1- President, Bangladesh Pediatric Association; President, Bangladesh Society for Pediatric Infectious Diseases, Former Head of Pediatric Medicine and Cardiology, Bangladesh Institute of Child Health and Ex-Director, Dhaka Shishu (Children) Hospital
2- Associate Professor, Division of Neonatal Cardiology, Department of Pediatric Cardiology, Bangladesh Institute of Child Health and Dhaka Shishu (Children) Hospital.
Comparing to adults, so far the direct effects of
COVID-19 on child and adolescent appears not significant. COVID-19 outbreak
adversely affect different services among the children of Bangladesh. These
include disruption to their healthcare, nutrition, protection, education, overall
mental wellbeing, vaccinations and preventive and curative services. Access to
essential health delivery services specially routine immunization has already
been hampered and threatens a significant increase in child mortality due to
Vaccine Preventable Disease (VPD) in coming days. But, the indirect effect
could be horrifying. If we reimagine and try to foresee the indirect impact, we
would visualize the horrific impact on child health at the post Pandemic
era. In the past, world had faced many
challenges, but the human race could overcome those with inventions of
vaccines, adopting appropriate policies and timely interventions. Here again,
we must be positive but at the same time must formulate appropriate policies
and take actions for timely implementation. Surely, one day the COVID-19
challenges will end, but we may have to face new challenges in post pandemic
era.
INTRODUCTION
An
outbreak of pneumonia of an unknown origin developed in Wuhan of Hubei
Province, China during December, 2019.1 By January 7, 2020, Chinese
scientists confirmed that the outbreak was caused by a novel coronavirus,
renamed as severe acute respiratory syndrome-related coronavirus 2
(SARS-CoV-2), and the disease is now termed coronavirus disease 2019
(COVID-19).2-4 On January 30, 2020, WHO declared a public health
emergency of international concern (PHEIC) and pandemic on 11 March 2020.5
While the global coronavirus crisis worsens, a surprising feature of the
disease appears that children might be immune from the worst of it. Studies suggest that
COVID-19 is more likely to infect older adult men, particularly those with
chronic comorbidities.6 There is only limited data detailing the effects of
COVID-19 on the pediatric population. A review of 72,314 cases by the Chinese
Center for Disease Control and Prevention showed that <1% of COVID-19 cases
were in children younger than 10 years. Children of all ages
were infected, with the median age being 7 years (range 1 day to 18 years) and
56% of the infected pediatric patients were male. Over 90% of the cases were
mild or moderate in nature.7 In Bangladesh 3% of children <10
years were identified as COVID-19.8 Young children, especially
infants, however, seemed to be more susceptible to severe disease than older
children; 10% of patients under 1 year of age had severe or critical disease.9
In another study of 1391 children under 16 years of age assessed and
tested for COVID-19, 171 (12.3%) were positive for SARS-CoV-2 infection. The
median age of infected children was 6.7 years and 15.8% of patients had no
symptoms or signs of pneumonia. Only 1.8% children required intensive care and
mechanical ventilatory support, but all had pre-existing medical conditions.10
The
mechanism by which children seem less susceptible to severe infection caused by
SARS-CoV-2 has yet to be elucidated. It has been theorized that the ACE2 (the
binding protein for SARS-CoV-2) in children is not as functional as it is in
adults, and thus SARS-CoV-2 is less infectious.9
BANGLADESH
SITUATION
As of 2 July 2020, according to the Institute of Epidemiology, Disease Control and Research (IEDCR), there are 153,277 confirmed COVID-19 cases in Bangladesh, including 1,926 deaths.8 In the epidemiological week 25, COVID-19 confirmed cases increased by 14%, in comparison to previous week (24,786 and 21,751). The number of COVID-19 related deaths also increased by 3.2% (292 and 283 respectively).11
Number
of cases |
Date |
100 |
6 April |
1,000 |
14 April |
10,000 |
3 May |
25,000 |
18 May |
50,000 |
1 June |
75,000 |
11 June |
100,000 |
18 June |
150,000 |
2 July |
Fig.- Weekly distribution of confirmed COVID-19 cases and death (9 March to 22 June 2020)11
As of 22 June 2020, the case doubling time in
Bangladesh remain 8 days. Available data shows that how quickly the number of
confirmed cases increased in Bangladesh and some countries in South-East Asia
region: India, Indonesia, Thailand, and Sri Lanka.
Fig.- Growth of confirmed COVID-19 cases in selected south east Asian countries starting from the day of 100th confirm case to 22 June 2020.11
So far among the confirmed COVID-19 cases 3% belongs to age <10 years and 7% belongs to age 11-20 years.
Fig.-
Distribution of COVID-19 confirmed cases by age group.8
Among the confirmed COVID-19 cases 0.82% deaths belong to age <10 years and 1.49% deaths belong to age 11-20 years.
Fig.-
Distribution of COVID-19 confirmed death cases by age group.8
First dedicated Child Corona Unit has been established in Dhaka Medical College Hospital on 10 May. They have treated 60 cases till 31 May 2020. Majority of the patients are of moderate severity (71%) and 25% were severe. Mortality was 13.3% among the admitted cases. Dhaka Shishu (Children) Hospital which is the largest pediatric hospital in Bangladesh also treating COVID-19 cases though it is not a dedicated corona hospital. Chittagong Medical College treated the highest number of COVID-19 pediatric cases so far. Many of the children with COVID-19 cases are managed in different dedicated COVID hospitals.
Table-
Distribution of children with covid-19 admitted in three major hospitals till
31 May 2020 (N=220)
Dhaka Shishu
(Children) Hospital (up to 31 May 2020)12 |
Total - 64 Male-41(64%), female-23(36%) <1 month - 12(19%) 1-12 months - 16(25%) 1-5 years - 8(12%) 5-10 years - 23(36%) >10 years - 5(8%) Total infected HCW 39 (Doctor-14, Nurse-12,
Technician-3, Others-10) |
Dhaka Medical
College13 |
Total
- 60 Asymptomatic
- 2(3%) Moderate
- 43(71%) Severe
- 15(25%) Died
- 8(13.3%) Discharged
- 24(%) DORB
- 3(%) |
Dhaka Shishu (Children) Hospital found many neonate
with COVID-19. Most of the cases were found positive from general ward and
cabin but only few were found from neonatal ward and NICU.
Table-
Distribution of neonates with covid-19 admitted in Dhaka Shishu (Children)
Hospital (N=15)14
Sl No |
Age |
Sex |
Primary
Diagnosis |
1 |
2 |
Female |
Occipital Encephalocele |
2* |
20 |
|
Term, AGA with
Sepsis |
3* |
4 |
Female |
Term with Perinatal Asphyxia with HIE-II with Pneumonia |
4 |
22 |
|
Anorectal
Malformation |
5 |
23 |
|
Congenital Heart Disease |
6 |
5 |
|
Neonatal Jaundice
with Sepsis |
7 |
20 |
Female |
Pneumonia with Sepsis |
8 |
1 |
|
Ruptured
Lumbo-sacral Meningomyolocele |
9 |
15 |
|
Posterior Urethral Valve |
10 |
8 |
|
AKI |
11 |
22 |
|
Perinatal Asphyxia with HIE-II with Sepsis |
12* |
6 |
Female |
Term, IUGR with
Perinatal Asphyxia with HIE-II with Sepsis |
13 |
20 |
|
Pneumonia with Congenital Heart Disease |
14 |
3 |
|
Anorectal
Malformation with Sepsis |
15* |
8 |
Female |
Term, AGA with Sepsis |
*Directly admitted in NICU |
GUIDELINE FOR PEDIATRIC POPULATION
Pediatrics
being an established speciality and it is already known that children are
unique in their requirement of fluid and electrolytes, oxygen delivery as well
as medicinal dose. For this Bangladesh Pediatric Association feels that a
guideline is necessary for the paediatricians and others who are concern with
children for proper management of COVID-19 patients. Experts from Bangladesh
Paediatric Association (BPA) have tried to share the most updated information
and these recommendations will be change periodically with upcoming evidence
and experience.15
REDUCTION IN HEALTH SERVICES
Health
services for children has decreased significantly due to the COVID-19 pandemic.
COVID-19 outbreak will
adversely affect the condition of children, particularly in the lives of most
vulnerable children. This includes disruption to their healthcare, nutrition,
protection, education and overall mental wellbeing including social interaction
with friends, peers, family members and caregivers, family planning, antenatal and postnatal care, child
delivery, vaccinations and preventive and curative services. The
uptake of maternal and newborn health services has decreased, approximately by
19 percent. In addition, key maternal health services such as antenatal
care visits and postnatal checkups in health facilities have decreased
substantially, and deliveries in facilities have decreased by 21 percent for
the period of January to March 2020 compared to October-December 2019.16
Critical health services for
under-five children has decreased significantly due to the COVID-19 pandemic.
The service utilization for children under 5 years of age in March 2020 was
down 25 per cent compared to March 2019. A large number of children could die
from preventable and treatable conditions if the pandemic leads to substantial
reductions in health service coverage. Based on the worst of three
scenarios in 118 low- and middle-income countries, the analysis estimates by
researchers from the Johns Hopkins Bloomberg School of Public Health, published
in The Lancet Global Health Journal warned that an additional 1.2 million
under-five deaths could occur in just six months, due to reduction in routine
health service coverage levels and an increase in child wasting. These
potential child deaths will be in addition to the 2.5 million children who
already die before their 5th birthday every six months, threatening to reverse
nearly a decade of progress on ending preventable under-five mortality.16
Reduction of health services could cause death of over 28,000 children under
the age of 5 years in the next 6 months as an indirect result of coronavirus
pandemic.17 The greatest number of additional child deaths will be
due to an increase in wasting prevalence among children, which includes the
potential impact beyond the health system, and reduction in treatment of
neonatal sepsis and pneumonia.
BREAST
FEEDING SITUATION
WHO and UNICEF encourage women to
continue to breastfeed during the COVID-19 pandemic, even if they have
confirmed or suspected COVID-19. While researchers continue to test breast milk
from mothers with confirmed or suspected COVID-19, current evidence indicate
that it is unlikely that COVID-19 would be transmitted through breastfeeding or
by giving breast milk that has been expressed by a mother who is confirmed or
suspected to have COVID-19. But breastfeeding is decreased and
Breast-milk Substitutes use is increased in Bangladesh.18
IMMUNIZATION
With lockdowns in place as a part of
the novel coronavirus (COVID-19) response, routine immunizations have been
severely disrupted, and parents are increasingly reluctant to take their
children to health centers for routine jabs. Sporadic outbreaks of
vaccine-preventable diseases, including measles and diphtheria, have already
been seen in parts of Bangladesh, Pakistan and Nepal. National mass vaccination
campaigns have been postponed. In Bangladesh, the postponed measles and rubella
campaign targets 34 million children aged from 9 months to 9 years. Though
routine immunization sessions continue, many outreach sessions have been
suspended and the transportation of vaccines remains challenging. The
Directorate General of Health Services in Bangladesh has issued guidelines to
continue routine immunization during COVID-19 pandemic in line with UNICEF and
WHO global and regional advisories. The routine immunization sessions are
continuing both in fixed and outreach sites as an essential service that
combats disease outbreaks.19
We must encourage that children receive their
routine immunizations with preventive measures including physical distancing,
handwashing, and face musk. We must make already panicked parents to understand
that Vaccines are safe, effective and life-saving tools to control and prevent
outbreaks of infectious diseases.
CHILDREN LIVING ON THE
STREETS HAVE FEW SAFE PLACES TO GO DURING THE COVID-19 LOCKDOWNS.
Hundreds of thousands of children
are living on the streets in Bangladesh, and the number is expected to continue
growing. For many of them, the COVID-19 pandemic is proving particularly tough.
Not only do these children often lack access to soap and clean water to help
protect against coronavirus, but even basic guidance like “stay home” means
little if you don’t have a home to go to.20
VIOLENCE AGAINST
CHILDREN
Many countries around the world have
implemented lockdowns, stay-at-home, and physical distancing measures to
contain the spread of COVID-19. The home, however, is not always a safe place
for children, adolescents, women and older people who are experiencing or are
at risk of abuse. Evidence shows that violence can increase during
and in the aftermath of disease outbreaks. In many
countries including Bangladesh affected by COVID-19, records from helplines,
police forces and other service providers indicate an increase in reported
cases of domestic violence, in particular child maltreatment. Although data on
family violence during the COVID-19 pandemic are currently scarce, established
evidence on violence against children.21
CONCLUSION
Pediatric patients are on the rise and unfortunately we noticed some casualties already. Comparing to adults, so far the direct effects of COVID19 on child and adolescent appears not significant. But, the indirect effect could be horrifying. COVID-19 outbreak adversely affect the condition of children. This includes disruption to their healthcare, nutrition, protection, education and overall mental wellbeing, vaccinations and preventive and curative services.
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17. COVID-19: Over 28,000 children could die in 6 months without urgent action. https://unb.com.bd/category/Bangladesh/covid-19-over-28000-children-could-die-in-6-months-without-urgent-action/51543. Accessed on 28.06.2020.
18. Countries failing to stop harmful marketing of breast-milk substitutes, warn WHO and UNICEFhttps://www.unicef.org/bangladesh/en/press-releases/countries-failing-stop-harmful-marketing-breast-milk-substitutes-warn-who-and-unicef. Accessed on 28.06.2020.
19. Disruption of child vaccination in South Asia poses an urgent threat to children’s health - UNICEF. Available from https://www.unicef.org/bangladesh/en/press-releases/disruption-child-vaccination-south-asia-poses-urgent-threat-childrens-health-unicef. Accessed on 28.06.2020.
20. Choedhury IA. For many in Bangladesh, staying home isn’t an option. https://www.unicef.org/bangladesh/en/stories/many-bangladesh-staying-home-isnt-option.Accessed on 28.06.2020.
21. Addressing violence against children, women and older people during the covid-19 pandemic: Key actions. World Health Organization. Available from https://www.who.int/publications/i/item/WHO-2019-nCoV-Violence_actions-2020.1. Accessed on 29.6.2020.