“I wonder what choice morsels you have for me today” he chattered to no one in particular.
The scientist shuffled slowly into the dimly lit lab, his yellowing lab coat flapping against his legs as he moved between benches scattered with forgotten specimens and broken bits of equipment.
“I wonder what choice morsels you have for me today” he chattered to no one in particular.
Back in 1986 a certain ex-film star, and former President of the United States, set in motion an annual event known as International Infection Prevention Week (IIPW). I had no idea Ronald Reagan was the person who started this, but apparently, he was! Okay, so along with trying to save lives he was also keen on reducing the amount of money being spent dealing with healthcare associated infections, but let’s give him the benefit of the doubt and say it was mainly about saving lives.
Since its inception IIPW has spread around the globe and now is an annual event in such diverse places as Australia, the United Kingdom, the Middle East, and Southeast Asia.
Each year IIPW has a theme. Recent themes include Vaccines are Everybody’s Business in 2019, Protecting Patients Everywhere in 2018, Antibiotic Resistance in 2017 and Break the Chain of Infection in 2016.
This year’s theme is “Make Your Intention Infection Prevention” …catchy huh? Our Infection Control Team has been running around the hospital sporting fancy T-shirts looking like “professional footballers”!
They told me that the idea behind this year’s theme is to encourage everyone, the general population as well as healthcare workers, to put infection control practices at the heart of what they do; make them an instinctive and everyday part of how we go about our lives.
Now this may seem obvious, surely everyone does this already …but do they? How many people wash their hands regularly? How many people self-isolate when they are unwell? How many people carry tissues around in case they sneeze? My suspicion is …not many!
Let’s look at the elephant in the room …Covid-19 (clearly my favourite topic!).
Below is a graph from the Department of Health (UK) website showing the cumulative number of cases of Covid-19 in the UK since the pandemic began.
Okay, it’s all over the News… no not the anxieties about Christmas shopping because of the lack of lorry drivers… although ECIC has just placed the turkey order! No I’m talking about the Parliamentary report from the Health and Social Care and Science and Technology Committees called “Coronavirus: lessons learned to date”… of course!
Okay, that’s a definite click-bait title but I have my reasons for asking the question. Over the past couple of weeks, I have had a number of calls about people who clearly have Covid-19 and yet it hasn’t even been considered in the diagnosis. Seriously, not even considered!? We are having between 35,000 and 40,000 cases of Covid-19 every day in the UK, it is almost certainly currently the most common infectious disease in the UK, and yet it is being “forgotten” and still being missed! WHY?!
“Is that the Duty Microbiologist? Can I please discuss a patient with you and get your advice?” asked the Junior Doctor.
The Microbiologist nearly fell off his chair… people were rarely that polite when calling…
“Certainly, what can I help you with?” he replied, feeling immediately predisposed to being happy and helpful. (A very weird and unfamiliar feeling for the Microbiologist!)
“I have a complex patient who had a kidney transplant about 6 months ago who keeps getting UTIs. She has had a number of positive urine cultures and she feels better after being treated, but when the antibiotics stop, she quickly becomes symptomatic again. We’re wondering where we go from here. Should we try a longer course of antibiotics to see if that helps or would she benefit from antibiotic prophylaxis?”
The Microbiologist had been listening intently.
“This could be BK virus infection causing ureteral stenosis. Have you imaged the transplanted renal tract?”
“Beaky what virus?” asked the Junior.
And it had been going so well….
The Microbiologist was doing his daily Critical Care ward round. The next patient to see had been admitted with severe abdominal pain and been diagnosed with a perforated appendix. They had had an urgent laparotomy the night before and had come to the Critical Care Unit as they were a bit unstable after the operation and needed close monitoring. They had improved steadily.
The Registrar mentioned that the patient had been on antibiotic prophylaxis since the operation, and they wondered whether it should stop after 24 hours.
“It’s not prophylaxis” said the Microbiologist.
“Yes, it is” replied the Registrar, “the Surgeons have written that they want the antibiotic prophylaxis to continue, but they haven’t said for how long.”
“No, it’s not prophylaxis” said the Microbiologist again, “it’s treatment. They are different things with different purposes”.
“Oh, here we go” muttered the Registrar, “pedantics again!”
“I heard that!” Exclaimed the Microbiologist, smiling, at least he knew someone had read his blog. “Let me explain…” he said in that manner of, shhh…listen!
The Registrar groaned inwardly, knowing a mini-lecture was coming and there was nothing he could now do to stop it…
The Microbiologist sat quietly eating his lunch, partially hidden behind a pot plant in the staff canteen, when he sensed someone standing behind him. “Damn!” he thought, thinking he had hidden well enough to prevent his lunch being interrupted with any clinical questions... but clearly not.
Looking around he met the gaze of the Cardiology Registrar who was clearly waiting to make eye contact before launching into “the patient’s story”!
…“I have a patient in her early twenties who came in with a fever and a rash, but over the last few days she has started to go into heart failure”.
The Registrar had been in the Microbiologist’s teaching session early in the week, and had clearly “swotted up” after being asked questions he didn’t know the answers too.
The Cardiology Registrar then delivered the “piece de resistance” and declared “I think this might be Rheumatic Fever”.
Home schooling looks like it’s over; schools are going back in two weeks. It’s amazing how much you can learn from Netflix but clearly, the constant “bubble burst” and “pingdemic” absence from school is not sustainable, there needs to be another solution.
Bring out the UK Government’s answer: change all the advice and guidelines… again!!! Don’t you just love them…so here’s a quick overview of the “new school rules”.
New guidance for school children who are contacts of Covid-19 cases:
As of now children are no longer required to self-isolate if they live in the same household as someone with Covid-19, or are a close contact of someone with Covid-19, if any of the following apply:
So basically, all children at school will fall into the “less than 18 ½ years old” group and will no longer need to self-isolate. No more missing school! GREAT!!
Instead, children (or their parents) will be contacted by NHS Test and Trace (we are still all paying for it so the Government needs to keep using it…cynic!), informed their child has been in close contact with a positive case and advised to get the child to take a PCR test. The UK Government “encourage” all individuals to take a PCR test if advised to do so… but this appears to mean that it is now no longer mandatory. Oh! And hooray, face coverings are no longer “advised”… let’s hope we can actually ditch them as I believe they hamper teaching and communication… (have you noticed more people seem to be “opting” to wear a face mask now they are not mandatory… we are a contrary nation!)
So, back to school, is this a good idea or will it lead to thousands of sick children across the country? Did we ever answer the question “do children spread Covid-19 in schools?”, and “do they get sick and die from the infection?”
Are schools a hot bed of Covid-19?
At the beginning of the pandemic, children were blamed for spreading Covid-19 amongst each other, “infecting teachers with plague” and then taking it back to their families. It was claimed that schools were a major source of cross infection between households, but it appears that that hasn’t really been the case after all.
The UK Government quote figures of attack rates for a number of situations where someone has come into contact with a case of Covid-19. The attack rate is the % number of new cases of Covid-19 due to contact with an infected person; the higher the number the higher the risk:
These figures suggest that school transmission is NOT the major source of spread of Covid-19, but rather that “social” and “household contact” IS the main source… However they don’t show how these figures were calculated, so I’d suggest caution, as statistics are easy to manipulate to show whatever you want them to show!
So, children going to school isn’t going to cause mass spread of the infection but do they get sick and die from the infection? Are we putting them at risk?
Do children die from Covid-19?
The simple answer to this rather disturbing question is YES… but it isn’t common. The overall mortality rate in children under 18 years old is about 1 in 500,000 and that is very low, apparently you are just as likely to die while bungee jumping. In the over 80s it is about 15% (that’s dying of Covid-19 not bungee jumping!) BUT 1 in 500,000 isn’t zero, and it’s important to remember that although the RISK is very low the CONSEQUENCE is absolute… at the end of the Covid-19 infection the child is either 100% alive OR 100% dead … not 1 in 500,000 parts dead. Please excuse the apparent callousness of that statement but it’s a really important concept that often gets lost when considering “outcomes of disease”; percentages can be misleading, things either “fully happen” or they “fully don’t happen”, death doesn’t partially happen.
So, reassuringly children going back to school are at very low risk of dying from Covid-19, Phew! BUT is there anything else other than severity of Covid-19 we need to take into account? What about long Covid?
Long Covid-19 in children
Do children suffer from long Covid? This is a really important question as up until now all we keep hearing is that severe Covid-19 in children is rare, but what about the less severe but equally debilitating long-term effects that might impact school attendance, disrupt physical activity and damage mental health. Surely in kids, these are just as important as severe infections, added to this, we know that in adults long Covid can happen whether you have a severe infection or no initial symptoms at all.
A large study from the UK, published in the Lancet, looked at 1743 children who tested positive for SARS CoV2 to see what symptoms they had and how long those symptoms lasted. The children (or their parents) reported symptoms via an online app. The study showed that only 1.8% of children with Covid-19 had symptoms that lasted up to 56 days, compared to the control group where 0.9% of children who hadn’t had Covid-19 but who reported feeling unwell (unsurprisingly, kids were still getting kids illnesses last year). The main symptoms of the Covid-19 group were fatigue and headache. So, in this study the “excess burden” of prolonged symptoms due to Covid-19 in children was only an additional 0.9% compared to “other children experiencing illnesses”.
Another study from Zurich, Switzerland, has also looked at the burden of prolonged symptoms in children following Covid-19. The Swiss team looked at 1355 children who had a serology sample taken between October and November 2020 and asked them questions about symptoms compatible with long Covid. They then tested the serum from these children to look for antibodies against SARS CoV2 which would indicate they had been infected in the past. This identified 109 children who had had Covid-19 and 1246 who had not. 4% of the Covid-19 children had symptoms lasting longer than 12 weeks compared to 2% of the children who, although had symptoms lasting longer than 12 weeks, had not had Covid-19 at all. The most common symptoms in the Covid-19 group were tiredness (3%), difficulty concentrating (2%) and increased need for sleep (2%). The Swiss team concluded that long Covid in children is uncommon, giving only a 2% increase in symptoms after 12 weeks.
A further, yet smaller study, from Australia showed no prolonged symptoms following Covid-19 in children at all. This would support the findings of the somewhat larger studies above; if something is so low then small studies won’t usually pick it up.
Results from the small number of other studies I have been able to find on this subject suggest long Covid symptoms in children are uncommon, up to about 2% perhaps. All of the studies are limited by the small numbers of children in the studies and so are all prone to bias and skewing of their data e.g. if you ask for people to report long Covid symptoms you are more likely to get responses from people with symptoms than without symptoms which will lead to higher apparent case numbers e.g. if you have 50 people in a study and 10 say they have symptoms this would be 20% even though it is possibly only 10 people out of the whole population. However, the studies all seem to suggest the same low rates of long Covid in children and that is reassuring.
So, what do I think? Am I in favour of the more relaxed rules around children going back to school?
Yes, I am in favour of a more relaxed approach to the return to school. I think the risk of severe disease in children is extremely low and the risk of long Covid is also very low. I think the risks associated with children missing school are considerable. And it’s not just the missing education that worries me; more importantly the lack of social interaction, play and physical activity can have very serious impacts on how children develop, not to mention that school meals are sometimes the main meal of the day for some children. And yes, as someone who is a product of the comprehensive school system in the UK, I think learning is important as well.
I just think we should be aware that there may be a risk with the more relaxed system, and we should keep an eye on what is happening, whether children are getting sick, or case rates are going up or long Covid in children is becoming more common, and we shouldn’t be afraid to change our minds if it’s all going wrong. One thing is for sure we all now know we need to wash our hands much more frequently! Maybe this generation will be top of the class on that lesson!
Now, I’m off to the shops to look for a new pencil case, some gym pumps and a satchel… yippee, back to school!!!! Don’t forget to sticky-back plastic your exercise books!!
There’s a story playing out over the news channels that is causing me some distress. There is an alpaca on death row who has tested positive for tuberculosis (TB) and therefore been sentenced to be culled as he poses a risk to other animals… He’s called Geronimo and he’s cute!
“Okay, this is going to sound odd, but can we test a baby for RSV?” asked the Paediatrician.
“You do realise it’s July, don’t you? I mean I know we’ve all been locked in our houses for months, it’s raining and the radio played a Christmas song this morning…but it’s still summer!” exclaimed the Microbiologist.
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