Did COVID measures cause immunity debt behind child hospitalizations?


Hospitals are reporting never-before-seen surges in children with severe viral infections that are pushing critical care beyond capacity

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A virus that infects and clogs a baby’s breathing tubes is running rampant. An Ottawa hospital where parents have camped out with sick kids in emergency for up to 20 hours has made the “gut-punch” decision to cancel some elective surgeries. In Montreal, doctors have likened the situation in their pediatric ERs to “a horror film.”

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“Anyone with young children will quickly agree that our kids seem to be getting more sick, and sick more often than in the past,” said Rodney Russell, a professor of immunology and virology at Memorial University of Newfoundland.

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An unseasonably early crush of respiratory viral infections has once again raised the spectre of an “immunity debt,” a concept described by some as an unintended boomerang effect of distancing, masking and other COVID containment measures used to slow SARS-CoV-2’s spread.

Experts disagree about whether “immunity debt” is a real phenomenon or convenient pseudoscience. But hospitals are reporting never-before-seen surges in children with severe viral infections that are causing historically long wait times and pushing critical care beyond capacity.

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Adult hospitals are being asked to accept teens 14 and older needing intensive care to free up beds for younger children. “It is anticipated that the next 2-3 months will bring significantly increased demands for pediatric critical care support,” the head of Ontario’s critical care COVID-19 command centre wrote to hospital CEO’s in a memo obtained by The Canadian Press.

At Ottawa’s CHEO, “it’s heart breaking to see so many children and families waiting so long to be seen,” Dr. Mona Jabbour, interim chief of CHEO’s department of pediatrics said on a media call Thursday.

There isn’t one, but several factors at play, including a lack of primary care in the community and a shortage of children’s pain and fever medications parents have been grappling with since late summer.

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But it’s the sheer volume and influx of children with RSV (respiratory syncytial virus), influenza, COVID and other infections that’s overwhelming hospitals. Some seasonal bugs, particularly RSV, are showing up earlier, “and in higher numbers than they normally do,” Russell said.

Masking, school and daycare closures, no birthday parties, no organized sports and other interventions to thwart COVID’s spread and keep hospitals from being overloaded slowed the spread of other pathogens as well.

“In previous years, younger babies would have had these illnesses, and by the time they’re aged two, three, four, they have some immunity to these viruses,” Jabbour said.

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“Because we didn’t see these viruses in the last few years, we’re seeing them all come together, and there isn’t that immunity that we usually see in older children.”

Babies are getting sick. Toddlers are getting sick. Older children, too. “It’s all happening at the same time,” Jabbour said.

Some researchers believe the immune system needs constant poking, that exposure to germs and bacteria in the environment are important to the development of the immune system. Without that prodding, the immune system is slower to respond to future infections.

Being exposed to seasonal viruses every year also acts as an immune booster, shoring up antibody levels to combat naturally waning immunity, Russell said.

“So, if all of us, not just children have now had a couple of ‘germ-free’ years, then all of us may have lower antibody levels than we might have had without masking,” and other public health interventions, he said.

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The idea of “immune debt” was cautioned when we first started hiding from SARS-CoV-2, Russell said. French researchers reported last year that a lack of “immune stimulation” could lead to more intense RSV and flu epidemics in coming years.

“The longer these periods of ‘viral or bacterial low exposure’ are, the greater the likelihood of future epidemics,” they wrote.

However, there are benefits to delaying first infections with a respiratory tract bug. Infants and toddlers are more at risk of hospitalization from RSV than older children, because with babies, that first infection has a greater likelihood of going deeper into the lungs.

Dr. Mona Jabbour, interim chief of CHEO’s department of pediatrics: “In previous years, younger babies would have had these illnesses, and by the time they’re aged two, three, four, they have some immunity.”
Dr. Mona Jabbour, interim chief of CHEO’s department of pediatrics: “In previous years, younger babies would have had these illnesses, and by the time they’re aged two, three, four, they have some immunity.” Photo by CHEO

Mucus starts plugging the small airways. Young children “come in for bronchiolitis, they come in for pneumonia, they may require oxygen therapy, they may require respiratory support to help them breathe,” said Dr. Jesse Papenburg, a pediatric infectious diseases specialist at Montreal Children’s Hospital. Sometimes children get so tired from the sheer effort of breathing, they end up dehydrated.

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There was almost no RSV in the winter of 2020-21, and a relatively short season last year that started in late summer and was done by late December.

If a pathogen like RSV or flu basically disappears for a series of years, “All of the people who normally would have been infected during those years don’t get infected, and that susceptible pool of people accumulates,” said McMaster University infectious disease expert Matthew Miller.

Take off the brakes — lift the public health measures — and a virus like RSV can spread quickly, with a high attack rate. More people susceptible to a disease means more infections. “It’s just a numbers game,” Miller said.

There isn’t a “defect” in the immunity of children, he and Papenburg said. The lockdowns and public health measures haven’t somehow made our children’s immunity weaker or damaged, they said.

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“Different people are using the term ‘immunity debt’ to mean different things,” Miller said. “Some have a scientific basis. Other iterations are misinterpretations of what data is out there.”

There are also concerns the concept is being used to justify that governments should never have mandated masks or other interventions. “I don’t see it that way,” Russell said.

“I still think many would have died unnecessarily, despite how annoying, frustrating, and psychologically and/or financially painful the public health measures were for many of us who didn’t have to worry about dying from COVID. But, of course, early on, we didn’t know our own COVID-19 risks.”

If there is an “immune debt,” Russell doesn’t believe it’s a large one, and that, whatever it is, it will quickly balance itself, “which is probably exactly what we’re seeing now — a kind of ‘making up for lost time’ on the part of the pathogens and the immune system.”

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