Racial and Ethnic Disparity in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 in Mississippi, USA

Abstract

We aimed to study the disparity in the clinical profile and outcomes of hospitalized Multisystem Inflammatory Syndrome in Children (MIS-C) patients at our center. The second goal was to examine the temporal association with preceding SARS-CoV-2 infection by race/ethnicity in our community in Mississippi. We found the racial disparity in the prevalence of MIS-C exceeded its temporal association with SARS-CoV-2 infections. We included 51 consecutive MIS-C patients hospitalized, whose median age was 9 (interquartile range [IQR] 5-12) years, 58% were male, 71% were black, 25% were white, and 4% belonged to other groups. We found a delay between onset of symptoms and hospitalization in black patients compared with white patients with a median of 2 (IQR 0-7) vs median of 0 (0-5) urgent care visits (P = .022), respectively. Black patients were hospitalized longer (median 8, IQR 2-39 days) than whites (median 5, IQR 3-14 days), P = .047. A total of 38.9% of blacks and 23.1% of whites were admitted to intensive care unit (P = .498); 36.1% of blacks had severe cardiac involvement vs 23.1% of white patients, P = .531. Future studies of MIS-C are required to improve health equity for children.

Introduction

Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare but severe condition that is temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The MIS-C develops 4 to 6 weeks following SARS-CoV-2 infection and is presumably initiated by the adaptive immune response.¹ The number of MIS-C cases in the United States is 6431, of whom 55 (0.8%) children died as of January 25, 2022.² According to the Centers for Disease Control and Prevention (CDC) report, the median age of children is 9 years, and half of the children with MIS-C are between the ages of 5 and 13 years. The male gender is predominantly affected (60%). Of the 6431 pediatric patients, race/ethnicity information was available in only 59% of cases. Hispanic patients constitute 25%, black patients 30.1%, white 34.9%, and others 10% among those where race/ethnicity was known.² There were 100 to 199 cases of MIS-C from Mississippi as of January 25, 2022, reported to the CDC.² A previous study before the surge of MIS-C cases from our institution between March 11, 2020, and August 12, 2020, has reported 624 (13%) SARS-CoV-2 positives by polymerase chain reaction (PCR) testing out of 4802 children in the community around the Children’s of Mississippi hospital. Minority children had higher positivity rates (black children 15.8% and Hispanic children 24.6%) compared with white children 5.9%.³

Racial and socioeconomic disparities in children’s health care in the United States are extensive, pervasive, and occur across the health care spectrum in all 50 states.⁴ Existing racial disparities have garnered renewed attention during the coronavirus disease 2019 (COVID-19) pandemic, and the gap is more striking among children, especially in the southern part of the United States.^5,6 Mississippi has a high number of SARS CoV-2 infections and had become the epicenter of the COVID-19 pandemic in the summer of 2020.⁷ Previous reports suggest racial and ethnic disparities in MIS-C exist in the United States, but the etiology is not clearly understood.^8-10 Hispanic and black children are disproportionately affected by acute COVID-19 infection,⁴ and one would expect that cases of MIS-C are higher in these 2 ethnic groups.

We systematically characterized the clinical presentation, inflammatory markers, cardiac biomarkers, and organ system involvement in consecutive MIS-C patients admitted to our center. We aimed to investigate the disparity in hospitalized MIS-C’s clinical profile and outcomes in this study. We hypothesized that our cohort’s variability and prevalence of MIS-C would follow the same racial/ethnic distribution as SARS-CoV-2 infection rates by PCR positivity in children in the same community.

Methods

Our study was a retrospective data collection of patients aged ≤18 years admitted to Children’s of Mississippi hospital between July 1, 2020, and June 30, 2021, with a diagnosis of MIS-C as defined by the CDC criteria.¹¹ Children’s of Mississippi hospital is the only tertiary care center for children in Mississippi and is part of the University of Mississippi Medical Center, Jackson, MS. The institutional review board approved this study. A multidisciplinary team managed all MIS-C patients during the study period, including pediatric rheumatologists, cardiologists, infectious disease specialists, intensivists, and hematologists. Depending on clinical manifestations, other subspecialties were consulted; these include but are not limited to pediatric neurology, nephrology, and gastroenterology. Our MIS-C protocol for diagnosis and management followed the guidelines from the CDC.^11-13

The MIS-C patients were identified by the clinical diagnosis as recorded in medical records and adjudicated by our multidisciplinary team from July 1, 2020, until June 30, 2021. We retrospectively collected the following data from electronic medical record review: demographics (age, sex, and race/ethnicity), SARS-CoV-2 PCR or antibody test results, clinical data (comorbidities, exposure to COVID-19, number of visits to urgent care centers for the same symptoms before hospitalization, clinical presentations), laboratory data (acute phase reactants, troponin-I, and brain-type natriuretic [BNP]), treatment (inotropic, immunomodulatory agents, and anticoagulants), hospital outcomes (prolonged length of stay [defined as >7 days of hospitalization],¹⁴ admissions to intensive care unit [ICU], and the need for respiratory support), and follow-up at 2 to 4 weeks after discharge from the hospital. All MIS-C patients were classified into 3 groups based on race and ethnicity: white, black, and other (Hispanic, Asian), as reported in the demographic section for each patient’s medical record. We investigated the disparity in clinical presentations and outcomes of MIS-C by race/ethnicity by comparing (1) clinical, (2) laboratory, (3) treatment, and (4) hemodynamic features between white and black patients. We compared the distribution of MIS-C in disparate racial groups with that of acute COVID-19 infection, as evidenced by the SARS-COV-2 PCR positivity rate.

We used median and interquartile range [IQR] to evaluate the continuous variables and percentages for categorical variables. Nonparametric tests were used to assess the difference between the study groups. Kruskal-Wallis test was used for continuous variables, and the Fisher exact test was used for categorical variables. We used univariable analysis of all factors associated with our study outcomes, and depending upon the risk factors, P < .2, were then analyzed with multivariable analysis. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS version 27; Chicago, Illinois).

Results

Patient Characteristics

The demographic and clinical characteristics of all 51 MIS-C patients admitted to our hospital during the study period are described in Table 1. The median age of patients was 9 (IQR 5-12) days, 30 (58%) were male, 36 (71%) were black, 13 (25%) were white, and 2 (4%) were of other race/ethnicity. The lower incidence of MIS-C in Hispanics and Asian descent children in our cohort led us to group them in the other group. The racial/ethnic distribution of MIS-C cases differed from the acute SARS-CoV-2 infection rates by PCR positivity between March 2020 and August 2020; 15.8% were black, 24.6% Hispanic, and 5.9% white children.³

Table 1.

Demographic and Clinical Presentation, Hemodynamic Characteristics, and Use of Immunomodulatory Agents for the Entire Cohort of Multisystem Inflammatory Syndrome in Children (MIS-C).

Demographics
Age in years, median (IQR)	9 (5-12)
Sex: male, No. (%)	30 (58%)
Race/ethnicity: black, No. (%)	36 (71%)
Comorbidities, No. (%)	18 (35%)
Delay in admission, median (IQR)	2 (0-4)
(Defined as if the patient had ≥2 visits to the urgent care for the same symptoms since the initial presentation)
Clinical presentation
Fever, No. (%)	51 (100%)
Abdominal pain, No. (%)	20 (39%)
Nausea/vomiting/diarrhea, No. (%)	25 (49%)
Kawasaki-like clinical features, No. (%)	20 (39%)
Cardiorespiratory symptoms, No. (%)	12 (24%)
Neurocognitive symptoms, N (%)	6 (12%)
Hemodynamic features
Systemic hypotension, No. (%)	16 (31.3%)
Use of inotropes/vasoactive agents in patients, No. (%)	15 (29.4%)
Invasive respiratory support, No. (%)	1 (1.9%)
Noninvasive respiratory support, No. (%)	2 (3.9%)
High-flow nasal oxygen, No. (%)	8 (15.6%)
ICU admission, No. (%)	18 (35%)
Treatment
IVIG, No. (%)	42 (82%)
Steroids, No. (%)	40 (78%)
Anakinra, No. (%)	3 (5.8%)
Anticoagulants, No. (%)	35 (69%)
Length of stay in days, median (IQR)	6 (4-8)

Abbreviations: ICU, intensive care unit; IQR, interquartile range; IVIG, intravenous immunoglobulin.

A total of 18 (35%) patients had pre-existing conditions, of which 7 were obese (body mass index ≥ 30), 3 had asthma, 2 had collagen vascular disease (juvenile rheumatoid arthritis and polymyositis), 2 had a single kidney, 3 had abnormal hemoglobin (Hb Barts), and 1 had severe atopic dermatitis. Two or more systems were involved in 18 (35%) patients. Cardiovascular symptoms were present in 12 (24%), and Kawasaki disease (KD)–like symptoms such as fever with rash, conjunctivitis, and lymph node enlargement were present in 20 (39%) patients. The MIS-C patients more frequently presented with cardiac dysfunction and gastrointestinal (GI) symptoms than classical KD patients. Twenty-five patients, of whom 24 were black, had multiple prior visits to the urgent care facilities for the same symptoms before hospitalization. Black patients had more delay in hospital admission from the beginning of symptoms which was arbitrarily defined by ≥2 visits to urgent care for the same symptoms for our study.

Out of a total of 51 patients, 48 (94%) had a positive PCR for SARS-CoV-2, 45 (88%) had positive antibodies, and 2 (4%) patients had neither PCR nor antibody test positive but had a history of exposure to close contacts with COVID-19. Fever was the most common presenting symptom, followed by GI symptoms (nausea, vomiting, diarrhea, abdominal pain). Seven patients were initially suspected of having appendicitis based on symptoms. Computerized tomographic scans of the abdomen were obtained; 4 cases had mesenteric adenitis, and none had confirmed appendicitis.

The hemoglobin, absolute neutrophil count (ANC), absolute lymphocyte count, platelet count, serum sodium, serum albumin, serum creatinine, serum alanine aminotransferase level, and peak inflammatory marker values of the cohort are summarized in Table 2. In our cohort, there was lymphopenia (76%), neutrophilia (90%), mild anemia (72%), thrombocytopenia (24%), and elevated inflammatory markers such as C-reactive protein (CRP) (100%), erythrocyte sedimentation rate (98%), d-dimer (88%), fibrinogen (80%), ferritin (84%), procalcitonin (80%), and interleukin-6 (76%). Hypoalbuminemia (8%) and hyponatremia (4%) were noted on admission. Liver enzymes were elevated in 45% of patients during hospitalization, elevated triglycerides in 80%, and elevated lactate dehydrogenase in 76%.

Table 2.

Laboratory Values at Presentation and Follow-up After Discharge From Hospital.

At 2-4 weeks follow-up laboratory values	At presentation N = 51, median (IQR)	At follow-up N = 43, median (IQR)
Hemoglobin, g/dL	10.4 (9.25-11.45)	11.1 (8.8-15.1)
Absolute neutrophil count, per mm3	7710 (2900-11 970)	3425 (1030-6300)
Absolute lymphocyte count, per mm3	1210 (620-2020)	2525 (950-22 950)
Platelet count, per mm3	190 000 (137 000-270 000)	301 000 (199 000-479 000)
C-reactive protein, mg/L	16.5 (5.9-26.3)	3.5 (1.5-6)
Erythrocyte sedimentation rate, mm/h	79 (45-109)	30 (11-56)
Sodium, mmol/L	139 (136-142)	139 (134-142)
Albumin, g/L	3.2 (3-3.6)	47 (32-58)
Alanine aminotransferase, IU/L	37 (22-64)	22 (11-72)
Creatinine, mg/dL	0.5 (0.3-0.7)	0.4 (0.3- 0.62)
Procalcitonin, ng/mL	0.44 (0.04-9.9)	0.02 (0.01-0.17)
Fibrinogen, g/L	501 (370-654)	267 (167-470)
Ferritin, ng/mL	371 (203-633)	58 (13-140)
d-Dimer, ng/mL	501 (370-654)	329 (160-488)
Triglycerides, mg/dL	143 (75-220)	125 (58-198)
Lactate dehydrogenase, IU/L	737 (560-946)	473 (272-592)
Interleukin-6, pg/mL	2.3 (0-37.9)	ND
NT-pro-brain natriuretic peptide, pg/mL)	3319 (124-10 682)	36 (6-186)
ECG abnormalities, No. (%)	19 (21.5%)	3 (6.9%)
ECHO: left ventricular dysfunction, No. (%)	19 (21.5%)	1 (2.3%)
ECHO: abnormal coronaries, No. (%)	7 (13.7%)	2 (4.6%)

Abbreviations: ECG, electrocardiographic; ECHO, echocardiogram; IQR, interquartile range, ND, not done.

The electrocardiogram was abnormal in 19 (37%) patients, of which 4 had prolonged QT interval (>460 ms), 8 had nonspecific ST changes, and 2 had prolonged PR interval (first-degree atrioventricular block), and 5 had sinus bradycardia. Echocardiogram performed within 24 hours of admission revealed decreased left ventricular (LV) ejection fraction (LVEF <55%) in 19 (37%) patients and coronary artery (CA) dilatation (z score >+2) in 7 (14%) patients. Thirty-nine (76%) patients had elevated N-terminal-pro-BNP (>200 pg/mL, median 3319 and IQR 124-10 682 pg/mL), whereas only 8 (15.6%) patients had elevated troponin (>0.01 ng/mL). In total, 18 (35%) patients were admitted to the ICU. Hypotension and shock (hypotension refractory to fluid resuscitation) were the main indication for admission in 16 patients, followed by hypoxia requiring invasive or noninvasive respiratory support, including high-flow oxygen requirement in 11 patients. Vasoactive agents to maintain blood pressure were used in 15 patients with hypotension refractory to fluid resuscitation. Table 3 describes the multivariate analysis of all variables to determine factors independently associated with admission to the ICU, the difference in length of stay, and cardiac involvement for the entire cohort. Of note, hypotension and shock were not included as variables for ICU admissions as these were clinically determined signs while the patient was in the emergency department. Based on the multivariate analysis, higher serum creatinine and ferritin levels were independently associated with admission to the ICU (P = .014 and .030, respectively). Only ANC was associated with cardiac dysfunction (P = .01). The d-dimer and ANC were independently associated with a length of stay in the hospital >7 days, P = .03 and P = .04, respectively.

Table 3.

Multivariate Analysis for Outcomes in Multisystem Inflammatory Syndrome in Children (MIS-C) in Our Cohort.

Outcomes	Variables	Odds ratio	95% confidence interval	P value
ICU admissions	Creatinine	1.09	1.02-1.19	.014
	Ferritin	1.00	1.00-1.01	.03
Length of hospitalization	d-Dimer	1.0	1.0-1.0	.03
	Absolute neutrophil count	1.0	1.0-1.0	.04
Cardiac involvement	Absolute neutrophil count	1.0	1.0-1.0	.007

(Univariate analysis was performed on each covariates: age, gender, race/ethnicity, delay in admission, comorbidities, multi-organ system involvement, WBC, ANC, ALC, platelet count, ALT, albumin, sodium, Cr, CRP, ESR, procalcitonin, IL-6, ferritin, d-dimer, fibrinogen, and NT-Pro-BNP. Then, covariates with P values <.2 in univariate analysis were retained as candidate predictors for multivariate analysis and stepwise variable selection procedure was performed on the candidate predictors to obtain the final multivariate model).

Abbreviation: ICU, intensive care unit.

A total of 42 patients received immunomodulatory therapy such as intravenous immunoglobulin (IVIG) (typically 2 g/kg, maximum 100 g), 40 patients received high-dose methylprednisone (10 mg/kg/d), and 3 patients received anakinra (4 mg/kg/d) intravenously. All 3 patients requiring anakinra received it in addition to IVIG and steroids and belonged to black ethnicity. The median length of hospitalization was 6 (IQR 4-8 days). There was 100% in-hospital survival to discharge.

After discharge from the hospital, 43 (84%) out of 51 patients had at least 1 follow-up between 2 and 4 weeks of their initial presentation. The difference in the number of patients at follow-up was similar to the average number of patients lost to follow-up (20%) at our hospital due to various reasons, including insurance status, socioeconomic status, and lack of adequate transport support. We compared the hemoglobin, ANC, absolute lymphocyte count, platelet counts, serum sodium, serum albumin, serum creatinine, serum alanine aminotransferase level, and inflammatory marker values at follow-up with initial values at the time of hospitalization in Table 2. There was a significant improvement in lymphocyte counts, platelet counts, and a substantial decrease in the inflammatory markers at follow-up. Only 1 patient had mildly decreased LVEF (was 51%), and 2 patients had mild ectasia of coronaries at the follow-up visit. The 1 patient with abnormal LVEF had cardiac magnetic resonance imaging 3 months after initial presentation and showed normal myocardial tissue characterization and normalization of function.

Disparities in Clinical and Laboratory Features Between Black and White MIS-C Patients

Figure 1 summarizes the differences between laboratory and inflammatory biomarkers between black and white MIS-C patients. There was no difference in age (8.7 ± 4.5 vs 8.6 ± 4.2 years, P = .09), body weight (48.1 ± 27.4 vs 37.8±20 kg, P = .25), or gender (M:F 7:5 vs 7:3; P = .906) between the 2 groups. There was a significant delay in admission to the hospital from the onset of symptoms in black patients (median 2, IQR 0-7) compared with white MIS-C patients (median 0, IQR 0-5 and P = .022) (Figure 2A). The median length of hospital stay in black MIS-C patients was 8 (IQR 2-39) days than whites, with a median of 5 (IQR 3-14) days, P = .047 (Figure 2B). There were 14/36 (38.9%) black patients admitted to ICU compared with 3/13 (23.1%) white patients with an odds ratio (OR) of 2.12 (95% confidence interval [CI] range 0.52-8.06), but not statistically significant (P = .498) (Figure 2C). Left ventricular dysfunction was noted more frequently in blacks (36.1%) than white patients (23.1%), with an OR of 1.88 (95% CI 0.46-7.2), but not statistically significant (P = .531) (Figure 2D). A total of 30 (82%) black children with MIS-C received both IVIG and steroids compared with only 8 (15.6%) white MIS-C patients (64%), P = .04. Three black MIS-C patients received anakinra in addition to IVIG and steroids. There was no in-hospital mortality in either group.

Figure 1.

Differences between black and white children with Multisystem Inflammatory Syndrome in Children (MIS-C).

Abbreviations: ALT, alanine transaminase; Cr, creatinine; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IL-6, interleukin-6; Pro-BNR, N-terminal pro-brain-type natriuretic peptide; WBC, white blood cells.

Figure 2.

Disparity in Multisystem Inflammatory Syndrome in Children (MIS-C) between black and white children: (A) delay in admission to hospital, (B) ICU admission, (C) length of hospitalization, and (D) cardiac dysfunction and coronary abnormality by echocardiogram.

Abbreviations: ICU, intensive care unit; LV, left ventricular.

Discussion

Our study is the first report of racial/ethnic disparity affecting children with MIS-C among southern states in the United States. Mississippi is known for the longstanding economic inequities and racial disparity in health and health care access and delivery. We found MIS-C in a substantially higher number of black children compared with white children in Mississippi and meagerly in Hispanic and Asian children (one each). Our findings of racial disparity are consistent with previously reported case series except for small numbers of MIS-C in Hispanic and Asian children in our cohort.^8-10,15-17 A disproportionately higher number of MIS-C cases in black and lowest among Hispanic children in comparison with the previously reported prevalence rate of SARS-CoV-2 infection in the same community by race/ethnicity was noted.³ Our findings suggest that MIS-C disparities by race/ethnicity exceeded SARS-CoV-2 infection rates in a local community around Children’s of Mississippi hospital. We found in our cohort that black children had a delay in hospital admission from the onset of symptoms than white children. We speculate that delay in hospitalization (≥2 urgent care visits from the beginning of symptoms before hospitalization) in black children led to a longer period of hospitalization, relatively higher ICU admissions, more intense treatment including multiple immunomodulatory therapies, and somewhat higher cardiac involvement, and acute renal insufficiency. We cannot exclude the disparity in approach to black children among urgent care providers, as this has been observed in pediatric fractures among black vs white children.¹⁸ Additional studies are required to target interventions to improve health equity for black children.

In our cohort, 88% of hospitalized MIS-C patients had positive antibodies against SARS-CoV-2. This finding further supports the hypothesis that MIS-C is related to immune dysregulation after the acute SARS-CoV-2 infection. In our cohort, most patients presented with 3 to 5 days of fever, followed by abdominal pain in 49%, GI symptoms (nausea, vomiting, and diarrhea) in 40%, symptoms similar to KD (rash, conjunctivitis, and mucous membrane involvement) in 40%, symptoms related to cardiorespiratory systems (chest pain, palpitation, and difficulty breathing) in 24%, and neurocognitive symptoms (headache and lethargy) in 12%. Our cohort’s clinical presentation, laboratory findings, and inflammatory markers are similar to the variability in clinical expression, and laboratory values in MIS-C reported in prior studies.^14-17,19-23 In our series, 18 patients (35%) were admitted to the ICU because of hypotension and shock, myocardial involvement, or respiratory failure. Our cohort’s incidence of shock, LV dysfunction, respiratory failure, and acute kidney injury are lower than in previous reports.^22,23 The ICU admission was more likely for MIS-C patients with shortness of breath, abdominal pain, increased CRP, troponin, ferritin, d-dimer, BNP, interleukin-6, reduced platelet or lymphocyte counts. We found several of these factors in our univariate analysis, but only serum creatinine and ferritin level on the multivariate regression model were independently associated with ICU admission. Also, among several of these above variables, only ANC at initial hospitalization was independently associated with cardiac dysfunction in MIS-C (P = .01). Approximately 30% to 40% of children had depressed LVEF in several large case series, and 8% to 24% had CA abnormalities.^13-17 We found that 21.5% of our patients had depressed LVEF, and 13.7% had CA ectasia. There was a rapid improvement in LVEF and finally normalized at follow-up between 2 and 4 weeks. Our findings are similar to a previous study.²⁴

The CDC has reported that counties with 5 racial and ethnic minority groups (Hispanic, black, Indian or Alaska natives, Native Hawaiian, and other Pacific Islander) have experienced high COVID-19 impact from April 1 to December 22, 2020.¹¹ The MIS-C cases follow incidents of COVID-19 and are likely to be higher in the minority population.^22,23 However, a previous study has shown that race and ethnic disparities in MIS-C cases exist, even after controlling for COVID-19 differences and geographic variation.⁸ In our study, we observed that, despite a higher infection rate for SARS-CoV-2 in Hispanic children in Mississippi, the number of hospitalized MIS-C among Hispanics is much lower. The disproportionately lower number of MIS-C cases in Hispanic and higher numbers in black children than infection rate for SARS-CoV-2 rates reported from Mississippi³ suggests that MIS-C disparities exceeded that of SARS-CoV-2 infection rates. The caveat is that the 2 studies were done during a rapidly evolving pandemic at different periods. Additional studies are required to understand our cohort’s lower prevalence of MIS-C in Hispanic children compared with national data. In a previous study from Massachusetts, lower socioeconomic status, higher social vulnerability index, Hispanic ethnicity, and black race/ethnicity independently increased the risk for MIS-C.⁸ Similar to our study, Stierman et al⁹ also reported that disparities in MIS-C by race and ethnicity exist, even after controlling for COVID-19 disparities and geographic variations. In our cohort, black children had a disproportionately higher incidence of hospitalization, but only 1 Hispanic and 1 Asian required hospitalization due to MIS-C, which is different from all previous reports.^{9,10,22,23,25}

The limitations of this study include those inherent in its retrospective chart review. The small sample size did not allow the regression models to be sufficiently powered, which explained why some variables were not statistically significant with the outcomes even though the OR was higher. Also, the single-center data could not be generalizable as this was limited to the community around Children’s of Mississippi hospital and did not include the entire state of Mississippi. Our pooled SARS-CoV-2 infection rate was also from the local community and may not reflect the statewide results. The other limitation is that we compared 51 hospitalized MIS-C patients over 12 months (July 2020 to June 2021) with the prevalence of SARS-CoV-2 infection by PCR positivity over 5 months (March to August 2020). However, the surge in MIS-C patients was observed after increasing SARS-CoV-2 in children and therefore was advantageous in our approach using the preceding SARS-CoV-2 infection rate by race/ethnicity in the same community. In the absence of publicly reported data for MIS-C breakdown by race/ethnicity in the Mississippi Department of Health report, we believe that the local community data was the best cohort for comparison.

Conclusions

Our study showed that disparities in MIS-C by race/ethnicity exist and were independent of SARS-CoV-2 infection rates in the community. In our analysis, Mississippi has a high proportion of black hospitalized MIS-C patients compared with white patients and only 1 Hispanic patient. This very low incidence of MIS-C among Hispanics is unexplained as SARS-CoV-2 positivity rates are high in Hispanic children. Multisystem Inflammatory Syndrome in Children in black children required more extended hospitalization than in white children. The delay in hospital admission from the onset of symptoms in black children may explain our study’s worse outcomes in black MIS-C patients. The lack of case fatality in our case series suggests that appropriate medical treatment is critical for a positive effect in MIS-C. We hope our findings may assist health care professionals in devising appropriate strategies for earlier recognition of MIS-C in black children. Future studies are needed to learn why certain racial or ethnic groups may be disproportionately affected and understand the risk factors for MIS-C.

Author Contributions

BBD: Contributed to conception and design; contributed to acquisition; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

DS: Contributed to design; contributed to acquisition; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

JAV: Contributed to design; contributed to interpretation; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

SG: Contributed to design; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

WBM: Contributed to design; contributed to analysis; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

OO: Contributed to design; contributed to analysis; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MDW: Contributed to design; contributed to analysis; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

SA: Contributed to design; contributed to analysis; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

VG: Contributed to design; contributed to analysis; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MBT: Contributed to design; contributed to interpretation; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.