Kids and Covid – What We Know and Don’t Know

This article was originally published at https://khn.org/news/article/scientists-examine-kids-unique-immune-systems-as-more-fall-victim-to-covid/ and is republished here with permission.

Scientists Examine Kids’ Unique Immune Systems as More Fall Victim to Covid

By Liz Szabo September 17, 2021

Eighteen months into the covid-19 pandemic, with the delta variant fueling a massive resurgence of disease, many hospitals are hitting a heartbreaking new low. They’re now losing babies to the coronavirus.

The first reported covid-related death of a newborn occurred in Orange County, Florida, and an infant has died in Mississippi. Merced County in California lost a child under a year old in late August.

“It’s so hard to see kids suffer,” said Dr. Paul Offit, an expert on infectious diseases at Children’s Hospital of Philadelphia, which — like other pediatric hospitals around the country — has been inundated with covid patients.

Until the delta variant laid siege this summer, nearly all children seemed to be spared from the worst ravages of covid, for reasons scientists didn’t totally understand.

Although there’s no evidence the delta variant causes more severe disease, the virus is so infectious that children are being hospitalized in large numbers — mostly in states with low vaccination rates. Nearly 30% of covid infections reported for the week that ended Sept. 9 were in children, according to the American Academy of Pediatrics.

Doctors diagnosed more than 243,000 cases in children in the same week, bringing the total number of covid infections in kids under 18 since the onset of the pandemic to 5.3 million, with at least 534 deaths.

Experts say it’s a question of basic math. “If 10 times as many kids are infected with delta than previous variants, then, of course, we’re going to see 10 times as many kids hospitalized,” said Dr. Dimitri Christakis, director of the Center for Child Health, Behavior and Development at the Seattle Children’s Research Institute.

But the latest surge gives new urgency to a question that has mystified scientists throughout the pandemic: What protects most children from becoming seriously ill? And why does that protection sometimes fail?

“This is an urgent and complex question,” said Dr. Bill Kapogiannis, senior medical officer and infectious-disease expert at the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

“We are doing everything we can to address it, using all the tools we have available,” Kapogiannis said. “Answers can’t come soon enough.”

Investigating Immune Systems

For much of the pandemic, doctors could only guess why children’s immune systems were so much more successful at rebuffing the coronavirus.

Despite the alarming number of hospitalized children in the recent surge, young people are much less likely to become critically ill. Fewer than 1% of children diagnosed with covid are hospitalized and about 0.01% die — rates that haven’t changed in recent months, according to the American Academy of Pediatrics. Most children shrug off the virus with little more than a sniffle.

A growing body of evidence suggests that kids’ innate immune systems usually nip the infection early on, preventing the virus from gaining a foothold and multiplying unchecked, said Dr. Lael Yonker, an assistant professor of pediatrics at Massachusetts General Hospital.

In a series of studies published in the past year, the husband-and-wife team of Drs. Betsy and Kevan Herold found that children have particularly strong mucosal immunity, so called because the key players in this system are not in the blood but in the mucous membranes that line the nose, throat and other parts of the body that frequently encounter germs.

These membranes act like the layered stone walls that protected medieval cities from invaders. They’re made of epithelial cells — these also line many internal organs — which sit side by side with key soldiers in the immune system called dendritic cells and macrophages, said Betsy Herold, chief of the division of pediatric infectious diseases at the Albert Einstein College of Medicine.

Significantly, these cells are covered in proteins — called pattern recognition receptors — that act like sentries, continuously scanning the landscape for anything unusual. When the sentries notice something foreign — like a new virus — they alert cells to begin releasing proteins called interferons, which help coordinate the body’s immune response.

In an August study in Nature Biotechnology, Roland Eils and his colleagues at Germany’s Berlin Institute of Health found that kids’ upper airways are “pre-activated” to fight the novel coronavirus. Their airways are teeming with these sentries, including ones that excel at recognizing the coronavirus.

That allows kids to immediately activate their innate immune system, releasing interferons that help shut down the virus before it can establish a foothold, Eils said.

In comparison, adults have far fewer sentinels on the lookout and take about two days to respond to the virus, Eils said. By that time, the virus may have multiplied exponentially, and the battle becomes much more difficult.

When innate immunity fails to control a virus, the body can fall back on the adaptive immune system, a second line of defense that adapts to each unique threat. The adaptive system creates antibodies, for example, tailored to each virus or bacterium the body encounters.

While antibodies are some of the easiest pieces of the immune response to measure, and therefore often cited as proxies for protection, kids don’t seem to need as many to fight covid, Betsy Herold said. In fact, the Herolds’ research shows that children with covid have fewer neutralizing antibodies than adults. (Both kids and adults usually make enough antibodies to thwart future coronavirus infections after natural infection or vaccination.)

While the adaptive immune system can be effective, it can sometimes cause more harm than good.

Like soldiers who kill their comrades with friendly fire, a hyperactive immune system can cause collateral damage, triggering an inflammatory cascade that tramples not just viruses, but also healthy cells throughout the body.

In some covid patients, uncontrolled inflammation can lead to life-threatening blood clots and acute respiratory distress syndrome, which occurs when fluid builds up in the air sacs of the lung and makes it difficult to breathe, Betsy Herold said. Both are common causes of death in adult covid patients.

Because kids typically clear the coronavirus so quickly, they usually avoid this sort of dangerous inflammation, she said.

Research shows that healthy children have large supplies of a type of peacekeeper cell, called innate lymphoid cells, that help calm an overactive immune system and repair damage to the lungs, said Dr. Jeremy Luban, a professor at the University of Massachusetts Medical School.

Kids are born with lots of these cells, but their numbers decline with age. And both children and adults who are sick with covid tend to have fewer of these repair cells, Luban said.

Men also have fewer repair cells than women, which could help explain why males have a higher risk of dying from covid than females.

Both children and adults can develop “long covid,” the lingering health issues experienced by about 10% of younger adults and up to 22% of those 70 and older. Studies suggest that 4% to 11% of kids have persistent symptoms.

Unanswered Questions

Scientists have fewer clues about what goes wrong in certain children with covid, said Kevan Herold, who teaches immunobiology at the Yale School of Medicine.

Research suggests that children have more robust innate immune systems than adults because they have experienced so many recent respiratory infections, within their first few years, which may prime their immune systems for subsequent attacks.

But not all children shrug off covid so easily, Eils said. Newborns haven’t been alive long enough to prime their immune systems for battle. Even toddlers may fail to mount a strong response, he said.

At Children’s Hospital New Orleans, half of covid patients are under 4, said Dr. Mark Kline, a specialist in infectious diseases and physician-in-chief.

“We’ve had babies as young as 7 weeks, 9 weeks old in the ICU on ventilators,” Kline said. “We had a 3-month-old who required ECMO,” or extracorporeal membrane oxygenation, in which the patient is connected to a machine similar to the heart-lung bypass machine used in open-heart surgery.

Even previously healthy children sometimes die from respiratory infections, from covid to influenza or respiratory syncytial virus.

But studies have found that 30% to 70% of children hospitalized with covid had underlying conditions that increase their risk, such as Down syndrome, obesity, lung disease, diabetes or immune deficiencies. Premature babies are also at higher risk, as are children who’ve undergone cancer treatment.

One thing hospitalized kids have in common is that almost none are vaccinated, said Dr. Mary Taylor, chair of pediatrics at the University of Mississippi Medical Center.

“There’s really no way to know which child with covid will get a cold and be just fine and which child will be critically ill,” Taylor said. “It’s just a very helpless sensation for families to feel like there is nothing they can do for their child.”

Although scientists have identified genetic mutations associated with severe covid, these variants are extremely rare.

Scientists have had more success illuminating why certain adults succumb to covid.

Some cases of severe covid in adults, for example, have been tied to misguided antibodies that target interferons, rather than the coronavirus. An August study in ScienceImmunology reported that such “autoantibodies” contribute to 20% of covid deaths.

Autoantibodies are very rare in children and young adults, however, and unlikely to explain why some youngsters succumb to the disease, said study co-author Dr. Isabelle Meyts, a pediatric immunologist at the Catholic University of Leuven in Belgium.

Although hospitalizations are declining nationwide, some of the most serious consequences of infection are only now emerging.

Two months into the delta surge, hospitals throughout the South are seeing a second wave of children with a rare but life-threatening condition called multisystem inflammatory syndrome, or MIS-C.

Unlike kids who develop covid pneumonia — the major cause of hospitalizations among children — those with MIS-C typically have mild or asymptomatic infections but become very ill about a month later, developing symptoms such as nausea, vomiting, a rash, fever and diarrhea. Some develop blood clots and dangerously low blood pressure. More than 4,661 children have been diagnosed with MIS-C and 41 have died, according to the Centers for Disease Control and Prevention.

Although scientists still don’t know the exact cause of MIS-C, research by Yonker of Massachusetts General and others suggests that viral particles may leak from the gut into the bloodstream, causing a system reaction throughout the body.

It’s too soon to tell whether children who survive MIS-C will suffer lasting health problems, said Dr. Leigh Howard, a specialist in pediatric infectious diseases at Vanderbilt University Medical Center.

Although an August study in The Lancet shows that delta doubles the risk of hospitalization in adults, scientists don’t know whether that’s true for kids, said Dr. Anthony Fauci, the country’s top infectious-disease official.

“We certainly don’t know at this point whether children have more severe disease, but we’re keeping our eye on it,” he said.

To protect children, Fauci urged parents to vaccinate themselves and children age 12 and up. As for children too young for covid shots, “the best way to keep them safe is to surround them by people who are vaccinated.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Tiny (and not so tiny) Human Disease Vectors – the Princeton-led Study

Children and young adults were found to be potentially much more important to transmitting the virus — especially within households — than previous studies have identified, according to a paper by researchers from the United States and India published Sept. 30 in the journal Science.

Researchers from the Princeton Environmental Institute (PEI), Johns Hopkins University and the University of California, Berkeley, worked with public health officials in the southeast Indian states of Tamil Nadu and Andhra Pradesh to track the infection pathways and mortality rate of 575,071 individuals who were exposed to 84,965 confirmed cases of COVID-19, the disease caused by SARS-CoV-2. It is the largest contact tracing study — which is the process of identifying people who came into contact with an infected person — conducted in the world for any disease.

Lead researcher Ramanan Laxminarayan, a senior research scholar in PEI, said that the paper is the first large study to capture the extraordinary extent to which SARS-CoV-2 hinges on “superspreading,” in which a small percentage of the infected population passes the virus on to more people. The researchers found that 71% of infected individuals did not infect any of their contacts, while a mere 8% of infected individuals accounted for 60% of new infections.

Largest COVID-19 contact tracing study to date finds children key to spread, evidence of superspreaders — https://www.princeton.edu/news/2020/09/30/largest-covid-19-contact-tracing-study-date-finds-children-key-spread-evidence

My original Tiny Human Disease Vector post is below:

Twelve children acquired COVID-19 in child care facilities. Transmission was documented from these children to at least 12 (26%) of 46 nonfacility contacts (confirmed or probable cases). One parent was hospitalized. Transmission was observed from two of three children with confirmed, asymptomatic COVID-19.

Transmission Dynamics of COVID-19 Outbreaks Associated with Child Care Facilities — Salt Lake City, Utah, April–July 2020 — https://www.cdc.gov/mmwr/volumes/69/wr/mm6937e3.htm?s_cid=mm6937e3_w

Handing out sugar to tiny humans this year is not happening at our house. AND Thanksgiving is going to be very, very tricky this year.

Tiny Human Disease Vectors

Twelve children acquired COVID-19 in child care facilities. Transmission was documented from these children to at least 12 (26%) of 46 nonfacility contacts (confirmed or probable cases). One parent was hospitalized. Transmission was observed from two of three children with confirmed, asymptomatic COVID-19.

Transmission Dynamics of COVID-19 Outbreaks Associated with Child Care Facilities — Salt Lake City, Utah, April–July 2020 — https://www.cdc.gov/mmwr/volumes/69/wr/mm6937e3.htm?s_cid=mm6937e3_w

Children are Silent Spreaders of Covid-19

“I was surprised by the high levels of virus we found in children of all ages, especially in the first two days of infection,” says Lael Yonker, MD, director of the MGH Cystic Fibrosis Center and lead author of the study, “Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Reponses,” published in the Journal of Pediatrics. “I was not expecting the viral load to be so high. You think of a hospital, and of all of the precautions taken to treat severely ill adults, but the viral loads of these hospitalized patients are significantly lower than a ‘healthy child’ who is walking around with a high SARS-CoV-2 viral load.”

Massachusetts General Hospital. “Researchers show children are silent spreaders of virus that causes COVID-19: Comprehensive pediatric study examines viral load, immune response and hyperinflammation in pediatric COVID-19.” ScienceDaily. http://www.sciencedaily.com/releases/2020/08/200820102442.htm (accessed August 20, 2020).

This article is a must read for parents and politicians. In person school around the country has started. Be prepared in case your kid brings back more than just homework from school.

COVID-19 Cases in Children Up 90% in Four Weeks

Screenshot_2020-08-13 COVID-19 Cases in Children Nearly Doubled in Just 4 Weeks

The joint report from the AAP and the Children’s Hospital Association draws on data from state and local health departments in 49 states, New York City, the District of Columbia, Puerto Rico, and Guam.  The cumulative number of COVID-19 cases in children as of Aug. 6, 2020, was 380,174, and that number is 90% higher – an increase of 179,990 cases – than the total on July 9, just 4 weeks earlier, the two organizations said in the report.

Yikes!

Many Children With COVID-19 Present Without Classic Symptoms

“I was not surprised by the finding that most children did not present with the classic symptoms of COVID-19 in adults based on other published studies and my personal clinical experience taking care of hospitalized children in New York City,” said Dr. Lee. “Studies from the U.S. and other countries have reported that fewer children experience fever, cough, and shortness of breath [compared with] adults, and that most children have a milder clinical course, though there is a small percentage of children who can have severe or critical illness,” she said.

  Many Children With COVID-19 Present Without Classic Symptoms

Tiny human disease vectors.

Yikes!

Covid-19 – Truth vs Lies and Misinformation

The strongest weapon we have against pandemic is telling the truth.

I continue rounding on my other COVID patients, recalling an article that I’d just read about how coronavirus didn’t affect the 17,000 children infected with it in Florida because coronavirus doesn’t affect children.

  “COVID doesn’t affect children.” You may want to rethink that.

Naturally I tend to focus on infection numbers where I live.  The 17,000 number in Florida shocked me so I went online to verify the number.

But these figures continue on the rise. According to state data released by the Florida Department of Health, Florida has tested 173,520 state residents under the age of 18 for COVID-19, the illness caused by the novel coronavirus. Of those tests, the number has gone up from 17,000 reported last Friday to 23,170 tests that came back positive.

UPDATED: More Than 23,000 Children Have Tested Positive for COVID-19 in Florida

I was wrong.  The number of children infected with Covid-19 in Florida is higher than 17,000.  I wish I had more cheerful news on this Sunday but the truth must be told.  We all need to cut through the noise to see the truth.

After a unanimous vote at a commissioner’s meeting to make masks mandatory, residents of Palm Beach County in Florida erupted in anger, which included threatening to arrest a doctor for “crimes against humanity” for their vote. Two Twitter accounts — BadMedicalTakes and BadCOVID19Takes – a YouTube study, and Facebook posts promoting bogus COVID-19 cures highlight some of the public health misinformation being spread on social media platforms. The political nature of wearing face masks for public health safety has resulted in misinformation about their effectiveness. Those who wrongly believe face masks have detrimental respiratory effects are interfering with the ability to scale our nation’s public health response. During this unprecedented time of dealing with a viral outbreak and its economic effects on such a large scale, our nation should be experiencing strong unity in championing public health safety measures. Instead, the decision to wear a mask outside the home is influenced by gender, political party, and education level.

COVID-19 misinformation is a public health crisis

It came as a complete surprise that I would stumble upon my calling and purpose on this Sunday.  I’m not young anymore and I’ve been thinking a lot about how to structure my retirement.  I admit to reading a lot (maybe too much) and the pandemic has tightened my focus on the virus.  I never envisioned my reading/research and sharing on social media would become my calling at this stage in life.

But it’s what I do.  I hope you benefit from my work and that it helps you cut through the bullshit making this pandemic way worse than it ever should have been.

WAR IS PEACE

FREEDOM IS SLAVERY

IGNORANCE IS STRENGTH

George Orwell – 1984

Masks are sexy.  Wear a mask.

 

Researchers report nearly 300 cases of inflammatory syndrome tied to Covid-19 in kids

Researchers report nearly 300 cases of inflammatory syndrome tied to Covid-19 in kids

Addendum to Post Pandemic Changes in Consumer Behavior.

Home schooling.  A lot more home schooling.

With approximately 1000 cases of MIS-C (including, here and below, those that have been classified as PIMS-TS) reported worldwide, do we now have a clear picture of the new disorder, or, as in the story of the blind men and the elephant, has only part of the beast been described? What are its cause and pathogenesis? How should it be diagnosed and treated, and are there wider implications for our understanding of Covid-19?

Link to the NEJM article.

Update 07.02.20

COVID-19 in Kids: New Neurologic, Radiographic Findings