As COVID-19 cases have soared throughout the islands in recent months, one of the most closely watched metrics for gauging whether to keep schools open for in-person learning, among other policies, has been the incidence of severe illness in children.

But state data on pediatric hospitalizations appears to be inflated due to the way it’s collected, making it difficult to get a clear picture of how kids are faring.

The Centers for Disease Control and Prevention has said the risk of complications or severe illness in children infected by COVID-19 is actually lower than the flu, which has provided some solace to anxious parents and health care professionals.

But as the highly contagious delta variant took hold throughout the country this summer, doctors in other states have reported alarming increases in pediatric hospitalizations.

Children under the age of 12 still aren’t eligible for the vaccines, and as older children prepared to return to school this fall, only half of those between the ages of 12 and 17 had received at least one shot, according to national figures.

At the Children’s Hospital in New Orleans, doctors and nurses have reported distressing increases in the number of children with COVID-19 being hospitalized and struggling to breathe, in some extreme cases being put on ventilators in an effort to save their lives.

Other towns and cities throughout the South, where vaccination rates are lower, also have reported worrisome increases in pediatric patients.

In Hawaii, it’s clear that cases among kids have soared since early July when the delta variant began to spread aggressively. By the last week of August, cases among children ages 17 and younger were 17 times higher than in early July.

During the week ending Aug. 29, more than 800 new cases were reported among children throughout the islands. But when it comes to figuring out how many of those kids are getting so sick they end up in the hospital, the picture is a lot murkier.

Prior to the rapid spread of the delta variant, 47 children with COVID-19 had been hospitalized in Hawaii since the start of the pandemic in early 2020, according to data posted on the Hawaii Department of Health website. In just the last two months, that number has more than tripled to 147.

One hundred pediatric hospitalizations in just two months is a worrisome figure. But health care officials at Kapiolani Medical Center for Women and Children, the state’s only hospital specializing in pediatric care, say those numbers seem high and not reflective of what they’re seeing.

On Aug. 27, hospital officials said they had admitted less than a dozen children for COVID-19 over the past month and a half.

Kaiser Permanente has treated only three pediatric COVID-19 cases since July, none of whom required ventilators, according to Laura Lott, a spokeswoman for the health care system.

State data indicates that just one child has died from COVID-19 in Hawaii since the start of the pandemic.

Hospitalizations

The Healthcare Association of Hawaii, a trade group for the state’s hospitals, reports statewide hospitalization data to the Department of Health, which posts it on its COVID-19 website under case outcomes. The data is used to estimate the percentage of COVID-19 cases that require hospitalization and is broken down by age group.

Amid questions about what is included in the data, a spokeswoman for the hospital association said the figures include children who have been admitted due to COVID-19, as well as children who test positive for the virus but may have been admitted for other reasons.

“The data is currently reported in aggregate, and this may give the false impression that there are more children needing hospital care primarily for COVID-19 than is actually the case,” said Stacy Wong, a spokeswoman for the Healthcare Association of Hawaii, by email. “Some pediatric patients are admitted primarily for COVID treatment, while some are admitted for other reasons, and are found to be COVID positive.”

Aggregating data in that way can significantly inflate numbers on COVID-19 outcomes, according to a study published in May by researchers at the Stanford University School of Medicine.

Amid the pandemic, hospitals throughout the country, including in Hawaii, began screening all inpatients for COVID-19 regardless of whether the virus was suspected. For pediatric patients, they could have been admitted for a variety of ailments not related to COVID-19, such as broken bones or an appendicitis.

That screening has been an important safety measure in hospitals, but the number of tests coming back positive can be misleading if the data is reported in a way that suggests the virus is the cause of all hospitalizations.

The study analyzed COVID-19 data from Lucile Packard Children’s Hospital Stanford between May 2020 and February 2021, and found that 117 hospitalized children had tested positive for COVID-19 or were admitted for MIS-C, a serious multisystem inflammatory condition in children that can develop weeks after a COVID-19 infection.

The study found that of the 117 patients, 39% had asymptomatic COVID-19 infections and 28% had mild to moderate sickness. Just 20% of the patients were severely or critically ill with COVID-19, while 12% had MIS-C.

The study’s authors concluded that 45% of the pediatric patients were admitted for reasons unrelated to COVID-19, under­scoring the importance of distinguishing between patients who were admitted because of COVID-19 and those who tested positive during screening but were asymptomatic and admitted for other reasons.

The Honolulu Star-Advertiser has tried unsuccessfully for several weeks to get the data broken down by only those children hospitalized because of COVID-19. On Wednesday, Wong said the Healthcare Association of Hawaii and health care executives were discussing whether the data could be modified in such a way to give a more accurate picture of how COVID-19 is affecting children. But she said that may run afoul of patient confidentiality.

“Patient confidentiality must be taken into consideration before any definitive steps can be taken,” she said by email.

Wong didn’t respond to a followup question about why reporting the number of patients hospitalized because of COVID-19 could hamper patient privacy.

Kristen Bonilla, a spokeswoman for Hawaii Pacific Health, which oversees Kapiolani Medical Center for Women and Children, said hospital officials are discussing the issue with the Healthcare Association of Hawaii and “hoping that either they or DOH can make that distinction when presenting those numbers moving forward to provide a clearer picture for the public.”

The Healthcare Association of Hawaii didn’t respond to a question about whether all of its hospitalization data, covering all age groups, is aggregated in the same way. Those numbers also are closely watched as the state’s health care resources, including oxygen supplies and capacity within intensive care units, remain strained.

Watching the data

Government leaders stand ready to enact more public restrictions, such as curfews and further limits on social gatherings, if hospitalizations climb.

On Friday, Lt. Gov. Josh Green reported 320 patients hospitalized with COVID-19 statewide, with numbers trending down in recent days.

But on July 7, the hospitalization number jumped to 473, according to state data, coming dangerously close to the 500 threshold Green has cited as a tipping point. If numbers get that high, Green, who also works as an emergency room physician, has said he would recommend that Gov. David Ige impose lockdowns.

“If we get anywhere near 500, you are going to have to take very strong action, life-preserving action, and that would likely come in the form of at least a temporary shutdown based on some standards,” Green told the Star-Advertiser’s Spotlight Hawaii live online program on Aug. 30. Green said at that point hospitals could be so strained they would have to begin rationing critical care.

Asked later whether he was concerned the hospitalization data could be inflated because of the way it’s collected, Green said there are instances that could skew the figures. For example, he said people can test positive for COVID-19 three or four months after they contracted the illness even though they have no symptoms and have been admitted to the hospital for a non-COVID-19-­related ailment.

But Green said he didn’t think it was a major issue.

“On occasion, they may track at a slightly higher number. But these are basically the numbers,” he said.