Children and young people remain at low risk of COVID-19 mortality

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Abstract

Since early reports from China stated that severe COVID-19 disease was rare in children, 1 we have analysed child COVID-19 mortality in seven countries. To put the deaths into a context that would help the understanding of parents, clinicians, and policy makers, we previously made comparisons of COVID-19 deaths with modelled mortality from all causes and other causes. Our first publication in April, 2020, 2 was followed by a trend analysis up to August, 2020. 3 We also update a data table online. Here, we update this analysis to February, 2021, in light of increases in adult mortality through the 2020–21 winter, and concerns about variant B.1.1.7, first identified in the UK in December, 2020 (probably circulating since September). 4 Table Age-specific data for seven countries showing estimated all-cause deaths compared with COVID-19 deaths Population All-cause deaths * COVID-19 deaths † COVID-19 deaths as percentage of all-cause deaths, % n per 100 000 n per 100 000 USA 0–4 years 19 810 275 23 844 120·36 67 0·34 0·28% 5–14 years 41 075 169 4990 12·15 67 0·16 1·34% UK 0–9 years 8 052 552 3793 47·10 7 0·09 0·19% 10–19 years 7 528 144 1109 14·73 22 0·29 1·98% Italy 0–9 years 5 090 482 1569 30·83 8 0·16 0·51% 10–19 years 5 768 874 772 13·38 10 0·17 1·30% Germany 0–9 years 7 588 635 2782 36·66 9 0·12 0·32% 10–19 years 7 705 657 1249 16·21 4 0·05 0·32% Spain 0–9 years 4 370 858 1369 31·31 28 0·64 2·05% 10–19 years 4 883 447 532 10·89 26 0·53 4·90% France 0–9 years 7 755 755 2916 37·60 7 0·09 0·24% 10–19 years 8 328 988 1068 12·82 4 0·05 0·38% South Korea 0–9 years 4 148 654 1519 36·61 0 0·00 0 10–19 years 4 940 455 814 16·48 0 0·00 0 Total 137 047 945 48 326 35·26 259 0·19 0·54% The sources of these data are provided in the appendix (p 2). * Includes all deaths from approximately March 1, 2020, to Feb 1, 2021. † Includes all COVID-19 deaths reported from the start of the pandemic up to Feb 3, 2021 (USA), Jan 29, 2021 (UK), Jan 20, 2021 (Italy), Feb 9, 2021 (Germany), Feb 10, 2021 (Spain), Feb 11, 2021 (France), or Feb 3, 2021 (South Korea). In the USA, UK, Italy, Germany, Spain, France, and South Korea, deaths from COVID-19 in children remained rare up to February, 2021, at 0·19 per 100 000 population, comprising 0·54% of the estimated total mortality from all causes in a normal year (table, appendix p 2). Deaths from COVID-19 were relatively more frequent in older children compared with younger age groups. The differences between countries need careful interpretation because of small numbers, possible differences in case definition and death reporting mechanisms, and the related condition paediatric inflammatory multisystem syndrome temporally associated with COVID-19, which might not always be captured in these data. The highest rate of deaths per 100 000 children was in Spain (0·64 for children aged 0–9 years; 0·53 for children aged 10–19 years) and the lowest in South Korea (0 deaths for children aged 0–9 years and 10–19 years). Overall, there was no clear evidence of a trend of increasing mortality throughout the period up to February, 2021, but additional deaths have clearly occurred in children and young people during periods of high community transmission, particularly in Spain, Germany, and Italy (appendix p 3). Although COVID-19 mortality data are contemporary and likely to accurately represent the reality in these countries, it is not possible to access such data for other causes of death. We therefore used estimates from the Global Burden of Disease 2017 database, which does not account for seasonality or changes in mortality patterns in this pandemic year. Nevertheless, the very low mortality we describe from COVID-19 compared with all-causes is likely to be of the correct magnitude. With the caveat that some children at high risk might be using extreme so-called shielding measures, children are overall not becoming seriously unwell with COVID-19, 5 and data from England show that children are also not requiring intensive care in large numbers. 6 Some of the measures to counteract the devastating impact of the virus on adults are having unintended negative consequences for children. 7 The possible benefit to wider society of these measures should be constantly scrutinised to ensure proportionality in line with outcomes for all. Our evidence indicates that children continue to be mostly, but not completely, spared the worst outcome of the pandemic, particularly compared with older adults who have been much harder hit. 8 We continue to caution that the virus is likely to change over time, and that these conclusions should be kept under review.

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COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study

Florian Götzinger, Begoña Santiago-Garcia, Antoni Noguera-Julian … (2020)

Summary Background To date, few data on paediatric COVID-19 have been published, and most reports originate from China. This study aimed to capture key data on children and adolescents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across Europe to inform physicians and health-care service planning during the ongoing pandemic. Methods This multicentre cohort study involved 82 participating health-care institutions across 25 European countries, using a well established research network—the Paediatric Tuberculosis Network European Trials Group (ptbnet)—that mainly comprises paediatric infectious diseases specialists and paediatric pulmonologists. We included all individuals aged 18 years or younger with confirmed SARS-CoV-2 infection, detected at any anatomical site by RT-PCR, between April 1 and April 24, 2020, during the initial peak of the European COVID-19 pandemic. We explored factors associated with need for intensive care unit (ICU) admission and initiation of drug treatment for COVID-19 using univariable analysis, and applied multivariable logistic regression with backwards stepwise analysis to further explore those factors significantly associated with ICU admission. Findings 582 individuals with PCR-confirmed SARS-CoV-2 infection were included, with a median age of 5·0 years (IQR 0·5–12·0) and a sex ratio of 1·15 males per female. 145 (25%) had pre-existing medical conditions. 363 (62%) individuals were admitted to hospital. 48 (8%) individuals required ICU admission, 25 (4%) mechanical ventilation (median duration 7 days, IQR 2–11, range 1–34), 19 (3%) inotropic support, and one (<1%) extracorporeal membrane oxygenation. Significant risk factors for requiring ICU admission in multivariable analyses were being younger than 1 month (odds ratio 5·06, 95% CI 1·72–14·87; p=0·0035), male sex (2·12, 1·06–4·21; p=0·033), pre-existing medical conditions (3·27, 1·67–6·42; p=0·0015), and presence of lower respiratory tract infection signs or symptoms at presentation (10·46, 5·16–21·23; p<0·0001). The most frequently used drug with antiviral activity was hydroxychloroquine (40 [7%] patients), followed by remdesivir (17 [3%] patients), lopinavir–ritonavir (six [1%] patients), and oseltamivir (three [1%] patients). Immunomodulatory medication used included corticosteroids (22 [4%] patients), intravenous immunoglobulin (seven [1%] patients), tocilizumab (four [1%] patients), anakinra (three [1%] patients), and siltuximab (one [<1%] patient). Four children died (case-fatality rate 0·69%, 95% CI 0·20–1·82); at study end, the remaining 578 were alive and only 25 (4%) were still symptomatic or requiring respiratory support. Interpretation COVID-19 is generally a mild disease in children, including infants. However, a small proportion develop severe disease requiring ICU admission and prolonged ventilation, although fatal outcome is overall rare. The data also reflect the current uncertainties regarding specific treatment options, highlighting that additional data on antiviral and immunomodulatory drugs are urgently needed. Funding ptbnet is supported by Deutsche Gesellschaft für Internationale Zusammenarbeit.

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Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults

Esther Crawley, Maria Loades, Gene Feder … (2020)

In the UK, paediatricians are increasingly concerned that parental worries over visiting healthcare centres are leading to a drop in vaccination rates and the late presentation of serious illness in children. This is likely to cause avoidable deaths and illness in the short and long term, a form of collateral damage from the COVID-19 emergency. In Italy, hospital statistics show a substantial decrease in paediatric emergency visits compared with the same time in 2018 and 2019 of between 73% and 78%.1 In April 2020, both the Clinical Commissioning Groups and the Royal College of Paediatrics and Child Health provided guidance for general practitioners and paediatricians in England that the threshold for face-to-face assessment hospital referrals in children should not change because of the COVID-19 pandemic.2 This intervention is welcome; however, we remain concerned about wider, perhaps less immediately visible collateral damage of strategies used against COVID-19 on vulnerable children. The Cambridge dictionary defines collateral damage as the ‘unintentional deaths and injuries of people who are not soldiers, and damage that is caused to their homes, hospitals, schools, etc’. In the fight against coronavirus, children are being put at risk, in order to reduce the spread of a disease that mainly causes direct harm to adults. One of the unique characteristics of the COVID-19 pandemic is the low hospitalisation and mortality rate (<0.2% for teenagers).3 However, children are experiencing additional harm due to social isolation, lack of protective school placements, increased anxiety and a drop in service provision from both the National Health Service (NHS), education and social services. This is particularly true for the most vulnerable children (see Box 1). Box 1 Definitions of vulnerable children Definitions of vulnerability, taken from the children’s commissioner technical paper 2 which defines seven groups of children as vulnerable.19 Formal categories of children in care of the state whether in care, or living in other forms of state provision such as offender institutions, residential special schools, mental health establishments or other forms of hospital. Formal categories of need that may reflect family circumstances such as children receiving free school meals or children in need, and asylum seeking children. Categories of need that reflect features of child development such as children in pupil referral units or with special education needs and disability. These groups might also include wider categories such as children subject to assessment or supervision under the Children Act, children subject to court orders or in receipt of youth justice services and missing children. Children who are in receipt of services following assessment even if they do not have a formal status. For instance, those within CAMHS but with no formal diagnosis, those receiving prevention services through children’s care, or youth justice, all of whom have been assessed by statutory agencies as vulnerable in some manner. Informal types of vulnerability that may be important to the practice of local agencies such as, for example, when a child is referred to CAMHS who does not reach the threshold required to access services but where unmet need and vulnerability may still exist, or a child identified as part of a family experiencing domestic violence and abuse. Definitions relating to national policy such as ‘troubled families’ or ‘just about managing’ families. This category will often relate closely to other categories and where children are identified as in need of support through such mechanisms they are in scope of this review. Scientific and academic literature on risk and resilience. and including tools and approaches such as the measurement of adverse childhood experiences. UK government definition of vulnerable children and young people during the COVID-19 pandemic20 Are assessed as being in need under section 17 of the Children Act 1989, including children who have a child in need plan, a child protection plan or who are a looked after child. Have an education, health and care (Education Health and Care) plan whose needs cannot be met safely in the home environment. Have been assessed as otherwise vulnerable by educational providers or local authorities (including children’s social care services), and who are therefore in need of continued education provision. “This might include children on the edge of receiving support from children’s social care services, adopted children, or those who are young carers, and others at the provider and local authority discretion”. Impact of school closure and social isolation School closures may have a limited impact on preventing deaths in adults.4 However, the closure of schools and confinement to home has multiple impacts on children in terms of education, social isolation, well-being and child protection. Almost all European countries have closed their schools (Sweden is an exception) to prevent the spread of COVID-19 and according to UNESCO, 91% of children have been impacted worldwide.5 Schools throughout the UK closed in March 2020 (see Box 2) and are only providing places for some primary school children of key workers and some vulnerable children. Uptake of these places in the latter group appears to be low.6 Some schools are providing learning online, but completion rates are unknown, particularly for those children with no or limited access to the internet. Children from poorer families have fewer resources, may be reliant on school meals and playgrounds for exercise, are less likely to have appropriate access to the internet/sufficient space to allow learning, or have access to additional resources to support other activities for mental or physical well-being. Children with special educational needs and disabilities should have the special provision required to meet their particular needs specified in their Education Health and Care Plan (EHCP). This has not necessarily been adapted for home learning and many EHCPs specify provision that cannot be delivered outside of specialist settings. Similarly, much of the wider support normally available to disabled children and other vulnerable learners is provided through facilities that are now closed and unlikely to be effectively replaced by efforts of volunteers. Box 2 What restrictions have been placed because of social distancing on children and young people in the UK? (government guidance updated 29 March 2020) Children and young people are not allowed to attend school, college, nurseries unless they are a vulnerable child (see UK government definition in Box 1) Children and young people are allowed ‘one form of exercise a day, for example, a run, walk, or cycle—alone or with members of your household’. Where parents do not live in the same household, children under 18 can be moved between their parents homes. All public gatherings are of more than two people are stopped (including weddings, baptisms and other religious ceremonies). Schools provide a safe space for vulnerable children and play a key role in safeguarding by detecting signs of abuse or neglect. The rapid closure of schools has not been accompanied by strengthened processes to support those most in need. This has occurred at the same time that the Coronavirus Act allows social services to reduce or suspend services (see below) leaving vulnerable children without a safety net. Social isolation, the withdrawal of peer support, the lack of structure and support from school and the increased anxiety over COVID-19 infection and risk to parents are all likely to have a negative impact on mental health in children and young people.7 Social isolation and loneliness in children, job loss, furlough and increased parental distress may lead to subsequent mental health problems, resulting in a substantial increase in need for Child and Adolescent Mental Health Services (CAMHS). Increased risk to the mental health of children from social isolation will also result from their exposure to domestic violence and abuse (DVA) during the pandemic. We know that violence against women increases during epidemics, such as Ebola.8 9 Now, in countries across the world that have imposed social isolation in response to COVID-19, there is evidence from helplines and police reports that the incidence and severity of DVA have increased.10–12 Children confined to home from school closure and young people not being able to leave home to see their friends will be more exposed to DVA. The stress and anxiety caused by forced isolation, economic uncertainty, home schooling and potentially difficult living conditions drive the increase in abusive and controlling behaviour. In over a third of families where DVA occurs, there is also direct child maltreatment: physical and emotional abuse, exploitation and neglect.13 The greatest risk will be to vulnerable children (defined in Box 1). Although the government has issued guidance in relation to COVID-19 and DVA, there is no mention of exposed children and young people.11 Moreover, as children’s services and DVA agencies scramble to change their working practices to remote support, there is uncertainty about the effectiveness of emergency methods of working in this field. Reduction in protection: withdrawal of services While the risk to children (and particularly vulnerable children) is increasing, the support mechanisms in both the NHS and social services are being withdrawn. Hospital outpatient clinics have closed, been suspended or moved to virtual home based clinics. This will have the greatest impact on new appointments, or appointments requiring an examination. Child and Adolescent Mental health services have reduced or suspended assessment and treatment clinics in many parts of the UK at a time when children and young people are experiencing higher levels of anxiety and depression. This is likely to contribute to higher rates of mental health disorders, self-harm and ultimately suicide. The impact is higher on vulnerable children On the 3rd of March, the UK government introduced the Coronavirus Bill,14 which became the Coronavirus Act on 25 March 2020. This included changes to the Care Act 2014 in England and the Social Services and Well-being (Wales) Act 2014 to “enable local authorities to prioritise the services they offer in order to ensure the most urgent and serious care needs are met, even if this means not meeting everyone’s assessed needs in full or delaying some assessments”.14 These changes meant that ‘local authorities will not have to prepare or review care and support plans’.15 The intention of the bill was for this to only come into effect if ‘if demand pressures and workforce illness during the pandemic meant that local authorities were at imminent risk of failing to fulfil their duties and only last the duration of the emergency’.15 However, in the absence of coronavirus testing (which means that many families are self-isolating) and with current government regulations on the movement of people, significant areas of social care have ceased with a potentially devastating impact on the most vulnerable children. There are over 78 000 looked after children in England alone16 who are now at higher risk because of the reduction or suspension of evidenced-based protective support and interventions. A variety of parental interventions, Looked After Children Reviews, social services input and respite care can improve children’s outcomes.17 Throughout the UK, these services have been suspended or reduced as social services move to working from home meaning that children and foster carers can no longer access face-to-face support from their appointed social worker or their independent reviewing officer. Respite care has generally been suspended, increasing the risk of physical, emotional abuse or neglect in families that are struggling. Where looked after children were receiving additional support from CAMHS, this has either stopped or is being continued remotely. Inevitably, these reductions in support and safeguards will have the greatest impact on the children with the most complex needs in the most challenged placements. Transition planning for children leaving care has largely been suspended. Services that were already struggling with workforce issues are now struggling even more as recruitment is almost impossible currently because of practical and economic considerations. It therefore seems likely that the decisions on social distancing contravene the UN Convention of the child. This convention states (article 3): “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration." We believe that the social distancing measures introduced in the UK and elsewhere, may marginally reduce the infection rate in adults but harms children. We do not believe that the “best interest of the child” are the “primary consideration” and therefore these actions do not comply with this convention. Can we mitigate these effects and minimise the ‘collateral damage’ experienced by children and young people? Several strategies have been suggested to reduce the risks of domestic violence including the organisation of safe spaces in hotels for women and children experiencing DVA, already implemented in Spain and France. Improving video and online access to services for which there is some evidence of effectiveness (such as Cognitive Behavioural Therapy (CBT) from CAMHS) could improve children’s resilience. The chronic underfunding and workforce crisis in social care and the domestic violence sector will only be exacerbated by the current emergency. The chancellor’s recognition of the need for greater financial support of the NHS18 should be matched with additional support to local authorities. CAMHS and social services for children are unlikely to be needed on the front line for COVID-19 and agile services could develop alternative methods to assess and treat children using video clinics. The physical and mental health needs of the UK’s children are unlikely to be short term, and funding will need to continue well after the COVID-19 pandemic is over. Perhaps more importantly, we all have a responsibility to promote the health and well-being of children at home, and to ask questions and fight for service provision in areas where clinicians are not needed to fight COVID-19, but are needed to protect children. Supplementary Material Reviewer comments Author's manuscript

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Children's mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers

Sunil Bhopal, Jay Bagaria, Raj Bhopal (2020)

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Journal ID (nlm-ta): Lancet Child Adolesc Health

Journal ID (iso-abbrev): Lancet Child Adolesc Health

Title: The Lancet. Child & Adolescent Health

Publisher: Elsevier Ltd.

ISSN (Print): 2352-4642

ISSN (Electronic): 2352-4650

Publication date PMC-release: 11 March 2021

Publication date (Electronic): 11 March 2021

Affiliations

[a ]Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK

[b ]Biosciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK

[c ]independent consultant, Edinburgh, UK

[d ]Usher Institute, University of Edinburgh, Edinburgh, UK

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Publisher Item ID: S2352-4642(21)00066-3

DOI: 10.1016/S2352-4642(21)00066-3

PMC ID: 7946566

PubMed ID: 33713603

SO-VID: b6a5ca6e-340c-4d92-9116-147caec8ba7c

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Children and young people remain at low risk of COVID-19 mortality

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Novel Coronavirus Disease COVID-19

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COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study

Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults

Children's mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers

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