Until recently, the World Health Organization had maintained that most children are either asymptomatic or exhibit only mild symptoms of the novel coronavirus, even prompting a few countries like Spain and Denmark to ease lockdown restrictions on children.
However, in the past month, there has been evidence of a small but growing number of children in Europe and the US struck by a mysterious illness linked to COVID-19. This has landed several children in intensive care units with a few reported deaths as well. In the past week, India too reported the first few cases of children afflicted with this condition, requiring emergency admission to intensive care.
What has been more perplexing for doctors are the medical complexities associated with diagnosing and treating this illness. Slowly but surely, doctors are realising that the notion that children are at low risk of getting COVID-19 or have very mild symptoms may have been an oversimplification. Policymakers need to take this new evidence into consideration while easing lockdown restriction on children. This is particularly true for India given our demographically young population and an already burdened healthcare system.
Countries that have seen a sharp rise in such cases in the recent past have raised a national alarm to caution everyone. On May 13, The Lancet published an article about an observational study on the outbreak of a severe Kawasaki-like disease and toxic shock syndrome in children in Bergamo province, the Italian epicenter of the COVID-19 epidemic. Kawasaki disease is a life-threatening, multisystem inflammatory disorder that affects the lymph nodes. It is characterised by persistent fever, widespread rash, difficulty in breathing, inflammation of blood vessels, diarrhea, redness and cracking of lips, fainting and confusion.
The study by Lancet found a 30-fold increase in the incidence of Kawasaki-like disease in children in the past month as compared to the pre-pandemic period. It also found within its study-group that children who tested positive for COVID-19 exhibited a more severe form of Kawasaki disease and concluded that there exists a strong correlation between the outbreak of Kawasaki-like disease and COVID-19 epidemic in children in Bergamo province. The article ended with a warning that a ‘similar outbreak of Kawasaki-like disease is expected in countries affected by the SARS-CoV-2 pandemic’.
Another publication by The Lancet found a similar correlation in a London-based pediatric hospital that reported that during a period of ten days in mid-April this year, there was an unprecedented cluster of eight children with hyper-inflammatory shock, showing features similar to Kawasaki disease. Within a week’s time, as the publication went to print, they had found evidence of a total of 20 children with similar symptoms requiring admission to intensive care units.
By the end of April, Europe had reported at least 100 cases in seven of its countries. New York, the epicenter of the pandemic in the US, also reported by mid-May that at least 110 children were affected by this mysterious syndrome, killing at least three children.
Medical practitioners across the world are slowly coming to terms with these new and alarming symptoms in children linked with COVID-19. More recently, US doctors observed that a small number of children in Brooklyn being treated for COVID-19 linked Kawasaki disease are beginning to exhibit high blood-sugar levels, consistent with diabetes. These young children were reported to have mild or no symptoms of coronavirus but ended up with this inflammatory syndrome and other serious complications a few weeks later.
A few days after The Lancet published these medical studies on children exhibiting serious Kawasaki-like disease linked to COVID-19, WHO, which had earlier suggested that most children with coronavirus were only mildly affected, revised its stance and put out a brief on May 15 stating the following:
“Recently, however, reports from Europe and North America have described clusters of children and adolescents requiring admission to intensive care units with a multisystem inflammatory condition with some features similar to those of Kawasaki disease and toxic shock syndrome. Case reports and small series have described a presentation of acute illness accompanied by a hyper-inflammatory syndrome, leading to multi-organ failure and shock. Initial hypotheses are that this syndrome may be related to COVID-19 based on initial laboratory testing showing positive serology in a majority of patients.”
The press conference by WHO, however, that accompanied the above brief appeared surprisingly understated. While cautioning healthcare professionals about this new syndrome, it took a softer approach towards communicating this information to the parents. The WHO states that since this syndrome had affected only a small number of children so far, no revision was warranted in our general understanding of the way COVID-19 affects children.
Given that the cases of children exhibiting serious symptoms of Kawasaki disease has been consistently growing in the US and Europe, notwithstanding the brief by WHO, these regions have raised a national alarm on this issue.
In India, a four-month old boy from Kolkata and an eight-year old boy from Chennai were reportedly admitted to intensive care units due to Kawasaki disease linked to COVID-19. The eight-year boy from Chennai, according to initial investigations, showed signs of pneumonia, COVID-19 pneumonitis, Kawasaki disease, and toxic shock syndrome with septic shock. Given that several states in India have seen a sharp rise in the number of children testing positive for COVID-19 over the last month, even the few reported cases of the above conditions in India represent a significant worry.
Despite evidence, most medical practitioners in India maintain that these cases are rare and that most children would continue to be either asymptomatic or have mild symptoms due to COVID-19. However, a few have acknowledged that given the complexity of diagnosing Kawasaki disease, the total number of children being afflicted with this condition could be under-reported in India.
As India enters Lockdown 4.0, the Government of India has requested schools and educational institutions to remain shut. Further, it has also requested children below 10 years of age to stay at home. However, given that each successive version of the lockdown has witnessed an increase in the pace of relaxations, there is a risk that restriction on the opening of educational institutions will soon be relaxed.
While traditionally, Kawasaki is only found in children under five, this Kawasaki-like disease linked to COVID-19 is also affecting older school-going children and making them fatally sick. This makes the recent decision by the Government of India to grant permission to the States to conduct class 10 and 12 board exams in July particularly worrisome. The Andhra Pradesh government too announced the reopening of schools in August while releasing a handbook on measures that educational institutions must take to ensure safety of our children.
Given the seriousness of the disease and the limited understanding that doctors currently have of its occurrence in children, prudence demands that policymakers exercise caution before easing lockdown restrictions on educational institutions, public parks and recreational facilities for children. Parents and caregivers must be cautioned about this alarming evidence of life-threatening illness in children so they can immediately seek medical help from a healthcare professional. Any relaxation that puts the life of children at risk should be thoroughly debated, lest in hindsight, we are forced to label our actions as premature and catastrophic.
Somya Sethuraman is a WASH (water, sanitation and hygiene) sector specialist and has worked with IFMR, the World Bank and IIT-Madras in the past. She has also served as the Sanitation Specialist at the Commissionerate of Municipal Administration, Government of Tamil Nadu.
Views expressed are personal.