‘We can’t move fast enough.’ Huge Canadian-led international study to explore impact of COVID-19 on kids in 13 countries
THE GOAL: Understand how the SARS-CoV-2 virus impacts children, define the clinical picture of COVID-19 infection in kids, identify risk factors that could lead to severe illness and determine how regional public health policies influence how the disease spreads.
THE TEAM: Dr. Stephen Freedman, a pediatric emergency medicine physician at the Alberta Children's Hospital in Calgary and clinician-scientist at the hospital's research institute, is the lead principal investigator. Anna Funk, a post-doctoral fellow at the University of Calgary, is a co-principal investigator, along with two others based in the United States, one at Northwestern University and one at University of California, Davis. The project has 49 hospital sites in 13 countries, including eight hospitals in Canada.
THE TIMELINE: The study, funded by the Canadian Institutes of Health Research, plans to recruit more than 12,000 children and is aiming to share data with policy-makers in real time. Freedman will present early findings on Aug. 26 to the World Health Organization. He anticipates the study will conclude by the end of 2020.
In February, as cases of a new coronavirus exploded across the globe, Dr. Stephen Freedman knew COVID-19 would soon show up in Canadian hospitals.
Like many of his colleagues in pediatric emergency medicine, Freedman had dozens of questions: What kinds of symptoms would kids have? How sick would they get? Would kids with severe cases of COVID-19 suffer lengthy illnesses? Of those who contracted the virus, who would die?
Instead of waiting for other scientists to come up with answers, Freedman decided to launch an international study to find out how COVID affects children.
As chair of Pediatric Emergency Research Canada, a network of researchers at 15 Canadian children's hospitals, Freedman had already garnered support to study COVID-19 in kids in Canada during the group's annual meeting in late January.
A few weeks later, after seeing how quickly the virus was spreading, Freedman took the Canadian research plan to the international Pediatric Emergency Research Network (PERN). He proposed a global COVID-19 trial using the same infrastructure PERN had established to study pneumonia at hospitals around the world.
By mid-April, after receiving funding from the Canadian Institutes of Health Research (CIHR), the study was well underway.
We knew that COVID was going to be a pandemic," Freedman says. This was an opportunity to ... rapidly recruit children into a study and quickly get answers."
How does the study work?
Children who are tested for COVID-19 in the emergency departments at participating hospital sites can enrol in the study.
So far, more than 3,000 children under the age of 18 have joined from 49 sites in 13 countries, including the United States, Australia, New Zealand, Argentina, Singapore and Spain. Canada has eight hospital sites, including the Hospital for Sick Children and the Children's Hospital of Eastern Ontario.
Researchers are recruiting children who test positive and negative for COVID-19 so they can compare symptoms and outcomes of kids with the SARS-CoV-2 virus to kids with other illnesses. Freedman, who believes this study is among the few to have such a data set, says many parents are willing to have their children participate.
Parents are asked to fill out a survey after they receive their child's test results, providing information on the type and severity of their child's symptoms, hospital test results, such as blood work and chest X-rays, and various behaviours and risk factors, including mask wearing, hand hygiene, travel and school attendance.
Researchers follow up with another survey in 14 days to see if the illness worsened, and again after six months to see if the child has any ongoing symptoms or other health worries.
We're looking for the development of chronic symptoms," Freedman says. We're just hitting six-month followups for some of these children."
What are some preliminary findings?
Freedman and his team were recently asked to present early analysis to the World Health Organization.
Though they are still teasing out findings ahead of the Aug. 26 presentation, Freedman says the study shows Canada has a dramatically lower COVID-19 positivity rate in kids than other countries. This is a measure of the percentage of conducted COVID-19 tests that were positive for the virus.
Canada has done a very good job in controlling the pandemic to date compared to other countries around the globe," he says. In our dataset, although not representative of the broader population, the COVID positive rate in Canada is about 2 per cent while in the U.S. it's approximately 25 per cent."
Early data also suggests children infected with COVID-19 are not more ill than children (with similar symptoms) who test negative in the emergency department, says Freedman.
And similar to what other research has found, this study shows most children with COVID-19 have very mild illness in the acute phase, he says.
We do see a fair amount of COVID infection in children who are quite young - under a year in age. That has been one interesting thing we've seen that I'm willing to say. But even they seem to do very well."
What can this study tell parents who are worried about sending their children to school during a pandemic?
It's important to reassure parents the vast majority of children infected with COVID-19 have a very mild illness, Freedman says.
My concern is not how sick children will be - even my own children - because they will not be that sick," he says. Very, very, very few will get very sick."
And while there are questions about the new multisystem inflammatory syndrome in children (MIS-C) linked to COVID-19, Freedman notes that it's extremely rare."
Instead, his concerns centre on how children may unwittingly spread the virus to others in their family and social circles.
I worry about it going to grandparents who live with school-aged children or to parents who are in their 50s and 60s - those higher-risk groups," he says. The reasons to prevent illness in children is from the safety of our broader community. That to me is the big message."
What is another pressing question that needs to be answered about kids and COVID-19?
Freedman will soon launch a study to see whether asymptomatic children with COVID-19 transmit the virus within family units - a question he says is important to answer as millions of Canadian children head back to school this fall.
Research shows many children with COVID-19 have few, if any, symptoms during their illness, while others may not develop mild symptoms until two or four days after contracting the virus. It's not yet clear how these kids contribute to asymptomatic or presymptomatic spread of the virus, he says.
Say your child picks the virus up from someone in school and they are initially asymptomatic. How likely are they to transmit that infection to another household member? And how likely are they to develop symptoms? The only way to know that is to identify asymptomatic children and follow the course of their illness."
This study, which also received funding from CIHR, will enrol children at 20 pediatric hospital sites in Canada and the U.S. who arrive to the emergency room for non-COVID reasons, such as an injury or cut. Kids will be tested for COVID-19 and followed at various intervals, along with members of their household.
To have a control group, researchers will match those who test positive - but have no symptoms - with children in other households who test negative.
We will then track them forward with the same questions so we can figure out if the household contacts of asymptomatic children are more likely to develop COVID than the household contacts of non-COVID infected children," Freedman says. That will allow us to determine who transmitted the infection to who in their household."
The team is finalizing the protocol and waiting for ethics approvals at some sites before officially launching in the coming weeks.
Everyone wanted the answer by September, but that's not going to happen. We wanted to move fast. But as fast as we move, we can't move fast enough."
COVID: Front-line Thinkers is part of a regular series highlighting COVID-19 research in Canada.
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie