Intended for healthcare professionals

Rapid response to:


Risks to children and young people during covid-19 pandemic

BMJ 2020; 369 doi: (Published 28 April 2020) Cite this as: BMJ 2020;369:m1669

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Rapid Response:

Re: Securing improved primary health care for children and adolescents post-COVID-19

Dear Editor

The COVID-19 crisis so far seems to be less intruding for children’s physical condition and it affects older people disproportionately. Much effort must be spent to control COVID-19 in this older age group and improve their living conditions, including quality of care. But this first impression is misleading. Once mortality and morbidity caused by COVID-19 are controlled in Western countries, the current state of primary health care for children also requires a forward view to improve the primary health care of the youngest generation.

Despite the expected economic shortfalls foreseen in the coming years, we must guarantee prolongation of effective primary health care systems available for children and adolescents. But we also need to thrive for the improvements recommended in the EU financed Models of Child Health Care Appraised (MOCHA) research project, [1].

So far, the mechanism of viral resistance for COVID-19 in children and young people is unknown. We probably do not need to be concerned about direct effects on their physical health, however, we do need to be concerned about their social and psychological condition caused by the COVID-19 crisis. It can be expected that children and especially those from disadvantaged families, will bear the health consequences of the crisis the world has fallen in.

Children from low income and migrant populations witness a disproportionate high morbidity and mortality among family members afflicted by COVID-19 [2]. They will also disprortionately experience the health consequences of the economic crisis and associated austerity, already significant [3]. Moreover, there are signs the lockdown affects the mental health of children and adolescents. The number of children who are victim of abuse, or witness of abuse and domestic violence, is expected to rise. The confinement through measures such as staying at home, not seeing friends and avoiding physical contact will also cause stress in children and adolescents.

There are also early signs that vaccination rates are dropping, and a parallel likelihood that children are not being presented early enough for lesser health problems or developmental delays – either because services are currently restricted, or because of concern at taking children to heavily protected settings [4]. The combination of focussing service redesign onto adult services, and the growing backlog of preventive and early diagnosis needs, bring a new double jeopardy to health services for children.

Yet the pre-pandemic baseline is itself deficient. We bring to readers’ attention a selection of the worrying issues the MOCHA research project brought to light. They need attention from primary care professionals and policy makers, especially in current circumstances with low budgets, making it even more desperate to bring about child health care systems’ change.

1. The immunization rate of children already gradually dropped in many European countries last years. The current children’s underuse of primary care due to COVID-19 will further influence this decline in the current cohorts ready to be immunized. This backlog has to be repaired as soon as possible putting primary care facilities for an enormous task to continue its immunization program. Hopefully vaccine hesitant parents have now become more aware of the viral threat and need for immunization of their child. COVID-19 underlines the need for EU countries to work together to align immunization programs and communicate about the importance of immunization. We have seen the impact of ‘fake news’ on the immunization rates, which we will have to continue to countervail. A uniform message should be brought to the public, based on science and supported by (social) media expertise: vaccination is the main tool and the safest way to prevent communicable diseases. At the same time, delivery systems should be better tuned to the needs of busy parents with employment as well as varied caring commitments, and to their concerns about indivuidual health issues [5,6].

2. Primary health care systems should secure a free access to mental health care for young people having experienced abuse or COVID-19 stress. They as ever should have access to child friendly units that can provide comprehensive care in a neutral empathetic climate and secure confidentiality when requested[7]. It is currently unclear in which contexts and settings confidential access should be guaranteed to adolescents. Discussions and agreement in the EU on access with and without parental consent is needed.

3. Professionals in primary care and school health services should be trained in mental health consequences of COVID-19. They should be skilled to identify adolescents who need psychological support or treatment, and to respond or refer adequately [8].

4. The MOCHA research project concluded that availability of data on health indicators for children and adolescents is poor and data are often incomparable between EU countries. Improved data collection and registration systems are needed that provide health care professionals at all levels with information and feedback. Such data systems are essential to monitor and compare the health and social consequences of the COVID-19 crisis for young people (Rigby et al, 2020). They also enable the evaluation of measures taken to control COVID-19 in EU-countries and anticipate future developments.

Primary health care systems’ improvements and data availability are unconditional to achieving a demonstrable healthy population of well-developed and happy children and adolescents, especially in low-income groups. This must be evident from figures on immunization rates, children’s psychosocial health and quality of care. We are aware of the enormous challenges our economic and health care systems face but claim attention to the care for the youngest generation – the adverse legacy of the Covid-19 pandemic will be further deepened if the health of the emergent next generation is also compromised. Therefore we must not forget to invest in the care for this future generation who can contribute to avoid such crisis as we are in now.

Paul L. Kocken PhD, research on behaviour change and policy at Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, the Netherland,

Danielle E.M.C. Jansen PhD, chair section Child and Adolescent Public Health, EUPHA, Research on organization of care for children and adolescents at Department of Health Sciences, University Medical Center Groningen, the Netherlands,

Daniela Luzi, research on models based on clinical standards and quality indicators at National Research Council Institute for Research on Population and Social Policies IRPPS, Italy,

Prof dr Michael Rigby, Emeritus Professor of Health Information Strategy at the School of Social, Political and Global Studies and School of Primary, Community and Social Care, Keele University, United Kingdom, Visiting Professor, Section of Paediatrics, Imperial College London, for the duration of the MOCHA project,

1. Blair M, Rigby M, Alexander D (eds). Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project. Emerald, Bingley, 2019. doi/book/10.1108/9781789733518. Open Access at
2. ICNARC report on COVID-19 in critical care. Intensive Care National Audit & Research Center, London, 2020. (accessed May 15 2020)
3. Rigby MJ. Potentially over 3 million children in EU Europe believed not to be receiving needed medical and dental treatment—and parents' reasons why. Child Care Health Dev 2020;1–7. 12757
4. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Lancet Child Adolesc Health 2020,
5. Expert Panel on Effective Ways of Investing in Health. Programmes and Health Systems in The European Union; Brussels, 2018 (available at
6. Bedford H, Attwell K, Danchin M, Marshall H, Corben P, Leask J. Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology; Vaccine 2018;36:6556–6558.
7. Michaud PA, Visser V, Vervoort JPM, Kocken PL, Reijneveld SA, Jansen DEMC. Availability and accessibility of mental health services for adolescents: national recommendations and services in E.U. European Journal of Public Health, accepted
8. Rigby MJ, Deshpande S, Blair M. Child health research and planning in Europe disadvantaged by major gaps and disparities in published statistics; European Journal of Public Health, 2020, doi:

Competing interests: No competing interests

15 May 2020
Paul L. Kocken
Assistant professor
Danielle E.M.C. Jansen PhD, Daniela Luzi, Prof dr Michael Rigby
Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam
P.O. Box 1738, 3000 DR Rotterdam, The Netherlands