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  • Clinical Research Article
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Pediatric COVID-19 severity by SARS-CoV-2 lineage and vaccine status in Canada: an IMPACT study

Pediatric Research volume 98, pages 697–705 (2025)Cite this article

Abstract

Background

Interpretations of pediatric COVID-19 severity are complicated by novel lineages and COVID-19 vaccine introduction. We estimated the risk of severe COVID-19 by SARS-CoV-2 lineage and vaccination status among hospitalized Canadian children.

Methods

Data were collected through the Canadian Paediatric Surveillance Program (April 2020–May 2021) and Canadian Immunization Monitoring Program, ACTive (June 2021–December 2022). Patients <17 years hospitalized for COVID-19 (excluding incidental SARS-CoV-2) at 13 pediatric hospitals were included. Lineages were defined via genetic sequencing or dominant lineage upon hospitalization. Severe disease included intensive care, ventilatory/hemodynamic requirements, systemic complications, and/or death.

Results

We analyzed 3218 COVID-19 hospitalizations, including 81.4% admitted during Omicron predominance. Median age was highest among Delta cases (2.9 years, interquartile range [IQR] 0.2–10.9) and lowest among Omicron BQ.1 cases (0.6 years, IQR 0.2–1.8). Severe COVID-19 remained common in Omicron vs. ancestral cases (27.2% vs. 23.2%). The proportion of hospitalized cases aged 5–16 years declined following the introduction of age-specific COVID-19 vaccines. Vaccination reduced the risk of in-hospital severe disease for ages 12–16 years (two vs. zero doses; adjusted risk ratio 0.49, 95% confidence interval 0.32–0.77).

Conclusion

More children were hospitalized with Omicron lineages than all prior lineages. COVID-19 vaccination was associated with a lower burden of severe disease among ages 5–16 years.

Impact statement

  • This study estimates the effect of SARS-CoV-2 lineage, Omicron sub-lineage, and vaccination on COVID-19 disease severity, using data from two Canadian national surveillance programs.

  • Few national studies describe the clinical presentation and severity of Omicron sub-lineages among hospitalized children.

  • In Canada, Omicron lineages were associated with substantially more pediatric COVID-19 hospitalizations than all prior lineages combined, though risk of severe COVID-19 was highest during the Delta period.

  • COVID-19 vaccines were associated with reductions in hospitalization (ages 5–16 years) and severe disease (ages 12–16 years) across Omicron sub-lineages.

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Fig. 1: Number of children and adolescents aged <17 years hospitalized for COVID-19 at IMPACT network hospitals, by calendar month.
Fig. 2: Risk ratios for severe COVID-19 relative to hospitalization with ancestral SARS-CoV-2 infection, by age group and SARS-CoV-2 lineage at IMPACT network hospitals.
Fig. 3: Interrupted time series of the proportion of IMPACT network hospitalizations by age category over time, before and after the first interim order authorization of age-specific COVID-19 vaccines.

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Data availability

Anonymized individual case data (including data dictionaries) from the CPSP and IMPACT COVID-19 studies can be made available to investigators whose secondary data analysis study protocol has been approved by an independent research ethics board, and which abides by the privacy rules of the Canadian Paediatric Society and Public Health Agency of Canada. Proposals should be submitted to the corresponding authors.

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Acknowledgements

We acknowledge all past IMPACT site investigators and working group members involved in IMPACT at the time of data collection, as well as the pediatricians, pediatric subspecialists, and health professionals who voluntarily respond to CPSP surveys. We thank Annick Audet (IMPACT Nurse Monitor Liaison) and Melanie Laffin Thibodeau (former CPSP Surveillance Manager) for their stewardship in the IMPACT and CPSP studies, respectively. We are also grateful to all IMPACT Nurse Monitors who collected data for the IMPACT COVID-19 study, and staff of the IMPACT data center. CPSP and IMPACT are joint projects of the Canadian Paediatric Society (CPS) and the Public Health Agency of Canada (PHAC). Funding for the surveillance activities conducted by these programs was provided by PHAC, in collaboration with the COVID-19 Immunity Task Force (CITF) for this project.

Author information

Author notes

  1. These authors jointly supervised this work: Karina A. Top, Fatima Kakkar, Shaun K. Morris.

  2. A list of members and their affiliations appears in the Supplementary Information.

Authors and Affiliations

  1. Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada

    Daniel S. Farrar & Shaun K. Morris

  2. Vaccine Evaluation Center, BC Children’s Hospital Research Institute, Vancouver, BC, Canada

    Julie A. Bettinger, Manish Sadarangani & Laura Sauvé

  3. Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

    Julie A. Bettinger, Manish Sadarangani & Laura Sauvé

  4. Division of Microbiology, The Hospital for Sick Children, Toronto, ON, Canada

    Aaron J. Campigotto

  5. Department of Health and Wellness, Halifax, NS, Canada

    Shelley L. Deeks

  6. Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada

    Olivier Drouin

  7. Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada

    Olivier Drouin

  8. Department of Paediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada

    Joanne E. Embree

  9. Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada

    Joanne E. Embree

  10. Department of Pediatrics and Department of Microbiology, Immunology, and Infectious Diseases, Centre de Recherche Azrieli du CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada

    Elie Haddad

  11. Canadian Center for Vaccinology, Dalhousie University and IWK Health Centre, Halifax, NS, Canada

    Scott A. Halperin & Karina A. Top

  12. Department of Pediatrics, Alberta Children’s Hospital, Calgary, AB, Canada

    Tajdin Jadavji

  13. Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, Canada

    Kescha Kazmi & Shaun K. Morris

  14. Canadian Paediatric Surveillance Program, Canadian Paediatric Society, Ottawa, ON, Canada

    Melanie King

  15. Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada

    Charlotte Moore Hepburn

  16. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Charlotte Moore Hepburn

  17. Division of Pediatric Infectious Diseases, Montreal Children’s Hospital, Montreal, QC, Canada

    Jesse Papenburg

  18. Division of Microbiology, McGill University Health Centre, Montreal, QC, Canada

    Jesse Papenburg

  19. Department of Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada

    Rupeena Purewal

  20. Division of Paediatric Infectious Diseases, Jim Pattison Children’s Hospital, Saskatoon, SK, Canada

    Rupeena Purewal

  21. Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada

    Rae S. M. Yeung

  22. Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada

    Rae S. M. Yeung

  23. Department of Immunology and Institute of Medical Science, University of Toronto, Toronto, ON, Canada

    Rae S. M. Yeung

  24. Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

    Karina A. Top

  25. Division of Infectious Diseases, CHU Sainte-Justine, Montreal, QC, Canada

    Fatima Kakkar

  26. Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Shaun K. Morris

  27. Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

    Shaun K. Morris

Authors
  1. Daniel S. Farrar
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  11. Melanie King
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  13. Jesse Papenburg
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  15. Manish Sadarangani
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Consortia

on behalf of the Canadian Immunization Monitoring Program, Active (IMPACT) Investigators

Contributions

Daniel Farrar planned and conducted the statistical analysis, and drafted the initial manuscript. Julie A. Bettinger conceptualized and designed the study, oversaw the analysis, and reviewed and revised the manuscript. Aaron Campigotto, Joanne E. Embree, Scott A. Halperin, Tajdin Jadavji, Kescha Kazmi, Jesse Papenburg, Rupeena Purewal, Manish Sadarangani, and Laura Sauvé contributed to the study design, data collection, and reviewed and revised the manuscript. Oliver Drouin and Charlotte Moore Hepburn were co-leads of the CPSP COVID-19 study, and reviewed and revised the manuscript. Melanie King was the Surveillance Manager of the Canadian Paediatric Surveillance Program when the analysis was conducted, and reviewed and revised the manuscript. Karina A. Top was co-Principal Investigator of the IMPACT COVID-19 study, conceptualized and designed the study, contributed to funding acquisition and data collection, oversaw the analysis, and reviewed and revised the manuscript. Fatima Kakkar and Shaun K. Morris were co-principal Investigators of the CPSP and IMPACT COVID-19 studies, conceptualized and designed the study, contributed to funding acquisition and data collection, oversaw the analysis, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Corresponding authors

Correspondence to Fatima Kakkar or Shaun K. Morris.

Ethics declarations

Competing interests

O.D. and F.K. are supported by a Clinical Research Scholars Award from the Fonds de recherche du Québec—Santé. S.A.H. received funding from multiple vaccine manufacturers to undertake phase 1–3 clinical trials of candidate COVID-19 vaccines. J.P. reported grants from Merck, and personal fees from Enanta, outside the submitted work. M.S. is supported via salary awards from the BC Children’s Hospital Foundation and Michael Smith Health Research BC. M.S. has also been an investigator on projects funded by GlaxoSmithKline, Merck, Moderna, Pfizer, and Sanofi-Pasteur. All funds have been paid to his institute, and he has not received any personal payments. K.A.T. received grants from the Coalition for Epidemic Preparedness Innovations outside the submitted work. S.K.M. has received honoraria for lectures from GlaxoSmithKline and Sanofi Pasteur and has been a member of ad hoc advisory boards for Pfizer, Sanofi Pasteur, and Apotex, all unrelated to this study. All other authors have no conflicts of interest to disclose.

Consent statement

The CPSP collects data elements for national child and youth health surveillance purposes on PHAC’s behalf, whose purpose is to support health protection and promotion under the Department of Health Act 4(2)c and the Public Health Agency of Canada Act 3(15). Healthcare providers are authorized under their provincial health privacy legislation (with the exception of Quebec) to disclose protected health information to public health agencies at the local, provincial, and federal levels for surveillance purposes. CPSP does not collect any individual data elements deemed to be unique identifiers. In Quebec, CPSP studies are conducted under center-specific research ethics board approvals and data transfer agreements. This is consistent with the Canadian Medical Association and Tri-Council Policy Statements, which allow for the collection of non-nominal and nonidentifiable information for conditions under surveillance. For the IMPACT COVID-19, investigators at each IMPACT center also obtained Research Ethics Board or hospital approvals from their institution, and received waivers of consent for secondary use of patient-level data.

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Farrar, D.S., Bettinger, J.A., Campigotto, A.J. et al. Pediatric COVID-19 severity by SARS-CoV-2 lineage and vaccine status in Canada: an IMPACT study. Pediatr Res 98, 697–705 (2025). https://doi.org/10.1038/s41390-025-03853-0

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