Thread by @jeffgilchrist

Children dying from Strep throat and other immune consequences

This virus season has been like no other with high hospitalization rates from RSV, Influenza and now more children are dying from Strep A bacterial infections. This long thread looks at what might be going on.🧵1/

So far in the UK, five children have died in England under age 10 within a week of diagnosis of invasive group A strep (a bacterial infection) and one 7 year old child in Wales ( bbc.com/news/health-63… ). H/T: @MeetJess 2/

The rates of invasive Strep A in children age 1-4 is 4.6x higher and age 5-9 is 3.7x higher than pre-pandemic 2017-2019 seasons according to the UKHSA. A 9 year old Canadian girl also recently died from a bacterial infection ( facebook.com/chrissy.hollin… ). 3/

Normally most infections cause mild illnesses but this bacteria can also cause scarlet fever ( nhs.uk/conditions/sca… ) and in rare occasions infect the lungs and bloodstream which needs urgent treatment and can be life-threatening. 4/

The bacteria can easily spread between people. This kind of infection is typically treated successfully with antibiotics but currently many places, including in Canada are facing antibiotics shortages so the necessary treatment may not be easily available. 5/

The UKHSA is advising people to call 911/999 or go to Emergency if your child is having difficulty breathing, there are pauses when your child breathes, your child's skin, tongue, or lips are blue, your child is floppy and will not wake up or stay awake. 6/

Why are serious Strep A bacterial infections worse this year than before the pandemic? Dr. David Fisman points out that surges in viral respiratory infections can lead to downstream surges in invasive bacterial disease (

https://twitter.com/DFisman/status/1599014102587781120

). 7/

His group has demonstrated this with influenza and pneumococcal disease ( jamanetwork.com/journals/jaman… ) and also a 4.3x increased risk after RSV and 2x increased risk after influenza activity for meningococcal disease ( pubmed.ncbi.nlm.nih.gov/21103353/ ). 8/

It isn't just bacterial infections that are on the rise but fungal infections as well where in India more than 4,300 COVID patients died after fungal infection (

https://twitter.com/jeffgilchrist/status/1587063576434466817

). 9/

The WHO warned in October that the risk of fungal infections on humans is skyrocketing especially from one called Candida albicans which is yeast that is responsible for infections like thrush and vaginal yeast infections ( my.clevelandclinic.org/health/disease… ). 10/

Can viral infection also impact your ability to fight off Candida fungus? It turns out that COVID-19 impairs the immune response to Candida albican including showing signs of T-cell exhaustion ( frontiersin.org/articles/10.33… ). H/T: @fitterhappierAJ 11/

Viruses have been found to have detrimental effects on the immune system before. "Widespread vaccination against measles can protect communities from a wide array of other viruses and bacteria by preventing 'immune amnesia'..." 12/

" — an unusual measles side effect scientists now think drives epidemics of other illnesses." ( cbc.ca/news/canada/lo… ). H/T: @MeetJess 13/

Measles has the nasty ability to alter the immune system itself to forget every single pathogen it has ever encountered (your immune memory) like rebooting your system as if you had never been exposed to a microbe or infection before. 14/

Most people who die from measles actually do so because of secondary infections. The virus binds to your immune memory cells and eliminates them, destroying B-cells and reducing the diversity of non-specific B cells ( pubmed.ncbi.nlm.nih.gov/34129794/ ). 15/

Another outbreak called "tomato flu" with over 80 cases mostly children under age 5 has been spreading in India which causes high temperature, intense joint pain, and rash where painful blisters can grow to the size of a tomato ( theconversation.com/tomato-flu-out… ). H/T: @CrabbBrendan 16/

After samples were analysed the virus was identified as coxsackie A16 which is the same virus that causes hand, foot, and mouth disease. It turns out this is not a new disease at all but the virus is now impacting children very differently than it used to. 17/

Scientists and doctors have noted that viruses have been doing strange things since the COVID pandemic started, such as typically winter seasonal viruses spreading in summer 2020, and a mysterious outbreak of hepatitis in children in 2021. 18/

Public Health Ontario (PHO) this past summer warned that COVID-19 infection can cause immune dysregulation. "A potential increase in acquired impaired immunity in the Ontario population..." ( publichealthontario.ca/-/media/Docume… ). H/T:
@lisa_iannattone 19/

"... could have significant impact on the incidence and associated burden of infectious diseases (e.g., high viral loads, increased antibiotic use and resistance) and other conditions in the longer-term." (

https://twitter.com/jeffgilchrist/status/1581963412518580224

). 20/

Besides potential immune dysregulation, COVID-19 infections have been found to cause damage to the lungs in children even with mild infections more than a year after infection (

https://twitter.com/jeffgilchrist/status/1581963424317132800

). 21/

Even the recovered kids still have measurable lung damage, and only 1 child in the study group had been vaccinated so it is not the vaccine causing the issue ( pubs.rsna.org/doi/10.1148/ra… ). 22/

It would not be surprising then that children previously infected with COVID that still have lung damage may be at higher risk for severe disease from other respiratory infections. If immune dysregulation is also happening, the risk could be even higher. 23/

What are we seeing so far? Pediatric hospitals all over North America and many other parts of the world are currently overwhelmed with severe cases of RSV and Influenza. 24/

The children's hospital in Canada's capital has recently had to request help from the Canadian Red Cross to support patient care where the ER recently saw 218 children with 11 waiting for a bed and critical care units operating at 130% capacity ( ottawa.ctvnews.ca/cheo-to-receiv… ). 25/

Not just hospitals, but ambulance services are also frequently running at "Level Zero" when no ambulances are available to respond. 26/

This tragically happened in Ottawa during October when a 911 call was made from an elementary school about an 11 year-old girl with no vital signs during a Level Zero who was unfortunately later pronounced dead after being transported to CHEO ( ottawacitizen.com/news/local-new… ). 27/

This is the new normal of living with infectious disease and not having measures in place to reduce the risk of infection during respiratory season when community transmission is high. 28/

From January 2022 to Sept. 23, there were 1,294 Level Zero events in Ottawa and paramedics spent 52,000 hours waiting to offload patients to hospitals that didn't have enough beds. 29/

The latest Canadian FluWatch data shows pediatric hospitalizations just for influenza are skyrocketing, and many times higher than the average number of hospitalizations from the 2014/2015-2019/2020 flu seasons before the pandemic ( canada.ca/en/public-heal… ). 30/

Wastewater tracking in Ottawa, Canada shows Influenza A levels are still increasing and RSV levels are still high ( covid.gilchrist.ca/Ottawa.html ). 31/ Click "Show replies" 👇 to continue reading thread.

We have lots of Influenza A, RSV and Strep infections happening now, much more than we used to see pre-pandemic, and enough to overwhelm pediatric hospitals in many locations. 32/

This time last year only fairly small percentage of kids had been infected with COVID-19 but seroprevalence data is now showing that in some places 76%+ of kids had been infected by summer so likely even more by now ( medrxiv.org/content/10.110… ). 33/

Dr. Lisa Iannattone points out that studies before the pandemic had already found kids with recurrent Strep A infections had reduced and dysfunctional B and T-cells in their tonsils (

https://twitter.com/lisa_iannattone/status/1598901324409470977

). 34/

Another study found COVID virus can be a reservoir in the tonsils and adenoids where it was detected in 25% of asymptomatic kids including infected immune cells such as dendritic, monocytes, B and T-cells ( sciencedirect.com/science/articl… ). 35/

Some people keep insisting that lockdown and lack of exposure to virus pathogens is causing these children to have more severe disease now. The evidence keeps mounting however that viruses including COVID-19 can cause immune dysfunction and damage in some of the population. 36/

Even if that percentage is relatively small, since so many people are getting infected, it is enough to overflow pediatric hospitals. 37/

Dr. Leonardi points out, 7 months after mild COVID infection, pDendritic immune cells were still wiped out (vs Healthy Donors HD in graph) which are responsible for making Interferon (IFN-A) which is critical to reduce RSV infection and severity (

https://twitter.com/fitterhappieraj/status/1592276788016971776

). 38/

Sure enough a different study found that COVID-19 could be a risk factor for RSV infection as 19.2% of RSV infected children in 2022 had documented prior-COVID infection compared to 9.7% of RSV uninfected children ( medrxiv.org/content/10.110… ). H/T: @GreeceLck 39/

Hospital admissions for RSV in Denmark really highlight that not getting exposed to RSV when very young and delaying that exposure is actually a benefit. (

https://twitter.com/lisa_iannattone/status/1597246724032303104

). 40/

Last year there was quite a large RSV wave and lots of kids were exposed, it was the year before that (2020/2021) that RSV was mostly non-existent. 41/

Benedict Barclay also points out that while the majority of those admitted to hospital for RSV are young children, this RSV season is also unusual in that there are also a relatively high number of hospital admissions for those age 45+ as well (

https://twitter.com/BarclayBenedict/status/1597247125997309952

). 42/

You can see from the graph the number of newly admitted patients per week for age 45-64 with this year's RSV season in yellow is more than 2x the level of previous years ( experience.arcgis.com/experience/220… ). 43/

Much higher levels of hospital admission for RSV this year can also be seen for ages 65+ as well ( experience.arcgis.com/experience/220… ). 44/

We saw in this thread that viruses can do nasty things to your immune system causing you to be more susceptible to other infections so it is in people's best interest not to get infected by them. 45/

Whatever is causing this massive increase in hospitalized cases from various respiratory viruses this year, the good news is that the protection is the same since they are all transmitted through aerosols. 46/

I have put together a thread on how these viruses transmit and how to protect yourself although it is too bad that governments and public health are not doing the same (

https://twitter.com/jeffgilchrist/status/1574709291520593923

). 47/

For people who want to share this outside of Twitter, he is a one page website link you can share: pingthread.com/thread/1599756…

If you are on or thinking about moving to Mastodon, this thread can also be found there: mstdn.science/@jeffgilchrist…

This text should go between 41/ & 42/ but got missed. The kids born in 2020/2021 who were not exposed to RSV during "lockdown" have been much *less* likely be hospitalized from RSV than a normal cohort so actually got immunity "credit" if anything (

https://twitter.com/BarclayBenedict/status/1597172291447971840

).41a/