This is the fourth in a series of Dr. Rob Ross Russell’s brief musings on aspects of the COVID-19 crisis.
They are all my personal views and should not for a moment be interpreted as advice or dogma – nor am I in any way seeking to undermine the national advice that is issued, but rather to reflect on some of the issues and verbalise some of the questions and thoughts that I have had.
For those that missed the first three, they can (should they wish) find them here, here and here.
In this piece I am thinking about the children – as a paediatrician that seems pretty appropriate, but there have been some unusual features, and perhaps hidden concerns.
The first notable issue is that they seem to be far less affected by this particular infection than you might expect. To date there have been no deaths in children under 10, and the mortality in older children is also very low. A paper published in Lancet Respiratory has set out to address the characteristics of the disease in children, but seems to shed little light on the reasons why children are relatively spared. It does reference a pre-publication article in Paediatrics that reviewed over 2000 children with COVID19. They note the relatively mild nature of the disease and suggest 2 or 3 possible reasons – less ACE-2 binding (the route by which coronavirus probably enters cells), better paediatric exposure to other respiratory viruses such as bronchiolitis (RSV), and a rather vague comment about a ‘maturing’ immune system.
There was a suggestion in the data, and in commentary on that, that perhaps infants did worse than older children – at least in terms of getting more severe disease, but the data relies heavily on who was tested and needs to be treated with great caution. Either way it is clear that infected children are still able to transmit the disease to others. Whatever the truth, this aspect of the pandemic is interesting and may yield useful clues about the disease itself.
However, of rather more interest is perhaps the way in which children are losing out as a result of the policies being enacted to deal with this crisis. Paediatricians are beginning to voice concerns at the impact of this pandemic on the weel-being of children throughout the world.
Allocation of resources: I suppose it is inevitable that as space within the hospitals is overwhelmed, then all areas will be involved, but nevertheless, the disruption of paediatric wards and intensive care units to ensure adequate space for adult patients should be causing us some concern. In my hospital, the paediatric area of the Emergency Department has been taken over, moving children to a separate (and less well equipped) part of the hospital. There have been discussions about admitting young adults up to the age of 25 on to Paediatric Intensive Care Units (PICUs). The latter has been endorsed after careful consideration by the PIC Society and Adult IC Society, and I applaud their co-operative working. However the impact on the ‘normal’ caseload must be assessed. Paediatric surgery is being cancelled. Many clinics are cancelled – care for children with chronic conditions is affected and their health may suffer.
Pulling together and supporting all services is essential, and I am as keen as anyone to support colleagues in trouble whatever their specialty or area. But let us also acknowledge that we are disadvantaging our children in doing so.
Routine care is being disrupted: Not only is hospital care being affected, but of greater concern is the effect of the pandemic on routine healthcare for children. The WHO regional office for Europe has issued a statement calling for routine vaccinations to be continued in children, but a number of countries are now talking of stopping their program in the light of concerns over cross-infection and workload. UNICEF has warned of a fall in vaccination rates, and especially of concerns in countries such as Syria or Afghanistan, where outbreaks of vaccine susceptible diseases may well emerge. Even in the UK, balancing self-isolation against a routine visit to the GP, makes for a difficult choice for families.
Our coverage in the UK (and most of Europe) is good enough that a delay of a few months in vaccination will not make a major difference. But rates of measles vaccination have fallen a lot over the last few years and so outbreaks of the disease are already more common than they were, given that 95% coverage is needed for proper immunity: