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16 September 2021

How life without germs has left us newly vulnerable

Unseasonal respiratory diseases are surging as children and others repay an “immunity debt” from lockdown.

By Anoosh Chakelian

Respiratory syncytial virus. Croup. Norovirus. Tonsillitis. Colds. Colds. Colds. More colds. If you are a parent of young children or work in childcare, this litany of diseases may sound familiar to you.

A wave of viruses has been hitting babies and toddlers across Britain – and spreading to the adults around them – as many encounter germs on a significant scale for the first time in their young lives. Populations have begun repaying their “immunity debt”: the phenomenon of Covid-19 control measures stopping children developing immunity to other diseases, leading to bigger outbreaks later on.

“Since May onwards, we have just been floored by bug after bug after bug – respiratory bugs, endless amounts of snot, bouts of vomiting and diarrhoea,” says Dr Shema Tariq, an HIV consultant and public health academic at UCL whose second child was born in the first week of the first lockdown.

“She’s a pandemic baby. She’s never been to baby groups, isn’t socialising with other babies outside the house or other adults outside the house; she’s not being exposed to germs. She’s completely vulnerable.”

In the space of six weeks, Tariq’s daughter has had suspected respiratory syncytial virus (RSV – a common respiratory virus among young children), suspected norovirus (a 48-hour vomiting bug) and countless colds.

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Although Tariq works in the world of viruses, she had not considered the “impact of lockdown on my baby’s immune system” – and what would happen once the restrictions were lifted and her daughter would begin a normal life. Nursery reopened in March 2021, and her daughter, who “hadn’t been exposed to anything at all” before, began picking up bugs, while her older two-and-a-half-year-old brother was fine.

“They go to nursery and you might as well just lick a toilet bowl! It’s such a petri dish of germs in nursery!” Tariq assumed her daughter would build up her immune system before the winter virus season. “I was woefully naive,” she sighs.

Now, when the family go for walks in the forest near their home, “and when she’s in the forest and she’s licking the floor, I’m like ‘Go for it!’” laughs Tariq. “I want her to get as many microbes into her as possible!

“As a doctor, I’m a really, really great believer in germs – germs are a really good thing, they reduce your risk of allergies long-term, they help you develop a more refined immune system.”

More commonly seen in winter months, respiratory viruses have increased significantly over the summer in the UK – leading to descriptions of a “winter in June” in hospitals for emergency paediatric doctors.

The two-year-old daughter of New Statesman managing editor Emma Haslett has suffered from tonsillitis, norovirus, croup (an infection that causes a distinctive barking cough), RSV and “approximately 100 million colds” between late May and the beginning of August.

“I make sure she’s outside, eating dirt”

“She’d maybe had two or three colds in her whole life before, and she’d never had a temperature before,” Haslett says. “Then suddenly, it all started piling on top of each other.”

During lockdown, Haslett remembers thinking it was “great” none of her family were catching colds, but also predicted “we are going to have hell to pay” when the country reopened. “I knew she was going to have a weaker immune system, and there were moments where I thought, ‘What are we doing to our kids’ immune systems?’ and I did make sure she was outside and eating dirt!”

The rise in RSV has been driven overwhelmingly by young children. In the final week of July, 32 in every 100,000 children in England aged four or under were hospitalised with the virus. From October 2020 until this May, that rate had never risen above 0.41.

RSV has also been spreading among older children, with the number hospitalised per 100,000 rising from a maximum of 0.08 between October and May to 1.07 in July. Direct comparison with previous summers is not possible – levels of RSV in summer are usually so low that Public Health England (PHE) does not even record them.

Graphs by Ben van der Merwe

Cases of acute bronchitis and bronchiolitis (inflammation of the smallest airways in the lungs), which are frequently caused by RSV infections, have also been increasing.

Data from GP surgeries shows that since April the number of out-of-hours visits for these conditions has risen far above baseline levels, a trend driven almost entirely by under-five year olds. Similarly, emergency departments saw around 130 attendances relating to acute bronchitis or bronchiolitis each day in late August. The expected number of daily attendances for this time of year is just six, according to PHE.

RSV routinely causes the hospitalisation of 2 per cent of infants – and since they’ve missed a year of coming into contact with that virus, there is a concern it will cause significant numbers of hospitalisations in young children, because so many are having their first exposure to it at the same time: two cohorts instead of one.

As more children are being hospitalised with bronchiolitis than previous years, parents are highlighting how serious it can be.

“For nine months, I lost count of the number of admissions to hospital at 13,” says Amy Keen, whose now two-year-old son suffered from numerous, serious bouts of bronchiolitis (caused by RSV) in 2019 from the age of four months. He was repeatedly admitted to children’s high dependency units because of his dangerously low levels of oxygen.

“Basically, every four weeks we were in hospital, he kept catching recurring infections,” she says.

Contrary to the downsides of a germless year, Keen suspects the coronavirus restrictions actually gave her son’s body some respite for the first time in his young life. After being prescribed an inhaler, his last bout of bronchiolitis was in December 2019, just as Covid-19 was beginning to spread.

“He may have grown out of it, or maybe being in lockdown helped, giving his immune system a chance to take a breath and not continually catch all these infections from other people,” Keen says.

“So being away from people for a couple of months actually might have worked in our favour, believe it or not, because he’s never been unwell like that since.”

More broadly, in summer, admissions relating to acute respiratory infection in under-fives surged to the highest they had been all year.

Gastroenteritis (which can be caused by norovirus) has also had a surge, though the relationship to age is less substantial.

“Norovirus, commonly known as the winter vomiting bug, has been at lower levels than normal throughout the pandemic with less opportunity to spread between people in the community, but as restrictions have eased we have seen an increase in cases across all age groups,” Professor Saheer Gharbia, the deputy director of PHE’s national infection service, told the Guardian in July.

Both New Zealand and the US have also been experiencing a wave of RSV in recent months. A similar surge in infections in Australia late last year has been attributed to the effect of lockdown in limiting children’s exposure to the virus.

With children’s admissions on the rise, Keen advises parents of children suffering from respiratory infections to “trust your instinct as a parent. If something’s not right, it’s not right for a reason – you know your child, you know when they’re not well.”

“People are going to have a rough few months, especially in winter”

The most notable change in our regular experience of infections has been the common cold. When nurseries were closed, it was rare during lockdown for those able to work from home with their children out of school to catch a cold.

Rhinovirus infections, which cause about 50 per cent of common colds, have not spread in the same way under coronavirus restrictions. As the typical adult catches a cold two to five times a year, a big surge of colds is expected as we draw into the colder months and begin socialising indoors.

“People are going to have a rough few months, probably in the indoor socialising winter season,” says Dr Eleanor Gaunt, a research fellow at the University of Edinburgh who investigates the molecular biology of influenza A virus and SARS-CoV-2. “We’ve got a few colds to catch up on!”

The lockdown effect of social distancing, staying at home, limiting human contact, sanitising and wearing masks has finally caught up with us – and it’s a snotty tsunami.

For over a year, we have been living in a new, relatively sterile world we created for ourselves to avoid catching and spreading Covid-19. Our attention to hygiene has been in overload, contact with others minimal, and we’ve sheltered ourselves from the usual day-to-day germs.

While the world wrung its hands about how missing school and staying indoors would affect the social skills and happiness of young children, little focus was given to their newly developing immune systems. Some scientists, however, predicted that the germ-avoiding measures either state-imposed or naturally adopted by populations during the pandemic could be affecting our bodies in unexpected ways.

“The intersection of the past century’s hygienic practices and recent Covid-19 pandemic control measures may negatively affect the microbiome and thus human health across multiple timescales,” hypothesised a February 2021 paper in the Proceedings of the National Academy of Sciences of the United States of America journal.

“We are living with the ‘Purell paradox’”

While the scientists behind the paper stressed the need to prevent coronavirus transmission, they came up with measures that could mitigate the potential impact on immune systems: keeping urban parks open, provision of remote breastfeeding support, promoting infant vaccination, ensuring healthy food assistance to low-income families, gardening, encouraging physical contact with the people and pets one is co-quarantining with, and avoiding unnecessary antibiotic prescriptions.

The trillions of microbes that live inside us, making up what is known as our microbiome, play many roles – including refining our immune systems, which help us fight infection. An extraordinary and rapid shift in our sanitary and social rhythms since the UK’s first lockdown last March came amid a decades-long rise in hygiene practices, antibiotics and urban living.

Some of these factors play a role in what is known as the “hygiene hypothesis”: the (contested) idea that modern extreme cleanliness can hinder our necessary exposure to germs, therefore leading to a rise in allergic and autoimmune diseases. Perhaps we can call the pandemic’s version of this the “Purell paradox”: the irony that constant hand-sanitising and other trappings of what has come to be dubbed “hygiene theatre” may not always be straightforwardly good for our health.

“The concern among some microbiologists for the past decade or so has been that the collateral damage of excessive sanitising and use of antibiotics is not good, in terms of microbes that we spent thousands of years evolving with,” Brett Finlay, a professor of microbiology and immunology at the University of British Columbia, told the Atlantic in April.

Doctors and public health experts are also increasingly concerned that we have had very little flu in over a year. Numbers of flu cases have been extremely low in the UK since the pandemic hit, despite concerns last year of a double winter wave of Covid-19 and influenza – but the latter never materialised.

The risk now is of a “triple threat” of viruses – Covid-19, RSV and flu – hitting hospitals this winter. The NHS, already under pressure from an unprecedented backlog, is preparing for this “worst-case scenario”.

This is why England’s flu immunisation programme is being expanded, with a record number of children and adults (over 35 million people) being offered the flu vaccine this year.

The usual pattern for flu is that it travels around the world, causing seasonal outbreaks – it usually comes from Australia and Asia and then migrates up to the UK. This means we can generally tell what type of flu is going to hit us in winter, and design that season’s vaccine accordingly.

“People are going to be more susceptible to flu”

“Because of all these protections we’ve had in place, the occurrence of flu has been really, really low for the past 18 months now,” says Gaunt. “Because the detection of flu has been so low, it’s very difficult to predict at this point, in terms of which flu strain becomes predominant in the coming respiratory season.”

This unpredictability is coupled with the lack of natural exposure to flu among the population. “The immune response is going to be dropped compared to where it usually is, which means that on average across the population, people are going to be more susceptible to flu.”

On average, a typical adult will become infected with flu every five years, so the jury’s out on whether an 18-month hiatus will have a significant impact.

“Given the current status of immunological naivety in the population, we can expect winter to be particularly bad when multiple factors come together for different viruses,” says Gaunt. “It’s quite possible we will be hit with different respiratory viruses at different times, but we always expect winter to be bad.”

There is no reason for parents to panic, or anyone to ditch vital coronavirus restrictions still in place. “We won’t know for sure until we actually see how all this plays out,” Byram W Bridle, a viral immunologist at the University of Guelph in Canada, told the Observer in May.

The long-term impact of the habits we’ve formed during lockdown are unknown, and many trends may have been better for our health: spending more time outdoors, increased pet ownership, and the rise in home cooking and gardening, for example. We also do not know how long certain habits we have formed will persist beyond the pandemic.

“There is a huge cultural change in our behaviour”

Dr Tariq isn’t taking any chances though. She decided to take both her children to be vaccinated against chicken pox, concerned they would no longer encounter it in the new Covid-19 world.

“My worry is if they don’t get chicken pox as children and they get it as adults, it’s an extremely serious illness and can be life threatening,” she says. “Pre-Covid, I would’ve just presumed they’d catch chicken pox at nursery.”

She believes Covid-19 is bringing about a “huge cultural change” in our behaviour. “Who knows? We may well be social distancing for a long time – everyone’s using hand sanitiser in a way no one was prior to 2020, the adults at nursery are masking,” she says. “And at the vaguest sign of any illness, a child is sent home.

“I don’t know if the next few years will pan out in the same way in terms of their [my children’s] exposure to viruses as they would’ve done before. That’s a weird side effect of Covid.”

Additional reporting by Ben van der Merwe.

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