For nine-year-old Rosalie Byrne, the first sign of trouble was an ache inside her belly. “I’m feeling yucky,” she told her parents.
When Rosalie tested positive for , her parents were told she’d likely feel better in a couple of days. But her symptoms worsened; food started tasting off, the humid air smelled repulsive, and she began to cough and struggle for breath.
When she started vomiting uncontrollably, her parents knew it was time to go to hospital. So at 3 a.m. on Aug. 3, Nathalie Byrne comforted her terrified, crying daughter on the bathroom floor as her husband, David, grabbed what they needed.
On the drive to Lakeridge Health, the closest hospital to their Oshawa home, David realized his five-year-old son never got to say goodbye. What if he never saw Rosalie again? Back home, Nathalie wondered the same.
“I was just so scared,” she said. “You don’t know what this thing is going to do.”
After 17 months of living cautiously — virtual schooling, masking at playgrounds, minimizing contacts — Rosalie joined a tiny but growing number of Ontario kids who have been hospitalized with Delta, the variant now driving Canada’s fourth wave.
In Canada, relatively few kids have been hospitalized since the pandemic began — 1,429 as of Aug. 13, just 1.9 per cent of total COVID hospitalizations, according to the Public Health Agency of Canada. Even with Delta, infected kids are far less likely to suffer severe disease than adults and the vast majority will only experience mild symptoms.
But in the United States, a Delta-driven surge is now causing spikes in pediatric hospitalizations, especially in states with low vaccination rates, igniting fears that Delta could be more dangerous for kids. With school approaching, there are concerns pediatric hospitals in Ontario will also be strained if the virus once again runs amok — and this time, there could be even less capacity to accommodate the swell.
Ontario’s vaccination rates are higher than the southern U.S. states that have seen the worst Delta surges. But roughly 2.4 million Ontarians eligible for vaccination have yet to receive a single dose, and another one million are still awaiting their second. That’s plenty of kindling for a COVID flare-up, experts say.
As always, the coronavirus will find vulnerable populations to infect — including Ontario’s 1.7 million kids still too young to be vaccinated. Only this time, the virus is far more infectious and mobility rates in Ontario are higher than they’ve been since the pandemic began, said Dr. Peter Juni, scientific director of Ontario’s COVID-19 Science Advisory Table.
If Ontario allows Delta to spiral out of control, these next few months could become the most dangerous phase of the pandemic for young kids, Juni warned. At the same time, he emphasized, safeguarding the school year and in-person learning has never been more critical.
Ontario has seen longer classroom closures than any other Canadian jurisdiction. So with a Delta-driven fourth wave, it’s more important than ever for everyone to do their part in keeping classrooms open and safe, said Dr. Nisha Thampi, a pediatric infectious disease physician with the Children’s Hospital of Eastern Ontario. This includes getting vaccinated.
“Children and youth have given so much to protect adults in their community,” she said. “And so I see it as a civic duty on our part, as adults, to do what we can to protect their access to education.”
Experts say they’re confident Ontario can avoid the nightmare scenarios in hardest-hit American states, as long as we stay in Step 3 and maintain safety protocols in schools. As the fourth wave accelerates, here is what we know, and don’t yet know, about Delta’s impact on kids — and whether Ontario is prepared.
Is Delta worse for kids?
In early August, as Louisiana’s children’s hospitals filled to capacity, the physician-in-chief of Children’s Hospital New Orleans delivered a stark message.
“I am as worried about our children today as I have ever been,” Dr. Mark Kline told reporters. “This virus, the Delta variant of COVID, is every infectious disease specialist and epidemiologist’s worst nightmare.”
Not only is Delta more infectious, Kline said, it’s also capable of causing severe disease. But are kids getting sicker with Delta? For most experts, this question remains unsettled.
The Star spoke with 10 experts in Canada, the U.S. and U.K. All said there is no conclusive evidence yet that Delta is making kids sicker than in previous waves.
“We don’t have firm evidence that Delta is more virulent in children,” said Dr. Jim Versalovic, interim pediatrician-in-chief with Texas Children’s Hospital, the largest pediatric hospital in the U.S. “But it certainly has spread like wildfire and that’s the real challenge here; it’s a numbers game. Because so many children and adolescents are being affected by Delta, we know a certain percentage are going to be requiring hospitalization.”
There is data to suggest that Delta is causing more adult hospitalizations and ICU admissions, however.
In the United Kingdom — one of the first western countries slammed by Delta — data from Public Health England shows the variant was roughly twice as likely to cause hospitalizations compared to Alpha, which fuelled the previous wave, said Christina Pagel, a professor of operational research with University College London and member of Independent Sage, which advises the U.K. government on its pandemic response.
But nobody has analyzed the U.K. data yet to see if kids specifically were more severely affected, Pagel said, adding that she and others are looking into this.
Juni said it’s plausible that kids would have an increased hospitalization risk with Delta similar to what adults are experiencing, and pointed to a preliminary analysis by fellow science table member Dr. David Fisman, an epidemiologist with the University of Toronto.
In Ontario, only 22 kids ages 0-9 have been hospitalized with Delta between May 1 and Aug. 12, according to Fisman’s analysis, which he shared with the Star. But in this age group, they appear to have a threefold higher risk of hospitalization with Delta compared to previous strains, he said.
Fisman said this held true even after adjusting for other factors like medical conditions and immunocompromised status, and stressed his analysis was preliminary and he could not account for all variables. Testing rates for kids dropped after schools closed, for example, and it’s unclear if some kids might have been hospitalized for other issues, only testing positive with Delta after admission.
Nevertheless, even if Delta doesn’t carry a threefold higher risk of hospitalization for kids, Ontario can still expect a bump in pediatric hospitalizations if the fourth wave spirals out of control, he said.
That’s because the biggest worry for hospitals is Delta’s extreme infectiousness — it’s 50 per cent more transmissible than Alpha.
“The fact is, as more children get infected, we will see larger numbers requiring hospitalization,” said Dr. Stephen Freedman, a pediatric emergency medicine physician at the Alberta Children’s Hospital in Calgary and clinician-scientist at the hospital’s research institute.
“Hospitalization represents the tip of the iceberg for COVID and children. That iceberg (of infections) is now bigger.”
Potential for a double or triple surge
The other big worry for Ontario’s fourth wave: COVID will likely overlap with other waves of respiratory illnesses typical in the fall.
Last year, these viruses — particularly influenza and respiratory syncytial virus, or RSV — were kept at bay, likely due to pandemic restrictions. But with mobility levels now higher than ever, doctors are bracing themselves for a resurgence.
In the U.S., pediatric hospitals have already been battling a double whammy of COVID and RSV, with many kids hospitalized with co-infections. RSV is a common childhood virus that infects nearly everybody by age three, but infection can be serious. A 2016 study published by Ottawa researchers in PLOS ONE found that in Ontario between 2005 and 2013, RSV accounted for nine per cent of infant hospital admissions.
“When you superimpose those (other viruses) on a very large fourth wave of COVID, particularly in children under 12 who are unvaccinated … we might be dealing with an unprecedented demand on acute care and pediatric services,” Freedman said.
This potential for a triple threat is among the biggest worries for Dr. Ronald Cohn, president and CEO of the Hospital for Sick Children.
“If we see a real surge of three viruses — RSV, flu and COVID — if all three of them surge at a high level, that is what concerns me. Not because kids will get more sick than before. But because of capacity, our ability to care for all those who need it.”
But high vaccination rates, coupled with current public health protocols, will likely help attenuate the risk, he said, noting this has been seen in some U.S. regions. “If public health measures inside and outside of school are maintained, we might be able to avoid a significant surge of COVID and RSV.”
According to data from the Public Health Agency of Canada, RSV has been quiet this summer but recent weeks have seen a rise in positive tests in Quebec.
Last fall, many Ontario hospitals saw a dramatic drop in the number of children admitted with influenza-like illnesses, likely due to masking, distancing and other protocols. At Mississauga’s Trillium Health Partners, no children were admitted to its hospitals for influenza-like illnesses in 2020 between Sept. 1 and Dec. 31, compared to 128 admissions during the same time period in 2019.
Experts say it’s not clear what will happen this fall. SickKids has not seen a rise in children sick with RSV. Though, like some other Ontario hospitals, Cohn said its emergency department is busier than a typical August with kids with colds and fevers, as more families mix.
On top of a potential triple surge of respiratory viruses, there are increased concerns about the number of children who will develop a rare complication to COVID, called multisystem inflammatory syndrome of children, or MIS-C.
Early U.S. data suggests 1 in 3,500 children infected with COVID will develop MIS-C, which typically appears weeks after a COVID infection, Freedman said. While the vast majority of kids with MIS-C will recover, about half will require intensive care, he said.
With all the unvaccinated kids “and a one-in-3,500 risk of MIS-C — that’s potentially a lot of children.”
What is Ontario’s pediatric ICU capacity?
At the peak of the spring wave, ICU cases soared to nearly 900, forcing the mass cancellation of hospital procedures and an unprecedented redistribution of health-care resources. In the first nine days of April, 130 critically ill adult patients were transported out of overloaded hospitals.
With Delta, there are fears that hospital capacity could again be strained, and Ontario health leaders are already preparing for the possibility of expanding ICU capacity for children.
Ontario has 93 pediatric intensive care beds at five hospitals in Toronto, Hamilton, London, Kingston and Ottawa. Outside of these, most hospitals have small pediatric wards with limited pediatric staff. Northern Ontario does not have any pediatric ICU beds.
In a statement to the Star, a spokesperson for Ontario Health said the Northern Region “has always had a mapped approach to pediatric ICU transfers to distribute to hospitals in the South,” with SickKids as a frequent transfer site.
But SickKids and other hospitals are now looking for ways to further “extend capacity,” said Cohn. Ontario Health confirmed it can increase critical care capacity for children by 40 per cent, having “identified 37 additional pediatric ICU beds that could be opened if required.”
A major concern, however, is staffing, and caring for children requires greater specialization, experts say. Ongoing talks among hospital leaders are prompted by what U.S. hospitals are facing, Cohn said. “We are preparing the maximum surge capacity we can.”
Should a fourth wave hit hard, there are worries the system will have even less ability to cope with surges.
Last spring, , taking on 36, while also accepting 372 pediatric patients from other GTA hospitals.
This time around could be different, Freedman says. “I worry a lot that (pediatric hospitals) won’t have the capacity to assist our adult colleagues.”
Every wave in the pandemic has disproportionately affected Ontario’s most marginalized communities. The fourth will be no different and the kids most deeply impacted by Delta will likely be those who’ve already suffered most.
Many postal codes with the lowest vaccination rates have lower incomes, more racialized people, and cramped housing — communities where learning losses have likely been greatest and kids may have already suffered the loss of a loved one to COVID-19, said Dr. Katharine Smart, a pediatrician and president-elect of the Canadian Medical Association.
“I’m trying to have people think about the impacts of COVID on children beyond just how many kids get COVID and die,” she said. “Yes, of course that’s important but that is a very small part of the story, in terms of the impact this pandemic has had on children.”
In Toronto, the highest rate of pediatric infections has been in Downsview-Roding-CFB, which includes Humber River Hospital and Downsview airport, where the majority of residents are immigrants and racialized. Here, nearly 800 kids aged 19 or younger have tested positive for COVID.
The neighbourhood with the most pediatric hospitalizations, 12, is Mount Olive-Silverstone-Jamestown, a neighbourhood with high concentrations of kids in addition to essential workers and unsuitable housing.
Pockets of Scarborough, like Woburn, Malvern and Rouge, have also seen some of the city’s highest counts of pediatric cases.
“In Scarborough, where some of the socioeconomic problems that have in the past put our population at risk, we’re worried that those kids may end up coming to hospital with more illness,” said Dr. Peter Azzopardi, chief and medical director of pediatrics at Scarborough Health Network.
Leaders at SHN closely monitor local vaccination rates. Currently, the lowest rates tend to be in the young parent demographic — the 30-39 age range — and in 12-to-15-year-olds, he said.
Both are a concern for Azzopardi, who worries young children infected at school will spread COVID to unvaccinated relatives.
“Families with kids under 11 — that’s where I see this virus still having a strong foothold,” Azzopardi said. “That puts families with children at particular risk and serves as a reservoir for this infection to go elsewhere.”
As the new school year looms, there is one thing Ontarians can do now to make everyone safer in the fourth wave, kids included, experts say: Get vaccinated.
Cohn is hopeful that COVID protocols in schools — masking, cohorting and hygiene measures — will help quell Delta transmission in classrooms. But increasing vaccination rates in adults is more important, he said.
“That’s how you create this ring around kids that protects them.”
For the Byrne family in Oshawa, having both parents vaccinated was one of the few silver linings in their ordeal. Nobody else in the family tested positive, even though Nathalie cared for Rosalie before she was hospitalized and David spent seven days with his daughter in an isolation room during two hospitalizations.
“Because my wife and I were vaccinated, we got to take care of my kids,” David said. “We got to stop this experience where it started. It didn’t go on; we didn’t have four people in our house sick.”
Although Rosalie has asthma, her worst COVID symptom was the non-stop vomiting and she was primarily treated for dehydration, David said. While Rosalie is recovering, the family is still reeling. Their daughter’s good spirits have returned, but David and Nathalie still wonder when she will return to normal.
Until a few days ago, they still had to carry her up and down the stairs. They also recently dug out her old stroller so the family can go for walks. “If we had her walking down the street, she’d be exhausted and lying down,” David said.
He said the family wanted to share Rosalie’s story “as a cautionary tale” and because they worry that with Delta, prior measures may no longer be as effective. They say they’ve been extremely careful and Rosalie’s only possible exposures were two trips to a playground and one to the mall, all while masked.
“I think the plan we have for the fall, right now, is very much based on (previous strains) that just weren’t as contagious,” David said. “But we have a couple of weeks left before school starts and there’s still time to take the necessary precautions.
“Nobody wants their kid to go through this.”
With data analysis by Andrew Bailey
Jennifer Yang is a Toronto-based health reporter for the Star. Follow her on Twitter:
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: