Chakraborty P, Rackimuthu S. Second wave of COVID-19 and its effect on children’s health during the ongoing COVID-19 pandemic in India. HPHR. 2021;34
Children’s health during the COVID-19 pandemic in India has not been a matter of principal interest. Available literature suggests that children are capable of being infected with SARS-CoV-2 but have decreased risk of death. With increasing transmission rates and possible progression to severe infection due to SARS-CoV-2 variants during the second wave, children’s health must also be prioritized. It is, therefore, crucial to pay heed and stress the importance of adhering to preventive measures such as hand hygiene, wearing facemasks and maintaining physical distance with children, and advocate for widespread vaccination of the pediatric age group.
India experienced a second wave of COVID-19, which started on February 11, 2021 and, as of July 10, 2021 11:55 GMT. The B.1.617 variant of the second wave spread rapidly in a country with an overwhelmed health system and, at the time, 401,173 COVID-19 deaths.1,2 A recent update by Ranjan et al. found the rate of infection in the second wave to be considerably higher than that of the first wave, with the actual reproduction number observed to be greater than 1 in almost every state in India.3 This suggests that the second wave possibly spread to almost every part of the country including rural areas barely impacted by the first wave.3 With increasing transmission rates and possible progression to severe infection due to SARS-CoV-2 variants during the second wave, children’s health must be prioritized.
Data concerning the impact of COVID-19 among children varies dramatically, with most studies indicating that rates of COVID-19 are lower, marked by milder disease and limited risk of mortality.6,7 A study testing n=2,143 children in China found that just over one-half (50.9%) had COVID-19, with just mild, flu-like symptoms, including fever, fatigue, myalgia, cough, sore throat, runny nose, sneezing, nausea, vomiting, abdominal pain and diarrhea.4 Another large-scale study by Ladhani et al. based in the United Kingdom with 35,200 children under 16 years old tested for COVID-19 found that only 4% of the children were positive for COVID-19, with the fatality rate reported as less than 0.5%, showing no confirmation of an increase in the number of pediatric deaths for the duration of the first wave.9 Other studies had mixed findings, including a smaller study of 41 patients in India. That study reported that the clinical progression of COVID-19 in children was less severe compared to adults.8 Neonates of COVID-19-infected mothers in the study were completely asymptomatic, and fever was seen in only 9 (21%) patients. Co-morbidities, however, were found in 25 (61%) patients.8 Similarly, a study of n=171 children admitted with COVID-19 at Wuhan Children’s Hospital found that among the mild influenza symptoms, a significant proportion of the children experience tachypnea (28.7%) and tachycardia (42.1%).5
It may be safe to conclude that children are capable of being infected by SARS-CoV-2 but have decreased risk of mortality. Hence, prioritizing COVID-19 vaccination as well as the mobilization of relevant health resources for adults and older populations—especially those with co-morbidities—is reasonable. The relatively lower mortality from COVID-19 infection in children might be due to faster recovery rates compared to adults. Potential causes altering the pathogenic mechanism of SARS-CoV-2 in children may be attributed to differences in gut microbiota, angiotensin-converting enzyme 2 structure and immune response.10
However, the question still remains as to whether children may still be less susceptible to the new variants of SARS-CoV-2. India and 40 other countries have been infected with the B.1.617 SARS-CoV-2 variant which has changes in the receptor binding domain of L452R and E484Q.11 A recent study found that this variant could have higher rates of transmission and pathogenicity. The same study also reported that it modestly decreased the sensitivity to antibodies from the Pfizer (BNT162b2 mRNA) vaccine.11 Data presented in a May 8, 2021 news article showed that 10-12% of the total population who tested positive for COVID-19 in the Akola and Amravati districts of Maharashtra were children less than 18 years old,12 a steep increase in the total number of cases compared to the first wave. Many pediatric centers have reported an exponential increase in multisystem inflammatory syndrome in children, also known as “pediatric inflammatory multisystem syndrome.”13,14 Children during the first wave may have been more likely to be asymptomatic or have only mild, short-lived symptoms, resulting in limited testing among this age group and an underestimation of COVID-19 among this age group. The increase likely reflects the greater attention and COVID-19 testing among this age group.
Closure of schools across the country has likely contributed to reducing COVID-19 spread among children. However, the efficacy of closing schools has yet to be ascertained, with contradictory outcomes observed during the first wave of the COVID-19 pandemic. In Taiwan, for instance, closing schools did little to decrease mortality and morbidity,15 and in other countries, reopening schools was not associated with any significant change in COVID-19 mortality and spread despite in-person attendance by students.16 In the U.S., one study showed that the closure of schools was associated with a notable, significant reduction in COVID-19 incidence including a reduction in clinical symptomatology.17
School closures, however, can adversely impact students, parents, and teachers, especially in regions with inadequate resources. The psychological, nutritional and developmental problems that stem from school closures are serious causes for concern because some students continue to depend on school resources and its welcoming, stimulating environment for their daily needs.18 It is, therefore, advisable to reopen schools in a phased manner, preferably first opening schools to those who are vaccinated, following a two-pronged approach wherein offline and online classes are held in tandem. It is equally important to pay heed and take into consideration measures of prevention such as hand hygiene, facemasks, and social distancing.
With the possibility of SARS-CoV-2 variants having an increased transmissibility and ability to cause severe illness, the vaccination of children against COVID-19 must be a matter of chief importance. In the U.S., emergency use authorization of the Pfizer/BioNTech COVID-19 vaccine was extended to adolescents 12 to 15 years old in May 2021, and to children ages 5-11 in November 2021.19 Implementation of similar vaccination strategies targeted toward children, following comprehensive research and clinical trials, resulted in the approval of Zydus Cadila’s COVID-19 DNA vaccine for use in children in August 2021 and Covaxin among children ages 2 and older, in November 2021.20,21 Increasing the availability of resources dedicated to critical pediatric cases also will help decrease mortality in children if there continues to be an increase in the number of cases, as has been seen during the second wave. Future studies on the effect of SARS-CoV-2 and its variants on children in India, with larger study populations, would be required to help provide a deeper understanding of how much of a threat COVID-19 will be to children.
We express our heartfelt gratitude to Dr. K. Shreedhara Avabratha, Professor and Head of the Department of Pediatrics at Father Muller Medical College for his constant help, guidance and encouragement.
Pallab Chakraborty received his bachelor’s degree in zoology from Calcutta University. He has published articles in the field of biology and immunology and is passionate about cell biology research.
Dr. Sudhan Rackimuthu is an intern at Father Muller Medical College, Mangalore, India. His clinical research interests include neurology, surgery and radiology. He is also very passionate about global and public health and will continue to advocate for health equity.