Is Canada ready to deal with a pandemic that affects mostly kids?

A future pandemic ‘may result in a marked increase in critical illness and mortality in children’ compared to COVID-19, researchers warn

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Children were spared the worst of COVID-19, but how prepared is Canada for a pandemic that predominantly affects children?

France is the latest European country to report a surge in cases of “walking pneumonia” and other respiratory infections among children, touching nerves already frayed by four years of COVID.

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Canadian specialists said they aren’t aware of any abnormal or unusually high rates of Mycoplasma pneumoniae, the bacterium believed behind many of the bacterial lung infections hitting kids in China, France, Sweden, Netherlands, Norway and Ireland.

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But RSV and influenza seasons are already weighing heavily in Canada, and last fall and winter’s weirdly early and massive wave of RSV, followed by the most intense flu season in children since the H1N1 pandemic in 2009, slammed hospitals and stressed pediatric health-care systems across the country.

The “tripledemic” of RSV, influenza and COVID-19 exposed severe gaps in Canada’s ability to handle major surges in children needing emergency care “and, more importantly, hospitalization and ICU care,” said Dr. Stephen Freedman, a University of Calgary professor of pediatrics and emergency medicine.

Apart from Montreal, most of the country’s large urban centres have only one specialized children’s hospital, and most of those serve wide geographical catchment areas. “There are few, if any, pediatric ICU beds at other locations in our major cities,” Freedman said.

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All pediatric hospitals operate at or over 100 per cent capacity almost all winter, when respiratory viruses spread more easily. Meaning, when there is a surge of sick children, there’s already no space. “There are no rooms in the emergency department, pediatric wards or ICUs,” Freedman said in late-night emails, which he sent after several “crazy busy days.”

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“There are limited personnel with the pediatric expertise needed to care for these sick children” and a large proportion of those who do have expertise have kids of their own, Freedman said. This means “a reasonable proportion of the health-care staff are unavailable either because they or a loved one are sick.”

None of this bodes well for an eventual pandemic surge. A just-published opinion piece in the influential British Medical Journal warns that the U.K. and other countries are unprepared for a pandemic “that predominantly (affects) children.”

“This is of concern as a future global pandemic may result in a marked increase in critical illness and mortality in children compared to the COVID-19 pandemic, where serious illness has been much lower than in adults,” the authors wrote.

“The emergence of a new virus with the pathogenicity and high transmissibility of measles would be devastating.”

From 2000 to 2018, measles vaccination prevented around 23 million deaths globally, mostly in children, the authors wrote, “showing the impact that a measles-like virus could have on children.”

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Countries should develop pandemic preparedness for kids “that is immediately actionable” and scalable, they said.

During last year’s RSV tsunami, dozens of women — medical leaders, hospital board chairs, former provincial cabinet ministers — called on Prime Minister Justin Trudeau and the premiers to hammer out a funding agreement earmarked for children’s health care, warning that “kids’ lives are on the line.”

Those with boots on the ground say little has been done since.

A survey of Canadian PICUs — pediatric intensive care units — warns that Canada’s ability to respond to a pandemic or epidemic surge of critically ill children may be seriously limited.

In early 2022, the country’s 19 PICUs reported a total of 275 funded beds to support a mechanically ventilated child. The units said they could free up another 108 temporary beds during a surge.

That wouldn’t be nearly enough to accommodate a wave of kids with a new viral infection, said Dr. Daniel Garros, a University of Alberta clinical professor of pediatrics and one of the study’s authors.

Roughly 13,385 Canadian children were admitted to a PICU in 2018, pre-COVID.

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“Children were somewhat spared from the brunt of the pandemic in terms of admissions to hospital,” Garros said. “We are not prepared at all in Canada for a significant surge in a pediatric infectious disease similar or close to COVID-19.”

All but the most urgent cardiac or other surgeries would have to be “ramped down or completely halted” to free those extra beds, the units reported, and the lack of surge capacity could also lead to difficult choices: who chooses which child to prioritize for potentially life-saving care?

Nationally, Canada had 3.5 intensive care beds per 100,000 children. While comparable to the U.K., it was less than half the U.S. ratio of eight beds per 100,000 kids. There were no PICUs in Yukon, Nunavut, Northwest Territories, Prince Edward Island or New Brunswick. Those provinces rely on neighbouring ones. Saskatchewan had the highest PICU bed capacity — 5.56 beds per 100,000 children 14 and younger.

Overall, a “sizeable proportion” of the beds we do have aren’t designed to isolate kids with respiratory viral infections, risking outbreaks and contamination of health-care workers during a crisis surge.

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Skeletal nursing staff, and too few respiratory therapists and doctors to staff those temporary surge beds “could be the most important ‘bottleneck’ in mounting a surge response,” according to the study.

Some ICU staff described spending hours on the phone with other ICUs in the province, in neighbouring provinces or outside Canada, to find a bed for a critically sick child.

During last year’s respiratory viral storm, teens were diverted to adult ICUs. Sick children were doubled up in single rooms. Heated trailers were set up outside packed emergency departments. Doctors were asked to practise outside their usual scope of practice. At SickKids in Toronto, the waitlist for non-urgent surgery swelled to 6,000 children.

“We really struggled with handling that increase in demand to provide care for the sickest children,” said Dr. Jesse Papenburg, a pediatric infectious diseases specialist at Montreal Children’s Hospital at McGill University Health Centre.

Little has changed since, Papenburg said. “In the last year, there really hasn’t been anything to increase the overall capacity of health care for children in Canada, certainly not to my knowledge.”

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“If you add on to that, what would happen if there would be a pandemic?”

“We need to increase space in pediatric emergency departments, increase the number of inpatient pediatric beds and the number of ICU beds,” Freedom said. Community pediatricians need to be better supported to provide acute care for kids who don’t require emergency care, he said.

Some efforts are underway to strengthen Canada’s ability to respond to future pandemics. A new federally funded research network was created, with the immediate goal to study the impact of COVID-19 on kids, and the unintended consequences of lockdowns and other restrictions. The longer-term goal is to develop the infrastructure needed to get studies in children up and running faster in Canada “if there was a challenge that required prompt attention,” Papenburg said.

“Obviously, a new infection would be number one on that list.”

In Canada, most kids who need emergency care are cared for in general hospitals, and not children’s hospitals. Through an app and website, another network provides step-by-step guidance on managing specific conditions. “What is this? Bronchiolitis? Asthma? Croup? What’s the best treatment for this kid — how sick are they,” said pediatric emergency physician Dr. Terry Klassen, scientific director of the Children’s Hospital Research Institute of Manitoba.

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Other researchers have begun assessing emergency rooms to determine just how ready they are to treat children. Do they have the appropriate staff, equipment, procedures and supplies?

Critically sick children treated in emergency departments with high “pediatric readiness” scores have up to a fourfold decreased risk of dying. “If (EDs) are ready, they’ll do a better job, and the kid has a higher chance of making it out of there,” Klassen said.

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