Effect of the new SARS-CoV-2 variant B.1.1.7 on children and young people

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Abstract

The clinical impact of the new SARS-CoV-2 lineage B.1·1.7 on children and young people (aged 18 years or younger) regarding acute respiratory COVID-19 is yet to be fully defined. Media reports of increases in admissions to hospital and more serious illness in children and young people have resulted in public confusion and implicated the B.1.1.7 variant as a more pathogenic infection within this group.1, 2 This uncertainty has necessitated a public statement from the Royal College of Paediatrics and Child Health. 3 It is important to rapidly clarify the true impact of the second wave on children and young people within the context of a high prevalence of the B.1.1.7 variant, estimated to account for 70% of infections in the London region in January, 2021. 4 Located in south London, King's College Hospital lies within an area of high disease prevalence, admitting large numbers of patients in both COVID-19 waves. We have previously published data pertaining to children and young people admitted during the first wave 5 and here, we compare those data with the characteristics of children and young people admitted with acute respiratory COVID-19 thus far during wave 2. Between March 1, and May 31, 2020, 20 children and young people (aged 18 years or younger and positive for SARS-CoV-2) were admitted to King's College Hospital. Between Nov 1, 2020, and Jan 19, 2021, 60 children and young people positive for SARS-CoV-2 were admitted. No significant differences were found in age, proportion of patients with comorbidities, proportion of patients from Black, Asian, and minority ethnicity background, or deprivation score between groups (table ). Disease severity necessitating oxygen therapy or ventilatory support was infrequent in both waves and was lower as a proportion of total admission in the second wave than in the first (table). Table Patient characteristics Wave 1 (March 1, to May 31, 2020) Wave 2 (Nov 1, 2020, to Jan 19, 2021) Number of patients 20 60 Age, years 1 (0·1–11) 6 (0·7–13) Sex Male 9 (45%) 40 (67%) Female 11 (55%) 20 (33%) Comorbidities 7 (35%) 25 (42%) BAME ethnicity 6 (46%; n=13) 20 (42%; n=48) IMD score 28·3 (11·6–36·1) 20·5 (14·7–32·2) Clinical severity (modified WHO definition)* Critical disease 4 (20%) 2 (3%) Severe disease 1 (5%) 3 (5%) Moderate disease 5 (25%) 8 (13%) Mild disease 8 (40%) 27 (45%) Asymptomatic or incidental findings 2 (10%) 20 (33%) Management Oxygen 7 (35%) 5 (8%) Non-invasive ventilation 3 (15%) 2 (3%) Invasive ventilation 4 (20%) 1 (2%) Remdesivir 1 (5%) 4 (7%) Steroids (low dose) 0 5 (8%) Monoclonal antibodies (casirivimab and imdevimab) 0 1 (2%) Data are n, n (%), or median (IQR), unless otherwise specified. BAME=Black, Asian, and minority ethnicity. IMD=Index of Multiple Deprivation score. * For the modified WHO definition see the appendix). These early second wave data show that many children and young people have been admitted to hospital. This might be due to the higher prevalence of SARS-CoV-2 within our local community. Indeed, the number of adult patients admitted to King's College Hospital in the second wave has also increased by about a third. Importantly, we have found no evidence of more severe disease having occurred in children and young people during the second wave, suggesting that infection with the B.1.1.7 variant does not result in an appreciably different clinical course to the original strain. These findings are in keeping with early national data. Severe acute respiratory COVID-19 remains an uncommon occurrence in children and young people.

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New variant of SARS-CoV-2 in UK causes surge of COVID-19

Tony Kirby (2021)

For most of November, 2020, England was in lockdown to force down the incidence of COVID-19 cases that had steadily increased in the late summer and autumn. Other countries in the UK (Wales, Scotland, and Northern Ireland) had also been reimposing and subsequently lifting restrictions, since each of the four nations is in charge of its own COVID-19 control plans. For a while, the strategy in England appeared to have worked, with many areas that previously had high case incidence seeing rates drop sharply in November, including northwest England and Yorkshire, areas which had previously seen some of the highest incidence rates in the UK. However, it soon became apparent that the English lockdown had not had the same effect in every region. In Kent, a large county in the southeast, cases actually continued to increase during the lockdown, despite having the same restrictions as other regions. When, on Dec 2, 2020, England lifted its lockdown and moved back into a three-level tiered restrictions system, cases continued to increase sharply in Kent and then rapidly in Greater London and other parts of the southeast. And despite the approval of two vaccines in recent weeks, the UK now faces a race against time to vaccinate as many vulnerable and elderly people as possible. The reason: a new variant of SARS-CoV-2, which various modelling exercises have estimated to be up to 70% more transmissible than the previously circulating form of the virus. In September, 2020, this variant represented just one in four new diagnoses of COVID-19, whereas by mid-December, this had increased to almost two thirds of new cases in London. UK Prime Minister, Boris Johnson, decided with his scientific advisors that he had no credible alternative other than to impose even stricter restrictions on these parts of England, creating a new tier 4, which meant all non-essential shops and gyms closed, and people were asked to stay at home wherever possible (hospitality venues already had to close in tier 3). However, until late December, 2020, the proportion of cases caused by the new variant were much lower in other parts of the country, with the northwest region that includes Liverpool and Manchester recording only 1 in 20 new cases of COVID-19 that were due to the new variant. As a result, many parts of England continued in the lower tier of restrictions, until on Dec 30, 2020, Johnson, in response to surging numbers of new diagnoses including an all-time high of 53 000 on Dec 29, 2020, decided to move all parts of England into tier 3 or 4. This effectively meant that no restaurants, bars, or other hospitality venues would be open on New Year's Eve. However, the latest data (early January, 2021) shows that cases due to the new variant are increasing in all areas of the country, although the south and southeast continue to be the worst affected. Commentators have questioned the logic of this move, and called instead for an England-wide lockdown equivalent to tier 4 restrictions. Scotland, Wales, and Northern Ireland are already in such nationwide lockdowns. “It is good that the majority of the country is in tier 4 as there is evidence we need at least this level of restriction to prevent rapid spread of the new variant”, explains Andrew Hayward, Professor of Infectious Disease Epidemiology and Inclusion Health Research at University College London, London, UK. Hayward, who is a member of the UK Government's Scientific Advisory Group for Emergencies (SAGE), adds: “The areas that are not currently in tier 4 can expect rapid increases in new variant cases which will likely lead to them needing to move into tier 4. Doing that now, instead of later, would prevent unnecessary hospitalisations and deaths and may decrease the length of time they need to be in tier 4.” At the time that this article went to press, the UK Government had been determined that school children would all be returning to school, albeit in a staggered fashion, immediately after the Christmas and New Year holidays. However, this plan is now in doubt, with the government suggesting only primary school children and secondary school children who are in important exam years (essentially 16 and 18 year olds) will return to the classroom immediately. Then, on New Year's Day, 2021, the Government announced a sudden change in strategy—all primary schools in London were told not to reopen as planned on Jan 4. There were calls (including from teachers' unions) to delay reopening of primary schools in all of England for 2 weeks, but in a hastily arranged television interview on the morning of Sunday Jan 3, Johnson said that only primary schools in the areas worst affected by the new variant would not reopen. He told the BBC that there is “no doubt in my mind that schools are safe” but did not rule out further closures. The leader of the opposition Labour Party, Kier Starmer, said in response that the virus was out of control and further school closures were “inevitable”. Starmer is among those calling for an immediate nationwide lockdown. Hayward explains that the decision to close schools or not could be the key factor in whether or not cases continue to increase. He said: “There is a high likelihood tier 4 will be insufficient to reduce the R number to below 1. Cases will continue to increase, albeit more slowly. This is based on the observation that the new strain increased in Kent and the southeast during lockdown, which is a more severe restriction than the current tier 4. Schools and universities being open may make the difference between being able to reduce R below 1 or not.” Following the latest announcements from the Prime Minster, Hayward adds that: “Even though schools have been provided with detailed guidance, and financial and practical support, it will be extremely challenging to implement mass testing of all pupils within the expected timeframes along with serial testing of classroom and other contacts of positive cases. The uptake and impact of school mass testing programmes is highly uncertain, as is the extent to which the new strain will increase transmission in schools and from school children to the wider community.” © 2021 Caia Image/Science Photo Library 2021 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. According to research published on Dec 29, 2020, by the UK Health Agency Public Health England, the new variant appears to be no worse than the previous dominant strain of SARS-CoV-2 in terms of the risk of hospital admission, severity of illness, or mortality. The UK is confronting this new variant during the same month that two vaccines against the virus have been approved; the Pfizer-BioNTech and the Oxford-Astra Zeneca vaccines. The Oxford vaccine in particular has raised hopes that the UK could regain control and turn the tide on the COVID-19 pandemic by as early as April 2021, since its storage requirements are a lot less complex than the deep cold required for the transport and storage of the Pfizer vaccine. This means that it will be far easier for vital vaccine supplies to reach, and be stored at, venues such as care homes for the elderly. Vaccinations with the new Oxford vaccine were due to begin across the UK on Jan 4, while vaccinations with the Pfizer-BioNTech vaccine continue. In another key policy shift, the UK's medical experts said it was crucial to inoculate as many vulnerable people as possible with the first dose, since this would offer the most protection, rather than giving people the regular two-dose schedule of either vaccine. The second dose, they explained, can be given in the subsequent weeks or months after mortality and admissions have hopefully stablised. At a media briefing on Dec 30, 2020, PM Johnson said: “The public must redouble its efforts to control the virus at this critical moment” before adding he was confident the country's situation will be “very much better” by April 5, 2021 (Easter weekend). “All of these measures in the end are designed to save lives and protect the NHS. For that very reason, I must ask you [the public] to follow the rules where you live tomorrow night and see in the new year safely at home.” However, the new variant has piled additional pressure on to the speed at which vaccination must be achieved. Hayward is worried that, just as had been possible in the first wave, very vulnerable people, such as the homeless, could be ruthlessly exposed due to plunging winter temperatures and the failure of the UK government to so far provide local authorities with the resources to house homeless people in single room accommodation, mainly hotels, which are mostly standing empty due to the temporary death of the tourism industry. Back in March, 2020, the government helped the appropriate agencies and organisations get everybody off the streets and into such accommodation. “Many homeless people have this time had to stay on the street because of the dangers of opening communal night shelters and alternative provision not being available. This new coronavirus variant especially could cause havoc and a huge surge of cases in people least equipped to face them”, says Hayward. The charity Crisis at Christmas has housed large numbers temporarily in single room accommodation over the Christmas period, but they will need to return to the streets in early January. Hayward warns that: “If there are severe cold weather spells after this it is likely communal shelters will need to open to prevent people freezing. Due to the government's failure so far to repeat their efforts of earlier this year, homeless people are currently facing a stark choice between the dangers of cold or the dangers of COVID-19.” The UK remains one of the most badly affected countries. As of Dec 30, 2020, it had recorded more than 2 million cases of infection and more than 70 000 deaths. Driven by the new variant's increased infectiousness, the UK has reported more than 50 000 cases a day (a new record) in the last few days of December and the first few days of the new year. Almost 1000 deaths were reported on Dec 30, 2020, alone, and there are fears that the pandemic may get very much worse in the country before it gets better. However, the hope is that deaths and hospitalisations will plummet as the number of elderly and vulnerable people receiving the vaccine sharply increases in the coming weeks. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/948152/Technical_Briefing_VOC202012-2_Briefing_2_FINAL.pdf

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Ethnicity and COVID-19 in children with comorbidities

Katharine Harman, Anita Verma, James Cook … (2020)

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread through human populations worldwide, presenting across a spectrum of severity from asymptomatic carriage to respiratory failure and death.1, 2 In adults, comorbidities, including advanced age, diabetes, and cardiovascular disease, are associated with severe disease and the highest risk of mortality.3, 4 In the UK and USA, which are countries with ethnically diverse populations, mortality is disproportionately high in minority groups. 5 Little is known about COVID-19 in children. Population data from China and Italy indicate that children are mildly affected in comparison to adults, representing approximately 5% of cases and less than 1% of admissions to hospital.6, 7 These data do not describe any association between comorbidities and severe disease in children, and are mostly derived from populations that are ethnically homogenous. We describe the effect of COVID-19 on paediatric patients with comorbidities and aim to facilitate rapid sharing of information in this dynamic and evolving situation. Children (aged 0–16 years) with confirmed COVID-19 and comorbidities who required admission to hospital were prospectively identified from King's College Hospital, London, UK, between Feb 25, 2020, and April 28, 2020. Demographic and clinical data were collected from electronic patient records or the clinical information system of the paediatric intensive care unit, or both. Combined nose and throat samples were tested by qualitative real-time RT-PCR targeting the RNA polymerase region. It uses two probes, one being specific to the SARS-CoV-2, which will not pick up the closely related severe acute respiratory syndrome coronavirus (SARS-CoV), and the second covering a broader specificity of SARS-CoV, SARS-CoV-2, and severe acute respiratory syndrome-related bat coronaviruses. 8 Samples were tested using KingFisher Flex automated RNA extraction (ThermoFisher Scientific) followed by Tecan robotics and detection on the QuantstudioTM 7 Flex Real-Time PCR System (ThermoFisher Scientific). All patients had extensive septic screening, including blood, urine, and respiratory secretions for bacterial and fungal cultures, and viral PCR for Epstein-barr virus, cytomegalovirus, herpes simplex virus, adenovirus, and hepatitis viruses in patients with liver disease. Fungal infection biomarkers (β-D-glucan and galactomannan) were measured weekly. We identified five children with COVID-19 and comorbidities requiring admission to hospital (appendix p 1). The mean age was 7·1 years (range 0·2–15·3). Two (40%) of five patients were aged less than 1 year and two patients (40%) were male. The most common symptoms on admission were fever (three patients [60%]) and tachypnoea (three patients [60%]). The pre-existing comorbidities included cerebral palsy, prematurity, Wilson disease, and dilated cardiomyopathy. Four patients (80%) were from a black, Asian, and minority ethnic (BAME) group. Investigations showed that three patients (60%) had lymphopenia and the same three patients had thrombocytopenia (appendix p 2). Of the four patients that had CRP measurements, three (75%) had elevated measurements. Radiographic evidence of new infiltrates was seen in two (50%) of four patients who had chest x-ray because of clinical indication. Respiratory support was required in three (60%) of five patients, of which two patients needed mechanical ventilation in the intensive care unit. All five children received antibiotics, one child received antiviral therapy (remdesivir) on compassionate grounds, and one child was treated with hydroxychloroquine. There were no side effects noted in either patient. Liver dysfunction was observed in four patients (80%), although two of these patients had underlying liver conditions (one patient was newly diagnosed), and renal dysfunction was detected in one patient. The child with Wilson disease underwent a liver transplant 3 weeks after the diagnosis of COVID-19 because of persistent coagulopathy and liver failure and is progressing well post-transplant. As of May 20, 2020, four patients have been discharged and one is still an inpatient, with a median length of stay of 20 days (range 7–84 days). None of the patients had signs or symptoms on admission that might have been compatible with the newly described syndrome: paediatric multisystem inflammatory syndrome temporally associated with COVID-19, as according to the Royal College of Paediatrics and Child Health guidelines. During the same period of time, seven children without comorbidities were admitted to hospital with COVID-19. The mean age was 4·8 years (range 0–15·4) and five patients (71%) were male. Five patients were from a BAME group and two were white. None of the patients were classified as obese. The most common signs on admission were fever (six patients [86%])) and tachypnoea (five patients [71%]). Median length of stay was 3 days (range 1–8). One of the patients was admitted to hospital for safeguarding concerns and another was a neonate with vertical transmission of COVID-19. Our cohort included patients with substantial comorbidities, in which the clinical course of COVID-19 has not been previously described. Overall, the number of children admitted was small (12 [0·5%]) in comparison with admissions to the adult wards (2288). However, despite the small number of children admitted to hospital, several important themes emerge: the wide range in severity of the disease, frequent multi-organ involvement, and that most patients were from BAME populations. Our hospital admissions covered a range of severity, from mild disease to critically unwell patients. The two patients that required intensive care unit admission had comorbidities associated with respiratory disease. Patient 1 had chronic lung disease on previous radiography, with severe scoliosis contributing to respiratory compromise. Patient 2 was born at 27 weeks preterm and despite being discharged home without oxygen, he had evidence of chronic lung disease of prematurity on previous imaging. Patient 3, by contrast, had severe chronic lung disease of prematurity, requiring ventilation via tracheostomy at baseline but required only increased oxygen during the admission. At the other end of the extreme, patient 4 had Wilson disease and presented with liver failure. It was unclear whether COVID-19 or the pre-existing condition had caused the liver failure. Patient 4 and patient 5 did not have respiratory symptoms. Four (80%) of five patients with comorbidities had multi-organ involvement. The liver was the most frequently affected organ. Patient 4 had an underlying liver condition, although the positive COVID-19 status coincided with worsening liver derangement. Reports suggest that approximately a third of adult patients with COVID-19 have some abnormalities on a liver function test. It is unclear whether the liver dysfunction is due to the viral damage per se, or whether the coexistence of systemic inflammatory response, respiratory distress syndrome-induced hypoxia, and multiple organ dysfunction might contribute. 9 Acute kidney injury is reported in approximately 25% of adults with COVID-19 with acute respiratory distress syndrome; however, little is known about the prevalence of acute kidney injury in children with COVID-19. 2 Only one child in this cohort had renal dysfunction, which was thought to be mostly due to prerenal acute renal failure. Four (80%) of five patients with comorbidities were from BAME groups. In the wider group of paediatric patients admitted to hospital with COVID-19, nine (75%) of 12 patients were from a BAME group. This partly reflects the population of inner London, where ethnic minorities make up 39% of the population compared to just 13% in the rest of the UK. BAME communities might be at increased risk of adverse outcomes for several reasons, including genetic influences on susceptibility and cultural, behavioural, and societal differences (eg, differences in socioeconomic status, health-care seeking behaviour, cohabitation arrangements, and amount of overcrowding in the environment).10, 11 Although hospitalisation for COVID-19 is rare in children, ethnicity and the presence of pre-existing comorbidities might be independent risk factors for severe disease.

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Horizontal transmission of severe acute respiratory syndrome coronavirus 2 to a premature infant: multiple organ injury and association with markers of inflammation

James Cook, Katharine Harman, Bogdana Zoica … (2020)

A male infant, born at 27 weeks' gestation, presented to our emergency department at 8 weeks of age (35 weeks corrected gestational age) following a 2-day history of poor feeding, sneezing, and dyspnoea. The infant had required 3 days of ventilation after birth because of neonatal respiratory distress syndrome, and had been fed with maternal expressed breast milk from day 3 of life. He had been discharged from the neonatal unit 10 days before presentation, in good health, with no ongoing respiratory support. There had been no cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on the neonatal unit before or following discharge, members of the infant's household (parents and a 4-year-old sibling) were asymptomatic, and there were no other reported contacts. On initial assessment, the infant was in respiratory failure and presumed septic shock. Blood pressure was unrecordable, and severe lactic acidosis was identified (venous blood pH 6·8, lactate 22 mmol/L). Resuscitation was commenced and respiratory support was instituted. The infant was ventilated with an initial fraction of inspired oxygen (FiO2) of 1·00 (figure 1 ). Empirical antimicrobial treatment (cefotaxime [50 mg/kg every 8 h], clarithromycin [15 mg/kg every 12 h], amoxicillin [30 mg/kg every 8 h], and gentamicin [5 mg/kg once a day]) and antiviral treatment (aciclovir [20 mg/kg every 8 h]) were initiated intravenously. A complete septic screen was done. A chest X-ray showed bilateral airspace opacification (figure 2 ), and quantitative RT-PCR showed that the patient's nasopharyngeal swab sample was positive for SARS-CoV-2. A blood culture, taken on admission, was positive for Staphylococcus epidermidis, at which point intravenous vancomycin (10 mg/kg three times a day) was initiated as a targeted treatment. Subsequent blood cultures on hospital days 3 and 5 and all vascular catheter tip cultures were negative. Bacterial cultures of cerebrospinal fluid, urine, and respiratory secretions were negative, and quantitative RT-PCR analysis of respiratory secretions identified no other common respiratory viruses. Figure 1 Timeline of hospital stay, symptoms, treatment, and investigations ICU=intensive care unit. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. Figure 2 Chest X-rays (A) Bilateral airspace opacification was visible on admission. (B) Repeat X-ray (hospital day 8) showed worsening bilateral airspace opacification consistent with acute respiratory distress syndrome. Over the first week following admission, biochemical evidence of renal and liver dysfunction resolved (figure 3 ). Normal cardiac function was shown on echocardiogram, and cardiac rhythm remained sinus. However, the infant became increasingly difficult to ventilate and repeat chest X-rays on hospital day 8 showed worsening bilateral airspace opacification consistent with acute respiratory distress syndrome (figure 2). On hospital day 8, conventional ventilation at high pressures (27/10 cm H2O) was considered to be failing, with a partial pressure of carbon dioxide of 12 kPa and FiO2 of 1·00. High-frequency oscillatory ventilation was commenced in conjunction with continuous inhaled nitric oxide and prone positioning. Antimicrobial treatment was optimised for a respiratory focus of infection, with the cessation of cefotaxime and initiation of intravenous meropenem (20 mg/kg every 12 h). The antiviral remdesivir was prescribed on compassionate grounds and administered intravenously (2·5 mg/kg loading dose, followed by 1·25 mg/kg daily for 10 days; figure 1). Figure 3 Longitudinal measurements of viral load, oxygen requirement, and laboratory findings Normal ranges: IL6 80 pg/mL compared with those with lower IL6 concentrations. 8 Respiratory improvement in this infant appeared to be associated with a decrease in IL6 concentration, ferritin, and lactate dehydrogenase, rather than a decrease in viral load, suggesting that the host pulmonary inflammatory response might have been important with regard to respiratory failure. At the point of respiratory deterioration, remdesivir was also prescribed. Remdesivir is a prodrug of a nucleotide analogue that inhibits viral RNA polymerases, and in-vitro testing has shown activity against SARS-CoV-2. 9 Outcomes of an adult cohort with severe COVID-19 treated with remdesivir have recently been published, although viral load in these patients was not reported. 10 The stable viral load in our patient does not suggest that remdesivir was important in the clinical improvement of this infant. No side-effects from remdesivir were apparent at the time of writing. SARS-CoV-2 can cause severe disease in infants, resulting in multiple organ injury. The severity of respiratory disease might be related to the host inflammatory response, as seen in adults with COVID-19. Detailed monitoring of the inflammation is recommended in paediatric severe disease, modulation of which might represent a potential avenue of treatment.

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Journal ID (nlm-ta): Lancet Child Adolesc Health

Journal ID (iso-abbrev): Lancet Child Adolesc Health

Title: The Lancet. Child & Adolescent Health

Publisher: Elsevier Ltd.

ISSN (Print): 2352-4642

ISSN (Electronic): 2352-4650

Publication date PMC-release: 10 February 2021

Publication date (Electronic): 10 February 2021

Affiliations

[a ]Department of Paediatric Respiratory Medicine, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK

[b ]Department of Infection Science and Virology, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK

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Publisher Item ID: S2352-4642(21)00030-4

DOI: 10.1016/S2352-4642(21)00030-4

PMC ID: 7906637

PubMed ID: 33581054

SO-VID: 36a3fbde-2870-4447-9a87-e020ebdea816

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

Effect of the new SARS-CoV-2 variant B.1.1.7 on children and young people

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New variant of SARS-CoV-2 in UK causes surge of COVID-19

Ethnicity and COVID-19 in children with comorbidities

Horizontal transmission of severe acute respiratory syndrome coronavirus 2 to a premature infant: multiple organ injury and association with markers of inflammation

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