Are children much less susceptible to COVID-19?

In the column, the author deliberates upon the issues of Covid-19 in children, the status of pediatric vaccines, risks and benefits of schools re-opening, and the scenario about booster vaccine shots.

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Are children much less susceptible to COVID-19 compared to adults? Is the risk negligible? If the majority of adult population has been vaccinated, can we send our kids to schools for the inevitable in-person classes?

It's not just academicians, parents and media persons who are still perplexed about these confounding issues. Many health experts and scientists are racking their brains to get clear-cut answers to these conundrums. What do we know so far?

There are divergent opinions about the impacts of Covid-19 on kids. But a consensus opinion is that, as far as infections are concerned, children are as susceptible as adults. They may also suffer from effects of Long Covid. However, several studies indicate that children may be at lower risk of developing serious illness and post-Covid complications (Long COVID).

The extent of COVID infections differ from country to country or from one region to another. In Indonesia, 13 per cent of infections in August 2021 were under 18, with a case fatality rate (CFR) of one per cent (BMJ, Sep. 24, 2021). In the US, children accounted for about 14.6 per cent of all cumulative cases till 26 August, according to the American Academy of Pediatrics, but the CFR in the recent surge was only 0.24 per cent.

In India, data about hospitalizations and deaths among children are lacking; with only a few states e.g. Karnataka, Tamil Nadu, and Kerala having published age-wise data. However, some NE states e.g. Meghalaya had the highest CFR (8.3 per cent) in the first wave and in this state, 22 per cent of total infections till August were in young people under 18. As per the BMJ report, of the 430,000 deaths from the COVID-19 pandemic in India, only 1,500 were of children.

Covid infections in children are usually asymptomatic or mildly symptomatic. But children with comorbidities (diabetes, asthma, GI conditions) may be more prone to dying if infected. One must also note that an NIDM panel says that the pediatric facilities in India are not "robust enough to treat children on a large scale." As vaccines for young people under 18 is still not available in India, special care must be taken for children living in areas where the adult vaccination rates are low.

Another news report says that Covid cases among children are rising in India, with the national average over 7 per cent (IT, Sep. 15, 2021). It says that, as the 2nd wave subsides and schools reopen in many states, there has been a gradual rise in Covid cases among children below the age of 10. Till pediatric vaccines arrive, parents and guardians must ensure that children wear masks while visiting outdoors and follow Covid-appropriate behaviour (CAB) including hand hygiene and social distancing etc.

Multisystem Inflammatory Syndrome in Children (MIS-C)

Children may also be affected by a post-COVID complication called MIS-C. It is a hyper inflammatory condition that may damage several organs such as heart, lungs, kidneys, eyes, brain, skin or GI organs. It's usually detected in children 2-6 weeks after infection; in severe cases, it could prove fatal. According to a paper published in the journalIndian Pediatrics, early detection and ICU admission may lead to a lower mortality rate. Children who recover from MIS-C may also take longer time to recover from tropical or seasonal infections e.g. dengue, pneumonia or hepatitis-A (BMJ, Sep. 24, 2021).

AmedRxiv preprint(Borel, M et al., 2021) reported several long-term effects of Covid infections in children. These effects include fatigue, joint pain, myalgia, headache, breathing problems, lack of focus, and sleep disturbances etc. The lack of social interactions may also lead to worsening of emotional, mental, and behavioral profile.

Another difficulty in children is how to distinguish Covid symptoms from that of the common cold. Fever, runny nose, sore throat, headache, cough, and GI problems are common in both the conditions. Loss of smell and taste is not usually found in Covid-infected kids. The only unique symptom in children and teens with Covid infections could be "Covid toes" (pinkish skin lesions, especially on the toes), but this condition is also very rare.

Pediatric Vaccines

Zydus Cadila's ZyCoV-D vaccine got EUA from DCGI in August but it has not been rolled out yet. It's a 3-dose DNA vaccine for people aged 12 and above. The company aims to produce about 100-120 million doses annually (The Mint, Sep. 24, 2021).

Pediatric Covaxin is also in the final stages of trial. The results will be submitted soon and the subject expert committee (SEC) will analyze the data and recommend it for approval, if the data are found satisfactory. Hopefully, the children's version of Covaxin will also be approved soon.

School Re-Opening

Several states in India have decided to re-open schools considering the low positivity rates and the lower risks of COVID in children. Karnataka had opened in-person classes for classes VI-XII recently. As a significant rise in cases was not observed among school children, the state is now mulling the reopening of schools for classes I-V (IE, Sep. 23, 2021).

However, there are too many imponderables for an overall prediction of the safety of re-opening. One factor is the rate of adult vaccinations. With less than 20 per cent of India's population fully vaccinated, the BMJ report (cited above) quotes many medical experts as saying that "opening schools at the moment might be 'premature'."

Booster Shots

Israel has gone ahead with booster doses for all people above the age of 12. Several other countries have also rolled out booster doses for various age groups. UK has approved booster shots for individuals over the age of 50.

Now the US has also approved booster shots of the Pfizer vaccine for certain categories of its population (CNBC, Sep. 24, 2021). On Friday, the CDC gave its approval (FDA had stamped its seal of approval a few days earlier). What categories are eligible for the booster doses? Those elegible for booster doses include:

1. People who're 65 or older: they must have taken 2 doses of the vaccine; the second dose must have been administered at least 6 months ago.

2. People of age 50-64: those with underlying conditions e.g. diabetes, cancer or heart conditions.

3. People aged 18-49: those with underlying conditions e.g. sickle cell disease, HIV infection, obesity, smoking, drug abuse, or pregnancy etc.

4. Any other category of people at high risk: healthcare workers, teachers, people who work in prisons and homeless shelters.

5. As of this date, Indian authorities aren't yet considering booster shots for any section of the Indian population.

12 Possible Measures for Manipur

We need to assume that there may be a third wave in Manipur too. Even if that may turn out to be a wrong anticipation, it's better to err on the side of caution. Accordingly, we must initiate measures to squarely face a possible third wave in our state. These may include:

1. Conducting immediate seroprevalence studies to understand what per cent of population in Manipur and in its different districts are still susceptible to the coronavirus.

2. Speeding up vaccinations in a big way; aggressive vaccinations with monthly targets to cover all eligible population with first doses in the next few weeks (4-6 weeks); and targeted vaccinations of all adult population with second doses in the next 2-3 months.

3. Regular & repeated COVID testing in hotspots.

4. Enhancing the ratio of RT-PCT to Rapid Antigen Testing (RAT).

5, Weekly "awareness messaging" about the pandemic to the public by a designated healthcare official.

6. Genomic sequencing of a subset of positive cases and surveillance of the variants including the delta variant: which COVID strains are there in Manipur, where are they, and where are they moving towards; and whether any new variants are emerging.

7. Contact tracing and government-monitored isolation of positive cases, wherever feasible.

8. Boosting healthcare provisions such as medical oxygen plants, tankers and cylinders; steroids, antifungal drugs, oxygen concentrators, ventilators, oximeters, masks, PPEs, sanitizers etc.

9. Strengthening of healthcare infrastructure such as construction of new COVID hospitals.

10. Provision of more COVID care centres (CCCs), more Covid beds and ICUs in existing hospitals

11. Constitution of a special taskforce for the third wave; a separate taskforce for pediatric COVID is also highly recommended.

12. Special provisions for kids such as pediatric hospitals, wards, and ICUs, pediatric oximeters, concentrators, and ventilators and strengthening of staff such as pediatricians and pediatric nurses and paramedical workers etc.

First Published:Sept. 26, 2021, 1:28 a.m.

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