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Boletín médico del Hospital Infantil de México

Print version ISSN 1665-1146

Bol. Med. Hosp. Infant. Mex. vol.78 n.1 México Jan./Feb. 2021  Epub Mar 24, 2021 

Artículos de investigación

International heterogeneity in coronavirus disease 2019 pediatric mortality rates

Heterogeneidad internacional en las tasas de mortalidad pediátrica por COVID-19

Nadia González-García1 

América L. Miranda-Lora2 

Juan Garduño-Espinosa3 

Javier T. Granados-Riverón4 

Jorge F. Méndez-Galván5 

Jaime Nieto-Zermeño6 

Ma. Fernanda Castilla-Peón3  * 

1Laboratorio de Investigación en Neurociencias. Hospital Infantil de México Federico Gómez, Mexico City, Mexico

2Unidad de Investigación en Medicina Basada en Evidencias. Hospital Infantil de México Federico Gómez, Mexico City, Mexico

3Dirección de Investigación. Hospital Infantil de México Federico Gómez, Mexico City, Mexico

4Unidad de Investigación en Patogenésis Molecular. Hospital Infantil de México Federico Gómez, Mexico City, Mexico

5Unidad de Investigación en Enfermedades Emergentes. Hospital Infantil de México Federico Gómez, Mexico City, Mexico

6Dirección General. Hospital Infantil de México Federico Gómez, Mexico City, Mexico



Severe coronavirus disease 2019 (COVID-19) is infrequent in children and shows a mortality rate of around 0.08%. This study aims to explore international differences in the pediatric mortality rate.


We analyzed several countries with populations over 5 million that report disaggregated data of COVID-19 deaths by quinquennial or decennial age groups. Data were extracted from COVID-19 cases and deaths by age database, National Ministeries of Health, and the World Health Organization.


We included 23 countries in the analysis. Pediatric mortality varied from 0 to 12.1 deaths per million children of the corresponding age group, with the highest rate in Peru. In most countries, deaths were more frequent in the 0-4-year-old age group, except for Brazil. The pediatric/general COVID-19 mortality showed a great variation and ranged from 0% (Republic of Korea) to 10.4% (India). Pediatric and pediatric/general COVID mortality correlates strongly with 2018 neonatal mortality (r = 0.77, p < 0.001; and r = 0.88, p < 0.001, respectively), while shows a moderate or no correlation (r = 0.47, p = 0.02; and r = 0.19, p = 0.38, respectively) with COVID-19 mortality in the general population.


International heterogeneity in pediatric COVID-19 mortality importantly parallels historical neonatal mortality. Neonatal mortality is a well-known index of the quality of a country’s health system, which points to the importance of social determinants of health in pediatric COVID-19 mortality disparities. This issue should be further explored.

Key words Coronavirus disease 2019; Mortality; Infant; Child; Adolescent; Geographic location



La COVID-19 grave es poco frecuente en la infancia. El objetivo de este estudio fue explorar las diferencias en la tasa de mortalidad internacional por COVID-19 en la población pediátrica.


Se analizaron países con poblaciones superiores a 5 millones de habitantes que reporten muertes por COVID-19 con datos desglosados por grupos de edad quinquenales o decenales. Los datos se extrajeron de la base de datos COVerAge-DBs, de los ministerios nacionales de salud y de la Organización Mundial de la Salud.


Se incluyeron 23 países. La mortalidad pediátrica varió de 0 a 12.1 muertes por millón de personas del grupo de edad correspondiente, con la tasa más alta en Perú. En la mayoría de los países, las muertes fueron más frecuentes en el grupo de 0 a 4 años, excepto en Brasil. La mortalidad pediátrica/general por COVID-19 mostró una gran variación entre países y osciló entre el 0% (República de Corea) y el 10.4% (India). La mortalidad pediátrica y pediátrica/general por COVID-19 se correlaciona fuertemente con la mortalidad neonatal de 2018, mientras que tiene una moderada o nula correlación con la mortalidad por COVID-19 en la población general.


Existe una importante heterogeneidad internacional en la mortalidad pediátrica por COVID-19, que es paralela a la mortalidad neonatal histórica, la cual es un indicador de la calidad de los sistemas de salud y señala la importancia de los determinantes sociales de la salud en las disparidades de mortalidad pediátrica por COVID-19. Este tema debe explorarse a fondo.

Palabras clave COVID-19; Mortalidad; Niños; Adolescentes; Países


Since the first cases of coronavirus disease 2019 (COVID-19) appeared in Wuhan, China, morbidity and mortality by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been significant in countries in every continent. Mortality is mostly concentrated in advanced age groups and the adult population with ongoing comorbidities1-5. Children and adolescents constitute 2% and 9.5% of all reported cases in Europe and the USA. Severe COVID-19 is infrequent in children, so intensive care unit admissions regarding this age group have been reported to be about 2% and mortality rate about 0.08%6. Besides, preliminary evidence suggests that both ethnicity (Black and Hispanic) and age (under 1 month and early adolescence [10-14 years]) are associated with admission to a critical care unit. Moreover, children from low-income families or non-White ethnicities are more likely to test positive for SARS-CoV-2 than White children and high-income families7,8.

Although some countries have published COVID-19 epidemiologic data in the pediatric population, the comparison among different populations is scarce. COVID-19 mortality in the population under 18 years of age might be heterogeneous between countries with different incomes and ethnicities. This brief report aimed to explore international differences in the COVID-19 pediatric mortality rate.


We included information about countries with populations over 5 million that reported COVID-19 deaths disaggregated by quinquennial or decennial age groups. Data on confirmed COVID-19 death counts were consulted in the COVID-19 cases and deaths by age database (COVerAge-DB)9. COVerAge-DB collects age- and sex-specific cumulative cases, deaths, and tests from official reports from multiple countries worldwide and several subpopulations. Data from Argentina, Canada, Peru, and Mexico were consulted from the local ministries of health10-13. Data from countries disaggregated by decennial age groups were estimated according to the countries’ age structure available data.

For the computation of age-specific mortality rates, we obtained both total and quinquennial age groups estimated populations for 2018 or the latest available year from the United Nations Statistics Division web site14. Data for general COVID-19 mortality were extracted from the World Health Organization reports15.

In an exploratory analysis, we also calculated the Spearman’s correlation coefficient between pediatric COVID-19 mortality rates with general mortality rates and newborn mortality by any cause in 2018 (before the COVID-19 pandemic). STATA 13.0 ® software was used for the analysis.


We included 23 countries in the analysis. Table 1 shows the general mortality and pediatric mortality rates from COVID-19. Specifically, 63% of deaths in the < 15 years of age population at the time of the study occurred in India (n = 1,622). However, when adjusting the mortality per million people for this age group, the highest rates were observed in Latin American countries (Peru, Brazil, Ecuador, and Mexico). Peru showed the highest overall COVID-19 mortality rate followed by European countries (the United Kingdom, Spain, and Italy). Furthermore, the highest pediatric to general population ratio of COVID-19 mortality was identified in Asian countries (India, Indonesia, and the Philippines).

Table 1 COVID-19 mortality rates and neonatal mortality in 2018 by country 

Country COVID-19 Neonatal mortality (every cause) per 1000 alive newborns in 2018 Data collection date
Deaths in the population < 15 years of age Mortality rate in <15 years of age per million people Mortality rate in the general population per million people (23/08/20) Pediatric/general mortality rate ratio (%)
Peru 94 12.1 852 1.4 7.3 09/08/2020
Brazilab 405 8.8 541 1.6 8.1 02/08/2020
Ecuadorb 25 5.5 367 1.5 7.2 13/08/2020
Mexico 169 5.1 472 1.5 7.5 18/08/2020
Indiaa 1622 4.35 42 10.4 22.7 05/08/2020
Chile 15 4.1 576 0.7 4.9 05/08/2020
Colombia 29 2.9 334 0.9 7.8 05/08/2020
Indonesiaab 88 1.3 25 5.2 12.7 05/05/2020
Philippinesac 40 1.2 29 4.3 13.5 05/08/2020
Argentinaa 13 1.1 153 0.7 6.4 10/08/2020
Spaina 5 0.8 616 0.1 1.7 21/05/2020
United States of Americaa 46 0.8 533 0.1 3.5 01/08/2020
United Kingdom 7 0.6 623 0.1 2.6 05/08/2020
Swedena 1 0.6 571 0.1 1.5 05/08/2020
Italy 4 0.6 586 0.1 2 28/07/2020
France 4 0.35 454 0.1 2.54 12/07/2020
Canadaa 1 0.1 245 0.1 3.4 26/08/2020
Germanya 1 0.1 111 0.1 2.2 05/08/2020
Australiaa 0 0 19 0 2.3 05/08/2020
Austria 0 0 83 0 2.1 05/08/2020
Finland 0 0 61 0 1 05/08/2020
Greece 0 0 22 0 2.6 05/08/2020
Republic of Korea 0 0 6 0 1.5 05/08/2020

aCountries that do not report data disaggregated by quinquennial age groups.

bThe latest population data were available in 2010.

cThe latest population data were available in 2015.

Table 2 shows COVID-19 pediatric mortality by quinquennial age groups. The highest mortality in children under 10 years old was observed in Peru, and the highest mortality in children > 10 years old was in Brazil.

Table 2 COVID-19 mortality rates by quinquennial age groups and country 

Country COVID-19
Population aged 0-4 years Population aged 5-9 years Population aged 10-14 years
Deaths Mortality rate (per million) Deaths Mortality rate (per million) Deaths Mortality rate (per million)
Peru 40 16.04 29 10.96 25 9.57
Indiaa 1519.1 13.47 20.5 0.16 82.2 0.62
Mexico 108 9.85 25 2.25 36 3.22
Ecuadorb 11 7.52 7 4.58 7 4.55
Chile 9 7.24 3 2.40 3 2.52
Colombia 15 4.94 9 2.70 5 1.38
Brazilab 38.2 2.77 103.8 6.93 263.1 15.33
Philippinesac 26 2.40 7 0.65 7 0.67
Indonesiaab 47.4 2.09 22.3 0.96 18.4 0.81
United States of Americaa 25.3 1.28 8.1 0.40 12.2 0.58
Argentinaa 3.5 0.94 3.5 0.94 5.5 1.56
Italy 2 0.82 2 0.82 0 0
United Kingdom 3 0.76 1 0.24 3 0.79
Swedena 0.4 0.66 0.6 0.98 0 0
Spaina 0.9 0.43 1.9 0.78 2.5 1.02
France 1 0.28 2 0.5 1 0.25
Germanya 1 0.26 0 0 0 0
Canadaa 0.25 0.13 0.25 0.12 0.25 0.13
Australia 0 0 0 0 0 0
Austria 0 0 0 0 0 0
Finland 0 0 0 0 0 0
Greece 0 0 0 0 0 0
Republic of Korea 0 0 0 0 0 0

aCountries that do not report data disaggregated by quinquennial age groups.

bThe latest population data were available in 2010.

cThe latest population data were available in 2015.

We found a significant correlation between both COVID-19 pediatric mortality and COVID-19 pediatric/general mortality ratio and neonatal mortality in 2018 (r = 0.77, p < 0.001; and r = 0.88, p < 0.001, respectively), while a moderate or no correlation was found with COVID-19 mortality in the general population (r = 0.47, p = 0.02; and r = 0.19, p = 0.38, respectively) (Table 3).

Table 3 Spearman correlation coefficient between COVID-19 pediatric mortality, COVID-19 general mortality, neonatal mortality in 2018, and COVID-19 pediatric/general mortality rate ratio 

COVID-19 mortality rate in < 15 years of age population COVID-19 mortality rate in the general population Neonatal mortality in 2018
COVID-19 mortality rate in <15 years of age population 0.47b 0.77a
COVID-19 mortality rate in general population 0.47b -0.03
COVID-19 pediatric/general mortality rate ratio 0.9a 0.19 0.88a

ap < 0.001;

bp < 0.05.


COVID-19 mortality in children is minimal in comparison to the adult population. However, we found significant heterogeneity between countries. Several factors should be explored to explain this variability. This report was elaborated with available data from different sources, and differences in reporting systems of epidemiological information may be accountable for some variation.

Remarkably, the highest pediatric mortality rates are among upper-middle-income countries in contrast with high-income countries (data for low- and lower-middle-income countries were not available). Similarly, high-income countries with high mortality rates in the general population showed low COVID-19 pediatric/general mortality rate ratio (adjusted for age).

In most countries, the pediatric population’s COVID-19 mortality rate is concentrated in the < 5-year-old population. Brazil has a disproportionately high mortality rate in adolescents, and the causes of this must be studied. In Mexico, about half of the deaths in the 0-4 age group are in infants < 1 year old. It is important to disaggregate data by age to estimate the share of child mortality, which corresponds to neonatal and infant mortality.

Child, infant, and neonatal mortality are known indicators of the quality of health-care systems16. It is noticeable that COVID-19 pediatric mortality and COVID-19 pediatric/general rate ratio are strongly correlated with historical basal neonatal mortality, while they are only moderately correlated with COVID-19 general mortality. These findings suggest an important role of social health determinants and the quality of health-care systems in discrepancies of COVID-19 pediatric mortality rates between countries. The relative importance of this set of factors over biological factors remains to be established.


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Ethical disclosures

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data. The authors declare that they have followed the protocols of their work center on patient data publication.

Right to privacy and informed consent. The authors declare that no patient data appear in this article.


Received: September 16, 2020; Accepted: October 03, 2020

* Correspondence: Ma. Fernanda Castilla-Peón E-mail:

Conflicts of interest

The authors declare no conflicts of interest.

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license