Edge of crisis: When kids suffer from COVID-19

With children reporting severe post-COVID-19 symptoms, India must prioritise its paediatric infrastructure

chronic fever
From inflammation in organs and eye sore to chronic fever, children are reporting  a myriad of post-COVID-19 complications (Photograph: Vikas Choudhary) From inflammation in organs and eye sore to chronic fever, children are reporting a myriad of post-COVID-19 complications (Photograph: Vikas Choudhary)

When seven-month-old Kiyant came down with fever in July 2021, his parents decided to treat him at home. Even after four days of care, the fever persisted and the family from Surat, Gujarat, took the infant to his paediatrician.

Kiyant’s doctor, Ketan Shah, after initial examination, warned the family that he might be suffering from multisystem inflammatory syndrome in children or MIS-C, a serious condition that appears to be linked to infectious diseases like the novel coronavirus (COVID-19).

His fears came true when Kiyant’s blood work showed antibodies to COVID-19 and echo-cardiogram showed dilated coronary arteries, which can lead to a heart attack.

“MIS-C happens when the antibodies against COVID-19 turn rogue and start attacking the human body. It can affect the brain and heart,” says Shah.

The condition is rare and 12 out of 10,000 infected children experience it, according to the Indian Academy of Pediatrics, an association of doctors. It usually develops four to six weeks after children and teenagers have recovered from COVID-19, suggest the “Guidelines on Operationalization of COVID Care Services for Children & Adolescents”, released by the Union Ministry of Health and Family Welfare (MoHFW) in June 2021.

Timely diagnosis saved Kiyant, who was administered intravenous immunoglobulin (antibodies produced by blood plasma cells) and steroids for six weeks, the recommended treatment for MIS-C.

“Subsequent tests showed improvement and he is healthy now,” says Kush Jayeshbhai Shah, Kiyant’s father. “We never thought he would be affected by COVID-19 or develop this life-threatening condition,” he adds.

During the first wave of the COVID-19 in the country, researchers from three medical colleges in Delhi studied the health condition of 41 hospitalised COVID-19-positive children. They found that almost half (20) of them developed MIS-C.

While 90 per cent of the children with MIS-C required oxygen, 65 per cent required mechanical ventilation, write the researchers from the All India Institute of Medical Sciences (AIIMS), Vardhman Mahavir Medical College and Safdarjung Hospital in the Journal of Tropical Pediatrics on January 29, 2021.

Supratim Sen, senior consultant paediatric cardiologist at SRCC Children’s Hospital, Mumbai, who has conducted a similar study in Maharashtra, said most children who recovered from MIS-C did not exhibit any long-term impact during their follow up of 6-12 months.

“Only a small percentage of children experience persistent dilation of coronary arteries, which can have long-term sequelae of coronary artery disease and ischemia,” said Sen.

MIS-C is just one of the variety of post-COVID-19 complications that children are experiencing. Sunil Singh, an ophthalmologist from Patna, Bihar, said August 2021 onwards, he is regularly visited by children who have recovered from COVID-19 but now suffer from headache, eye sore and lack of concentration.

“In July 2021, a 10-year-old girl visited my clinic with redness and fatigue in her eyes. She had recovered from COVID-19 in May and developed the problem shortly after. As little is known about post-COVID-19 complications in children, I could only prescribe her vitamins and eye muscle exercises,” says Singh.

In September 2021, five children with post-COVID-19 symptoms were admitted at AIIMS Patna, says Sanjeev Kumar, nodal officer, COVID-19 at the hospital.

“These children showed symptoms of respiratory distress and their lungs were unable to pump sufficient oxygen. One of the children, an 11-year-old girl, could not be saved,” he adds.

COVID weakness

The most debilitating complication that several physicians share with Down To Earth is that children recovered from COVID-19 are easily falling ill. Kamal Kumar Khushwaha, physician in Uttar Pradesh’s Itawa district, says his daughter has had chronic fever ever since his family came down with COVID-19 in April 2021.

Khushwaha also says there has been an increase in children suffering from dengue and pneumonia post COVID-19, which is because the infection weakens the immunity.

AK Tiwari, another physician from Bahraich district of the state, says one of his patients, a two-and-a-half-year-old boy, has contracted common cold and fever six times in the eight months since his recovery from COVID-19.

“The boy’s father, a teacher, contracted COVID-19 during election duty in April 2021. Soon after, the entire family got infected. While they have all recovered, the boy is suffering from recurrent fevers,” he says.

Like Khushwaha, Tiwari also says COVID-19-recovered children have low immunity, but this aspect has not been researched conclusively.

Several international studies, however, give credence to the claims of Khushwaha and Tiwari. A survey on long COVID by UK researchers shows children can continue to experience the adverse effects of COVID-19 even after three months. The analysis posted as a preprint on August 10, 2021, on Research Square studied children between 11 and 17 years.

Researchers at the Norwegian Institute of Public Health in Oslo, Norway, also studied the health status of COVID-19-positive children between 1 and 19 years. They say these children needed to see their doctor repeatedly for up to six months, unlike those who did not contract the disease.

The researchers also observed that children in pre-school age needed health services for a longer time (three to six months) after COVID-19 than those who were in primary and secondary schools (one to three months). The findings were published as a preprint on MedRxiv on June 5, 2021.

Risks abound 

While doctors say only a fraction of COVID-19 cases in children are reporting sequelae, conditions that are the consequence of a previous disease or injury, they caution that this trend can change without any warning.

Gauranga Mohapatra, who heads the Odisha chapter of Jan Swasthya Abhiyan, a national network of civil society organisations working on health rights, says the percentage of post-COVID-19 symptoms in children is more than that in adults, even though fewer children had symptomatic infections.

While the proportion of children getting infected by COVID-19 is still not frightening, it is significant enough to establish that children are not as immune to post-COVID-19 complications as thought. Even the sketchy government numbers suggest a steady increase in the share of children in India’s total active COVID-19 cases, which includes patients still infectious. 

The share of children aged 1-10 years in the total active COVID-19 cases has more than doubled from 2.8 per cent in March 2021 to 7.04 per cent in August 2021.

The reason behind the steady increase is that while adults are getting vaccinated, children are left vulnerable. Even the MoHFW guidelines say serosurvey reports have confirmed that COVID-19 infection in children above 10 years occurs in similar frequency to that of adults and that every time there is a spike in new cases, the “numbers of children and adolescents with confirmed COVID-19 have also increased”.

Sanjeev Kumar of AIIMS Patna, says the share of children with serious post-COVID-19 complications could increase in the coming months because of new strains of the virus.

So far, they have been protected because of their immune response. While adults respond to the virus through an adaptive immune system (which humans acquire following disease exposure), children use their innate immune system (which they are born with).

A study published in Nature Communications on April 1, 2021, suggests that adults have more cross-reactive antibodies targeted at parts of SARS-CoV-2 virus that were similar to bits of other coronaviruses, whereas children tended to produce a broader range of antibodies against all sections of the virus.

But over the past two years, children’s innate immune system has been exposed to this virus, and they could be losing the advantage.

The virus also seems to be evolving in ways that could thwart innate protection. The Alpha variant, first reported in November 2020 in the UK, developed tricks that allow it to suppress the body’s innate immune response.

A preprint study posted on BioRxiv on June 7, 2021, says that Alpha-infected cells make 80 times more copies of a gene that helps the virus block a human protein essential for fighting the virus.

Harm away from school

Doctors also say the country must open in-person schools and colleges soon, as locking children up in their homes leads to other long-term impacts.

“Lockdowns have increased sedentariness, screen time, stress, irregular mealtimes, consumption of less nutritious foods, and fewer opportunities for physical activity and recreational sports. As a result, there is an increased risk of overweight and obesity among children. In countries like India, where children were dependent on school meals, this also meant increased malnutrition,” says Monika Arora, director, Health Promotion Division of non-profit Public Health Foundation of India.

“Children are struggling with delayed speech development because of limited interaction with the outside world. Behavioural changes have also been reported due to isolation,” says Shikha Prakash, an Ayurvedic physician in Dehradun.

In Slovenia, where physical activity interventions were implemented throughout the pandemic, researchers found two months of self-isolation erased over 10 years of hard-fought health gains acquired from public health policies. Their study was published in Frontiers in Public Health in March 2021.

There is also evident from earlier pandemics. In case of the Spanish flu pandemic in 1918, children born to women exposed to the virus were found to have more physical ailments and a lower lifetime income than those born a few months earlier or later in the US, reports a 2006 paper published in the Journal of Political Economy.

Similarly, long-term effects have been observed during the Zika outbreak, which can result in Guillain-Barre syndrome (a disorder in which the body’s immune system attacks the nervous system) and microcephalia (a medical condition involving a smaller-than-normal head) in unborn children of infected mothers.

A worthy plan

Considering that children have to live with the adverse health effects for a long time, it is imperative that steps are taken to protect them. Globally, the most popular recommendation is to get children vaccinated. Paul Licciardi, team leader, New Vaccines, Murdoch Children’s Research Institute, Australia, says:

“Protecting children from COVID-19 is critical (as any population group is) but with children, there are also the indirect effects associated with school closures and impact on education and social interaction. Vaccination is the best and simplest way to protect children from both getting the infection but also ensuring schools can remain open.”

The Strategic Advisory Group of Experts of the World Health Organization (WHO) has already recommended vaccination for children aged 12 years and above and suggests that children at high risk should be vaccinated first. For this, they have approved a Pfizer/BionTech vaccine.

Individual countries have taken decisions too. In November, the US Food and Drug Administration (FDA) issued emergency use authorisation to the Pfizer/BioNTech vaccine meant for children between five and 11 years. The UK, Norway, Switzerland, Italy, Israel, China, Argentina, Chile, Cuba and some others have also started administering COVID-19 vaccines to children.

India is taking an active role in developing vaccines for children. In August 2021, the country approved Zydus Cadila’s ZYCoV-D vaccine for children above 12 years.

Zydus Cadila claims that the three-dose vaccine has an efficacy rate of 66.7 per cent, but has not publicly released the trial data. Several other vaccines are under clinical trials in the country. These include vaccines being developed by Serum Institute of India, Bharat Biotech and Johnson & Johnson.

Vaccines also do not find mention in the government’s COVID-19 control programmes for children. There are two documents released by the government and its agencies on COVID-19 and children: the June 2021 guidelines by MoHFW and a report by the National Institute of Disaster Management (NIDM) released in August 2021.

Both the documents recommend augmentation of existing health facilities for children. “The existing paediatric health care facilities are not robust enough to treat children on a large scale...the existing COVID facilities should be augmented; the numbers of beds available should be enhanced by at least 10 per cent,” says the NIDM report.

Most doctors agree with the government action plan as they say the current levels are not alarming enough to administer untested vaccines on children. “We also do not know if the vaccines will prevent MIS-C,” says Sen.

They, however, say that the government should promptly implement the guidelines and be prepared for a paediatric COVID-19 outbreak. More importantly, it should closely monitor paediatric COVID-19 cases and study post-recovery complications. The idea should be to ensure that parents can send their children back to schools and colleges, without losing their peace of mind.

The article was first published in DTE print edition January 1-15, 2022

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