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The Global Wave of Childhood Pneumonia

The Global Wave of Childhood Pneumonia

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The news that Northern China is dealing with a mystery pneumonia outbreak in children was headlined in many news outlets worldwide. Chinese health officials failed to alert the world about a former novel coronavirus outbreak in 2003 (SARS) and 2019 (SARS-CoV-2). The WHO has stated: Chinese authorities claimed there has been no detection of any unusual or novel pathogens or unusual critical presentations so far, but only multiple known pathogens. 

It’s not only China that is dealing with increasing numbers of respiratory illnesses. The Netherlands and Denmark reported a sharp rise in pneumonia and whooping cough in children, while England is noticing a brutal cold virus in adults and children and Argentina reported a strep A breakout. Most recently in the US, a childhood pneumonia outbreak, dubbed white lung syndrome, has been reported. 

The culprit of the higher number of people affected at the start of this winter is most likely a dramatic degradation of the human immune system, which is a moresuitable environment for many opportunistic pathogens from bacteria to fungi to viruses to take over in human microbiota dysbiosis. 

The past years many people, and especially children, have lost their previous mental and physical strength. Chronic fear, anxiety, and pandemic measures have changed lives and driven more people into disabilities, poverty, and/or homeless, leaving them lonely, in hunger, and in cold. These conditions cause  risk for pneumonia and sepsis.

The remarkable sudden fall in usual winter pathogens by pandemic measures needs investigation, as does the mysterious rise in pathogens that varies among areas. Immunity debt as the cause of a rise in respiratory illnesses remains questionable.

In time, treatment for pneumonia and sepsis is crucial as theymay cause death in a few days. As healthcare systems are overstressed with many at the brink of financial and organizational collapse and the number of people needing hospital and primary care is yet in pre-winter season much higher than in previous years, public health is in real trouble. 

There is no other way out than immediate actions to secure the availability of sufficient healthcare staff, safe and effective antibiotics, and/or effective natural treatments for early treatment. At the same time, restoring health to strengthen the immune system with affordable nutritious food and warmth is urgently needed for healthy generations.

Last month, local media reported that hospitals nationwide were seeing an increase in infections, with clusters of cases often emerging in schools and nurseries. Especially in the Northern part of China in cities Beijing and Lianiong, children’s hospitals were crowded with parents waiting for long hours for treatment of sick children with unusual symptoms that included inflammation in the lungs, high fever, and no cough. Many developed pulmonary nodules.

Sources of Epoch Times News reported children with white lung syndrome (Chest scans showing diffusely damaged lungs) were seen. This can be a result of infection by Streptococcus pneumoniae (Sp)

A report from ProMed – a large publicly available surveillance system which monitors human and animal disease outbreaks worldwide – in mid-November alerted about the widespread outbreak of an undiagnosed respiratory illness. Up to now there are only a very few critical cases and no related deaths so far. The average number of days for patients in the hospital is around 14 days.

Official data provided indicate an increase in cases in Influenzavirus (flu), Respiratory Syncytial Virus (RSV), and Adenovirus since October while a rise in Mycoplasma pneumonia (Mp) known as walking pneumonia was noticed since May. Symptoms of walking pneumonia-which generally affects young children-include sore throat, fatigue, and a lingering cough that can last for weeks or months. In severe cases this can develop into pneumonia. Before Covid, Mp tended to cause major outbreaks every three to seven years in China. 

Physicians noticed that patients with multiple pathogens coexisting and lobar pneumonia, which affects one or more sections, is more frequently observed. Unfortunately, there is a fear of a growth of antibiotic resistance as more than 80% of Mp in children hospitalized in China is already macrolide-resistant. Antibiotic use in China accounts for half of worldwide antibiotic consumption, which mainly takes place in outpatient and community settings and often unnecessarily for self-limiting, community-acquired infections.

Chinese officials and scientists argue that the trend seen in China follows other countries, where strict pandemic restrictions led to weakened population immunity following years of suppressed transmission. In Taiwan, Mp is still circulating at low levels making up less than 1% of flu-like illnesses diagnosed in Taiwanese hospitals. But waves of respiratory diseases have been high after reopening and lifting pandemic measures in many countries all over the world.

The Netherlands

Soon after reporting on the uptick of childhood pneumonia in China, the Netherlands reported unusually high numbers of children hospitalized with pneumonia from unknown origin. Among the age 5-14 years, pneumonia is two times higher than the highest level reached last year. The number of children with pneumonia in the age 0-4 years is rising as well. The Dutch National Public Health Institute reports that there doesn’t seem to be a relation with the outbreak in China. Last week, the Netherlands reported more children with pneumonia and a rise of whooping cough, Bordetella pertussis (Bp), which is now higher than three years ago.

Denmark

On November 29 the Staten Serum Institute (SSI) reported Mp infections have reached the epidemic level, with an increase that started in the summer but has risen significantly over the past 5 weeks. In May and June (SSI) reported an increase in whooping cough with a proportion that was much larger than before the pandemic. An infant died from it this summer. Whooping cough, also called the 100-day cough, with only low fever doesn’t usually cause a danger for older children and adults. Whooping cough typically occurs with increased frequency every three to five years. The previous epidemic was in 2019/2020. 

Norway is also experiencing an increase in whooping cough, while cases have plumped during the Covid pandemic. It is expected that cases will rise in the coming year as the current acellular pertussis vaccine is less protective than the previous whole cellular vaccine. Norway is arguing to introduce vaccinating pregnant women and repeating vaccinations every ten years.

US and UK

Recently US officials announced flu cases are on the rise, and RSV infections may be peaking in the next week or so. RSV is a common cause of mild cold-like symptoms, but it can be dangerous for infants and older people. Reports came from Ohio and Massachusetts about white lung syndrome. Currently Covid-19 causes most hospitalizations and deaths among respiratory illnesses. In April 2023 the US reported Strep A infections remained 30% higher than the pre-pandemic peak in 2017. Argentina is reporting a Strep A outbreak.

Since August, 145 cases of pediatric pneumonia have been reported. Most of the children recovered at home with antibiotics, but infections have been more severe than in previous years. Illnesses were caused by various common bacteria or viruses (Covid-19, flu, RSV, and Mp).

Dr Mandy Cohen, head of the Centers of Disease Control and Prevention, stated that there has been zero evidence of this outbreak being connected to other outbreaks either statewide, nationally, or internationally. Today we believe this is not a novel pathogen. Advice from officials is to stay at home when ill, wash hands, cough in the elbow, and stay up to date with vaccinations. In several places mask mandates have been reintroduced.

Last week the newspapers in the UK reported a brutal cold virus, whose symptoms are worse than any winter bug, is sweeping the UK this month, leaving sufferers bedbound for days and housebound for weeks. The virus has symptoms, including fever headaches, blocked noses, coughs, and fatigue. 

This flu-like season arrives in many countries in times of a collapsing and exhausted healthcare system with increasing shortages of medical staff as compared to the previous year.

The ‘Immunity Debt’ Question

A trend chart of emergency hospital admissions of pneumonia in the UK, shows that while cases went up 50% the previous ten years, they suddenly dropped in 2021. In 2019 charities said the current figure was equivalent to six children being taken to the hospital every hour. Admissions were highest in the most deprived areas of England.

Analysis of UK data for all children aged 0-14 years admitted to NHS hospitals in England with an infection from 1 March 2-17 to 30 June 2021 found substantial and sustained reductions in hospital admission for all but one of the 19 infective conditions studied, while childhood immunization programs had been disrupted and emergency department visits delayed. 

Reductions were similar across all UK geographical regions, and ethnic groups, as well as among children with existing conditions who are at greatest risk of severe illness and death from infection. The authors of the article as well as an editorial at the British Medical Journal argue that the indirect effects of behavioral changes and societal strategies overall on children’s health are substantial, concluding that some pandemic measures like mask wearing had positive effects, although temporary. The authors recognized that school closures came with significant social and economic costs that are likely to increase health disparities.

While in contradiction with their observations, it was noted that the proportion of children admitted for pneumonia who died within 60 days increased. More recent data also indicate that some respiratory infections increased to higher levels than usual after May 2021. Strangely, there were more amoxicillin prescriptions during the summer of 2021 in the UK than in previous summers. 

In the Netherlands a strong increase (28%) in amoxicillin use was observed in 2022 as compared to 2021, while also 2021 showed an increase in antibiotic use as compared to the previous year. Antibiotics prescription is highest for elderly people (> 75 yrs) and relatively high for children (0-10 yrs).

Dynamics of increasing childhood infections seem comparable in other countries, albeit for different pathogens. In December 2022 the WHO reported an increase in invasive Group A streptococcal infections among children under 10 years of age in Europe including fatalities. In France and the UK the number of iGAS (infections usually cause mild illness including sore throat, headache, and fever, along with a fine red rash) in children has been several fold higher than pre-pandemic levels for the equivalent period of time. Observed increases reported to the European Centre for Prevention and Disease (ECDC) followed a period of reduced incidence of infections with GAS during the Covid Pandemic. 

In a race to control a tripledemic with a spike in RSV Covid and flu, hospitals in the US were close to brink in 2022. During several periods in 2021 and 2022 the US had consistently experienced RSV infections and related bacterial infections. In December 2022 RSV hospitalization was seven times higher than it was in 2018, the last full season before the pandemic. 

In the US important medical supplies have been repeatedly unavailable for purchase, with a national shortage for the antibiotic amoxicillin leaving parents in stress. In 2014 a WHO guideline for treatment of lower chest indrawing pneumonia with oral amoxicillin on an out-patient basis was released. Unfortunately, the US, Canada, and the EU have made themselves vulnerable and dependent on production of medicine by China. 

Even in wealthy countries, one in 56 babies who are born on time and are otherwise healthy will be hospitalized with RSV during their first year of life, although severe infection is seen most in premature infants and children with comorbidities. There are no drugs. Supplemental oxygen, intravenous fluids, or mechanical ventilation are needed until they get better. Having sufficient intensive care beds is crucial as the case fatality rate in untreated children with pneumonia is high, reaching 20%, and death can occur as early as 3 days after illness onset. 

Many countries including China are facing worse flu-like illness symptoms and pneumonia than in any previous winter, while until today no novel pathogen has been identified as the cause of the symptoms. The reason for an uptick of common pathogens in China causing more severe symptoms this winter season is explained by many officials and scientists as because of ‘immunity debt.’ 

However, the pandemic measures in the Netherlands, Denmark, the UK, and the US have been lifted before the previous winter season started, whereas this year infection rates with common pathogens are more severe and higher as compared to the 2022/2023 winter season. 

A Mystery of Diagnosis 

The reported sharp drop in emergency hospital admission for pneumonia in children in 2021 in many countries is remarkable. It is hardly possible to find explanations that the immune systems of deprived children who are at the highest risk for pneumonia and sepsis could strengthen during lockdowns, school closures, wearing masks, disrupted immunization schemes, delayed visits to medical doctors, and increasing poverty. 

Massive scientific literature supports the devastating effects of pandemic measures that come at high costs for children’s immune system and mental (depression, learning disabilities) and physical health that will take years or even generations to recover.

New studies found masks are linked with Covid infections, exposure to toxic compounds, and pathogenic bacteria and fungi. Finally a recently published systematic review on child mask mandates for Covid-19 in the BMJ concluded that ‘the current body of scientific data does not support masking children for protection against Covid-19.’ Children have been exposed to more disruptive circumstances as has never been seen before. The number of children in poverty has doubled during one year in the US.

After a 12-day visit in the UK this autumn, the UN rapporteur on extreme poverty stated: ‘UK government policies continue to entrench poverty and inflict unnecessary misery on millions of people.’ Unfortunately, all are cumulative, contributing to disrupt the precious human microbiota of children.

The cities Beijing and Lianiong, reporting high childhood pneumonia rates, followed the most stringent zero Covid policies in the world with quarantine camps built outside the city where people were isolated for up to 40 days with poor food and sanitation. In addition, in-house masking, use of disinfectant, fear, and anxiety for forced isolation in camps could have contributed to weakening children’s developing immune systems. 

The dramatic degradation of the human immune system with an increasing risk for infectious diseases, chronic diseases, and sudden death especially for children and young adults can no longer be ignored. Humanity Project Reports from Phinance Technologies, based on official data, are demonstrating alarming levels of excess mortality in children and young people in the UK, the Netherlands, and other European countries that started in the summer 2021 and continued to increase in 2022 in most age groups.

In 2022 the WHO sounded the alarm for a mysterious rise in acute hepatitis. While an adenovirus infection was thought to be responsible, no specific pathogen could be identified for all cases. 

Mixed viral and bacterial infections are common. However, bacterial infections are frequently underreported. Efforts to identify clinical features to better diagnose bacterial pneumonia have not been successful thus far. There are no reliable signs or symptoms that differentiate Mp infection in Community Acquired Pneumonia (CAP) from other etiologies. Additionally current diagnostic tests do not reliably distinguish between Mp infection and carriage. Moreover, inclusion criteria of certain tests might be a subjective judgement of pediatricians. 

Since the end of 2015 increased incidence of Mp infections have been reported across Japan, China, and England. But data obtained by the first global prospective surveillance study suggest Mp was the only absent respiratory pathogen after long periods with discontinued pandemic measures worldwide while during the same period infections with other pathogens resurged, indicating increased community transmission.

If Mp would resurge, it is suggested that it might affect the world population which has not been exposed to Mp for the past 3 years and result in an increase in rare severe disease and extrapulmonary manifestations. In the surveillance, Mp was not detected by a direct method, often used in pre-pandemic periods, but PCR tests or antibody tests.  broad use of Covid-19 PCR tests for surveillance that showed it is difficult, depending on the Ct threshold used, to distinguish between infectious and an asymptomatic carrier.

It starts to be more complex as Chinese researchers state the clinical diagnostic standard for pertussis is not specific in China and differs among age groups. Similar to Mp, a high prevalence of macrolide resistant Bp was found in China in 2014-2016.

There are many differences in testing and treatments among countries and even among areas . A research project among Nordic countries on childhood vaccines, antibiotic prescriptions, and hospitalizations showed widely diverging practices and results. Protocols, transport medium, and methods may differ. It can affect the detection rate, and colder climate can be another reason. For example, Mp infection positively correlates with temperature. Infection rate of Mp gradually increased with the increase in the minimum temperature. Sp is also a seasonal phenomenon.

During the pandemic, coinfections with bacterial pathogens have been underestimated due to limited testing and a low sensitivity of the tests used. Retrospective research suggests that rates of mortality, ventilatory support, and length of hospital stay were significantly worse in patients with a coinfection of SARS-CoV-2 and Mp. A German study showed an increase in respiratory viruses not being SARS-VoV-2 and coinfections with Sp in 2021. In the second half of 2021 near pre-pandemic levels were reached for patients > 60 years. Previous studies showed if Sp coinfection was present; this was associated with a high case-fatality.

To reduce childhood deaths early identification and prompt treatment are essential. The absence of more specific diagnostics for pneumonia hinders both the rational application for treatments and appropriate antibiotic stewardship. As it is clinically impossible to differentiate viral from bacterial pneumonia, prompt treatment of clinical pneumonia with antibiotics will remain a priority for the foreseeable future. Unfortunately, the backslash is that treatment with antibiotics will disrupt the childrens’ microbiome/immune system and if not treated well increase a risk for future chronic diseases.

A Call to Action to Save Children’s Lives

Childhood pneumonia is known to be an important leading cause of death of children in mostly developing countries and deprived areas, and for children with comorbidities. Despite the many programs initiated to reach near zero ventilator-associated pneumonia, the world post-Covid pandemic is facing an alarming rise in childhood pneumonia. A recent paper showed that socioeconomic deprivation, comorbidity, learning disabilities, and a history of extensive antibiotic exposure are associated with developing non-Covid 19 related sepsis (sepsis occurs when the immune system overreacts to an infection and starts to damage our own tissue) and 30-day mortality in England.

Opportunistic pathogenic bacteria like Streptococcus is one of the pathogens that could possibly play an important role. Although childhood pneumococcal vaccines are available, increased risk of infection often with serotypes that are not covered or escape vaccines are seen in children most at risk. Moreover, repeated use of antibiotics may have disrupted a child’s microbiota that may increase the risk for long-term health impacts.

Chinese researchers recently suggested a relation of human microbiota dysbiosis and bacteria like Streptococcus and Prevotella and the potential to predict prognosis of infectious diseases. The immune system and children’s microbial dysbiosis and the role of opportunistic pathogens are an emerging field of discovery. In a previous article published at Brownstone Institute a hidden role of Sp in pandemics and human microbial dysbiosis and diseases has been explored.

For many children time will be too short to await research for the whole picture to solve. Each mandated intervention from mask mandates to vaccine injections without a check on the child’s health condition and informed consent could be the final drop to exacerbate the disbalance of the microbial population into severe disease, sepsis, or sudden death. 

For Public Health Authorities and medical doctors, this is an urgent call to acknowledge the risks of mandates and disruptive effects of poverty, malnutrition, hunger, cold, fear, and anxiety on the child’s immune system/microbiota. From history it is known that early treatments for imbalances are the best way to keep a precious balanced child’s immune system, a prerequisite for healthy generations.



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Author

  • Carla Peeters

    Carla Peeters is founder and managing director of COBALA Good Care Feels Better. She obtained a PhD in Immunology from the Medical Faculty of Utrecht, studied Molecular Sciences at Wageningen University and Research, and followed a four-year course in Higher Nature Scientific Education with a specialization in medical laboratory diagnostics and research. She studied at various business schools including London Business School, INSEAD and Nyenrode Business School. She worked for 15 years as an interim manager of change in healthcare of which several years as an interim CEO guiding to less sick leaves, improved quality of care and income

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