The number of confirmed COVID-19 cases among children has shot up over the past few weeks, with as much as 20 percent of all confirmed cases being children.
Although the vast majority of cases exhibit only mild symptoms, there have been reports of children developing acute encephalitis, leading to many fatalities and unease in the population.
Most of these cases are children of preschool age, and the observed course of the disease is extremely aggressive, rapidly deteriorating one or two days after the initial onset of symptoms, and leading to death on the third or fourth day.
The situation is similar to a large enterovirus outbreak in 1998 that claimed the lives of 78 children, and many of its survivors experiencing long-term health problems.
In the initial stages of that outbreak, I had called many times on health authorities to take it seriously and work with academia to research the virus.
For this reason, Taiwan became a center for the study of the prevention of enterovirus in children. Even today, countries around the world rely on Taiwan’s experience to treat enterovirus among children.
As a pediatric physician and an old hand at fighting epidemics, and with more than 20 years of frontline experience, I see Taiwan once again facing a severe crisis as a result of a virus.
First, a message for parents: The Central Epidemic Command Center has announced eight warning signs, or prodromes — early symptoms indicating onset — of enterovirus in children. Parents should not panic, but should keep a close eye on any changes in their child’s condition and take them to a hospital as soon as they notice any untoward symptoms.
Second, a word for pediatricians: The majority of children with COVID-19 exhibit only mild symptoms, and pediatricians only need to treat those typical COVID-19 symptoms. If the prodromes of enterovirus occur, transfer the child to a specialized hospital.
The doctors in such a hospital should closely monitor brain stem symptoms, including cramping, involuntary muscle jerks, lapses in the child’s ability to concentrate, uncontrolled eyeball movements — such as eyes drifting to one side or becoming cross-eyed — and symptoms deriving from cranial nerve dysfunction, such as paralysis, weakness or pain.
If any of these symptoms occur, the child could develop a cerebral herniation within a few hours, possibly leading to cardiac arrest or respiratory failure.
The third point concerns triage. On May 20, with the assistance of the Centers for Disease Control, the Taiwan Pediatric Association and pediatric departments specializing in neurology, infectious diseases, respirology, critical care and emergency issued clinical guidelines for COVID-19-associated encephalitis in children.
The course of this disease can change rapidly, and it should be treated by specialist teams with experience in pediatric care.
I previously recommended that each city, county and special municipality in Taiwan should equip at least one of its hospitals to specialize in severe COVID-19 cases in children, and to allocate resources and hospital beds according to the Regional Emergency Medical Operational Center platform.
If a child exhibiting prodromes of encephalitis cannot be transferred to such a hospital, access to telemedicine should be arranged, through which a team of specialists could discuss the child’s condition on a twice-daily basis.
The fourth recommendation is to provide children with free rapid tests for COVID-19. These tests, available as part of the real-name registration system, have a specificity of as high as 99 percent, and a large number of children are testing positive. A positive rapid test result on a child should confirm that they have COVID-19, and they should proceed to the next stage of treatment.
Taiwan only recently began vaccinating children aged five to 11 against COVID-19. The government should expand the distribution of free rapid tests to pediatric emergency clinics, and cases treated in overcrowded pediatric emergency clinics should be sent to general clinics.
The fifth recommendation concerns pathological studies into the disease. During an epidemic, similar symptoms and disease courses can be caused by different viruses, and the same virus might also cause different pathologies and clinical situations. It is of paramount importance that the disease is studied.
In June 1998, after discussing the matter with me, a couple that had lost their child to enterovirus put aside their grief to compassionately agree to donate the body of their child.
Under the direction of Shieh Wun-ju (謝文儒), a doctor at the US Centers for Disease Control, a dissection of the body was performed, leading to the identification of the EV71 variant of enterovirus as the cause of most cases of “brainstem encephalitis and its subsequent neuropulmonary edema and heart failure.”
Taiwan is now seeing different disease courses of COVID-19-associated encephalitis in children, as well as rapid onset of symptoms, making it difficult to carry out a detailed investigation.
Pathological studies are therefore even more important if Taiwan is to understand how the disease transitions to a more severe stage and how to provide a more effective treatment.
The government should therefore make arrangements with parents who have lost a child.
Finally, Taiwan should look at why the disease has taken the course it has. The situation Taiwan is experiencing is different from that in the West, while Singapore has not had any cases of the disease and only two have been reported in Hong Kong. Ethnic differences might well be a major contributing factor.
Genetic research of Taiwanese children who developed severe symptoms is extremely important. My team recently discovered a gene susceptible to enterovirus in Taiwan, and Jean-Laurent Casanova, head of the the St Giles Laboratory of Human Genetics of Infectious Diseases at the Rockefeller University in the US, recently discovered that severe cases of COVID-19 are related to a faulty gene.
COVID-19 encephalitis progresses unexpectedly to convulsions, coma and death. To treat the disease in a timely manner, Taiwan must identify the factors that predict early progression to severe encephalitis, such as the relationship between viral load, cycle threshold values and infectious markers such as C-reactive proteins, procalcitonin and IL-6. These studies need to be conducted nationally and quickly.
Additionally, if an emergency use application is approved for a vaccine for children between six months and five years old, the government should purchase it and roll it out as soon as possible.
Every child is precious, not just to their parents, but also to the nation’s future. Following the 1998 enterovirus epidemic, Taiwan’s medical community developed world-class competencies in pediatric critical care.
The government has done an exemplary job in its response to the COVID-19 pandemic, and with some careful planning, the outstanding pediatricians of this country can not only save childrens’ lives, but provide them the chance to fully recover and contribute to the nation’s future as they grow up.
Lin Tzou-yien is a former minister of health and welfare.
Translated by Paul Cooper
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