Emergency physician and leading epidemiologist in Brazil, Dr Fatima Marinho, is seeing symptoms of Covid-19 in children that starkly contrast with the message that has been relayed globally throughout the pandemic that children do not appear to suffer severely from the virus.
Severe muscle aches, diarrhoea, coughing, abdominal pain and hospitalisation – all of these are happening to children with Covid-19 in Brazil, Marinho says.
The latest available data extracted by Marinho on 15 April showed 2,216 children aged between zero and nine had died from Covid-19. This includes 1,397 babies under one year old. Meanwhile, more than 67,000 children in the zero-to-nine years old age group have been hospitalised in Brazil.
Marinho, a senior adviser to the global public health organisation Vital Strategies, tells Guardian Australia: “The epidemic in Brazil is changing the profile of severe cases.”
“We see more young people hospitalised and dying by Covid compared to 2020,” she says. “Soon Brazil must start to vaccinate young people because of the risk due to new variants. But there isn’t enough vaccine.”
On Saturday, the World Health Organisation (WHO) urged wealthier countries who had completed vaccinating their most vulnerable to delay vaccinating children and instead donate those doses to its Covax facility so they can be distributed to countries most in need. Vaccinations of children has already begun in some countries, with Canada and the US among those vaccinating 12 to 15 year-olds.
“In low and lower-middle income countries, Covid-19 vaccine supply has not been enough to even immunise healthcare workers, and hospitals are being inundated with people that need lifesaving care urgently,” the WHO director general, Dr Tedros Adhanom Ghebreyesus, said.
“I understand why some countries want to vaccinate their children and adolescents, but right now I urge them to reconsider and to instead donate vaccines to Covax.”
But among those requiring lifesaving care in countries still being ravaged by the virus including India, Brazil and Indonesia are children. So why is Covid-19 infecting and affecting children so severely in some countries but not in others, to the point where some countries may forgo vaccinating children for the time being ?
While more research is needed, Marinho says there are several factors playing a role. One is that diagnosis of Covid-19 in children is coming too late, when children are already severely unwell and treatment is more difficult.
“There is a culture of ‘there is no risk for children’, so physicians don’t think in terms of Covid-19,” she says.
“As well as low access to timely healthcare, there is also poverty and inequalities, and people living in areas and houses with difficulty in social distancing. In poor houses, there are more than four people per room.”
Social distancing outside the home is also difficult, she says. “Members of the family must go out every day for work or searching for a job,” Marinho says. “New Sars-CoV-2 variants also have a higher viral load compared to other variants.” This means people are also more infectious.
“Brazil needs more tests for Covid-19, without testing and tracking cases and controls, the virus cannot be controlled and will continue spreading around the country,” she says. “The risk is new mutations.”
In Indonesia, the Indonesian Paediatrician Association (IDAI) said official figures that suggest 28 children have died from Covid are an underestimate, and the number is closer to 160. The ADAI chairman, Dr Aman B Pulungan, told the ABC in June, “It proves that it is not true that the under-18 age bracket is not susceptible to Covid-19”.
In India, not only have children been left orphaned due to the high Covid-19 death rate, but the devastating second wave is seeing more children infected. While child mortality is still low overall, they are being hit more severely.
A paediatric pulmonologist working in Bangalore, Dr Srikanta JT, says during the previous wave of Covid there might be one child a week with Covid.
“But according to data from most [health] centres in India and our own data collated over [the] last few months, the second wave seems to be impacting children quite significantly with numbers gradually increasing, with almost 12 to 15 positive cases a day,” he tells Guardian Australia. These include young children and adolescents.
While most children seem to have asymptomatic to mildly infections which could be managed at home, there is a growing number of severe cases in children.
“We are also witnessing a significant number of severe cases like severe pneumonia requiring ventilatory support to children presenting with type 1 diabetes mellitus and complications of it like diabetic ketoacidosis, to multisystem inflammatory syndrome, with significant morbidity and mortality. Even though it quantifies to approximately 5% of our cohort, the numbers are quite significant.”
As well as the role of underlying conditions that are more common in children living in harsh conditions, Srikanta says once lockdowns and other restrictions were lifted following the first wave, there was a sense in the general public that the pandemic was behind them.
“And most started either completely or partially refraining from Covid-appropriate behaviour,” he says. “This inappropriate behaviour has led to significant intermingling and hence a second wave.”
A theory as to why children generally appear less susceptible to the virus than adults is that they have less of a type of receptor known as ACE2 in their respiratory tract. These receptors are a key pathway for the entry of the virus that causes Covid-19 to enter the cells. Fewer ACE2 receptors, it is theorised, means fewer opportunities for the virus to take hold.
“During the first wave of pandemic, it was generally thought that both absence and reduced number of these receptors in children was generally protective,” Srikanta says. “But along came the second wave with a more virulent strain, which seems to bypass the apparatus required for entry and evade the immune system better, hence an increase in both numbers in children and severity in infection.”
The latest WHO Covid-19 epidemiological report says the highest numbers of new cases reported in the week to 11 May were from India [2,738,957 new cases; a 5% increase), followed by Brazil (423,438 new cases; similar to the previous week). Indonesia had the third highest number of new cases in the south-east Asia region, behind India and Nepal, with 36,882 new cases, a 2% increase on the week prior.
A professor of paediatrics and child health at the University of Sydney, Robert Booy, says the sheer population size of those countries is also likely behind the higher cases in children there. Whether variants or other mechanisms such as the one involving ACE2 described by Srikanta are driving the rates in children needs more study, he says.
“As this virus keeps mutating it carries the risk of becoming much more transmissible, which is the primary thing we’ve noticed the last six months, but it may actually become more severe for children,” he says. “We just don’t know everything there is to know yet.”