COVID-19 rate in kids may be higher than known, experts say, and until they can be vaccinated, pandemic may linger

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Originally published April 25, 2021.

Riley Wells was diagnosed with COVID-19 four months ago. Its aftereffects — constant pain, numbness, weariness and muscle spasms — may be with the 15-year-old for years.

The mild bout of COVID-19 unleashed Parsonage-Turner Syndrome on the high school freshman. In the simplest terms, it stops his nerves from communicating with muscles. Doctors warn it could take months for the "pain phase" to end, and years for full recovery, his mother, Jennifer Uile-Wells, said.

"A lot of people don't understand what it's even like, especially how painful it is," Wells said.  "I can go through the day pretending like there's no pain and walking around like there's nothing happening. But it hurts pretty bad to do pretty much everything."

Throughout the more than yearlong pandemic, data on kids and the coronavirus has been murky. While it is clear that children can become sick — and, rarely, become very sick, or worse, from COVID-19 — they generally fare better than adults. Often, they may feel no or minimal symptoms, according to doctors, which carries its own risk as their infections go undiagnosed.

But cases of COVID in kids have shown some spikes and have increased recently, experts said. Current COVID-19 vaccines have been approved only for adults or older teens. Until vaccines are authorized and widely administered to young people, their undiscovered infections may pose a hurdle to breaking through the pandemic, they said.

"We're seeing more cases in children, and this is actually something that we're seeing globally. It's not just Iowa, it's not (just) my county or your county," said Dr. Melanie Wellington, an infectious disease specialist with the University of Iowa Hospitals and Clinics. " And there's a lot of debate right now as to the cause."

Comparing viral activity now to earlier in the pandemic isn't possible because of how different the state of the pandemic is in Iowa and the world, Wellington said in an interview. But young people's COVID cases could make the pandemic last longer.

"I do believe that if we don't eventually immunize a large portion of our children, it's going to be extremely difficult to get past this pandemic," said Dr. Joel Waddell, a pediatric infectious disease specialist at Blank Children's Hospital. "Kids make up a large portion of our population, and we need herd immunity."

'The cases that we detect in kids are the tip of the iceberg'

This time last year, tests for coronavirus infections were hard to come by, and "children were an incredibly low priority for testing for good reason," Wellington said. Then, as now, older people and people with underlying health conditions were most at risk for the most severe cases of COVID-19. 

Now, testing is widely available, and everyone 16 or older qualifies for a COVID-19 vaccine, potentially suppressing the ratio of adult-to-child testing. 

As of April 15, Iowans 17 or younger accounted for about 10.7% of all cases in Iowa, or about 41,668 confirmed cases, according to the American Academy of Pediatrics. The increasing proportion of children testing positive became most noticeable in March, Wellington said, but seems to have been tapering off.

Children accounted for about 4% of all positive tests in the past week, or about 127 children out of more than 3,100 new cases, according to the Iowa Department of Public Health. The department's coronavirus website does not provide historic infection rate data broken down by age.

The COVKID Project, which tracks cases in youths nationwide with weekly data collections, shows positive coronavirus tests in Iowa largely lining up with prior surges. That includes a massive surge in November, when the positive cases among Iowa children reached 84.9 cases per 100,000 people aged 0-17 in Iowa, followed by an uneven recovery.

After another spike in January, positive cases largely tapered off until reaching 7.8 cases of youth infections per 100,000 children on March 21. They nearly doubled the following week, and sat at about 10 cases of young people who tested positive per 100,0000 the week of April 16. Nationally, daily case rate has increased from about 13 children per 100,000 in mid-March to 18 per 100,000 in mid April.

Beth Pathak, an epidemiologist who runs the COVKID Project, noted that while Iowa's trajectory among children isn't terrible, it is concerning in neighboring states like Minnesota. 

But testing may not show the whole picture. Since children are more likely to show no symptoms, or symptoms mild enough that they can be mistaken for a minor cold, seasonal allergies or a mild headache, they may not be tested for the virus. 

"The cases that we detect in children are the tip of the iceberg," Pathak said. "We have a huge number of undetected asymptomatic cases in kids. On the one hand, it's not a problem for the individual child because the child is not getting sick. So, fine. But for the community and for controlling the pandemic, it's a big problem, because we know for sure, the evidence is very clear, that people who are infected and asymptomatic, people who never get sick, can still spread the virus to other people."

She added that while many may have minor symptoms, COVID can still devastate some families and should be taken seriously.

Waddell, the Blank hospital pediatric infectious disease specialist and father of two, said he empathizes with parents who grimace watching a nasal swab move uncomfortably far up their child's nose to complete a coronavirus test.

"You can tell adults this is going to hurt, it's going to be uncomfortable, and they'll try to stay still," Waddell said. "But you tell that to your 3-year-old and they'll still kick you in the face. It's not an insignificant thing to have done, but it can protect our communities."

Riley Wells said a few of his friends got sick with COVID-19 before him. Most had mild symptoms, though one he recalled had a bad case. They all bounced back, he said. When he got sick, he remembers mostly lying around in bed, coughing a lot, and being anxious to return to the wrestling mat.

An early symptom of his worsening condition: One of his shoulder blades bulged out like a wing after a post-quarantine wrestling practice.

"(COVID) might not hurt some kids, but there's always kids out there that are going to get hurt by it," Riley Wells said.

Study: Current testing practice may miss 9 out of 10 kids infected with coronavirus

Coronavirus infection rates among students could be six times higher than what’s found with typical testing of people with symptoms, a study by the University of Nebraska Medical Center found. The project involved monitoring wastewater and routine virus testing of students, teachers and staff in the Omaha Public School District who volunteered for the study.

Dr. Jana Broadhurst, the study's author, said the findings likely mirror what’s happening across the nation. The usual process of testing only symptomatic students and those exposed to infectious people may miss as many as nine in 10 cases of students who are infected and showing no or minor symptoms, she said.

“If we don't look for asymptomatic infections, we will always under ascertain our cases, right, and it is seeming that the proportion of asymptomatic cases is higher in children,” Broadhurst said in a Zoom news conference announcing the findings on Tuesday. “So this becomes even more important to do active case finding of asymptomatic infections in school-aged children.” 

Iowa, like almost all of the country, does not routinely test students and school staff for the coronavirus.

Iowa Gov. Kim Reynolds said at a news conference earlier this month that officials are watching for virus activity among young people, but noted children are less likely to have severe cases of the disease. She has emphasized hospitalization rates as a key metric for the state of the pandemic in Iowa.

"We'll continue to monitor it like we normally do," Reynolds said then, adding that the disease's effects on young people aren't as severe as on older people.

The number of people hospitalized with COVID-19 in Iowa have lingered at about 220 for most of April, up from a recent low of 160 people in mid-March. The state reported 235 people hospitalized Thursday, the most in a single day since mid-February. 

Doctor: Kids can and do spread virus; masking is needed

After shutting down much of everyday life last spring, Reynolds became a strong advocate over the summer for returning children to classrooms.

Despite concerns early on, schools have not become hot spots of community transmission, Waddell, the infectious disease specialist, said.

The fact that schools did not become hot spots is likely a mix of children not transmitting the virus as effectively as adults and efforts such as mask wearing, he said. But it's largely a moot point: Layered mitigation is effective, Waddell said. 

Even if kids are not the most effective superspreaders, they can and do spread the virus, Waddell said, particularly among members of their own families. 

"It's exhausting for everyone," Waddell said. "But we've got to keep up the fight to decrease our risk of spread throughout our communities."

Mike Beranek, president of the Iowa Education Association, said it is "imperative for us as a society" to maintain mitigation efforts, including masking in schools. While noting the protections that mitigation efforts and vaccines provide teachers and other adults at Iowa's public schools, he emphasized that science doesn't have answers on the long-term effects of a coronavirus infection. 

"We don't know the unintended consequences for our children 20, 30 years from know," he said.

According to the union, 270 school districts in Iowa, or about 82% of the total, have mask requirements for students and staff. That accounts for about 92% of the enrollment in the state. But some schools have lifted mask requirements or are considering doing so. 

After Beranek was interviewed, state Sen. Amy Sinclair, R-Allerton, introduced an amendment that would allow school principals to waive mask requirements if they felt face covering interfered with students' ability to learn. To gain final approval, the bill must pass the Senate, and the House must also concur with the Senate's amendment. Leadership in the House has not publicly indicated whether it supports the proposal. 

Waddell, meanwhile, encouraged everyone eligible and able to receive a COVID-19 vaccine. Being vaccinated is an act of love, he said, because it protects people nearby as well as the vaccinated. 

Wells and his mother acknowledge his is a rare case, and they're hopeful his pain will ease, and he'll return quickly to being an active teenager.

Uile-Wells hopes, however, that others will do what they can — wear masks, socially distance — to help COVID-19 from hurting other kids. 

"He may be just one kid, but he's my kid," said Uile-Wells, who is also the president of the West Des Moines School Board. "If I can do anything as a mom to prevent other people from getting sick, or injured, or hurt, I would do it in a heartbeat."