15 August 2020: Of Plagues and Children

Section III of Wiliam McNeill’s classic text “Plagues and Peoples” describes the interplay between population expansion in China, the Middle East, India, Europe and the toll exacted by infectious diseases (“microparasitism” – his term). With surprisingly parallel experiences, diseases introduced into sufficiently dense population centers were highly lethal, leading to large die offs in the population. As encounters with epidemics increased (via trade and communication posts), death tolls decreased. Shortened times between successive exposures led to a larger proportion of individuals with effective immunity.

McNeill concludes, “an infectious disease which immunizes those who survive and which returns to a given community at intervals of five to ten years, automatically becomes a childhood disease.”

We are on the brink, and perhaps have already passed, COVID-19 becoming a childhood disease. Thus far, children have been relatively unaffected as the environment placing them at highest risk – schools – closed in March.

In California, children aged 5-17 comprise 16.7% of the population but only 7.6% of COVID-19 cases. Mortality rate in this group has been quite low: 0.002% – a case fatality rate made all the more remarkable when compared to the observed mortality rate among older adults:

70-74: 3.0%

75-80: 12.2%

80+: 22.9%

What we are seeing currently with COVID-19 is a pattern that has shaped city-states, trading routes and dynasties for millenia. A disease attacking a population without any natural resistance has resulted in sudden and large scale death.

Children, thus far, have been spared primarily because they have remained less often infected as compared of the rest of the population. While it remains true that COVID-19 has a far lower risk of mortality for a 14 year old as compared to an 84 year old, children have yet to bear the full brunt of the epidemic. Carelessly sending them to school without physical distancing, masks, disinfection protocols and a coherent testing plan will lead to large scale infection and, in turn, death.

The threat is serious enough that the CDC yesterday sent out guidance for pediatric practices. In this document, they note that although “children infected with SARS-CoV-2 are less likely to develop severe illness compared with adults, children are still at risk of developing severe illness and complications from COVID-19. Recent COVID-19 hospitalization surveillance data shows that the rate of hospitalization among children is low (8.0 per 100,000 population) compared with that in adults (164.5 per 100,000 population), but hospitalization rates in children are increasing. While children have lower rates of mechanical ventilation and death than adults, 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, which is the same in adults.”

Further, “similar to adults, children with severe COVID-19 may develop respiratory failure, myocarditis, shock, acute renal failure, coagulopathy, and multi-organ system failure. Some children with COVID-19 have developed other serious problems like intussusception or diabetic ketoacidosis. Children infected with SARS-CoV-2 are also at risk for developing multisystem inflammatory syndrome in children (MIS-C).”

Should you be worried? Absolutely. Florida is already experiencing COVID-19 as a childhood disease (Link: https://www.sun-sentinel.com/…/fl-ne-children-getting…). We have learned this tragic lesson across millenia and, it appears, will be learning it once again.

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