One in four COVID cases in NSW outbreak has been a child under 19

Early in the pandemic, experiences in Australia and around the world suggested that children were less likely to be affected by COVID or transmit the virus. But with the emergence of Delta that concept has started to evolve.
 
In NSW’s current outbreak, children and adolescents aged 10–19 are overrepresented; of the 2397 cases acquired locally from 16 June to 26 July, 15% (360 cases) were in this age bracket, despite it only comprising 11.9% of that state’s population. A further 223 children aged under 10 have been infected with COVID-19 in that same period, equal to 9% of cases in the current outbreak.
 
Children and adolescents aged 0–19 also account for more COVID cases in Australia (4805) than all cohorts aged 70 and over combined (3839).
 
But Dr James Best, a NSW GP and Chair of RACGP Specific Interests Child and Young People’s Health, told newsGP that the numbers are not very surprising, especially given young people and children are not yet eligible for vaccination.
 
‘We do know that children get COVID and that they often get it. How often it is asymptomatic we’re still quite unsure about,’ he said.
 
‘We also know that the hospitalisation rate in children is very low, but it is increasing, and that may be a reflection that we’re finding it more and also that children, as a percentage, are increasing because of that vaccination driver.’
 
To address this, the Therapeutic Goods Administration (TGA) took the first step in approving COVID vaccination for children in Australia late last week, approving Pfizer for 12–17-year-olds.
 
Associate Professor Asha Bowen, an infectious diseases paediatrician, told newsGP the TGA’s approval means Australia has one more tool to tackle COVID. But she also believes there are a number of factors the Australian Technical Advisory Group on Immunisation (ATAGI) is likely to consider, starting with how to implement the strategy.
 
‘It’s all about the number of doses available and I do still think in Australia we have a really important need to continue to focus on the older age groups and vaccinate through those most at-risk populations,’ she said.
 
‘We’ve also got some high risk frontline style of workers that haven’t been prioritised.’
 
A recently published analysis of severe illness and death rates among younger cohorts in the UK shows that in the first 12 months of the pandemic, 6000 children and teenagers who contracted the virus were hospitalised, and 25 died.
 
Children with pre-existing medical conditions or severe disabilities were among those most at risk.
 
In light of this, Professor Kim Mulholland, a paediatrician with subspecialty training in immunology, respiratory medicine and epidemiology, says if Australia opens up vaccine eligibility to children, that those with comorbidities should be prioritised.
 
‘We know that there are vanishingly small chances of an otherwise healthy child getting into trouble or indeed dying with this disease,’ he told newsGP.
 
‘Now we know the conditions that are associated with high risk for children, in my personal opinion, we should be taking steps to ensure that children with those conditions are vaccinated.’
 
Associate Professor Bowen suspects Australia may follow the UK in offering vaccination to children as young as 12 with comorbidities, particularly neurological, respiratory and obesity.
 
‘I think the rationale for that is that there is a side effect profile to the Pfizer vaccine, which is myocarditis and pericarditis, and balancing that likelihood of occurring, particularly in males after the second dose, compared to the direct benefit that can be achieved from the vaccine,’ she said.
 
But what about the long-term implications for those who develop even mild disease?
 
Professor Mulholland says there have been a string of reports of long COVID in children, but that the evidence is still out.
 
‘We see, for example, studies that in the months following an episode of COVID-19 children have more visits to their GP for various things,’ he said.
 
‘Now whether that constitutes the same kind of thing that we’re seeing in adults, which is very distressing and troubling and may actually lead to long-term health issues … I’m not yet convinced that we have evidence this occurs in children – but I’m also not convinced that we do not.
 
‘If even 5% of children, for example, were getting long-term effects from this, that would be a very powerful argument in favour of vaccinating children. And so this is an area we need to know much more about.’
 
While the risk–benefit for children is the priority, Professor Mulholland says the increased infectiousness of Delta means children may be playing a larger role than previously thought in transmitting the virus.
 
‘Evidence seems to suggest that in the household studies, for example, the Delta variant doesn’t just infect one or two other members, but infects all the other members,’ he said.
 
‘We can assume that children probably play a greater proportional role in terms of transmission of the virus with a Delta variant … but this hasn’t really been proven because in most communities, the adult community is partially vaccinated.’
 
When looking at the long-term goal of Australia returning to some form of pre-pandemic life, Dr Best says Australia is ‘already behind the eight ball’ in vaccinating the adult population, and that excluding children may hold plans back even further.
 
‘But, of course, you’ve got to look at how much safety data we have and all the rest of it,’ he said.
 
‘These are complex issues.’
 
Pfizer and Moderna have now announced that they will be expanding the size of their studies in children aged 5–11 to detect rare side effects, including myocarditis and pericarditis.
 
In the meantime, Associate Professor Bowen believes the NSW Government’s decision to give supermarket workers in affected LGA’s priority access is a smart strategy that could also be applied to teachers and other school staff.
 
‘I think it’s really important that the adults around children and young people get vaccinated,’ she said.
 
‘That will give us that ability to reopen the schools.
 
‘Schools being closed in NSW now for the third week, with no end in sight, is a really big risk for our children and young people because every school day matters.’
 
If vaccination is to be opened up to children, Dr Best says the messaging will be ‘critical’ and that general practice, as is often the case, ‘may be doing the heavy lifting’.
 
‘People get very emotional when it comes to their children, and we’re already over-worrying about some age groups and complication rates. So I think it’s going to be even more challenging when it comes to convincing parents that it’s a good idea to vaccinate their child,’ he said.
 
‘We’ve got to get the decision making right based on all of the variables, and we’ve got to get the messaging clear.’
 
But for now, Dr Best says the best way to protect children and the broader community is to encourage people to get tested, no matter how mild their symptoms may be.
 
‘There can be a reluctance from parents to actually want to put their child through the discomfort of having a COVID test done – I’m certainly seeing that on the ground, and I’ve heard my colleagues saying similar things,’ he said.
 
‘But as GPs we need to overcome the misconception that a child with mild respiratory symptoms is very unlikely to have COVID and doesn’t need to be tested.
 
‘It’s a really important message to get out there that if we find a case, particularly in an area where we didn’t realise COVID was present, we need to do that as early as possible in order for the contact tracing and all those other systems to kick in as soon as they can.’
 
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