Evidence Centre seminar: December 2021

DR GRANT: Just as a little summary of the presentation, I'm not planning to talk for terribly long but I'm going to cover three areas: child physical health, child mental health, and delivering child health, all in the context of the pandemic and the situation we're in currently. 

Now, as you can imagine, child physical health and child mental health, you could talk about those for a long, long time, so I'm just going to provide one example each of a communicable disease and a non‑communicable disease and talk about each of those to begin with. 

And for the communicable disease, I'm going to focus on acute respiratory infections.  COVID is primarily an acute respiratory infection so I think it's an important one to focus on, obviously, but also acute respiratory infections are such a dominant feature of physical health in New Zealand, certainly in young children.  I spend the majority of my inpatient time working with children and families of children who've got acute respiratory infections.  It's also a big issue for adults and the elderly in New Zealand. 

Acute respiratory infections are the commonest reason that children are hospitalised in New Zealand and they remain the main killer, still, of young children around the world, so a really important area.  New Zealand has been doing some very careful surveillance on acute respiratory infections for a number of years now and we were fortunate to have this surveillance in place.  Auckland became the southern hemisphere influenza surveillance site for the United States Centers for Disease Control in the early 2010s.  I think we got this contract because we have the best acronym: the SHIVERS project, Southern Hemisphere Influenza and Vaccine Effectiveness Research and Surveillance.  This is a project led by the ESR and with input from the University of Auckland, the University of Otago, Counties Manukau and Auckland DHBs, with surveillance for children hospitalised with acute respiratory infections at Starship and Kidz First Children's Hospital.  What I'm going to show you here is data from that surveillance from 2012 to 2015, just to give you an idea of what normal, pre‑COVID life was like in the clinical setting in these hospitals. 

These graphs here show the annual patterns of acute respiratory infection hospital admissions caused by any respiratory virus at these two hospitals from 2012 to 2015.  As you can see, we have this regular, annual, seasonal pattern of a big increase during the winter and spring months of each year.  That's for all acute respiratory infections.  Then the smaller and darker graph is for respiratory syncytial virus, which is the respiratory virus that causes the most ‑ but as you can see, certainly not all ‑ of the acute respiratory infections, but one for which a lot of work was being done on development of a vaccine prior to the beginning of the COVID pandemic. 

Just to give you an idea of using this same data, you can see that we had a fairly regular pattern there, a rate of acute respiratory infection hospital admission that didn't vary a whole lot from year to year, just a variance of around 24%, quite predictable and something that we could prepare for each year.  For example, we could increase the number of staff in the general paediatric service during those winter months to help us cope with the increased volumes. 

What really surprises me, alongside that, is the fact that for a long time now we've just tolerated this quite shocking variance in disease burden for acute respiratory infections by ethnic group and by deprivation status: diseases that affect Māori and Pacific children particularly, and diseases that affect children living in the more deprived neighbourhoods particularly.  Just a phenomenon that repeats itself year after year. 

Then 2020 came and the circulation in New Zealand of most respiratory viruses was just interrupted.  Our non‑pharmaceutical interventions, all of the social isolation, the distancing, the use of masks, the handwashing, all of those things had a dramatic impact.  What we showed in New Zealand, from a global point of view, was really quite significant.  The World Health Organization had not previously had these non‑pharmaceutical interventions as part of their pandemic plan but we were able to demonstrate the impact they had on virus circulation in New Zealand because we had this surveillance up and running, and they have clearly become part of the pandemic plan.  So some very important learnings from there. 

Because we had the surveillance in place, we were able to compare virus numbers in 2020 post‑lockdown, shown in the orange, with what had been our average experience from the preceding five years.  You really can't see any influenza because we managed to completely remove influenza circulation in New Zealand.  You can see these huge reductions for each of the respiratory viruses: the respiratory syncytial virus that I mentioned, human metapneumovirus, enterovirus, adenovirus, parainfluenza virus, and rhinovirus; rhinovirus being the only one that continued to circulate at all.  That, we believe, is partly because it's not quite so susceptible to detergents, to handwashing, as some of the other viruses.  The rhinovirus doesn't have an envelope around it, which all these other viruses do.  When you wash your hands with soap that disrupts the envelope, whereas with rhinovirus it was still able to circulate a bit.  But you can see these enormous reductions in circulation of these viruses: quite incredible. 

That translated to quite a remarkable reduction in acute respiratory infection hospital admissions that we saw in 2020.  Here's the data for children less than two years old at Kidz First Children's Hospital in Counties Manukau DHB in South Auckland.  You can see it just completely fizzled out in 2020: quite amazing. 

We have neighbours and we were interested to see what happened in Australia late in 2020.  This graph here shows the data for respiratory syncytial virus detections in Australia.  You can see they closed their borders here.  They saw this dramatic reduction compared to what their average experience had been in previous years.  But then in late 2020, during their summer, which is a very unusual time for this to happen, they had this dramatic increase in their RSV virus detections, with this being data from Western Australia.  What they also noticed is that the age distribution of those notifications had changed with a larger proportion of older children being identified.  What this indicated to them is that all of the children who would normally have been exposed to RSV in the preceding year having not been exposed, as well as all the new babies that were born in 2020, they had a much wider age range who'd never seen this virus before and who got exposed to the virus to the first time.  As with most viruses, the first time you get exposed to it is when you get the most severe illness and present to healthcare, hence the infection gets identified. 

This is a graph from New Zealand showing what happened in New Zealand during 2020 and then during 2021.  Here we have the start of the quarantine‑free travel from Australia early this year.  Here we have the first RSV notification in New Zealand early this year.  Then here we have this massive, massive increase in hospital admissions for bronchiolitis, which is the acute respiratory infection that's most common in young children and that is the one most commonly caused by RSV.  Just this massive, massive increase. 

This here shows laboratory data from New Zealand for 2021, shown here in the blue, compared to the average during the preceding years, shown there in the grey.  This is based upon laboratory surveillance by the ESR and by six hospital laboratories in Auckland, Waikato, Wellington, Christchurch and Dunedin.  Quite dramatic. 

What did this mean for those working in hospitals in New Zealand?  The effect was really quite staggering.  I've certainly not ever experienced anything quite like it.  Hospital admission rates to the general paediatric service, where most of these acute respiratory infection admissions occur, were just way higher than anything anyone had ever remembered in the previous several decades. 

Hospitals across New Zealand had to change what they did enormously.  All elective admissions were cancelled.  The surgical wards had to be converted to medical wards to cope with the numbers of children admitted.  Staff had to be directed towards caring for young children hospitalised with acute respiratory infections.  We had to have staff who normally work in all sorts of other areas coming in and helping in this area.  We had to group sick children together in multi‑bed rooms on the orthopaedic service, so you could imagine what that means.  The parents would be on mattresses either beside the bed or on the floor.  I expect you could count the number of hours of parental sleep during those admissions on - I don't know - your little finger, perhaps. 

Intense pressure on intensive care unit beds with the constant need for trying to find space for children, trying to decide whether there were any children who could leave intensive care so that new ones could arrive.  A really challenging time. 

Intense pressure on transfer of patients between hospitals.  Patients from around New Zealand, if they required intensive care, would get flown to Starship.  They would then leave Starship.  They can't go directly back to their referring hospital.  They would come to the general paediatric ward.  We would then be trying to transfer them back to their referring hospital at the same time that the referring hospital's trying to transfer children back to Starship.  It really was quite challenging. 

Alongside that, there were other children who needed care for other health problems, who needed, for example, to be transferred to Starship for investigation, possibly for cancer or for other problems.  Trying to find ways of doing that was also really, really challenging. 

Staff sickness.  A lot of staff got these infections, became unwell and had to stand down.  This created a lot of issues.

And fear, staff fear.  You've got fear in that you're worried about the number of patients that each person's caring for and you've got fear because you know that some of these patients will develop complications.  For example, if you have 100 children in hospital with RSV bronchiolitis, about 90 to 95 of those will follow a very predictable course where you can manage them with sometimes oxygen, sometimes increasing that to high flow oxygen, putting them on nasogastric feeds, stopping their sucking feeds and then following the course over a number of days of slowly getting worse but then slowly getting better. 

But the other 5% or 10% will do something different from that.  They, for example, as well as getting an RSV infection, will then get a bacterial pneumonia as a complication of that, and that can kill them.  Your job as the paediatrician is to make sure you find those five or ten children.  When you've got two or three times as many children under your care as normal, then that becomes very challenging because you know you can't see them all.  It requires you to be listening so carefully to the story being told to you by the person who's admitted them overnight.  You're looking for any inconsistency in the story, any hesitancy, any uncertainty.  Any time any staff member mentions they're worried at all about a child then you just have to find a way to see them.  You just had to hope that you were able to find them at these very challenging times. 

Moving now on to non‑communicable disease, I'm going to use overweight and obesity as the example of a non‑communicable disease.  Here's a list of non‑communicable diseases, which is what we commonly think of: the cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes.  Probably with the exception of cancer in most instances, all of those other non‑communicable diseases will occur as a consequence of overweight and obesity so I think overweight and obesity is a good measure to use. 

We don't have quite as good data on this as we do on acute respiratory infections and I'm going to be talking partly about data from other countries, then having us think what that might mean for New Zealand.  This is data on changes in the percentage of overweight and obese children in the United States during the pandemic.  It's based upon the Kaiser Permanente Southern California healthcare record data.  Kaiser Permanente is a large healthcare management organisation that's had really good data information systems for a long time now, so they're able to do these kinds of population studies quite well. 

Each child had to have had an in‑person visit with at least one body mass index measurement before, and one during the pandemic.  What they showed is that in the pre‑pandemic time period, they really didn't see much difference in the proportion of children who were overweight or obese by any of the three age group categories: 5 to 11 years, in blue, 12 to 15, in orange, or 16 to 17, in grey.  Not much difference in the pre versus the post.  But then when they looked in the pandemic period they saw that there had been quite an increase in the proportion of children who were overweight and obese, with this being most noticeable in the 5‑to‑11‑year age group, which is of great concern because the younger age at which you become overweight or obese the more likely it is to be a lifelong problem. 

Just to try to put that a little bit in the New Zealand context, I'm presenting here some data from the Whānau Pakari project.  I'm not sure if many of you are familiar with this project but this is a fantastic project established in the Taranaki DHB by Yvonne Anderson, who is a paediatrician down there, who is actually just about to leave New Zealand to take up a new role in Western Australia but hopefully will come back.  She developed a healthy lifestyles programme and recruited children in the region, with the programme seeking to enable access to healthcare for obesity‑related conditions for Māori and for rural‑dwelling children. 

This just shows the proportion of children referred to the Whānau Pakari service who had comorbidities.  You can see a wide range of abnormalities: headaches, visual disturbance, asthma, sleep‑related issues, prehypertension and hypertension, raised inflammatory markers, elevated serum lipids, and abnormal liver function tests, with between a quarter and a half of the children having any one of these and many of them having multiple of these problems. 

I'm sure many of you are familiar with this data showing that if a problem is a problem in the United States, which is the OECD country with the highest prevalence of obesity, then it's probably also going to be a problem in New Zealand, which is the country with the third‑highest prevalence of obesity in the OECD.  Those figures also apply to children. 

The data we have on child obesity in New Zealand is not as detailed as we have for acute respiratory infections.  We collect our data through the Ministry of Health National Health Survey, which is a rolling, ongoing survey.  The most recent data we have is from 2019 and 2020, which had showed that there had been a small reduction in the proportion of children who were obese.  This survey also has shown that in New Zealand, obesity begins in the preschool years.  We don't know what the data is for the current year but I would be very surprised if we haven't had a similar experience to what's been described in the United States.

Moving on now to child mental health, again an issue in which New Zealand's statistics are poor.  We have the highest youth suicide rate in the world.  Work has been done on the impact of social isolation and loneliness on the mental health of children and adolescents during the COVID‑19 pandemic.  This is a rapid systematic review that was published in 2020 looking at data on children less than 11 years of age and adolescents 12 to 18 years of age.  It showed that social isolation and loneliness increased the risk of depression and possibly anxiety at the time at which loneliness was measured, and also, subsequently, when you measured it anywhere between three months and nine years later.  It showed that the duration of loneliness was more strongly correlated with mental health symptoms than the intensity of the loneliness.  It showed that children and adolescents are probably more likely to experience high rates of depression and, most likely, anxiety during and after enforced isolation ends. 

The data that we have for New Zealand really just shows the tip of the iceberg.  We have data on parasuicide hospital admissions and we have data on admissions for children with eating disorders, both of which are red flags, they're canaries in the coal mine, if you like, and they give us an idea of what's going on.  This is data just published earlier this year looking at hospital discharge diagnoses, the number of children 0 to 14 years of age with a discharge diagnosis of parasuicide, which includes suicide and self‑inflicted poisoning by any of those substances, and suicide and self‑inflicted injury by any of those mechanisms.  Pretty drastic, devastating, horrible events to document.  The graph below just shows the trend over time that we have seen.  These were problems that were already increasing but we saw a 60% increase during 2021.  Really concerning. 

Alongside this, here's data looking at admissions of children and youth with eating disorders.  I'm only showing here the data for children 10 years of age and older.  That doesn't mean that we didn't have admissions for children younger than 10 years of age because we certainly have.  Our experience is that we've had younger children admitted and the children who are admitted have tended to be sicker.  You get admitted to the general paediatric service with an eating disorder if you are physiologically unstable, if your life is at risk due to your heart rate being very, very low, having a large difference in your blood pressure between when you're lying or standing, your blood sugar being low, or having a heart rhythm abnormality that puts you at risk of sudden death.  As you can see, we had an increase in admissions, both to the Child and Adolescent Mental Health Unit, but most particularly to the general paediatric service.  This would be apparent within days of a lockdown happening.  The most recent lockdown in New Zealand, in Auckland ‑‑ when was that?  In August I think it started.  I'm sorry, I'm having trouble remembering back.  Within three or four days of that lockdown happening, we had an increase in admissions of these children.  They're already in a precarious situation, just managing, and then you throw lockdown in and that just tips them over. 

Lastly, I just wanted to touch a bit on delivering child health because I think the delivery of child health has been impacted enormously.  I'm not sure that we'll ever go back to delivering child health in the way that we used to. 

One of the big things that's changed is that we now wear personal protective equipment in many, many of our patient interactions.  We have intense training on the donning and doffing of personal protective equipment to make sure you use it in a way that you get the maximum protection from it.  We have videos that we watch, we have practice sessions once a week, and we have someone observing you when you're putting it on, and particularly when you're taking it off, to make sure that you don't do anything where you might contaminate the environment.  You have to follow exact sequences.  You have to be so careful not to touch anything.  When, for example, you're taking your face shield off, you have to be so careful not to let it spin in your hand so that it could flick any aerosol out.  You just have to follow these processes really, really carefully, which is really hard to do when you're worried about all the sick people that you're looking after and how much time you have, and you're wanting to get to the bathroom, you're wanting to get a drink and all those other things. 

From a child's perspective, it changes things completely.  Children are frightened because, where everyone's dressed up like this and looks quite threatening.  You can't use your face, you can't use your facial expression.  They can't see if you're smiling.  You can't be heard properly.  You can't touch normally.  You certainly don't embrace people in the way that you did previously, obviously.  It's just changed your interactions incredibly.  The odd occasion when I have been asked to see a child and they're been able to come in the day stay unit because they've got some other, non‑respiratory problem, and you can actually see them without PPE on and interact with them normally, it's just unbelievable how different it is. 

It also influences staff behaviours in staff's attempts to reduce transmission.  Every room you're about to enter, you stop and ask who should go into the room.  Do I go in there with a junior doctor?  Does the medical student come in with me?  Should we all go in there?  We can't take the notes in with us.  We've got to be careful to remember everything that happened in the room.  All of that stuff goes on before every room, which just changes the dynamic enormously.  Inevitably, there are fewer staff interactions in each patient room and fewer opportunities, for example, for students just to spend time in the room with the families, talking and finding out about them and just interacting with them in a compassionate way. 

The interactions are different.  We had a recent example of a little child in hospital with an acute respiratory infection and both the child's parents were deaf.  You can't use sign language very effectively and the parents certainly can't lip‑read when you've got masks on.  It really does create all sorts of challenges.

As I mentioned, we've had this acute respiratory infection surge and we've had this mental health admission surge.  The two have happened at the same time and I don't think there could be two more extreme conditions, probably, to be trying to care for at the same time.  We've just reflected on the general paediatric service, the skillset that staff have had to learn, over the last 12 months in particular, I would never have imagined would be part of our working life. 

Nurses have to learn how to care for very physically unwell young infants on high flow oxygen, very technical intense care, after just having been verbally abused by very mentally unwell young people.  As I'm sure you know, any of you who have worked with young people when they're mentally unwell, they can be so vicious in what they say and that can be very hard to hear, particularly for younger staff members, and particularly when you're already very, very stressed. 

Staff are having to learn how to protect themselves from physical assault whilst caring for children.  Children, you imagine, with eating disorders are often tiny but my goodness me, they are incredibly wilful and have such pervasive and overwhelming thought disorder processes that their capacity to resist staff attempts, for example, to feed them though a nasogastric tube are just quite phenomenal. 

How to work with security staff when caring for children.  We have security staff on the ward the whole time.  The security staff workforce has expanded enormously and is a very caring and critical part of our healthcare team now.  We've had to learn how we all work together. 

I think the last thing to comment on regarding COVID is that COVID is phenomenal at identifying vulnerability.  The vulnerability of the families affected, that come into hospital, is quite incredible.  These are already families who are struggling, generally, families who have difficulty accessing healthcare, and they find themselves now in an even more challenging situation. 

We get children, for example, who are admitted to hospital because their parents are both in hospital with severe COVID and there's no one else to care for the children.  The children come into hospital.  They don't have an adult caregiver with them whom they know.  Many of the children may themselves be COVID‑positive, which clearly influences greatly the situation in which they're being cared for, where they're kept in isolation.  They require parenting, they require play therapy, they require input for their mental health much more than they require medical care, and all those things are very hard to deliver in the context.  We find we have to be working very, very closely with adult services.  We have a child admitted and you find their caregiver has a chronic illness for which they were seen in an outpatient clinic in the adult service two days previously, so you have to make sure that adult services know about this potential exposure and then can contact all the other adults. 

The process of trying to get a caregiver from home into care for the child who's in hospital with COVID is unbelievably complex and requires us to be working with the adult services, the community services and the ambulance services.  Just all the logistics around that inevitably require a lot of time. 

The rapidity with which our care delivery changes has been quite staggering.  We have negative pressure rooms in Auckland City Hospital and Starship Children's Hospital, and a number of other hospitals are building those currently.  You try and care for children with COVID in a negative pressure room.  A negative pressure room means that when you open the doors, the air in the room doesn't come out.  That's a good strategy for trying to prevent any infection in that room from leaving the room.  But we've only got have a limited number of negative pressure rooms and we've had two instances already where we've overwhelmed the number of rooms that we've had, and so we've had to then change the structure so that half of one of the wards becomes the isolation area.  It doesn't have that full negative pressure facility so it's not as good as negative pressure but it's what you have to do because it's your only option.  You have to continue to make compromises in what you do in order to manage situations, and the rapidity with which that changes is quite incredible.  We had a clinical meeting of the general paediatric service last Friday and our clinical director showed a picture of his feet, where he had put two different shoes on one day.  He said he wasn't necessarily surprised that that had happened but he was surprised that it took him until about the middle of the day before he realised that that's what he'd done. 

Lastly, I just want to touch upon the impact of the personal protective equipment that is being used in terms of what it's doing to the environment.  I mean, the volumes are just staggering.  We currently do not have a process where we can attempt to recycle this equipment.  There is work being done in this area.  Again, that team in Taranaki that I mentioned have also been doing this incredible project on whether you can clean and recycle PPE, so do watch this space, but this is a phenomenal global problem. 

Here's my one‑slide summary of what I've tried to cover today.  I've tried to talk about the impact of the pandemic on child health.  I've mentioned child physical health issues, communicable diseases and non‑communicable diseases. 

From a communicable diseases perspective, it's more variable and more extreme.  Whenever I do my weeks on call now I know that they will be more extreme than previously, they will go from having fewer patients than normal to having way more than normal, and that that will change very, very quickly.  It's way more unpredictable. 

From a non‑communicable disease perspective, we have more non‑communicable disease, it's more extreme, and I haven't even touched on the issues to do with people with non‑communicable diseases trying to access care currently, which is really challenging. 

Child mental health issues, more and more extreme and, as the literature suggests, likely to have an ongoing impact for some time after the pandemic and after any periods of isolation have been in place. 

Lastly, child healthcare delivery, which has become compromised and has become more challenging.  I think we almost reminisce on how easy we feel healthcare delivery was in years gone by, even though we know it was far less than perfect.  But goodness me, what a cakewalk that was compared to what we're facing now.