GALVESTON BAY : Statewide Interventions and Covid-19 Mortality in the United States: An Observational Study and Galveston County, Texas update

2020 Jul 8;ciaa923. doi: 10.1093/cid/ciaa923. Online ahead of print.

Statewide Interventions and Covid-19 Mortality in the United States: An Observational Study

Nadir Yehya 1, Atheendar Venkataramani 2 3, Michael O Harhay 3 4 5

Affiliations expand

PMID: 32634828 DOI: 10.1093/cid/ciaa923

Abstract

Background: Social distancing is encouraged to mitigate viral spreading during outbreaks. However, the association between distancing and patient-centered outcomes in Covid-19 has not been demonstrated. In the United States social distancing orders are implemented at the state level with variable timing of onset. Emergency declarations and school closures were two early statewide interventions.

Methods: To determine whether later distancing interventions were associated with higher mortality, we performed a state-level analysis in 55,146 Covid-19 non-survivors. We tested the association between timing of emergency declarations and school closures with 28-day mortality using multivariable negative binomial regression. Day 1 for each state was set to when they recorded ≥ 10 deaths. We performed sensitivity analyses to test model assumptions.

Results: At time of analysis, 37 of 50 states had ≥ 10 deaths and 28 follow-up days. Both later emergency declaration (adjusted mortality rate ratio [aMRR] 1.05 per day delay, 95% CI 1.00 to 1.09, p=0.040) and later school closure (aMRR 1.05, 95% CI 1.01 to 1.09, p=0.008) were associated with more deaths. When assessing all 50 states and setting day 1 to the day a state recorded its first death, delays in declaring an emergency (aMRR 1.05, 95% CI 1.01 to 1.09, p=0.020) or closing schools (aMRR 1.06, 95% CI 1.03 to 1.09, p<0 .001="" and="" associated="" deaths.="" excluding="" jersey.="" more="" new="" results="" span="" unchanged="" were="" when="" with="" york="">

Conclusions: Later statewide emergency declarations and school closure were associated with higher Covid-19 mortality. Each day of delay increased mortality risk 5 to 6%.

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CONCLUSION

We provide evidence of an association between earlier statewide nonpharmaceutical interventions of social distancing and lower mortality in the early weeks of Covid-19. Specifically, each day of delay in a state declaring an emergency or closing schools increased mortality risk by 5 to 6%.

Keywords: SARS-CoV-2; coronavirus; nonpharmaceutical interventions; pandemic; social distancing.

https://pubmed.ncbi.nlm.nih.gov/32634828/

https://academic.oup.com/cid/article-pdf/doi/10.1093/cid/ciaa923/33472653/ciaa923.pdf

Galveston County Texas Covid-19 update

Galveston County Health District Covid-19

Today we're reporting:

👉 125 new positive #COVID19 cases, county total at 7,479

👉 100 new recoveries, county total at 2,433

👉 96,487 total tests administered

Today’s report includes a testing increase of 1,132 putting the rate of positive COVID-19 tests at 11 %.

Please continue to do your part to slow the spread of #coronavirus:

🏡 Stay home when possible

😷 Wear a face covering in public spaces

↔️ Stay at least 6 feet from other people

🖐 Frequently wash your hands with soap and water for at least 20 seconds

You can find more case information in today's news release:

https://www.gchd.org/Home/Components/News/News/3689/65

Interactive charts and graphics:

https://www.gchd.org/about-us/news-and-events/coronavirus-disease-2019-covid-19/galveston-county-confirmed-covid-19-cases/-fsiteid-1

Testing information: www.gchd.org/testing

Our next case update will be Wednesday after 5 p.m.

A few notes:

➡️ We are seeing an increase in positive cases. This is due to community spread, not necessarily the demand for more testing.

Yes, there is an increase in testing. But more importantly, there is an increase in the percentage of people testing positive.

When we first began testing in March and April, the percentage of those testing positive hovered around 2-3 percent. Today's rate is 11%.

➡️ Our daily case update reflects Galveston County residents only.

➡️ The number of active cases hospitalized reflects hospitalized Galveston County residents only. You may see different numbers published by county hospitals. Those numbers reflect that hospital's patients, which likely includes patients from areas outside of Galveston County.

➡️ Antibody testing is included in our case count graphic. Antibody tests and negative/ positive results are reported separately. A positive antibody test means you were previously exposed to the virus or that you are currently infected.

The health district only counts lab confirmed positive COVID-19 viral tests as cases.

➡️ On average, 15-20 percent of Galveston County cases have been asymptomatic.

➡️ A positive case is counted only once. Some positive cases are tested again as a way to deem them recovered per the CDC. Those additional tests are not counted as a new case.

➡️ Cases must meet CDC criteria before being considered recovered.

Symptomatic

Symptom based:

At least 24 hours have passed since last fever (without the use of fever-reducing medicine); and improvement in symptoms; and at least 10 days since symptoms first appeared.

Test based:

Resolution of fever without the use of fever-reducing medicine; and improvement in respiratory symptoms; and negative results from at least two COVID-19 tests collected at least 24 hours apart.

Asymptomatic (lab-confirmed COVID-19 positive)

Time based:

At least 10 days have passed since the date of their first positive COVID-19 diagnostic test, assuming symptoms have not developed. If symptoms develop, then cases must meet CDC symptomatic recovery criteria.

Test based:

Negative results from at least two COVID-19 tests collected at least 24 hours apart.

https://facebook.com/gchdinfo

*** 100 new recoveries, county total at 2,433

this in my opinion is an oxymoron imo., to say someone that survived Covid, ones that left the hospital and went home may never fully recover, others may take months, years, if ever, and how many might still die from these long term effects?

-----Original Message-----
From: Terry Singeltary <flounder9@verizon.net>
To: T7DSwartz@dickinsonisd.org <T7DSwartz@dickinsonisd.org>
Cc: CVoelkel@dickinsonisd.org <CVoelkel@dickinsonisd.org>; T4JPittman@dickinsonisd.org <T4JPittman@dickinsonisd.org>; T2VVeasey@dickinsonisd.org <T2VVeasey@dickinsonisd.org>; T5CMagliolo@dickinsonisd.org <T5CMagliolo@dickinsonisd.org>; T6JRodriguez@dickinsonisd.org <T6JRodriguez@dickinsonisd.org>; T3FSamford@dickinsonisd.org <T3FSamford@dickinsonisd.org>; T1MMackey@dickinsonisd.org <T1MMackey@dickinsonisd.org>; laura-dupont@ccisd.net <laura-dupont@ccisd.net>; jay-cunningham@ccisd.net <jay-cunningham@ccisd.net>; arturo-sanchez@ccisd.net <arturo-sanchez@ccisd.net>; scott-bowen@ccisd.net <scott-bowen@ccisd.net>; jennifer-broddle@ccisd.net <jennifer-broddle@ccisd.net>; page-rander@ccisd.net <page-rander@ccisd.net>; win-weber@ccisd.net <win-weber@ccisd.net>
Sent: Tue, Jul 21, 2020 2:37 pm
Subject: Covid-19 and our children, we must never politicize

Covid-19 and our children, we must never politicize

Greetings Honorable Board of Trustees DISD and CCISD et al,

i wish to kindly send you some of the latest science on the covid and risk factors for children, and risk factors for children to spread it on to teachers, parents, friends, etc. we must NOT politicize our children's health. we must use science. please use as you wish...

kindest regards, terry

just out cdc et al;

***> We showed that household transmission of SARS-CoV-2 was high if the index patient was 10–19 years of age.

The role of household transmission of SARS-CoV-2 amid reopening of schools and loosening of social distancing underscores the need for a time-sensitive epidemiologic study to guide public health policy. Contact tracing is especially important in light of upcoming future SARS-CoV-2 waves, for which social distancing and personal hygiene will remain the most viable options for prevention. Understanding the role of hygiene and infection control measures is critical to reducing household spread, and the role of masking within the home, especially if any family members are at high risk, needs to be studied.

We showed that household transmission of SARS-CoV-2 was high if the index patient was 10–19 years of age. In the current mitigation strategy that includes physical distancing, optimizing the likelihood of reducing individual, family, and community disease is important. Implementation of public health recommendations, including hand and respiratory hygiene, should be encouraged to reduce transmission of SARS-CoV-2 within affected households.

Volume 26, Number 10—October 2020

Dispatch

Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020

Young Joon Park1, Young June Choe1, Ok Park, Shin Young Park, Young-Man Kim, Jieun Kim, Sanghui Kweon, Yeonhee Woo, Jin Gwack, Seong Sun Kim, Jin Lee, Junghee Hyun, Boyeong Ryu, Yoon Suk Jang, Hwami Kim, Seung Hwan Shin, Seonju Yi, Sangeun Lee, Hee Kyoung Kim, Hyeyoung Lee, Yeowon Jin, Eunmi Park, Seung Woo Choi, Miyoung Kim, Jeongsuk Song, Si Won Choi, Dongwook Kim, Byoung-Hak Jeon, Hyosoon Yoo, Eun Kyeong JeongComments to Author , and on behalf of the COVID-19 National Emergency Response Center, Epidemiology and Case Management Team Author affiliations: Korea Centers for Disease Control and Prevention, Cheongju, South Korea (Y.J. Park, O. Park, S.Y. Park, Y.-M. Kim, J. Kim, S. Kweon, Y. Woo, J. Gwack, S.S. Kim, J. Lee, J. Hyun, B. Ryu, Y.S. Jang, H. Kim, S.H. Shin, S. Yi, S. Lee, H.K. Kim, H. Lee, Y. Jin, E. Park, S.W. Choi, M. Kim, J. Song, S.W. Choi, D. Kim, B.-H. Jeon, H. Yoo, E.K. Jeong); Hallym University College of Medicine, Chuncheon, South Korea (Y.J. Choe)

Abstract

We analyzed reports for 59,073 contacts of 5,706 coronavirus disease (COVID-19) index patients reported in South Korea during January 20–March 27, 2020. Of 10,592 household contacts, 11.8% had COVID-19. Of 48,481 nonhousehold contacts, 1.9% had COVID-19. Use of personal protective measures and social distancing reduces the likelihood of transmission.

Effective contact tracing is critical to controlling the spread of coronavirus disease (COVID-19) (1). South Korea adopted a rigorous contact-tracing program comprising traditional shoe-leather epidemiology and new methods to track contacts by linking large databases (global positioning system, credit card transactions, and closed-circuit television). We describe a nationwide COVID-19 contact tracing program in South Korea to guide evidence-based policy to mitigate the pandemic (2).

The Study

South Korea’s public health system comprises a national-level governance (Korea Centers for Disease Control and Prevention), 17 regional governments, and 254 local public health centers. The first case of COVID-19 was identified on January 20, 2020; by May 13, a total of 10,962 cases had been reported. All reported COVID-19 patients were tested using reverse transcription PCR, and case information was sent to Korea Centers for Disease Control and Prevention.

We defined an index case as the first identified laboratory-confirmed case or the first documented case in an epidemiologic investigation within a cluster. Contacts in high-risk groups (household contacts of COVID-19 patients, healthcare personnel) were routinely tested; in non–high-risk groups, only symptomatic persons were tested. Non–high-risk asymptomatic contacts had to self-quarantine for 14 days and were placed under twice-daily active surveillance by public health workers. We defined a household contact as a person who lived in the household of a COVID-19 patient and a nonhousehold contact as a person who did not reside in the same household as a confirmed COVID-19 patient. All index patients were eligible for inclusion in this analysis if we identified >1 contact. We defined a detected case as a contact with symptom onset after that of a confirmed COVID-19 index patient.

We grouped index patients by age: 0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and >80 years. Because we could not determine direction of transmission, we calculated the proportion of detected cases by the equation [number of detected cases/number of contacts traced] × 100, excluding the index patient; we also calculated 95% CIs. We compared the difference in detected cases between household and nonhousehold contacts across the stratified age groups.

We conducted statistical analyses using RStudio (https://rstudio.com).External).))

We conducted this study as a legally mandated public health investigation under the authority of the Korean Infectious Diseases Control and Prevention Act (nos. 12444 and 13392).

We monitored 59,073 contacts of 5,706 COVID-19 index patients for an average of 9.9 (range 8.2–12.5) days after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was detected (Table 1). Of 10,592 household contacts, index patients of 3,417 (32.3%) were 20–29 years of age, followed by those 50–59 (19.3%) and 40–49 (16.5%) years of age (Table 2). A total of 11.8% (95% CI 11.2%–12.4%) household contacts of index patients had COVID-19; in households with an index patient 10–19 years of age, 18.6% (95% CI 14.0%–24.0%) of contacts had COVID-19. For 48,481 nonhousehold contacts, the detection rate was 1.9% (95% CI 1.8%–2.0%) (Table 2). With index patients 30–39 years of age as reference, detection of COVID-19 contacts was significantly higher for index patients >40 years of age in nonhousehold settings. For most age groups, COVID-19 was detected in significantly more household than nonhousehold contacts (Table 2).

Conclusions

We detected COVID-19 in 11.8% of household contacts; rates were higher for contacts of children than adults. These risks largely reflected transmission in the middle of mitigation and therefore might characterize transmission dynamics during school closure (3). Higher household than nonhousehold detection might partly reflect transmission during social distancing, when family members largely stayed home except to perform essential tasks, possibly creating spread within the household. Clarifying the dynamics of SARS-CoV-2 transmission will help in determining control strategies at the individual and population levels. Studies have increasingly examined transmission within households. Earlier studies on the infection rate for symptomatic household contacts in the United States reported 10.5% (95% CI 2.9%–31.4%), significantly higher than for nonhousehold contacts (4). Recent reports on COVID-19 transmission have estimated higher secondary attack rates among household than nonhousehold contacts. Compiled reports from China, France, and Hong Kong estimated the secondary attack rates for close contacts to be 35% (95% CI 27%–44%) (5). The difference in attack rates for household contacts in different parts of the world may reflect variation in households and country-specific strategies on COVID-19 containment and mitigation. Given the high infection rate within families, personal protective measures should be used at home to reduce the risk for transmission (6). If feasible, cohort isolation outside of hospitals, such as in a Community Treatment Center, might be a viable option for managing household transmission (7).

We also found the highest COVID-19 rate (18.6% [95% CI 14.0%–24.0%]) for household contacts of school-aged children and the lowest (5.3% [95% CI 1.3%–13.7%]) for household contacts of children 0–9 years in the middle of school closure. Despite closure of their schools, these children might have interacted with each other, although we do not have data to support that hypothesis. A contact survey in Wuhan and Shanghai, China, showed that school closure and social distancing significantly reduced the rate of COVID-19 among contacts of school-aged children (8). In the case of seasonal influenza epidemics, the highest secondary attack rate occurs among young children (9). Children who attend day care or school also are at high risk for transmitting respiratory viruses to household members (10). The low detection rate for household contacts of preschool-aged children in South Korea might be attributable to social distancing during these periods. Yet, a recent report from Shenzhen, China, showed that the proportion of infected children increased during the outbreak from 2% to 13%, suggesting the importance of school closure (11). Further evidence, including serologic studies, is needed to evaluate the public health benefit of school closure as part of mitigation strategies.

Our observation has several limitations. First, the number of cases might have been underestimated because all asymptomatic patients might not have been identified. In addition, detected cases could have resulted from exposure outside the household. Second, given the different thresholds for testing policy between households and nonhousehold contacts, we cannot assess the true difference in transmissibility between households and nonhouseholds. Comparing symptomatic COVID-19 patients of both groups would be more accurate. Despite these limitations, the sample size was large and representative of most COVID-19 patients early during the outbreak in South Korea. Our large-scale investigation showed that pattern of transmission was similar to those of other respiratory viruses (12). Although the detection rate for contacts of preschool-aged children was lower, young children may show higher attack rates when the school closure ends, contributing to community transmission of COVID-19.

Dr. Young Joon Park is the preventive medicine physician leading the Epidemiology and Case Management Team for the COVID-19 National Emergency Response Center, Korea Centers for Disease Control and Prevention. His primary research interests include epidemiologic investigation of infectious disease outbreaks. Dr. Choe is an assistant professor at Hallym University College of Medicine. Her research focuses on infectious diseases epidemiology.

Acknowledgment

We thank the Ministry of Interior and Safety, Si/Do and Si/Gun/Gu, medical staff in health centers, and medical facilities for their efforts in responding to COVID-19 outbreak.

https://wwwnc.cdc.gov/eid/article/26/10/20-1315_article

Published: 10 July 2020

Extrapulmonary manifestations of COVID-19

Aakriti Gupta, Mahesh V. Madhavan, […]Donald W. Landry Nature Medicine volume 26, pages1017–1032(2020)

Abstract

Although COVID-19 is most well known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications. Given that ACE2, the entry receptor for the causative coronavirus SARS-CoV-2, is expressed in multiple extrapulmonary tissues, direct viral tissue damage is a plausible mechanism of injury. In addition, endothelial damage and thromboinflammation, dysregulation of immune responses, and maladaptation of ACE2-related pathways might all contribute to these extrapulmonary manifestations of COVID-19. Here we review the extrapulmonary organ-specific pathophysiology, presentations and management considerations for patients with COVID-19 to aid clinicians and scientists in recognizing and monitoring the spectrum of manifestations, and in developing research priorities and therapeutic strategies for all organ systems involved.

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Conclusions and future directions Beyond the life-threatening pulmonary complications of SARS-CoV-2, the widespread organ-specific manifestations of COVID-19 are increasingly being appreciated. As clinicians around the world brace themselves to care for patients with COVID-19 for the foreseeable future, the development of a comprehensive understanding of the common and organ-specific pathophysiologies and clinical manifestations of this multi-system disease is imperative. It is also important that scientists identify and pursue clear research priorities that will help elucidate several aspects of what remains a poorly understood disease. Some examples of areas that require further attention include elucidation of the mechanism by which SARS-CoV-2 is disseminated to extrapulmonary tissues, understanding of the viral properties that may enhance extrapulmonary spread, the contribution of immunopathology and effect of anti-inflammatory therapies, anticipation of the long-term effects of multi-organ injury, the identification of factors that account for the variability in presentation and severity of illness, and the biological and social mechanisms that underlie disparities in outcomes. A number of organ-system-specific research questions are summarized in Table 1. There is also a need for common definitions and data standards for research relating to COVID-19. Regional, national, and international collaborations of clinicians and scientists focused on high-quality, transparent, ethical, and evidence-based research practices would help propel the global community toward achieving success against this pandemic.

https://www.nature.com/articles/s41591-020-0968-3?fbclid=IwAR0zAz2Jxagk8U0ShTAz-WBq80bjasYgu0_vQUF0cNc28IE1r_B08FwaTnw

85 children under age 2 tested positive for coronavirus in 1 Texas county, as U.S. sets new record The Nueces County health director said

85 children under age 2 have tested positive, including 52 under 1 year old. "These babies have not even had their first birthdays yet," she said...

https://www.nbcnews.com/news/us-news/85-infants-have-tested-positive-coronavirus-1-texas-county-u-n1234293?fbclid=IwAR27RSKV0iF3WkH4XFaY7G3N5hLyOO05hOIN9XCSa7dCYfPrmpYeC82YLcI

Last Friday, Nueces County Medical Examiner Adel Shaker was shocked to learn that a baby boy, less than 6 months old, had tested positive for COVID-19 and died shortly after. The same day, Shaker had requested an additional refrigerated truck to store bodies...

https://www.texastribune.org/2020/07/18/texas-coronavirus-hot-spots/?utm_campaign=trib-social&utm_content=1595085379&utm_medium=social&utm_source=facebook&fbclid=IwAR1wc7G-y5Wgfe-8YzilZbkWyG5ii8-11AJ0YW7E_C-SB0B8-YGJsZnN5WU

we will most likely never know, trump has banned the cdc from reporting covid figures and ceased all reporting to them on covid figures, so we will now have to wait for state run media Fox News with hannity and tucker to relay those figures. I figure covid figures on death and case count to drastically improve, and covid will disappear just like that, a miracle before our 👀 eyes, with trump speaking about children this morning stating TRUMP: “Many of those cases are young people that would heal in a day. They have the sniffles and we put it down as a test.”

https://www.foxnews.com/politics/transcript-fox-news-sunday-interview-with-president-trump?fbclid=IwAR1peaE1pnl654FF_FwTEG_pmsyjLpnyAjO6hU_UGqS8m6hGEScd3jKDY3c

Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study

Published:June 25, 2020DOI: https://doi.org/10.1016/S2215-0366(20)30287-X

Summary Background Concerns regarding potential neurological complications of COVID-19 are being increasingly reported, primarily in small series. Larger studies have been limited by both geography and specialty. Comprehensive characterisation of clinical syndromes is crucial to allow rational selection and evaluation of potential therapies. The aim of this study was to investigate the breadth of complications of COVID-19 across the UK that affected the brain. Methods During the exponential phase of the pandemic, we developed an online network of secure rapid-response case report notification portals across the spectrum of major UK neuroscience bodies, comprising the Association of British Neurologists (ABN), the British Association of Stroke Physicians (BASP), and the Royal College of Psychiatrists (RCPsych), and representing neurology, stroke, psychiatry, and intensive care. Broad clinical syndromes associated with COVID-19 were classified as a cerebrovascular event (defined as an acute ischaemic, haemorrhagic, or thrombotic vascular event involving the brain parenchyma or subarachnoid space), altered mental status (defined as an acute alteration in personality, behaviour, cognition, or consciousness), peripheral neurology (defined as involving nerve roots, peripheral nerves, neuromuscular junction, or muscle), or other (with free text boxes for those not meeting these syndromic presentations). Physicians were encouraged to report cases prospectively and we permitted recent cases to be notified retrospectively when assigned a confirmed date of admission or initial clinical assessment, allowing identification of cases that occurred before notification portals were available. Data collected were compared with the geographical, demographic, and temporal presentation of overall cases of COVID-19 as reported by UK Government public health bodies. Findings The ABN portal was launched on April 2, 2020, the BASP portal on April 3, 2020, and the RCPsych portal on April 21, 2020. Data lock for this report was on April 26, 2020. During this period, the platforms received notification of 153 unique cases that met the clinical case definitions by clinicians in the UK, with an exponential growth in reported cases that was similar to overall COVID-19 data from UK Government public health bodies. Median patient age was 71 years (range 23–94; IQR 58–79). Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis. The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric diagnoses as classified by the notifying psychiatrist or neuropsychiatrist, and 21 (92%) of these were new diagnoses. Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and four (17%) had an affective disorder. 18 (49%) of 37 patients with altered mental status were younger than 60 years and 19 (51%) were older than 60 years, whereas 13 (18%) of 74 patients with cerebrovascular events were younger than 60 years versus 61 (82%) patients older than 60 years. Interpretation To our knowledge, this is the first nationwide, cross-specialty surveillance study of acute neurological and psychiatric complications of COVID-19. Altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. This study provides valuable and timely data that are urgently needed by clinicians, researchers, and funders to inform immediate steps in COVID-19 neuroscience research and health policy.

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30287-X/fulltext

Original Investigation

June 8, 2020

JAMA. Published online June 8, 2020. doi:10.1001/jama.2020.10369

Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2

Elizabeth Whittaker, MD1,2; Alasdair Bamford, MD3,4; Julia Kenny, MD5,6; et al

Key Points Question What are the clinical and laboratory characteristics of critically ill children who developed an inflammatory multisystem syndrome during the coronavirus disease 2019 pandemic?

Findings This case series included 58 hospitalized children, a subset of whom required intensive care, and met definitional criteria for pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS), including fever, inflammation, and organ dysfunction. Of these children, all had fever and nonspecific symptoms, such as abdominal pain (31 [53%]), rash (30 [52%]), and conjunctival injection (26 [45%]); 29 (50%) developed shock and required inotropic support or fluid resuscitation; 13 (22%) met diagnostic criteria for Kawasaki disease; and 8 (14%) had coronary artery dilatation or aneurysms. Some clinical and laboratory characteristics had important differences compared with Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome.

Meaning These findings help characterize the clinical features of hospitalized, seriously ill children with PIMS-TS and provide insights into this apparently novel syndrome.

Abstract Importance In communities with high rates of coronavirus disease 2019, reports have emerged of children with an unusual syndrome of fever and inflammation.

Objectives To describe the clinical and laboratory characteristics of hospitalized children who met criteria for the pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) and compare these characteristics with other pediatric inflammatory disorders.

Design, Setting, and Participants Case series of 58 children from 8 hospitals in England admitted between March 23 and May 16, 2020, with persistent fever and laboratory evidence of inflammation meeting published definitions for PIMS-TS. The final date of follow-up was May 22, 2020. Clinical and laboratory characteristics were abstracted by medical record review, and were compared with clinical characteristics of patients with Kawasaki disease (KD) (n = 1132), KD shock syndrome (n = 45), and toxic shock syndrome (n = 37) who had been admitted to hospitals in Europe and the US from 2002 to 2019.

Exposures Signs and symptoms and laboratory and imaging findings of children who met definitional criteria for PIMS-TS from the UK, the US, and World Health Organization.

Main Outcomes and Measures Clinical, laboratory, and imaging characteristics of children meeting definitional criteria for PIMS-TS, and comparison with the characteristics of other pediatric inflammatory disorders.

Results Fifty-eight children (median age, 9 years [interquartile range {IQR}, 5.7-14]; 33 girls [57%]) were identified who met the criteria for PIMS-TS. Results from SARS-CoV-2 polymerase chain reaction tests were positive in 15 of 58 patients (26%) and SARS-CoV-2 IgG test results were positive in 40 of 46 (87%). In total, 45 of 58 patients (78%) had evidence of current or prior SARS-CoV-2 infection. All children presented with fever and nonspecific symptoms, including vomiting (26/58 [45%]), abdominal pain (31/58 [53%]), and diarrhea (30/58 [52%]). Rash was present in 30 of 58 (52%), and conjunctival injection in 26 of 58 (45%) cases. Laboratory evaluation was consistent with marked inflammation, for example, C-reactive protein (229 mg/L [IQR, 156-338], assessed in 58 of 58) and ferritin (610 μg/L [IQR, 359-1280], assessed in 53 of 58). Of the 58 children, 29 developed shock (with biochemical evidence of myocardial dysfunction) and required inotropic support and fluid resuscitation (including 23/29 [79%] who received mechanical ventilation); 13 met the American Heart Association definition of KD, and 23 had fever and inflammation without features of shock or KD. Eight patients (14%) developed coronary artery dilatation or aneurysm. Comparison of PIMS-TS with KD and with KD shock syndrome showed differences in clinical and laboratory features, including older age (median age, 9 years [IQR, 5.7-14] vs 2.7 years [IQR, 1.4-4.7] and 3.8 years [IQR, 0.2-18], respectively), and greater elevation of inflammatory markers such as C-reactive protein (median, 229 mg/L [IQR 156-338] vs 67 mg/L [IQR, 40-150 mg/L] and 193 mg/L [IQR, 83-237], respectively).

Conclusions and Relevance In this case series of hospitalized children who met criteria for PIMS-TS, there was a wide spectrum of presenting signs and symptoms and disease severity, ranging from fever and inflammation to myocardial injury, shock, and development of coronary artery aneurysms. The comparison with patients with KD and KD shock syndrome provides insights into this syndrome, and suggests this disorder differs from other pediatric inflammatory entities.

Snip...

Since the first reports of an unusual inflammatory illness in children that emerged in the months following the onset of COVID-19, there have been additional reports from many countries of children with fever and inflammation, for which no cause could be identified, first in health alerts and web exchanges between professional groups, and then in case reports and small case series in rapid publications.2-4 As these cases have emerged in temporal association with the pandemic, a link with SARS-CoV-2 is likely.

https://jamanetwork.com/journals/jama/fullarticle/2767209?guestAccessKey=9c376c5e-f2da-4939-aa3e-ad6f7df2b679&utm_source=silverchair&utm_campaign=jama_network&utm_content=covid_weekly_highlights&utm_medium=email

COVID-19 AND CHILDREN

Published Online May 6, 2020 https://doi.org/10.1016/ S0140-6736(20)31094-1

Hyperinflammatory shock in children during COVID-19 pandemic

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,1 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 AfroCaribbean 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 bronchoalveolar 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 echobright 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 SARSCoV-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).

We declare no competing interests.

*Shelley Riphagen, Xabier Gomez, Carmen Gonzalez-Martinez, Nick Wilkinson, Paraskevi Theocharis shelley.riphagen@gstt.nhs.uk

South Thames Retrieval Service for Children, Evelina London Children’s Hospital Paediatric Intensive Care Unit, London SE1 7EH, UK (SR, XG); and Evelina London Children’s Hospital, London, UK (CG-M, NW, PT)

https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2931094-1

2 New York Boys Die Of Multi-System Inflammatory Syndrome Affecting Children Amid Coronavirus Pandemic

May 8, 2020 at 11:41 pmFiled Under:Coronavirus, COVID-19, Health, Jessica Layton, Local TV, multi-symptom inflammatory syndrome, New York, Tony Aiello, Valhalla, Westchester County

VALHALLA, N.Y. (CBSNewYork) — A Westchester County boy has died after coming down with an illness affecting dozens of children in New York State.

The 7-year-old boy died late last week at Maria Fareri Children’s Hospital in Valhalla. Dr. Michael Gewitz said he suffered neurological complications from what is now called pediatric multi-system inflammatory syndrome.

Health officials said there have been 73 suspected cases of the illness statewide and investigators are doing a deep dive into the circumstances.

Gov. Andrew Cuomo shared an update Friday, announcing the death of a 5-year-old boy, who CBS2 later confirmed died at Mount Sinai Kravis Children’s Hospital.

“Right now we have a new issue that we’re looking at, which is something we’re just investigating now, but, while rare, we’re seeing some cases where children affected with the COVID virus can become ill with symptoms similar to the Kawasaki disease or Toxic Shock-like syndrome that literally causes inflammation in their blood vessels,” Cuomo said. “This past Thursday, a 5-year-old boy passed away from COVID-related complications, and the State Department of Health is investigating several other cases that presents similar circumstances.”

The hospital said in part, “We must emphasize that based on what we know thus far, it appears to be a very rare condition.”

WATCH: Gov. Cuomo Warns About New Disease Affecting Children Amid Pandemic

It’s still unclear exactly how the syndrome relates to the coronavirus.

The Westchester boy tested positive for COVID-19 antibodies, meaning he was previously infected and had recovered, CBS2’s Tony Aiello reported.

“And we know that in some of the households parents or grandparents or others were diagnosed with COVID and were actually on the record being positive, and apparently the children did not develop symptoms until two to four days before presenting to the hospital for treatment,” said Dr. Dial Hewlett of the Westchester County Department of Health.

“This is very serious. The disease can be fatal, and we want to make sure everyone in Westchester County is aware to be on the lookout for symptoms that may lead to this,” County Executive George Latimer added.

Web Extra: Health Advisory On Pediatric Multi-System Inflammatory Syndrome

Seek care immediately if a child has:

Prolonged fever (more than 5 days)

Difficulty feeding (infants) or is too sick to drink fluids

Severe abdominal pain, diarrhea, or vomiting

Change in skin color – becoming pale, patchy, and/or blue Trouble breathing or is breathing very quickly

Racing heart or chest pain

Decreased amount or frequency of urine Lethargy, irritability, or confusion

“So this is every parent’s nightmare, right? That your child may actually be affected by this virus. But it’s something we have to consider seriously now,” Gov. Cuomo said.

In New Jersey, a 4-year-old child with underlying health issues has also died. It’s unclear if he was affected by the inflammatory syndrome, but there are a handful of other suspected cases in Garden State kids.

“It’s a virus that’s proving to be extremely challenging at every level,” Gov. Phil Murphy said.

Dr. Gewitz said while COVID-19 is likely to infect a large number of children, “most of whom, at least many, are totally asymptomatic. This particular complication is relatively infrequent, unusual.”

https://newyork.cbslocal.com/2020/05/08/coronavirus-covid-19-multi-symptom-inflammatory-syndrome-westchester-boy-dies/

SARS-CoV-2 Infection in Children

Of the 1391 children assessed and tested from January 28 through February 26, 2020, a total of 171 (12.3%) were confirmed to have SARS-CoV-2 infection. Demographic data and clinical features are summarized in Table 1. (Details of the laboratory and radiologic findings are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) The median age of the infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema. A total of 27 patients (15.8%) did not have any symptoms of infection or radiologic features of pneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any symptoms of infection. During the course of hospitalization, 3 patients required intensive care support and invasive mechanical ventilation; all had coexisting conditions (hydronephrosis, leukemia [for which the patient was receiving maintenance chemotherapy], and intussusception). Lymphopenia (lymphocyte count, <1 .2="" 10-month-old="" 149="" 2020="" 21="" 4="" 6="" 8="" a="" admission.="" after="" and="" as="" been="" bilateral="" child="" common="" condition="" death.="" died="" discharged="" div="" failure="" finding="" from="" general="" ground-glass="" had="" have="" hospital.="" in="" intussusception="" liter="" march="" most="" multiorgan="" of="" one="" opacity="" patients="" per="" present="" radiologic="" stable="" the="" there="" total="" wards="" was="" weeks="" were="" with="">

This report describes a spectrum of illness from SARS-CoV-2 infection in children. In contrast with infected adults, most infected children appear to have a milder clinical course. Asymptomatic infections were not uncommon.2 Determination of the transmission potential of these asymptomatic patients is important for guiding the development of measures to control the ongoing pandemic.

https://www.nejm.org/doi/full/10.1056/NEJMc2005073

Two COVID-19 infected children, aged 12 and 13, die in Belgium and UK

By Alasdair Sandford with AFP, AP • last updated: 01/04/2020

A health worker in the intensive care ward observes a COVID-19 patient at a hospital in Belgium, March 27, 2020. (AP Photo/Francisco Seco, File)

A 12-year-old girl in Belgium and a 13-year old boy in the UK infected with the novel coronavirus have died, authorities said.

They are believed to be the youngest victims of the disease in their respective countries.

The 12-year-old girl's death was announced during the daily news conference given by Belgium's health service, at the end of its regular update on casualty figures and hospitalisations.

“It's an emotionally difficult moment because it involves a child, and it has also upset the medical and scientific community,” said spokesman Dr Emmanuel André, visibly upset.

"We are thinking of her family and friends. It's a very rare event, but one which devastates us."

Another spokesman added that the child had had a fever for three days and had tested positive for the coronavirus. No other details were given of the girl's background.

Until now the youngest person to die from the virus in Belgium was a 30-year-old female nurse, according to Belgian media.

Just a few hours later, London's King's College Hospital announced that a 13-year-old COVID-19 patient had also died.

"Sadly, a 13-year old boy who tested positive for COVID-19 has passed away, and our thoughts and condolences are with the family at this time," a Trust spokesperson said in a statement.

"The death has been referred to the Coroner," it added.

An appeal posted on the GoFunMe crowdfunding platform by Madinah College, named him as Ismail and said that he didn't have "any pre-existing health conditions.

"Sadly he died without any family members close by due to the highly infectious nature of COVID-19," it added.

Ismail is believed the be the youngest victim of the disease in the UK.

Last week French authorities said a 16-year-old girl had died at a children's hospital in Paris. The death of the teenager, identified as Julie A. and described as otherwise healthy, has provoked strong emotions in France.

Coronavirus in France: healthy 16 year-old dies of COVID-19

Deaths from COVID-19 among people so young are exceptional. Health authorities have said previously that serious cases of the illness -- although predominant in older and more vulnerable age groups -- can occur in adults of any age.

Last weekend the US state of Illinois announced the death of an infant under one year old who had tested positive for coronavirus. The cause of death was being investigated. Medical reports on cases in China have documented the death of a 10-month-old baby and a 14-year-old boy.

A recent US study by the Centers for Disease Control and Prevention (CDC) of 2,500 patients found no cases of deaths among people aged under 19. But it did find that people of all ages were liable to become seriously ill: more than a third of those hospitalised were aged between 20 and 54.

Coronavirus in Europe: Latest numbers on COVID-19 cases and deaths

The Belgian girl's death was included among the latest national figures released on Tuesday, confirming nearly 200 more deaths since the previous update. More than 700 people in the country have died from coronavirus since the outbreak began.

Hospitals in three regions have been particularly badly affected, the authorities say -- around Brussels, in Limburg in eastern Flanders, and in Hainaut in Wallonia to the west.

With 12,775 confirmed COVID-19 cases as of Tuesday, Belgium has the 10th highest number of infections among countries worldwide, according to data compiled by the US Johns Hopkins University Coronavirus Resource Center.

https://www.euronews.com/2020/03/31/coronavirus-doctors-devastated-as-covid-19-claims-life-of-12-year-old-girl-in-belgium?fbclid=IwAR2UD5bAHEQ49xpUGJwq6n5xph1dMQubs_e_6nmAo6JOIJNZdi-WxPIqdYI

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

Florian Götzinger, MD * Begoña Santiago-García, PhD * Prof Antoni Noguera-Julián, PhD Miguel Lanaspa, PhD Laura Lancella, PhD Francesca I Calò Carducci, PhD et al.

Published:June 25, 2020DOI:https://doi.org/10.1016/S2352-4642(20)30177-2

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 0="" 1="" 25="" 578="" 5="" 95="" activity="" admission="" alive="" anakinra="" analyses="" and="" antiviral="" at="" being="" by="" case-fatality="" children="" ci="" conditions="" corticosteroids="" died="" div="" drug="" end="" extracorporeal="" factors="" followed="" for="" four="" frequently="" hydroxychloroquine="" icu="" immunoglobulin="" immunomodulatory="" in="" included="" infection="" intravenous="" lopinavir="" lower="" male="" medical="" medication="" membrane="" month="" most="" multivariable="" odds="" of="" one="" only="" or="" oseltamivir="" oxygenation.="" p="" patient="" patients="" pre-existing="" presence="" presentation="" rate="" ratio="" remaining="" remdesivir="" requiring="" respiratory="" risk="" ritonavir="" seven="" sex="" significant="" signs="" siltuximab="" six="" still="" study="" support.="" symptomatic="" symptoms="" than="" the="" three="" tocilizumab="" tract="" used="" was="" were="" with="" younger="">

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.

snip...

Discussion

To our knowledge, this is the first multinational, multicentre study on paediatric COVID-19, and also the largest clinical study in children outside of China to date. The inclusion of such a substantial number of cases was made possible by involving a large number of specialist centres across Europe via a well established collaborative paediatric tuberculosis research network, allowing this study to provide one of the most detailed accounts of COVID-19 in children and adolescents published to date.

It is important to highlight that this study has primarily captured data from children and adolescents who were seen or managed within the hospital setting, and that the majority of participating units were part of tertiary or quaternary health-care institutions. Consequently, the study population is likely to primarily represent individuals at the more severe end of the disease spectrum. Notably, a recent letter summarising 171 PCR-confirmed cases in Wuhan suggests that close to 20% of children and adolescents with SARS-CoV-2 infection are asymptomatic.10 At the time our study was conducted, testing capacity for SARS-CoV-2 in many European countries was lower than clinical demand, and therefore many children with symptoms consistent with COVID-19 in the community were not tested and consequently not diagnosed. Nevertheless, our data indicate that children and adolescents are overall less severely affected by COVID-19 than adults, particularly older patients. Previous, large-scale data suggest that the CFR in adults older than 70 years is close to 10%,6 potentially due to immunosenescence.21 It is reassuring that our data show that severe COVID-19 is uncommon in young children, including infants, despite their immune maturation being incomplete,22, 23 with only few requiring mechanical ventilation. It was striking that all children who died in our cohort were older than 10 years.

The Centers for Disease Control and Prevention (CDC) reported 2572 confirmed cases of COVID-19 in individuals younger than 18 years in the USA as of April 2, 2020, representing only 1·7% of the total number of recorded cases (n=149 760).14 The Australian Health Protection Agency has reported that children accounted for only 4% of confirmed COVID-19 cases in Australia.24 Unfortunately, in the CDC report, clinical data were only available in a small proportion of patients (n=291; 11%). In concordance with our observations, fever and cough were the predominant clinical features at presentation (present in 56% and 54% of individuals, respectively), with similar rates observed in a study from Italy.25 In our cohort almost a quarter of patients had gastrointestinal symptoms, some of whom had no respiratory symptoms, and a substantial proportion of children were entirely asymptomatic. The CDC report also mentions three deaths,14 but it is unclear how many patients were still hospitalised by the time of publication, so it is difficult to come to firm conclusions regarding the CFR in US children. Our data indicate that the CFR in children and adolescents across Europe is less than 1%. Considering that many children with mild disease will never have been brought to medical attention, and therefore not diagnosed, it is highly probable that the true CFR is substantially lower than the figure of 0·69% observed in our cohort. This hypothesis is further supported by an epidemiological study from China, in which the CFR in individuals aged 19 years or younger was only 0·1% (one death in 965 confirmed cases).6 Furthermore, our data indicate that sequelae related to COVID-19 are likely to be rare in children and adolescents. However, after the closure of our study, reports of a hyperinflammatory syndrome affecting children that is temporally, and potentially causally, associated with SARS-CoV-2 infection have emerged, which has subsequently been named paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS; sometimes known as MIC-S).26, 27 Further research will be required to characterise this emerging disease entity in detail, and determine the long-term outcome of affected children.

Importantly, our data show that severe COVID-19 can occur both in young children and in adolescents, and that a significant proportion of those patients require ICU support, frequently including mechanical ventilation. A small study from Madrid also found that four (10%) of 41 children with SARS-CoV-2 infection required admission to ICU.28 In our cohort, being younger than 1 month, male sex, presence of lower respiratory tract infection signs or symptoms at presentation, and presence of a pre-existing medical condition were associated with increased likelihood of requiring ICU admission. Our results also show that the majority of children who are intubated due to respiratory failure require prolonged ventilation, often for 1 week or more. This contrasts with observations in children with RSV infection who, on average, only require mechanical ventilation for 5–7 days,29 but is not dissimilar to observations in children with influenza.30 This has important implications for service planning, as although the overall demand for ICU support might be lower in children than in adults, each patient is likely to occupy ICU space for an extended period of time. At this time of intense strain on health-care services worldwide, it is vital that adequate resources are allocated to paediatric services to sustain the provision of high-quality care for children.

The observation that, in our study, individuals with viral co-infection (ie, infected with SARS-CoV-2 and one or more other viral agents) were more likely to require ICU support than those in whom SARS-CoV-2 was the only viral agent identified might have implications for the winter period 2020–21, when the incidence of other viral respiratory tract infections, including RSV and influenza virus infections, is bound to increase. This could result in a greater proportion of paediatric patients with COVID-19 requiring ICU support than in the cohort described here, as the influenza season 2019–20 was already over in Europe before the study commenced.

Our data also reflect the uncertainties regarding drug treatment options for COVID-19. In some countries, including Spain and Italy, national guidelines were encouraging the use of hydroxychloroquine for selected cases, as reflected in our data, while in other countries, recommendations were more guarded regarding the use of antiviral agents in the absence of robust human data. An expert consensus statement from the USA has emphasised that antiviral treatment should be reserved for patients at the severe end of the disease spectrum, ideally within a clinical trial.31 Overall, the expert panel appeared to favour the use of remdesivir over other agents, based on the currently available data from in-vitro and animal studies, including in non-human primates, and recent data from compassionate use in humans.32, 33 The panel members' opinion was split regarding the use of lopinavir–ritonavir, given the disappointing results of a recently published randomised controlled trial. 34

The main limitation of this study relates to the number of variables for which data were collected. In the context of the ongoing COVID-19 pandemic, to ensure high levels of participation and avoid diverting substantial time away from clinical front-line duties, a decision was made not to collect detailed data on laboratory parameters or ICU interventions. A further limitation was that a variety of in-house and commercial PCR assays were used across different participating centres, precluding an assessment of diagnostic test performance. Also, the number of children receiving antiviral or immunomodulatory treatment was too small to draw meaningful conclusions regarding their effectiveness, which will be addressed by the aforementioned randomised trials. A further limitation is that different countries were using different thresholds to screen for SARS-CoV-2 at the time the study was done, with some recommending screening of all children admitted to hospital or conducting community screening, whereas others were using more selective testing strategies. Despite those limitations, to our knowledge, this study provides the most comprehensive overview on COVID-19 in children and adolescents to date.

In conclusion, our data, originating from a large number of specialist centres across Europe, show that COVID-19 is usually a mild disease in children, including infants. Nevertheless, a small proportion of children and adolescents develop severe disease and require ICU support, frequently needing prolonged ventilatory support. However, fatal outcome is rare overall. Our data also reflect the current uncertainties regarding specific treatment options, highlighting that more robust data on antiviral and immunomodulatory drugs are urgently needed.

Contributors

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30177-2/fulltext

February 24, 2020

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China

Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Zunyou Wu, MD, PhD1; Jennifer M. McGoogan, PhD1

Author Affiliations Article Information

JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648

Most case patients were 30 to 79 years of age (87%), 1% were aged 9 years or younger, 1% were aged 10 to 19 years, and 3% were age 80 years or older. Most cases were diagnosed in Hubei Province (75%) and most reported Wuhan-related exposures (86%; ie, Wuhan resident or visitor or close contact with Wuhan resident or visitor). Most cases were classified as mild (81%; ie, nonpneumonia and mild pneumonia). However, 14% were severe (ie, dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300 and="" infiltrates="" lung="" or="">50% within 24 to 48 hours), and 5% were critical (ie, respiratory failure, septic shock, and/or multiple organ dysfunction or failure) (Box).1

The overall case-fatality rate (CFR) was 2.3% (1023 deaths among 44 672 confirmed cases). No deaths occurred in the group aged 9 years and younger, but cases in those aged 70 to 79 years had an 8.0% CFR and cases in those aged 80 years and older had a 14.8% CFR. No deaths were reported among mild and severe cases. The CFR was 49.0% among critical cases. CFR was elevated among those with preexisting comorbid conditions—10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer. Among the 44 672 cases, a total of 1716 were health workers (3.8%), 1080 of whom were in Wuhan (63%). Overall, 14.8% of confirmed cases among health workers were classified as severe or critical and 5 deaths were observed.1

COVID-19 rapidly spread from a single city to the entire country in just 30 days. The sheer speed of both the geographical expansion and the sudden increase in numbers of cases surprised and quickly overwhelmed health and public health services in China, particularly in Wuhan City and Hubei Province. Epidemic curves reflect what may be a mixed outbreak pattern, with early cases suggestive of a continuous common source, potentially zoonotic spillover at Huanan Seafood Wholesale Market, and later cases suggestive of a propagated source as the virus began to be transmitted from person to person (Figure 1).1

https://jamanetwork.com/journals/jama/fullarticle/2762130

SARS-CoV-2 Infection in Children

TO THE EDITOR:

As of March 10, 2020, the 2019 novel coronavirus (SARS-CoV-2) has been responsible for more than 110,000 infections and 4000 deaths worldwide, but data regarding the epidemiologic characteristics and clinical features of infected children are limited.1-3 A recent review of 72,314 cases by the Chinese Center for Disease Control and Prevention showed that less than 1% of the cases were in children younger than 10 years of age.2 In order to determine the spectrum of disease in children, we evaluated children infected with SARS-CoV-2 and treated at the Wuhan Children’s Hospital, the only center assigned by the central government for treating infected children under 16 years of age in Wuhan. Both symptomatic and asymptomatic children with known contact with persons having confirmed or suspected SARS-CoV-2 infection were evaluated. Nasopharyngeal or throat swabs were obtained for detection of SARS-CoV-2 RNA by established methods.4 The clinical outcomes were monitored up to March 8, 2020.

Table 1.

Table 1. Epidemiologic Characteristics, Clinical Features, and Radiologic Findings of 171 Children with SARS-CoV-2 Infection.*

Characteristic Value

Age

Median (range) 6.7 yr (1 day–15 yr)

Distribution — no. (%)

<1 31="" div="" yr="">

1–5 yr 40 (23.4)

6–10 yr 58 (33.9)

11–15 yr 42 (24.6)

Sex — no. (%)

Male 104 (60.8)

Female 67 (39.2)

Diagnosis — no. (%)

Asymptomatic infection 27 (15.8)

Upper respiratory tract infection 33 (19.3)

Pneumonia 111 (64.9)

Exposure or contact information — no. (%)

Family cluster 154 (90.1)

Confirmed family members 131 (76.6)

Suspected family members 23 (13.5)

Unidentified source of infection 15 (8.8)

Contact with other suspected case 2 (1.2)

Signs and symptoms

Cough — no. (%) 83 (48.5)

Pharyngeal erythema — no. (%) 79 (46.2)

Fever — no. (%) 71 (41.5)

Median duration of fever (range) — days 3 (1–16)

Highest temperature during hospitalization — no. (%)

<37 .5="" 100="" div="">

37.5–38.0°C 16 (9.4)

38.1–39.0°C 39 (22.8)

>39.0°C 16 (9.4)

Diarrhea — no. (%) 15 (8.8)

Fatigue — no. (%) 13 (7.6)

Rhinorrhea — no. (%) 13 (7.6)

Vomiting — no. (%) 11 (6.4)

Nasal congestion — no. (%) 9 (5.3)

Tachypnea on admission — no. (%)† 49 (28.7)

Tachycardia on admission — no. (%)‡ 72 (42.1)

Oxygen saturation <92 4="" div="" during="" hospitalization="" no.="" of="" period="">

Abnormalities on computed tomography of the chest — no. (%)

Ground-glass opacity 56 (32.7)

Local patchy shadowing 32 (18.7)

Bilateral patchy shadowing 21 (12.3)

Interstitial abnormalities 2 (1.2)

* Percentages may not total 100 because of rounding.

† The normal ranges of respiratory rate (in breaths per minute) were as follows: 40 to 60 for newborns, 30 to 40 for children younger than 1 year of age, 25 to 30 for those 1 to 3 years of age, 20 to 25 for those 4 to 7 years of age, 18 to 20 for those 8 to 14 years of age, and 12 to 20 for those older than 14 years of age. Tachypnea refers to a respiratory rate higher than the upper limit of the normal range according to age.

‡ The normal ranges of pulse rate (in beats per minute) were as follows: 120 to 140 for newborns, 110 to 130 for children younger than 1 year of age, 100 to 120 for those 1 to 3 years of age, 80 to 100 for those 4 to 7 years of age, 70 to 90 for those 8 to 14 years of age, and 60 to 70 for those older than 14 years of age. Tachycardia refers to a pulse rate higher than the upper limit of the normal range according to age.

Xiaoxia Lu, M.D. Liqiong Zhang, M.D. Hui Du, M.D. Wuhan Children’s Hospital, Wuhan, China

Jingjing Zhang, Ph.D. Yuan Y. Li, Ph.D. Jingyu Qu, Ph.D. Wenxin Zhang, Ph.D. Youjie Wang, Ph.D. Shuangshuang Bao, Ph.D. Ying Li, Ph.D. Chuansha Wu, Ph.D. Hongxiu Liu, Ph.D. Huazhong University of Science and Technology, Wuhan, China

Di Liu, Ph.D. Wuhan Institute of Virology, Wuhan, China

Jianbo Shao, M.D. Xuehua Peng, M.D. Huazhong University of Science and Technology, Wuhan, China

Yonghong Yang, M.D. Beijing Children’s Hospital, Beijing, China

Zhisheng Liu, M.D. Yun Xiang, M.D. Furong Zhang, M.D. Wuhan Children’s Hospital, Wuhan, China

Rona M. Silva, Ph.D. Kent E. Pinkerton, Ph.D. University of California, Davis, Davis, CA

Kunling Shen, M.D. Chinese National Clinical Research Center for Respiratory Diseases, Beijing, China

Han Xiao, Ph.D. Institute of Maternal and Child Health, Wuhan, China

Shunqing Xu, M.D., Ph.D. Wuhan Children’s Hospital, Wuhan, China xust@hust.edu.cn

Gary W.K. Wong, M.D. Chinese University of Hong Kong, Shatin, China wingkinwong@cuhk.edu.hk

for the Chinese Pediatric Novel Coronavirus Study Team

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on March 18, 2020, at NEJM.org.

Drs. Lu, J. Zhang, Y.Y. Li, and D. Liu and Drs. Shen, Xu, and Wong contributed equally to this letter.

https://www.nejm.org/doi/10.1056/NEJMc2005073

Experts warn against ‘false sense of security’ as the number of children with COVID-19 increases in Dallas County School closures early in the pandemic may have helped keep kids from contracting coronavirus.

Updated at 7 p.m.: Revised to include information about infant cases in North Texas.

The number of children infected with coronavirus in Dallas County has increased steadily as the summer has worn on — and with classes soon to resume statewide, health experts say the perception that kids aren’t susceptible to COVID-19 needs to end.

Since the pandemic began in Dallas County, 3,821 children under 18 have tested positive for the virus. That accounts for nearly 10% of all the cases reported between March 24 and July 17, according to data collected by Dallas County.

The number of children with the virus more than tripled between March and May, jumping from 2% to 11% of cases for those months, respectively, the data shows. The number decreased slightly in June but already jumped back to 11% at the halfway point of July.

And though children still represent only a fraction of the more than 40,000 confirmed cases in the county, some health experts worry the numbers convey a wrong impression.

“There’s a false sense of security right now for many people,” said Dr. Jeffrey Kahn, chief of pediatric infectious diseases at Children’s Health and a professor of microbiology at UT Southwestern. “They think that their children are not going to get COVID because children have this innate protection against viral infection. That’s not true.”

Health experts have said statewide figures highlight a problem health experts have stressed throughout the pandemic: Not much is known about what role children play in the transmission of the disease.

State data show a relatively small proportion of kids have been affected. Although the state health department doesn’t keep track of the number of children who have tested positive over time, cumulatively 7.3% of the people who have tested positive have been under 19.

The data, however, are incomplete. Although more than 332,000 cases of COVID-19 have been reported across Texas, demographic results were available only for just over 28,200 patients as of Monday because of reporting lags between the state and local health departments.

Kahn said it is important to pay attention to the increasing reports of kids getting seriously ill.

In Corpus Christi, for example, a 6-week-old boy died after he contracted the virus, the Corpus Christi Caller-Times reported. He had a co-infection and his death was identified as sudden infant death syndrome.

“Unfortunately it does not discriminate,” Dr. Adel Shaker, Nueces County Medical Examiner, told CNN. “It affects people with co-morbidities, and with pre-existing conditions like diabetes, hypertension and obesity, but now it affects everybody. Nobody is secluded from infection.”

In the same county, 85 infants under 1 year old have tested positive for the virus, CNN reported. No other details were available about their conditions.

More than 400 infants have contracted the virus in North Texas, KXAS-TV (NBC5) reported. There have been 240 cases in Dallas County among children younger than 1, 113 in Tarrant County, 42 in Collin County and 38 in Denton County.

In Dallas County, a 17-year-old girl who had no known underlying health conditions died from the virus in April. Her family declined to comment.

Hospitalizations of children with COVID-19 have been steadily increasing in Dallas County since the early days of the pandemic. A total of 101 have been hospitalized with the virus as of July 17, according to the county’s data. The largest jump in hospitalizations among children came in June, with 17 children hospitalized at the beginning of the month and almost 50 by the end of the it.

Fifteen children were hospitalized with the virus at Children’s Health as of Monday.

Why are cases in Dallas County increasing?

Kahn said the rising cases among children in Dallas County could be due to a larger portion of infections being in people who are likely to have children, who they then go on to expose.

Dallas County health officials have said more than half of the cases reported after June 1 have been among people between the ages of 18 and 39.

“I would say overall — and this is not only true for COVID, it’s true for just about any respiratory virus — the greatest chance of you acquiring infection is if someone in your household is infected,” Kahn said.

Likewise, the main concern with children is that if they get a mild form of the virus, they may go on to infect older adults.

In Hidalgo County in South Texas, where health officials have described a “tsunami” of cases, a child went on to infect his parents, the San Antonio Express-News reported. The parents later died from the virus, said Dr. Ivan Melendez, a physician and Hidalgo County’s local health authority.

“This is not a conspiracy theory. This is the absolute truth,” he said in an online briefing, according to the Express-News.

Kahn said day cares, which were allowed to reopen in mid-May after they were restricted to essential workers during the early days of the outbreak, may be contributing to the increase in cases because children are in close contact in them.

Since June 1, more than 54 COVID-19 cases in children and staff members were reported in at least 26 separate day cares in Dallas County, health officials said.

What does this mean for school in the fall? Some health experts have said the lack of data about how kids spread coronavirus could stem from the fact that schools were closed early in the pandemic.

Others say children overall haven’t been tested as much as adults, making the results less complete. Dr. Deborah Birx, the White House Health adviser, said last week that nationwide, the lowest proportion of testing has been in children under 10.

Most health experts agree that it’s better to be cautious when it comes to the coming school year.

After weeks of deliberating how to resume classes, the Texas Education Agency announced Friday that schools can opt for online learning until as late as November.

Although many districts are still deciding how to proceed, health officials have ordered private and public schools to remain closed through Sept. 7 in Dallas, El Paso, Laredo and Tarrant counties.

However, private religious schools could still open regardless of local orders, Attorney General Ken Paxton said Friday in a letter. He said those schools provide religious services, which the governor considers essential. Several local private schools have said they are still deciding how to begin the school year.

Kahn said when it is time for parents to decide whether to send their kids to school, they should get advice from a pediatrician and consider whether the child or other household members are in a high-risk group for the virus.

He said parents should prepare their children by getting them in the habit of wearing masks, social distancing and washing their hands often to prepare for school. If kids are having trouble wearing masks, Kahn said, their parents should acclimate them to wearing them at home a half-hour or an hour at a time.

Kahn said such steps have helped prevent the spread of illness since the 1918 flu epidemic, before viruses were even discovered, and children are capable of learning to take these steps.

“It’s striking to me that we’re having to relearn this lesson,” Kahn said. “It’s three simple things you can do to reduce the risk.”

Staff writer Tom Steele contributed to this report.

https://www.dallasnews.com/news/2020/07/20/experts-warn-against-false-sense-of-security-as-the-number-of-children-with-covid-19-increases-in-dallas-county/?fbclid=IwAR0UFYJ0nwBa_Y6YGsYiUcmSniZbXjexRHdj4YVvEdREviAUpMkGp7vhjoM

Nearly one-third of children tested for COVID in Florida are positive. Palm Beach County’s health director warns of risk of long-term damage

By SKYLER SWISHER

SOUTH FLORIDA SUN SENTINEL |

JUL 14, 2020 AT 5:57 PM

Nearly one-in-three children tested for the new coronavirus in Florida has been positive, and a South Florida health official is concerned the disease could cause lifelong damage even for children with mild illness.

Dr. Alina Alonso, Palm Beach County’s health department director, warned county commissioners Tuesday that much is unknown about the long-term health consequences for children who catch COVID-19.

ADVERTISING Ads by Teads X-rays have revealed the virus can cause lung damage even in people without severe symptoms, she said.

“They are seeing there is damage to the lungs in these asymptomatic children. ... We don’t know how that is going to manifest a year from now or two years from now,” Alonso said. “Is that child going to have chronic pulmonary problems or not?”

Her comments stand in contrast to Gov. Ron DeSantis’ messaging that children are at low risk, and classrooms need to be reopened in the fall. DeSantis has said he would be comfortable sending his children to school if they were old enough to attend.

Some studies suggest that children are less likely to catch COVID-19 than adults. Children are also far less likely to die of the disease. About 17,000 of Florida’s roughly 287,800 cases have been people younger than 18. Of the 4,514 COVID-19 deaths reported by Florida as of Tuesday, four have been younger than 18.

Still, it’s possible COVID-19 could have long-term consequences that will take time to understand, Alonso said.

“This is not the virus you bring everybody together to make sure you catch it and get it over with,” she said. “This is something serious, and we are learning new information about this virus every day.”

State statistics also show the percentage of children testing positive is much higher than the population as a whole. Statewide, about 31% of 54,022 children tested have been positive. The state’s positivity rate for the entire population is about 11%.

Researchers have linked a serious and potentially deadly inflammatory condition with COVID-19 in children. The condition, called pediatric multisystem inflammatory syndrome, doesn’t appear to be widespread. The Florida Department of Health lists 13 confirmed cases of the syndrome.

Dr. Jorge Perez, co-founder of Kidz Medical Services, said it’s too early to say how common and severe long-term damage could be from COVID-19, but early evidence suggests some children infected with the virus could have lasting damage.

“We are learning something every day,” said Perez, who operates pediatric offices throughout South Florida. “We have to be knowledgeable about this and continue to monitor to see what effects it has in children.”

DeSantis told talk radio host Rush Limbaugh last week that the risk to children is “very low.”

“I’ve got a 3-year-old daughter, 2-year-old son, and a newborn daughter,” DeSantis said in the radio interview. “And I can tell you if they were school age, I would have zero concern sending them.”

Skyler Swisher can be reached at sswisher@sunsentinel.com, 561-243-6634 or @SkylerSwisher.

https://www.sun-sentinel.com/coronavirus/fl-ne-pbc-health-director-covid-children-20200714-xcdall2tsrd4riim2nwokvmsxm-story.html?fbclid=IwAR0XpWFRT4si3J8kwD3FrJfCU7nHCashNI0kqvaiZ1V5zQc4H9Hvk95bvZQ

85 children under age 2 tested positive for coronavirus in 1 Texas county, as U.S. sets new record The Nueces County health director said

85 children under age 2 have tested positive, including 52 under 1 year old. "These babies have not even had their first birthdays yet," she said...

https://www.nbcnews.com/news/us-news/85-infants-have-tested-positive-coronavirus-1-texas-county-u-n1234293?fbclid=IwAR27RSKV0iF3WkH4XFaY7G3N5hLyOO05hOIN9XCSa7dCYfPrmpYeC82YLcI

Nueces County Statement Regarding COVID-19 Positive Tests in Infants Post Date:07/18/2020 5:25 PM

https://www.nuecesco.com/commissioners-court/advanced-components/list-detail-pages/current-news?fbclid=IwAR1pZq7o5WtRoR80A2QtR021CvoEqnceVF_-M7l10tyXOo5RgtqJaFxsAUU

until we know more, with sound science, not political science, but more sound science from peer review science and scientist, sending children back to school now is insane, it is absolutely irresponsible, imo...it's just science.

Terry S. Singeltary Sr., Bacliff, Texas 77518

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Statewide Interventions and Covid-19 Mortality in the United States: An Observational Study and Galveston County, Texas update

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