Lois Levine

When one thinks about global warming, one doesn't necessarily connect it to  increased infectious disease in children, but that is exactly what is happening. Dr Saul R Hymes, MD, assistant professor of clinical pediatrics,  Stony Brook University Renaissance School of Medicine, Stony Brook, New York, spoke of this phenomenon at the virtual 2020 American Academy of Pediatrics National Conference & Exhibition. 

Hymes first pointed to a number of climate change consequences that are already known. Heat-elevated temperatures, for example, can cause heat-related death and illnesses. Outdoor air quality affects everything from wildfires to asthma. Flooding can contaminate waters and cause drowning, and warmer weather year round is upping the numbers of vector-borne infections like Lyme Disease.

"A number of human infections are spread by insects, from black-legged ticks, which carry Lyme Disease, to mosquitos that carry a number of infectious diseases," Hymes noted. Between 2001 and 2013, the Centers for Disease Control reported a huge increase in Lyme Disease across the United States. The Environmental Protection Agency lists Lyme Disease as one of the biggest indicators of climate change's impact on human health. And with more and more warmer months year round, the disease is also moving north, and expanding into the winter months of November, December, and January, where "more and more people have been pulling ticks off themselves during warm spells of these months," says Hymes.

Hymes then discussed the fascinating pathway of what was known as the "Lone Star tick," which previously had only been recognized in the Southeastern United States. Bizzarely, this tick, after biting a human, transmits a delayed allergic reaction a few hours after someone eats red meat or pork, often resulting in vomiting, stomach cramps, and anaphylaxis in all forms.  And while it is not infectious, it cannot be treated. "This tick is now being found in the Upper Midwest, the mid-Atlantic states, and New England," says Hymes.

Natural disasters, such as hurricanes and tornadoes, can have a profound affect on patient health in ways health care providers might not initially suspect. "They bring saltwater organisms into the water and food supply; there is sewage contamination due to overloaded sewers; and they spread displaced animal vectors like rats," Hymes points out. Saltwater organisms can cause diarrhea and wound infections, while freshwater and soil organisms can produce botulism and pneumonia, among other illnesses. Without clean water and with sewage contaminations, people can contract cholera, typhoid, E coli, and hepatitis A/E. Meanwhile, displaced rodents can transmit typhus, salmonella, rabies and more. "With Hurricane Katrina, we saw 6 cases of cholera, cases of E coli, salmonella, flu, and pneumonia, all which included problems from overcrowding of evacuees," says Hymes.

And while all this is grim news indeed, Hymes stresses ways that pediatricians can be at the forefront of prevention. "Familiarize yourself with diseases like Lyme and Zika, and expect usual suspects at unusual times," Hymes says. "In other words, Coxsackie virus—in February? If it's a warm February, yes, it's possible." Hymes also suggests checking infectious disease risks in your patients. "Are they evacuees, do they have access to clean water, are they living in an overcrowded place?" asks Hymes. "Consider the odd organisms, and call your local infectious disease doctor if you are not sure." 

Finally, Hymes suggests that we can all help contain the problem of climate change personally, with our own life adjustments. "Purchase an electric or hybrid car; convert to solar power if you can, and purchase carbon offsets."

(To read more about climate change and its impact on health, see this panel discussion on 

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At the virtual 2020 American Academy of Pediatrics National Conference & Exhibition, Dr Saul R Hymes discusses how climate change directly impacts infectious disease in children.

Climate change and pediatric infectious disease

The 90th anniversary of the AAP's National Conference & Exhibition was celebrated with its first-ever virtual event. AAP president Dr Sally Goza opened the plenary session by introducing keynote speaker Dr Anthony S Fauci, director of the National Institute of Allergy and Infectious Diseases, and now not only a household name, but arguably the most trusted voice in medicine today.

Dr Fauci kicked off his talk with a concise history of COVID-19, explaining coronaviruses in general and reminding everyone that "coronaviruses go back decades and decades for us, and among other things, are responsible for the common cold." 

He then dove into the beginnings of the current pandemic, which was first noted in humans in Wuhan, China in January. "Fast-forward to where we are now," Fauci soberly noted, "where the world has experienced 33 million cases and over 1 million deaths, with an end nowhere in sight," stating that "the world has not seen something like this since the pandemic of 1918." He discussed a myriad of trajectories of the virus in both Europe and the United States, noting the direct correlations between cases decreasing during periods of total and drastic shut-downs, and now, as the world is attempting to re-open schools and businesses, numbers ticking back up. 

Symptoms, he reiterated, are very similar to clinical manifestations of influenza, with an unusual added symptom, "the peculiar loss of smell and taste that precedes the onset of respiratory symptoms." He conceded that the variants of this virus continue to be a head-scratcher. "In all my experience," Fauci observed, "I have never seen a disease range from asymptomatic to mild to fatal like this one." The most severe cases, Fauci said, can cause acute kidney injury, cardiac dysfunction, sudden death from congestive heart failure," italicizing that people with underlying conditions that include heart problems, chronic kidney disease, obesity, cancer, sickle cell anemia, hypertension, diabetes 1, and more are at much greater risk.

"Another troublesome aspect of this pandemic is its racial disparities," Fauci said. "Blacks, Hispanics, and Native Americans have an increased risk of getting infected, and if they do, they can be severe. The numbers are strikingly higher with these groups," in terms of both risk of infection and severity of illness. 

Fauci also touched on, of course, multisystem inflammatory syndrome in children (MIS-C), which has more than 800 cases globally, and a median age of infection of 8 years old. While the death rate in children remains low, and children have less severe symptoms in general, Fauci did note that studies are reporting now that "older children seem to transmit the virus more efficiently than younger children." Finally, Fauci discussed post-viral syndromes that have been noted to affect people of all ages after they have had the virus. These include fatigue, malaise, shortness of breath, and "brain fog," an inability to focus and concentrate. 

Fauci discussed the 2 noted therapies that are proving some success: remdesivir and dexamethasone, as well as convalesent plasma, monoclonal antibodies and antivirals. 

And what about the latest status of vaccines? Fauci said, "By the end of the year, in November or December, we will have an answer as to whether we have a safe and effective vaccine. No guarantee, but we could start vaccinating people by the end of the year."

Fauci's talk was followed by a question-and-answer period, in which Dr Goza posed several questions coming in from the virtual pediatrician audience. One physician was worried about whether or not enough children will be included in clincial trials to assure a safe vaccine for them. Fauci explained that "the phase 3 trials of vaccines do not include children until you get a certain degree of safety, which will be known reasonably soon. At that point, a phase 1 trial in children would start, without too much of a delay."

An interesting question was posed to Fauci: What 3 actions could have changed the outcome of the pandemic? Laughing, Fauci responded, "It's almost an impossible question to answer. We could have known sooner, tested in abundance, and have the country act in a uniform way. But we have a large country, with 50 states and additional territories, and there is a tradition of individuality and states rights, which is why we have an uneven response to this pandemic. But we could have done better. I am not happy with the baseline infections that we have: retrospectively, you could always find a way to do things better."

Dr Anthony Fauci speaks on "COVID-19: Public Health and Scientific Challenges" at the virtual 2020 American Academy of Pediatrics (AAP) National Conference & Exhibition

Dr Anthony Fauci talks COVID-19 at AAP conference

 hosted a webcast, “The race for a vaccine,” with 3 world-renowned scientists leading a lively discussion on the history of vaccines, past and future efficacies within the vaccine world and just what a COVID-19 vaccine might look like in the near future. The panel included Dr Walter A Orenstein, MD, professor and associate director of the 

 at Emory University School of Medicine; Dr Angela Rasmussen, PhD, associate research scientist at the 

Center for Infection and Immunity at Columbia University

; and Dr Gregory A Poland, MD, editor-in-chief of the journal 

Dr Rasmussen got the conversation going with a colorful history of the vaccine, and then noting that, while presently, more than 150 vaccines against the coronavirus are being researched, only 6 are currently in phase 3. Three currently leading the vaccine race include mRNA ; Replicating RNA (replicon); and DNA. While all share the benefits of being easy to manufacture (none require the infectious virus to build the vaccine), Dr Rasmussen points out each one comes with disadvantages as well. Both mRNA and replicon are not temperature stable/more reactogenic, while DNA is proving difficult to deliver to target cells.

Following Dr Rasmussen, Dr Poland introduced his, “Vaccines: principles, prejudices and porcupines,” starting with a sobering quote from Albert Camus: “They fancied themselves free, and no one will ever be free so long as there are pestilences.” He then dove into the massive controversies currently clouding the medical media landscape, reminding us that “you can have your own opinions, but not your own facts-science is not a democracy,” and reinforcing the principles of scientific evidence, which is intentional, explicit, peer-reviewed, and agnostic to results.

Additionally, Dr Poland noted the public’s collective temperature in response to the vaccine race, citing concerns of cutting corners, vaccines being produced at warp speed and vaccine allocation (utilitarian or egalitarian). And while the bad news was that, with multiple national and international tabletop exercises and 3 novel coronaviruses cross the species barrier in the past 16 years, there is no excuse for not being ready, prepared and in sync for COVID-19 right now, Poland reminded us that, despite the public pressure for treatments and vaccines, there is also no substitute for careful, clinical studies and trials. The scientific community should be careful not to over-promise, and italicized, that despite what first comes to market, the ideal vaccine, among other things, should be able to be mass-produced quickly, have an excellent safety profile, be stable at room temperatures, and able to be stored indefinitely.

Next, Dr Orenstein continued the discussion with a frank look at questions that may still be unanswered, even at the time of the first COVID-19 licensing. These include who priority groups for the vaccine would be, risk factors for vaccine failure and waning immunity, and the impact of the vaccine in reducing transmission. On a brighter note, however, Dr Orenstein reminded us that “vaccine safety continues to be monitored even after the public begins using the vaccine” through a number of watchdog groups, including the Vaccine Adverse Event Reporting System (VAERS) the Vaccine Safety Datalink (VSD), the Post-Licensure Rapid Immunization Safety Monitoring (PRISM), and the Clinical Immunization Safety Assessment Project (CISA).

Finally, Dr Orenstein wrapped up with a reminder to all clinicians to follow recommendations of the Advisory Committee on Immunization Practices (ACIP) and to continue to report cases of COVID-19 to local and state health departments, including vaccination status.

Three scientists discuss the global race for a COVID-19 vaccine.

Author | Lois Levine

Articles

Climate change and pediatric infectious disease

Dr Anthony Fauci talks COVID-19 at AAP conference

The race for a COVID-19 vaccine