Introduction by Croakey: A growing body of work is challenging the view that COVID-19 does not pose a significant threat to most children and young people. It comes amid growing concerns that there could be long-term implications for some young people who have contracted the virus.
The dominant view has seen authorities take a less than rigorous approach to ventilation in schools, and has put young people further down the list when it comes to vaccination — although that view is changing, with the Centres for Disease Control recently updating its advice and recommending everyone aged six months and over receive the updated COVID-19 vaccine to protect against serious illness.
The updated CDC advice comes as the northern hemisphere heads into winter, while in Australia, there is little political and policy discussion on the issue, despite the emergence of new SARS-CoV-2 strains, with no evidence of any planning for problems with these new variants.
Jennifer Doggett writes:
This view is reflected in the most recent advice from the Australian Technical Advisory Group on Immunisation (ATAGI) that an additional 2023 vaccination is not recommended for anyone aged under 18.
However, this view is being challenged by some public health experts and advocacy groups who say that hospitalisation and mortality data shows how COVID-19 has taken a significant toll on Australian children and young people over the past two years.
This includes data showing that:
- Around 50,000 children aged 0-14 were hospitalised with COVID between 2021-2022.
- On average one child was admitted to ICU every day in 2022, totalling 362 admissions among 0-14-year-olds.
- Hospitalisation and mortality rates for COVID far exceed those for other respiratory diseases such as influenza and RSV.
Key data sources
One key source of data on COVID-19 hospitalisations is the Australian Institute of Health and Welfare (AIHW).
The graph below from an AIHW report shows that hospitalisations for children and young people for COVID-19 were high over the 2021-22 period.
In fact, for males hospitalisation numbers were higher in the 5 to 14-year-old group than for any other cohort under 65 (note this graph shows raw numbers of hospitalisations not the rate per head of population).
Another important data source is the 2022 SPRINT-SARI annual report. SPRINT-SARI is hospital-based surveillance database of patients with COVID-19 in Australian hospitals and Intensive Care Units endorsed by the WHO and the Australian and New Zealand Intensive Care Society Clinical Trials Group.
The table below from this report shows that in 2022 there were 305 children aged 0-9 years hospitalised with COVID-19 sick enough to need admission to an intensive care unit.
Data from the Australian Bureau of Statistics shows that 20 children and young people aged 1-19 died of COVID between 2020 and June 2023.
Comparisons with other respiratory illnesses
Throughout the pandemic, some public figures have downplayed the seriousness of COVID-19 by comparing it to other common respiratory conditions, such as flu and RSV.
But it’s clear from the data that COVID-19 is having a much more significant impact than these diseases on hospitalisation and death rates among Australian children.
The graph below, compiled by a health professional using AIHW and research into RSV-related hospitalisations and provided to Croakey, compares the hospitalisation rate for children with COVID-19 in FY2021-22 with the average annual hospitalisation rate for flu (2016-2018) and RSV (2005-2016).
It shows that children and young people were hospitalised with COVID-19 at significantly higher rates than for flu or RSV. For example, children aged 0-4 years were hospitalised for COVID-19 in FY2021-22 at almost nine times the average rate of hospitalisation for flu over the years 2016-2018.
What about long COVID?
The above data focusses on the impacts of the acute phase, but the health impacts of COVID-19 can last much longer for a significant percentage of children and adolescents. These impacts may not show up in hospitalisation and mortality data, but evidence suggests they are significant.
Research from the UK suggests that more than half of all children aged between 6 and 16 years old who contract the virus have at least one symptom lasting more than 120 days.
Another systematic review and meta-analyses published in Nature concluded that:
“Protective measures are essential to prevent long-COVID in children…Long-COVID represents a significant public health concern, and there are no guidelines to address its diagnosis and management. Our meta-analyses further support the importance of continuously monitoring the impact of long-COVID in children and adolescents and the need to include all variables and appropriate control cohorts in studies to better understand the real burden of paediatric long-COVID.”
The recent report from the Australian Senate inquiry into Long COVID and repeated COVID infection found that “children and adolescents may be at greater risk of repeated COVID-19 infections due to factors including: their extended time spent in high density settings such as schools, an increased likelihood of being asymptomatic, and this group’s lower vaccination rates compared to the adult population.”
The report also cited evidence from the National Clinical Evidence Taskforce which advised that “it would be prudent to monitor emerging evidence around the potential impacts of long COVID on the paediatric population, who may have to live with outcomes for a longer period of time, with potential ramifications for their health, quality of life, along with associated impacts on the healthcare system and social and economic flow-on effects.”
The Federal Government has committed to developing a national plan to respond to long COVID, taking into account the recommendations of the Senate Committee, but has not provided a timeline for its release.
Emerging evidence of long-term problems
Meanwhile, researchers working in this area are finding more evidence of the long-term health and cognitive problems being experienced by children as a result of COVID-19 infections.
In a recent lecture, Professor Jeremy Nicholson, Director of the Australian National Phenome Centre and Pro-Vice Chancellor for Health Sciences at Murdoch University, described some concerning findings from his research into the cardiovascular impact of COVID-19 infections on children.
“People said children aren’t very much affected and that really isn’t true… we need to worry about the long-term cardiovascular risks of children that have had COVID, even if they weren’t necessarily very ill at the time. And that’s a deeply worrying situation.”
Nicholson told Croakey that it’s clear from multiple reports and published work, including work undertaken at Murdoch, that cardiovascular risks for multiple cardiac end points are significantly elevated in COVID-19 patients and post-COVID patients.
“We have assessed blood plasma lipoprotein risk markers for atherosclerosis and myocardial infarction and find that these are elevated during the acute disease episode and then fall slowly in most people. We are in the process of publishing similar studies in children with COVID-19 and Multisystem Inflammatory Disease in Children (MIS-C )and find that the same markers are also raised in the acute disease phase, but as yet we do not know if these levels are persistent or to what extent this poses a long-term risk to the children in later years,” he said.
Nicholson added that given this may not be known for some time, we should act conservatively and protect our children by vaccination where possible as we do with most other diseases where there is a vaccine available.
“The disease is still evolving and we do not know if it will surge back, so again the advice to adults is to stay protected by vaccination and not to let the immunity fade – the protection afforded by the vaccination may only be a year or so.”
Other concerning research findings suggest that even mild respiratory infections with COVID-19 may lead to ongoing problems with the brain.
Stanford neurologist and paediatric oncologist, Dr Michelle Monje, who has treated and studied cancer patients with similar symptoms following chemotherapy, believes that inflammatory molecules released in the lungs of someone with COVID may trigger a reaction of immune cells in the brain, similar to that experienced by people having chemotherapy for cancer.
She describes the cognitive impact of widespread COVID-19 infections as an unfolding “neurological health crisis” which needs urgent attention by governments and health authorities.
Associations between a diagnosis of COVID-19 and increased incidence of auto-immune diseases such as type 1 diabetes have also been identified by researchers, with some studies indicating that there is a causal link.
“Increased resources and support may be needed for the growing number of children and adolescents with diabetes,” was one conclusion of this systematic review and meta-analysis published in the Journal of the American Medical Association.
Loss of parents and caregivers
Along with the direct health impacts of COVID-19 infections, it’s important to remember that children and young people also suffer when adults in their lives become sick or die from COVID-19.
While Australia has had lower COVID mortality rates than many other countries, there are still significant numbers of children who have lost parents and caregivers to COVID.
Statistical modelling undertaken by the Imperial College London on behalf of its COVID-19 Response Team suggests that 2,363 Australian children and young people were orphaned due to COVID-19 from 1 March 2020 to 31 December 2022.
Stronger measures needed
Given widespread evidence demonstrating the impact of COVID-19 on young people of COVID-19 infections (and repeated infections and/or co-infections with other respiratory diseases), experts and advocates are calling for stronger measures to prevent infections in this age group, in particular in school settings.
The advocacy group COVID-Safe Schools was formed to promote better ventilation and other COVID mitigation measures in schools, including real-time CO2 monitoring, HEPA filtration when existing natural ventilation is insufficient or cannot be maintained, and HVAC [heating, ventilation and air conditioning] systems to ensure optimal heating and cooling is achieved in order to provide the best learning environments possible.
The group has been working at state and federal levels to raise awareness of the risks posed by COVID in schools and to encourage politicians and educational authorities to follow the evidence from international research showing that improved ventilation measures are effective in preventing transmission in schools.
For example, a recent Italian study of more than 10,000 classrooms found that in those equipped with mechanical ventilation systems, the relative risk of infection of students decreased at least by 74 percent compared with a classroom with only natural ventilation. Another study being conducted in Northern England has found that schools with relatively low-cost air cleaning technologies fitted showed significantly lower absence rates than those with poorly ventilated classrooms.
In addition to decreased COVID-19 and other airborne infectious disease transmission, research shows that ventilation and air cleaning improvements in schools are likely to lead to improved academic performance (in particular reading and math performance), fewer missed school days for students, higher scores on cognitive function tests, and many benefits for teachers including decreased respiratory symptoms and increased teacher retention.
Where mechanical ventilation systems are not available or not able to provide the level and type of ventilation required to effectively reduce COVID-19 transmission, the evidence suggests the use of portable air cleaners with high efficiency particulate air (HEPA) filtration.
For example, a report from the Lancet COVID-19 Commission stated:
“In schools without mechanical ventilation systems (or without the ability to meet improved ventilation demands), or in schools that cannot support higher efficiency HVAC filtration, properly sized portable air cleaners (sized in relation to the volume of the space), with HEPA filters and high clean air delivery rates can be effective in reducing exposures to airborne infectious respiratory particles. Portable air cleaners can significantly increase the clean air supply in a classroom, and therefore can be considered a cost-effective supplementary measure where the total ventilation airflow rate is insufficient.”
Other research studies have demonstrated the effectiveness of mask mandates in preventing the transmission of COVID in schools. For example, this study in the new England Journal of Medicine found that average weekly staff and student COVID-19 absences were 50% higher in mask-optional weeks compared to prior weeks when masking was required and that the removal of a statewide masking policy resulted in an additional 44.9 Covid-19 cases per 1000 students and staff over a 15 week period.
COVID-Safe Schools argue that the above advice and research is not being followed in Australian schools and that in some cases parents have been misled about the safety of their children’s classrooms. They are currently calling for an ICAC inquiry into allegedly false information provided by NSW Premier Dominic Perrottet and other senior members of government about ventilation measures implemented in NSW schools.
Spokesperson Karen Armstrong told Croakey that while some states, notably Victoria and Western Australia, had made an effort to improve air quality in classrooms, a consistent national policy approach was needed, along with a commitment to ensuring policies are being implemented.
“This includes making evidence-based measures, such as air quality monitoring in classrooms, compulsory and educating teachers on why they are important. Where filters are required, it is important that there are processes put in place to make sure they are being used properly and consistently. This will ensure the money being spent on these mitigations delivers maximum health benefits.
“While these measures may require an investment of resources initially, this is a modest sum in comparison with the cost of COVID infections and repeated infections among students and teachers. For example, a classroom can be fitted out with a CO2 monitor and HEPA filter for not much more than the cost of employing a single casual teacher for one day,” Armstrong said.
Parents speaking out
Parents around Australia are advocating for action at their children’s schools but many report being ignored by educational authorities and ministers.
Victoria Stone is a mother of two school aged children, one of whom experienced a serious seizure from a COVID infection in the early stages of the pandemic.
Despite her daughter being at a high risk of harm from any additional infections, Stone has had to fight for a HEPA filter to be installed in her classroom at a NSW school. After 18 months of advocacy, a filter was finally provided, but when Stone visited the classroom, she found that it was insufficient for the space due to a lack of knowledge within the Education Department about the type of filter required.
Stone told Croakey that one of her main concerns is the inequity in the mitigations provided in classrooms across the country as jurisdictions take markedly different approaches to air quality in classrooms and do not appear to be sharing their learnings about best practices in this area.
“Victoria acknowledged early on that COVID is airborne and that engineering solutions are needed to protect students and staff from infections. They installed HEPA filters suitable for the size of the classrooms and provided education to teachers on their use. However, in NSW the Education Department undertook an online audit and made a guess about what type of filter might be required. In the end, they determined that the windows and doors, in rooms they never visited, would provide sufficient natural ventilation and that no HEPA filters were necessary,” Stone said.
Croakey also spoke to a parent with two children in an independent school in regional NSW who was alarmed to learn that the school was allowing COVID positive and symptomatic teachers to teach in enclosed classrooms.
“My complaints to the school on learning this were ignored,” he said.
“Given the obvious risk to multiple children, including my own, I contacted NSW Health, the Minister for Education, my local NSW MP, the Office of the Children’s Guardian, the Department of Families and SafeWork NSW to gain assistance. With the exception of SafeWork NSW, no-one was interested in providing any assistance, although all agreed this was not something the school should be doing.
“After several months and visits to the school by SafeWork inspectors, the school was found to have breached its duty of care to staff and students by allowing and in some cases encouraging teachers to come to school while positive with COVID.”
Experts speak out
Along with parents, Australian air quality experts have also called for an increased focus on clean air as part of Australia’s public health response to the pandemic.
Professor Lidia Morawska, Director of the International Laboratory for Air Quality and Health at the Queensland Institute of Technology, has spoken on the OzSage platform about the importance of improving COVID mitigations in schools.
“The highest priority is making sure that schools are safe, as children under 12 will be unvaccinated. Many children under 16 will also be unvaccinated. We can reduce the risk of transmission of COVID-19 by practical initiatives such as checking ventilation using a CO2 meter and opening windows where this is possible. Don’t guess, test. A serviceable CO2 meter can be bought for less than $200, with some much less,” Morawska said.
Another OzSage member, Professor Geoff Hanmer, has also emphasised the need to improve air quality to reduce the risk of COVID infection in indoor spaces.
“Think of COVID as spreading like deadly cigarette smoke – it builds up and is removed in the same way, but you can’t see it. By ensuring we breathe fresh air, we can avoid most COVID transmission. Where we can’t freshen up rooms, we need good masks, filters to clean the air, and less people. Something as simple as opening windows and not recycling air inside vehicles can make a tremendous difference,” he said.
Other groups are seeking changes to vaccine programs to provide more protection for children exposed to COVID-19.
Sue Jennings is a co-founder of the Cleaner Air Collective an advocacy group campaigning to improve Australia’s COVID-19 response. She is currently campaigning to increase access to COVID vaccination to children under the age of five, telling Croakey that this is not only critical for the health and well-being of our children, but it is also essential for the overall health of the Australian economy.
“The long-term health and well-being of our children should be our top priority. We should not tolerate the preventable deaths of children to a disease with an available vaccine,” she said.
This position is at odds with ATAGI advice but is supported by some experts, including leading epidemiologist, Raina McIntyre, Professor of Global Biosecurity at UNSW, who told the Saturday Paper recently that Australia should follow the USA’s policy of recommending vaccination for healthy children under five.
“We vaccinate kids under five for all kinds of other infections for which the death rate is not as high as COVID in kids,” she said
A great scandal
Professor Deborah Lupton, from the University of New South Wales and another OzSage member, has been advocating for improved ventilation in school settings, based on evidence for the broad benefits this would deliver to both students and teachers.
She says it is a “great scandal” that the health of children and young people is being ignored by governments and health agencies. “I am very concerned that Australian public school system is failing to protect both staff and students from the ongoing impacts of COVID-19,” she told Croakey.
“There has been a lot of talk in the media about learning loss from lockdowns but the ongoing learning losses associated with repeated infections and continuing health problems – on the part of both students and teachers – is largely being ignored.
“Better ventilation in schools is not hard to achieve – the government just needs to fund schools to implement evidence-based ventilation systems. This would help every single person in the school and also protect them against non-COVID airborne diseases as well as other hazards such as bushfire smoke and pollens.
“Schools and individual students and teachers can do little on their own – it’s up to governments to commit to clean air infrastructure in schools,” Lupton said.
Unions could potentially play an important role in lobbying governments to improve workplace safety for their members through improved ventilation and air quality.
At the national level the Australian Education Union (AEU) has spoken out on this issue previously, with Federal Secretary Mr Kevin Bates providing evidence to the Senate Inquiry into long COVID and repeated COVID infections at a public hearing last year.
At that hearing, Bates emphasised the role of COVID in exacerbating the critical national teacher shortage and argued that a “lack of vigilance” towards COVID infections in schools would lead to “a loss of immediate productivity through absence due to sickness…[and]… significant potential for teachers to suffer repeat COVID infections and suffer long COVID, which could cause extended absence from the classroom and fuel the teacher shortage crisis.”
Bates also stressed the concerns of AEU members on this issue saying, “Certainly, our members have reported to us that they have experienced COVID infection multiple times, in some cases four and five repeat infections….while it’s not possible to give you specific information about numbers, because those aren’t being collected, what we know from anecdotal evidence is that repeat infections are common and, indeed, are a cause for concern amongst our members.”
Information obtained under FoI and provided to Croakey by COVID Safe Schools also shows that at a local level education union members are asking their organisations to speak up on this issue. For example, the following correspondence from March 2022 between the ACT branch of the Australian Education Union and a local sub-branch reports concerns among members about a lack of action on COVID mitigations at a Year 11 and 12 college in Canberra:
“Just a quick note to pass along the motion passed by the Dickson College subbranch. We are concerned about the lack of planning as temperatures drop and COVID case numbers are still high. Dickson College relies on open windows for ventilation, and currently our rooms are dropping below 18 degrees. Next week we expect this to be a significant problem from Wednesday when wet weather and low temperatures combine. Already we are battling as teachers and students close windows, this will get worse. We don’t believe we should have to make a choice between the health of our school community and a comfortable learning space.”
It is not clear from the documents obtained under FOI whether these concerns have been addressed by the ACT Education Directorate or whether union members in other jurisdictions are taking similar actions to push for improved public health responses in schools.
Croakey invited comment from the Australian Education Union (federal and ACT branch), the Teachers Federation (NSW) and the Independent Education Union on current government policies on COVID mitigations in schools but none were able to provide a response.
The article has been updated with a more recent graph from @Mirella_PhD. Croakey will update this article with any comments received from unions after publication.
Jennifer Doggett is currently working with other concerned parents to advocate for safer conditions in ACT schools.