Covid19 Investigation
Covid19 Investigation
Covid19 Investigation
Summary
Lancet Respir Med 2020
Background To date, influenza epidemics have been considered suitable for use as a model for the COVID-19
epidemic, given that they are respiratory diseases with similar modes of transmission. However, data directly Published Online
December 17, 2020
comparing the two diseases are scarce. https://doi.org/10.1016/
S2213-2600(20)30527-0
Methods We did a nationwide retrospective cohort study using the French national administrative database (PMSI), See Online/Comment
which includes discharge summaries for all hospital admissions in France. All patients hospitalised for COVID-19 https://doi.org/10.1016/
from March 1 to April 30, 2020, and all patients hospitalised for influenza between Dec 1, 2018, and Feb 28, 2019, were S2213-2600(20)30577-4
included. The diagnosis of COVID-19 (International Classification of Diseases [10th edition] codes U07.10, U07.11, *Contributed equally
U07.12, U07.14, or U07.15) or influenza (J09, J10, or J11) comprised primary, related, or associated diagnosis. Inserm CIC 1432, Clinical
Epidemiology/Clinical Trials
Comparisons of risk factors, clinical characteristics, and outcomes between patients hospitalised for COVID-19 and
Unit, Clinical Investigation
influenza were done, with data also stratified by age group. Centre (Prof L Piroth MD,
A-S Mariet MD,
Findings 89 530 patients with COVID-19 and 45 819 patients with influenza were hospitalised in France during the Prof C Quantin MD), Infectious
Diseases Department
respective study periods. The median age of patients was 68 years (IQR 52–82) for COVID-19 and 71 years (34–84) for
(Prof L Piroth, M Blot MD),
influenza. Patients with COVID-19 were more frequently obese or overweight, and more frequently had diabetes, Biostatistics and
hypertension, and dyslipidaemia than patients with influenza, whereas those with influenza more frequently had Bioinformatics (DIM)
heart failure, chronic respiratory disease, cirrhosis, and deficiency anaemia. Patients admitted to hospital with (J Cottenet MSc, A-S Mariet,
Prof C Quantin), and Reference
COVID-19 more frequently developed acute respiratory failure, pulmonary embolism, septic shock, or haemorrhagic
Centre for Rare Pulmonary
stroke than patients with influenza, but less frequently developed myocardial infarction or atrial fibrillation. Diseases, Pulmonary Medicine
In-hospital mortality was higher in patients with COVID-19 than in patients with influenza (15 104 [16·9%] and Intensive Care Unit
of 89 530 vs 2640 [5·8%] of 45 819), with a relative risk of death of 2·9 (95% CI 2·8–3·0) and an age-standardised Department
(Prof P Bonniaud MD), Dijon
mortality ratio of 2·82. Of the patients hospitalised, the proportion of paediatric patients (<18 years) was smaller for
University Hospital, Dijon,
COVID-19 than for influenza (1227 [1·4%] vs 8942 [19·5%]), but a larger proportion of patients younger than 5 years France; Faculty of Medicine,
needed intensive care support for COVID-19 than for influenza (14 [2·3%] of 613 vs 65 [0·9%] of 6973). In adolescents University of Bourgogne-
(11–17 years), the in-hospital mortality was ten-times higher for COVID-19 than for influenza (five [1·1% Franche-Comté, Dijon, France
(Prof L Piroth, Prof P Bonniaud,
of 458 vs one [0·1%] of 804), and patients with COVID-19 were more frequently obese or overweight. J Cottenet, A-S Mariet,
Prof C Quantin); Inserm LNC
Interpretation The presentation of patients with COVID-19 and seasonal influenza requiring hospitalisation differs UMR1231, LipSTIC LabEx Team,
considerably. Severe acute respiratory syndrome coronavirus 2 is likely to have a higher potential for respiratory Dijon, France (Prof P Bonniaud);
and Université Paris-Saclay,
pathogenicity, leading to more respiratory complications and to higher mortality. In children, although the rate of UVSQ, Université Paris-Sud,
hospitalisation for COVID-19 appears to be lower than for influenza, in-hospital mortality is higher; however, low Inserm, High-Dimensional
patient numbers limit this finding. These findings highlight the importance of appropriate preventive measures for Biostatistics for Drug Safety
COVID-19, as well as the need for a specific vaccine and treatment. and Genomics, CESP, Villejuif,
France (P Tubert-Bitter PhD,
Prof C Quantin)
Funding French National Research Agency. Correspondence to:
Prof Catherine Quantin,
Copyright © 2020 Elsevier Ltd. All rights reserved. Biostatistics and Bioinformatics
(DIM), Dijon University Hospital,
Dijon 21079, France
Introduction transmission and cause respiratory disease. Patients with catherine.quantin@chu-dijon.
In December, 2019, a new disease now known as COVID-19 were also anticipated to benefit from the fr
COVID-19, caused by severe acute respiratory syndrome clinical knowledge and care management of influenza.
coronavirus 2 (SARS-CoV-2), emerged as a major world A global pandemic was declared on March 11, 2020. By
threat. Considering its ability to spread and the relatively July 10, 2020, more than 12 million cases of COVID-19
low case-fatality rates initially reported in China, and 554 000 COVID-19-related deaths had been identified
SARS-CoV-2 was thought to be more similar to influenza worldwide. In France, it had already caused more than
than SARS-CoV-1.1 The preventive measures for this new 30 000 deaths, nearly 20 000 of which were in hospital.2 At
infection were based on a comparison with the influenza this point, COVID-19 had developed into a pandemic
virus because the viruses have similar modes of associated with substantial morbidity and mortality,
Research in context
Evidence before this study database including more than 89 000 patients with COVID-19
We searched PubMed with the terms “COVID-19” and and more than 45 000 patients with seasonal influenza,
“influenza” for articles in any language published up to including patients of all ages. We identified excess mortality
July 16, 2020, that compared clinical characteristics, intensive associated with COVID-19 relative to seasonal influenza, with an
care unit (ICU) admission, morbidity, and mortality of patients age-standardised mortality ratio of 2·8. We evaluated differences
hospitalised for COVID-19 and for seasonal influenza. After between the characteristics of the two epidemics by age group,
excluding co-infection studies and studies of influenza and more specifically in children aged 0–5 years (around 600
pandemics, we identified five studies. An international study patients with COVID-19 and 7000 with influenza) and 6–17 years
compared comorbidity and previous medications in adult (around 600 patients with COVID-19 and 2000 with influenza).
patients (≥18 years) hospitalised either for COVID-19 or for
Implications of all the available evidence
seasonal influenza over the 2014–19 period. Another study
In-hospital case mortality was found to be higher in younger
focused on the risk of ischaemic stroke, including ICU admission
patients with COVID-19 compared with younger patients with
and in-hospital mortality, of adult patients visiting emergency
influenza, even though children were at a lower risk of
departments or hospitalised for COVID-19 in 2020 in
hospitalisation for COVID-19 than for influenza (as observed in
two New York hospitals compared with adult patients with
our study and previously). However, the findings relating to
seasonal influenza from 2016 to 2018. The three other studies
deaths in children with COVID-19 are based on small numbers
identified by our search had smaller populations. One small
and should be treated with caution. More generally, the severe
study was done in a French hospital and compared adult
forms of COVID-19 and seasonal influenza requiring
patients, and another focused on children younger than 1 year,
hospitalisation differ considerably. This underlines the need for
comparing those hospitalised for influenza in the past few years
additional studies to better characterise and understand the
to published features of COVID-19 in low-income and middle-
role and relative importance of risk factors associated with
income countries. Finally, another small study compared the
COVID-19 mortality, such as obesity, particularly in adolescents.
clinical characteristics and treatments of children under the age
This study also reinforces the importance of preventive and
of 5 years hospitalised in Wuhan for COVID-19 or influenza.
curative measures against both diseases. These data are
Therefore, little information is available on the comparative
particularly relevant as the epidemic continues to grow around
burden of COVID-19 and seasonal influenza, particularly in
the world and several countries prepare for potential
children, who are considered to be at low risk of severe disease.
overlapping of the seasonal influenza and COVID-19 epidemics.
Added value of this study
This study provides novel information about hospitalised
patients with COVID-19. Our analysis uses a large national
putting great strain on hospitals and the health system in aim of the present study was to compare, using French
general. nationwide data, the population hospitalised for
The case-fatality rate in COVID-19 appears to be higher COVID-19 and the population hospitalised for influenza
than in seasonal influenza, even though both diseases during the 2018–19 season, and to assess the differences
mainly affect older adults (>65 years) with frailty. The in terms of risk factors, clinical characteristics, and
higher case-fatality of COVID-19 could be due to outcomes.
differences in underlying comorbidities of patients, the
pathogenicity of the virus, population immunity, and Methods
host responses to infection. For example, vaccines and Study design and participants
approved treatments are available for influenza but not We did a retrospective cohort study using the national
for COVID-19. Moreover, the considerable strain that was Programme de médicalisation des systèmes d’information
put on hospitals within a short period of time led to (PMSI) database, which is designed to include discharge
limitations in available care for the patients who were summaries for all inpatients admitted to public and
most frail. private hospitals in France. Inspired by the American
Few studies have directly compared the respective diagnosis-related group (DRG) model,6 the gathering of
burdens of the COVID-19 and influenza epidemics.3–5 national administrative health data was established in
A comprehensive assessment of the outcomes and France in 1991 and extended to all French health-care
mortality of the two diseases and risk factors for facilities in 1997. This coding system was initially
hospitalisation and mortality could be used to identify designed to analyse hospital activity and to contribute to
specific at-risk populations, to strengthen and focus the development of strategic health-care plans.
specific preventive measures in these populations, and to Since 2008, each hospital’s budget depends on the
help define the future needs of health-care facilities. The medical activity described in a specific computer program
that compiles discharge abstracts for all admissions. The deficiency anaemia, pulmonary bacterial infection,
information in these abstracts is anonymous and covers immunocompromised status) and complications (acute
both medical and administrative data. Diagnoses respiratory and kidney diseases, stroke, myocardial
identified during the hospital stay are coded according to infarction, atrial fibrillation, venous thrombosis including
the 10th edition of the International Classification of pulmonary embolism). Deficiency anaemia included iron
Diseases (ICD-10), and procedures done during anaemia and other causes of deficiency anaemia.
hospitalisation are coded according to the French Immunocompromised patients were those with
Common Classification of Medical Procedures. Each agranulocytosis, immunodeficiency, medullar aplasia and
facility produces its own standardised anonymous cancer treated by chemotherapy. We also identified
dataset, and these are compiled to create a national ventilation procedures. The Charlson comorbidity index8
dataset.
In France, stage 1 of the COVID-19 epidemic was COVID-19 (n=89 530) 2018–19 seasonal influenza p value
declared on Feb 23, 2020; stage 2 was declared on Feb 29; (n=45 819)
and stage 3 was declared on March 14. The peak of the Sex
epidemic in France occurred during the second week of
Female 42 035 (47·0%) 23 701 (51·7%) <0·0001
April, 2020. Although during stages 1 and 2 all patients
Male 47 495 (53·0%) 22 118 (48·3%) ··
with COVID-19 were hospitalised regardless of clinical
Age, years
presentation, only those in a serious clinical condition
were admitted to hospital during stage 3. A PMSI database Mean (SD) 65 (20) 59 (32) <0·0001
was developed for COVID-19, and hospitals were asked Median (IQR) 68 (52 to 82) 71 (34 to 84) ··
to perform accelerated data transmission for patients Range 0 to 106 0 to 108 ··
with COVID-19 from March, 2020, onwards at the Age category, years
request of the government, according to the decree dated <18 1227 (1·4%) 8942 (19·5%) <0·0001
April 21, 2020. 18–30 4384 (4·9%) 1836 (4·0%) ··
For the COVID-19 cohort in this study, all patients
31–40 6065 (6·8%) 1568 (3·4%) ··
hospitalised for COVID-19 from March 1 to April 30, 2020,
41–50 8892 (9·9%) 1626 (3·5%) ··
were included, regardless of their age. Patients were
51–60 13 110 (14·6%) 3164 (6·9%) ··
followed up until the end of their hospital stay, even if
61–70 15 345 (17·1%) 5624 (12·3%) ··
that date was after April. Hospital stays for COVID-19
71–80 16 265 (18·2%) 7693 (16·8%) ··
were identified by primary diagnoses, related diagnoses,
81–90 17 841 (19·9%) 11 276 (24·6%) ··
or associated diagnoses, with ICD-10 codes U07.10,
>90 6401 (7·1%) 4090 (8·9%) ··
U07.11, U07.12, U07.14, or U07.15.7 For the influenza
Social deprivation score
cohort, all patients in the PMSI database hospitalised
Mean (SD) –0·27 (1·78) –0·17 (1·56) <0·0001
during the 2018–19 influenza outbreak period (admitted
Median (IQR) –0·15 (–1·23 to 0·92) –0·01 (–0·96 to 0·87) ··
from Dec 1, 2018, to Feb 28, 2019), and identified by
Social deprivation quartile*
ICD-10 codes J09, J10, or J11 (as primary, related, or
associated diagnoses) were included, regardless of their First (least deprived) 22 922 (26·9%) 9195 (21·2%) <0·0001
This study was approved by the Comité Ethique et Third 19 926 (23·4%) 12 608 (29·1%) ··
Scientifique pour les Recherches, les Etudes et les Evaluations Fourth (most deprived) 21 593 (25·3%) 10 256 (23·7%) ··
dans le domaine de la Santé (CESREES) and L’Institut Comorbidity scores
national des données de santé (INDS, registration Charlson comorbidity index
number 1611357) and authorised by the Commission Mean (SD) 1·19 (1·85) 1·23 (1·78) <0·0001
nationale de l’informatique et des sibertés (CNIL, registration Median (IQR) 0 (0 to 2) 1 (0 to 2) ··
number DR-2020–250). 0 45 237 (50·5%) 21 715 (47·4%) <0·0001
1 19 730 (22·0%) 10 539 (23·0%) ··
Variables 2 10 654 (11·9%) 6132 (13·4%) ··
The following variables were extracted for each inpatient ≥3 13 909 (15·5%) 7433 (16·2%) ··
stay: age, sex, transfer to an intensive care unit (ICU), and Elixhauser comorbidity score
hospital death. We also included all diagnoses (ICD-10 Mean (SD) 2·01 (1·96) 2·01 (2·03) 0·59
codes for primary, related, and associated diagnoses) Median (IQR) 1 (0 to 2) 2 (0 to 3) ··
recorded in the discharge abstracts for the included 0 25 701 (28·7%) 14 080 (30·7%) <0·0001
hospital stays (COVID-19 and influenza) to analyse 1 17 497 (19·5%) 8691 (19·0%) ··
comorbidities (hypertension, diabetes, dementia, HIV, 2 15 458 (17·3%) 7280 (15·9%) ··
heart failure, chronic respiratory and kidney ≥3 30 874 (34·5%) 15 768 (34·4%) ··
diseases, cirrhosis, peripheral vascular disease, (Table 1 continues on next page)
overweight (body-mass index ≥25 kg/m²), dyslipidaemia,
patients with influenza. By contrast, patients with Expected in-hospital death with influenza 5355 (6·0%) ·· ··
age-specific mortality
COVID-19 less frequently had heart failure or chronic
Standardised mortality ratio 2·82 ·· ··
respiratory disease in all age groups except those younger
In-hospital death among patients in ICU 3949/14 585 (27·1%) 885/4926 (18·0%) <0·0001
than 18 years. Indeed, in children, patients with
Mean (SD) stay in ICU among 15 (15) 8 (9) <0·0001
COVID-19 more often had hypertension, chronic non-deceased patients, days
respiratory disease, heart failure, and pulmonary Median (IQR) stay in ICU among 10 (3–21) 5 (2–9) <0·0001
bacterial infection, and were more often obese or non-deceased patients, days
overweight. In-hospital death among patients in ICU 3312/10 430 (31·8%) 780/3004 (26·0%) <0·0001
Regarding the clinical evolution after admission (table 2), with mechanical ventilation
hospitalised patients with COVID-19 were more likely to In-hospital death among non-ventilated 477/2773 (17·2%) 81/1496 (5·4%) <0·0001
develop acute respiratory failure, pulmonary embolism, or patients in ICU
septic shock, but less likely to develop myocardial infarction Data are n (%) or n/N (%) unless otherwise indicated. ICU=intensive care unit. Data are for patients who were
or atrial fibrillation. Haemorrhagic strokes were more hospitalised for COVID-19 between March 1 and April 30, 2020, and for patients who were hospitalised for seasonal
influenza between Dec 1, 2018, and Feb 28, 2019.
common among patients with COVID-19 compared with
patients with influenza, but there were no significant Table 2: Main outcomes of patients hospitalised in France for COVID-19 or seasonal influenza
differences in other types of stroke.
Patients with COVID-19 were more likely to need
intensive care, and the mean length of stay in the ICU for patients according to the main comorbidities, the See Online for appendix
COVID-19 was twice as long (15 days [SD 14] for in-hospital mortality for patients with COVID-19 was
COVID-19 vs 8 days [9] for influenza; table 2). A quarter roughly three-times higher than that of patients with
of patients with COVID-19 remained in the ICU for more influenza, for all the main comorbidities except
than 3 weeks (table 2). Patients with COVID-19 were pulmonary bacterial coinfection, for which in-hospital
more likely to require invasive mechanical ventilation mortality was two-times higher for patients with
than patients with influenza. If admitted to the ICU, COVID-19 (appendix p 4).
patients with COVID-19 were also more likely to need After stratification by age (figure 1, appendix pp 5–6),
mechanical ventilation than patients with influenza. the proportion of patients in the ICU was significantly
In-hospital mortality was higher in patients hospitalised higher in the COVID-19 group than in the influenza
for COVID-19 than patients hospitalised for influenza, group for patients younger than 18 years and those aged
with a relative risk of death of 2·9 (95% CI 2·8–3·0). We 61 to 80 years. By contrast, the proportion of patients in
found a standardised mortality ratio of 2·82. Therefore, the ICU was lower in the COVID-19 group than in the
the number of observed deaths was considerably higher influenza group for patients older than 80 years. In
than what would be expected if the COVID-19 population patients older than 50 years and younger than 18 years,
had the same probability of dying as the influenza in-hospital mortality was higher in the COVID-19 group
population. Mortality was also higher in patients with than the influenza group.
COVID-19 who were admitted to the ICU, whether they We identified 1227 children hospitalised for COVID-19
were mechanically ventilated or not. After stratifying and 8942 children hospitalised for influenza (figure 2,
Influenza
25 influenza. However, the risk of misclassification is low
because the period studied in 2020 was at the end of the
20 influenza epidemic in France. In addition, the results of
care support (%)
pulmonary embolism.30 A higher risk of haemorrhagic distinguish between acute and chronic conditions; for
stroke (but not ischemic stroke, as has been more example, in heart failure the same code is used for
commonly observed31,32) was also observed in our study, chronic heart failure and for cardiac decompensation.
not only because of specific COVID-19-induced cerebral Moreover, the PMSI inpatient database for COVID-19,
vasculitis, but also because of the high doses of with accelerated transmission of COVID-19-related
anticoagulants used to prevent or reduce the risk of patient data, was only recently developed on the request
thromboembolism. Of note, we found that patients with of the government (following the decree of April 21, 2020),
COVID-19, who are often considered to have higher and these data are still pending consolidation. This is, in
cardiac risks (including for acute coronary syndrome, particular, the consequence of strains on our health-care
myocarditis, arrhythmias, and cardiogenic shock),33 system, its mobilisation to care for sick individuals, and
actually had lower risk of myocardial infarction and atrial the willingness to act quickly. Information relating to
fibrillation than patients with seasonal influenza. do-not-resuscitate orders was not available in our
Patients with influenza were more likely to have chronic database, nor was ethnicity data because its collection is
heart failure at baseline, but the question of not authorised in France. We were also lacking detailed
whether the incidence and the impact of seasonal data for some potentially relevant findings, such as the
influenza-related myocarditis is underestimated requires higher frequency of septic shock in COVID-19 patients or
further investigation.34 the underlying reasons for mortality in adolescents.
Although this study includes data collected on a We acknowledge that, despite the collection of nationwide
national level from more than 100 000 hospitalised data, the conclusions about ICU support and deaths in
patients of all ages, we recognise that it has several children are based on small numbers (eg, in children
limitations. First, the comparison between COVID-19 and younger than 5 years, three deaths were associated with
seasonal influenza has some difficulties, such as possible COVID-19 and 13 with influenza). Whether genetic
testing biases and differences between viruses. characteristics could be associated with severity could not
More patients were likely to have been tested for be assessed in these cases.35 Finally, for some variables,
COVID-19 in 2020 than for influenza during the 2018–19 information is not completed in the discharge abstract
season, but our study included only hospitalised patients. when there is no direct impact on patient care during
Tests systematically done in an ambulatory care setting hospitalisation (eg, tobacco use). This is often the case for
for COVID-19 should have little influence on the number day-care hospitalisations but it did not apply to the
of patients hospitalised, particularly in ICUs. However, hospitalisations considered in this study.
testing practices for influenza are likely to be highly In conclusion, significant differences exist between
variable across hospitals, whereas practices for COVID-19 patients with COVID-19 and seasonal influenza requiring
may be more standardised (eg, all hospitalised patients hospitalisation. SARS-CoV-2 appears to have a higher
require testing). The comparison between COVID-19 and potential for respiratory pathogenicity, leading to more
seasonal influenza might also not be direct because the respiratory complications in patients with fewer
study periods are roughly 1 year apart. We cannot comorbidities, and it is associated with a higher risk of
ascertain whether the 2018–19 seasonal influenza is mortality, particularly in adolescents, although any
representative of all seasonal influenzas, even though it conclusions for this age group must be treated with caution
was the most severe season in the past 5 years in France. considering the small number of deaths. These findings
Some patients with COVID-19 might also have had were confirmed even after we considered the constraints
influenza at the same time, but this scenario is linked to the sudden influx of patients during the epidemic.
unlikely because influenza diagnostic procedures were In future, the possibility of overlapping influenza and
accessible throughout the study period, and because the COVID-19 epidemics will certainly also increase the
2019–20 influenza epidemic was ending at the start of the complexity of patient management. At a time when no
COVID-19 epidemic. In addition, we found no differences treatment has been shown to be effective for the COVID-19
between the sensitivity analyses restricted to stage 3 of the clinical course, this study highlights the importance of all
COVID-19 epidemic and the main analyses. In the stage 3 measures of physical prevention and the need for a specific
period (March 14, onwards), COVID-19 patients were vaccine for SARS-CoV-2 and treatment for COVID-19.
unlikely to have influenza. The characteristics of patients Contributors
who died from COVID-19 in places outside of the hospital LP, PB, PT-B, and CQ were involved in the conception and design of the
setting, in a nursing home for example, could be different study. CQ was the coordinator of the study. JC, A-SM, and CQ were
responsible for the data collection. LP, PT-B, and CQ wrote the first
from those of the 15 104 individuals who died in our draft. JC was in charge of the analysis. JC and CQ accessed and verified
study. Another limitation is the potential for biases the data. All authors were involved in the interpretation, critically
related to misclassification or under-detection, especially reviewed the first draft, and approved the final version.
for comorbidities because they were only identified Declaration of interests
during the stays for COVID-19 or for influenza. Even so, LP reports travel grants from Janssen-Cilag, Merck Sharp & Dohme,
this misclassification bias is likely to be non-differential Pfizer, and Gilead. PB reports personal fees and other fees from Roche
(board participation, consulting fees, travel fees), Boehringer Ingelheim
for the majority of the comorbidities. We cannot always
(board participation, consulting fees, conference fees), and Novartis 16 Götzinger F, Santiago-García B, Noguera-Julián A, et al. COVID-19
(board participation, consulting fees, conference fees), personal fees in children and adolescents in Europe: a multinational, multicentre
from TEVA, AstraZeneca, and Sanofi, and other fees from Chiesi (travel cohort study. Lancet Child Adolesc Health 2020; 4: 653–61.
fees) and Stallergene (conference fees). All other authors declare no 17 Li Y, Wang H, Wang F, et al. Comparison of hospitalized patients
competing interests. with pneumonia caused by COVID-19 and influenza A in children
under 5 years. Int J Infect Dis 2020; 98: 80–83.
Data sharing 18 Vanhems P, Endtz H, Dananché C, Komurian-Pradel F,
The PMSI database was made available by the French national agency Sanchez Picot V. Comparison of the clinical features of
for the management of hospitalisation data (Agence technique de SARS-CoV-2, other coronavirus and influenza infections in infants
l’information sur l’hospitalisation, ATIH). The use of these data by our less than 1-year-old. Pediatr Infect Dis J 2020; 39: e157–58.
department was approved by CNIL. We are not permitted to share these 19 Davies P, Evans C, Kanthimathinathan HK, et al. Intensive care
data. PMSI data are available from ATIH to researchers who meet the admissions of children with paediatric inflammatory multisystem For more on ATIH see https://
criteria for access (requests for access are evaluated by CNIL). syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in www.atih.sante.fr/nous-
the UK: a multicentre observational study. contacter
Acknowledgments Lancet Child Adolesc Health 2020; 4: 669–77.
This project was funded by the French National Research Agency. 20 Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem
We thank Suzanne Rankin for reviewing the English and inflammatory syndrome in U.S. children and adolescents.
Gwenaëlle Periard for help with the layout and coordinating the N Engl J Med 2020; 383: 334–46.
preparation of this Article. 21 Docherty AB, Harrison EM, Green CA, et al. Features of 20 133 UK
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