The relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population

Amelia T. Collings, MD
Christina Georgeades, MD
Manzur Farazi, PhD
Mary E. Fallat, MD, FACS, FAAP
Peter C. Minneci, MD, MHSc, FACS, FAAP
K. Elizabeth Speck, MD, MS, FACS
Kyle Van Arendonk, MD, PhD, FACS
Katherine J. Deans, MD, MHSc, FACS, FAAP
Richard A. Falcone Jr., MD, MPH, MMM, FACS, FAAP
David S. Foley, MD, FACS, FAAP
Jason D. Fraser, MD, FACS, FAAP
Samir Gadepalli, MD, FACS, FAAP
Martin S. Keller, MD
Meera Kotagal, MD, MPH, FACS, FAAP
Matthew P. Landman, MD, FACS, FAAP
Charles M. Leys, MD, FACS
Troy A. Markel, MD, FACS, FAAP
Nathan Rubalcava, MD
Shawn D. St. Peter, MD, FACS, FAAP
Thomas T. Sato, MD, FACS, FAAP
Katherine T. Flynn-O’Brien, MD, MPH, FACS, FAAP

The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a lens on the vulnerability of many communities. The objective of this study was to investigate the pediatric trauma experience of vulnerable populations, including those of minority race and lower socioeconomic status, during the COVID-19 pandemic.

A US-based multi-institutional, retrospective study was conducted evaluating patients <18 years old with traumatic injuries. “Historical” controls from an averaged period of March-September 2016-2019 were compared to patients injured after the implementation of regional stay-at-home orders through September 2020 (“COVID” cohort). The US census tract-based Social Vulnerability Index (SVI) is a measure of a community’s ability to function during a disaster. Minority race was defined as non-white. Differences in injury type, intent, and mechanism were explored based on race and SVI.

A total of 47,385 pediatric trauma patients met study inclusion. Overall pediatric trauma volume increased during the COVID cohort compared to the Historical cohort (Historical 5,891 patients vs. COVID 7,068 patients). During COVID, children of minority race experienced a significant increase in intentional injuries (COVID 17.7% vs. Historical 14.5%, p=0.02), while their white counterparts had no significant change (COVID 4.5% vs. Historical 5.4%, p = 0.06). Likewise, firearm-related injuries doubled in minority children (COVID 163 patients [10.0%] vs. Historical 80 patients [5.7%], p<0.001), but did not change in white children (p = 0.23). Children from the most vulnerable neighborhoods, as defined by the highest SVI quartile, had an 84% increase in penetrating injuries (p< 0.01), however there was no statistically significant change in penetrating injuries in the least vulnerable, or lowest SVI quartile, neighborhoods (p = 0.34). More specifically, during COVID, children from the most vulnerable neighborhoods also suffered an increase in firearm-related injuries (COVID 11.1% vs. Historical 6.1%, p=0.001) while children from the least vulnerable neighborhoods had no change (COVID 0.44% vs. Historical 0.66%, p = 0.60).

Injured children of minority race and higher SVI experienced a disproportionate increase in violence during the COVID-19 pandemic in the United States compared to white children and children from neighborhoods with lower SVI. The pandemic appeared to widen existing disparities. Addressing these disparities is essential to mitigate the impact of future pandemic effects on violent injury in minority children and vulnerable communities.

1. During COVID, children of minority race experienced a significant increase in intentional injuries, however there was no change among white children.
2. During COVID, firearm-related injuries doubled in minority children but did not change in white children.
3. During COVID, children from the most vulnerable neighborhoods had an increase in penetrating injuries, while there was no statistically significant change in penetrating injuries in the least vulnerable neighborhoods .

Characteristics and neighborhood-level opportunity of assault-injured youth in Milwaukee

Christina Georgeades, MD
Manzur Farazi, PhD
Carisa Bergner, MA
Alexis Bowder, MD
Laura Cassidy, PhD
Mike Levas, MD
Mark Nimmer
Katherine T. Flynn-O’Brien, MD, MPH

Violent injuries have been increasing over time. Multiple studies have explored demographic characteristics and neighborhood disadvantage in relation to the rise in violent injuries and also the risk of reinjury. However, few have explored protective factors and their effect on violent reinjury. The Childhood Opportunity Index (COI) uses neighborhood-level indicators to measure and map the degree of opportunity and protective factors a child has based on quality of resources such as education, social environment, and economic resources. We examined child and injury characteristics, in addition to COI, between reinjury and non-reinjury populations in assault-injured youth.

The Children’s Wisconsin Trauma Registry (TR) was queried for all children ? 18 years old with assault injuries from 1/1/2016 to 5/31/2021. The electronic medical record (EMR) was also queried for children treated and released from the Emergency Department who did not qualify for the TR. Reinjured children were compared to the non-reinjured population. Reinjury was defined as any child who sustained more than one assault injury during the time frame. Pearson chi-squared tests were used to compare categorical variables and Wilcoxon rank-sum test was used to compare continuous, skewed variables. Area Deprivation Index (ADI), a marker of socioeconomic status was evaluated using census block groups and COI was determined through census tract data.

55,862 encounters for trauma met inclusion criteria during the study period from the EMR and TR. Of those, 1,122 (2.0%) assault injury encounters were identified. 41 (4.0%) were assault reinjuries. The median time to reinjury was 240 days (interquartile range [IQR] 63-406 days). Reinjured children were significantly more likely to be older at the index encounter than non-reinjured children (median age 15 [IQR 13-17] vs. median age 14 [IQR 10-16], p=0.006). There were no differences in sex, race, ethnicity, insurance status, or ADI. Additionally, there were no differences in type, mechanism, and severity of injury between the two populations. Furthermore, children who experienced more than one injury did not live in areas of higher or lower COI than non-reinjured children.

Children who experience more than one assault were more likely to be older but were otherwise similar in demographic and injury characteristics to non-reinjured children. Furthermore, living in an area with more or less opportunity as measured by COI did not seem to mitigate the risk of reinjury. Though older children may be a focus of intervention efforts, identification of other factors on a social or environmental level that may lead to assaultive reinjury warrants further exploration. Additionally, additional investment in targeted interventions after index injury may help prevent reinjury.

1. In our study, there was no difference in the Childhood Opportunity Index, which measures the degree of opportunity and protective factors a child has, between reinjured and non-reinjured children. This highlighted the need for identification of social and environmental factors that lead to assaultive injury in addition to the importace of targeted intereventions after index injury to prevent reinjury.

2. Reinjured children were more likely to be older than non-reinjured children; however, there was no difference in other demographic factors such as sex, race, ethnicity, insurance status, or socioeconomic status.

3. There were no differences in type, mechanism, and severity of injury between reinjured and non-reinjured children