Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study

Dear Editor.

Lessons for the current and future pandemics.

In the week the children are returning to school in the UK, although it is acknowledged they are at low risk from COVID (Swann et al., 2020), it is surprising we are still having the debate about the use of face masks. From the beginning, we have been told the government is ‘following the science’, which in turn waited for published evidence to be generated on issues ranging from whether SARS-CoV-2 spreads by droplets or aerosols to how long it can survive on various surfaces. However, the benefits of wearing a face mask, avoiding crowded places and social distancing, for a respiratory condition spread by an airborne virus, are a matter of common sense. The benefits of these measures were recognised at the time of the Spanish flu in 1918 (Markel et al., 2007). Recently, there has been a dramatic decrease in the number of deaths from flu in the southern hemisphere, which also reflects the benefits of restrictions on international travel (Servick, 2020). It then follows that hand washing and social distancing alone might be giving people a false sense of security, and we don’t need to wait for a peer reviewed publication, to inform us of the importance of adequate ventilation in all enclosed spaces.

Many critical policy mistakes have been made in the UK since the start of the pandemic. We ignored early warnings dating back to 2015 (Gates, 2015; Menachery, 2015). We ignored the devastating impact of COVID-19 in mainland Europe, dithering between mitigation and suppression, playing a blame game, and delaying the lockdown. We relied too much on modelling to predict what the worst case scenario might be, and at what point will our hospitals be unable to cope, while ignoring the tasks at hand - the devastating effects on front line healthcare workers, lack of availability of PPE, disproportionate effect of COVID on minorities, track and tracing, to name a few. We acted too late. We have amongst the worst rates for COVID in the world. Unlike other countries with a far better record of containment, including China, South Korea and Taiwan, we have not been preparing for this pandemic. Interestingly, the vice president of Taiwan, Chen-Jen, a former epidemiologist trained at Johns Hopkins university, put plans in place that have been in the making for almost 20 years.

It is about time we recognize the best science in the world is not just being carried out in UK and major new insights into COVID-19 have come out of studies from China, USA, Germany and the rest of the world. Therefore, it would make sense to broaden the government scientific advisory base to include more basic scientists, especially virologists, and follow the lead of the MRC and the Wellcome Trust scientific advisory panels to include international experts.

Meanwhile COVID19 has highlighted some stark inequalities, with a disproportionate effect on some communities. Many of the underlying comorbidities are most prevalent in the most deprived and under-represented members of society, and in light of the ‘Black Lives Matter’ campaign, racism is now recognised as a public health issue. Coronavirus doesn’t see race but responds to racism. Furthermore, we cannot exclude the environmental effects of malnutrition, and adverse life circumstances or poverty, on our genes.

Many questions remain, including the origin of SARS-CoV-2. No intermediate hosts have been identified despite the fact its nearest match is the horseshoe bat coronavirus (RaTG13) which diverged approximately 40 years ago (Boni et al., 2020). The origin of SARS, which also originated from bats in China, also remains unknown almost 20 years since the outbreak (Cui, Li, and Shi, 2019). It was proposed the virus adapted in humans by natural selection (Andersen et al., 2020), but there is no evidence for this, and moreover this appears to be a slowly mutating virus (Kupferschmidt, 2020).

Bats are natural reservoirs for viruses that have some of the highest fatality rates of any viruses that people acquire from wild animals – including rabies, Ebola and the SARS coronavirus. Yet attempts to identify the source in bats have been stopped in their tracks by political meddling from the Trump administration which rescinded NIH funding to the EcoHealth Alliance (Wadman, 2020). On the other hand, the inadvertent escape of viruses from research labs (Nomile, 2004) is also a big concern and needs policing.

Amidst all this uncertainty and gloom, the only thing we can be certain of is the presence of hundreds of bat coronaviruses with zoonotic potential (Latinne et al., 2020). With increasing globalisation, destruction of ecosystems and trade in and consumption of endangered species, future pandemics can’t be ruled out, so let’s prepare for the worst. Even the 2011 blockbuster movie Contagion, saw this coming!

Jamal Nasir, Ph.D. Division of Life Sciences, University of Northampton.
Nirmal Vadgama, Ph.D. Department of Cardiovascular Surgery, Stanford University School of Medicine.

REFERENCES

Andersen KG, Rambaut A, Lipkin WI, Holmes EC, Garry RF. The proximal origin of SARS-CoV-2. Nat Med. 2020 Apr;26(4):450-452.

Boni, M.F., Lemey, P., Jiang, X. et al. Evolutionary origins of the SARS-CoV-2 sarbecovirus lineage responsible for the COVID-19 pandemic. Nat Microbiol. 2020. https://doi.org/10.1038/s41564-020-0771-4

Cui, J., Li, F. and Shi, Z-L. Origin and evolution of pathogenic coronaviruses. Nature Reviews Microbiology. 2019. 17:181-192.

Gates, B. The next epidemic--lessons from Ebola. N Engl J Med. 2015. 372(15):1381-4.

Kupferschmidt, K. The pandemic virus is slowly mutating. But does it matter? Science. 2020. 369 (6501): 238-9.

Latinne, A., Hu, B., Olival, K.J. et al. Origin and cross-species transmission of bat coronaviruses in China. Nat Commun. 2020. 11, 4235. https://doi.org/10.1038/s41467-020-17687-3

Markel, H., Lipman, HB., Navarro, JA., Sloan, A., Michalsen, JP., Stern, AM., Cetron., MS. Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic. JAMA. 2007 298(6):644-54. doi: 10.1001/jama.298.6.644

Menachery, V., Yount, B., Debbink, K. et al. A SARS-like cluster of circulating bat coronaviruses shows potential for human emergence. Nat Med. 2015. 21, 1508–1513.

Normile, D. Mounting Lab Accidents Raise SARS Fears. Science. 2004. 304 (5671) 659-661.

Servick, K. How will COVID-19 affect the coming flu season? Scientists struggle for clues. Science. 2020. doi:10.1126/science.abe3374

Swann, OV., Holden, KA., Turtle, L. et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ2020;370:m3249.

Wadman, M. NIH imposes ‘outrageous’ conditions on resuming coronavirus grant targeted by Trump. Science 2020. doi:10.1126/science.abe4057.