COVID-19 and Immune Symptoms in Kids
Welcome back to the healthcare triage podcast today. We're going to be talking to Dr. Jim would from Indiana. University School of Medicine. He's a pediatric infectious disease doctor. We're GONNA be talking about covert and some of the immune syndromes. We've seen in children who seem to have had it. This healthcare podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient CARE I. I School of Medicine is leading Indiana University's burst grand challenge, the precision health initiative with bold goals to cure multiple myeloma, triple, negative breast, cancer and charts coma, and prevent type, two diabetes and Alzheimer's Disease Jim Welcome. Thanks for for having me. So why don't you start by telling us a little bit about yourself? How did you get to be what you are? What do you do? Yeah, so I got interested in pediatric infectious disease, probably when I was a medical student, but Never really knew path. I was going to go down as I went through residency. I found all the cool cases happen to be kids that had infections at least to me, so I had two mentors in residency, and then decided to pursue a fellowship in infectious disease. I went to Vanderbilt University in had. Really good experience. There was some great mentors and just got really interested in both clinical aspects of it as well as the research. Aspects of infectious disease so when you talk about the research aspects. What specifically are you interested in? Yeah, so My interest is in kids that have invasive bacterial infections. That's kind of fancy words for kids that come in with bad kind of common infections of their bones and joints, pneumonia things like that caused by bacteria that often are treated. As. Outpatients in clinics, but sometimes get bad enough where they have to come into the hospital in us. Can you give us a little more information about that? Can you talk about like when you talk about research in that area? What specifically do you want to study that others have not before? Yeah, so things that I'm interested in our standing. Why certain kids get really severe disease, and why other kids don't get much of a have a pretty mild course of disease, and so one of the things that's really interesting to me is is figuring out. kind of markers and kind of clinical signs of which kids are at risk for really bad disease, and then using those markers and signs as doctors and clinicians to help target therapies and improve. Improve the way that kids are treated so one of the reasons we wanted to talk to you. Today was because everyone in the world is focused on the current pandemic and with a Vid, and although this doesn't seem to be affecting kids as much it's still is affecting kids, but before even get into that. Let's just start with in your experience. has this been a disease that seems to be infecting kids? Kids because you turn on the news and some people are panicked. Some people are not what's really going on. I think that you're right the level of panic in the level of kind of anxiety around this is super high and I think what we're seeing is that in general kids from the infection of covid in corona virus are really mildly affected in general, there most kids don't seem to be. Be Getting it in big numbers, and if they do most of them, handle it pretty well. Either have no symptoms at all. Our mild infection that said we have seen you know a handful of kids that have come into the hospital in Ben. Pretty Sick and certainly we've. We've had to take care of those kids as well, but overall kind of big picture. Kids seem to be less affected than adults do. So when they come in they, they seem to be very sick. What are they meeting with Cova? They're they're needing. Respiratory support so that they're needing oxygen. They're needing help breathing. The majority of kids are coming in just having a lot of issues with with respiratory things, especially chest pain in trouble breathing. Are these otherwise healthy kids are the kids who seem to have other come. kind of seeing a little bit of both for the most part. They're healthy kids. The ones that we've seen in particular are pretty healthy teenagers. In general, a Kinda you know anywhere from ten to a eighteen nineteen years of age but really we kind of a mixed bag of kids are pretty healthy, otherwise as well as some that have a little bit more health issues. Do you have any sense of whether? It's that kids are not being infected as much as adults are. Is it just that they're most of them? Don't even notice or just her handling. It well yeah. I. Think that that is a really good question in a bit of a hot topic right now. I think that we don't really know exactly. Why some kids are getting? Getting severe not an end, and why kids as opposed to adult I mean certainly when we know what other respiratory infections young young kids, a kind of the extremes of ages usually are most affected. That doesn't seem to be the case with this. It seems like in general. Kids don't tend to build quite as much of this big inflammatory response that we're seeing an adults. So I think that's interesting. I'm not sure and correct me if I'm wrong, but I'm not sure that everybody understands that it's not just getting the virus that is dangerous. It's in many ways. The body's response can sometimes be so severe and trying to combat the virus that the immune response can actually become dangerous. Yeah, that's definitely true, and that's something not necessarily. NECESSARILY UNIQUE TO CORONA VIRUS although We're really seeing quite a bit in this. where the actual infection itself can be, it can be severe, but more than anything. oftentimes, it's that it's that revved up immune system and inflammation that the body makes that really affects the rest of the body in a particular with this disease. It seems to really affect the lungs in. People that are severely affected. One of the things that's been going around recently is that people are becoming more and more concerned about an immune response issue that seems to be affecting children were seeing in New York, and before we even get into that people are likening this to a Kawasaki is like syndrome, so bring to that? Can you talk a bit about what Kawasaki Syndrome is shore? Yeah, so Kawasaki. Kawasaki Disease and I should have probably mentioned. This earlier is another area of interest of mine in terms of treatment of kids with sake season. We have studies going on at you. Look in Riley. Looking at which treatments are most effective for these kids, but in general Kawasaki Disease is something that was described I in Japan quite a while ago by Dr Kawasaki and it's. For lack of a better term, it's a inflammatory disease or syndrome that seems to affect kids mostly school age. That's triggered by something. We don't know exactly what triggers this inflammation response. There's been lots of studies and lots of hypotheses about what the actual trigger is, but no one's actually found the one trigger. If there is one, there's likely multiple, but it seems like in kids that are genetically. Genetically Susceptible to this syndrome. There's a trigger in the environment which Kinda sets off a cascade of inflammation in their body. The way that we see these kids as they come in with prolonged fever so fever for at least five days they come in with rash. oftentimes readiness in their is can jump device they'll have hands and feet are swollen, cracked in swollen lips, and sometimes they'll have. have big lymph nodes. It's Kinda diagnosis that we have to make just putting all the symptoms and signs together. It's this kind of inflammatory syndrome that kids get. It really seems to affect their blood vessels a good deal the things we love most about and worry most about the blood vessels around the heart. The coronary arteries as we know that those can be severely affected in Kawasaki. Kawasaki Disease So it's this vascular in just big inflammatory response that we seen Kawasaki Disease What Causes Nobody knows there's a lot of work that's been ongoing for a while looking to take on figure that, but it seems like most likely kids that have a genetic predisposition to this get triggered by something and whatever that something isn't. It's probably multiple. Something's they they kind of go down this. This pathway and how to retrieve, so it's treated with a couple of different medicines, one cold Ivig that is a bunch of pooled antibodies, and what that really does is kind of tamp down the immune system. So this is a very inflammatory condition. The IVIG we think works kind of decrease that inflammation in especially protective for those blood vessels around the arc. We also treat it with aspirin so. So. We don't generally give kids. especially young kids aspirin because of risk of of rice in your own, but in this disease in particular, we give kids aspirin because it's been shown to help. decrease their risk of having a clot in their heart, and it also helps in high doses with the inflammation so I mean it sounds serious, is it? It can be serious, especially untreated we. We recognized early. The risk of complications, especially with heart complications is pretty low like less than two percent on when it's treated early if it goes undiagnosed and not treated the risk of coronary artery, inflammation goes way up in so it can be very serious especially, if not caught, but if treated in general, it's it's a very treatable disease. What are some of the research that you're doing? Doing and Kawasaki Disease Then Yeah so it's pretty well established as I mentioned that the treatment for Kelly. Sake is I've E. I, G. AN ASPIRIN. That's pretty much what every kid across the US gets when they had the diagnosis of Kawasaki Disease We know a subset of these kids, probably about fifteen twenty percent, or so end up having symptoms after that first initial treatment so IBM. is as it sounds like an ivy treatment that we give over about twelve hours and about twenty percent of kids. They have fever that POPs up after giving the IVIG. We watch him for about two days after giving them the treatment to make sure that they're inflammation is down a mixture. They don't have fever and the kids that have fever again. There's really not a good or established treatment regimen for those kids, and so what we're looking at as part of a big group of senators across the country is what is the best treatment for kids that have what we call refractory Kawasaki? It is our fever. After that initial treatment were comparing different treatments, one a second dose of E. G. versus a medicine called inflicts. Both of which are pretty potent at decreasing that inflammation. talked me a bit. Then about this this immune syndrome, we're seeing with kids with respect to Kovic and why it should or should not be compared to Kawasaki Disease Yeah. So reasons that it even has come up in terms of the discussion of Kawasaki Disease is just because of the remarkable overlap symptoms and a lot of kids. What we found. Is that in places where Kawasaki Disease We kind of have an idea of the level or Or the number of kids that get admitted to children's hospitals with Kawasaki Disease, and what we started to see these big numbers and clusters of kids that were coming in with a lot of the symptoms that looked like how Asaki disease, so high fever, rash, conjunctiva, itis, crack pans are cracked lips swelling of the hands and feet. All those things and people started saying. Wow, we're seeing these big clusters of kids with Kawasaki Disease. Disease, but what the link was was that all these kids seem to be or most of them, anyway had some association with covert nineteen, so they either had disease, or when tested for antibodies or it look like they had passed disease for it and so that then people started to think okay. Is this an inflammation syndrome that's associated with covert in. That's kind of where we're at right. Now is seeing kids that have had. had this either exposure to or pass or in the minority of kids, present infection with covid nineteen they having this big inflammatory syndrome. The has a lot of the same features as Kawasaki. There are differences It's not exactly the same or seeing kids that are a bit older. The average age is somewhere between eight to ten wearing. Kawasaki. It's a it's a lot younger usually, it's less than five in most of the kids. The inflammation markers were seeing are a little bit different as well in this in this covid related inflammatory syndrome. So are all the kids who've had this syndrome. They've all had covert. Most of the ones that are tested I think some of them you know as as you probably know, and as a lot of folks. No, the testing isn't the best in so Roy. Tom, in the kids that are negative. Negative We're still kind of pursuing that workup and looking to see if we can retest them and see by and large, the vast majority are associated. How common is this? It's rare you know it makes the news because it's a, it's a disease, it's affecting kids, and it's Cova nineteen but in general. This is a rare condition. This is something that a lot of states are seeing but. If we think about how many kids are likely have been infected the course of the whole population This is this is a pretty rare entity. So why do you think then it's making so much news well? There's probably a few different reasons, but. Any time we see a disease that pops up kids it. It gets everybody's scared and rightfully so from the get go with Covid we've said kids are. Not generally severely affected. We've said that Luckily you know we're not seeing big. Numbers of kids admitted to the hospital and boom. We start seeing these kids being admitted with this syndrome, and so even though numbers are low anytime. You have a serious infection requiring kids to be in the hospital especially in the ICU. The hospital it's a big deal, and and it makes headlines. ARE THEIR KIDS IN INDIANA. Who've had this? We have seen kids across the state of Indiana that have this here at. Riley we see a lot of them were actually just talking today? Amongst our group about discussing with you know all the other hospitals across the state to kind of get a good idea of the numbers of cases, the State Department health is collecting that data, but certainly to getting more information for all of us. is also helpful, and what's been going on a New York. It sounds like it's been much worse. Yes, so New York just most likely, because of how Severe Cova nineteen was there. More kids were exposed, and so therefore more kids have this. This link of of having disease and what we're seeing is on average. It's seemingly around for weeks or so after they were initially exposed where they're getting this inflammatory syndrome, so yeah numbers in New York are a lot higher than anywhere else in our country, and that likely because of that exposure to we have to do anything different for the Mercer. Just wait and see so there's been a lot of talk about that, too, and were almost on daily calls with with our critical care, folks with our rheumatology folks with lots of people that treat kids with a lot of inflammation, and were establishing guidelines kind of locally as well as nationally how to treat these kids. The the vast majority of these kids we're treating them very similar to Kawasaki disease so almost all the kids in our hospital, and a lot of the hospitals across the country are getting that same IVIG medicine thirty of them are also getting aspirin and then depending on the situation, some of them are getting other inflammation medicine, anti-inflamation medicine, so steroids and other kind of potent inflammatory medicines to help. Tamp down that response. Is there anything people can do to look for this or prevent it? There's. There's nothing that we know of that can prevent it than obviously trying to limit exposure to covid nineteen so kind of keeping with that social distancing listening to all the you know the health experts in the area about what ways to prevent getting over nineteen, but in general. There's not really a good preventative way to to deal with it. I think the the big thing is for for families in parents to look out for. Is that anytime? Their child has a prolonged fever and that's kind. Kind of a tough thing I realized because a lot of things can gazyeta fever for a while, but this is fever. That's kind of unrelenting three four five six days. That alone should kind of make you start to want. Call Your doctor and just ask you know. Get at least being communication but if you start pairing that with things like rash things like redness of the is one of the big things we're seeing to is abdominal pain so real severe abdominal pain kids along with these symptoms. Symptoms those are kind of some of the distinguishing feature, so one of those on the surface may or may not be the syndrome. When you put all those together. It's certainly something to talk to to the doctor about. Does any of this change your thoughts about how we move forward? Yeah, that's a good question. And I would say that it doesn't really change. the thoughts about how we should move forward to me. Any policies that were put in place should be protecting kids anyway right in so. Despite kids, not having severe infection in general with covid nineteen. Wanted kids to get exposed, and and you know because of that risk of you know we don't know who's GonNa have bad disease so to me. This is just another piece of the puzzle to say okay something to look out for, but I don't really think that. This changes how we move forward. Are there nationwide network set up to watch for this a Sunni Organization for that there are multiple kind of different study groups and organizations that are looking into this Again as part of this network of centres is looking at and studying Kawasaki Disease We. Just recently got information that will be doing a study kind of tracking this, and so we'll be looking at the number of kids that come into each center with with this syndrome. What their clinical features are so kind of what their symptoms are as well as their labs as well as will be looking at some of their bloodwork to look to see what you know some of the features of this syndrome. How is testing going for covert in general, do obviously he's quite a bit depending on where you are I would say in general, we are getting better. It is certainly not great in. It's not where it probably needs to be. In terms of you know antibody testing as well as that nasal swab testing things are getting better and I think that our capacity to do these better, and we're figuring out which tastes are good and bad or better or worse, All of that is getting better, but we're not where we need to be. I know you're actually conducting a study right now. Looking into how prevalent this could you talk a bit about that? We were super interested. As Pediatric Pediatricians and Pediatric Infectious Disease Physicians to figure out within our community and kind of thinking of extrapolating this to the vigor community. How many kids and families are affected by cove nineteen that have no symptoms at all, so we were able to partner with all in for health network, which is a research network within Indiana and within the school medicine to recruit families in the community. And what we're able to do is bring testing kits to these families, so they didn't have to testing center, and so throughout our area around Indianapolis. We brought testing kits and we were able to do nasal swabs on families, especially focusing on kids to figure out how many kids were actually carrying covid nineteen without any symptoms. When are the results going to be out for that? We've wrapped up. This study were hopeful to get the results in the next couple of weeks to think people be surprised that it's more common or less common than than they think, I think, people will likely be surprised that it's less common than they think I think as we hear more and more again, we hear lots and lots about it. The expectation is that most of the population is. Is already been exposed to this and we're covered and we're good, and we should just back on with our lives, but I think that that's really unlikely to be the case. Certainly there is a number of people that had a symptomatic infection or had cova nineteen without ever knowing it, but I think the numbers are likely going to be a lot lower than we think they are. So what do we do about schools in the fall? Yeah, WE GONNA how we're going to reopen school and have it be safe that again is is the million dollar question that we always know and there's not one right way. I don't think I mean it's really gonNA. Be Dependent on. What the local prevalence is into partnering with a local health departments and understanding where we're at in terms of this disease, kind of in the community is going to be super essential to knowing when it's safe to to go back to school when we need to pull back a little bit I mean. Completely understand and recognize that getting kids back to school. Getting them back into the routine is really important Um. We just need to be very careful about. How do that and I? Think that what? That's gonNA mean is going back to school at times in person. If we start to see a big spike in the community, pulling back a little bit and potentially going back to learning or decreasing the amount of students in each school system is going to have to be real thoughtful how they do that and also making sure I think that each school has the resources they need to be able to do that. Is Super Important? Do you think that's going to happen. I mean it's it's funny. 'cause I totally agree I. Think there's so many things we say we need to do, but I can't even imagine how schools would make some of the changes. We've already just told restaurants and businesses they need to. Do you have your capacity? We can't just do that in school or space. Kids out every six feet. How do you do that in his? So are they just GonNa, not or do you think that they're really going to have to make a swing at this? At every single level I think being apparent of a foreign six year old the idea of keeping them. Separated and or masked throughout the day is. Completely unrealistic I don't think that's GonNa Happen. It's great on paper. A lot of things are great on paper, but practically what are we going to do? I think that you know potentially in older kids in high school. Maybe but again there have this feeling of invincibility, so they're probably not gonNA listen to so I think it's really just going to be having to pay attention to what is going on within the community I. Don't know that going half half the students coming in is. A Realistic Way to get around this I. Just it's a really hard logistical thing to do see. This is where take I'm sort of fascinated because I feel like this is a solvable problem like with with enough time money and effort. We could do this we could. Have sent some kids in the morning. Some kids in the afternoon. We could you know send some kids Monday Wednesday? Friday some kids Tuesday Thursday. We could you know figuring out ways to have every kid eat at their desk. The food will be made in. The lunchroom brought to them we could. We could figure out ways to stagger bus. Systems like we could do. It would require money. Don't get me wrong, but we could, but it would require massive amounts of planning and thought and I'm seeing no one do that yet. Do you think that's going to happen or are we going to bury our heads in the sand and then freak out an August and then just throw the doors? Oh. Exactly what you said is a realistic thing, but that that money is you in that whole. How much time that will take if this was something? They could do in a year from now. Heke I think it could be done, but just with school abs, you know in some places the both the restart up in a couple of months. It's going to be. It's GonNa. Be a tough tough sell, thanks. So. Do you think that there's going to be long-term changes to the ways we all behave because of of all of this or do you think will will retrench will someday figure this out, and we'll go back to normal I think there will be a new normal for quite a long time. How long who knows I mean? This is not the first pandemic the world our country has. Has Seen Right and we've all forgotten a not not that most of us were alive back then in those other things, but a lot of the lessons learned and a lot of the things that were done. had had faded away now. How long that took hard to say, but for a long time. We're going to be doing things differently. We're going to be thinking about. Where we go, who we you know how many people are around? But there will be you know there will be a sense of getting back to normal at some point is just that how long man I don't know. Where do you stand on vaccine? Optimistic or pessimistic I am optimistic. Vaccine will be produced in available I am not optimistic. That is going to be. BE A cure all for everybody, but even kind of decreasing. Some of that is being able to provide protection for those at most at risk I think is super important, and I am optimistic. DOTS now the timeframe that's been laid out for that probably unlikely. I mean you know the quickest vaccines that were ever made. You're talking about years, not months and so. It's it's pretty unlikely to me that we're going to be seen vaccine in two thousand twenty now they are going through trial and error accelerating fast, and so that's great, but to me. The safety of these vaccines and the improving the efficacy is really super important and I want. I want to make sure those things are safe and I am a very pro vaccine person. But making sure making sure they're effective in more than anything. Making sure they're safe is going to be important before we roll them out. We talked of all. I agree with you I think there's very little chance we see one in two thousand twenty, but what I think a lot of people don't grasp is there's a difference between the day that the vaccine is approved, and when everyone's going to get one I, mean realistically. How quickly can we make? Billions of doses of vaccines and then get them out to people. In a lot of that will have to do with what vaccine actually makes it to market right, and so there are some vaccines are able to be ramped up pretty quickly in again not days, but like pretty quick, there are other vaccines that take a heck of a lot longer to make, and that just depends on the technology that's needed to make these vaccines and so. I think it's you know it's possible that these things can be ramped up again on the order of like months weeks and months not days but a lot of it will depend on which vaccine actually makes it the market in which technology that we're using. How would you prioritize? WHO GETS THE VACCINE? I yeah, that's another great million dollar question. I think we look at the you know the people that are most severely affected with the disease in a and that's unfortunately not as necessarily fair way to do things, but unfortunately when in a lot of things in medicine when we are pressed with making tough decisions in tough choices, I think one of the important things is making sure that we are protecting the people most vulnerable, so high risk populations, and especially those folks that. That are on the front lines as well as folks that are at high risk for getting severe disease probably should get get the vaccine I. So, what Lessons Have you learned from the syndrome? Yeah, so there's been a few lessons that I've learned in kind of I. Think the whole medical community, learning and one. It's that when a new disease comes out Even when we think we have a handle on what's going on. We always need to be on the lookout and kind of looking for new things associated with it. In general, the medical community has done an impressive job of coming together to send that signal alert of hey, we're seeing something funny here and We want everybody to know about it. Some of the folks in England were the first to report this and it and it started popping up in the US, and in everybody kind came together, and we like I said we've been on calls. Conference calls. With folks across the country, the CDC and everything to really delve into what's going on, and that's been an amazing thing just as open line of communication and kind of breaking down some of these silos that traditionally the medical community has had have been really impressive. The other thing is that improbably probably most important is that although it's a new syndrome are doctors, and especially our ICU folks in critical care folks. They're really good at taking care of sick kids, so they know how to take. Take care of kids with complications around their heart or with their lungs, and so you know. I think that it's reassuring to me that although this is new syndrome, the symptoms and signs are very familiar to folks, and they know how to treat it, and we know how to handle it, and so it's been a really interesting thing to see unfold as we've kind of taken care of these kids as how we're all collaborating together and working together to share information and really treat these kids well. It's important work. Jim. Thanks so much for joining us. Thanks for having me again this. PODCAST is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana beyond by promoting innovation and excellence in education research patient care.