Pediatric Annals

Editorial Free

Current Status of the COVID-19 Pandemic, Influenza and COVID-19 Together, and COVID-19 Viral Variants

Joseph R. Hageman, MD

As the coronavirus 2019 (COVID-19) pandemic continues to evolve and with the total number of cases on the increase, it will be important for pediatric clinicians to be aware of differences in the epidemiology, clinical presentation and course, management, and outcomes for seasonal influenza and COVID-19 disease.1–3

In the majority of pediatric COVID-19 patients, the illness is a mild upper respiratory tract or gastrointestinal tract infection and a significant percentage of children are asymptomatic.2–4 Hospitalizations are uncommon in children, with the weekly rate for children age 0 to 17 years at 0.3 per 100,000.1 In the systematic review by Hoang et al.,4 a total of 7,780 pediatric patients with COVID-19 in 13 studies across 26 countries from articles published between December 1, 2019 and May 14, 2020, the most frequent signs were fever (59.1%) and cough (55.9%), and 19.3% were asymptomatic. The children who become more severely ill are those who are immunocompromised and/or have underlying chronic diseases.4 Also, there are those who develop multisystemic inflammatory syndrome or the Kawasaki-like syndrome including a shock syndrome, which included a total of 11 children (0.4%).4

Now that influenza season is approaching, it makes sense to review the recent article by Song et al.5 in which a comparison of hospitalization rates, severity of illness, and outcomes of 1,402 children younger than age 18 years admitted to Children's National Medical Center in Washington, DC, with influenza (October 1, 2019–June 6, 2020) and 315 children admitted with COVID-19 (March 25, 2020–May 15, 2020). This was a cohort study and the investigators found similar hospitalization and intensive care admission rates, respectively: COVID-19, 54 (17%) versus influenza, 291 (21%); and COVID-19, 18 (6%) versus influenza, 98 (7%).5 There were no COVID-19 or influenza B deaths; however, there were two influenza A deaths. More patients with COVID-19 reported clinical symptoms at the time of diagnosis including fever, headache, vomiting or diarrhea, body ache, myalgia, and chest pain.5

There were no patients with COVID-19 and influenza A or B coin-fections in this study;5 however, coin-fection of COVID-19 with other respiratory viruses including influenza virus has been reported in the literature.6 It is interesting that in the study by Nowak et al.,7 the coinfection rate of COVID-19 and other respiratory viruses was only 2.9%. The article also highlighted the theory of competitive advantage one group of viruses may have over another group such that the viruses compete for the attachment sites.7 Also, the host immune response also plays a role in coinfection of viruses.7 According to Nowak et al.,7 the study was not designed to demonstrate whether patients who had coinfection had more severe illness.

To help prevent the acquisition and spread of seasonal influenza and COVID-19, pediatric clinicians should convey to patients and families that the following are effective measures: social distancing, wearing masks (with mouth and nose covered), frequent hand washing, avoiding large gatherings and crowds, regular exercise, eating well-balanced, nutritional meals, getting adequate sleep, careful social interaction, returning to in-person school safely, and being mindful overall of COVID-19 risks.

One approach would be to have families keep a daily diary with a simple checklist to keep track of these strategies. We should also keep up to date with the evidence-based approach to the development of COVID-19 therapies and the COVID-19 vaccine.8,9 Currently, children and pregnant women are not included in the vaccine trials.10

Also, keep in mind that a spike protein mutation or variant has been identified and that vaccines being tested are based on the original spike protein.10 Therefore, as the flu vaccine is modified every season based upon predictions of which types are thought to be most likely, we may also have different types of COVID-19 vaccines in the future.10,11


  1. Centers for Disease Control and Prevention. Laboratory-confirmed COVID-19-associated hospitalizations. Preliminary cumulative rates as of Oct 10, 2020. Accessed October 22, 2020.
  2. Centers for Disease Control and Prevention. COVID-19 laboratory-confirmed hospitalizations. Preliminary data as of Oct 10, 2020. Accessed October 22, 2020.
  3. Centers for Disease Control and Prevention. Infuenza (Flu). Preparing for the 2020–2021 flu season? Here is what you need to know. Accessed October 23, 2020.
  4. Hoang A, Chorath K, Moreira A, et al. COVID-19 in 7780 pediatric patients: a systematic review. EClinicalMedicine. 2020;24:100433. doi:10.1016/jeclinm.2020.100433 [CrossRef] PMID:32766542
  5. Song X, Delaney M, Shah RK, Campos JM, Wessel DL, DeBiasi RL. Comparison of clinical features of COVID-19 vs seasonal influenza A and B in US Children. JAMA Netw Open. 2020;3(9):e2020495. doi:10.1001/jamanetworkopen.2020.20495 [CrossRef]
  6. Khaddour K, Sikora A, Tahir N, Nepomuceno D, Huang T. Case report: the importance of novel coronavirus disease (COVID-19) and co infection with other common respiratory pathogens in the current pandemic. Am J Trop Med Hyg. 2020;102(6):1208–1209. doi:10.4269/ajtmh.20-0266 [CrossRef]
  7. Nowak MD, Sordillo EM, Gitman MR, Mondolfi AEP. Coinfection in SARS-CoV-2 infected patients: where are influenza virus and rhinovirus/enterovirus?J Med Virol. 2020;92(10):1699–1700. doi:10.1002/jmv.25953 [CrossRef]
  8. Faust SN, Munro AP. It's time to put children and young people first during the global COVID-19 pandemic [published online ahead of print September 25, 2020]. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.4582 [CrossRef] PMID:32975576
  9. Leeb RT, Price S, Sliwa S, Kimball A, et al. COVID-19 trends among school aged children - United States, March 1-September 19, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(39):1410–1415. doi:10.15585/mmwr.mm6939e2 [CrossRef] PMID:33001869
  10. Hageman JR. The COVID-19 vaccine and viral variant. Today. 2020;15(9):108–109.
  11. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee of immunization practices-United States, 2020–21 influenza season. MMWR Recomm Rep. 2020;69(8):1–24. doi:10.15585/mmwr.rr6908a1 [CrossRef] PMID:32820746
Joseph R. Hageman, MD

Pediatric Annals Editor-in-Chief Joseph R. Hageman, MD, is the Director of Quality Improvement, Section of Neonatology, Comer Children's Hospital; a Senior Clinician Educator, The University of Chicago Pritzker School of Medicine; and an Emeritus Attending Pediatrician, NorthShore University HealthSystem.

Address correspondence to Joseph R. Hageman, MD, via email:

Disclosure: Joseph R. Hageman is a member of the Owlet, Inc advisory board.


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