The coronavirus raging around the globe has tended to tread gently with children, who account for the smallest percentage of the infections identified so far. Now, reports The New York Times, the largest study to date of children and the virus has found that while most develop mild or moderate symptoms, a small percentage – especially babies and pre-schoolers – can become seriously ill.
The study by researchers at Shanghai Jiao Tong University School of Medicine, China Hospital Development Institute, Jiao Tong University School of Medicine, Anhui Medical University and Nanjing Medical University, looked at more than 2,000 ill children across China, where the pandemic began. It provides a clearer portrait of how the youngest patients are affected by the virus, knowledge that experts say can help influence policies like school closures, hospital preparedness and the deployment of an eventual treatment and vaccine.
The researchers analysed 2,143 cases of children under 18 that were reported to the Chinese Centres for Disease Control and Prevention as of 8 February. Just over a third of those cases were confirmed with laboratory testing. The rest were classified as suspected cases based on the child’s symptoms, chest X-rays, blood tests and whether the child had been exposed to people with coronavirus.
The report says about half of the children had mild symptoms, such as fever, fatigue, cough, congestion and possibly nausea or diarrhoea. More than a third – about 39% – became moderately sick, with additional symptoms including pneumonia or lung problems revealed by CT scan, but with no obvious shortness of breath. About 4% had no symptoms at all.
But there were 125 children – nearly 6% – who developed very serious illness, and one 14-year-old boy with confirmed coronavirus infection died, said Shilu Tong, the study’s senior author, who is director of the department of clinical epidemiology and biostatistics at Shanghai Children’s Medical Centre. Thirteen of those were considered “critical," on the brink of respiratory or organ failure. The others were classified as “severe” because they had dire respiratory problems.
“Effectively, what this tells us is that hospitals should prepare for some paediatric patients because we can’t rule out children altogether,” said Dr. Srinivas Murthy, an associate professor of paediatrics at the University of British Columbia, who was not involved in the study.
Abstract
Objectives: To identify the epidemiological characteristics and transmission patterns of pediatric patients with COVID-19 in China.
Methods: Nationwide case series of 2143 pediatric patients with COVID-19 reported to the Chinese Center for Disease Control and Prevention from January 16 to February 8, 2020 were included. The epidemic curves were constructed by key dates of disease onset and case diagnosis. Onset-to-diagnosis curves were constructed by fitting a log-normal distribution to data on both onset and diagnosis dates.
Results: There were 731 (34.1%) laboratory-confirmed cases and 1412 (65.9%) suspected cases. The median age of all patients was 7 years (interquartile range: 2-13), and 1213 cases (56.6%) were boys. Over 90% of all patients were asymptomatic, mild, or moderate cases. The median time from illness onset to diagnoses was 2 days (range: 0 to 42 days). There was a rapid increase of disease at the early stage of the epidemic and then there was a gradual and steady decrease. Disease rapidly spread from Hubei Province to surrounding provinces over time. More children were infected in Hubei province than any other province.
Conclusions: Children at all ages appeared susceptible to COVID-19, and there was no significant gender difference. Although clinical manifestations of children’s COVID-19 cases were generally less severe than those of adults’ patients, young children, particularly infants, were vulnerable to infection. The distribution of children’s COVID-19 cases varied with time and space, and most of the cases concentrated in Hubei province and surrounding areas. Furthermore, this study provides strong evidence for human-to-human transmission.
Authors
Yuanyuan Dong, Xi Mo, Yabin Hu, Xin Qi, Fang Jiang,a Zhongyi Jiang, Shilu Tonga
Reports of hospital admissions show that even among younger people this is a virus that can cause serious disease, writes Jonathan Ball is professor of molecular virology at the University of Nottingham in The Guardian.
Ball writes: “A study from the US shows that 38% of 508 patients hospitalised with coronavirus were aged between 20 and 54 (children under 19 accounted for less than 1% of the total admissions). Of these 508 patients, 121 were admitted to intensive care; nearly half of this group was under 65.”
Meanwhile, the World Health Organisation has warned that young people are not immune from coronavirus and must avoid socialising and communicating it to older, more vulnerable people. The choices made by the young can be "the difference between life and death for someone else", WHO director-general Tedros Adhanom Ghebreyesus is quoted in BBC News as saying. The WHO chief's remarks follow reports that young people in many countries are being complacent about health warnings, because of the greater susceptibility to the virus among older patients. Tedros said: "Although older people are hardest hit, younger people are not spared."
He added: "I have a message for young people: You are not invincible, this virus could put you in hospital for weeks or even kill you. Even if you don't get sick the choices you make about where you go could be the difference between life and death for someone else."
Dr Steven L Zeichner, the head of UVA Health's division of paediatric infectious diseases, and Dr Andrea T Cruz, a paediatric emergency medicine physician at Houston's Baylor College of Medicine have authored a commentary accompanying the research. "Many infectious diseases affect children differently than adults and understanding those differences can yield important insights," the commentary authors write. "This will likely be true for COVID-19, just as it was for older infectious diseases."
Zeichner and Cruz note that there are subgroups of children who appear to be at greater risk of COVID-19 complications, particularly those who are younger, immune-compromised or have other pulmonary health problems. However, the presence of other viral infections in up to two-thirds of childhood coronavirus cases makes it very difficult to assess the true effect of COVID-19 on children, they state.
While much remains unknown, Cruz and Zeichner caution that children, even asymptomatic children, could play a "major role" in disease transmission. For example, they cite a study that found the virus remained in children's stool for several weeks after diagnosis. That, combined with other routes of transmission such as nasal secretions, could pose a major challenge for schools, day care centres and the children's families, they note.
"Since many children infected with COVID-19 appear to havemild symptoms, or even no symptoms at all, it is important to practice all the social distancing, hygiene and other precautions being recommended by public health authorities to minimize transmission from children to others, including family members who may be at greater risk from the infection, such as grandparents or family members with chronic medical conditions," said Zeichner, who is working on innovative potential COVID-19 vaccines in his lab.
"In addition, studies of the reasons why children are affected differently than adults by the infection may yield insights that can be helpful in understanding the disease and ways to treat or prevent it."
[link url="https://www.nytimes.com/2020/03/17/health/coronavirus-childen.html"]Full report in The New York Times[/link]
[link url="https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf"]Pediatric abstract[/link]
[link url="https://www.theguardian.com/commentisfree/2020/mar/23/scientists-effects-coronavirus-children-studies-carriers?CMP=Share_iOSApp_Other"]The Guardian[/link]
[link url="https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w"]CDC study[/link]
[link url="https://www.bbc.com/news/world-51982495"]Full BBC News report[/link]
[link url="https://www.sciencedaily.com/releases/2020/03/200319125201.htm"]University of Virginia Health System material[/link]
[link url="https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0834.full.pdf"]Pediatrics abstract[/link]