COVID and kids/younger adults: bad outcomes

On March 18 the CDC released data on severe outcomes in those with Covid-19, from February 12 to March 16 (see https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm ). [this blog was written last week]

Details:

-- in the US, as of March 16, there been a total of 4226 documented Covid-19 cases reported to the CDC (increasing 500 more cases per day beginning March 14)

-- older people did the worst:

    -- >65yo: 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths

    -- highest percentage of severe outcomes was among people >85yo

    -- overall statistics, by age:

       -- >85yo: 6% of cases, 9% of hospitalizations, 7% of ICU admissions

       -- 65-84yo: 25% of cases, 25% of hospitalizations, 46% of ICU admissions

       -- 45-64yo: 36%, 35% of hospitalizations, 36% of ICU admissions

            --they did not disaggregate the 45-54yo vs 55-64yo age groups for ICU admissions, but the number of cases and hospitalizations were the same for 45-54 and 55-64yo

        -- 20-44yo: 29% of cases, 20% of hospitalizations, 12% of ICU admissions

        -- <19yo: 5% of cases, <1% of hospitalizations, no ICU admissions

-- fatalities (the upper limits in the range include number of persons hospitalized, admitted to ICU or who died among total in age group with known hospitalization status):

    -- >85yo: 10 to 27%

    -- 65-84yo: 3 to 11%

    -- 55-64yo: 1 to 3%

    --20-54yo: <1%

    -- <19yo: none

Commentary:

-- so far 170,000 confirmed cases worldwide, including an estimated 7000 deaths in approximately 150 countries [these numbers are way worse now!!!]

-- in China, 80% of deaths occurred in adults >60yo, with only one death in a person <19yo

-- the above numbers are quite different from previously reported/anticipated:

    -- the percent of people hospitalized in the different age groups very closely matched the percentages of cases reported (this may partially be related to our skewed testing approach, which has emphasized testing sicker people because of the striking lack of testing kits, but it does reveal that lots of people in the 20 to 64 year range are admitted to the hospital)

    -- and, the number of people admitted to the ICU, though more skewed to older people, is still pretty strikingly high for younger ones: 36% of those 45 to 64 and 12% of those 20 to 44

    -- of note, the French health ministry said that ½ of those in ICUs in Paris were <65yo and ½ in the Netherlands were <50yo (see article in Washington Post: https://edition.pagesuite.com/popovers/dynamic_article_popover.aspx?artguid=74f0401a-1eee-4fdf-bb4f-1d1ee2f1bba0&appid=1165 )

-- the accelerating number of case reports no doubt has to do with both increased testing (though still profoundly underdone) as well as increasing spread of the disease

-- of note half the cases were in those 30 to 54 years old

-- limitations of data, per the CDC:

    --9 to 53% of cases were missing accurate data on age and outcomes

    -- we do not have ultimate outcomes on many of these cases

    -- the initial approach to testing focused on those with travel histories or more severe disease, likely to overestimate the prevalence of severe disease

    -- still no data to disaggregate age as a risk factor from the presence of comorbidities (for example, it is possible that many of the young people who died actually had significant comorbidities, such as asthma or diabetes)

    -- and, as they in the CDC themselves admit, testing has been too limited to really understand what is going on

So,

-- the numbers so far in the US suggests that this is a very serious disease even in younger people

-- there are concerns, as articulated in the Washington Post article, that the initial message from China was that young people were relatively immune, and would likely get relatively mild disease; and this might result in their having more cavalier behavior

    -- It is incumbent on us clinicians, and even more so for our public health personnel, to make sure that younger people do understand the risk, that they also self-distance, vigorously hand wash, minimize contact overall with friends and family as appropriate, and stay at home is much as possible

--I am sure that we will get better numbers overall, a better sense of the disease epidemiology and spread, and a better sense of which nonmedical interventions we are all doing are working or not, whether they need to be tweaked a little or lot, and what should be added or eliminated

    --which brings up perhaps our most deficient issue: not enough testing is being done. We need to test huge numbers of people, especially including asymptomatic ones and minimally symptomatic ones

    --and, and, and: we need to finally learn the lesson, which was articulated very clearly at the time of SARS (20 yrs ago) and MERS (10 yrs ago): these animal-to-people transmissions will inevitably continue in the future. It is incumbent on us and our public health systems to try to decrease the likelihood by decreasing these high-risk animal/people interactions but also to be prepared for the future. We need lots of personal protective equipment, easily accessible hospital beds (more quickly available volume), more respirators (even ECMO machines), etc.  Maybe even more toilet paper…..

Another analysis just came out looking at  COVID-19 in kids in China (see covid kids china peds2020 in dropbox, or DOI: 10.1542/peds.2020-0702 ). This analysis suggests that kids can also get bad disease, especially the young ones. thanks to Ed Tronick for forwarding this to me.

Details:

-- nationwide case series of 2143 pediatric patients <18yo in China

--731 (34% had laboratory confirmed cases), 1412 (66%) had suspected cases

    -- suspected cases were those with 2 of the following:

        --fever/respiratory symptoms/digestive symptoms, or

        -- laboratory tests showing normal or decreased WBC, or high lymphocyte count/CRP, or

        --abnormal chest x-ray

-- median age 7, 57% were boys (not statistically significantly different from girls)

-- 90% were asymptomatic, mild, or moderate cases overall

-- overall time from illness onset to diagnosis was 2 days (0 to 42 days)

-- Since there are often many different viral infections that happen in kids, here is a breakdown of those with confirmed Covid 19

    -- 94 (13%) were asymptomatic, 315 (43%) were mild, 300 (41%) were moderate, (3%) were severe, and only 3 cases (0.4%) were critical

    -- median days from symptom onset to diagnosis: 3

-- severity of illness/age (this includes suspected as well as confirmed cases):

    -- asymptomatic: 60% were 6-15yo, 16% were either 1-5yo or >15yo, and only 7% were <1yo

    -- mild: 48% were 1-10yo, 18% were <1yo or 11-15yo, and 15% were >15yo

    -- moderate: quite evenly divided among age groups, lowest being 15% in those<1yo

    -- severe: 30% <1yo, 30% 1-5yo, 20% 6-10yo and 8% >15yo

    -- critical: 54%<1yo, 23% 11-15yo, 8% >15yo

    -- one 14-year-old boy died

-- symptom onset to diagnosis was almost all in the 1^st 5 days

Commentary:

-- other studies have suggested that children do get the infection at roughly the same rates as adults, but they tend to have milder symptoms. This was confirmed in the above study, however there were more severe symptoms than had been suggested before

-- it does seem that the children <1yo are particularly susceptible to bad infection

-- though, those 6-15% were more likely to be asymptomatic (and perhaps more likely to be unsuspected SARS-CoV-2 vectors...)

-- one can only speculate as to why children seem to get milder cases. One comment is that ACE2 levels are lower in children, another is that their inflammatory response may be less (perhaps related to a less mature immune system)

-- limitations of study include:

    -- there were no granular data on the clinical characteristics of children (For example, a few times in the paper they referred to GI symptoms, which are considered pretty marginal in adults having only 1 to 2% presenting with GI symptomatology)

    -- there are no data presented on the relative frequency of testing children of different disease severity in the community

        --2143 patients of whom only 731 had confirmatory tests does suggest there may be significant bias in testing

        -- and, this might be especially true within the greater community and especially for milder or asymptomatic cases

        -- and their inclusion criteria for a high-risk child would eliminate many of the mild cases

--------------------------

And, yet another study of kids came out of China, from the Wuhan Children’s Hospital, the only center assigned by the central government for treating infected children <16 yo in Wuhan (see covid kids china nejm2020 in dropbox, or DOI: 10.1056/NEJMc2005073)

Details:

-- symptomatic and asymptomatic children with known contact with persons having confirmed or suspected Sars-CoV-2 were evaluated by nasopharyngeal or throat swabs

-- 1391 children were assessed from January 28 through February 26, 171 (12%) were confirmed to have the virus

--median age 6.7 years, <1y 18%/1-5 yo 23%/6-10yo 34%/11-15yo 25%, 61% male

-- asymptomatic 16% (no symptoms or radiologic features of pneumonia), URI 19%, pneumonia 65%

-- exposure: family cluster 90%

-- symptoms:

    -- cough 49%

    -- pharyngeal erythema 46%

    -- fever 42% (of those 9% were > 39°C, and 23% were 38 to 39°C

    -- GI: diarrhea 9%, vomiting 6%

    -- other symptoms: fatigue 8%, rhinorrhea 8%, nasal congestion 5%

-- tachypnea on admission 29%, tachycardia 42%, O2 saturation<92% in 2%

-- chest x-ray: groundglass opacity 33%, local patchy shadowing 19%, bilateral patchy shadowing 12%

Results:

-- 3 patients required intensive care and invasive mechanical ventilation (all had coexisting conditions: hydronephrosis, leukemia, intussusception)

-- one death: 10 month old with intussusception and multiorgan failure

-- 21 patients were stable in the general words, 149 were discharged

-- so, this report does provide some granular data on signs and symptoms in kids. The above data notes the prevalence of single symptoms; it is still unclear how the symptoms were coupled in individual patients.

     --also, this study also suggests that there are a higher % of kids with GI symptoms, vs adults (on the order of 1-2%)

-- And, it seems that there was a long enough follow-up to know that this relatively high number of asymptomatic patients remained asymptomatic

    --these numbers also confirm the pretty large number of asymptomatic kids. would be good to have more data on the actual likelihood of virus communicability by kids of different ages.

    --The data in adults suggests a much lower number, though would be really great to have much more community data in the US, through more aggressive testing

BUT, the real lesson from these studies in kids and young adults is that they are quite susceptible to the really bad consequences of SARS-CoV-2 infection. which i think really means:

--there really needs to be aggressive advertising to kids, through their major media as well (ie social messaging), that they are at high risk of being hospitalized/in the ICU from this virus

--the message needs to be unequivocal, and directly combat earlier messages that it was pretty much the older folks who had bad cases

    --and it really needs to be sensitive to the issues of young people, and their often held beliefs that they are invulnerable, being macho(a) is cool, susceptible to peer pressure (perhaps from a bored friend being at home too much), etc

--there need to be very easy, perhaps largely phone-based, access to behavioral health specialists, who can help kids/young adults deal with the tremendous social/economic/psychologic disruptions from the current pandemic

--also many will become unemployed during this period, cutting them off from another social connection. and also the needed income: this is a social issue that needs to be addressed (and not just giving boatloads of money to the airlines; pardon the mixed metaphor)

--and they really should practice the same self-care as adults, especially social distancing and avoiding close contact with more vulnerable family members (by age, comorbidities, etc)

and, it seems that we all are in this for the longish term.  these messages to kids/young adults (as well as us older ones) need to be reinforced over time, with the likelihood of significant increases over time in all of these medical and psychosocial traumas

and, learn the lesson finally that these types of infections will continue to recur in the future, we should anticipate them/prepare in advance for them, and our response to them needs to be immediate, aggressive, and communal (ie, not pretend that this is an isolated issue in another part of the world and not a potential global threat, or vilify/blame those countries initially hit instead of embracing them/providing huge international support).

geoff​

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