No evidence yet of Covid paediatric impact

There is a lot of discussion going on that the third wave would affect mainly children. In a hearing, a Bench of the Supreme Court has asked about the government’s plan to protect children from the third wave. Maharashtra has set up a separate state task force for Covid-19 in children. The Karnataka State Commission for Protection of Child Rights has recommended the setting up of paediatric task forces on Covid-19 in every district. Some health experts have suggested that special paediatric Covid-19 intensive care units, catering to up to 5 per cent of the child population, should be set up.

These developments have been interpreted by many as confirmation that the third wave would primarily affect children.

A number of countries have already experienced three or four waves of the pandemic and there is no scientific evidence and epidemiological data from any part of the world that children were more commonly affected in any subsequent wave. In fact, states such as Delhi have already seen four waves and the children have not been affected disproportionately.

Fifteen months into the pandemic, we have a better understanding of SARS CoV-2 and Covid-19. Successive sero-surveys in Indian cities and states and even national surveys have revealed that children have developed a proportionately similar rate of infection as any other age-group. It is just that they simply don’t develop a moderate or severe disease. The reason is that ACE-2 receptors on which SARS CoV-2 binds are underdeveloped in children and the virus fails to find its way to their lungs.

Yet, why is it being thought that children could be more widely affected in the next wave? Let us examine the possible reasons.

One, in the second wave, doctors attending Covid-19 children reported to have seen more cases than in the first wave. The children admitted reported to be sicker than in the previous wave.

A few weeks ago, Niti Aayog and the Indian Council of Medical Research (ICMR) released facility-based data comparing age distribution in the two waves. It found that in the second wave, of the total admitted patients, 5.8 per cent were 0-19 years, and this was 4.2 per cent in the first wave. The age group constitutes nearly 43 per cent of the population. Clearly, Covid-19 infections in children remain low.

Therefore, if paediatricians have seen more infections and cases of children in the second surge, it must also be noted that the overall Covid-19 cases in the country have also increased by four to five times and sustained for a few weeks.

An epidemiologist will explain that to make any correct inference, the data from both groups — the clinicians (who have a better sense of admissions of children, the numerator) and the data experts (who have a broader picture of the overall cases in the entire population, the denominator) — is needed and they must work together. This will address the ‘numerator-denominator dissociation’ to make a correct interpretation.

Two, for illnesses which require hospitalisation, people always try to ‘seek care at the next level of healthcare facility’ than the one closer to them: those in villages go to the city, those in the city go to a major city, and those in a major city, seek a hospital in metropolitan cities. This care-seeking behaviour is seen more frequently for children. Therefore, most of the higher-level facilities in large cities and catering to Covid-19 children might have received a higher number of sick children than in the other age-groups, leaving the impression (to the attending doctors) that more children were affected in the second wave.

Three, there is no evidence that the virus or the new strains have increased transmissibility or pathogenicity to the younger age-groups or children. Yet, we know that while additional Covid-19 facilities were opened to cater to the increased caseload, the proportion of Covid-19 facilities for children did not witness a proportionate increase.

Therefore, due to a shortage of beds and ventilators, only those with moderate or severe conditions were admitted to Covid facilities. This triage of already sick patients for hospital admission, to a treating physician, gave the impression that the severity of the illness was higher, while it was a selection bias.

In short, there is no data from India to support that children were more commonly affected in the second wave (in comparison to the first wave) or would have a higher risk of disease in the third wave.

However, to ensure an effective pandemic response, the government should analyse the available Covid-19 data by age, gender and other stratifiers with comparison between the two waves and make it public. That is essential to develop evidence-informed strategies and dispel the unsubstantiated assertions, which may create fear.

Also, both the Centre and states should prepare for all possible scenarios (informed by data and not merely opinion) to respond to the third wave. There is merit in ensuring that Covid-19 testing and treatment services for children are also strengthened.

The genomic sequencing and clinical studies regularly examine transmissibility or pathogenicity of the circulating strains in all age-groups. Setting up a separate task force for Covid-19 may be an attractive idea, but it has the risk of a fragmented response. It would be better if a single task force at the state level, with the participation of child health experts, were to look into the strategies and plans holistically.

Consideration on the opening of the schools and plan for vaccination of children should be a part of the overall plans for the pandemic response.

Health experts need to support their assumptions not merely based on their clinical experience but in the broader epidemiological context to avoid any possible panic.

As of now, there is no reason to conclude that children would be at a higher risk of contracting Covid-19 in the third wave, as and when that happens. However, preparation without causing unnecessary alarm and panic has to be the approach to be followed.