H5N1

Bill Gates on COVID-19, vaccines and global health

Via The New York Times: Bill Gates on Coronavirus, Vaccines and Global Health. Excerpt:

On Monday, the Bill and Melinda Gates Foundation released the fourth of its annual Goalkeeper reports, which track the slow but steady progress the world has made toward more than a dozen health-related goals set forth by the United Nations in 2015.

This year’s was unrelentingly grim. The coronavirus pandemic has scorched away years of work: More families are in dire poverty, malnutrition is increasing, far fewer children are getting immunized. 

The assessment comes as the United States, stung harder by the virus than any other country, is retreating from the global health stage and seems focused primarily on saving itself. Could it ever return to its role as the world’s leader in both competence and generosity? In an interview with The New York Times, Mr. Gates devoted a half-hour to explaining why he was optimistic that it would. 

“It’s my disposition,” he said. “Plus, I’ve got to call these people up and make the pitch to them that this really makes sense — and I totally, totally believe it makes sense.”

By “these people,” he was referring to leading figures in the White House and Congress, whom he has personally lobbied to do “this”: namely, add an extra $4 billion to the fiscal stimulus package now under debate in Congress so that poor countries can get Covid-19 vaccines.  

Ultimately his goal is far more ambitious: to double American foreign aid from less than 0.25 percent of gross domestic product to 0.5 percent or more. He sees the pandemic as an opportunity to do that. 

“As they say,” he added cheerily, “the U.S. government — after it’s tried every other thing — does the right thing.” 

As he did in Silicon Valley while battling competitors and antitrust regulators, Mr. Gates can calculate his chances of success with a ruthless logic. That has rarely been as true as it is now, as a once-in-a-century pandemic devastates the impoverished countries where he focuses his giving.  

The damage has been wrought less by the virus — so far it has killed much smaller percentages of the populations of Asia and Africa than of the Americas and Western Europe — than by the economic impact, which has been far greater in countries where people and governments “have no spare reserves to draw on,” Mr. Gates said. 

The collapse of tourism, declines in remittances from relatives working abroad, the shutdown of ports, mines and oil wells, school closings and new stresses on fragile health care systems have all created enormous suffering. 

Not since 1870 have so many countries been in recession at once, according to the Goalkeeper report. Between 1990 and 2020, the percentage of the world’s population living in extreme poverty, which is now defined as living on less than $2 a day, shrank to less than 7 percent from 37 percent. In just the past few months, 37 million people have fallen back below the line, the report estimated.  

“The longer the pandemic lasts, the worse its economic scars will be,” it added.

Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom

Via The BMJ: Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. The abstract:

Objective To characterise the clinical features of children and young people admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK and explore factors associated with admission to critical care, mortality, and development of multisystem inflammatory syndrome in children and adolescents temporarily related to coronavirus disease 2019 (covid-19) (MIS-C).  

Design Prospective observational cohort study with rapid data gathering and near real time analysis. 

Setting 260 hospitals in England, Wales, and Scotland between 17 January and 3 July 2020, with a minimum follow-up time of two weeks (to 17 July 2020).  

Participants 651 children and young people aged less than 19 years admitted to 138 hospitals and enrolled into the International Severe Acute Respiratory and emergency Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK study with laboratory confirmed SARS-CoV-2.  

Main outcome measures Admission to critical care (high dependency or intensive care), in-hospital mortality, or meeting the WHO preliminary case definition for MIS-C. 

Results Median age was 4.6 (interquartile range 0.3-13.7) years, 35% (225/651) were under 12 months old, and 56% (367/650) were male. 57% (330/576) were white, 12% (67/576) South Asian, and 10% (56/576) black. 42% (276/651) had at least one recorded comorbidity. 

A systemic mucocutaneous-enteric cluster of symptoms was identified, which encompassed the symptoms for the WHO MIS-C criteria. 18% (116/632) of children were admitted to critical care. On multivariable analysis, this was associated with age under 1 month (odds ratio 3.21, 95% confidence interval 1.36 to 7.66; P=0.008), age 10-14 years (3.23, 1.55 to 6.99; P=0.002), and black ethnicity (2.82, 1.41 to 5.57; P=0.003). Six (1%) of 627 patients died in hospital, all of whom had profound comorbidity. 

11% (52/456) met the WHO MIS-C criteria, with the first patient developing symptoms in mid-March. Children meeting MIS-C criteria were older (median age 10.7 (8.3-14.1) v 1.6 (0.2-12.9) years; P<0.001) and more likely to be of non-white ethnicity (64% (29/45) v 42% (148/355); P=0.004). Children with MIS-C were five times more likely to be admitted to critical care (73% (38/52) v 15% (62/404); P<0.001). 

In addition to the WHO criteria, children with MIS-C were more likely to present with fatigue (51% (24/47) v 28% (86/302); P=0.004), headache (34% (16/47) v 10% (26/263); P<0.001), myalgia (34% (15/44) v 8% (21/270); P<0.001), sore throat (30% (14/47) v (12% (34/284); P=0.003), and lymphadenopathy (20% (9/46) v 3% (10/318); P<0.001) and to have a platelet count of less than 150 × 109/L (32% (16/50) v 11% (38/348); P<0.001) than children who did not have MIS-C. No deaths occurred in the MIS-C group. 

Conclusions Children and young people have less severe acute covid-19 than adults. A systemic mucocutaneous-enteric symptom cluster was also identified in acute cases that shares features with MIS-C. This study provides additional evidence for refining the WHO MIS-C preliminary case definition. Children meeting the MIS-C criteria have different demographic and clinical features depending on whether they have acute SARS-CoV-2 infection (polymerase chain reaction positive) or are post-acute (antibody positive).

Children and COVID-19: State-level data report

A news release from the American Academy of Pediatrics: Children and COVID-19: State-Level Data Report.

State-level reports are the best publicly available data on child COVID-19 cases in the United States. The American Academy of Pediatrics and the Children’s Hospital Association are collaborating to collect and share all publicly available data from states on child COVID-19 cases (definition of “child” case is based on varying age ranges reported across states; see report Appendix for details and links to all data sources).  

On August 20, the age distribution of reported COVID-19 cases was provided on the health department websites of 49 states, New York City, the District of Columbia, Puerto Rico, and Guam. While children represented only 9.3% of all cases in states reporting cases by age, over 442,000 children have tested positive for COVID-19 since the onset of the pandemic.

A smaller subset of states reported on hospitalizations and mortality by age, but the available data indicated that COVID-19-associated hospitalization and death is uncommon in children.  

At this time, it appears that severe illness due to COVID-19 is rare among children. However, states should continue to provide detailed reports on COVID-19 cases, testing, hospitalizations, and mortality by age so that the effects of COVID-19 on children’s health can be documented and monitored. 

Summary of Findings Reported on 8/20/20: 

(Note: Data represent cumulative counts since states began reporting) 

Cumulative Number of Child COVID-19 Cases* 

• 442,785 total child COVID-19 cases reported, and children represented 9.3% (442,785/4,766,825) of all cases  

• Overall rate: 583 cases per 100,000 children in the population 

Change in Child COVID-19 Cases, 8/6/20 – 8/20/20 

• 74,160 new child cases reported from 8/6-8/20 (358,469 to 432,629), a 21% increase in child cases over 2 weeks 

Testing (9 states reported)* 

• Children made up between 4%-12.1% of total state tests, and between 3.2%-17.8% of children tested were tested positive 

Hospitalizations (21 states and NYC reported)* 

• Children were 0.4%-4.6% of total reported hospitalizations, and between 0.2%-8.6% of all child COVID-19 cases resulted in hospitalization 

Mortality (45 states and NYC reported)* 

• Children were 0%-0.3% of all COVID-19 deaths, and 21 states reported zero child deaths  

 • In states reporting, 0%-0.7% of all child COVID-19 cases resulted in death  

*Note: Data represent cumulative counts since states began reporting; All data reported by state/local health departments are preliminary and subject to change; ^ In making this 2-week comparison, the count excludes Alabama due to change in definition of child case as of 8/13; see full report.

COVID-19 and multisystem inflammatory syndrome in children and adolescents

Via The Lancet Infectious Diseases: COVID-19 and multisystem inflammatory syndrome in children and adolescents. The summary:

As severe acute respiratory syndrome coronavirus 2 continues to spread worldwide, there have been increasing reports from Europe, North America, Asia, and Latin America describing children and adolescents with COVID-19-associated multisystem inflammatory conditions. However, the association between multisystem inflammatory syndrome in children and COVID-19 is still unknown. 

We review the epidemiology, causes, clinical features, and current treatment protocols for multisystem inflammatory syndrome in children and adolescents associated with COVID-19. We also discuss the possible underlying pathophysiological mechanisms for COVID-19-induced inflammatory processes, which can lead to organ damage in paediatric patients who are severely ill. 

These insights provide evidence for the need to develop a clear case definition and treatment protocol for this new condition and also shed light on future therapeutic interventions and the potential for vaccine development.

US COVID-19 death toll set to reach 200,000 by Labor Day, CDC forecast says

Via The Guardian: US coronavirus death toll set to reach 200,000 by Labor Day, CDC forecast says. Excerpt:

The US death toll from the coronavirus pandemic is set to reach 200,000 by Labor Day as children across the country prepare to return to school, according to a Centers for Disease Control and Prevention (CDC) forecast.  

The rate of new deaths could rise in California and Colorado over the coming four weeks and decline in Arizona, the CDC said. More than 160,000 people have died from Covid-19 in America, although scientists have pointed out the number of excess deaths so far this year exceeds even this toll. 

“Covid-19 deaths could be being undercounted or the pandemic could also be causing increases in other types of death. It’s probably some of both,” said Ronald Fricker, a professor of statistics at Virginia Tech. “Regardless of the reason, the Covid-19 pandemic has resulted in substantially more deaths than would have otherwise occurred, and it is not over yet.”  

The grim projection comes as states outside the US north-east continue to struggle to dampen a surge in new infections, with California on Thursday becoming the first state to register 600,000 Covid cases. 

A summer leap in new infections prompted California to shut down bars and indoor dining for a second time, although the governor, Gavin Newsom, said this week the state is “turning the corner on this pandemic”, citing a drop in new hospitalizations. 

The ongoing crisis, marred by a bungled governmental response to contain the virus and the spread of misinformation over mask-wearing and touted miracle cures to stem the outbreak, could end up being as deadly or worse than the 1918 flu pandemic, researchers have warned.  

When improvements in hygiene and modern medicine are factored in, the increase in deaths in the initial months of the Covid-19 pandemic was “substantially greater” than during the peak of the 1918 event, a study has found. 

Despite the mounting death toll, Donald Trump’s administration is continuing to push for schools to reopen as normal. Schools in several states have already returned, often with adverse consequences – more than 2,000 students and teachers across five states have been quarantined following several hundred positive Covid-19 cases.  

In just one school district in Georgia, 1,100 students had to be isolated at home due to an outbreak of the virus. Trump has said the virus’s risk to children is “very, very low” although experts have warned this should not be comforting to parents.

US: Missouri governor’s comments on COVID-19, McCloskeys raise eyebrows

Via stltoday.com: Missouri governor’s comments on coronavirus, McCloskeys raise eyebrows. Truly amazing. Excerpt:

A series of controversial remarks by Missouri Gov. Mike Parson on a St. Louis radio show are getting widespread attention — and some pushback.  

In an interview on Friday with talk-radio host Marc Cox on KFTK (97.1 FM), Parson indicated both certainty and acceptance that the coronavirus will spread among children when they return to school this fall. The virus has killed 1,130 people in the state despite a weekslong stay-at-home order in the spring that helped slow the virus’ spread — and the state set a record on Saturday with 958 new cases. 

In the same 10-minute interview, Parson said that if it came to it, he would probably pardon the Central West End couple who pointed guns at protesters marching past their home on a private street on June 28. 

Parson’s comment on the coronavirus signaled that the decision to send all children back to school would be justified even in a scenario in which all of them became infected with the coronavirus. 

St. Louis-area schools are expected to release their reopening plans on Monday.  

“These kids have got to get back to school,” Parson told Cox. “They’re at the lowest risk possible. And if they do get COVID-19, which they will — and they will when they go to school — they’re not going to the hospitals. They’re not going to have to sit in doctor’s offices. They’re going to go home and they’re going to get over it.” 

He emphasized that people who are at high risk of becoming seriously ill should be protected but said most people in the state were smart enough to figure out how to stay safe without government interventions such as mask mandates.  

“We gotta move on,” he said. “We can’t just let this thing stop us in our tracks.”  

In an email on Sunday, Dr. Alex Garza, incident commander of the St. Louis Metropolitan Pandemic Task Force, called the question about returning to school a “Gordian knot.”  

While it is important for children to be in school, he said, and it is true that they do not typically get seriously ill from COVID-19, “we worry about those in school who are not children — teachers, support staff and volunteers. Many of those people will have a much more serious response to the virus and that is what we want to avoid. These children could also come home and spread the virus to others in their household who could also be at a greater risk of a serious outcome.” 

In a tweet on Friday, state Auditor Nicole Galloway, the Democratic candidate for governor, said Parson’s comments displayed “stunning ignorance … on how COVID-19 affects children. He admitted that he’s okay with your kids (and your families) getting the deadly disease when he sends them back to school. Does he not realize multiple American kids have died after being infected?”

Routine childhood immunisation during the COVID-19 pandemic in Africa

Via The Lancet Global Health: Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection. The summary:

Background 

National immunisation programmes globally are at risk of suspension due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing COVID-19 pandemic. We aimed to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through visiting routine vaccination service delivery points. 

Methods 

We considered a high-impact scenario and a low-impact scenario to approximate the child deaths that could be caused by immunisation coverage reductions during COVID-19 outbreaks. In the high-impact scenario, we used previously reported country-specific child mortality impact estimates of childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever to approximate the future deaths averted before 5 years of age by routine childhood vaccination during a 6-month COVID-19 risk period without catch-up campaigns. 

In the low-impact scenario, we approximated the health benefits of sustaining routine childhood immunisation on only the child deaths averted from measles outbreaks during the COVID-19 risk period. We assumed that contact-reducing interventions flattened the outbreak curve during the COVID-19 risk period, that 60% of the population will have been infected by the end of that period, that children can be infected by either vaccinators or during transport, and that upon child infection the whole household will be infected. 

Country-specific household age structure estimates and age-dependent infection-fatality rates were applied to calculate the number of deaths attributable to the vaccination clinic visits. 

We present benefit–risk ratios for routine childhood immunisation, with 95% uncertainty intervals (UIs) from a probabilistic sensitivity analysis. 

Findings 

In the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa. 

The benefit–risk ratio for the vaccinated children is 85 000 (4900–546 000), for their siblings (<20 years) is 75 000 (4400–483 000), for their parents or adult carers (aged 20–60 years) is 769 (148–2700), and for older adults (>60 years) is 96 (14–307). 

In the low-impact scenario that approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10); if the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000). 

Interpretation 

The deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children. Routine childhood immunisation should be sustained in Africa as much as possible, while considering other factors such as logistical constraints, staff shortages, and reallocation of resources during the COVID-19 pandemic.

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.