per year—and that was without masking or distancing.

These irrefutable figures, reported by the Centers for Disease Control and Prevention, reveal that last year, pediatric Covid-19 deaths were around 490% (500%) that of pediatric flu deaths in a typical 21st century season.

Make no mistake: Covid-19 is imparting an unusual burden on children compared to all other respiratory viruses. Since the turn of the century, there have been just 7 instances in which a respiratory virus killed (i.e., appeared on death certificates as an underlying or contributing cause) more than 65 children in a single month in the US. Influenza did it twice: once during the H1N1 pandemic of 2009 (which hit children harder than most realize) and once in March of 2003 (2009; typo). Covid-19 accounts for each of the other 5 instances, all of which occurred between just August 2021 and February (January; typo) 2022. In fact, of known respiratory viruses, only Covid-19 has ever killed more than 100 US children in a month (underlying cause) in the modern era (for as far back as I can track into the 1990s); it also did so as an underlying or contributing cause) three times during Delta and Omicron alone. Flu did that once (underlying or contributing cause), during the peak of the 2009-2010 H1N1 pandemic.

Yes, this reflects more contagious variants. Yes, this reflects decreased adherence to physical distancing as the pandemic has dragged on. That’s the point.

Covid-19 killed more than 100 US children in August 2021, September 2021, and January 2022. No other virus has done that in the modern era, including pandemic H1N1 (2009).

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And yet, you might have heard that influenza sometimes kills over 500 (and even 1,000) children per year. These figures are routinely trotted out by minimizers. Their source? Also the Centers for Disease Control and Prevention.

Wait, what?

Who is right about the number of children who die of flu each year, the CDC or the CDC?

The answer comes down to differences in how two separate centers at the CDC assesses things. The National Center for Health Statistics (NCHS) counts every single death that occurs in the United States every year. If 3 million people die, there are exactly 3 million “underlying” causes of death.

Meanwhile, the National Center for Immunization and Respiratory Diseases (NCIRD) estimates the overall burdens of a number of diseases. That means they consider both underlying and contributing causes of death. (They also correct for some other assumptions, some more plausible than others.) If a person dies primarily of terminal cancer, but influenza might have played a role in the timing of their death, the NCIRD might include that death in its annual assessment of influenza’s “burden of disease.”

The NCHS’s annual counted number of flu deaths, on the other hand, are highly accurate and are certainly the right comparator for Covid-19. Why? Because like all Covid-19 deaths, pediatric influenza deaths are mandated for reporting to public health officials, which the NCHS then reports. (Adult influenza deaths are not mandated for reporting, by the way.) Since we have both counted pediatric flu and Covid-19 deaths there is no need to estimate one and count the other; Doing so is actually epidemiologically inappropriate. To compare Covid-19 to influenza correctly, we have to do apples-to-apples comparisons, something I’ve advocated for in Scientific American and in medical journals.

Of course some unsavvy observers looking to downplay Covid (or maybe they are savvy) have been known to repeat CDC “facts” that in some years, around “650” children died of flu. As mentioned, this reflects NCIRD estimates which include deaths caused primarily by other diseases. If you’re going to cite 650 flu deaths (or similar numbers estimated by the NCIRD), you’d have to compare that to estimated (not counted) numbers of Covid-19 deaths using at least a semblance of the same methodology. But since that does not match the biases of the minimizers, they don’t do that.

That’s the key difference to understand. Estimating and counting deaths yield markedly different numbers. For example, the NCIRD estimated that flu was involved in the deaths of 1,161 children in the 2012-2013 season. During that period, the NCHS counted just 142 pediatric flu deaths—and remember, reporting is mandated. The NCIRD seems to think that pediatricians and local public health officials somehow failed to detect 89% of all pediatric flu deaths. That’s simply preposterous.

If you don’t agree, consider this. During the 2012-2013, the NCIRD estimate on pediatric flu deaths overshot the total number of children that the NCHS knows died from all respiratory illnesses combined (flu included) during that same time period. Oops.

If similar estimation methodologies were applied to Covid-19, the NCIRD would indeed report higher numbers of Covid-19 deaths than NCHS figures. And in fact, they have started to do so. The same modelers who think flu has killed over 500 kids in some years also think that Covid-19 hospitalized over 266,000 children from February 2020 to September 2021. By comparison, they usually estimate that around 40,000 children are hospitalized by influenza each season.

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Another way minimizers downplay pediatric Covid-19 is by comparing outcomes to geriatric adults. It’s true that older adults are orders of magnitude more likely to die of Covid-19 than children are. But in public health, you compare groups to themselves, if you want to understand a particular threat. You wouldn’t downplay pediatric cancer by noting that 80-year-olds die of cancer at a rate that is 541-times greater that of 8-year-olds (which, by the way, is true). You’d assess these groups on their own terms.

I’m not using these statistics to argue that schools ought to be closed again. But some are incorrectly using CDC statistics to argue that we should basically do nothing to protect children from Covid-19 (i.e. masks during surges, testing, etc) because of these misunderstood numbers. They are welcome to join a coherent conversation about how to keep schools open and safe. At the moment, though, they appear attached to the fantasy of keeping schools open without any mitigation, which ultimately backfires (schools close during outbreaks, if you haven’t noticed). I favor keeping schools open by keeping them safe.

Letting our guard down, I fear, is how we learned just how deadly this virus can be, especially for unvaccinated children. Comparing flu estimates to Covid counts has been weaponized to mislead people (parents) into a false sense of security. That has to end.

I’ve spent significant time working on this issue with CDC officials.

They tell me they get it.

They say they are working on clarifying much of what I’ve written here.

I hope they get around to it soon.

Pediatric Covid-19 vaccination rates remain woefully low. Understanding the real risk that Covid-19 poses to children is about the only thing I can think of that might convince parents to do the right thing.

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Acknowledgements: Dr. Esther Choo for the nudge to write this.