Mumbai: India’s COVID-19 tally stands at 1024 (as of 7.30 p.m. on March 29) and the country is on the sixth day of a 21-day countrywide lockdown put in place to arrest the spread of the virus. While it is known that those with pre-existing respiratory diseases such as tuberculosis and the elderly have the worst outcomes if infected, not much is known about COVID-19 risks for children and women who are pregnant or lactating.

Karen Kotloff of the University of Maryland School of Medicine (UMSOM), US, a specialist in infectious diseases and pediatrics, fielded some questions from journalists during a webinar organised by the International Center for Journalists on March 24, 2020.

In a career spanning more than three decades, Kotloff has focused on epidemiology of infectious diseases and their prevention with the use of vaccines in both the US and in developing countries. She is principal investigator of the Vaccine Treatment and Evaluation Unit at the UMSOM's Center for Vaccine Development.

Kotloff said COVID-19 has been milder in 90% of the children infected so far, but said little is known about how children with malnutrition will fare if infected. She added that a vaccine is possibly 12-18 months away, at best.

Edited excerpts:

Our general view is that COVID-19 affects adults much more adversely than children. Why is that?

That has been the experience so far. To be really honest, we don’t know why that is. There are a few theories on that. One theory that is particularly interesting: If you see what happens in adults who have COVID-19, the first week they have a respiratory illness and that may even start to get better. And then in the second week, that’s when they really fall into trouble in terms of respiratory disease. And we know that in the second week it’s their vigorous immune responses that is triggering the pathology in their lungs. And we wonder if there is a difference in the immune response of children to the infection. So, they get the first week of upper respiratory infection but they don’t get that explosion of inflammation that’s harmful to their lungs. Whether this difference in immune response to infection is related to children’s previous experience and level of immunity to coronaviruses or some other inherent difference, we really don’t know yet.

Have any children had lasting effects once they have been exposed to COVID-19?

I am afraid there are a lot of question marks here. What we know is that, by far, most children who become infected have mild disease. We know that about 10% will have more severe disease but there are only a handful of children who will actually die from this infection. I think one thing that we can feel assured from the information that we have so far, is that children are faring well for the most part and I think that is the most wonderful part of this news. I don’t think that we have enough information at this point to know what happens to the children down the line, if it puts them at increased risk. We don’t know. I think that we should just focus on the fact that it’s milder in children and that’s wonderful news.

Is there regional variation in the impact of COVID-19 on children?

We know from other viruses that there are regional differences and that the immune suppressant effect of things like HIV and malnutrition have caused some to have a more severe illness. We don’t know whether that’s the case with COVID-19. We haven’t yet seen a lot of reports of more severe disease in people who are immunocompromised. That’s not one of the major underlying illnesses. So maybe that won’t be an important factor in determining the degree of illness. But to be honest, the only information that we have about children comes out of China, a little bit from Italy, and now a little bit from the US.

And so, we really don’t know what happens to children in places like Africa and Asia where malnutrition is a big problem.

When we are dealing with densely populated countries like Nigeria or India, what are the best tools for controlling the virus?

What we keep learning about infections that spread from person to person is that you have to take the social context and the political context into account when you are trying to stop the spread. And so what works in China, didn’t work in Italy, probably can’t be implemented in the United States. And they are very specific. In Africa in particular, where I work the most, that needs to be taken into account. There are families in rural areas that have 200 people who share a cooking fire, who are considered households, who are in one compound, even though some of those spaces are outdoors.

And so when we talk about social isolation, it is not feasible and is not going to work in an environment like that. We need to start seriously thinking about how to approach control of this infection if we see that it is starting to spread in Africa and to come up with policies and procedures that are applicable. And I do worry very much that a vaccine or some type of prevention on that scale will really have to be the answer in environments like that.

Are children in sub-Saharan Africa more susceptible than children in affluent countries simply because they are exposed to high levels of poverty and malnutrition?

I think they are probably going to be more susceptible to infection if they are going to have heavy exposures. My hope is that those co-infections (HIV/TB) won’t make their illness more severe. But we are going to have to watch it as it unfolds.

How do we ensure that children in internally displaced camps stay safe?

It could be an explosive situation putting everybody at risk. The same is true when you have low resource settings in refugee camps and the best thing you can do is to provide as much soap and water as possible and to separate people as much as possible.

What are the effects on pregnancy?

We are looking at that. We know that for certain infections like the flu, which is also a respiratory virus, pregnant women are more susceptible to more severe infections. It is being watched very carefully. It is also being watched because during SARS there was an increased risk of bad pregnancy outcomes. But so far, what we’ve seen is that COVID-19 doesn’t seem to more severely affect pregnant women.

And in terms of outcomes of pregnancy, what happens to the baby is that there have been premature infants who have been born but we really don’t know if the risk for prematurity has increased with COVID-19 and it is going to take some time to tease that out. There are reports from China that maybe in the first year the infection is a little bit more severe than it is for older children. But still the majority of those infants will have good outcomes.

Is there anything known about COVID-19 transmission from pregnant women to the foetus?

It’s been looked at in a handful of pregnancies. So far, nobody has been able to detect evidence that the mother can pass it during pregnancy to the baby. So we are very hopeful. It is going to need further studies but so far there is no evidence.

Should pregnant women who are infected breastfeed?

That is something a lot of people are considering. It’s contextual but overwhelmingly it appears that the benefits of breastfeeding outweigh the potential risk. It is recommended that women who know they are infected could continue to breastfeed but take precautions. If the mother has a mask or a way to cover her nose and mouth during breastfeeding, she should do that. She should wash her hands before she touches the baby and in countries where pumping is available, she could pump but she should make sure that her hands are clean and that her face is covered.

(Shetty is a reporting fellow with IndiaSpend.)

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Disha Shetty

    Disha Shetty is a science journalist based in Bengaluru. She mainly writes about public health, climate change and the intersection between the two. Disha holds a Bachelors in Mass Media from SIES (Nerul), a PG Diploma in TV Journalism from ACJ and MA in Science, Environment & Medicine Journalism from Columbia University. She has won the Global Health Reporting Contest (2018), third prize at SCARF Awards for reporting on mental health (2018) and second prize at PII-ICRC Awards for best article in a humanitarian subject (2019). Disha has reported from the UN as an RAF fellow (2019) and received reporting grants from EJN, IWMF & Pulitzer Center. She has previously worked with the Times Group and DNA.