Hamilton County school-aged children have accounted for roughly 1 in 4 of the county's new COVID-19 cases in the past month — underscoring that the highly contagious delta variant of the coronavirus and other compounding forces are creating a new academic year far different from the last.
Dr. James Antoon, a hospitalist and assistant professor of pediatrics at Monroe Carell Jr. Children's Hospital at Vanderbilt, said it's difficult to compare the state of the COVID-19 outbreak in children now to last year — when far more protective measures were in place and a less contagious strain of the coronavirus was circulating.
This school year, state officials have banned universal mask mandates for children by overriding local school districts with an order requiring parent opt-outs. Also, state officials have blocked local school systems from switching to districtwide virtual learning as a way to stop the spread of the virus.
Also, the now predominant delta variant that's driving a record-breaking coronavirus surge across the region is a "completely different animal than previous versions of the virus," Antoon said.
Experts and officials have been calling the surge of the delta variant a "pandemic of the unvaccinated." That applies to people who have resisted getting the shot, but also, children under 12 not eligible to be vaccinated. And even those 12 to 17 had a slow start to getting vaccinated, as they were approved for the shots late in the pandemic.
Delta is at least 40% more transmissible than the alpha variant, which was first identified in the U.K. in late 2020, and significantly more contagious than the initial coronavirus variant.
An average of 34 new daily COVID-19 infections in children ages 5-18 in Hamilton County were reported in the week leading up to when Hamilton County Schools resumed classes on Aug. 12, according to data from the Tennessee Department of Health. That number has nearly doubled since, with an average of 66 confirmed school-aged cases reported each day in the past week.
Similar trends are happening across the state. Although children represent 18.4% of COVID-19 cases since the start of the pandemic, with most cases among 14- to 18-year-olds, there were 21,468 child cases — representing 37.6% of all cases — reported the week of Aug. 22, according to the department of health. There were 14,627 child cases, amounting to 31.4% of all cases, the week of Aug. 29.
"Given what we know about the delta variant, I think this was anticipated, especially in the context of schools reopening — many without the full COVID prevention measures in place," Antoon said, adding that it's also hard to say how many of those cases are linked to school itself.
"The timing corresponds with school opening. I don't think we can say for sure that's where it's coming from and not other places in the community," he said. "But I think common sense would say that any place where children are interacting and mingling in large numbers, there's going to be transmission points, and school certainly fits that."
Before school started, children's hospitals across Tennessee were already strained by a summer influx of patients with other respiratory viruses — namely RSV — normally only seen in children during the winter months.
Dr. Charles Woods, a pediatric infectious disease specialist and the CEO of Children's Hospital at Erlanger, said the volume of RSV patients is still above normal for this time of year but has subsided a bit. However, the number of COVID-19 hospitalizations in children has increased significantly since early August.
Erlanger's children's hospital has seen more COVID-19 in the past month than ever before, Woods said, although it hasn't pushed the hospital past its capacity and seems to have stabilized.
"I have optimism about this, but I don't want to put too much optimism out yet, because we're not a full week even yet from Labor Day. So, there's concern that we might see another bump," he said. "We're still in the wait and watch category."
Woods said he doesn't want to sound alarmist, because children's hospitals across the state are not overrun with COVID-19 patients at this time. However, he also acknowledged the gravity of the current surge in the community combined with the higher volumes of other illnesses hospitals experience when school starts.
Most people who become infected by the coronavirus experience mild or moderate symptoms that don't require hospitalization, and because some people who fall ill never receive a COVID-19 test, high hospitalizations serve as an indicator of high community spread.
Although children typically fare much better against the coronavirus than their adult counterparts, some do become seriously ill and require hospitalization, including intensive care and mechanical ventilation.
As of Friday, there were 68 people aged 18 and under hospitalized with COVID-19 in Tennessee, including 26 in intensive care and 13 on ventilators.
Woods said pediatric COVID-19 hospitalizations are just the "tip of an iceberg that's much bigger" when it comes to overall burden of childhood infections across the region.
"We know that iceberg — as a whole — is a lot bigger, because we've had the most children with COVID in the hospital," he said. "But it's not like we've had a hospital full of children with COVID."
Another concern Woods has is whether or not the hospital will see a spike in multisystem inflammatory syndrome in children, a rare but serious condition associated with COVID-19 that causes inflammation in different parts of the body, such as the heart, lungs, kidneys, brain, skin or gastrointestinal organs.
Symptoms of the syndrome in children typically appear between two and six weeks after COVID-19 infection, so Woods said it may be too early to see the effects of the current wave.
Since the start of the pandemic, 179 Tennessee children have been affected by the syndrome, with one of those cases resulting in death. As of Sept. 7, the Tennessee Department of Health was reporting an additional four probable cases and another 17 under investigation.
"It will be interesting to see if we have less of that than we might have anticipated with delta than with the early variants," he said. "If we aren't seeing more of it in the next two to three weeks, that may be an interesting observation, and we'll be comparing notes nationally with others."
Antoon said vaccinations combined with other COVID-19 prevention measures are still desperately needed in the pediatric population. Even though children are less likely overall to wind up in the hospital, when they do, the trends are similar to adults, he said.
"It's the unvaccinated 12- to 18-year-olds who are getting severe illnesses, and really the only way that we can protect those who are unvaccinated — those kids who are less than 12 and especially those kids with underlying comorbidities who are at risk for severe COVID and potentially dying from COVID — is to vaccinate everybody around them to try and protect them," he said.
Even though vaccines offer good protection against the delta variant, particularly against severe illness, the vast majority of school children in Hamilton County and Tennessee remain either unvaccinated or ineligible.
Prior infection does also provide protection, although it's unclear for how long. As of Sept. 9, at least 8,470 Hamilton County children ages 5-18 had confirmed COVID-19 infections since the start of the pandemic in March 2020.
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