H5N1

Filling in the blanks: National research needs to guide decisions about reopening schools in the US

An email from Johns Hopkins: New Report: Filling in the Blanks: National Research Needs to Guide Decisions about Reopening Schools in the US. Excerpt:

Today (Friday, May 15, 2020), the Center for Health Security at Johns Hopkins Bloomberg School of Public Health has released a new report calling for a national mandate to prioritize and fund research about children and COVID-19 so that governors, school districts, teachers, parents and guardians can make informed decisions about reopening schools in the US.     

According to the report, “Filling in the Blanks: National Research Needs to Guide Decisions about Reopening Schools in the US,” there is an urgent need to generate additional evidence to better assess the potential risks of students and teachers returning to school classrooms in the fall. While published studies to date indicate that children with COVID-19 are less likely to suffer severe illness than adults, there is only limited scientific evidence to gauge whether children with COVID-19 in school can transmit the virus to other children, teachers, school staff and family members.   

New research would help answer key questions including: 

• How vulnerable to severe illness are students who have underlying health conditions, such as asthma, diabetes, or severe obesity? 

• How safe is it for adults with serious underlying health conditions to send their children back to school without fear of those children bringing the virus home and infecting others in the family? 

• How safe is it for teachers, administrators, and other school staff, especially those who are medically vulnerable, to return to school and interact with students who may be asymptomatic but infectious? 

While some research relevant to these questions has begun, the authors say, the U.S. government (as well as other national governments, non-governmental organizations and philanthropies) should fund additional studies aimed at understanding the role of children in transmission of COVID-19. 

The report also includes a summary of other countries’ approaches to school reopenings. The authors recommend tracking these various efforts closely to monitor whether any result in increased community transmission, and whether successful approaches could be translated to the US education landscape.   

As COVID-19 devastates already fragile health systems, over 6,000 additional children under five could die a day, without urgent action

Via ReliefWeb, a UNICEF news release: As COVID-19 devastates already fragile health systems, over 6,000 additional children under five could die a day, without urgent action. Excerpt:

NEW YORK, 13 MAY 2020 – An additional 6,000 children could die every day from preventable causes over the next six months as the COVID-19 pandemic continues to weaken health systems and disrupt routine services, UNICEF said today. 

The estimate is based on an analysis by researchers from the Johns Hopkins Bloomberg School of Public Health, newly published in The Lancet Global Health journal. Based on the worst of three scenarios in 118 low- and middle-income countries, the analysis estimates that an additional 1.2 million under-five deaths could occur in just six months, due to reductions in routine health service coverage levels and an increase in child wasting.  

These potential child deaths will be in addition to the 2.5 million children who already die before their 5th birthday every six months in the 118 countries included in the study, threatening to reverse nearly a decade of progress on ending preventable under-five mortality. 

Some 56,700 more maternal deaths could also occur in just six months, in addition to the 144,000 deaths that already take place in the same countries over a six-month period.  

“Under a worst-case scenario, the global number of children dying before their fifth birthdays could increase for the first time in decades,” said UNICEF Executive Director Henrietta Fore. “We must not let mothers and children become collateral damage in the fight against the virus. And we must not let decades of progress on reducing preventable child and maternal deaths be lost.”

Characteristics and outcomes of children with COVID-19 in North American PICUs

Via JAMA Network: Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. The key points and abstract"

Question  What has been the early experience of coronavirus disease 2019 (COVID-19) in pediatric intensive care units (PICUs)? 

Findings  In this cross-sectional study of 46 North American PICUs, between March 14 and April 3, 2020, 48 children were admitted to 14 PICUs in the US and none in Canada. A total of 40 children (83%) had preexisting underlying medical conditions, 35 (73%) presented with respiratory symptoms, and 18 (38%) required invasive ventilation, and the hospital mortality rate was 4.2%. 

Meaning  This early study shows that COVID-19 can result in a significant disease burden in children but confirms that severe illness is less frequent, and early hospital outcomes in children are better than in adults.  

Abstract 

Importance  The recent and ongoing coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented toll on adults critically ill with COVID-19 infection. While there is evidence that the burden of COVID-19 infection in hospitalized children is lesser than in their adult counterparts, to date, there are only limited reports describing COVID-19 in pediatric intensive care units (PICUs). 

Objective  To provide an early description and characterization of COVID-19 infection in North American PICUs, focusing on mode of presentation, presence of comorbidities, severity of disease, therapeutic interventions, clinical trajectory, and early outcomes. 

Design, Setting, and Participants  This cross-sectional study included children positive for COVID-19 admitted to 46 North American PICUs between March 14 and April 3, 2020. with follow-up to April 10, 2020.  

Main Outcomes and Measures  Prehospital characteristics, clinical trajectory, and hospital outcomes of children admitted to PICUs with confirmed COVID-19 infection.  

Results  Of the 48 children with COVID-19 admitted to participating PICUs, 25 (52%) were male, and the median (range) age was 13 (4.2-16.6) years. Forty patients (83%) had significant preexisting comorbidities; 35 (73%) presented with respiratory symptoms and 18 (38%) required invasive ventilation. Eleven patients (23%) had failure of 2 or more organ systems. Extracorporeal membrane oxygenation was required for 1 patient (2%). Targeted therapies were used in 28 patients (61%), with hydroxychloroquine being the most commonly used agent either alone (11 patients) or in combination (10 patients). 

At the completion of the follow-up period, 2 patients (4%) had died and 15 (31%) were still hospitalized, with 3 still requiring ventilatory support and 1 receiving extracorporeal membrane oxygenation. The median (range) PICU and hospital lengths of stay for those who had been discharged were 5 (3-9) days and 7 (4-13) days, respectively. 

Conclusions and Relevance  This early report describes the burden of COVID-19 infection in North American PICUs and confirms that severe illness in children is significant but far less frequent than in adults. Prehospital comorbidities appear to be an important factor in children. These preliminary observations provide an important platform for larger and more extensive studies of children with COVID-19 infection.

5-year-old dies in NYC of rare illness linked to COVID-19

Via The New York Times: 5-Year-Old Dies in N.Y.C. of Rare Illness Linked to Virus. Now we have a new term: pediatric multisystem inflammatory syndrome, or PMIS.

A 5-year-old died in New York City on Thursday from what appeared to be a rare syndrome linked to the coronavirus that causes life-threatening inflammation in children, Gov. Andrew M. Cuomo said.  

It is believed to be the first known death in New York related to the mysterious new syndrome, which officials said began appearing in recent weeks.  

Mr. Cuomo said Friday that 73 children in New York area had been reported afflicted with the illness, which doctors have labeled “pediatric multisystem inflammatory syndrome.” 

He said the state Health Department was investigating whether other deaths of children were caused by the syndrome. 

“This would be really painful news and would open up an entirely different chapter,” Mr. Cuomo said. “Because I can’t tell you how many people I spoke to who took peace and solace in the fact that children were not getting infected.” 

According to the most recent breakdown from the state, three children under age 10 had died of the virus, out of more than 21,000 fatalities.  

In an apparently separate case, officials in Westchester County, just north of New York City, said on Friday that a child being treated there for the illness had died last week. 

The child suffered neurological complications from the syndrome, said Dr. Michael Gewitz, the physician-in-chief at Maria Fareri Children’s Hospital in Valhalla, where the child was being treated.  

The county’s health commissioner, Dr. Sherlita Amler, said that officials were still assessing whether underlying conditions might have been a factor in the child’s death.  

Mr. Cuomo also announced the state’s daily death toll: 216 more people died, a drop from the previous four days when about 230 people per day were dying.

Hyperinflammatory shock in children during COVID-19 pandemic

Via The Lancet: Hyperinflammatory shock in children during COVID-19 pandemic. Excerpt:

South Thames Retrieval Service in London, UK, provides paediatric intensive care support and retrieval to 2 million children in South East England. During a period of 10 days in mid-April, 2020, we noted an unprecedented cluster of eight children with hyperinflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome (typical number is one or two children per week). This case cluster formed the basis of a national alert. 

All children were previously fit and well. Six of the children were of Afro-Caribbean descent, and five of the children were boys. All children except one were well above the 75th centile for weight. Four children had known family exposure to coronavirus disease 2019 (COVID-19). Demographics, clinical findings, imaging findings, treatment, and outcome for this cluster of eight children are shown in the table.

Clinical presentations were similar, with unrelenting fever (38–40°C), variable rash, conjunctivitis, peripheral oedema, and generalised extremity pain with significant gastrointestinal symptoms. All progressed to warm, vasoplegic shock, refractory to volume resuscitation and eventually requiring noradrenaline and milrinone for haemodynamic support. Most of the children had no significant respiratory involvement, although seven of the children required mechanical ventilation for cardiovascular stabilisation. Other notable features (besides persistent fever and rash) included development of small pleural, pericardial, and ascitic effusions, suggestive of a diffuse inflammatory process.

All children tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on broncho-alveolar lavage or nasopharyngeal aspirates. Despite being critically unwell, with laboratory evidence of infection or inflammation3 including elevated concentrations of C-reactive protein, procalcitonin, ferritin, triglycerides, and D-dimers, no pathological organism was identified in seven of the children. Adenovirus and enterovirus were isolated in one child.

Baseline electrocardiograms were non-specific; however, a common echocardiographic finding was echo-bright coronary vessels (appendix), which progressed to giant coronary aneurysm in one patient within a week of discharge from paediatric intensive care (appendix). One child developed arrhythmia with refractory shock, requiring extracorporeal life support, and died from a large cerebrovascular infarct. The myocardial involvement2 in this syndrome is evidenced by very elevated cardiac enzymes during the course of illness.

All children were given intravenous immunoglobulin (2 g/kg) in the first 24 h, and antibiotic cover including ceftriaxone and clindamycin. Subsequently, six children have been given 50 mg/kg aspirin. All of the children were discharged from PICU after 4–6 days. Since discharge, two of the children have tested positive for SARS-CoV-2 (including the child who died, in whom SARS-CoV-2 was detected post mortem). All children are receiving ongoing surveillance for coronary abnormalities.

We suggest that this clinical picture represents a new phenomenon affecting previously asymptomatic children with SARS-CoV-2 infection manifesting as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome. The multifaceted nature of the disease course underlines the need for multispecialty input (intensive care, cardiology, infectious diseases, immunology, and rheumatology).

The intention of this Correspondence is to bring this subset of children to the attention of the wider paediatric community and to optimise early recognition and management. As this Correspondence goes to press, 1 week after the initial submission, the Evelina London Children's Hospital paediatric intensive care unit has managed more than 20 children with similar clinical presentation, the first ten of whom tested positive for antibody (including the original eight children in the cohort described above).

Hard fought gains in immunization coverage at risk without critical health services, warns WHO

A news release: Hard fought gains in immunization coverage at risk without critical health services, warns WHO. Excerpt:

Shutting down immunization services in the COVID-19 pandemic risks triggering a resurgence of diseases that can be prevented with safe and effective vaccines, warns WHO in the lead-up to World Immunization Week (24-30 April).   

When immunization services are disrupted, even for brief periods during emergencies, the risk of vaccine-preventable disease outbreaks, such as measles and polio, increase. Last year’s deadly measles outbreak in the Democratic Republic of the Congo, which took more than 6000 lives in a country already facing its largest Ebola outbreak, highlights the importance of maintaining essential health services, such as immunization in times of emergency. Further disease outbreaks will also overwhelm health systems already battling the impacts of COVID-19. 

“Disease outbreaks must not remain a threat when we have safe and effective vaccines to protect us,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “While the world strives to develop a new vaccine for COVID-19 at record speed, we must not risk losing the fight to protect everyone, everywhere against vaccine-preventable diseases. These diseases will come roaring back if we do not vaccinate.” 

WHO is working with partners all over the world to accelerate research and development of a safe and effective vaccine and ensure equitable access for the billions of people who will need it.  

But even with an expedited process, development of a vaccine for COVID-19 will take time. Precautionary measures are essential now to help keep us safe from disease, including diseases for which vaccines already protect children and adults. 

Too many people are still excluded from the benefits of vaccines 

Prior to the COVID-19 pandemic, the world had made immense progress in ensuring that children are vaccinated. In 2018, 86 percent of children under the age of five globally were vaccinated with three doses of diphtheria, tetanus and pertussis (DTP3) and one dose of the measles vaccine, up from 72 percent in 2000 and 20 percent in 1980. The number of children paralyzed by polio has been reduced by 99.9 percent worldwide.  

Yet, global vaccination coverage is still far from the 95 per cent coverage needed to fully protect communities against outbreaks of this vaccine-preventable disease.  

In 2018 nearly 20 million children worldwide – more than 1 in 10 – missed out on lifesaving vaccines, such as measles, diphtheria and tetanus. Roughly, 13 million of the children have never received any vaccines, putting them and their communities at risk of disease and death. The majority of these children live in countries with already fragile health systems, further limiting their access to essential health services when they fall sick. 

Measles continues to remain an ever-present threat, especially if vaccination rates drops. Current projections indicate that the number of reported measles cases for 2019 will be at least 800 000. In 2020 there are increasing concerns about another resurgence, especially if vaccination rates fall due to delay or suspension of scheduled immunization activities as a result of COVID-19. 

DRC Ebola: Secure burial of 11-year-old girl carried out

Via Actualite.cd: DRC-Ebola: Secure burial of 11-year-old girl carried out. The Google translation:

The Ebola response team announced on Monday that the dignified and secure burial of the 11-year-old girl who died in Beni has been completed. Her body had been kept in the morgue of the Beni General Reference Hospital. 

The same source informs that 32 contacts were pre-listed around this case, including 4 family members (her mother already vaccinated), 2 motorcycle drivers, 7 co-tenants, 17 co-patients and 2 nursing staff. The teams continue the listing and the investigations in order to determine the circumstances of contamination.  

Since the start of the epidemic, the cumulative number of cases has been 3,457, of which 3,312 have been confirmed and 145 are probable. In total, there were 2,277 deaths (2,132 confirmed and 145 probable) and 1,169 winners (healed persons, or survivors).

Ebola in the DRC: About that second case...

Via 7sur7.cd: North Kivu: New Ebola death case registered in Beni. The full report and then a comment:

A new positive case of Ebola virus disease notified in Beni (North Kivu) died on Sunday, April 12, 2020, just a few days after the death of another patient in the same city.   

Medical sources indicate that this new case is an 11-year-old girl, living in the Butanuka district, who was allegedly co-ill with the 26-year-old young man who died on Friday, April 10.  

Faced with this new community death, the living and social forces of Beni fear the renewed epidemic in the region when all seemed to already hope for the official declaration of the end of the disease this same Sunday.  

Health officials have announced that the necessary arrangements have already been made to cut off all transmission chains, adding that around 100 suspected cases who were in contact with the first patient have been listed for immediate follow-up.  

On Saturday April 11, the mayor of Beni called on the population to take action to prevent Ebola from returning to Beni, a city already affected by the Covid-19 pandemic with 2 cases already tested.   

On the doubt expressed by civil society as well as the clash which opposed, the same Saturday, the young people of Beni to the response team, Nyonyi Bwanakawa reassured that tests will be doubled in different laboratories in order to clear up any misunderstandings.

This report raises an immediate question: How old was the second Ebola case, 11 months, or 11 years? Reuters cites WHO as the source for the case being a baby. 7sur7.cd cites "medical authorities" as the source for the child being 11. I have no idea which is correct, but I hope we'll learn more about both cases on Monday.

It's also worth noting that "young people" in the northeast DR Congo continue to be hostile to Ebola response teams. Some things never change. 

Left at home for six days: Disabled Chinese boy dies after carer dad and brother are quarantined for coronavirus checks

Via the South China Morning Post: Left at home for six days: disabled Chinese boy dies after carer dad and brother are quarantined for coronavirus checks. Excerpt:

A disabled teenager in rural central China died after he was left at home for six days without care while his relatives were quarantined on suspicion of having the Wuhan coronavirus, Beijing Youth Daily reported on Thursday. 

The 17-year-old, named Yan Cheng, had cerebral palsy, a severe motor disability that requires around-the-clock attention. He died in Hubei province on Wednesday, local government officials were quoted as saying. Authorities had launched an investigation, the report said. 

Cheng, his 49-year-old father and his 11-year-old autistic brother travelled from Wuhan on January 17 to celebrate Lunar New Year in their ancestral village in Huahe township, Hongan county – about 150km (93 miles) from the central Chinese city where the coronavirus was first reported. 

The father, Yan Xiaowen, developed fever three days later. He and Cheng’s younger brother were quarantined by authorities at a treatment facility on Friday, leaving Cheng at home without regular care, food or company. There was no official statement on the cause or circumstances of the teenager’s death. 

Cheng’s mother committed suicide about a year after the birth of the younger brother, Yan was quoted as saying in a report on Wednesday by Damihexiaomi, a WeChat publishing platform that campaigns for families of children with autism and other conditions. 

Worried that Cheng was not getting proper care from the local Communist Party officials entrusted with the boy’s welfare, his father appealed for help on Weibo, China’s Twitter-like network, on Tuesday. 

“I have two disabled sons. My older son Yan Cheng has cerebral palsy. He cannot move his body, he cannot speak or look after himself. He has already been at home by himself for six days, with nobody to bathe him or change his clothes and nothing to eat or drink,” Yan wrote in a post that included several photos of him and his son, as well as his own medical treatment information and his Chinese identity card.

WHO: DRC Ebola update, January 16

WHO has published Ebola virus disease – Democratic Republic of the Congo. Note one error in the last paragraph of the excerpt, which refers to the start of the outbreak on May 8, 2018. That was the beginning of the 9th outbreak, in Equateur province, and it was briskly wrapped up even as the 10th outbreak began in North Kivu; it was declared on August 1, 2018.

Fourteen new confirmed cases were reported from 8 to 14 January in the ongoing Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo. The confirmed cases were reported from Mabalako (64%, n=9), Beni (29%, n=4) and Musienene (7%, n=1) Health Zones in North Kivu Province. All new confirmed cases (100%, 14/14) reported in the past seven days were registered contacts prior to symptom onset and had epidemiological links to the transmission chain which originated from Aloya Health Area in Mabalako Health Zone. 

In the past 21 days (25 December 2019 to 14 January 2020), 40 confirmed cases were reported from 14 health areas within seven active health zones in North Kivu and Ituri Provinces (Figure 1, Figure 2, Table 1): Mabalako (43%, n=17), Butembo (20%, n=8), Beni (13%, n=5), Mambasa (10%, n=4), Kalunguta (8%, n=3), Katwa (5%, n=2), and Musienene (3%, n=1). Mabalako Health Zone remains the current hotspot of the outbreak, having reported 43% of confirmed cases in the past 21 days. The majority of cases (88%, 35/40) reported from this period are linked to known chains of transmission, which is similar to the period from 4 to 24 December 2019 (89%, 47/53). In the past 21 days, 8% (3/36) of the confirmed EVD deaths were people who died in the community, outside of Ebola treatment centres. From these three community deaths, 15 additional cases occurred, which reinforces the need for continued activities to follow contacts, detect symptomatic patients as early as possible, and engage communities in response efforts.  

As of 14 January, a total of 3406 EVD cases were reported, including 3288 confirmed and 118 probable cases, of which 2236 cases died (overall case fatality ratio 66%) (Table 1). Of the total confirmed and probable cases, 56% (n=1910) were female, 28% (n=960) were children aged less than 18 years, and 169 (5% of all reported cases) were health care workers. 

In the coming week, there will be nine health zones in North Kivu and Ituri Provinces that will have contacts in or entering their high-risk period (seven to 13 days after last exposure to the virus). In Kalunguta Health Zone, North Kivu Province, where five individuals were confirmed with EVD from 24 to 28 December 2019, all 153 contacts have cleared their 21-day follow-up, with no new cases reported. In Mambasa Health Zone, Ituri Province, where four new cases were reported from 4 to 5 January 2020, more than 400 followed contacts are nearing the end of their high-risk period. 

It has been 20 months since the outbreak was first declared on 8 May 2018. The number of cases reported per week is lower than the period from March to September 2019 (Figure 1). However, there are several health areas which are difficult to reach due to insecurity, including Mandima Health Zone, where there are rumours of several community deaths in Lwemba Health Area. Continued response efforts in active health zones, including in insecure areas, and preventing reintroduction of the disease into health zones with dense populations which have previously been cleared are crucial to ending ongoing transmission.