COVID, SCHOOLS AND CHILDREN
WHY WE NEED TO PUT THE RISKS IN PERSPECTIVE
Over the past two months, Dr. Ronald Cohn has spoken with 18 summer camp directors, curious to hear how children were adjusting and reconnecting with other kids after a most unnatural year.
It normally takes a couple of days for children to get used to camp, the directors told Cohn. Most said this year it took 10. Cohn, president and CEO of Sickkids in Toronto, stressed the reports are purely anecdotal. Still, they fit with published data showing heightened levels of anxiety and depression among children and youth, the indirect, adverse impacts of this wearisome, hellish pandemic on children.
Again, it's anecdotal. But Sickkids infectious diseases specialist Dr. Ari Bitnun has teen patients who were online schooled the entire year — at home, near a fridge, rarely leaving the house — who gained a staggering 40 kilograms.
“When it comes to kids, what I think people have not done a good job of is looking at the overall wellbeing as important, as opposed to just focusing on COVID,” said Bitnun. “And it's become completely clear over the last year and a half that we're causing an immense amount of harm to kids by locking them in their homes.”
The Sickkids doctors have been fielding many emails lately. With more American children being admitted to hospital with COVID-19 in states with low vaccination uptake, and schools reopening in mere weeks, many parents are worrying: just how safe is it to send kids — especially the unvaccinated under-12s — back to class?
Delta is spreading. Case counts are up in some of Canada's most populous jurisdictions.
“National severity trends have begun to increase,” Canada's chief public health officer, Dr. Theresa Tam, reported in her Friday update, primarily involving the unvaccinated.
Deaths from COVID in children are extremely rare. Children tend to have mild symptoms, like headache and fatigue, or no symptoms whatsoever. But children can, and do, spread COVID. A pre-print paper published this week reports children of all ages can carry high SARSCOV-2 viral loads, whether or not they have symptoms, and that unvaccinated children have the potential “to serve as a community reservoir of actively replicating virus, with implications for both new waves of infection and the evolution of new variants.”
“I won't lie. I'm worried myself,” said Mcmaster University immunologist Dawn Bowdish. “I'm really worried about kids going back to school. I'm really worried not just about hospitalizations, but long-term health consequences.” It upsets her to see young people, six, eight, nine months after their infection, with lung damage, immune disorders and neurological issues. “It's extremely upsetting to me.”
Long COVID in children remains an enigma. The phenomenon first surfaced in adults, when people began reporting a bewildering array of symptoms — brain fog, breathlessness, headache, heart palpitations — weeks or months after what, in many cases, began with a mild bout of COVID. Data in children has been conflicting: a large study out of the United Kingdom found that long COVID does occur in school-aged children, but it's uncommon.
Of the 1,734 children studied, 4.4 per cent still had symptoms one month out, but by eight weeks almost all had recovered.
Another British study in April from the U.K. Office of National Statistics estimated closer to 10 per cent of two- to 11-year-olds, and 13 per cent of children aged 12 to 16 had at least one lingering symptom five weeks after a COVID diagnosis.
But, as Nature has reported, there's no one single set of agreed-upon diagnostic criteria for long COVID in adults, least of all children, and very few good studies are available to answer how it manifests in children, or how common it really is. “That's probably the most important question we need to learn in the next six to 12 months,” Cohn said. “How prevalent is long COVID? What does it actually look like?”
The other worry is Delta. Is it more virulent, more dangerous to children? Does it make them sicker than Alpha, formerly known as the U.K. variant, or the original strain?
Pediatric cases are rising in major children's hospitals in Florida, Texas, Missouri and Arkansas. But doctors told The Washington Post nearly all admissions involve children under 12 who are not yet eligible for the shots, or teens who put off being vaccinated. When there's high community transmission in areas with meagre vaccination uptake, it comes down to a numbers game: the more virus circulating, especially the hyper-contagious Delta, the more likely children are to get infected, with a small proportion of them sick enough to need hospital care. And as more adults are vaccinated, unvaccinated children will account for a bigger proportion of reported cases.
But there's no clear signal, at least as of now, that children are getting more severely sick from Delta, Cohn said.
In Canada, as of Aug. 13, children under 19 accounted for 15, or 0.1 per cent, of Covid-related deaths, and 1.9 per cent of hospitalizations since the start of the pandemic.
The country's doctors have seen more admissions related to a POST-COVID complication known as MIS-C, or multi-system inflammatory syndrome in children, than for COVID itself. With MIS-C, different parts of the body, like the heart, lungs, and kidneys, can become inflamed.
“While some of those kids can get very sick, most of them respond really quickly to treatment,” Bitnun said.
So far, the most common underlying risk factor for severe COVID in children appears to be obesity.
Despite the spike in U.S. cases, polls show American parents are clamouring for their kids to get back to inclass learning. The higher we can drive immunization rates of the 12 and older, putting a protective ring around children too young to be vaccinated (Pfizer and Moderna are testing their shots in children down to six-montholds) “the better off we will be,” Bitnun said. Masking, cohorting, upgraded ventilation, more robust testing when there is a positive case — a bundle of measures will help minimize the risk of widespread outbreaks when school resumes, said Cohn, who also supports mandating vaccines for teachers, the way vaccines have been mandated for Sickkids staff.
“Seventy per cent of our kids are not eligible to get vaccinated,” he said. The same is true for a large population of children in school.
Bitnun has a different perspective. It's not a science perspective, “it's more of a view of society and freedoms,” he said. “And I am very loath to impose on people things they don't want to do.”
Cohn worries we've lost a bit of perspective. When the pandemic hit, people suddenly began grappling with risk-benefit calculations. What's safe to do? What's not? Can I go see my grandmother? “We are not doing the same risk-benefit analysis when it comes to our children,” he said.
When he and Bitnun and “hundreds of our colleagues” argue that children need to be in school, they've been accused of suggesting that it's fine if a few kids get sick. “Of course it's not,” Cohn said. “Every single individual who gets sick and has to go to hospital, God forbid, is one too many. But what is the alternative? We've pretty much had children out of school here in Ontario for over half the year last year.”
The thought of keeping children home for another year is “intolerable, it's untenable to think about.”
No one should downplay the risks of COVID to children, he and others said. The risk-benefit analysis is different for every family, and it's seriously difficult to tolerate any risk when it comes to children. But “marinating in a toxic brine of fear and uncertainty can make us sick — whether from fatigue and insomnia or irritability and burnout,” Dr. Lucy Mcbride, a practising internist in Washington, D.C., wrote in The Atlantic. “And when our children hear us processing endless loops of what-if thinking, they can become worried and depressed too. Fixating on a single threat to children's health can keep us from recognizing their broad human needs.”
No one knows what the coming months will bring. But SARS-COV-2 isn't going away, Bitnun said. “At some point we're going to have to get used to it as another virus that is circulating. I don't know when that point is, but I think people need to start thinking about that.”