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With so much attention on #COVID19 in children, time for an updated #tweetorial on what we do and don't know!
We'll talk impact, risk, hyperinflammation syndrome, transmission, schools and more
Lets go!
1/21
We'll talk impact, risk, hyperinflammation syndrome, transmission, schools and more
Lets go!
1/21
Children remain grossly underrepresented in all case numbers, hospital admissions and deaths worldwide
See latest ISARIC report of >15,000 severe cases, or @PHE_uk UK deaths
https://media.tghn.org/medialibrary/2020/05/ISARIC_Data_Platform_COVID-19_Report_6MAY20.pdf
https://publichealthmatters.blog.gov.uk/2020/04/23/coronavirus-covid-19-using-data-to-track-the-virus/
2/21
See latest ISARIC report of >15,000 severe cases, or @PHE_uk UK deaths
https://media.tghn.org/medialibrary/2020/05/ISARIC_Data_Platform_COVID-19_Report_6MAY20.pdf
https://publichealthmatters.blog.gov.uk/2020/04/23/coronavirus-covid-19-using-data-to-track-the-virus/
2/21
This report from @sunilbhop and friends looks at child deaths from #COVID19 compared to other causes to put them in perspective
Of ~37,000 child deaths, 43 were from COVID19
In the words of @d_spiegel , children are "unbelievably low risk"
3/21 https://twitter.com/sunilbhop/status/1262315964898697217?s=20
Of ~37,000 child deaths, 43 were from COVID19
In the words of @d_spiegel , children are "unbelievably low risk"
3/21 https://twitter.com/sunilbhop/status/1262315964898697217?s=20
Are some children higher risk?
Small numbers, but children usually at risk from viral respiratory infections look equally at risk from #COVID19, including tech dependent, neurodisability, malignancy or chronic lung disease
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037
https://www.jpeds.com/article/S0022-3476(20)30580-1/fulltext
4/21
Small numbers, but children usually at risk from viral respiratory infections look equally at risk from #COVID19, including tech dependent, neurodisability, malignancy or chronic lung disease
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037
https://www.jpeds.com/article/S0022-3476(20)30580-1/fulltext
4/21
Important to note outcomes still pretty good for these groups, and there a number of documented cases for some (e.g. oncology, immunosuppressed) which had a predominantly mild clinical course
Even most of these children don't get very sick
https://jamanetwork.com/journals/jamaoncology/fullarticle/2766112
5/21
Even most of these children don't get very sick
https://jamanetwork.com/journals/jamaoncology/fullarticle/2766112
5/21
What about this hyperinflammatory syndrome?
It's called PIMS-TS (or MIS-C in the USA)
It seems to be an immune reaction after COVID19 infection (approx 2 - 4 weeks)
Usually starts with persistent fever, abdo pain and D&V, then can present similar to Kawasakis (+/- shock)
6/21
It's called PIMS-TS (or MIS-C in the USA)
It seems to be an immune reaction after COVID19 infection (approx 2 - 4 weeks)
Usually starts with persistent fever, abdo pain and D&V, then can present similar to Kawasakis (+/- shock)
6/21
We currently have 3 published cohorts from London, Italy and France
Many kids get very sick, but most recover well
It seems to be dissipating (following trends in peaks of infection)
Read more about it here
https://dontforgetthebubbles.com/pims-ts/
7/21
Many kids get very sick, but most recover well
It seems to be dissipating (following trends in peaks of infection)
Read more about it here
https://dontforgetthebubbles.com/pims-ts/
7/21
It can be serious, but is incredibly rare
In Europe there have been about 230 cases and very few deaths. There are >80 million children
Europe CDC considers it a low risk. Be reassured
https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-risk-assessment-paediatric-inflammatory-multisystem-syndrome-15-May-2020.pdf
8/21
In Europe there have been about 230 cases and very few deaths. There are >80 million children
Europe CDC considers it a low risk. Be reassured
https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-risk-assessment-paediatric-inflammatory-multisystem-syndrome-15-May-2020.pdf
8/21
OK - transmission. Let's go step by step.
How easily to children catch it?
5 studies have looked at transmission to children (mainly household) and 4/5 found *significantly lower* attack rates in children than adults
https://dontforgetthebubbles.com/the-missing-link-children-and-transmission-of-sars-cov-2/
9/21
How easily to children catch it?
5 studies have looked at transmission to children (mainly household) and 4/5 found *significantly lower* attack rates in children than adults
https://dontforgetthebubbles.com/the-missing-link-children-and-transmission-of-sars-cov-2/
9/21
How many children actually have/had COVID19?
<2% of known cases have been in children, but given symptoms are so mild have we just missed them all? Are they mainly asymptomatic? Are they silent assassins?
This is harder to tell, but there is some evidence...
10/21
<2% of known cases have been in children, but given symptoms are so mild have we just missed them all? Are they mainly asymptomatic? Are they silent assassins?
This is harder to tell, but there is some evidence...
10/21
Iceland tested those at risk and found 1/2 rate of infection in children <10y compared to adults, and 0 cases in asymptomatic screening
https://www.nejm.org/doi/full/10.1056/NEJMoa2006100
Vo, Italy screened >85% of the population. 2.6% had COVID19, but 0 children <10y
https://www.medrxiv.org/content/10.1101/2020.04.17.20053157v1
11/21
https://www.nejm.org/doi/full/10.1056/NEJMoa2006100
Vo, Italy screened >85% of the population. 2.6% had COVID19, but 0 children <10y
https://www.medrxiv.org/content/10.1101/2020.04.17.20053157v1
11/21
Some say ONS data shows there's no difference between children and adult infection rates
But they found ~30 positive cases in 10,000 people
The CIs are too wide for inference about relative infection rates (compatible with 10x rates in any group)
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/england14may2020?WT.mc_id=9e5557c21c93a6f19d36bf985082f4de&WT.sn_type=TWITTER&hoot.message=There%20is%20currently%20no%20evidence%20that%20age%20affects%20the%20likelihood%20of%20being%20infected%20with%20COVID-19%20%5BLINK%5D&hoot.send_date=2020-05-14%2013%3A15%3A14&hoot.username=ONS&hoot.send_dayofweek=Thursday&hoot.send_hour=13&hootPostID=602e6bfaca6d5de6b869e70e6e9a7230#main-points
12/21
But they found ~30 positive cases in 10,000 people
The CIs are too wide for inference about relative infection rates (compatible with 10x rates in any group)
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/england14may2020?WT.mc_id=9e5557c21c93a6f19d36bf985082f4de&WT.sn_type=TWITTER&hoot.message=There%20is%20currently%20no%20evidence%20that%20age%20affects%20the%20likelihood%20of%20being%20infected%20with%20COVID-19%20%5BLINK%5D&hoot.send_date=2020-05-14%2013%3A15%3A14&hoot.username=ONS&hoot.send_dayofweek=Thursday&hoot.send_hour=13&hootPostID=602e6bfaca6d5de6b869e70e6e9a7230#main-points
12/21
The same principle applies for 2 sero-epi studies from Switzerland & Germany
Despite lower rates of infection in children, numbers too small to be statistically significant
This is not evidence for equal rates of infection
https://www.medrxiv.org/content/10.1101/2020.05.02.20088898v1
https://www.medrxiv.org/content/10.1101/2020.05.04.20090076v1
13/21
Despite lower rates of infection in children, numbers too small to be statistically significant
This is not evidence for equal rates of infection
https://www.medrxiv.org/content/10.1101/2020.05.02.20088898v1
https://www.medrxiv.org/content/10.1101/2020.05.04.20090076v1
13/21
What do we find if we do proper sized sero-epi?
Infection rates of 1-3% in children compared to 5% in adults in a Spanish study of >60,000 people
https://www.ciencia.gob.es/stfls/MICINN/Ministerio/FICHEROS/ENECOVID_Informe_preliminar_cierre_primera_ronda_13Mayo2020.pdf
14/21
Infection rates of 1-3% in children compared to 5% in adults in a Spanish study of >60,000 people
https://www.ciencia.gob.es/stfls/MICINN/Ministerio/FICHEROS/ENECOVID_Informe_preliminar_cierre_primera_ronda_13Mayo2020.pdf
14/21
How infectious are children when infected?
Hard to say. Some examples of children not spreading at all despite multiple exposures (>100 other children) but spreading other respiratory viruses
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa424/5819060
15/21
Hard to say. Some examples of children not spreading at all despite multiple exposures (>100 other children) but spreading other respiratory viruses
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa424/5819060
15/21
A German study claimed to find similar viral loads in children as adults, stating they're "just as infectious"
https://zoonosen.charite.de/fileadmin/user_upload/microsites/m_cc05/virologie-ccm/dateien_upload/Weitere_Dateien/analysis-of-SARS-CoV-2-viral-load-by-patient-age.pdf
Amongst other issues, if analysed properly the data actually showed significantly lower viral loads in children
https://osf.io/bkuar/
16/21
https://zoonosen.charite.de/fileadmin/user_upload/microsites/m_cc05/virologie-ccm/dateien_upload/Weitere_Dateien/analysis-of-SARS-CoV-2-viral-load-by-patient-age.pdf
Amongst other issues, if analysed properly the data actually showed significantly lower viral loads in children
https://osf.io/bkuar/
16/21
National reports from Netherlands
https://www.rivm.nl/en/novel-coronavirus-covid-19/children-and-covid-19
Iceland
https://www.eapaediatrics.eu/eap-blog-covid-19-series-5-icelands-data-on-the-infectivity-of-children-cross-infection-risk/
Norway
https://www.fhi.no/contentassets/c9e459cd7cc24991810a0d28d7803bd0/notat-om-risiko-og-respons-2020-05-05.pdf
Australia
http://ncirs.org.au/sites/default/files/2020-04/NCIRS%20NSW%20Schools%20COVID_Summary_FINAL%20public_26%20April%202020.pdf
Have found limited evidence of children contributing to spread of COVID19. Most transmission is adult to adult.
17/21
https://www.rivm.nl/en/novel-coronavirus-covid-19/children-and-covid-19
Iceland
https://www.eapaediatrics.eu/eap-blog-covid-19-series-5-icelands-data-on-the-infectivity-of-children-cross-infection-risk/
Norway
https://www.fhi.no/contentassets/c9e459cd7cc24991810a0d28d7803bd0/notat-om-risiko-og-respons-2020-05-05.pdf
Australia
http://ncirs.org.au/sites/default/files/2020-04/NCIRS%20NSW%20Schools%20COVID_Summary_FINAL%20public_26%20April%202020.pdf
Have found limited evidence of children contributing to spread of COVID19. Most transmission is adult to adult.
17/21
What does it mean for schools?
https://adc.bmj.com/content/early/2020/05/19/archdischild-2020-319474
Children can get COVID19 so can almost certainly spread it
But, they are barely affected by infection, and appear less likely to catch or spread it than adults
Schools seem lower risk than adult work environments
18/21
https://adc.bmj.com/content/early/2020/05/19/archdischild-2020-319474
Children can get COVID19 so can almost certainly spread it
But, they are barely affected by infection, and appear less likely to catch or spread it than adults
Schools seem lower risk than adult work environments
18/21
Will outbreaks happen? Of course.
But this is our new reality for the foreseeable future. We need to mitigate against the risks and ensure mechanisms for quick response (track/trace/isolate) are in place
Children suffer harm from lockdown
https://bmjpaedsopen.bmj.com/content/4/1/e000701
19/21
But this is our new reality for the foreseeable future. We need to mitigate against the risks and ensure mechanisms for quick response (track/trace/isolate) are in place
Children suffer harm from lockdown
https://bmjpaedsopen.bmj.com/content/4/1/e000701
19/21
Now for WHY children seem so much less affected...
Still no clear answers. Possible differences in ACE2 expression, but they seem small
https://jamanetwork.com/journals/jama/fullarticle/2766524?utm_source=twitter&utm_campaign=content-shareicons&utm_content=article_engagement&utm_medium=social&utm_term=052020#.XsVklEVpvmF.twitter
Some suggest immune differences. Need to be proven.
https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30135-8/fulltext
More research needed...!
20/21
Still no clear answers. Possible differences in ACE2 expression, but they seem small
https://jamanetwork.com/journals/jama/fullarticle/2766524?utm_source=twitter&utm_campaign=content-shareicons&utm_content=article_engagement&utm_medium=social&utm_term=052020#.XsVklEVpvmF.twitter
Some suggest immune differences. Need to be proven.
https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30135-8/fulltext
More research needed...!
20/21
Thanks for making it to the end!
For our comprehensive review of all paediatric #COVID19 literature (cited by @UKRI_News and @WHO ) check it out here on @DFTBubbles
https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
21/21
For our comprehensive review of all paediatric #COVID19 literature (cited by @UKRI_News and @WHO ) check it out here on @DFTBubbles
https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
21/21
