COVID-19 Diagnosis,Severity,and Long COVID Among U.S. Adolescents,National Health Interview Survey,2022

Abstract

Purpose

Understanding disparities in COVID-19 outcomes, overall and stratified by vaccination status, is important for developing targeted strategies to increase vaccination coverage and protect adolescents from COVID-19.

Design

The 2022 National Health Interview Survey (NHIS) is a cross-sectional nationally representative household survey of U.S. adults.

Setting

A probability sample of households in the U.S.

Sample

One child aged 12-17 years is randomly selected from each family in the household. A knowledgeable adult (eg, parent or guardian), responds on behalf of the child through an in-person interview (response rate = 49.9%).

Measures

Input measures-sociodemographic characteristics and COVID-19 vaccination status; output measures-ever had COVID-19, moderate/severe COVID-19, long COVID

Analysis

Prevalence of COVID-19 outcomes was assessed for adolescents aged 12-17 years. Factors associated with each COVID-19 outcome were assessed with multivariable logistic regression analyses.

Results

Conclusion

Targeted messaging to highlight the importance of early treatment, the harms of long COVID-19, and the benefits of vaccination in protecting against long-term effects may be necessary to ensure that all adolescents and their families are adequately protected.

Keywords

disparities COVID-19 outcomes adolescents long COVID severe COVID vaccination vaccine hesitancy vaccine confidence

Purpose

During the COVID-19 pandemic from January 2020 to May 2023, there were 6.9 million COVID-19 cases and 900 deaths among adolescents 12-17 years.¹ While adolescents with COVID-19 are usually asymptomatic or have mild COVID symptoms, some experience severe symptoms that require hospitalization or have long term health consequences. A major concern is long COVID, which is characterized among the general population by persisting symptoms following COVID-19 infection such as fatigue, sleep disturbance, concentration difficulties, loss of appetite, and muscle or joint pain.² However, data on long COVID among adolescents is limited, and as a result, the true incidence and risk of long COVID among adolescents remains uncertain.² Understanding more about disease severity and long COVID-19 among adolescents is critical for protecting this population from serious health outcomes.

Despite recommendations for adolescents aged 12-17 years to receive the COVID-19 vaccine starting in May 2021, coverage in this age group has been suboptimal.^3,4 Health provider data demonstrate that among 12-17 year old adolescents in the United States, only 72.2% received any COVID-19 vaccines, with 61.8% completing the primary series, and 7.8% receiving booster vaccines as of May 10, 2023.⁵ While vaccination has shown to be effective in protecting adolescents from COVID-19 infection and hospitalization,^6,7 receipt of all recommended COVID-19 vaccines varied by sociodemographic characteristics, with significant disparities by sex, race/ethnicity, region, and other factors.⁸ Possible factors contributing to non-vaccination may be access barriers or vaccine hesitancy, which is defined as the delay or refusal of vaccines despite availability of vaccination services.⁹ The goal of this study is to understand disparities in COVID-19 outcomes among adolescents aged 12-17 years, overall and stratified by vaccination status, in order to develop targeted strategies to increase vaccination coverage and protect adolescents from COVID-19.

Methods

Design/Sample

The National Health Interview Survey (NHIS) is an annual cross-sectional nationally representative household survey of U.S. adults conducted by the U.S. Census Bureau for the Center for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics.¹⁰ After a probability sample of households is selected, 1 child is randomly selected from each household. A knowledgeable adult, most often the parent or guardian of the child, responds on behalf of the child. Using the 2022 NHIS (response rate = 49.9%), we assessed data reported by adults who have an adolescent ages 12-17 years (n = 2758).¹¹ Per Emory University Institutional Review Board determination assessments, this study is not considered human subjects research.

Measures

COVID-19 diagnosis was defined as whether the adolescent was ever told by a doctor or other health professional that they had or likely had COVID-19. COVID-19 severity was categorized as moderate/severe if respondents stated that their coronavirus symptoms was moderate or severe when they were at their worst. Those who stated that they had no symptoms or mild symptoms were categorized as not having moderate/severe symptoms. Long COVID was categorized as having any symptoms lasting 3 months or longer that he/she did not have prior to having COVID-19. Vaccination status was determined by having at least 1 dose of a COVID-19 vaccination. Sociodemographic variables assessed for adolescents were the adolescent’s age, sex, race/ethnicity, poverty level, and region.

Analysis

Sociodemographic characteristics, COVID-19 vaccination status, and COVID-19 outcomes (COVID-19 diagnosis, moderate/severe COVID, long COVID) were assessed for adolescents aged 12-17 years. Multivariable regression analyses were conducted to assess factors that were associated with each COVID-19 outcome, and adjusted for age, sex, race/ethnicity, poverty level, region, and vaccination status. Prevalence differences were presented for the differences in COVID-19 outcomes between vaccinated and non-vaccinated adolescents for each sociodemographic characteristic. Analyses were conducted using appropriate sampling weights in STATA to account for complex sample survey design and to produce nationally representative estimates. All tests were two-tailed with the significance level set at α < .05.

Results

Among 2758 adolescents aged 12-17 years in 2022, 60.5% had received ≥1 dose of COVID-19 vaccine, 30.2% had ever been diagnosed by a doctor that they had COVID-19, 29.5% had moderate/severe COVID-19, and 6.2% had long COVID (Table 1). Adolescents who were vaccinated with ≥1 dose were less likely to be diagnosed with COVID-19 (adjusted odds ratio [aOR] = .79, 95% confidence interval [CI]: .65-.97) and less likely to have long COVID (aOR = .30, 95%CI: .16, .57). Furthermore, adolescents who were non-Hispanic (NH) Black were less likely to be diagnosed with COVID-19 (aOR = .61, 95%CI: .43, .88) compared to adolescents who were NH White.

Table 1.

Sociodemographic Characteristics and Factors Associated With COVID-19 Outcomes Among Adolescents 12-17 Years, National Health Interview Survey, United States, 2022.

	Overall	Bivariate analysis				Multivariable analysis
	Weighted percent N = 2758	Vaccinated N = 1767	Ever had COVID-19 N = 848	Moderate/severe symptoms N = 314	Long COVID N = 55	Ever had COVID-19	Moderate/severe	Long COVID
	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	aOR (95% CI)^a	aOR (95% CI)^a	aOR (95% CI)^a
Overall		60.5 (58.0, 63.0)	30.2 (28.1, 32.2)	29.5 (26.1, 32.9)	6.2 (4.4, 8.0)
Age
12-15 years	67.2 (65.2, 69.2)	57.3 (54.1, 60.4)	29.2 (26.7, 31.8)	27.2 (23.0, 31.3)	4.8 (2.7, 6.9)	Ref	Ref	Ref
16-17 years	32.8 (30.8, 34.8)	67.1 (63.3, 70.8)	32.1 (28.9, 35.4)	33.9 (28.4, 39.5)	8.5 (5.1, 11.9)	1.19 (.98, 1.45)	1.38 (1.00, 1.89)	2.27 (1.14, 4.53)
Child’s sex
Male	51.0 (48.6, 53.3)	60.2 (56.9, 63.5)	30.0 (27.2, 32.8)	26.6 (21.9, 31.4)	4.8 (2.6, 7.1)	Ref	Ref	Ref
Female	49.0 (46.7, 51.4)	60.8 (57.4, 64.1)	30.4 (27.5, 33.2)	32.4 (27.7, 37.0)	7.4 (4.5, 10.3)	1.02 (.84, 1.23)	1.32 (.96, 1.83)	1.66 (.84, 3.26)
Child’s Race/ethnicity
NH White	50.8 (48.1, 53.5)	57.0 (53.7, 60.3)	31.7 (28.7, 34.6)	30.8 (26.0, 35.5)	6.9 (4.2, 9.6)	Ref	Ref	Ref
NH Black	12.3 (10.6, 14.0)	58.8 (51.2, 66.4)	21.5 (16.1, 26.8)	34.0 (21.8, 46.2)	2.7 (.0, 7.0)^b	.61 (.43, .88)	1.16 (.65, 2.08)	.43 (.07, 2.57)
NH Multi/other	10.3 (8.9, 11.6)	75.3 (69.7, 80.9)	27.3 (22.3, 32.4)	24.1 (15.9, 32.4)	3.7 (.0, 7.7)^b	.86 (.64, 1.15)	.71 (.43, 1.15)	.64 (.19, 2.12)
Hispanic or latino	26.6 (24.1, 29.2)	62.2 (57.8, 66.5)	32.5 (28.3, 36.6)	27.3 (21.3, 33.3)	6.7 (3.3, 10.1)	1.07 (.83, 1.37)	.83 (.56, 1.23)	1.13 (.54, 2.36)
Child’s poverty level
At or above	86.0 (84.2, 87.8)	63.0 (60.4, 65.5)	30.6 (28.4, 32.7)	29.9 (26.3, 33.5)	6.0 (4.1, 7.8)	Ref	Ref	Ref
Below	14.0 (12.2, 15.8)	45.3 (38.4, 52.2)	27.7 (21.6, 33.8)	26.3 (16.7, 35.9)	7.8 (1.3, 14.2)	.83 (.59, 1.17)	.91 (.53, 1.55)	1.18 (.43, 3.23)
Region
Northeast	16.4 (14.5, 18.2)	69.1 (63.3, 75.0)	31.4 (26.2, 36.5)	28.3 (19.3, 37.4)	6.6 (1.8, 11.4)	Ref	Ref	Ref
Midwest	20.3 (18.2, 22.3)	58.0 (52.6, 63.3)	27.9 (23.1, 32.6)	32.9 (24.5, 41.4)	8.5 (4.1, 12.8)	.83 (.59, 1.17)	1.25 (.69, 2.27)	1.28 (.47, 3.54)
South	39.0 (36.4, 41.7)	52.4 (48.2, 56.6)	29.2 (26.3, 32.0)	28.9 (23.8, 33.9)	5.6 (2.8, 8.4)	.88 (.66, 1.18)	1.01 (.60, 1.72)	.76 (.29, 2.03)
West	24.3 (21.9, 26.8)	69.7 (65.1, 74.4)	32.9 (28.3, 37.4)	28.8 (22.2, 35.5)	5.1 (1.6, 8.6)	1.06 (.76, 1.47)	1.05 (.60, 1.84)	.82 (.27, 2.52)
Vaccinated
Yes	60.5 (58.0, 63.0)	100.0	28.3 (25.7, 30.9)	28.7 (24.5, 32.9)	3.6 (2.1, 5.2)	.79 (.65, .97)	.88 (.64, 1.23)	.30 (.16, .57)
No	39.5 (37.0, 42.0)	0.0	32.5 (29.2, 35.7)	30.6 (25.3, 36.0)	9.8 (6.0, 13.7)	Ref	Ref	Ref

Abbreviations: NH = Non-Hispanic, CI = confidence interval, aOR = adjusted odd ratio; ref = reference.

^aAdjusted for age, child’s sex, child’s race/ethnicity, child’s poverty level, region, and vaccination status.

^bEstimates are unstable due to RSE >30%.

There were also disparities in COVID-19 outcomes by vaccination status (Figure 1 and Table 2). For example, COVID-19 diagnosis was significantly lower among vaccinated compared to unvaccinated adolescents for those aged 12-15 (26.2% compared to 32.4%), those identifying as NH White (27.7% compared to 36.2%), those living at or above poverty level (28.6% compared to 33.3%), or those living in the Midwest (23.0% compared to 34.1%). Long COVID was also lower among vaccinated compared to unvaccinated adolescents for those aged 16-17 years (4.7% compared to 17.0%), females (3.4% compared to 13.8%), and those living at or above poverty level (3.3% compared to 10.2%).

Figure 1.

Distribution of COVID-19 outcomes among adolescents aged 12-17 years by COVID-19 vaccination status, National Health Interview Survey, United States, 2022.

Table 2.

Prevalence of COVID-19 Outcomes by Vaccination Status Among Adolescents 12-17 years, National Health Interview Survey, United States, 2022.

	Ever had COVID-19			Moderate/severe symptoms			Long COVID
	Vaccinated	Not vaccinated	Prevalence difference	Vaccinated	Not vaccinated	Prevalence difference	Vaccinated	Not vaccinated	Prevalence difference
	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)
Overall	28.3 (25.7, 30.9)	32.5 (29.2, 35.7)	4.2 (.0, 8.4)	28.7 (24.5, 32.9)	30.6 (25.3, 36.0)	1.9 (−4.9, 8.7)	3.6 (2.1, 5.2)	9.8 (6.0, 13.7)	6.2 (2.0, 10.4)
Age
12-15 years	26.2 (23.0, 29.4)	32.4 (28.5, 36.2)	6.2 (1.2, 11.2)	25.9 (20.8, 31.1)	28.8 (22.1, 35.5)	2.9 (−5.6, 11.4)	2.8 (.9, 4.7)	7.0 (3.1, 11.0)	4.2 (−.2, 8.6)
16-17 years	32.0 (27.9, 36.1)	32.7 (26.7, 38.6)	.7 (−6.5, 7.9)	32.9 (26.1, 39.7)	35.5 (25.5, 45.5)	2.6 (−9.5, 14.7)	4.7 (1.9, 7.5)	17.0 (8.1, 25.9)	12.3 (3.0, 21.6)
Child’s sex
Male	27.8 (24.3, 31.3)	32.8 (27.8, 37.8)	5.0 (−1.1, 11.1)	24.4 (18.8, 30.0)	29.4 (21.4, 37.4)	5.0 (−4.8, 14.8)	3.9 (1.4, 6.3)	5.8 (1.8, 9.7)	1.9 (−2.7, 6.5)
Female	28.8 (25.3, 32.4)	32.1 (27.4, 36.9)	3.3 (−2.6, 9.2)	33.0 (26.9, 39.0)	32.0 (24.7, 39.2)	−1.0 (−10.4, 8.4)	3.4 (1.4, 5.4)	13.8 (7.4, 20.2)	10.4 (3.7, 17.1)
Child’s Race/ethnicity
NH White	27.7 (24.1, 31.3)	36.2 (31.7, 40.7)	8.5 (2.7, 14.3)	32.8 (26.8, 38.8)	29.2 (22.2, 36.3)	−3.6 (−12.9, 5.7)	2.9 (.9, 4.9)^a	11.4 (6.1, 16.7)	8.5 (2.8, 14.2)
NH Black	24.3 (17.1, 31.5)	17.1 (8.7, 25.6)	−7.2 (−18.3, 3.9)	32.0 (17.4, 46.6)	35.5 (14.6, 56.3)	3.5 (−22.0, 29.0)	4.1 (.0, 10.9)^a	^a	^b
NH Multi/other	25.3 (19.5, 31.2)	33.7 (22.4, 45.0)	8.4 (−4.3, 21.1)	21.1 (12.0, 30.1)	32.2 (15.9, 48.4)	11.1 (−7.5, 29.7)	1.8 (.0, 4.4)^a	8.5 (0, 20.5)^a	6.7 (−3.8, 17.2)
Hispanic or latino	32.5 (27.1, 37.9)	31.9 (25.5, 38.2)	−.6 (−8.9, 7.7)	24.1 (17.4, 30.7)	31.9 (20.3, 43.5)	7.8 (−5.6, 21.2)	5.6 (2.0, 9.2)	9.1 (1.8, 16.4)^a	3.5 (−4.6, 11.6)
Child’s poverty level
At or above	28.6 (25.9, 31.3)	33.3 (29.7, 36.9)	4.7 (.2, 9.2)	28.8 (24.5, 33.1)	31.5 (25.6, 37.4)	2.7 (−4.6, 10.0)	3.3 (1.7, 4.8)	10.2 (6.0, 14.3)	6.9 (2.5, 11.3)
Below	25.8 (17.3, 34.3)	28.8 (20.4, 37.2)	3.0 (−9.0, 15.0)	27.7 (14.5, 40.8)	26.2 (11.5, 40.8)	−1.5 (−21.2, 18.2)	8.0 (.0, 16.5)^a	8.0 (.0, 17.7)	.0 (−12.1, 12.1)
Region
Northeast	29.4 (24.2, 34.7)	35.0 (23.8, 46.2)	5.6 (−6.8, 18.0)	30.2 (20.4, 40.0)	24.5 (8.4, 40.6)^a	−5.7 (−24.5, 13.1)	3.5 (.0, 7.1)^a	11.6 (.0, 23.8)^a	8.1 (−4.3, 20.5)
Midwest	23.0 (17.2, 28.8)	34.1 (26.5, 41.6)	11.1 (1.6, 20.6)	31.6 (21.0, 42.2)	35.4 (22.6, 48.3)	3.8 (−12.9, 20.5)	5.8 (.5, 11.0)^a	11.8 (4.7, 19.0)	6.0 (−2.9, 14.9)
South	28.1 (23.6, 32.6)	30.2 (26.2, 34.2)	2.1 (−3.9, 8.1)	28.0 (21.1, 34.8)	29.8 (22.4, 37.3)	1.8 (−8.3, 11.9)	2.7 (.6, 4.8)^a	9.1 (3.6, 14.5)	6.4 (.6, 12.2)
West	31.5 (26.3, 36.7)	34.6 (26.8, 42.3)	3.1 (−6.2, 12.4)	26.9 (19.0, 34.8)	31.8 (20.2, 43.5)	4.9 (−9.2, 19.0)	3.7 (.9, 6.5)^a	8.4 (.0, 17.4)^a	4.7 (−4.4, 13.8)

Abbreviations: NH = Non-Hispanic, CI = confidence intervals.

^aEstimates are unstable due to RSE >30%.

^bNo data available.

Discussion

Summary

This study found disparities in COVID-19 outcomes as well as a significant inverse association between vaccination and COVID-19 outcomes (ie, vaccination was associated with lower COVID-19 outcomes, specifically diagnosis and long COVID). Lower reports of COVID-19 diagnosis among NH Black adolescents compared to NH White adolescents may reflect disparities in access and health care resources for COVID-19 diagnosis in Black communities. Inequities in COVID-19 testing may increase the spread of COVID-19, which may result in severe illness for some people. Furthermore, this study found lower COVID-19 outcomes among vaccinated adolescents by sociodemographic characteristics, suggesting the opportunities for targeted vaccination promotion campaigns in these specific sub-populations.

These results also demonstrate that COVID-19 diagnosis and moderate/severe COVID were relatively common among adolescents, with 1 in 3 adolescents reporting these outcomes. Furthermore, a small number (6.2%) of adolescents had long COVID. However, COVID-19 vaccination coverage was less than optimal, with approximately 60% of adolescents who received any dose of vaccination in 2022, with disparities by age, sex, race/ethnicity, income, and region. These results also illustrate groups with greatest reduction in COVID-19 outcomes through vaccination, such as females, those who are NH White, live at or above poverty level, or live in the Midwest. These results suggest that more efforts are needed to prevent serious outcomes among adolescents, increase access to testing to reduce the transmission of disease, and increase uptake of COVID-19 vaccines among adolescents.

Limitations

The study is subject to a few limitations. First, although the NHIS is designed to be nationally representative of households in the U.S., it may not be representative of adolescents. Second, this is a cross-sectional study so causal inference cannot be determined. Third, COVID-19 vaccination coverage, diagnosis, severity, and long COVID was based on respondent report and were not verified by medical records, so may be subject to recall or social-desirability bias. However, prevalence of disease diagnosis and COVID-19 vaccination found in this study are consistent with provider-reported data.¹² Fourth, these estimates represent prevalence that was reported at one point in time during 2022, and may not be consistent with other studies reporting prevalence during specific periods in 2022. Finally, small sample sizes may have contributed to unstable estimates and prevented detection of significant results.

Significance

Despite these limitations, this study demonstrates disparities in COVID-19 outcomes among adolescents where efforts to diagnosis, treat, and mitigate the potential for severe adverse outcomes can protect adolescents from harmful health consequences of COVID-19. This is one of the largest studies on long COVID among a nationally representative sample of household with adolescents, and demonstrates areas where targeted messages and strategies can make the greatest impact in reducing disparities in COVID-19 outcomes and vaccination coverage. These findings reinforce the benefits of vaccination for protecting adolescents against COVID-19 outcomes, which is especially important as coverage has plateaued in this population.¹² Targeted messaging to highlight the importance of early treatment, the harms of long COVID-19, and the benefits of vaccination in protecting against long-term effects may be necessary to ensure that all adolescents and their families and communities are adequately protected.

So What?

What is already known on this topic?

While adolescents with COVID-19 are usually asymptomatic or have mild COVID symptoms, some experience severe symptoms that require hospitalization or have long term health consequences.

What does this article add?

One in 3 adolescents reported having a prior COVID-19 diagnosis and moderate/severe COVID, and 6.2% of adolescents had long COVID. COVID-19 vaccination was associated with lower COVID-19 prior diagnosis and long COVID, overall and by selected sociodemographic groups.

What are the implications for health promotion practice or research?

This study demonstrates disparities in COVID-19 outcomes among adolescents where efforts to diagnosis, treat, and mitigate the potential for severe adverse outcomes can protect adolescents from harmful health consequences of COVID-19. Targeted messaging to highlight the importance of early treatment, the harms of long COVID-19, and the benefits of vaccination in protecting against long-term effects may be necessary to ensure that all adolescents and their families and communities are adequately protected.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Robert Bednarczyk was supported by National Cancer Institute (NCI) grant number R37CA234119. The other authors received no external funding.

ORCID iD

Kimberly H. Nguyen

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