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by: Megan Schellong

Posted: / Updated:

Boys and girls sitting at desks, raising hands (Getty Images).

Lansing, Mich. (WLNS) - State health officials reported K-12 schools are the top hot spot for new COVID-19 outbreaks in Michigan.

In total, sate health officials today reported 103 new outbreaks across 21 different settings in the state.

Looking at the trend, COVID-19 outbreaks are up in K-12 school settings for the second week in a row with 27 new outbreaks.

Back in January, new COVID-19 outbreaks in K-12 schools reached an all-time low of two new outbreaks on both Jan 4 and Jan 11.

Which schools?

Outbreaks were reported in the following counties in K-12 schools. WLNS TV 6 has listed the school names for those located in the Mid-Michigan area. The full list of K-12 schools with new COVID-19 outbreaks is available here.

Bay

Cass

Cheboygan

Detroit

Eaton- Hayes Middle School, Waverly High School, Grand Ledge High School, Charlotte High School

Genesee

Hillsdale- Hillsdale High School

Ingham - Okemos High School

Jackson- Spring Arbor University, Portage Central Elementary

Kalamazoo

Leelanau

Macomb

Marquette

Midland

Saginaw

Sanilac

Wayne

Across the state, the top three settings for COVID-19 outbreaks are K-12 school settings, long-term care facilities and manufacturing and construction.

These three sites have consistently ranked in the top 3 settings for new COVID-19 outbreaks in Michigan throughout the pandemic.

Trends in other settings

New outbreaks in retail settings among employees are up by 3 new outbreaks.

Office settings saw an increase of 2 new outbreaks.

Religious services saw a drop down to 0 outbreaks from 2 the week prior.

New outbreaks in healthcare settings are up by 3.

None of these settings documented as many outbreaks as long-term care facilities, K-12 schools and manufacturing and construction.

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K-12 Schools are a hot spot for new COVID-19 outbreaks, according to state health data

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Lansing, Mich. (WLNS) - State health officials reported K-12 schools are the top hot spot for new COVID-19 outbreaks in Michigan. In total, sate health officials today reported 103 new outbreaks across 21 different settings in the state. Looking at the trend, COVID-19 outbreaks are up in K-12 school settings for the second week in [...]

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New Jersey on Tuesday reported two new in-school outbreaks of the coronavirus, bringing the state's total to 144 outbreaks and 686 cases linked among students, teachers, and school staff this academic year.

Outbreaks - defined as cases in which people were confirmed to have caught or transmitted the virus in the classroom or during academic activities - have been reported in all 21 counties, according to the state's COVID-19 dashboard.

On Tuesday, New Jersey reported another 3,144 confirmed coronavirus cases of and 31 additional deaths, while more than 1 million people have received at least their first COVID-19 vaccine dose and more than 386,000 have been fully vaccinated.

The Garden State's seven-day average for new confirmed positive cases is now 2,797, down 8% from a week ago and down 48% from a month ago, as the second wave of the pandemic continues to show signs of easing.

New Jersey health officials do not identify the individual school districts that have suffered outbreaks and cases, but those numbers are broken down by county.

The state's totals do not include cases tied to school sports teams or cases in which contact tracers failed to conclude whether students and teachers caught the virus within their schools.

The total number of school cases by county are:

Bergen County: 32 confirmed outbreaks and 129 linked cases

Camden County: 14 confirmed outbreaks and 70 linked cases

Salem County: 13 confirmed outbreaks and 53 linked cases

Burlington County: 8 confirmed outbreaks and 26 linked cases

Cape May County: 8 confirmed outbreaks and 23 linked cases

Monmouth County: 8 confirmed outbreaks and 23 linked case

Warren County: 8 confirmed outbreaks and 20 linked cases

Cumberland County: 7 confirmed outbreaks and 14 linked cases

Gloucester County: 7 confirmed outbreaks and 42 linked cases

Passaic County: 7 confirmed outbreaks and 32 linked cases

Sussex County: 6 confirmed outbreaks and 15 linked cases

Atlantic County: 5 confirmed outbreaks and 14 linked cases

Ocean County: 5 confirmed outbreaks and 42 linked cases

Mercer County: 4 confirmed outbreaks and 18 linked cases

Somerset County: 3 confirmed outbreaks and 9 linked cases

Hudson County: 2 confirmed outbreaks and 10 linked cases

Hunterdon County: 2 confirmed outbreaks and 7 linked cases

Morris County: 2 confirmed outbreaks and 10 linked cases

Essex County: 1 confirmed outbreaks and 92 linked cases

Union County: 1 confirmed outbreaks and 23 linked cases

Middlesex County: 1 confirmed outbreaks and 3 linked cases

Our journalism needs your support. Please subscribe today to Adam Clark may be reached at aclark@njadvancemedia.com. NJ.com.

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COVID infections in N.J. schools increase to 144 outbreaks, 686 cases. Here's the county-by-county list.

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New Jersey on Tuesday reported two new in-school outbreaks of the coronavirus, bringing the state's total to 144 outbreaks and 686 cases linked among students, teachers, and school staff this academic year.

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School Outbreaks

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A total of 87 students and staff at 17 K-12 school districts and three colleges have been infected by coronavirus in new school-related outbreaks, according to data released Monday, Feb. 15, by the Michigan Department of Health and Human Services.

The biggest outbreak involves 24 students and staff at Forest Hills Central High School near Grand Rapids.

The three colleges with outbreaks involved nine students at Cleary University in Howell; eight students at Lawrence Tech in Southfield, and two students at College of Creative Studies in Detroit.

New K-12 school outbreaks also were identified in 10 counties. Below are those outbreaks listed by county:

Antrim County: Elk Rapids High School, two students.

Calhoun County: Westlake Elementary in Battle Creek, three students and staff.

Gladwin County: Gladwin Junior High, two students.

Kent County: Forest Hills Central, 24 students and staff

Lapeer County: Schickler Elementary in Lapeer, student and staffer; Dryden High School, five students and staff.

Mackinac County: St. Ignace LaSalle High School, two students.

Macomb County: Endeavor Middle School in Ray, four students.

Oakland County: Carpenter Elementary School in Lake Orion, staffer and student; Oakland University High School in Ferndale, two staff.

Ottawa County: Black River Public School in Holland, staffer and student; Cityside Middle School in Zeeland, two students; Jenison Christian School, two students.

St. Clair County: Marysville High School, five staff and students.

Wayne County: Barack Obama Leadership Academy in Detroit, five staff; Jalen Rose Leadership Academy in Detroit, two students; Divine Child Elementary School in Dearborn, two students.

A cumulative total of 8,255 individuals have been sickened in ongoing outbreaks, the Feb. 15 report says. Ongoing outbreaks include clusters identified earlier but that had at least one additional case in the past 28 days.

Most of those ongoing outbreaks involve college communities, and most of those outbreaks occurred outside classroom settings. A total of 7,689 infections linked to ongoing outbreaks have occurred in and around 21 college communities.

Among K-12 schools, there were 566 staff and students infected in ongoing outbreaks at 93 schools serving pre-K through high school. The latest list includes buildings with at least one case in the past 28 days.

The largest ongoing outbreaks in K-12 schools: 47 infected at Lapeer High School; 24 at the LISD Tech Center in Adrian; 23 at North Branch Elementary in Ubly; and 20 each at Ubly Junior High and

Outbreak data for K-12 schools includes only cases in which the student or staff was infected at school or at a school-related function. Those who caught the virus outside of school are not included.

A COVID-19 outbreak is defined as two or more cases with a link by place and time indicating a shared exposure outside of a household.

Below is an online database that allows readers to search outbreak data by school name or by city or county. The number of those infected is a cumulative total since the original outbreak.

Below is an interactive map showing both new and ongoing outbreaks listed in the Monday, Feb. 15, report. You can put your cursor over a dot to see the underlying data.
Read more on MLive: Michigan administers more than 1.5M doses of COVID-19 vaccine Mental health struggles are surging in Michigan families during the pandemic. Here are their stories. The pandemic's psychological toll on our children Father of Capitol rioter helped thwart potential 2005 terrorist attack linked to Oklahoma City bombing

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87 infected in new coronavirus outbreaks at 20 schools, says Michigan's Feb. 15 school outbreak report

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A total of 87 students and staff at 17 K-12 school districts and three colleges have been infected by coronavirus in new school-related outbreaks, according to data released Monday, Feb. 15, by the Michigan Department of Health and Human Services. The biggest outbreak involves 24 students and staff at Forest Hills Central High School near Grand Rapids.

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Two days after the Escondido Union School District returned to hybrid-model in-classroom teaching, 81 students and 18 staff members at four schools have been quarantined.

The members of the community were quarantined after seven different students tested positive at four different schools. According to the district's COVID-19 dashboard:

Four of the positive cases are at Farr Elementary, leading to 44 students and 5 staff members being placed under quarantine

At Pioneer Elementary, 1 positive case has led to 9 students and 2 staff members being quarantined

At Rock Springs Elementary, 12 students have been quarantined as the result of 1 positive case.

At Mission Middle School. 16 students and 4 staff members were quarantined after a single positive case

In addition, one positive case has led to four people being quarantined from the district's maintenance and operations department.

As alarming as the numbers may look, the district's superintendent said the positive cases and quarantines are not unexpected.

"Any time you get one case, of course, it's alarming," Superintendent Luis Rankins-Ibarra said. "But we've got protocols in place and the quarantines occur as a precautionary measure."

The quarantines are likely to re-ignite the debate on the return to in-class teaching. In fact, Escondido Elementary Educators Association president Romero Maratea said the quarantines raise a tremendous concern.

"Our concerns about reopening now, which we expressed to the school board and superintendent, were primarily a result of the prevalence of the virus in Escondido as compared to other areas of the county," Maratea wrote in an email sent to NBC 7. "The numbers have spoken for themselves."

Under new public health guidelines, the quarantines last 10 days, which has been reduced from a previous guideline of two weeks.

The superintendent is confident the positive cases were not transmitted on campus but, rather, were brought in from the community.

Rankins-Ibarra also said robust safety protocols are in place, including temperature checks prior to students entering class, portable air-filtration systems in classrooms, spacing between desks, and compulsory mask wearing in classrooms. The students who tested positive may have been asymptomatic, which would explain how they were able to get into classrooms.

The elementary school hybrid model in the district allows for a maximum of 12 students in class. There are morning and afternoon cohorts, with students attending class four half-days a week.

Rankins-Ibarra said the decision to return to in-class instruction was made based on COVID-19 metrics trending in a positive direction recently

"It was really following the data, following the case rates and the percentage of positivity rates," Rankins-Ibarra said.

"We believe we can sustain this for a long period of time," Rankins-Ibarra added. "I would have not recommended reopening if we were going to go right back into a full district closure or schools would suddenly going into closures."

Romero told NBC 7 that educators were concerned about just that -- the prospect of infections forcing the district to cycle between repeated closures.

"Our primary concern is for the safety of students, families and staff, some of which have already lost loved ones to the virus," Romero wrote. "The second concern is whether a return to campuses is sustainable. Parents and staff have voiced strong concern regarding the "on-again-off-again" scenario which has played out in our district. The numbers since live teaching and learning resumed this week are, unfortunately, not overly encouraging, and we must always remember that numbers represent real people."

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100-Plus Escondido Union School District Staffers, Students Quarantined

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Two days after the Escondido Union School District returned to hybrid-model in-classroom teaching, 81 students and 18 staff members at four schools have been quarantined. The members of the community were quarantined after seven different students tested positive at four different schools.

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Categories of Disability

SDC/MS
Severely Disabled
Profoundly Disabled
Intellectual Delay
Intellectual Disability
Medically Fragile
Medically Complex

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A total of 129 students and staff at 34 K-12 school districts and four colleges have been infected by coronavirus in new school-related outbreaks, according to data released Monday, Feb. 1, by the Michigan Department of Health and Human Services.

The biggest outbreak involved 20 students and staff at Washington Middle School, which is part of the Calumet school district in the Upper Peninsula.

Three other schools also have new outbreaks in the double-digits: Andrews College had 11 students and staff infected; Alma College had an outbreak involving 10 students, and 11 students and staff tested positive at East Jordan High School near Charlevoix.

In addition to Andrews and Alma, new college outbreaks were reported by Lake Superior State University, where eight students were infected, and at Olivet College, with two students infected.

New K-12 school outbreaks also were identified in 17 counties. Below are those outbreaks listed by county:

Barry County: Star Elementary in Hastings (three staff and students); Fuller Elementary in Nashville (three staff and students), Southeastern Elementary in Hastings (two students).

Calhoun County: Harrington Elementary in Albion (two staff).

Charlevoix County: East Jordan High School (11 staff and students) and East Jordan Preschool (two students).

Eaton County: Delta Mills Early Childhood Center in Lansing (two students); Greyhound Intermediate in Eaton Rapids (one staff and one student); Galewood Elementary in Charlotte(two students); Olivet High School (two students).

Emmet County: St. Michael's Academy in Petoskey (four students); Alanson Head Start (two staff and students).

Houghton County: Washington Middle School in Calumet (20 staff and students).

Huron County: Huron Area Tech Center in Bad Axe (four staff and students); North Huron School in Kinde (three staff and students).

Jackson County: George Long Elementary in Grass Lake (two staff and students); Napoleon High School (two students); Springport High School (two students).

Kalamazoo County: Mattawan High School (two students).

Lenawee County: LISD Porter Center (three staff and students).

Livingston County: Howell High School (two students); bus transportation for Three Fires and Southwest elementaries in Howell (two students).

Manistee County: Bear Lake Elementary School (two staff and students).

Missaukee County: Northern Michigan Christian in McBain (three staff).

Newaygo County: Fremont Christian School in Fremont (two staff).

Ottawa County: New Groningen Elementary School in Zeeland (one staff and one student); White Pines Middle School in Grand Haven (two students); Unity Christian School in Hudsonville (two students); Zeeland East High School (two students).

Washtenaw County: Dexter Middle School (two staff).

Wexford County: Buckley Middle School (two students).

A cumulative total of 6,907 have been sickened in ongoing outbreaks, the Feb. 1 report says. Ongoing outbreaks include clusters identified earlier but that had at least one additional case in the past 28 days.

Most of those ongoing outbreaks involve college communities, and most of those outbreaks occurred outside classroom settings. A total of 6,523 infections linked to ongoing outbreaks have occurred in and around 14 college communities.

Among K-12 schools, there were 384 staff and students infected in ongoing outbreaks at 55 schools serving pre-K through high school. The latest list includes buildings with at least one case in the past 28 days.

Outbreak data for K-12 schools includes only cases in which the student or staff was infected at school or at a school-related function. Those who caught the virus outside of school are not included.

A COVID-19 outbreak is defined as two or more cases with a link by place and time indicating a shared exposure outside of a household.

Monday's report is based on data collected Thursday, Jan. 28.

Below is an online database that allows readers to search outbreak data by school name or by county. The number of those infected is a cumulative total since the original outbreak.

Below is an interactive map showing both new and ongoing outbreaks listed in the Monday, Feb. 1, report. You can put your cursor over a dot to see the underlying data.
Read more on MLive: Restaurants reopen today for indoor dining - here are Michigan's new rules Double masking as coronavirus variants spread, where to find the right masks 9% of Michigan adults vaccinated against COVID-19 so far; see numbers in your county

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129 infected in 38 new coronavirus outbreaks, says Michigan's Feb. 1 school outbreak report

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A total of 129 students and staff at 34 K-12 school districts and four colleges have been infected by coronavirus in new school-related outbreaks, according to data released Monday, Feb. 1, by the Michigan Department of Health and Human Services.

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Equipment Positioning Team
Lift and Transfer Team
Seizure Response Team
Positioning

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For Walton Special Center teachers, "It's all love"

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Sunday

For more than 40 years, Walton Special Center has provided a nurturing environment for the most severely disabled students in Stockton Unified. Teachers and other staff members work with students ages 3-22.

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For Walton Special Center teachers, 'it's all love'

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Sunday For more than 40 years, Walton Special Center has provided a nurturing environment for the most severely disabled students in Stockton Unified. Teachers and other staff members work with students ages 3-22.

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Respiratory illness in children with disability: a serious problem?

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Respiratory illness in children with disability: a serious problem?

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Could autism spectrum disorders be a risk factor for COVID-19?

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Could autism spectrum disorders be a risk factor for COVID-19?

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Abstract

The coronavirus SARS-CoV-2 pandemia is infecting millions of people and some studies relate conditions that might increase the risk of developing a fatal course for the disease, such as diabetes, cardiovascular diseases and obesity. In COVID-19 physiopathology, one of the main inflammation mechanisms is the "cytokine storm", causing a pro-inflammatory state, related to cardiac and pulmonary damage. There is also a less effective role of lymphocyte B and T in the humoral immunity due to the reduction of their proliferative response. The physiopathology of ASD (Autism Spectrum Disorder) involves several modifications at the genetic and at the immune level, such as the increase of inflammatory cytokines and abnormal immune response in several levels. We hypothesize that ASD could be a risk-factor as the other conditions are.

Keywords: Coronavirus, SARS-CoV-2, COVID-19, Autism Spectrum Disorder, Risk Factor

Introduction

The coronavirus SARS-CoV-2 infection surprised the world with the spread of a new pandemia, spreading itself through over 200 countries and infecting millions of people. Its main manifestation is a flu-like syndrome that can evolve rapidly into an atypical pneumonia and affect other important systems, such as cardiovascular, digestive and immune systems , .

Some studies started relating conditions that might increase the risk of developing a fatal course for the disease , . Are included diabetes, hypertension, cardiovascular and coronary diseases, and obesity. These comorbidities present a large inflammatory component, which directly modulates the individual's immune system, increasing its vulnerability to the virus .

Approximately 1.6% of American children aged 8 years old had an ASD and it is estimated an international prevalence of 0,76% , . Epidemiology also estimate that more patients are men, with the rate of 3:1 . There has been a worldwide tendency of increase in ASD prevalence in the last few years, which could be explained by changes in diagnostic practice, coding tendency and community awareness. However, ASD prevalence could be increasing due to changes in true risk factors . Furthermore, data analysis regarding the rise of frequency in this condition should be cautious.

The physiopathology of ASD (Autism Spectrum Disorder) involves several modifications at the genetic and at the immune level, such as the increase of inflammatory cytokines and abnormal immune response in several levels . Some of these modifications are common in the conditions that are considered risk-factor to symptomatic COVID-19 and its worse outcome, and it is possible to stablish a correlation between them.

Since ASD is a disorders that affects a small, but growing and expressive portion of world's population, and the fact that we do not yet fully understand the entire physiopathology of COVID-19, we would like with this article bring known data that can support the hypothesis of ASD being a risk-factor as the other conditions are.

Coronavirus disease 2019 (COVID-19)

Clinically, the infection and the immune response manifest in two phases. Initially there is an endogenous immune response, which depends on individual health and genetic characteristics, which prevents the virus from spreading through organism. It is believed that has close relation to specific HLA and histocompatibility complex to activate the immunity. The response is linked to the destruction level of the virus, the patient's innate response, and it determines its inflammation status and symptomatology .

Studies that investigate COVID-19 physiopathology demonstrate that there is a second phase of hyper-activation of cytokines (known as "cytokine storm"), especially in respiratory epithelium . The main cytokines activated are IL-1-beta, IL-6 and TNF-alfa. They are related with aggravation of respiratory symptoms, particularly severe pneumonia and fatal acute lung injury. These cytokines act causing damage to the pulmonary microvasculature, while affecting apoptosis and chemotaxis, decreasing epithelial barriers and causing alveolar edema.

A correlation was also found between a secretory increase of ACE-2 (angiotensin-converting enzyme 2) and COVID-19 patients . ACE-2 is a regulator in angiotensin-2 transformation into angiotensin-, , , , , , , metabolite that has pro-inflammatory effects, causing vasodilatation, anti-proliferation and apoptosis, being a common way with cardiovascular diseases . In COVID-19 infection, there seem to exist an ACE-2 super-expression leading to a pro-inflammatory state, related to cardiac and pulmonary damage .

Risk factors for COVID-19

According to Wu et al , the main factors associated with the development of acute respiratory distress syndrome and death were neutrophilia, organ dysfunction, inflammation and older age. Neutrophils and inflammation are strictly related due its function of being a source of chemokines and cytokines, contributing to the "cytokine storm". Older age, contrarywise, presents a less vigorous immune response, exposing the organism to an inadequate protection against viral destruction.

A recent study demonstrated that a significant amount of patients (about 40%) of pneumonia due to COVID-19 in the city of Wuhan, China, presented cardiovascular and cerebrovascular diseases, such as diabetes and coronary disease . They were also more related to the development of acute respiratory distress syndrome. It is also revealed in the study that male patients are epidemiologically more related to the infection and with the severity of the pathological process.

There is a theory that male genetics are more vulnerable thanks to major expression on androgen receptors, considered to be primary factors in the genetic transcription of virus proteins (spike protein) . This relationship is also enhanced by the presence of polymorphically relation to an X chromosome-linked inheritance between the loci of androgen receptor genes and ACE-2 receptor gene. This way, it is believed that the hyperandrogenic phenotype is correlated to an increased viral load and viral spread, and with the severity of lung involvement.

Badawi and Ryoo had shown in their study that similar respiratory syndrome caused by coronavirus have a worse prognostic when associated with hypertension, diabetes and obesity .

In diabetes and obesity, occurs a chronic activation of neutrophils and macrophages - considering them as chronic inflammatory diseases . The increase of natural-killer cells and pro-inflammatory cytokines is related with higher lethality due to sepsis and multiple organ failure. There is also a metabolic disfunction associated with glucose, glutamine and fats, with their less to generate energy to combat acute events.

An additional mechanism causes the decrease of the immune system in these patients: a less effective role of lymphocyte B and T in the humoral immunity due to the reduction of their proliferative response , . It is also common the disfunction of chemotaxis and phagocytosis in the cellular immunity .

Coronaviruses have neuroinvasion and neurotropism characteristics, also causing demyelination and central nervous system (CNS) inflammation with a possible pathway through the olfactory nerve due to its nasal inoculation , . It is known that viral nervous dissemination is possible due to histopathological alterations in neurons located in cortex and hypothalamus, facilitated by proteins dinein and kinesin, affecting brain stem areas which regulate the respiratory rhythm . This could likewise be found in SARS-CoV-2 infection, although the data in literature are still insufficient to establish an association.

Autism spectrum disorder and co-morbidity

A large amount of patients with ASD shares co-occurring medical conditions. Attention Deficit Hyperactivity Disorder (ADHA) is commonly present within these patients, as well as others neuropsychiatric conditions such as intellectual disability, sleeping problems, anxiety, irritability, language and motor impairments . Gastrointestinal symptoms are seen in 47% of people with ASD . Epilepsy has a reported prevalence of 8-6% in autistic patients . The variety of other clinical conditions, which usually affects the immune system as well, should be considered when analyzing the role of chronic neuroinflammation among these patients.

Autism spectrum disorder and immune system

The concept of persistent inflammation of the CNS among patients with ASD and its role in neurodevelopmental outcome has been gaining increasing credibility. Proliferation of glial cells and subsequent release of multiple pro-inflammatory mediators, markedly cytokines and chemokines, lead to abnormal immune profiles and altered neural signaling and cognitive function .

Immune system dysregulation in ASD determines abnormal innate and adaptive immunity responses. Natural Killer (NK) cells from individuals with ASD present higher resting but reduced stimulated cytolytic activity, leading to an impaired response following injury stimulus and an excessive baseline level of activity .

Numerous studies in animal models established that a maternal immune activation could lead to macrophage inflammatory state, up-regulation of interferon-gamma (IFN-γ) and systemic deficits of T regulatory cells .

Studies suggest an alteration in cytokines profile in patients with ASD. Elevation of prenatal levels of IL-1 beta and IL-4 could be associated with cognitive development in autistic patients. Moreover, an increase of pro-inflammatory cytokines such as IL-1 beta, IL-1, IL-5, IL-6, IL-8, IL-12, IL-13, IL-17, 1L-23 and TNF-alfa is often seen in ASD patients, even in postnatal period .

Some alleles of human leukocyte antigens (HLA) were also associated with ASD. Higher frequencies of HLA-DRB1*03 and HLA-DRB1*11 were found in ASD children. This evidence support the theory of autism as an autoimmune disorder, leading to chronic neuroinflammation .

Autism spectrum disorder and COVID-19

People with low-grade chronic inflammation conditions, such as diabetes or chronic heart failure are at high risk of developing Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. This may be explained by a massive inflammatory activation - "cytokine storm" - facilitated by an already pro-inflammatory environment observed in these conditions . This supposition raises the question that patients with ASD, a chronic neuroinflammatory disorder, are at risk of poor outcome in COVID-19. The relation of factors is resumed in .

The neural pathway of coronavirus through the olfactory nerve could lead to a major immune response on CNS, leading to an important state of neuroinflammation. This state is also seen in ASD patients and could be related directly to the organism capacity of defense and to the functionality of the respiratory tract.

Although no major mutation has been identified as a genetic etiology for ASD, epidemiology shows that it is more common in male patients and some genetic syndromes, as the Fragile X, have some clinical resemble , straightening the possibility of a correlation with hyperandrogenic phenotype, as seen in SARS-CoV-2 infection.

It is important to make a parallel with the vulnerability of the older patients in COVID-19. Some studies have shown that ASD patients present higher levels of viral and bacterial seromarkers, as well as increased diagnosis of numerous infections, including common cold, being also considered more vulnerable, especially when they in the first three years of life . Although the mechanism is yet unclear, there can be similarities between the exposure and the risk in both conditions.

Conclusion

ASD patients present several comorbidities that usually potentialize their inflammatory system. Even though there are blank spaces in COVID-19 physiopathology, we know that patients who manifest endogenous inflammation tend to present a worst prognostic.

Given the complexity of COVID-19 and ASD, it is possible to notice a coincidence in immune and genetic factors in their physiopathology, particularly when it comes to comorbidities considered risk-factor for worse prognostic of the viral infection. Thus, further studies are necessary for the confirmation of this correlation.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We thank the Study Group on Neuroinflammation and Neurotoxicology of Autistic Spectrum Disorder - GENIT/UECE.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

References

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Could autism spectrum disorders be a risk factor for COVID-19?

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The coronavirus SARS-CoV-2 pandemia is infecting millions of people and some studies relate conditions that might increase the risk of developing a fatal course for the disease, such as diabetes, cardiovascular diseases and obesity. In COVID-19 physiopathology, one of the main inflammation mechanisms is the "cytokine storm", causing a pro-inflammatory state, related to cardiac and pulmonary damage.

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What Does “Medically Fragile Child” Mean?

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What Does “Medically Fragile Child” Mean?

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There are certain health ailments most children go through: Ear infections. Chickenpox. The common cold. Strep throat.

But what happens when you notice your child has more health issues than others? What if you received a diagnosis that requires long-term observation of your infant's well-being?

This blog's purpose is to provide you with some of the answers to questions often posed by parents of medically fragile children.

Definition of Medically Fragile

A medically fragile child is defined as a child whose medical conditions or health problems require 24-hour supervision from a skilled nurse. Often, they are not able to care for themselves and need help with basic activities, such as bathing and feeding themselves, regardless of age.

Medically fragile children sometimes need medical equipment to keep them alive. Some may require a skilled nurse to monitor their heart rate or breathing constantly. Others need to be hooked to a ventilator or be fed intravenously. They may need continuous physical therapy, a urinary catheter, or orthotics.

Hospital visits and doctor appointments are common. They become part and parcel of everyday life for the child and the child's family and will last for the entirety of the child's life.

What Causes a Child to Be Medically Fragile?

Several things can cause a child to become medically fragile. Among the most common are the following:

It's also common in children with debilitating chronic illnesses, such as:

Caring for a Medically Fragile Child

Caring for a medically fragile child is physically and emotionally demanding. They need someone to constantly watch them in case of seizures or if the child stops breathing.

It requires multiple doctor appointments on a regular basis. It may require various hospitalizations or numerous surgeries. It means knowing when to administer medications, and often, it means needing assistance from a specially trained medical caregiver.

This not only affects the child, but the entire family. There are plenty of support groups to help parents navigate this difficult life change.

There are also several things to consider when living with a medically fragile child, such as:

Becoming familiarized with the child's medical conditions

Becoming familiarized with how to care for the child

How to deal with side effects from medications

Figuring out health insurance coverage and how to financially care for the child

Modifications to the home to accommodate the child's needs

Long-term pediatric care

Backup generators to keep life support machines working if there's a power outage

How to schedule 24/7 care for the child

In addition to the logistics, parents also have to figure out a way to explain the illness to a child (whether the medically fragile one or siblings), and to field questions from people who mean well, but who don't fully understand the emotional toll this lifestyle has on parents.
Related Article: 17 Travel Tips for Traveling with a Medically Fragile Child
Contact Sonas for Medically Fragile Child Care

We understand how overwhelming it is to have to research home health care providers. This is why we can sit with you and discuss all of your available options.

Whether that means entrusting us with your child's care or going another route, we want to provide you with all of the answers and resources you need.
If you are considering pediatric home health care services in Florida, contact the caring staff at Sonas Home Health Care. Call today (888) 592-5855.

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What Does "Medically Fragile Child" Mean? | Sonas Home Health Care

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A medically fragile child is one who needs around-the-clock supervision due to ongoing health reasons. Often, they are not able to care for themselves and need help with basic activities. Learn some of the answers to questions often posed by parents of medically fragile children.

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"Its all Love"

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For Walton Special Center teachers, 'it's all love'

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Populations Served at Walton
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Points of Awareness and Concern
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COVID-19 Who's at Risk?
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Risk and Underlying Conditions
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A Maskless Student Body
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Level of Contact
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Listing School Outbreaks
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Transportation (Busing)
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Measuring Frailty and Vulnerability
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Specialized Skills (Walton)
Team Skills (Walton)
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Definitions
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Seizure Management
Vagus Nerve Stimulation
Oral Suctioning
Trache Suctioning
Diaper Changing (98%)
Toilet Training (Trip Training)
Feedings
Difficulty Swallowing
Special Diets
G-Tube Feedings
Hand-Over-Hand Support
Communication
Behavior Management
Aggressive Behavior
Anger Management
Elopement
Functional Skills

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Little Miracles at Walton

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STOCKTON - It's early on a cool and sunny mid-September morning as the school buses begin pulling into the courtyard at Walton Special Center.

STOCKTON - It's early on a cool and sunny mid-September morning as the school buses begin pulling into the courtyard at Walton Special Center.

Automated lifts are opened at the backs of the buses, and some of the children inside are wheeled onto platforms, which then are lowered to the ground. Other children, at least one wearing a protective helmet, haltingly come down the steps. A few arrive not by bus but with their parents.

They have cerebral palsy or autism or seizure disorders or any number of other syndromes, and it is to Walton - Stockton Unified's school for the district's population of severely disabled students, ages 3-22 - that they go to receive the free and appropriate education guaranteed them by law.

Some of these children - six medically fragile boys and girls in wheelchairs, ages 4, 5 and 6 - spend their day with teacher Amy Terra, who is in her sixth year at Walton.

In many ways, Terra's classroom looks like any other.

But the differences are quickly evident. Colorful posters decorate the walls, but they display messages preaching equality for the disabled.

There are sinks in the bathroom, but they are at wheelchair level.

Cubbies hold children's meals, but instead of peanut butter-and-jelly sandwiches, they store liquid nutritional products such as PediaSure and Nutren.

As the day begins, Terra's classroom has visitors - several students from Kohl Open School, the K-8 campus adjacent to Walton.

These Kohl students are regulars, part of a "reverse mainstreaming" program in which typically developing children visit special-education classrooms to help out and to socialize.

"It makes (the Walton students) feel more integrated with the regular-ed kids," says Kohl seventh-grader Samuel Cornelison, whose father, Rick, is a Walton teacher. "It's also fun for me."

Across the room, volunteer Maria Razonable is spoon-feeding yogurt to 4-year-old Priscilla Villalobos. Nobody calls the 70-year-old Razonable by her name, however.

Instead, she is "Grandma," and the more time you spend at Walton, the more you discover that the place is rife with people called "Grandma" and "Grandpa." Terra has two volunteers, Grandma Maria and Grandpa Don Donato, 71. Walton's Grandmas and Grandpas volunteer through a "foster grandparents" program coordinated by Valley Mountain Regional Center.

"I want to work with children," says Grandma Maria, who once was a teacher in her native Philippines. "I'm happy for this."

In addition to Grandma and Grandpa, Terra has two classroom assistants, Martha DeCarillo and Carla Toon. At 8:15 a.m., DeCarillo puts shoes on the feet of 6-year-old Jayden Correa, takes him to the bathroom, massages his cheeks and brushes his teeth.

Jayden suffers from a seizure disorder and wears a nerve stimulator that teachers and assistants can activate to stop seizures and shorten recovery time.

"He has a lot of seizures every day," Terra says. "They used to be really long, like hours. He used to basically seize almost constantly and now he's down to maybe, here at school, 16 to 20 seizures a day, but they're lasting less than a minute. It's a huge improvement for him."

After breakfast and hygiene is taken care of, it's time for the children to go outside. Kohl students help push the chairs, and a caravan of kids tours the campus searching for everyday objects shaped like the letters of the alphabet.

Back in class, Amy asks Grandpa to lay Jayden on a cushion and give him a massage. Jayden is massaged with a special sensory brush that stimulates his extremities to help give him greater awareness of his body. While on the cushion, he has a brief seizure.

When Jayden stops shaking, Terra speaks to him softly.

"Hi," she says. "Welcome back. We missed you while you were gone. I hate it when you're not here with us."

Cecilia Alcaraz, meanwhile, is listening to music. There's a button on the headrest of her wheelchair and when she wants to listen to music, she leans back and pushes the button with the back of her head, turning on the music. But 5-year-old Cecilia is not listening to "Barney" or "Baby Mozart" or "Sesame Street." She's listening to rap.

"This is the only thing that keeps her calm," Terra explains. "So we make exceptions for standard preschool music selections for her. With these kids, you've got to do what works."

Twenty feet away, DeCarillo is working with Priscilla, who is lying face down in a Creepster Crawler - a four-legged device on wheels. Priscilla is suspended by a harness, her knees on the carpet. Movement - any attempt to crawl - is the goal.

Priscilla is new at this and hasn't got the hang of it. She's going nowhere. But Edmarc Toreno, 4, is touring the room in his Creepster Crawler.

"When kids who have never had movement get a taste of it, they take off," Terra says. "They're so used to not having control, so it's foreign and exciting when they finally get it."

Terra's class is only one of many at Walton. One of the others, in a different wing of the school, is the class for kindergartners through sixth-graders taught by Allen Lujan, 52.

The eight children in Lujan's class are a little older than those in Terra's but face many of the same obstacles. They also are bigger than Terra's children, making the lifting and assisting that much more taxing.

"I sleep good," says Lujan, who has medical training as a nurse and served years ago as a U.S. Navy Corpsman. "The amount of lifting and diaper changing and handling safely, you do get worn out. It's a very rewarding kind of physical exertion."

Lujan says this as he is attempting to lift 11-year-old Armando Mejia-Duarte, who has cerebral palsy. Armando's nickname, Lujan says, is "The Cricket," because his disorder makes it difficult for him to stay still. Mittens are placed on his hands so he won't hurt his eyes by poking at them.

"His muscles won't relax unless he's sleeping," Lujan says.

At 11, the lunch cart arrives bearing a feast of meatballs, fruit, mashed potatoes, salad, and plain and chocolate milk. Feeding must be done with care so the children don't choke.

Lujan says he can understand many of the sounds his students make because he has come to know them so well. But 10-year-old Pepe Gutierrez is the only child in the class able to use language, and he asks others in the room to sit with him while he is fed by classroom assistant Jane Young.

Cups have tops with small holes so they cannot spill. Spoons are bendable so they are at an angle the children can guide into their mouths. The plates have high edges for the food to be pushed against.

Pepe asks if the class can sing "Happy Birthday," though it's no one's birthday today. The children gather around Lujan, who plays songs through an iPad. The children work to gain the physical control to enable their hands or feet to push a big yellow button. The reward if they can gain this mastery and push the yellow button is a string of red, white and blue lights that goes on and off.

Next, Lujan's students work on another difficult physical skill, blowing bubbles, as they listen to "If You're Happy And You Know It!"

And then Young dons a swimsuit and takes 9-year-old Daphne Lopes for a 45-minute session in Walton's therapeutic swimming pool. Young lowers Daphne, who wears a flotation collar, into the warm water and moves her around in gentle circles.

After this, it is recess time - an integrated play period during which the gate between Walton and Kohl is opened and children from both schools can freely mingle.

Tom Whitesides, who has been Walton's principal since 1997, looks around at the swirl of activity and the sparkling sky and his facility, which recently benefited from a $15 million makeover.

"We are where we need to be, not to say we're going to stop how we grow and provide for these people," Whitesides says. "Whatever is the next best thing, we're going to continue to provide for these students."

Soon, the day ends and the students are helped into the school buses.

Young, the classroom assistant, said, "Every morning when I wake up, I want to come to work. I couldn't have a better job. Everyone works well together. The children are awesome. They can do things doctors say won't happen, and they do it here at Walton."

Contact reporter Roger Phillips at (209) 546-8299 or rphillips@recordnet.com. Visit his blog at recordnet.com/phillipsblog.

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Little miracles at Walton Special Center

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STOCKTON - It's early on a cool and sunny mid-September morning as the school buses begin pulling into the courtyard at Walton Special Center. STOCKTON - It's early on a cool and sunny mid-September morning as the school buses begin pulling into the courtyard at Walton Special Center.

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Little Miracles: Long Day's Journey

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Photos: Long day's journey: Walton Special Center

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View photos from a day in the life at Walton Special Center.

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In Case of Emergency

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STOCKTON - Michael Montes, a student at Walton Development Center, wore a neon green identification sticker on his back and held his teacher's hand while waiting to board a bus outside his classroom Wednesday morning.

STOCKTON - Michael Montes, a student at Walton Development Center, wore a neon green identification sticker on his back and held his teacher's hand while waiting to board a bus outside his classroom Wednesday morning.

An emergency evacuation was under way.

The challenges are many for Stockton Unified School District in evacuating this school for developmentally disabled students. Most of them do not speak or walk. Some need constant medical attention.

The good news Wednesday: It was only a drill.

"This is an evacuation drill that we've been planning for a year," said Principal Thomas Whitesides prior to calling the drill. "We told the staff it would be sometime this week. They didn't know when."

It was the first time in the special school's four-decade history that officials have coordinated an evacuation drill. Unlike most schools, where students and staff can follow instructions and leave campus quickly during an emergency, the children at Walton must be assisted by adults and handled with care.

Of 125 students, 52 of them are in wheelchairs. Some of them are on feeding tubes and others require medical equipment. Some use diapers, and some must have cold towels on hand to avoid a heat-related seizure.

Whitesides called for the evacuation at 9:15 a.m.

Teachers and staff prepared their students to leave. Ten buses arrived 15 minutes later.

"The biggest thing right now (for students) is the disruption in routine," said teacher Nicholas Pufnock. "Routine is very important to them. They are doing extraordinarily well considering we are breaking that routine."

Loading students into buses took about 30 minutes, which was satisfactory for school officials because wheelchair ramps can only handle one at a time. All together, the evacuation took 45 minutes to complete.

"If this were any other school, I'd be writing them up for taking too long," said Jim West, Stockton Unified police chief, observing the evacuation drill. "For this school, with this student population, we need to define a new 'normal' in terms of how long this is going to take."

West said in the event of a fire, the students would be taken somewhere safe off campus before boarding the buses.

If a flood from the nearby Calaveras River occurred, there would normally be hours of warning that the levee could break.

School officials hope an evacuation at the school will never be necessary. However, Walton officials nearly made that call recently when a nearby laundromat caught fire.

Stockton Unified Health and Emergency Services administrator Tammy Evans said the district also must plan to make sure any site where the Walton students are transported to, in the event of an emergency, is set up to accommodate their special needs.

"We need to be fully prepared," she said.

Contact reporter Keith Reid at (209) 546-8257 or kreid@recordnet.com. Visit his blog at recordnet.com/lodiblog.

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STOCKTON - Michael Montes, a student at Walton Development Center, wore a neon green identification sticker on his back and held his teacher's hand while waiting to board a bus outside his classroom Wednesday morning.

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Overview of Severe Autism

The Symptoms and Challenges

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Article Highlight: Challenges in Severe Autism

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Article Highlight: Challenges in Severe Autism

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What are the DSM-5 diagnostic criteria for autism?

In 2013, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The DSM-5 is now the standard reference that healthcare providers use to diagnose mental and behavioral conditions, including autism.

By special permission of the American Psychiatric Association, you can read the full-text of the new diagnostic criteria for autism spectrum disorder and the related diagnosis of social communication disorder below.
Also see: Answers to frequently asked questions about DSM-5 criteria for autism A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):
DSM-5 Autism Diagnostic Criteria

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
Specify current severity: Severity is based on social communication impairments and restricted repetitive patterns of behavior. (See table below.)

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior. (See table below.)

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:

With or without accompanying intellectual impairment

With or without accompanying language impairment
(Coding note: Use additional code to identify the associated medical or genetic condition.)

Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder[s].)

With catatonia

Associated with a known medical or genetic condition or environmental factor

Table: Severity levels for autism spectrum disorder

Level 3
"Requiring very substantial support"

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches

Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.

Level 2
"Requiring substantial support"

Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and how has markedly odd nonverbal communication.

Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.

Level 1
"Requiring support"

Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to- and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.

Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper inde

Social (Pragmatic) Communication Disorder
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
Diagnostic Criteria
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities). D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains or word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.

1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on the playground, talking differently to a child than to an adult, and avoiding use of overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).

DSM-5 and Autism: Frequently Asked Questions
For more information

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Autism Diagnosis Criteria: DSM-5 | Autism Speaks

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In 2013, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is now the standard reference that healthcare providers use to diagnose mental and behavioral conditions, including autism.

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First aid for any type of seizure

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Centers for Disease Control and Prevention

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About 1 out of 10 people may have a seizure in their lifetime. 1,2 Would you know how to help someone during or after a seizure?

First aid for any type of seizure

There are many different types of seizures, and seizures might not look like what you would expect. Most seizures last for just a few minutes. Follow these important steps to help someone who is having any type seizure:

1. Stay with the person and keep them safe from injury until the seizure ends. After it ends, help the person sit in a safe place. Once they are alert and can talk, tell them what happened in very plain terms.

2. Comfort the person and speak calmly.

3. Keep yourself and other people calm.

4. Check to see if the person is wearing a medical bracelet or other emergency information.

5. Offer to call a taxi, friend, or relative to make sure the person gets home safely.

Seizures don't usually require emergency medical attention. Only call 911 if one or more of these things happen:

The person has never had a seizure before.

The person has difficulty breathing or waking after the seizure.

The seizure lasts longer than 5 minutes.

The person has another seizure soon after the first one.

The person is hurt during the seizure.

The seizure happens in water.

The person has a health condition like diabetes, heart disease, or is pregnant.

First aid for generalized seizures (with muscle stiffening, jerking, falling, or loss of awareness)

When most people think of a seizure, they think of a generalized seizure, or what used to be called a tonic-clonic or grand mal seizure. In this type of seizure, the person may cry out, fall, shake or jerk, and become unaware of what's going on around them.

Here are things you can do to help someone who is having a generalized seizure:

1. Ease the person to the floor.

2. Turn the person gently onto one side. This will help breathing.

3. Clear the area around the person of anything hard or sharp to prevent injury.

4. Put something soft and flat, like a folded jacket, under his or her head.

5. Take off eyeglasses.

6. Loosen ties or anything around the neck that may make it hard to breathe.

7. Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.

Do not hold the person down or try to stop his or her movements.

Do not put anything in the person's mouth. This can injure the teeth or jaw. A person having a seizure cannot swallow his or her tongue.

Do not try to give mouth-to-mouth breaths (like CPR). People usually breathe on their own after a seizure.

Do not offer the person water or food until he or she is fully alert.

1. Hauser WA, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia. 2008;49(Suppl.1):8-12. htmlexternal icon .

2. Hesdorffer DC, Logroscino G, Benn EKT, Katri N, Cascino G. Hauser WA. Estimating risk for developing epilepsy. Neurology 2011;76:23-27. htmlexternal icon .

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About 1 out of 10 people may have a seizure in his or her lifetime, meaning they are common. Would you know what to do if someone had a seizure? Learn what you can do to help them during and after the

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Special Education Glossary and Acronym Dictionary

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Special Education Glossary and Acronym Dictionary

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How to help someone having a seizure

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Trends in Pediatric Hospitalizations for Coronavirus Disease 2019

JAMA Pediatrics. Published online January 11, 2021.
"Our results present concerning trends in pediatric hospitalizations. Adult, and especially geriatric, incidence of COVID-19 continues to dominate the national picture, but pediatric populations may require resources that are not readily available across the country."

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Post-COVID lungs worse than the worst smokers' lungs, surgeon says

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A Texas trauma surgeon says it's rare that X-rays from any of her COVID-19 patients come back without dense scarring. Dr. Brittany Bankhead-Kendall tweeted, "Post-COVID lungs look worse than any type of terrible smoker's lung we've ever seen. And they collapse. And they clot off. And the shortness of breath lingers on... & on... & on."

"Everyone's just so worried about the mortality thing and that's terrible and it's awful," she told CBS Dallas-Fort Worth. "But man, for all the survivors and the people who have tested positive this is - it's going to be a problem."

Bankhead-Kendall, an assistant professor of surgery with Texas Tech University, in Lubbock, has treated thousands of patients since the pandemic began in March.

She says patients who've had COVID-19 symptoms show a severe chest X-ray every time, and those who were asymptomatic show a severe chest X-ray 70% to 80% of the time.

"There are still people who say 'I'm fine. I don't have any issues,' and you pull up their chest X-ray and they absolutely have a bad chest X-ray," she said.

In X-ray photos of a normal lung, a smoker's lung and a COVID-19 lung that Bankhead-Kendall shared with CBS Dallas, the healthy lungs are clean with a lot of black, which is mainly air. In the smoker's lung, white lines are indicative of scarring and congestion, while the COVID lung is filled with white.

"You'll either see a lot of that white, dense scarring or you'll see it throughout the entire lung. Even if you're not feeling problems now, the fact that that's on your chest X-ray - it sure is indicative of you possibly having problems later on," she said.

Dr. Amesh Adalja, an infectious disease expert and senior scholar at Johns Hopkins University Bloomberg School of Public Health, told CBSN that some patients with severe COVID-19 could feel the impact for years to come.

"When someone recovers from pneumonia, whether it's a bacterial pneumonia or a viral pneumonia, it's going to take some time for their chest X-rays to improve. Chest X-rays lag your clinical improvement. So you may be better, but your chest X-ray still looks bad," he said. "And we know that people with COVID-19 can get severe pneumonia, and some of that pneumonia will lead to damage to the lungs that will take time to heal. And some of it may be permanent."

He said the potential long-term health consequences are another reason people should take warnings about the disease seriously.

"It's not something you can blow off. This isn't something you want to have. Because even if you survive, you still may be left with some severe complications that make it very hard for you to go back to your baseline functioning."

Bankhead-Kendall said it's important that if you're experiencing shortness of breath after your COVID-19 goes away, you stay in touch with your primary care doctor.

She also points out, "There is no long-term implication of a vaccine that could ever be as bad as the long-term implications of COVID."

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Post-COVID lungs worse than the worst smokers' lungs, surgeon says

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A Texas trauma surgeon says it's rare that X-rays from any of her COVID-19 patients come back without dense scarring. Dr. Brittany Bankhead-Kendall tweeted, "Post-COVID lungs look worse than any type of terrible smoker's lung we've ever seen. And they collapse. And they clot off. And the shortness of breath lingers on...

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Parenting is hard. There is so much to worry about, then throw in a Complex Medical Condition. Whenever a parent receives a dire diagnosis for their child, their entire world comes crashing down. What does it all mean? How can you understand everything better? Is there anything you can do to improve your child's condition?

When you hear a phrase such as "medically complex", the list of questions gets even longer. Suddenly, you have this new unexpected reality. It can feel overwhelming, stressful, and requires a lot of support. It is because of these reasons that we've put together an overview of what it means to have a medically complex child and what you need to know about it.

What is a Medically Complex Child?

The term "medically complex" is a vague umbrella term used to describe a wide range of medical conditions that present unique challenges and require special care on an ongoing basis. They are usually rare illnesses that are functionally limiting at best and life-threatening at worst.

They also require long hospital stays, and once discharged to go home, these children are likely to need recurring and extended hospitalizations. In addition, when they are not hospitalized, medically complex children still require extensive home care, often through skilled nursing.

Medically Complex Conditions

Typically, these conditions include:

Children who are medically complex are reliant on caregivers and technological devices to do some of the simplest activities of daily living.

What's the Difference Between Medically Complex and Medically Fragile?

Medically fragile and medically complex children have many things in common: Requiring constant monitoring and assistance even for physiological and basic activities. Medically complex children are also medically fragile, and some parents use the term interchangeably. However, a medically fragile child may have one condition, while medically complex children have several of them.

Diagnosing a Medically Complex Child

Identifying a child as being medically complex is not a straightforward process. It starts by diagnosing the child with several chronic conditions associated with functional limitations and/or mortality. In addition, medical providers consider the degree of dependence on life support equipment, such as ventilators or a tracheostomy.

Other factors that are taken into account include how the diagnosed conditions will affect the child's long-term ability to eat, digest food, breathe, communicate, reach developmental milestones, develop motor skills, and walk independently. Generally, medically complex children experience the following:

Multiple major medical conditions

Multiple specialists having to provide care

Dependency on high-intensity care

Risk of a life-threatening event

Caring for a Medically Complex Child

Medically complex children require 24/7 monitoring, even more so than regular children. In the blink of an eye, the child may have difficulty breathing or experience a seizure. This is why home health is often a necessity.

Everyone who's going to be on rotation caring for the child needs to be well-versed on the following:

The child's medical conditions and how to care for them

The child's medications, times, and dosage

How to modify the home to accommodate the child's needs

How to use all of the medical equipment and what to do in the event of a power failure.

Children who are medically complex should also not be exposed to any additional risks. If someone you know has even the slightest indication of having the common cold, keep that person away from your child. The child will also need regular visits from a physical or occupational therapist. When hospitalized, the child will need medical attention from an entire team of pediatric specialists.

Parenting a child with any type of special needs can be overwhelming. It is essential for parents to obtain support for themselves. Caring for a child who's medically complex means not only providing the usual care and nurturing, but also becoming an expert on their child's diagnosis and care. Being aware of available resources and support groups can help alleviate some of the mental and psychical strain.

What is a Medically Complex Child Waiver?

The Medically Complex Child Waiver is a program that provides support to families with a loved one who is medically complex or fragile. This is because, despite the fact that only about 1% of children are deemed to be medically complex, they account for a substantial amount of medical services that are administered at hospitals.

The program is designed to ease the financial burden on families of medically complex children. Some of the services included in the program include home health care, private duty nursing, physical therapy, occupational therapy, nutritional counseling, respite care, and medical equipment.

To qualify for a Medically Complex Waiver, a person must meet the following criteria:

Must have been diagnosed by age 20

Must live at home or at least 60 consecutive days in a skilled nursing facility

Diagnosed with a spinocerebellar disease

Be eligible for Social Security Disability

Be at risk for hospitalization

Services will continue for the child's entire life, as long as he or she continues to qualify for it. To apply for a waiver, families can do so through the Children's Multidisciplinary Assessment Team (CMAT).

Contact Sonas for Pediatric Home Care Services in Florida

If you are overwhelmed caring for a medically complex child, let us help you. At Sonas Home Health Care, we have an entire team of experienced caregivers to ensure the wellbeing of our patients.
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What is a Medically Complex Child? | Sonas Home Health Care

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Parenting is hard. There is so much to worry about, then throw in a Complex Medical Condition. Whenever a parent receives a dire diagnosis for their child, their entire world comes crashing down. What does it all mean? How can you understand everything better? Is there anything you can do to improve your child's condition?

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Defining Children With Medical Complexities

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Defining Children With Medical Complexities

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Improving Care of the Medically Fragile Child

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Improving Care of the Medically Fragile Child

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'I'm exhausted': Parents of medically fragile children feel battered by COVID-19

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'I'm exhausted': Parents of medically fragile children feel battered by COVID-19

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Caring for 2-year-old Lily Wolff means round the clock home care, constant checks of medical equipment, and frequent consultations with doctors. This year, the coronavirus pandemic has made those already overwhelming concerns even more daunting.

Lily has was born extremely prematurely at 24 weeks gestation and stayed in the neonatal intensive care unit for eight months. The micro-preemie spent months on a ventilator, which left her lungs permanently scarred. Mom Jessica Wolff said any exposure to COVID-19, which primarily affects the respiratory system, could be deadly for her immunocompromised daughter.

It's not just exposure to the disease, which is infecting nearly 200,000 Americans daily. Wolff said she worries about lack of access to hospital care - hospitals across the country are overwhelmed, with hospitalizations due to COVID-19 reaching record highs - and she's concerned about the medical supply chain, which she relies on to get the equipment needed to keep Lily alive.

"We are doing absolutely everything we can to keep Lily safe and to limit exposure, but we are concerned about the 800 other things that can go wrong on a normal day for her," Wolff explained. "What if we change out her trach tube and can't get it back in? What if it falls out and needs to be surgically replaced? All of those things that would take us to the emergency room or hospital are an all day, every day concern."
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The Wolff family is not the only one grappling with these concerns. In 2017, U.S. News & World Report estimated that 3 million children in the United States are considered medically fragile or medically complex, meaning they have ongoing, serious medical issues that can require hospitalization or frequent care.

In a pandemic, the ability to access that care can be compromised. As COVID-19 cases fill hospitals to capacity and push nurses and doctors to their breaking points, parents fear that the system won't have space for their kids.

"We have no local hospital that can treat Liam, and I know the St. Louis hospital we go to was 80% full as of yesterday," said Amy Rhoades, whose son Liam was born at 25 weeks and has health issues similar to Lily Wolff's. He uses a ventilator to help him breathe at night.

"When he had rhinovirus, which is just a simple cold, he had to be life-flighted (to the hospital)," Rhoades said. "It was a very scary time. So I think about that, and I think about COVID. That's my biggest fear."

Wolff said that if Lily was to require hospitalization, she likely would need to be air-lifted to a children's hospital to get the care she needs, but concerns about COVID spread and contamination might mean that her parents wouldn't be able to sit by her bedside.

"If she has to go in, we can't go with her," Wolff predicted.

Both Liam and Lily rely on complex medical tools like ventilators, tubing and tracheal tubes to stay alive, but their parents are concerned that rising coronavirus cases could leave those supplies inaccessible to them.

Wolff said her most recent delivery of supplies, which she received on Nov. 20, had some changes.

"We received different ventilator circuits, which are not specifically made for her ventilator. They seem to be a generic one-size-fits-all," Wolff said. "It's definitely not ideal, but circuits for her ventilator are being diverted to hospitals."

Since March 2020, Rhoades has had difficulty getting what she needs, including simple things like thermometers and distilled water.

"Stores were limiting the distilled water, and I actually had to get a note from the doctor to show them that I had a medically frail child. It was insane," Rhoades explained. "Now, a lot of times they have had back orders on the tubing that goes to his ventilator, so we have to be very cautious and try to make sure all of our equipment is up to snuff and if we have to keep the tubing longer we have to make sure it stays good."

Wolff said she's been warned to anticipate further complications.

"We were told to expect other items to either be back-ordered or replaced with suboptimal interim supples in the coming months," she said. "I'm thankful that we have something, but we'd rather know that we're getting what we need on a monthly basis."

Since the situation is so dire and the risk so high, many families of medically complex children have been incredibly isolated for the past nine months.

Wolff said that in addition to not seeing family or friends, she and her husband stopped using trained nurses for Lily's round-the-clock care and now tend to everything themselves.

"We canceled our nursing altogether, so everything has just fallen on my husband and I ... We would love to have our nurses back. I'm freaking exhausted," she said. "We really just shut everybody out. ... We have 100% of everything delivered to our house and we literally just don't leave."

Tiffany Belt, a mom in Florida whose youngest daughter has hypertonic cerebral palsy and is considered high-risk, said she has become more hesitant to go outside as cases in her area have spiked.

"It's getting bad again, and people could care less," said Belt, who noted that both her daughters have been doing virtual learning this year. "It makes me even more apprehensive when I have to take my daughter out. I'm social distancing, but some people just don't care. ... My older daughter hasn't been able to see any friends, even the ones who live a street or two away, at all."

Wolff said the approaching holidays make the isolation even more difficult.

"We have not had a large family gathering in two years," she said. "Most of our families have not met Lily, which is sad, but it's what we have to do to keep her safe."

All three mothers said they live in areas where mask-wearing and social distancing are sporadic at best. It's an extra hurdle to overcome.

"We can't even feel comfortable going to Walgreens to quickly grab something because there are a ton of people who are not masked," Wolff said. "It's difficult."

"There are of course the people that just don't get it, and are being rebels and saying, 'This isn't real,'" Rhoades said. "No, it is real. It's very real if you look at the numbers."

Rhoades added that the current spike in cases and the response to it has her more concerned about the pandemic than ever before.

"I was listening to the officials (in the spring) who said that we were going to spike and then it would go down, level out, and not be as bad," she said. "I did not think this second surge would be this bad. It's crazy to see that it's worse than it was in March, and it's scary."
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'I'm exhausted': Parents of medically fragile children battered by COVID-19

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Caring for 2-year-old Lily Wolff means round the clock home care, constant checks of medical equipment, and frequent consultations with doctors. This year, the coronavirus pandemic has made those already overwhelming concerns even more daunting. Lily has was born extremely prematurely at 24 weeks gestation and stayed in the neonatal intensive care unit for eight months.

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Preterm birth: Potential risk factor for greater COVID-19 severity?

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Preterm birth: Potential risk factor for greater COVID-19 severity?

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The novel coronavirus disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major health (& economic) issue across the globe. As of June 20th, more than eight and a half million human infections have been confirmed worldwide. While the exact pathophysiology is still investigated, significant individual variability in the disease severity and subsequent consequences has been demonstrated. The respiratory distress syndrome related to SARS-CoV-2 infection seems highly specific with a desaturation despite sometimes an absence of dyspnea and distinct manifestations like large intrapulmonary shunt or vascular abnormalities such as thrombosis and increased angiogenesis (Ackermann et al., 2020). Current evidence from large prospective COVID-19 patients cohort studies suggests that the key independent risk factors for mortality and severe complications include higher age, male sex and chronic comorbidities, predominantly related to obesity and metabolic dysfunctions (Liang et al., 2020). Fast identification of "more-at-risk" populations is key for optimization of therapy selection and timing, especially when health care system capacities are limited.

One such, to-date neglected population that is potentially more "vulnerable" to COVID-19 consists of prematurely born individuals. Given that preterm birth prevalence is currently estimated at approximately 10 % births worldwide, the potential consequences of prematurity relate to a significant part of the population. We argue, that three important features associated with prematurity constitute the basis of such probable vulnerability: First, the detrimental long-term consequences on respiratory system development, control and function. Second, higher levels of (and possibly reduced tolerance to) oxidative stress and third, potentially elevated Angiotensin-converting enzyme (ACE2) activity/expression.

Prematurity can provoke life-long adverse sequelae in numerous physiological systems but might predominantly affect the respiratory system. Importantly, recent accumulating evidence suggests that the respiratory drive/control might be particularly compromised under hypoxemic conditions. Indeed, it is well established that the ventilatory response to hypoxic stimuli is blunted in prematurely born individuals as compared to their full-term born and physical capacity matched counterparts (Bates et al., 2014; Debevec et al., 2019). Whilst the exact mechanisms of prematurity-related altered resting cardiorespiratory control and carotid chemoreceptor dysfunction remain unknown, perinatal hyperoxia was hypothesized to be the key underlying factor.

Other anatomical and functional consequences of prematurity might even further exacerbate the observed respiratory dysfunction. The reduced ventilatory response to hypoxia may lead to greater systemic hypoxemia. This can be particularly problematic in already hypoxemic clinical populations. Hypoxemia is a defining feature of COVID-19 that is independently associated with in-hospital mortality (Xie et al., 2020) and might importantly underline the disease-related respiratory challenges and end-point outcomes in this cohort. Whilst other factors associated with COVID-19 also importantly modulate the ventilatory drive (i.e., higher metabolic drive related to fever & inflammation) the potentially blunted hypoxic ventilatory response and subsequently greater systemic hypoxemia in prematurely born individuals should be considered when managing COVID-19 patients.

Recently, it has been speculated that the hypoxemia and associated pulmonary pathology observed in COVID-19 patients may arise from a reduced oxygen-sensing capacity in pulmonary arteries and in carotid bodies (Archer et al., 2020). The resulting dysfunctional regulation of ventilation may be particularly deleterious in combination with pre-existing deficits of the ventilatory response, as is the case in prematurely born individuals.

It is well established that oxygen sensing in the lung and carotid bodies depends on mitochondrial function. The known vulnerability of mitochondria to oxidative stress suggests an additional feature of prematurity to be relevant for impaired oxygen sensing and COVID-19 severity; potentially higher oxidative stress levels as compared to full-term born individuals (Filippone et al., 2012; Martin et al., 2018). This difference in redox balance has indeed been hypothesized to be directly involved in the modulation of the ventilatory response to hypoxaemia in prematurely born persons.

Inflammation related to COVID-19 further increases oxidative stress, while oxidative stress, in turn, can promote inflammation. A basal redox regulation deficit thus might increase the risk to get trapped in this detrimental feedforward loop. Oxidative stress furthermore leads to oxidized phospholipids, commonly present in COVID-19 patient lungs. Oxidized phospholipids have been linked to coagulation abnormalities and low platelet counts, which are associated with adverse outcome of COVID-19 (Merad and Martin, 2020). Given that COVID-19 risk factors/conditions are commonly characterized by high oxidative stress levels it seems plausible that redox balance deficits are among the underlying mechanisms of vulnerability to COVID-19. Therefore, the potentially altered oxidative stress status linked to prematurity must be considered as it might exacerbate the clinical status.

Finally, accumulating evidence indicates that prematurity might also be associated with higher ACE2 activity and/or expression (South et al., 2018). ACE-2 is known to be directly involved in SARS-CoV-2 cell-binding, representing the main host cell receptor for all human pathogenic coronaviruses including SARS-CoV-2. Thus, the higher ACE2 activity/expression in the prematurely born individuals might result in greater COVID-19 severity. One also has to bear in mind that the prematurity-related higher ACE2 activity might be additionally heightened by potential hypertension or diabetes drug therapies which often include ACE inhibitors and/or angiotensin II receptor blockers, both upregulating ACE2.

In summary, prematurely born COVID-19 patients could be particularly vulnerable to both infection and adverse outcome. High ACE2 activity levels may enable enhanced virus-binding, thus increasing infection risk. A pre-existing adverse redox balance could then contribute to the aggravation of inflammatory mechanisms by oxidation of different biomolecules including phospholipids, incidentally exacerbating vascular and lung injury. Oxidative damage to oxygen-sensing mitochondria in conjunction with COVID-19-related hypoxemia and prematurity-associated ventilator response deficits may synergistically deteriorate the health status facilitated by a potentially compromised respiratory system of the prematurely born individual. We believe that the above-summarized data and mechanisms observed in prematurely born individuals should be considered when managing/treating COVID-19 patients. As no sound epidemiological data currently exist on the topic, future epidemiological and experimental efforts are urgently warranted to elucidate the relationship between prematurity and COVID-19 severity and thereby optimize therapeutic approaches for this, up-to-now neglected, population.

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Preterm birth: Potential risk factor for greater COVID-19 severity?

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The novel coronavirus disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major health (& economic) issue across the globe. As of June 20th, more than eight and a half million human infections have been confirmed worldwide.

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Article Highlight: Preterm birth: Potential risk factor for greater COVID-19 severity?

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Article Highlight: Preterm birth: Potential risk factor for greater COVID-19 severity?

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Could autism spectrum disorders be a risk factor for COVID-19?

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People/Children with Certain Medical Conditions

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People/Children with Certain Medical Conditions

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CDC Feb 2021

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Centers for Disease Control and Prevention

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Important update: Healthcare facilities

CDC has updated select ways to operate healthcare systems effectively in response to COVID-19 vaccination. Learn more

People with Certain Medical Conditions

If you or your family member are at high risk for severe illness, wear a mask or respirator with greater protection in public indoor spaces if you are in an area with a high COVID-19 hospital admission level. Talk with your healthcare provider about wearing a mask in a medium COVID-19 hospital admission level.

If you have symptoms consistent with COVID-19 and you are aged 50 years or older OR are at high risk of getting very sick, you may be eligible for treatment. Contact your healthcare provider and start treatment within the first few days of symptoms. You can also visit a Test to Treat location. Treatment can reduce your risk of hospitalization by more than 50% and also reduces the risk of death.

What You Need to Know

A person with any of the medical conditions listed below is more likely to get very sick with COVID-19. If you have one of these conditions, talk with your healthcare provider about how best to protect yourself from severe illness from COVID-19.

The list below does not include all possible conditions that put you at higher risk of severe illness from COVID-19. If you have questions about a condition not included on this list, talk to your healthcare provider about how best to manage your condition and protect yourself from COVID-19.

Staying up to date with COVID-19 vaccines and following preventive measures for COVID-19 are important. This is especially important if you are older or have severe health conditions or more than one health condition, including those on the list below.

Approved and authorized COVID-19 vaccines are safe and effective.

Some people who are immunocompromised, or people with weakened immune systems, may get additional doses of COVID-19 vaccine.

Overview

Based on the current evidence, a person with any of the conditions listed below is more likely to get very sick from COVID-19. This means that a person with one or more of these conditions who gets very sick from COVID-19 (has severe illness from COVID-19) is more likely to:

Be hospitalized

Need intensive care

Require a ventilator to help them breathe

Die

In addition:

Staying up to date with COVID-19 vaccines and taking COVID-19 prevention actions are important. This is especially important if you are older or have severe health conditions or more than one health condition, including those on this list. Learn more about how CDC develops COVID-19 vaccination recommendations. If you have a medical condition, learn more about Actions You Can Take.

The conditions on this list are in alphabetical order. They are not in order of risk.

CDC completed a review for each medical condition on this list. This was done to ensure that these conditions met criteria for inclusion on this list. CDC conducts ongoing reviews of additional underlying conditions. If other medical conditions have enough evidence, they might be added to the list.

Because we are learning more about COVID-19 every day, this list does not include all medical conditions that place a person at higher risk of severe illness from COVID-19. Rare medical conditions, including many conditions that mostly affect children, may not be included on the list below. We will update the list as we learn more.

A person with a condition that is not listed may still be at greater risk of getting very sick from COVID-19 than other people who do not have the condition. It is important that you talk with your healthcare provider about your risk.

Cancer

Having cancercan make you more likely to get very sick from COVID-19. Treatments for many types of cancer can weaken your body's ability to fight off disease. At this time, based on available studies, having a history of cancer may increase your risk.

Get more information:

Chronic kidney disease

Having chronic kidney disease of any stage can make you more likely to get very sick from COVID-19.

Get more information:

Chronic liver disease

Having chronic liver disease can make you more likely to get very sick from COVID-19. Chronic liver disease can include alcohol-related liver disease, non-alcoholic fatty liver disease, autoimmune hepatitis, and cirrhosis (or scarring of the liver).

Get more information:

Chronic lung diseases

Having a chronic lung disease can make you more likely to get very sick from COVID-19. Chronic lung diseases can include:

Asthma, if it's moderate to severe

Bronchiectasis (thickening of the lungs' airways)

Bronchopulmonary dysplasia (chronic lung disease affecting newborns)

Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis

Having damaged or scarred lung tissue known as interstitial lung disease (including idiopathic pulmonary fibrosis)

Pulmonary embolism (blood clot in the lungs)

Pulmonary hypertension (high blood pressure in the lungs)

Get more information:

Cystic fibrosis

Having cystic fibrosis, with or without lung or other solid organ transplant (like kidney, liver, intestines, heart, and pancreas) can make you more likely to get very sick from COVID-19.

Get more information:

Dementia or other neurological conditions

Having neurological conditions, such as dementia, can make you more likely to get very sick from COVID-19.

Get more information:

Diabetes (type 1 or type 2)

Having either type 1 or type 2 diabetes can make you more likely to get very sick from COVID-19.

Get more information:

Disabilities

People with some types of disabilities may be more likely to get very sick from COVID-19 because of underlying medical conditions, living in congregate settings, or systemic health and social inequities, including:

Get more information:

Heart conditions

Having heart conditions such as heart failure, coronary artery disease, cardiomyopathies, and possibly high blood pressure (hypertension) can make you more likely to get very sick from COVID-19.

Get more information:

HIV infection

Having HIV (Human Immunodeficiency Virus) can make you more likely to get very sick from COVID-19.

Get more information:

Immunocompromised condition or weakened immune system

Some people are immunocompromised or have a weakened immune system because of a medical condition or a treatment for a condition. This includes people who have cancer and are on chemotherapy, or who have had a solid organ transplant, like a kidney transplant or heart transplant, and are taking medication to keep their transplant. Other people have to use certain types of medicines for a long time, like corticosteroids, that weaken their immune system. One example is called primary immunodeficiency. Being immunocompromised can make you more likely to get very sick from COVID-19 or be sick for a longer period of time.

People who are immunocompromised or are taking medicines that weaken their immune system may not be protected even if they are up to date on their vaccines. Talk with your healthcare provider about wearing a mask in a medium hospital admission level and what additional precautions may be necessary in medium or high COVID-19 hospital admission levels. Additionally, people who are moderately or severely immunocompromised may get additional doses of updated COVID-19 vaccine. Because the immune response following COVID-19 vaccination may differ in people who are moderately or severely immunocompromised, specific guidance has been developed.

Get more information:

Mental health conditions

Having mood disorders, including depression, and schizophrenia spectrum disorders can make you more likely to get very sick from COVID-19.

Get more information:

Overweight and obesity

Overweight (defined as a body mass index (BMI) is 25 kg/m ² or higher, but under 30 kg/m ²), obesity (BMI is 30 kg/m ² or higher, but under 40 kg/m ²), or severe obesity (BMI is 40 kg/m ² or higher), can make you more likely to get very sick from COVID-19. The risk of severe illness from COVID-19 increases sharply with higher BMI.

Get more information:

Physical inactivity

People who do little or no physical activity are more likely to get very sick from COVID-19 than those who are physically active. Being physically active is important to being healthy. Get more information on physical activity and health, physical activity recommendations, how to become more active, and how to create activity-friendly communities:

Pregnancy

Pregnant and recently pregnant people (for at least 42 days following end of pregnancy) are more likely to get very sick from COVID-19 compared with non-pregnant people.

Get more information:

Sickle cell disease or thalassemia

Having hemoglobin blood disorders like sickle cell disease or thalassemia (inherited red blood cell disorders) can make you more likely to get very sick from COVID-19.

Get more information:

Smoking, current or former

Being a current or former cigarette smoker can make you more likely to get very sick from COVID-19. If you currently smoke, quit. If you used to smoke, don't start again. If you've never smoked, don't start.

Get more information:

Solid organ or blood stem cell transplant

Having had a solid organ or blood stem cell transplant, which includes bone marrow transplants, can make you more likely to get very sick from COVID-19.

Get more information:

Stroke or cerebrovascular disease

Having cerebrovascular disease, such as having a stroke which affects blood flow to the brain, can make you more likely to get very sick from COVID-19.

Get more information:

Substance use disorders

Having a substance use disorder (such as alcohol, opioid, or cocaine use disorder) can make you more likely to get very sick from COVID-19.

Get more information:

Tuberculosis

Having tuberculosis (TB) can make you more likely to get very sick from COVID-19.

Get more information:

Additional Information on Children and Teens

People of all ages, including children, can get very sick from COVID-19. Children with underlying medical conditions are at increased risk for getting very sick compared to children without underlying medical conditions.

Current evidence suggests that children with medical complexity, with genetic, neurologic, or metabolic conditions, or with congenital heart disease can be at increased risk for getting very sick from COVID-19. Like adults, children with obesity, diabetes, asthma or chronic lung disease, sickle cell disease, or who are immunocompromised can also be at increased risk for getting very sick from COVID-19. Check out COVID-19 Vaccines for Children and Teens for more information on vaccination information for children.

Actions You Can Take

It is important to protect yourself and others by taking COVID-19 prevention actions:

Stay up to date with your COVID-19 vaccines

Improve ventilation

Get tested if you have symptoms

Follow recommendations for what to do if you have been exposed

Stay home if you have suspected or confirmed COVID-19

Seek treatment if you have COVID-19 and are at high risk of getting very sick

Avoid contact with people who have suspected or confirmed COVID-19

Wear a mask or respirator

Increase space and distance

Please contact your state, tribal, local, or territorial health department for more information on COVID-19 vaccination in your area. It is also important for people with medical conditions and their healthcare providers to work together and manage those conditions carefully and safely. Stay up to date with your COVID-19 vaccines.If you have a medical condition, the following are actions you can take based on your medical conditions and other risk factors.

Put together your COVID-19 plan so you have all the information you need on hand if you get sick with COVID-19. Download, edit and save, and share your plan with your family, friends, and healthcare provider.

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View PDF in English Other Languages

Seek care when needed

Call your healthcare provider if you have any concerns about your medical conditions or if you get sick and think that you may have COVID-19. Discuss steps you can take to manage your health and risks. If you need emergency help, call 911 right away.

Do not delay getting care for your medical condition because of COVID-19. Emergency departments, urgent care, clinics, and your healthcare provider have infection prevention plans to help protect you from getting COVID-19 if you need care.

Continue medications and preventive care

Continue your medicines and do not change your treatment plan without talking to your healthcare provider.

Have at least a 30-day supply of prescription and non-prescription medicines. Talk to a healthcare provider, insurer, or pharmacist about getting an extra supply (i.e., more than 30 days) of prescription medicines, if possible, to reduce your trips to the pharmacy.

Follow your current treatment plan (e.g., Asthma Action Plan, dialysis schedule, blood sugar testing, nutrition, and exercise recommendations) to keep your medical condition(s) under control.

When possible, keep your appointments (e.g., vaccinations and blood pressure checks) with your healthcare provider. Check with your healthcare provider about safety precautions for office visits and ask about telemedicine or virtual healthcare appointment options.

Learn about stress and coping. You may feel increased stress during this pandemic. Fear and anxiety can be overwhelming and cause strong emotions. It can be helpful to talk with a professional like a counselor, therapist, psychologist, or psychiatrist. Ask your primary care provider if you would like to speak with a professional. Getting regular exercise and being physically active is also a great way to reduce stress.

Accommodate dietary needs and avoid triggers

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See a list of medical and underlying conditions that make adults more at risk for COVID-19, and links to more information for each condition.

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CDC: People with Certain Medical Conditions

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Many of these students will have additional disabilities

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Many of these students will have additional disabilities

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Students with severe to profound general learning disabilities are likely to be severely impaired in their functioning in respect of a basic awareness and understanding of themselves, of the people around them and of the world they live in.

Many of these students will have additional disabilities such as autistic spectrum disorders (ASDs), challenging and/or self-injurious behaviour, emotional disturbance, epilepsy, hearing impairment, physical impairment, severe impairment in communication skills and visual impairment. Insofar as IQ (Intelligence Quotient) may be used as an indicator of general learning disability, a student with a severe general learning disability is described as having an IQ in the range 20 to 35 on standardised IQ tests, and a student with a profound general learning disability is described as having an IQ under 20.

Students with severe to profound general learning disabilities exhibit a wide and diverse range of characteristics, including a dependence on others to satisfy basic needs such as feeding and toileting, difficulties in mobility, problems with generalising skills from one situation to another, significant delays in reaching developmental milestones and significant speech and/or communication difficulties. Some students may have associated behavioural problems. Students may have limited communication skills and will therefore not have control of the multiple means by which other students communicate such as speech, body language, facial expressions and print. (It should be remembered that the students' difficulties in expressing themselves does not diminish their communicative intent. Opportunities to enable the student to communicate should underpin learning and teaching.) Remember that each student is different - what works for one may not work for another.

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Students with severe to profound general learning disabilities are likely to be severely impaired in their functioning in respect of a basic awareness and understanding of themselves, of the people around them and of the world they live in.

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People who may find it difficult to wear a mask

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People who may find it difficult to wear a mask

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Centers for Disease Control and Prevention

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Face shields and goggles

For example, people who interact with those who are deaf or hearing impaired may find that a face shield is better than a mask when communicating. If you must wear a face shield instead of a mask:

Choose a face shield that wraps around the sides of your face and extends below your chin or a hooded face shield. This is based on the limited available data that suggest these types of face shields are better at preventing spray of respiratory droplets.

Wash your hands after removing the face shield. Avoid touching your eyes, nose, and mouth when removing it.

Clean and disinfect reusable face shields according to the manufacturer's instructions or by following CDC face shield cleaning instructions. If you use a disposable face shield, wear it once and throw it away according to the manufacturer's instructions.

Mask adaptations and alternatives

CDC recognizes that wearing masks may not be possible in every situation or for some people. Those who cannot wear a mask are urged to prioritize virtual engagement when possible. For in-person activities, we have provided a few examples of what you can do to make wearing a mask more feasible and how to reduce the spread of COVID-19 if you cannot wear a mask.

Situations where wearing a mask may not be possible

Make sure to maintain physical distance from others when you cannot wear a mask.
Dining

CDC recommends wearing a mask while dining in a restaurant, particularly indoors and when speaking with restaurant workers and servers, except when actively eating or drinking. The risk of COVID-19 spread increases in a restaurant or bar setting as interactions within 6 feet of others increase. Masks may reduce the risk of COVID-19 spread when worn in any of these risk scenarios.
Water activities

Do not wear a mask when doing activities that may get your mask wet, like swimming at the beach or pool. A wet mask can make it difficult to breathe and may not work as well when wet.
High intensity activities

Masks should be used in public settings, but if you are unable to wear a mask because of difficulty breathing during high intensity activities, choose a location with greater ventilation and air exchange (for instance, outdoors versus indoors) and where you can keep at least 6 feet from others during the activity.

If you are able to wear a mask, remove your mask if it gets moist from sweat and replace it with a clean mask.

Opt for an activity that does not require using mouth guards or helmets. Wearing a mask with these types of protective equipment is not safe if it makes it hard to breathe.

Supervise children who are wearing a mask while playing sports.

Certain groups of people who may find it difficult to wear a mask
Some children 2 years and older, and people of any age with certain disabilities
Appropriate and consistent use of masks may be challenging for some children and for people of any age with certain disabilities, including cognitive, intellectual, developmental, sensory, and behavioral disorders.

When deciding if children and people with certain disabilities should wear a mask, determine if they can:

Use a mask correctly

Avoid frequent touching of the mask and their face

Limit sucking, drooling, or having excess saliva on the mask

Remove the mask without assistance

If children and people with certain disabilities are unable to wear a mask properly or cannot tolerate a mask, they should not wear one.

Those caring for children and people with certain disabilities who may not be able to wear a mask should

Ask their healthcare provider for advice about their wearing a mask

Ensure proper mask size and fit

Remove their mask before sleeping, napping, when they may fall asleep (such as in a car seat or stroller), and in situations when continual supervision is not possible

Consider prioritizing wearing a mask in public settings and when around people who don't live in your household, particularly when indoors. Masks may not be necessary when you are outside by yourself away from others, or with other people who live in your household. However, some localities may have mask mandates while out in public and these mandates should always be followed.

Masks should not be worn by:
People who are deaf or hard of hearing, and those who will interact with people who are hearing impaired
If you interact with people who rely on reading lips, you may have difficulty communicating while wearing a mask.

Consider wearing a clear mask or a cloth mask with a clear panel

If you are not able to get a clear mask, consider using written communication, closed captioning, or decreasing background noise to make communication possible while wearing a mask that blocks lips

People with certain underlying medical conditions
Most people with underlying medical conditions can and should wear masks.

If you have respiratory conditions and are concerned about wearing a mask safely, discuss with your healthcare provider the benefits and potential risks of wearing a mask.

If you have asthma, you can wear a mask. Discuss with your healthcare provider if you have any concerns about wearing a mask.

Outdoor workers
If you work in a setting where masks could increase the risk of heat-related illness or cause safety concerns (for example, straps getting caught in machinery):

Mask use and carbon dioxide

Wearing a mask does not raise the carbon dioxide (CO₂) level in the air you breathe

A cloth mask does not provide an airtight fit across the face. The CO ₂ completely escapes into the air through and around the sides of the cloth mask when you breathe out or talk. CO 2 is small enough to easily pass through any cloth mask material. In contrast, the virus that causes COVID-19 is much larger than CO ₂, so it cannot pass as easily through a properly designed and properly worn cloth mask.

Cold Weather

Recent studies

Mueller AV, Eden MJ, Oakes JM, et al. Quantitative Method for Comparative Assessment of Particle Removal Efficiency of Fabric Masks as Alternatives to Standard Surgical Masks for PPE (July 2020). https://doi.org/10.1016/j.matt.2020.07.006external icon https://www.sciencedirect.com/science/article/pii/S2590238520303647external icon

Anindita M, Das K.COVID-19 Pandemic: Is Cloth Mask Really Protect Public From SARS-CoV-2? (The way of handling to get Results) (May 2020). https://www.ijisrt.com/assets/upload/files/IJISRT20MAY228.pdf pdf icon [498 KB, 5 pages] external icon

Lustig SR, Biswakarma JJH, Rana D, et al. Effectiveness of Common Fabrics to Block Aqueous Aerosols of Virus-like Nanoparticles (May 2020). https://pubs.acs.org/doi/abs/10.1021/acsnano.0c03972external icon

Sousa‐Pinto B, Fonte AP, Lopes AA, et al.Face masks for community use: An awareness call to the differences in materials (August 2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361409/external icon

Chughtai AA, Seale H, Macintyre CR. Effectiveness of Cloth Masks for Protection Against Severe Acute Respiratory Syndrome Coronavirus 2 (July 2020). https://europepmc.org/article/med/32639930external icon

Bagheri MH, Khalaj I, Azizi A, et al. Filtration Efficiency, Breathability, and Reusability of Improvised Materials for Face Masks (July 2020) PREPRINT. https://engrxiv.org/nrtgb/external icon

Gandhi M, Beyrer C, Goosby E. Masks Do More Than Protect Others During COVID-19:

Reducing the Inoculum of SARS-CoV-2 to Protect the Wearer. J Gen Intern Med. DOI: 10.1007/s11606-020-06067-8

Wang H, Wang Q, Lin YL, Kilinc-Balci FS, Price A, Chu L, Chu MC. Household materials selection for homemade cloth face coverings and their filtration efficiency enhancement with triboelectric charging. Nano Letters. 2020 Jun 2."

Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. The New England journal of medicine. 2020;382(10):970-971.

Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. The New England journal of medicine. 2020;382(12):1177-1179.

Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. The Lancet Infectious diseases. 2020.

Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. Jama. 2020.

Kimball A HK, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility - King County, Washington, March 2020. MMWR Morbidity and mortality weekly report. 2020; ePub: 27 March 2020.

Wei WE LZ, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23-March 16, 2020. MMWR Morbidity and Mortality Weekly Report. 2020;ePub: 1 April 2020.

Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science (New York, NY). 2020.

Furukawa NW, Brooks JT, Sobel J. Evidence Supporting Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 While Presymptomatic or Asymptomatic [published online ahead of print, 2020 May 4]. Emerg Infect Dis. 2020;26(7):10.3201/eid2607.201595. Link

Oran DP, Topol Prevalence of Asymptomatic SARS-CoV-2 Infection: A Narrative Review [published online ahead of print, 2020 Jun 3]. Ann Intern Med. 2020;M20-3012.

National Academies of Sciences, Engineering, and Medicine. 2020. Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020). Washington, DC: The National Academies Press. https://doi.org/10.17226/25769external icon

Schwartz KL, Murti M, Finkelstein M, et al. Lack of COVID-19 transmission on an international flight. CMAJ. 2020;192(15):E410.

Anfinrud P, Stadnytskyi V, Bax CE, Bax A. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering. N Engl J Med. 2020 Apr 15. doi:10.1056/NEJMc2007800.

Davies A, Thompson KA, Giri K, Kafatos G, Walker J, Bennett A. Testing the efficacy of homemade masks: would they protect in an influenza pandemic? Disaster Med Public Health Prep. 2013;7(4):413-8.

Konda A, Prakash A, Moss GA, Schmoldt M, Grant GD, Guha S. Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks. ACS Nano. 2020 Apr 24.

Aydin O, Emon B, Saif MTA. Performance of fabrics for home-made masks against spread of respiratory infection through droplets: a quantitative mechanistic study. medRxiv preprint doi: https://doi.org/10.1101/2020.04.19.20071779, posted April 24, 2020.

Ma QX, Shan H, Zhang HL, Li GM, Yang RM, Chen JM. Potential utilities of mask-wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020.

Leung, N.H.L., Chu, D.K.W., Shiu, E.Y.C. et al.Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020.

Johnson DF, Druce JD, Birch C, Grayson ML. A quantitative assessment of the efficacy of surgical and N95 masks to filter influenza virus in patients with acute influenza infection. Clin Infect Dis. 2009 Jul 15;49(2):275-7.

Green CF, Davidson CS, Panlilio AL, et al. Effectiveness of selected surgical masks in arresting vegetative cells and endospores when worn by simulated contagious patients. Infect Control Hosp Epidemiol. 2012;33(5):487‐494.

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For example, people who interact with those who are deaf or hearing impaired may find that a face shield is better than a mask when communicating. If you must wear a face shield instead of a mask: Choose a face shield that wraps around the sides of your face and extends below your chin or a hooded face shield.

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Most Students at Walton Can Not Wear a Mask

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Most Students at Walton Can Not Wear a Mask

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Respiratory illness in children with disability: a serious problem?

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Respiratory illness in children with disability: a serious problem?

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Introduction

Children with severe neurocognitive impairment often present to paediatric clinics with recurrent and chronic lower airway infections and increased risk of respiratory insufficiency [ 1]. These pulmonary problems play an important role in the morbidity and even the mortality of children with neurocognitive impairment [ 2- 5]. However, the impact may be insufficiently recognised by caregivers and doctors, and the medical literature pays relatively little attention to this topic. Studies are scarce and often involve retrospective data from small cohorts. This is most likely because studies are not easy to set up in this population and the complexity of setting up studies on, for example, pneumonia occurrence and risk factors have been well described [ 6].

Epidemiology

The prevalence of lower airway infections in children with neurocognitive and motor impairment have mainly been studied in specific conditions such as cerebral palsy [ 5, 6] or in well-defined subgroups like children with disability referred for gastrostomy or because of feeding problems [ 7, 8]. In an Australian cerebral palsy registry, respiratory problems were very common, with daily cough or wheeze in 58%, obstructive sleep apnoea in 10%, cough with drinking in 40% and abnormalities on clinical pulmonary exam in around 20% [ 9]. Children with cerebral palsy have an increased risk of sudden death during sleep and most of these patients have a cluster of respiratory problems such as recurrent aspiration pneumonia, chronic bronchitis and (nocturnal) respiratory insufficiency [ 10]. Pneumonia may disproportionally contribute to mortality in cerebral palsy and some data suggest that pneumonia was responsible for 40% of all deaths [ 9].

We studied the respiratory morbidity in more than 120 children with profound intellectual and multiple disability in the setting of specialised care centres [ 11]. Almost all patients were classified as Gross Motor Function Classification System (GMFCS) class 4-5, and one out of four had a diagnosis of cerebral palsy. The median number of lower airway infections per year was less than anticipated (4, interquartile range 1-4). Around 12% of patients had three or more hospital admission for respiratory illnesses in the previous 5 years, again lower than expected from our hospital experience. We hypothesise that in hospital, we mainly treat a small subgroup of children with neurocognitive impairment needing recurrent inpatient respiratory care while the majority of these children are never seen in the acute hospital setting. However, around 25% of patients had some form of chronic respiratory treatment ( i.e. mucolytics, nebulised inhaled corticosteroids or bronchodilators, chest physiotherapy, or long-term antibiotics) reflecting significant chronic respiratory morbidity.

In a study of children with cerebral palsy referred for gastrostomy, the median number of antibiotic treatments over a 6 months period was 1.8 and the median number of hospital admissions for respiratory reasons was <1 [ 8]. In a group of 34 children with severe disability and feeding problems, however, only 10 did not have respiratory infections at all and 16 had severe lower airway infections [ 7]. However, the latter preselected groups cannot be compared to our group.

Risk factors and underlying causes

The underlying causes for respiratory illness in children with neurocognitive impairment are multiple and in most children, several risk factors are simultaneously present (). Most risk factors are only recognised based on clinical experience [ 12] and again, limited research has been done in this field.

Kyphoscoliosis

Children with cerebral palsy and other neurological problems are prone to develop musculoskeletal deformities. The underlying neurological insult may results in a loss of selective motor control, an increase in underlying muscle tone and muscle imbalance, which can lead to abnormal deforming forces acting on the immature skeleton [ 13]. Kyphoscoliosis can lead to mechanical disadvantage of the respiratory muscles and decrease the chest wall compliance. If present in early childhood, kyphoscoliosis can also limit lung growth. The net effect is an increased respiratory effort, decreased vital capacity and unequal lung ventilation resulting in risk of respiratory failure [ 12, 14]. In a study on children and adults with severe neurological impairment, kyphoscoliosis was one of the major factors predicting increased end-tidal carbon dioxide, a measure of respiratory ventilator insufficiency [ 15]. Occasionally, severe kyphoscoliosis can lead to airway compression by the displaced spine [ 16].

Gastro-oesophageal reflux, swallowing and aspiration

An important risk factor for chronic lower airway infections and recurrent pneumonia is aspiration, either secondary to dysphagia and swallowing dysfunction or secondary to gastro-oesophageal reflux (GOR) [ 17- 23]. For evaluation of swallowing function and possible aspiration, different tests are used in addition to clinical observation: barium video fluoroscopy, salivagram and milk scanning. Milk scanning is the least sensitive and overall, the agreement between these tests in poor [ 24, 25]. Children with abnormal findings on a salivagram have a high rate of abnormal findings on chest radiography suggestive of lung disease secondary to chronic aspiration [ 26]. For more advanced evaluation, combination of video fluoroscopy and swallow manometry is suggested [ 27]. For evaluation of GOR, 24-h pH studies, preferably with impedance and oesophagogastroscopy, are the gold standard [ 23].

Cough

For efficient clearing of airway secretions and for protection against aspiration, an effective cough is necessary. This requires good coordination and timing of expiratory and glottis muscles [ 12]. Many patients with neurocognitive impairment have no spontaneous cough or an insufficiently forceful cough.

Upper airway obstruction

Obstructive breathing due to upper airway obstruction (UAO) is a common problem in children with neurological impairment, especially in the context of cerebral palsy. The main cause is loss of muscle tone of the pharynx which, during sleep, can lead to sleep disordered breathing, hypercarbia and hypoxaemia with risk of pulmonary hypertension [ 28].

The prevalence of UAO in a cohort of hospitalised children from South Africa with cerebral palsy was 8.8%. Epilepsy, feeding complications and severe physical disability are associated with UAO in this cohort of children with cerebral palsy (R. Petersen, Red Cross Hospital, Cape Town, South Africa; personal communication).

Chronic airway colonisation and infection

A paediatric intensive care unit (ICU)-based study demonstrated an association between Pseudomonas aeruginosa lung infections in cerebral palsy patients and morbidity [ 29]. Children with cerebral palsy and isolation of P. aeruginosa or other Gram-negative bacteria from airway cultures had an increased frequency of ICU admissions, intubation and large pleural effusion. Additionally, they had more prolonged hospitalisations and were more at risk for multiple hospitalisations [ 30].

General risk factors

The clinician should not forget to look for common causes of recurrent or chronic airway problems in this specific group. Asthma, passive smoke exposure and immobility as well as immunodeficiency should not be overlooked.

In our cohort study, a wide range of risk factors were identified and many patients had a combination of several risk factors. As could be expected, GOR, swallowing problems and aspiration increased the risk of hospital admissions. Other risk factors were axial hypotonia, epilepsy, scoliosis and absence of spontaneous cough reflex [ 11].

Treatment

Chest physiotherapy

While in paediatric neuromuscular disorders, the use of chest physiotherapy with specific devices has been well studied, the literature on this topic in cerebral palsy and other neurocognitive impairment is scant [ 31- 34]. Interventions such as cough assist devices and intrapulmonary percussion are now commonly used in neuromuscular patients for prevention and treatment of lower airway infections and impaction of secretions. One of the few studies on chest physiotherapy in cerebral palsy investigated the use of high-frequency chest wall compression (Vest system; Hill-Rom, Amsterdam, the Netherlands) in a prospective, uncontrolled study in seven patients with cerebral palsy (five with a tracheostomy). The total number of pneumonia episodes and antibiotic courses decreased significantly, as did the pneumonia-associated hospital admissions [ 35]. Another study also showed that the use of the Vest technique for chest physiotherapy reduced the number of hospital admissions in children with cerebral palsy or neuromuscular disease compared to controls [ 36]. A recent Cochrane review on this topic concluded that although the available studies consider different treatments methods, potential benefits were found for most the interventions in the absence of adverse events [ 37].

Based on clinical experience, chest physiotherapy is an important tool to treat children with inefficient cough and chronic or recurrent lower airway infections. A recent abstract reported on the impact of home based respiratory physiotherapy service with a significant decrease in emergency visits and hospital admission in children with neurodevelopmental and muscular disorders [ 38].

Gastrostomy feeding

The main indication for gastrostomy feeding is unsafe swallowing with risk for aspiration. In case of failure of medical management of additional GOR, this may be combined with an antireflux procedure.

In a recent meta-analysis of three retrospective studies, the outcome of percutaneous gastrojejunostomy was compared to fundoplication with gastrostomy in children with neurological impairment [ 39]. Procedure-related mortality was 1% in both groups. Rates of pneumonia during follow-up were high but comparable in the two groups (17% versus 19%). Complications did not differ statistically between the two groups, with a tendency for more major complications with the open procedure and more minor complications with the percutaneous procedure.

In our cohort, gastrostomy feeding was a risk factor for respiratory morbidity, or in other words, it did not seem to protect the patients from airway problems. In the context of disability, needing a gastrostomy should be seen as an indirect parameter for bulbar dysfunction. This is in accordance with a study on survival in young patients with cerebral palsy where GMFCS level 5 and gastrostomy were indicators of lower survival [ 2].

This by no means suggests that we should not consider a gastrostomy in cases of swallowing disorders in order to protect the airway. In a preselected cohort specifically looking at the number of lower airway infections before and after, a positive effect was seen [ 8].

A Nissen procedure can mostly be performed by laparoscopy with acceptable complication rates even in this vulnerable population. In a report from our institution, 106 consecutive patients referred for a laparoscopic Nissen procedure were evaluated (57 neurologically normal and 49 neurologically impaired). Mortality was 0% and conversion rate to laparotomy was 2.8%. Major post-operative complications occurred in 12 patients, mostly with neurologically impairment [ 40].

While gastrostomy feeding prevents aspiration of food, it does not prevent the aspiration of saliva and upper airway secretions. Some centres opt for surgical closure of the larynx in cases of intractable aspiration [ 41] and recently, novel surgical closure techniques with a lower risk of complications have been described [ 42]. In our centre, we have no experience with these surgical techniques in children, and the decision is not easy because it implicates loss of phonation and the presence of a permanent tracheostomy.

Hypersalivation is a common finding in children with neurodevelopmental problems and this may increase the risk of aspiration. Apart from medical treatment options (hyoscine and glycopyrrolate), botulinum toxin injections in the salivary gland or surgical gland resection are effective treatment options [ 43, 44].

Scoliosis surgery

In many centres, children with severe and progressive scoliosis in the context of severe disability are referred for spinal surgery. Although neuromuscular scoliosis surgery may improve the scoliosis curve, evidence that it prolongs survival is lacking. Furthermore, in the severely impaired child, the ethical dilemma of whether to subject the child to an extremely painful, complication-prone procedure involving a prolonged hospital stay needs to be carefully considered. In a recent meta-analysis, neuromuscular scoliosis patients have diverse and high complication rates after scoliosis surgery, with 30% of children with cerebral palsy having respiratory complications [ 45]. In a survey performed in our centre, almost 50% of children with cerebral palsy developed a pneumonia or atelectasis post-surgery and 20% had wound-related issues. There was, however, no surgery-related mortality (unpublished data).

Unfortunately, qualitative data on long-term outcome ( i.e. comparing quality of life (QOL) and survival with or without surgery) are, to my knowledge, not available. Some reports describe very subjective and descriptive results after spinal fusion of improved sitting position, fewer pressure sores and subjectively better breathing, for example, in patients with Rett syndrome [ 46]. In a retrospective cohort, spinal fusion improved the activity and participation as assessed by the caregiver, while mobility, feeding, GMFCS level and communication did not change [ 47].

A questionnaire-based study reported positive effects on overall function, QOL and ease of care as evaluated by the parents, and improved motor function reported by the therapist [ 48]. Data on change in respiratory outcome are scarce. In one retrospective cohort, lifetime pneumonia risk was related to epilepsy, non-cerebral palsy causes and major scoliosis. However, the yearly incidence of pneumonia did not decrease after spinal surgery [ 49]. In a recently published retrospective cohort with early onset neuromuscular scoliosis, spinal fusion was associated with minimal short- and long-term morbidity, but there was 28% mortality at 10-year follow-up and 50% predicted mortality at 15 years [ 47, 50].

Upper airway obstruction

Treatment for obstructive sleep apnoea syndrome (OSAS) is stepwise in children with neurocognitive impairment. Adenotonsillectomy may be considered in this context as a first step, together with sleep position (prone or on the side rather than on the back) as a second step. Rapid weight increase may aggravate OSAS and excessive weight gain after the start of gastrostomy feeding should be avoided. Changes in medication for epilepsy or spasticity may also increase pharyngeal hypotonia and/or upper airway secretions, and thus OSAS. Some centres have had positive experiences with the use of nasopharyngeal airways in this context. Start of nasal continuous positive airway pressure (nCPAP) may be considered but should be carefully weighed against the increased burden of care, increased cost and possible side-effects. Data on improved QOL or daytime functioning after the start of nCPAP in this group are largely missing. One small study (with only three children with nCPAP) documented improved QOL and daytime function (compared with a control group without OSAS diagnosis) [ 51]. In cases of severe obstructive breathing, a tracheostomy may be considered [ 52]. Again, this should be carefully set against the drawbacks of a tracheostomy increasing the complexity and intensity of the care.

Conclusion

Children with neurocognitive impairment often present with chronic or recurrent respiratory problems, which have an important impact on QOL and life expectancy. The underlying causes are multiple, ranging from risk of aspiration, insufficient cough and UAO to progressive kyphoscoliosis. Concomitant disease such as asthma or immunodeficiency should not be overlooked. There is often a complex interplay between these known risk factors. The diagnostic and therapeutic approach should be multidisciplinary and decisions for treatment should be individualised, aiming to improve the QOL of the child. Advanced care planning in children with neurocognitive disability should not only concentrate on intellectual development, motor function, orthopaedic aspects and feeding, but also on the respiratory problems that may be encountered [ 53].

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Respiratory illness in children with disability: a serious problem?

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Children with severe neurocognitive impairment often present to paediatric clinics with recurrent and chronic lower airway infections and increased risk of respiratory insufficiency [ 1]. These pulmonary problems play an important role in the morbidity and even the mortality of children with neurocognitive impairment [ 2- 5].

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Bus transportation for special needs students in a pandemic

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Bus transportation for special needs students in a pandemic

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The safe return to school for students with special needs may require modifications in related service transportation that were not required prior to COVID-19, as notes the Student Transportation Aligned for Return to School (STARTS) Task Force report, developed by national school transportation leaders and published in July. The report includes 18 guidelines specific to transportation for students with disabilities. The guidelines cover topics such as:

* Masks. The required use of masks by students with special needs should be considered on a case-by-case basis after district personnel are informed about the capacity of each individual student to wear a mask, the guideline states. Excluding a student from transportation solely because of the inability to wear a mask would likely be a violation of the IDEA and Section 504 provision of students being assured a free appropriate public education (FAPE).

* Social distancing. Students not capable of following social distancing and "no touching" requirements is also not an acceptable reason to deny FAPE, the report states. A recommendation is to create age-appropriate travel training support to be shared with families. An alternative transportation option can be discussed and offered at no cost to parents.

* Hand sanitizers. Because some students with disabilities may put their fingers into their mouth, try to lick off a sanitizer or have an allergic response to one, prior parent knowledge and approval is required is sanitizers are going to be used before entry to a bus or while on a bus.

* Ventilation. Measures such as opening windows require careful planning and may not be reasonable on buses where students have certain respiratory conditions with breathing difficulties that are triggered by fumes, temperature changes, dust or other factors.

* Ability to comply with procedures. Some students with disabilities are unable to understand or follow new transportation policies and procedures developed in response to COVID. Drivers and attendants must understand individual student needs to work effectively with them and make necessary adaptations for safe transport. Students with limited capacity to comply should have a contingency and support plan developed by their team.

The STARTS report and related tools can be accessed here, with the Special Education Guideline Addendum beginning on page 23.
Related feature: Bus stops: 9 school busing realities to recognize

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Bus transportation for special needs students in a pandemic

# data[].attributes.attachment_link.description
The safe return to school for students with special needs may require modifications in related service transportation that were not required prior to COVID-19, as notes the Student Transportation Aligned for Return to School (STARTS) Task Force report, developed by national school transportation leaders and published in July.

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-Children with Autism

-Children with Severe Autism

-Children with Autism and Intellectual Disabilities

-Children with Intellectual Disabilities

-Children with Down Syndrome

-Children with Emotional Disturbance
-Children with Severe Behavior

-Medically Fragile Children

-Medically Complex Children

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New Jersey officials reported 10 new in-school outbreaks of the coronavirus, bringing the total to 131 outbreaks and 629 cases linked among students, teachers and school staff, according to the latest numbers Tuesday.

The outbreaks - defined as cases in which people were confirmed to have caught or transmitted the virus in the classroom or during academic activities - were reported in all 21 counties, according to the state's COVID-19 dashboard.

One outbreak at an Essex County school was linked to 92 cases.

The names of the schools were not released to protect the privacy of the children and school staff members who tested positive, state officials said.

Gov. Phil Murphy said social distancing rules and safety measures designed to keep students and teachers safe in schools continue to work for the most part. But schools are "certainly not batting a thousand," the governor said.

Murphy, who has said he does not want to order a statewide school shutdown, continues to allow local school districts to decide for themselves whether to hold in-person classes or switch to virtual learning. Some have yet to have any in-person classes this school year.

The Newark school district, the state's largest district, pushed back returning to classrooms until April 12. Jersey City is extending all-remote learning until April 21 and Trenton has pushed the return to in-person classes to May.

Hillside's school district has already announced plans to remain remote through the end of the school year.

Case rates for the coronavirus dropped last week in all six New Jersey regions tracked by the state and used by school districts to evaluate risk in educational settings.

But, for the ninth week in a row, all 21 counties are orange, indicating "high" coronavirus activity, according to data released by the state Department of Health Thursday.

New Jersey health officials on Tuesday reported another 4,117 confirmed cases and 133 additional deaths as the state surpassed 600,000 confirmed cases on the same day as hitting 600,000 vaccinations administered.

The state's seven-day average for new confirmed COVID-19 positive tests is 4,416, down 13% from a week ago, and down 3% from a month ago, as numbers continue to show signs of the pandemic's second wave starting to fall.

The total number of school cases by county are:

Bergen County: 29 confirmed outbreaks and 121 linked cases

Camden County: 13 confirmed outbreaks and 66 linked cases

Salem County: 13 confirmed outbreaks and 43 linked cases

Cape May County: 8 confirmed outbreaks and 23 linked cases

Burlington County: 7 confirmed outbreaks and 24 linked cases

Gloucester County: 7 confirmed outbreaks and 41 linked cases

Monmouth County: 7 confirmed outbreaks and 21 linked cases

Cumberland County: 6 confirmed outbreaks and 14 linked cases

Passaic County: 6 confirmed outbreaks and 27 linked cases

Atlantic County: 5 confirmed outbreaks and 14 linked cases

Ocean County: 5 confirmed outbreaks and 42 linked cases

Sussex County: 5 confirmed outbreaks and 13 linked cases

Warren County: 5 confirmed outbreaks and 12 linked cases

Mercer County: 3 confirmed outbreaks and 14 linked cases

Somerset County: 3 confirmed outbreaks and 9 linked cases

Hudson County: 2 confirmed outbreaks and 10 linked cases

Hunterdon County: 2 confirmed outbreaks and 7 linked cases

Morris County: 2 confirmed outbreaks and 10 linked cases

Essex County: 1 confirmed outbreaks and 92 linked cases

The state's totals do not include cases tied to school sports teams or cases in which contact tracers failed to conclude whether students and teachers caught the virus within their schools.
Our journalism needs your support. Please subscribe today to NJ.com

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10 new in-school COVID outbreaks increases N.J. total to 131 with 629 cases

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New Jersey officials reported 10 new in-school outbreaks of the coronavirus, bringing the total to 131 outbreaks and 629 cases linked among students, teachers and school staff, according to the latest numbers Tuesday.

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Safety measures can help lower, but not eliminate, the risk of virus transmission.

Credit: Dania Maxwell/Los Angeles Times

Credit: Dania Maxwell/Los Angeles Times

As schools inch closer to reopening campuses in some parts of California, medical experts are warning that the spread of the coronavirus will be inevitable and schools need to prepare.

Recent studies have shown that while children infected with the coronavirus are less likely to have symptoms, they often carry larger viral loads and can be " super spreaders," passing the virus to each other, their families and teachers.

And without widespread testing and contact tracing, identifying children who are infected is nearly impossible because most are asymptomatic, doctors said.

"It's very likely that even with careful screening, kids are going to end up in school with infections," said Dr. Dylan Chan, associate professor of otolaryngology (ear and throat medicine) at UC San Francisco. "Schools need to recognize that and get strategies in place."

Schools in some parts of California have reopened or are close to reopening, either because the state has granted them a waiver or their county health officials have given approval. Small in-person classes for students in special education or other high-needs groups have also started in some districts.

Schools that reopen must adhere to the state's strict health and safety protocols that include social distancing, mask requirements, deep cleaning and sending home students who might be sick.

So far, the California Department of Public Health has seen a "very small" number of outbreaks - defined as three or more cases - at K-12 schools that have reopened, according to the department.

Last week, Dr. Mark Galhy, head of the state's Health and Human Services Department, credited the small caseload to schools' and communities' precautionary measures.

"So far, it's encouraging to see the tremendous effort and planning that communities and their schools and their staff have done to make sure that it's lower risk for students and staff alike and...I think that's encouraging for all of California," he said.

Nonetheless, as more schools open, outbreaks associated with schools will be inevitable - whether they originate at the school or within the community, according to the Department of Public Health.

"As long as Covid-19 is circulating in communities, it should be expected that cases will be reported in a variety of settings, including among school students, teachers and staff in schools that have reopened for in-person learning," a department spokesperson wrote in an email to EdSource. "However, these cases may be associated with transmission within schools or community transmission, and there are school and public health plans in place for when COVID-19 occurs at a school, to implement control measures that will limit transmission within schools."

But even the strictest safety protocols might not be enough to prevent infected students from coming to school and unknowingly transmitting the virus to others, according to Chan and his colleagues at UC San Francisco. In studying random coronavirus tests of 30,000 children nationwide, Chan and his team found that the infection rate among children - even if they're asymptomatic - mirrors that of the communities in which they live.

Based on that equation, they developed a tool for schools to determine how many infected students they can expect on campus. For example, in Los Angeles County, a school with 500 students is 98% likely to have at least one student who's infected.

"It's important to note that even in communities with low infection rates, we still found kids with asymptomatic infections," Chan said. "Schools need to focus on reading the risks and protecting people."

Researchers at the Kaiser Family Foundation reached a similar conclusion, saying that outbreaks related to schools reopening may be unavoidable.

Here are some recent studies of coronavirus and children:
Rand Institute: How to Re-Open Schools Mathematica: New Data Help Cut Through the Uncertainty of 'Back to School' Amid Covid UC San Francisco Risk Calculator for Asymptomatic SARS-CoV-2 Infection Among Children Kaiser Family Foundation: What Do We Know About Children and Coronavirus Transmission
"Where there is already widespread community transmission, as is the case in many areas in the U.S., there is clearly a risk of spread associated with reopening schools," according to a Kaiser Family Foundation report published July 29. "This challenge may be more pronounced where testing and contact tracing capacity is limited."

In addition to masks and social distancing, some schools are considering installing ventilation systems that keep air flowing, since research suggests the virus is airborne; holding classes outdoors as weather permits; hiring extra staff to clean classrooms and enforce safety protocols; limiting the number of students in a classroom; and separating desks by 6 feet.

Those steps can help lower, but not eliminate, the risk, according to Laura Flaherty, a policy researcher at the Rand Corporation, a nonprofit research and policy think tank.

"There are a number of ways to reduce the transmission of Covid-19 in schools, although none of these measures take the risk to zero," she said in a video on the Rand website.

Flaherty and her colleagues suggested that schools space students apart as much as possible, expanding classes to other facilities such as libraries and community centers, if necessary; trying a week-on, week-off schedule so students and teachers have some consistency with instruction; having teachers rotate among small groups of students; and hiring tutors to work with students when teachers are unavailable.

A hybrid model of in-person and remote instruction might be one of the most important ways schools can reduce the transmission of Covid-19, researchers at Mathematica, a policy and research firm, found.

Examining 400,000 simulations of possible virus transmission in schools, researchers found that schools can "dramatically" lower the chance of an outbreak by combining a hybrid schedule with strict safety protocols, like wearing masks and eliminating in-person social interactions outside of class.

Researchers also found that temporarily closing schools when an outbreak occurs is a less effective way to control the virus than adopting a hybrid model and enforcing safety protocols to begin with.

But no method is foolproof, researchers said.

"The possibility that schools could exacerbate the pandemic is a serious concern," they said on the Mathematica website. "Every school that is opening its building to students - part-time or full-time, starting now or later in the school year - needs to prepare for the likelihood that a student or staff member will become infected with Covid-19, and have a plan in place for what to do next."

Still, some believe that the benefits of reopening schools outweigh the risks - especially for students for whom distance learning has been a struggle, or whose parents work.

Distance learning has been a fiasco for too many students, especially those who were already at risk of falling behind, and it exacerbated an achievement gap in California that was among the widest in the country even before the pandemic, said Samantha Tran, senior managing director for education at Children Now, an advocacy and research organization.

Students who lack reliable internet access, technical devices or a quiet place for online learning are falling dangerously behind their peers academically, she said. And many other students - even those with adequate technology at home - are simply not engaged in school, she said.

"We're talking about significant learning loss. Months and months and months," she said. "It's a serious equity issue. These kids have a fundamental right to an education, and they're not getting it right now."
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Virus outbreaks unavoidable as school campuses reopen, experts warn

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Credit: Dania Maxwell/Los Angeles Times Credit: Dania Maxwell/Los Angeles Times As schools inch closer to reopening campuses in some parts of California, medical experts are warning that the spread of the coronavirus will be inevitable and schools need to prepare.

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CDC Jan 2021 Developmental and Behavioral Disorders

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CDC Jan 2021 Developmental and Behavioral Disorders

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Centers for Disease Control and Prevention

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Developmental and behavioral disorders are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may affect day-to-day functioning, and usually last throughout a person's lifetime.

Some developmental and behavioral disorders include:

What do people with developmental and behavioral disorders need to know about COVID-19?

Know who is at risk for severe illness from COVID-19

Most people with developmental or behavioral disorders are not naturally at higher risk for becoming infected with or having severe illness from novel coronavirus (COVID-19). However, people with developmental or behavioral disorders who have serious underlying medical conditions may be at risk of serious illness. Some people with developmental or behavioral disorders may have difficulties accessing information, understanding or practicing preventative measures, and communicating symptoms of illness.

Know how to protect yourself and others

The best way to prevent illness is to avoid being exposed to this virus. Advice on preparation for COVID-19 and prevention of exposure to COVID-19 is available.

Continue with your routine care

Don't stop any medications or change your treatment plan without talking to your healthcare provider.

Discuss any concerns about your treatment with your healthcare provider.

Ensure that you are obtaining the tests ordered by your healthcare provider.

Continue to get your routine immunizations.

Talk to your healthcare provider, insurer, and pharmacist about creating an emergency supply of prescription medications. Make sure that you have at least 30 days of prescription and over-the-counter medications and supplies on hand in case you need to stay home for a long time. Ask your healthcare provider if it is possible to obtain a 90-day supply of your prescription medications.

Make or update care plans or an emergency notebook. They typically include important information about a person's medical conditions, how to manage those conditions, how to contact healthcare providers and therapists, allergies, information on medications (names, dosages, and administration instructions), preferences (food and other), and daily routines and activities. This may help you receive consistent care if your Direct Service Providers or family members are unavailable.

Know how to manage stress and cope during the pandemic

It is natural to feel concerned or stressed as more cases of COVID-19 are discovered and our communities take action to slow the spread of disease. Taking care of yourself, your friends, and your family can help you cope with stress.

Ways to cope with stress

Take breaks from watching, reading, or listening to news stories, including social media. Hearing about the pandemic repeatedly can be upsetting.

Take care of your body.

Make time to unwind. Try to do some activities you enjoy.

Connect with others. Talk with people you trust about your concerns and how you are feeling.

Click here for information on how to take steps to help yourself cope with stress and anxiety.

Take care of your mental health

Anxiety, depression, and other mental health conditions can be more common in people with some developmental and behavioral disorders. If you are being treated for a mental health condition it is important to continue any therapies or medications.
Look out for these common signs of distress:

Feelings of numbness, disbelief, confusion, anxiety, or fear

Changes in appetite, energy, and activity levels

Difficulty concentrating

Difficulty sleeping or nightmares and upsetting thoughts and images

Physical reactions, such as headaches, body pains, stomach problems, and skin rashes

Worsening of chronic health problems

Anger or short temper

Increased use of alcohol, tobacco, or other drugs

If you experience these feelings or behaviors for several days in a row and are unable to carry out normal responsibilities because of them, call your healthcare provider or use the resources below to get help. If you are feeling overwhelmed with emotions like sadness, depression, anxiety, or thoughts of hurting or killing yourself or others:

During this pandemic, it is critical that you recognize what stress looks like, take steps to build your resilience and cope with stress, and know where to go if you need help.

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Developmental and behavioral disorders are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may affect day-to-day functioning, and usually last throughout a person's lifetime.

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CDC Jan 2021 People at Increased Risk for Severe Illness

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CDC Jan 2021 People at Increased Risk for Severe Illness

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Centers for Disease Control and Prevention

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Some people need to take extra precautions to avoid getting sick from COVID-19, like people at increased risk for severe illness or people in some vulnerable populations.