A Theory On why Children May be safer #COVID-19

All along in medicine, we have described the extremes of ages: the very old and the very young as the most vulnerable especially in the case of infections. Indeed you may have noticed that school-going children have common colds almost every other week with adults catching the same sporadically. The argument has long been that the immunity in these two extremes is not as strong as for human body at its peak immunity.

Come COVID-19 and all of sudden studies are showing that the children are not only less susceptible to virus, but they also develop less severe disease (to be clear, children of all ages have been affected and at least one, a 14 year old boy has died from the virus)

We thank God that our children are relatively safe but what is the scientific reason? There are many theories but this is mine. Starting from the “fact” that children’s immunity is not stronger than that of healthy adults, I look to see what children may have that adults don’t that would confer an advantage. The answer I arrive at, and this is no more than a theory, is vaccines for other illnesses and the concept booster doses in vaccinations.

What vaccines aim to do is to 1. prevent illnesses and 2. result in milder symptoms should the patient catch the disease nonetheless. What this means is that vaccinated individuals are less likely to catch the infection against which they were vaccinated and if they do, it will be less severe. But then, most adults also got the same vaccines the children have right? Yes. But this is where the concept of booster doses comes in. You see, in many vaccines, for as long as one is not exposed to the disease, the immunity acquired from the vaccine tends to wear off with time and a booster dose is required at some point. This may be the case in adults.

Finally, there is the obvious issue that there is currently no vaccine against SARS-CoV-2, the virus that causes COVID-19 and therefore, there is no possibility that any child could ever have got it. This is true. However, the whole theory is that there is an existing vaccine now that is given in childhood that has some efficacy against SARS-CoV-2 and COVID-19. Childhood vaccines cover a number of organisms including viruses such as those that cause Measles, Mumps, Rubella, Polio and hepatitis viruses. In addition, there are non-core vaccines that are increasingly provided to children including seasonal flu vaccines, rotavirus and many other viruses. All these are viruses first before they branch out into their respective families. Some are closer than others, but there are some commonalities across board. It is therefore not inconceivable that a vaccine designed against one organism could be bear some efficacy against another.

Whereas this is just a theory, which in effect amounts to just a hunch not backed by any study, studies into the treatment of COVID-19 already present such possibilities. The drug chloroquine and its relative hyrdoxychloroquine were created for completely different diseases but are now being investigated for their efficacy against COVID-19. Early reports from China have shown promise.

Most theories are not correct but even when they are, they require studies to prove them. Still, I choose to document this view, today, 22nd March 2020, just in case there is merit to it. I am yet to come across an alternative argument that makes sense to me.

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With COVID-19, when you have seven confirmed cases, responding as if you have 7 cases is responding a few weeks too late. I would propose an approach that models a projected scenario three weeks later, asks what measures we would take then, then proceeds to have those measures implemented today. Here is the reason.

On 28th January, Italy had only two confirmed cases. For the next three weeks up t o 18th February, they had only one additional case bringing the total to three. Then suddenly, there was an explosion of cases and a wild-fire like escalation. It seems like out of the blue, COVID-19 went out of control. Why did this occur? The truth is that it was never out of the blue. Understanding how the Sars-Cov-2/COVID-19 spreads and presents suggests that this pattern was always possible. Data from countries that have witnessed exponential spread suggests that confirmed cases especially early on are a true tip of the iceberg. They represent a small view of a bigger problem festering underneath the surface: spread among yet unknown and unsuspecting individuals.

Confirmation of the first cases requires a series of things:

  1. A symptomatic patient meeting the case definition who either presents to a facility or is identified through a robust screening process
  2. The presence of mind by the healthcare workers to link this patient to COVID-19 and act as per protocol
  3. An accessible and reliable diagnostic laboratory

These seem reasonable until we realize that:

  1. COVID-19 can be symptom-free for up to fourteen days (one case is suspected to have been symptom free for much longer).
  2. There is an indication that the virus can be spread for up to two days before the onset of symptoms.
  3. 80% of patients will develop only mild symptoms that are indistinguishable from common ailments, and may never present to hospital, especially early on.

All these mean that the likelihood that all or even most of actual initial cases will present to a hospital let alone get tested for COVID-19 is very low. They continue to spread the virus nonetheless and it is this unknown population that bears the greatest risk to our health system with a large number of possible new infections among people who do not even know that they are sick. The magnitude of the problem would become evident only two to three weeks later when symptoms start to show and a big enough population has been infected. Countries like South Korea, Iran, Italy and many others have gone through this very cycle. If we are to learn any lessons from them, then we should take every measure to ensure that we limit this invisible spread, appreciating that it is likely there. If we wait for the numbers to hit a hundred, we might very well be too late.

For instance, having churches and schools closed and bars and clubs opened is not a situation we should be happy about.

It is understandable the concern of those who advocate for conservative, less drastic measures: the economic disruption should we take drastic steps. Perhaps we can learn from the same debate when we were considering limiting flights: concern about the impact on airlines and economic ties made us delay shutting down borders. Fast forward a few weeks later and the same drastic measures we were trying to avoid are now in place, only that they are no longer enough to contain the situation and more drastic, and economically costly measures will be required. The same is likely to happen with other drastic measures being considered today. If we delay them, it is likely that we will still be forced to implement them but in situations in which they will no longer be enough or as effective as if they were to be implemented today.

If we have reason to believe that COVID-19 will fade away, then the conservative measures will do. If however we see a scenario in which the infection will spread, and that is the lesson from other countries, we have to try get ahead of it. That means that we implement today the measures we are contemplating putting in place three weeks from now. That means reacting not to the numbers we have confirmed today, but to what we see those numbers look like three weeks from now. This way, we give ourselves a good chance to succeed.

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Dear Colleagues,

Today, our country is faced with a scary challenge: a new virus that infects easily, has the potential to cause severe illness, and for which there is no ready cure. We have always said in our quests for better health systems that healthcare workers too are consumers of the same healthcare delivery structure. There is never a more explicit demonstration of this fact than when epidemics and pandemics occur. We too being human means that we are as susceptible to the virus as any other person. Yet it is to us that the sick will turn, not because we are immune, but because we bear the best human hope for relief and survival. Indeed, if the pattern witnessed in other countries is anything to go by, it is guaranteed that a number of health workers will be infected. Therein, as is natural to humans, lies a real concern.

The natural instinct when faced with danger is to get away from it and to preserve self. In this context, the COVID-19 challenge, what would that mean? China today is closing the last of the temporary hospitals that were built to combat the virus in Wuhan. The success they have witnessed is credited in part to the efforts of healthcare workers in that country who demonstrated sheer heroism. They projected character in the face of adversity, courage when faced with fear, admirable resilience and another level of selflessness. Without them, thousands more would have died, and it is unlikely that the outbreak would have been brought under control. On the flipside, had they not done what they did, it would have made their community less safe: everyone including the healthcare workers, and their families would have been at greater risk, for longer, with nowhere to turn to.

Allow me to draw another parallel. During the Dusit terrorist attack, Kenyan soldiers put themselves on the line: they stood up as the force between bullets fired by a set of killers and their intended victims. Indeed, one of them, Japhet Nduguja, lost his life in the process. It is this commitment to duty and common good that kept us…keeps us, safe.

Now it is our turn. The frontline in facing the enemy we face now cannot consist of the armed forces. That frontline has to be you and I. The risk to us should we turn our backs to this challenge is that where we run to, our homes, will have the very virus severe, for longer and we will have nowhere to turn to. It is not lost on me that there are no guarantees should we stand and give it our best shot. It’s worse that Js and Is have been in charge of health policies for a long time and got us to a place in which our system is not as robust as it could have been. That notwithstanding, we remain our best hope and during this time, have to be at our very best as healthcare professionals and as part of humanity. I know that this is a tough ask, but I also know that Kenya does have some of the best healthcare workers in the world: underappreciated, but some of the best nonetheless. It is our time.

To the long-unemployed doctors, nurses, and other healthcare workers, I apologize on behalf of my country for downplaying your importance, disregarding you and leaving you on your own despite our gaps. Should we just now remember you, and I pray that we do, you would be justified to refuse to listen. My prayer is that you would nonetheless, step up and answer the call for your value is inherent and not determined by the opinions of the Js and Is.

It is for instances such as these that the concept of calling becomes real, and the daily sacrifice becomes amplified. Our society needs us. Our families need us: paradoxically, this need is served best not by flight, but by fight: fighting as hard as we can to make this disease as short and as limited in spread and effect as possible. It is our turn. Let us pray, and give it our best. This way we will win.

May the almighty God grant you wisdom, protect you, bless you, bless your family and bless our country. Thank you.

Dr. Victor Ng’ani

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