As of November 25th 2021, four SARS-CoV - 2 variants of concern (VOC: Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2)) have been detected. Variable degrees of increased transmissibility of the VOC have been documented, with potential implications for hospital and health system capacity and control measures. This rapid review aimed to provide a synthesis of evidence related to health system responses to the emergence of VOC worldwide.Seven databases were searched up to September 27, 2021, for terms related to VOC. Titles, abstracts, and full-text documents were screened independently by two reviewers. Data were extracted independently by two reviewers using a standardized form. Studies were included if they reported on at least one of the VOC and health system outcomes.Of the 4877 articles retrieved, 59 studies were included, which used a wide range of designs and methods. Most of the studies reported on Alpha, and all except two reported on impacts for capacity planning related to hospitalization, intensive care admissions, and mortality. Most studies (73.4%) observed an increase in hospitalization, but findings on increased admission to intensive care units were mixed (50%). Most studies (63.4%) that reported mortality data found an increased risk of death due to VOC, although health system capacity may influence this. No studies reported on screening staff and visitors or cohorting patients based on VOC.While the findings should be interpreted with caution as most of the sources identified were preprints, evidence is trending towards an increased risk of hospitalization and, potentially, mortality due to VOC compared to wild-type SARS-CoV - 2. There is little evidence on the need for, and the effect of, changes to health system arrangements in response to VOC transmission. 

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Health system impacts of SARS-CoV − 2 variants of concern: a rapid review

Objectives: To describe the severity and clinical spectrum of coronavirus disease 2019 (COVID‐19) in children during the 2021 New South Wales outbreak of the Delta variant of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).

COVID‐19 in New South Wales children during 2021: severity and clinical spectrum

THE START OF THE PANDEMIC When COVID19 reached the UK in early 2020, the emphasis was, appropriately, on caring for adults. From spring to autumn 2020, COVID19 had minimal direct impact on children, with few severe cases or deaths. School closures and other restrictions meant children were mixing much less than usual, and when schools reopened they were protected by bubbles and, at times, masks. This also meant that children suffered fewer severe respiratory illnesses than in a ‘normal’ year. However, children’s health was affected in other ways: many elective National Health Service (NHS) treatments were suspended, space was taken in several UK paediatric intensive care units (PICUs) by adult patients, and unmet need grew for diagnosis and treatment of physical and mental health problems and for child protection. So there were a range of risks to children, but what about direct risks from COVID19? Serious illness requiring intensive care is relatively rare in childhood. Across the four nations of the UK, 26 PICUs are commissioned, but in 2020 a single PICU was unlikely to admit more than a few children with severe COVID19. However, among them there were some with a pandemicrelated paediatric phenotype, the paediatric multisystem inflammatory syndrome temporally associated with SARSCoV2 (PIMSTS; affecting the kidneys, heart, lungs and brain). The existence of an excellent national audit, collecting data from PICUs, allowed it to be characterised, while further insights came from enrolment of children in large national studies, such as the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) study and Randomised Evaluation of COVID19 Therapy (RECOVERY) trials. FROM ALPHA TO DELTA Fortunately, the initial policy responses were effective and paediatric cases fell, but by autumn 2020 a new Alpha variant had emerged, spreading rapidly once schools returned. Over 3 winter months (see figure 1) NHS England recorded 2603 hospital paediatric admissions, the national audit recorded 348 PICU admissions (COVID19 infection and PIMSTS), and the Office for National Statistics (ONS) recorded 5 deaths caused by COVID19 in children aged under 15 years old, and 14 deaths in children aged 15–19 years old. Underlying health conditions emerged as risk factors for adverse outcomes, especially deaths. Following a calmer period in spring 2021, during which schools resumed and the adult vaccination programme progressed, ‘Freedom Day’ in England on 19 July removed most remaining mitigations, including in schools. The new and more contagious Delta variant spread rapidly in all confined spaces, including schools, and although very few infected children were seriously ill, high rates of COVID19 infection meant that the absolute numbers rose steeply. There was, however, some good news. The UK medicines regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), approved the Pfizer/BioNTech vaccine for use in children aged 12–15 years on 4 June 2021, and the reduced (1/3) dose dose Pfizer/BioNTech vaccine for use in children aged 5–11 years on 22 December 2021. However, in contrast to equivalent bodies elsewhere, the Joint Committee on Vaccination and Immunisation (JCVI) did not follow regulatory approval of these vaccines with their own prompt approval for use in healthy children. The JCVI minutes (19 August 2021) indicate that only a threshold for PICU admission ‘greater than 100 per million’, which was the risk faced by children with underlying health conditions and similar to the ‘adult at risk definition’, justified offering vaccination. Approvals were therefore granted only for children with underlying health conditions or living with a vulnerable family member. The JCVI were concerned about rare cases of postvaccine myocarditis, which despite having a mild clinical course, carries the potential for longerterm risks. Yet the US Centers for Disease Control and Prevention found the risk of myocardial injury from COVID19 greatly exceeded the risk from vaccination in children aged 12–15 years old, with an even better safety profile for the vaccine approved for use in 511 year olds, for whom the risk of myocarditis is ~1 per million. In the European Union, Israel and North America children aged 12–15 years received

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What should be done to protect children from COVID-19 in the UK?

Abstract Objective To describe hospital admissions associated with SARS-CoV-2 infection in children and adolescents. Design Cohort study of 3.2 million first ascertained SARS-CoV-2 infections using electronic health care record data. Setting England, July 2020 to February 2022. Participants About 12 million children and adolescents (age <18 years) who were resident in England. Main outcome measures Ascertainment of a first SARS-CoV-2 associated hospital admissions: due to SARS-CoV-2, with SARS-CoV-2 as a contributory factor, incidental to SARS-CoV-2 infection, and hospital acquired SARS-CoV-2. Results 3 226 535 children and adolescents had a recorded first SARS-CoV-2 infection during the observation period, and 29 230 (0.9%) infections involved a SARS-CoV-2 associated hospital admission. The median length of stay was 2 (interquartile range 1-4) days) and 1710 of 29 230 (5.9%) SARS-CoV-2 associated admissions involved paediatric critical care. 70 deaths occurred in which covid-19 or paediatric inflammatory multisystem syndrome was listed as a cause, of which 55 (78.6%) were in participants with a SARS-CoV-2 associated hospital admission. SARS-CoV-2 was the cause or a contributory factor in 21 000 of 29 230 (71.8%) participants who were admitted to hospital and only 380 (1.3%) participants acquired infection as an inpatient and 7855 (26.9%) participants were admitted with incidental SARS-CoV-2 infection. Boys, younger children (<5 years), and those from ethnic minority groups or areas of high deprivation were more likely to be admitted to hospital (all P<0.001). The covid-19 vaccination programme in England has identified certain conditions as representing a higher risk of admission to hospital with SARS-CoV-2: 11 085 (37.9%) of participants admitted to hospital had evidence of such a condition, and a further 4765 (16.3%) of participants admitted to hospital had a medical or developmental health condition not included in the vaccination programme’s list. Conclusions Most SARS-CoV-2 associated hospital admissions in children and adolescents in England were due to SARS-CoV-2 or SARS-CoV-2 was a contributory factor. These results should inform future public health initiatives and research.

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Hospital admissions linked to SARS-CoV-2 infection in children and adolescents: cohort study of 3.2 million first ascertained infections in England

Most Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections in children are mild or asymptomatic. Severe Coronavirus Disease 2019 (COVID-19) in children is infrequent. An estimated 0.3-1.3% of children with SARS-CoV-2 infection were admitted to hospital, and of these 13-23% needed critical care. SARS-CoV-2 related deaths were very rare in children, estimated at 2 per million. The vast majority of admitted children had one of shortness of breath, fever, and cough, but atypical symptoms are more common in children. Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) have been linked to SARS-CoV-2 infection. Cardinal symptoms include prolonged fever, clinical signs of inflammation, gastro-intestinal symptoms, and cardiac dysfunction. Twenty two to 80% of patients with MIS-C needed critical care;mortality of MIS-C is around 2%. Six to 24% of children with MIS-C had coronary artery dilatation or cardiac aneurysms. Equipoise still exists between first-line treatment with immunoglobulins and steroids. Outcomes for children with MIS-C are generally very good in those recognised early and started on appropriate treatment. Vaccination schemes for children are rapidly expanding, with the benefits of preventing severe COVID-19 disease and MIS-C and reducing community transmission outweighing the risks of adverse events of, amongst others, myocarditis temporally related to COVID-19 vaccination in children and young adults. The imposed social distancing measures reduced the overall number of children with acute illness or injury presenting to urgent and emergency care facilities worldwide. No clear signal was seen that large numbers of children had a delayed presentation to emergency care departments with a serious illness. The social distancing measures negatively impacted the mental health of children.

The impact of the COVID-19 pandemic on child health

Background Children and young people (CYP) were less affected than adults in the first wave of SARS-CoV-2 in the UK. We test the hypothesis that clinical characteristics of hospitalized CYP with SARS-CoV-2 in the UK second wave would differ from the first due to the combined impact of the alpha variant, school reopening and relaxation of shielding. Methods Patients Findings 2044 CYP aged Interpretation Severe disease in CYP admitted with symptomatic SARS-CoV-2 in the UK remains rare. One in five CYP in this cohort had asymptomatic/incidental SARS-CoV-2 infection. We found no evidence of increased disease severity in W2 compared with W1. Funding Short form: National Institute for Health Research, UK Medical Research Council, Wellcome Trust, Department for International Development and the Bill and Melinda Gates Foundation. Long form: This work is supported by grants from the National Institute for Health Research (award CO-CIN-01) and the Medical Research Council (grant MC_PC_19059) and by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford (NIHR award 200907), Wellcome Trust and Department for International Development (215091/Z/18/Z), and the Bill and Melinda Gates Foundation (OPP1209135). Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research (grant reference: C18616/A25153). JSN-V-T is seconded to the Department of Health and Social Care, England (DHSC). The views expressed are those of the authors and not necessarily those of the DHSC, DID, NIHR, MRC, Wellcome Trust, or PHE.

https://www.medrxiv.org/content/medrxiv/early/2021/09/17/2021.09.14.21263567.full.pdf

Comparison of children and young people admitted with SARS-CoV-2 across the UK in the first and second pandemic waves: prospective multicentre observational cohort study

Thomas M Drake MBChB

Papers

Comparison of children and young people admitted with SARS-CoV-2 across the UK in the first and second pandemic waves: prospective multicentre observational cohort study