The message was alarming: seven little children had to be resuscitated over the span of 48 hours in the emergency department of Ottawa’s children’s hospital. Three on Monday. “Sunday there were 4,” tweeted Children’s Hospital of Eastern Ontario President Alex Munter.
“Help stop the spread of preventable infectious disease,” Munter posted before pleading for residents to mask up and heed other public health advice.
When asked about the nature of the resuscitation cases, a CHEO spokesperson said Thursday that some, but not all, of the seven children mentioned had a respiratory viral illness.
Still, the tweet echoed some anecdotal reports that children caught in the respiratory viral storm seem sicker than years past. “It’s the worst I’ve seen in my 14 years on staff.” tweeted dr. Tracey Bruce, a pediatric anesthesiologist at McMaster Children’s Hospital. “Multiple viral infections, often in the same child,” and secondary bacterial infections “with catastrophic implications and incredible morbidity,” Bruce said. “Please wear a damn mask!”
The viral surge has renewed speculation that COVID may be weakening children’s immune systems, leaving them less able to cope with viral infections as efficiently as before.
In addition to mild and moderate infections, hospitals are seeing high numbers of children with severe RSV and flu, as well as complications like meningitis, pneumonia and empyema, or pockets of pus around the lungs. “We’re seeing more serious illness in children with these illnesses than we would on average in the past,” said Dr. Michael Howlett, president of the Canadian Association of Emergency Physicians.
These secondary infections are not new. There are just more of them. Is it just a reflection of the overall number of kids being infected, or is there something different about their immune responses? “That’s what we’re trying to flesh out,” said Dr. Upton Allen, chief of the division of infectious diseases at Toronto’s SickKids hospital.
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His gut feeling is that there isn’t anything unusual about the “host,” meaning the child, and that a much more plausible explanation is “less background immunity to the various viruses, year over year.”
“People were locked away, kids were locked away during the pandemic,” Allen said, likely resulting in less exposures to various viruses, and less opportunity to build some cross protection this year.
“At the moment there is no evidence we are seeing more severity per child infected,” said Dr. Stephen Freedman, a University of Calgary professor of pediatrics and emergency medicine.
“They’re behaving exactly the same way kids with RSV did five years ago,” added Dr. Fatima Kakkar, an infectious diseases pediatrician at Montreal’s Sainte-Justine Hospital who just finished a week on call covering the ICU and the most severe cases. “There’s just so many more of them.”
A storm of overlapping respiratory viruses is hammering emergency rooms as more children who weren’t exposed in the last few years are becoming infected for the first time.
RSV, or respiratory syncytial virus, a virus that causes infections of the lungs and lower respiratory tract, is mostly what’s currently bringing kids into the hospital and ICU, Kakkar said. “What we’re seeing now is infants under six months,” especially two- to four-month-olds, with severe bronchiolitis, or inflammation of the small airway passages entering the lungs that causes a tell-tale wheezing from the inflammation.
Normally, most children are infected with RSV by age two. But older children, two-, three- and four-year-olds who hadn’t been exposed to RSV in the last few years are now getting sick for the first time. “In general, most of them are less severe, but there are some exceptions,” Kakkar said, including children with asthma or a family history of it, children with weakened immune systems who “decompensate” or have trouble with any viral infection and high -risk children with cystic fibrosis, pulmonary disease or heart disease. “We’re seeing those kids as well in the ICU,” Kakkar said.
With two past winter seasons of very low to “non-existent” levels of influenza and RSV “we have a bigger cohort of children who have naïve immune systems to these viruses,” Freedman said.
People also now largely no longer change the way “we live, work and play,” said Dr. Paul Offit, a pediatrician and vaccine expert at Children’s Hospital of Philadelphia. “We now gather in large indoor settings without masks. I think, for most people, the pandemic is behind us, so they’re doing nothing, really, to limit interaction. You’re just seeing this full-blown sharing of respiratory viruses.”
Vaccination rates for both influenza and COVID are also low, especially among children under five (there is currently no vaccine approved for RSV). As of Nov. 14, seven per cent of children under four in Canada had received at least one dose of a COVID vaccine, and just two per cent two doses, according to the Public Health Agency of Canada.
The number of flu-associated hospitalizations are well above levels typical of this time of year, according to the agency’s FluWatch reports, The federal government doesn’t track RSV-related hospitalizations and ICU admissions, but in the US, babies under a year old are being hospitalized at rates six times higher than at the same point in 2019, Vox reported.
In Canada, staffing pressures, historically and excruciatingly long waits for emergency care and a country-wide shortage of children’s liquid Tylenol and Advil is exacerbating the viral crush. The situation is so severe, McMaster Children’s Hospital is running out of cribs. “We are seeing three winters in one — three winter surges in one,” the hospital’s chief of pediatrics, Dr. Angelo Mikrogianakis told a media briefing this week. The surge is expected to only get worse. “There’s a lot of time left in what is traditionally the children’s viral season,” said hospital president Bruce Squires.
Every emergency room has a resuscitation area. Children sent to “resus” may need high levels of urgent IV fluids or intensive oxygen. More rarely the child is in complete cardiac arrest, or on the verge of “coding.”
Last week, half of the children in Sainte-Justine’s full ICU were babies with RSV. Some were on ventilators, though “we try really hard not to ventilate babies with RSV,” Kakkar said.
For reasons that aren’t clear, influenza “seems to be hitting kids in the pre-teens, like six and above and below the teen years, pretty hard this year,” said Dr. Sam Wong, president of the Alberta Medical Association’s pediatrics section.
“There is anecdotal evidence, you talk to enough people, you talk to enough physicians, and they say, ‘This is the worst year we’ve had.’ And certainly, I would say in my last 25 years of practicing, this is by far the worst I’ve seen with RSV and influenza.”
Wong has heard reports of four children at one hospital being intubated in a span of 24 hours. “It just doesn’t happen regularly where you are putting kids on a ventilator in that short of a period of time.”
Some people have raised “immune dysregulation” caused by SARS-CoV-2 as a factor behind the surge, drawing comparisons to a virus like measles, which can impact a person’s ability to mount an immune response to future viruses. One study found that children have a higher risk of being diagnosed with diabetes30 days after a COVID infection, than those without COVID.
Some research in adults suggests that a COVID infection can lead to immune changes that may be prematurely aging or destabilizing human immune systems. But McMaster University immunologist Dawn Bowdish said it’s a dangerous game to extrapolate observations in adults to children.
With three viruses circulating at the same time, the chance of co-infection is also much higher, Bowdish said, and being infected with RSV and influenza is worse than having either on its own.
Low vaccination rates also aren’t helping, including in pregnant women. Influenza and COVID vaccines can protect babies for the first six months of life.
Kakkar hasn’t seen any evidence, either in the kids that she has seen, or in their blood or their workouts, or in the literature, to suggest that there’s immune dysfunction, or that the kids are more severely ill than before.
Allen said it’s a question people are asking. “No one has the answer yet.”