COVID-19-associated pediatric mortality
2026 Case Definition

Background

COVID-19, the disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, first emerged in humans in late 2019. To reflect the evolution of the virus as well as the public health response, in 2024, CSTE updated the standardized surveillance case definition for SARS-CoV-2 infection, removed SARS-CoV-2 from the NNC List, and recommended further development of an integrated national surveillance strategy for COVID-19 that more closely aligns with surveillance for influenza and respiratory syncytial virus (RSV) disease. Alignment among COVID-19, influenza, and RSV disease surveillance reflects the similarities among these diseases, including clinical presentation, potential for severe outcomes in pediatric populations, availability of preventive interventions, and reliance on surveillance data from multiple sources to understand the timing, impact, and relative burden of these conditions. Such alignment includes surveillance efforts focused on severe outcomes, especially in populations of interest, to enhance understanding of the relative burden for each of these pathogens. The CSTE position statement establishes a standardized surveillance case definition for COVID-19-associated pediatric mortality to estimate disease burden, characterize mortality, inform prevention strategies, and enhance coordination of surveillance across COVID-19, influenza, and RSV disease.

Clinical Criteria

• Death in an individual <18 years of age resulting from an illness clinically compatible with COVID-19,^* AND
• There was no period of complete recovery between the COVID-19 illness and death (i.e., COVID-19 illness was NOT followed by full recovery to baseline health status prior to death), AND
• There is no alternative agreed-upon cause of death.^†

^*“Illness clinically compatible with COVID-19" refers to the presence of signs or symptoms associated with COVID-19 or identified as related to COVID-19 by a provider, medical examiner, or coroner. See Appendix A for a non-exhaustive list of compatible signs and symptoms associated with COVID-19.

^†Alternative causes of death are limited to non-natural manners or external causes of death.

Laboratory Criteria

Confirmatory Laboratory Evidence:

• Detection of SARS-CoV-2 nucleic acid in a clinical or post-mortem specimen using a diagnostic molecular test (e.g., nucleic acid amplification test [NAAT]) performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified provider,^‡  OR
• Detection of SARS-CoV-2 RNA in a clinical or post-mortem specimen by genomic sequencing,^§ OR
• Detection of SARS-CoV-2–specific antigen by diagnostic immunocytochemistry staining performed by a CLIA-certified provider.^‡

Presumptive Laboratory Evidence:

• Detection of SARS-CoV-2–specific antigen in a clinical or post-mortem specimen using a diagnostic test performed by a CLIA-certified provider.^‡

Supportive Laboratory Evidence:

• Detection of SARS-CoV-2 nucleic acid or specific antigen using a test performed without CLIA oversight.^¶

Note: The categorical labels used here to stratify laboratory evidence are intended to support the standardization of case classifications for public health surveillance. The categorical labels should not be used to interpret the utility or validity of any laboratory test methodology.

Note: In specimens collected in association with the COVID-19 clinically compatible illness.

^‡ Includes those tests performed under a CLIA certificate of waiver.

^§Some genomic sequencing tests that have been authorized for emergency use by the U.S. Food and Drug Administration do not require an initial reverse transcription-polymerase chain reaction result to be generated. Genomic sequencing results may be all the public health agency receives.

^¶Includes at-home tests.

Vital Records Criteria

• An individual <18 years of age whose death certificate lists COVID-19 disease or SARS-CoV-2 infection or an equivalent term^# as an underlying cause of death or a significant condition contributing to death.^**

^#See Appendix B for examples of equivalent terms for COVID-19 disease or SARS-CoV-2 infection in death certificate data.

^**Unless after review and consultation, COVID-19 disease or SARS-CoV-2 infection is excluded as a direct or contributing cause of death.

Suspect

• Meets clinical criteria AND supportive laboratory evidence.

Probable

• Meets vital records criteria.

Confirmed

• Meets clinical criteria AND confirmed or presumptive laboratory evidence.