key: cord-0953489-bs9lwgbr
authors: Abrams, Elissa M; Greenhawt, Matthew; Shaker, Marcus; Pinto, Andrew D; Sinha, Ian; Singer, Alexander
title: The COVID-19 Pandemic: Adverse Effects on the Social Determinants of Health in Children and Families
date: 2021-10-23
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2021.10.022
sha: cf0cb6c144080f0cc8a7d123a3eed83d707f7174
doc_id: 953489
cord_uid: bs9lwgbr

OBJECTIVE: To describe the impact of social determinants on the experience of the COVID-19 pandemic within the pediatric population, how this impact may influence the long-term health and security of children, and what measures can be taken to ameliorate this impact moving forward. DATA SOURCES: Non-systematic review of relevant literature and news sources Study Selections: Relevant literature and news sources Results: There have been increases in housing insecurity and food insecurity during the pandemic, as well as global increases in poverty. Public policies such as school closures have had a disproportionate impact on those facing adverse social determinants. There has been a dramatic increase in reports of abuse-related injuries, and other injuries indicative of child abuse during the pandemic. In addition, there are disproportionate impacts of COVID-19 based on race and ethnicity within the United States. It is clear that children are facing more adverse determinants as a result of this pandemic, and that there are both short-term and long-term implications associated. For those living in poverty or with other adverse social determinants of health, the pandemic has made a bad situation worse. Ongoing studies are required to measure the impact of COVID-19 on those with adverse social determinants, in particular among children. CONCLUSION: Social determinants of health must be part of pandemic research priorities, public health and vaccination goals, and economic policy implementation. The impact of the COVID-19 pandemic has further served to shed a light on the broad disparities that exist within our society and their direct and indirect impact on health outcomes.

Dr. Matthew Greenhawt has received past support from the Agency for Healthcare Research and Quality; is an expert panel and coordinating committee member of the NIAID-sponsored Guidelines for Peanut Allergy Prevention; has served as a consultant for the Canadian Transportation Agency, Thermo Fisher, Intrommune, and Aimmune Therapeutics; is a member of physician/medical advisory boards for Aimmune Therapeutics, DBV Technologies, Sanofi/Genzyme, Glaxo Smith Kline, Genentech, Nutricia, Pfizer, Novartis, Kaléo Pharmaceutical, Nestlé, Aquestive, Allergy Therapeutics, Allergenis, Aravax, Prota, and Monsanto; is a member of the scientific advisory council for the National Peanut Board; has received honorarium for lectures from Thermo Fisher, Aimmune Therapeutics, DBV Technologies, Before Brands, multiple state allergy societies, the American College of Allergy Asthma and Immunology, the European Academy of Allergy and Clinical Immunology; is an associate editor for the Annals of Allergy, Asthma & Immunology; and is a member of the Joint Taskforce on Allergy Practice Parameters. Author Contribution: All authors have equally (1) made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafted the article or reviewed it critically for important intellectual content; (3) given final approval of the version to be published; and (4) agree to be accountable for all aspects of the work related to its accuracy or integrity.

Objective: To describe the impact of social determinants on the experience of the COVID-19 pandemic within the pediatric population, how this impact may influence the long-term health and security of children, and what measures can be taken to ameliorate this impact moving forward.

Data Sources: Non-systematic review of relevant literature and news sources Study Selections: Relevant literature and news sources Results: There have been increases in housing insecurity and food insecurity during the pandemic, as well as global increases in poverty. Public policies such as school closures have had a disproportionate impact on those facing adverse social determinants. There has been a dramatic increase in reports of abuse-related injuries, and other injuries indicative of child abuse during the pandemic. In addition, there are disproportionate impacts of COVID-19 based on race and ethnicity within the United States. It is clear that children are facing more adverse determinants as a result of this pandemic, and that there are both short-term and long-term implications associated. For those living in poverty or with other adverse social determinants of health, the pandemic has made a bad situation worse. Ongoing studies are required to measure the impact of COVID-19 on those with adverse social determinants, in particular among children.

Conclusion: Social determinants of health must be part of pandemic research priorities, public health and vaccination goals, and economic policy implementation. The impact of the COVID-19 pandemic has further served to shed a light on the broad disparities that exist within our society and their direct and indirect impact on health outcomes.

 Social determinants of health have helped contribute to the detrimental impact of COVID-19 on pediatric health, apart from direct disease manifestations  COVID-19 has affected black communities disproportionately, including higher infection and fatality rates, and lower vaccination rates  Households experiencing homelessness and housing insecurity as a result of the pandemic were associated with increased COVID-19 related morbidity and morbidity, secondary to reduced access to public health measures to reduce disease transmission  Food insecurity among children has risen dramatically as a result of the pandemic, influenced in part by reduced access to school lunches, fragility in the food supply chain, as well as rising food costs and risks of unemployment  Rates of extreme poverty (living on less than $1.90 per day) are anticipated to rise for the first time in 20 years. Poverty is a negative influence on child health, in particular chronic conditions and mental health.  Domestic violence, including child abuse and intimate partner violence, has increased during the pandemic, both of which are associated with long term adverse health outcomes in children 

Homelessness is a major health disparity facing children, and this poses general difficulties to maintaining optimal pediatric health. It may also worsen the ability for children to maintain control over chronic illnesses such as asthma or other allergic diseases. Epidemiologic studies have linked housing insecurity and poor housing conditions with worsening chronic conditions such as asthma, and with increased risk of respiratory infections that can precipitate asthma exacerbations. 4 Pest infestations including mouse infestation have also been linked broadly to pediatric asthma outcomes. 5 Pre-pandemic, more than 500,000 families have experienced homelessness in the US at some point over the last decade. 6 A fact often missed is that up to 59% of people experiencing homelessness are children, and in a one year period close to 5% of adolescents reported homelessness unaccompanied by an adult caregiver. 7, 8 There has been a significant increase in housing insecurity and homelessness during COVID-19. It has been estimated in the US that an additional 400,000 shelter beds are required to accommodate all families experiencing homelessness during the current pandemic. 9

This increase in housing insecurity in the US may have profound impacts on children. One such impact is the increased risk of COVID-19 disease spread among multigenerational families in overcrowded housing. In a Boston study of 408 individuals experiencing homelessness and living in a shelter, 147 (36%) had a positive SARS-CoV-2 PCR test. 10 Families experiencing homelessness are more difficult to track, contact trace, and treat and/or vaccinate for COVID-19

than the general population. 11 This higher risk of COVID-19 transmission and morbidity is attributed to a variety of factors. Families experiencing homelessness may have reduced access to public health measures to reduce COVID-19 transmission such as the ability to self-isolate and access hygiene supplies. 8, 11 Crowded living facilities such as shelters or campgrounds, especially those with communal kitchens and bathrooms, reduce the ability to physically distance. 8, 11 Families facing homelessness also have reduced access to healthcare and screening facilities, and are generally more mobile which makes contact tracing and medical treatment more challenging. 12, 13 Children experiencing homelessness and their families have higher rates of underlying medical comorbidities that put them at higher risk of infection in general, and have higher acuity as a result of these infections including being more likely to require Emergency Department (ED) care. 8, 14 This, in particular could be troublesome for children with asthma or who are immunocompromised.

Poor community housing conditions (such as overcrowding, or incomplete kitchen or plumbing facilities) impact up to 15% of US families, and can also influence COVID-19 outcomes. 15 A cross-sectional analysis of count-level data from the US Centers for Disease Control and Prevention (CDC) of 3135 US counties found that for each 5% increase in percent households with poor housing conditions, there was a 50% higher risk of COVID-19 incidence and a 42%

higher risk of COVID-19 mortality. 15 Families living in poverty are more likely to have jobs deemed essential, and are more likely to use public transportation. 16, 17 Mobility data from an anonymized sample of smartphone users demonstrated a strong and statistically significant gradient between neighbourhood income and physical distancing, associated with increased family employment outside of the home. 18 To some degree, -the ability to practice social distancing has become a social determinant of health during this crisis.‖ 8

Housing insecurity also has detrimental long-term impacts on the physical and psychological development of children. Children experiencing homelessness are at increased risk of lead poisoning, anemia, asthma, recurrent infections, poor dental hygiene and nutrition, educational/developmental delays and psychiatric comorbidities including depression and anxiety. 19, 20 While -an ounce of prevention is worth a pound of cure‖ with respect to children and housing insecurity, the current pandemic and resulting economic insecurity has exacerbated the challenges in addressing and mitigating the impact of homelessness among children in the US. 20 It is unclear what impact this has had regarding outcomes with respect to specific allergic diseases, in particular those that need more regular follow-up care that could be disrupted by housing insecurity issues.

Various measures have been proposed to address the impact of housing insecurity including a ban on evictions for failure to pay rent, meal programs in shelters that allow for physical distancing, increased numbers of beds within shelters, areas designed within shelters for isolation/quarantine and recovery, and drop-in sites in hotels and motels to increase capacity. 12, 21 Some municipalities have utilized existing infrastructure with increased capacity due to the pandemic to enable self-isolation and ideal physical distancing such as hotel rooms. In order to meaningfully impact the burden of housing insecurity further expansion of both temporary and permanent solutions are needed, so that children have a stable housing situation, and this does not disrupt the family's ability to manage any chronic disease, including asthma, that the child may have.

Food insecurity is defined by being unable to consistently access adequate and appropriate food, and impacted about 10% of US families prior to the COVID-19 pandemic. 22 Food insecurity disproportionately impacts specific populations, such as immigrant families, families headed by single women, families with lower healthy literacy, and Black or Hispanic families. 23 In 2018, the prevalence of food insecurity was significantly higher in Black (21.2%) and Hispanic (16.2%) households than in the general population (11.1%). 24 Estimates suggest that food insecurity in US households with children have doubled to tripled during the COVID-19 pandemic. 25, 26 As early as April 2020, it was reported that 2 in 5 households with pre-adolescent children were food insecure (unable to afford for all family members to have enough food to live healthy lives), and 50% of these households were actively experiencing food insecurity. 27, 28 There is significant and long-term morbidity associated with even brief periods of food insecurity during childhood. Specific to allergic conditions, food insecurity has been linked with an increased risk of asthma in school-aged children, and household poverty strengthens this association. Poor nutrition is also tied to other risk factors for respiratory illness. 26 For children with food allergy, food insecurity can be potentially dangerous as this may result in decreased access to allergen-safe foods for the child. 29 More broadly, children from food insecure households are at higher risk of developmental delay 30 and behavioral issues including anxiety and reduced social skills. 31 Food insecurity in childhood is associated with a reduced immune innate and adaptive immune response (which has the potential to increase risk of viral transmission), 32,33 and increased risk of hospitalization. 34 Longer-term food insecurity in childhood and adolescence is associated with many chronic diseases of adulthood including type 2 diabetes and cardiovascular disease. 35 School meals can comprise up to 70% of a child's daily nutrition needs, and it has been noted that meals eaten in schools are often healthier than those which are brought from home. 32 Some of these meals also help guarantee provision of an allergen-safe meal in food allergic children. 29 However, the dramatic increase in food insecurity during COVID-19 is not attributed to lack of school lunch programs alone (which may even further disproportionately affect food allergic and asthmatic children dependent on such programs), and broader conceptual and bidirectional models to explain the impact of COVID-19 on food insecurity have been developed. 38 For example, changes to the fragile food system (increased demand for food at home, disruptions to food supply), and structural factors (increased unemployment, reduced grocery store donations to food banks with increased panic purchasing, higher costs for food banks) contribute as well. 38 Of those who lost their jobs during the pandemic, 31% report food insecurity and 33% report eating less due to financial constraints. 39 It has been noted that already vulnerable populations are more likely to have both higher rates and more intense forms of food insecurity during COVID-19, which is predicted to persist long after the immediate effects of the pandemic have resolved. 38 There have been various solutions proposed to help address the issue of food insecurity among children, especially with respect to lack of access to the school lunch programs. One solution, which has been implemented in some states, involve -grab and go‖ meal sites, or meal deliveries to bus stops or homes. 32 However, it has been noted that this approach may not ensure equitable food distribution and may not access those at highest need or provide access to allergen-safe food that food allergic children require. 32 Another recommended approach is to adopt the USDA's summer feeding program structure within school districts. 32 Pediatricians and other primary care providers have a role in screening for food insecurity, and assisting with liaising families with federal nutritional assistance programs. 40

The World Bank has estimated that the global rate of extreme poverty (living on less than $1.90 per day) is expected to rise for the first time in over 20 years as a result of the COVID-19

pandemic. 41 Preliminary estimates are that an additional 88 to 115 million people will be categorized as living in extreme poverty, with the total rising to up to 150 million by the end of 2021. The US has the highest child poverty rate among all high-income countries (approximately 22%) with this level anticipated to rise during the current pandemic. 42 Close to 8 million Americans experienced poverty between the spring and fall of 2020, with close to 900,000 families filing for unemployment benefits in a single week in the fall. 43 Poverty is strongly associated with the risk of COVID-19 infection and adverse outcomes. A US study documented that counties with higher overall poverty had larger numbers of confirmed COVID-19 cases, and greater number of deaths attributed to COVID-19, than counties with lower poverty. 16 Another US study, inclusive of 158 counties in 10 major US cities, found that the death rate due to COVID-19 was 3.8 times higher among counties with more, versus less, poverty. 44 There are many potential contributors to this including: poor housing conditions, unemployment or employment in a field considered essential with greater exposure risk, use of public transportation, and lack of healthcare access (which may be a compounded risk for children with chronic disease). 16, 17 There is also a longer-term impact of poverty on childhood development and health. Poverty is associated with reduced educational attainment (with high school graduation rates less than 50%

in areas of the US with high poverty rates), and lower IQ (even after correcting for parental age, marital status, education and ethnicity). 42 Living in poverty increases the risk of childhood infection, chronic disease into adulthood, and mental health outcomes as well. 42 There are no economic stimulus packages within the US which have specifically targeted children directly. 37 While various relief packages such as the US Families First Coronavirus

Response Act and the US Coronavirus Aid, Relief and Economic Security Act may indirectly impact children, a focus specifically on the impact of poverty on long-term outcomes of children is absolutely essential. 37

Public policies such as school closures, while often essential to mitigate the spread of COVID-19, have a disproportionately negative impact those already facing other adverse social determinants. School closures have had a significant impact on school performance especially among vulnerable populations. Brown University projected, based on learning patterns of 5 million students, that school-aged children in the US started school in the fall having learned less than 50% of math skills and less than 70% of language art skills than they would have acquired with in-person learning last spring. 45 income or single income households, families in whom English is a second language, and families who don't have access to technology at home. 45 A recent editorial poignantly stated that -no credible scientist, learning expert, teacher or parent believes that children aged 5 to 10 years can meaningfully engage in online learning without considerable parental involvement, which many families with low incomes are unable to provide because parents must work outside the home.‖ 48 In some low income urban areas of the US, up to 30% of students were not participating in online classes in the spring, largely due to lack of virtual access at home. 37 In 2020, while 81% of adults with an income of over $75,000 per year use the internet, only 34% of those with an income of less than $30,000 per year use the internet. 49 Chronic absenteeism (missing more than 10% of the school year) disproportionately affects children living in poverty, a gap that has been further widened with COVID-19, and has been associated with poorer longterm educational outcomes, including higher school dropout rates. 37 For children dependent on school-based health programs for management of chronic diseases, school closures may critically risk reducing access to necessary care including school based asthma management programs. 50 The Organization for Economic Cooperation and Development (OECD) has estimated that school closures in the spring will result in about a 3% lower income for children impacted by the closures over their entire lifetime, but will be even more deeply felt by vulnerable children who will have larger learning losses, and therefore deeper losses in lifetime earnings 51 As described in a recent editorial, the impact of school closures on children living in poverty has been deemed a -social crisis in the making.‖ 47

Moving forward, it has been suggested that -future decisions regarding school closures during the pandemic should consider the association between educational disruption and decreased expected lifespan and give greater weight to the potential outcomes of school closure on children's health.‖ 46 In addition, decisions regarding school closures must also bear in mind providing support to lower income families, who are much more impacted by school closures.

Internationally, there has been a dramatic increase in reports of abuse-related head injuries, and other injuries indicative of child abuse, during the COVID-19 pandemic. Child maltreatment and abuse have been associated with a variety of long-term adverse health outcomes including psychological disorders (e.g., depression, anxiety disorder, eating disorders, post-traumatic stress disorder), high risk behaviors (e.g., smoking, alcohol abuse, unsafe sexual practices) and overall lower health status. 52 In the first month of the pandemic in the United Kingdom there was a more than 100-fold increase in admissions for suspected abusive head trauma in the United Kingdom. 53 In April 2020, reports of child abuse and maltreatment to the ChildHelp National Child Abuse Hotline in the US increased about 20% compared to the previous year. 54 Notably, these statistics may still reflect some degree of under-reporting of suspected abuse due to pandemic school closures and fewer child interactions with trusted adults outside the home. 55 Both the World Health Organization and UNICEF have identified school closures, unemployment, and social isolation (all of which have reduced usual sources of support for families) as contributing to an increased risk of child abuse. 56, 57 There has also been disruption in community-based services that support families during times of stress such as access to social workers, mental health care, and overall healthcare professionals. 55 In the US, approximately 20% of reports of abuse and neglect to child protective services are made by schools. 58 Physical distancing measures, while at times essential, have resulted in a distancing of children from adults most likely to be protective, such as their teachers and other family members. 55 School closures appear to be putting children at even higher risk than usual because a usual source of identification of abuse is not occurring. During the pandemic, as recently stated, -nobody's watching kids except the families…there may be abuse that hasn't been reported because nobody knows that it's happening.‖ 54

These same social factors also put children at higher risk of sexual exploitation online, bullying, and exposure to intimate partner violence (IPV). 53 transmission. 54 There have also been reductions in shelter personnel during the pandemic, and closures of shelter hotlines. 54 Loss of employment also makes it hard for those experiencing IPV to move out on their own. 54 Domestic violence has been termed -a pandemic within a pandemic‖ in the US, causing both short-term and long-term harm to the children involved. 60 Witnessing IPV has been shown to affect children's relationships with peers, dating partners, and long-term partners. 61 It has been recommended that given school closures, school educators should receive training in identifying children at risk in a distance-learning model and screen for home safety with virtual learning models. 58 Additionally, as in the past, health care providers can play a key role in identifying child maltreatment and supporting vulnerable families including screening for family stress, identifying children at risk, and recognizing signs of child maltreatment. 55 outcomes also drive asthma outcomes including the risk of exacerbations. 67 It has been stated that -racism, not race, drives inequity across the COVID-19 continuum‖ 68 , and what may have driven a disproportionate impact of COVID-19 on racialized communities is systemic racism that pre-dated the pandemic, but continued during it. Food insecurity disproportionately affects Black and Hispanic households. 38 Close to 80% of families experiencing homelessness identify as non-White. 8 African Americans have poorer access to care and can have more comorbid medical conditions which put them at higher risk. 69, 70 Structural racism (an understanding that racism is not just a result of personal prejudice but also compounded by policy and social norms) 71 and its impact on American neighbourhoods has led to housing areas that are overcrowded and underserviced. 72 A recent rapid review found evidence from three large observational studies of an association between race or ethnicity and socioeconomic deprivation and increased likelihood of COVID-19 infection and hospitalization. 73 The noted health disparities by race are not driven by genetic constructs but instead by structural and interpersonal racism. 74 As noted by the World Health Organization, -In societies marked by racial discrimination and exclusion, people's belonging to a marginalized racial/ethnic group affects every aspect of their status, opportunities and trajectory throughout the life-course.‖ 75

Mitigating racism and its impacts both direct and indirect on this pandemic is by no means a straightforward task. However, the first step in dealing with this contributor is first recognizing its influence and making a fulsome effort to prioritize strategies that promote equality rather than simply equity. The Centers for Disease Control and Prevention note that -Communityand faithbased organizations, employers, healthcare systems and providers, public health agencies, policy makers, and others all have a part in helping to promote fair access to health…[we must work together] to ensure that people have resources to maintain and manage their physical and mental health, including easy access to information, affordable testing, and medical and mental health care.‖ 76 However, community engagement is not enough and broader more just policy solutions are urgently needed.

Much remains to be learned about the impact of adverse social determinants of health on the long-term outcomes of children as a result of the COVID-19 pandemic. However, it is clear that children are facing more adverse determinants as a result of this pandemic, and that there are both short-term and long-term implications associated. For those living in poverty or with other adverse social determinants of health, the pandemic has made a bad situation worse. Ongoing studies are required to measure the impact of COVID-19 on those with adverse social determinants, in particular among children.

Past pandemics have taught us that those facing adverse determinants suffer the brunt of any long-term impact. 13, 77 Moving forward, social determinants of health must be part of pandemic research priorities, public health and vaccination goals, and economic policy implementation.

The impact of the COVID-19 pandemic has further served to shed a light on the broad disparities that exist within our society and their direct and indirect impact on health outcomes.

Nevertheless, there also remains the opportunity to further recognize how disparity directs health outcomes, particularly during a global pandemic, and to focus efforts to ameliorate unjust disparities moving forward. 13, 62 Success in reducing social disparities indeed has the potential to improve the long-term outcomes of children, perhaps even more poignantly so in times of crisis. 

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