COVID-19, Immunodeficiency and School Attendance

30 July 2020 Update

This information has been developed for parents and carers, to guide decisions about school attendance for children with primary immunodeficiency (PID) during the COVID-19 pandemic. Public health measures implemented by Australian and New Zealand governments have been successful in controlling the spread of SARS-CoV-2, the coronavirus that causes COVID-19 in most regions. This means that most regions have re-opened schools for face to face learning.  However, in regions where there are outbreaks, some students may be required to temporarily return to remote learning.

pdfASCIA PCC COVID-19 Immunodeficiency School Attendance 2020 July Update177.45 KB

For parents of more vulnerable children, including those with PID, the decision to send their children back to school during or after an outbreak is complex. The type and degree of immunocompromise varies widely between children with PID, so it is important to ask your child’s clinical immunologist if you have specific questions.

Schools in Australia and New Zealand should have measures in place to reduce the spread of COVID-19 (and other respiratory infections), so we recommend that many children with PID can return to school, in regions where there are no outbreaks.

This advice is based upon the following facts:

  • Children are far less likely than adults to contract SARS-CoV-2 infection and the risk of severe COVID-19 is very low.
  • Evidence suggests that most immunosuppressed children are not at a significantly higher risk of severe COVID-19 than their age matched peers.
  • Very low rates of community transmission mean that the risk of contracting SARS-CoV-2 infection is currently very low. The improved availability of testing and contact tracing mean that we are well placed to isolate and contain outbreaks as they occur.
  • There is good evidence that children don’t spread SARS-CoV-2 like adults. Child-to-child transmission is rare and it is very unusual for asymptomatic children to spread COVID-19.
  • The low risk of contracting SARS-CoV-2 is likely to persist for many months or even longer, depending upon if, and when a vaccine becomes available. It is not in children’s best interests to exclude them from school indefinitely when the evidence suggests that the risk of developing severe COVID-19 is very low.

We understand there will be questions about this advice and will attempt to answer some questions here.

What evidence suggests that children with PID don’t have an increased risk of severe COVID-19?

ASCIA has been following reports and liaising with colleagues from countries that have been much more severely affected by the pandemic than Australia or New Zealand. An international survey is underway to document how many patients with PID have COVID-19. As of early May 2020, only a small number of patients with known PID have been diagnosed with COVID-19 and there is currently no evidence that children with PID are at increased risk of severe COVID-19.

What is the evidence that transmission of COVID-19 in schools is rare?

There have been a number of studies which have shown that the risk of transmissions in schools is low:

  • The NSW government has released a report regarding their investigation of 15 schools where cases were identified in March 2020. There were only two cases of probable secondary infection among 735 students who were close contacts of known cases (0.2%).
  • A population-based study in Iceland did not detect any cases of asymptomatic infection in children under 10 years of age.
  • International studies have consistently found that it is quite rare for children to infect other children or adults.

What is the Government advice regarding children with complex medical conditions?

  • Australian and New Zealand Governments provide official and up-to-date online advice for people at higher risk of COVID-19.
  • Advice from the Australian Health Protection Principal Committee (AHPPC) on reducing the potential risk of COVID-19 transmission in schools is available here.
  • Guidance from the New Zealand Ministry of Health on assessing for COVID-19 in schools is available here

Are there any groups of patients who should not return to school?

The type and degree of immunocompromise varies widely between children with PID, so it is important to ask your child’s clinical immunologist if you have specific questions. Advice may differ depending upon the child’s circumstances, infection transmission rates in their community and possibly the state or country they live in.

Is the risk different for primary or secondary school aged children?

There is a slight increase in risk of contracting COVID-19 in secondary school aged children, compared to primary school aged children, and the risk of transmission at school appears to be slightly higher in older teenagers. However, this slight increase in risk is not sufficient to make different recommendations regarding returning to school for these two groups.

Do children have to practice physical/social distancing at school?

Returning to school does not mean that everything will return to normal. There will be an increased focus on handwashing, other hygiene measures and physical/social distancing measures, where practical  

We understand that physical/social distancing is not practical for younger children, and in regions where there is low community spread it does not appear to be necessary, due to low risk of transmission in this age group.

Older students are generally more capable of complying with physical/social distancing recommendations and have a slightly higher risk of contracting the virus from other students. Therefore, older children should make every effort to follow recommendations regarding regular handwashing and physical/social distancing.

The greatest risk for school outbreaks remains adults. Therefore, it is very important that parents comply with restrictions to minimise contact they have with other parents, teachers and students in the school environment

Should children wear masks at school?

The role of masks has attracted a lot of attention in the media. The use of masks has mostly been recommended in countries and regions where there is widespread community transmission, to reduce spread of the virus.

It is understood that the potential benefit of widespread use of masks is to reduce the risk of asymptomatic adults spreading the virus, rather than protecting someone from contracting the virus. Therefore, wearing a mask at school is unlikely to provide any additional protection for your child.

However, in regions where there are outbreaks, the wearing of masks is recommended when physical/social distancing is not possible. 

Further information

This information has been adapted with permission from the Australian & New Zealand Children’s Haematology/Oncology Group (ANZCHOG) oncology and bone marrow transplant (BMT) advice.

The ASCIA COVID-19 webpage www.allergy.org.au/members/covid-19 is regularly reviewed and updated.

© ASCIA 2020

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology research go to www.allergyimmunology.org.au 

COVID-19 and Immunodeficiency

Updated 15 May 2020

ASCIA COVID 19 ImmunodeficiencyThis information has been developed for people with primary and secondary immunodeficiencies, in response to the COVID-19 infectious respiratory disease pandemic caused by SARS-CoV-2, the most recently discovered coronavirus. Public health measures and restrictions that were implemented by the Australian and New Zealand governments since mid-March 2020 have been successful in controlling the spread of COVID-19.

This information has been updated, following the easing of some restrictions in mid-May 2020.

pdfASCIA PCC COVID-19 and Immunodeficiency 2020140.58 KB 

What is COVID-19 and how does it spread?

Coronaviruses are a large family of viruses that cause respiratory infections, including the common cold and more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).

The most recently discovered coronavirus (SARS-CoV-2), causes coronavirus disease (COVID-19), with symptoms that include cough, fever and shortness of breath. This virus and disease were unknown before the outbreak began in December 2019.

The World Health Organisation (WHO) is assessing ongoing research on how COVID-19 is spread. Studies to date suggest that the coronavirus that causes COVID-19 is mainly spread through contact with respiratory droplets containing the virus. COVID-19 can spread when someone:

  • Inhales droplets containing the virus when a person with COVID-19 coughs or sneezes.
  • Touches a person or surface that is contaminated with droplets containing the virus, then touches their eyes, nose or mouth. From there, the virus can enter the body and cause illness.

What precautions should people with immunodeficiencies take?

Most people with immunodeficiencies and those on medications that suppress their immune system are immunocompromised and are therefore at greater risk of any respiratory infections.

However, we do not know whether people with immunodeficiencies are at risk of more severe symptoms if they get COVID-19.

Precautions they take to prevent infections are consistent with the actions listed below, and they should follow the usual advice from their physician.

People with severe immunodeficiency or immunosuppression, including those undergoing bone marrow (stem cell) transplant are at high risk from all infections. They will already be aware of the need to avoid infections, (including actions listed below) and what to do if they are unwell or come in contact with any infectious disease.

People with immunodeficiencies who receive monthly immunoglobulin replacement therapy infusions in hospitals still need to receive their treatment. Hospital infection control policies are in place with extra precautions to isolate patients with, or at risk of getting COVID-19. If infection of COVID-19 is suspected at the time of infusion, promptly contact the treating team for advice.

Additional advice for people with immunodeficiencies

In addition to the actions listed below:

  • Request telehealth (video or phone) consultations if your immunologist agrees, and discuss having the influenza vaccine, and any additional vaccines you may benefit from.
  • If you are on immunoglobulin replacement therapy, continue to have this, it as previously prescribed.
  • Do not stop or reduce medicines, including any antibiotics or other medicines used to prevent infections, or immune suppressing medicines, without discussing this with your immunologist.

What actions can reduce the spread of COVID-19 and other respiratory infections?

To reduce the spread of COVID-19 and other respiratory infections, the following actions should be taken:

  • Hand hygiene is the top priority. Regular and thorough hand washing with soap and water throughout the day, particularly after using the bathroom and before eating is vital for preventing infections. Alcohol-based hand-gel can be used to sanitise hands when soap and water isn’t available. Avoid touching your eyes, nose and mouth. Also avoid shaking hands or any other greeting that involves contact. 
  • Respiratory hygiene is also a priority. This involves covering the mouth and nose with a bent elbow or tissue when coughing or sneezing, then disposing of the used tissue immediately. It is also important to maintain at least 1.5 metres distance away from anyone, especially if they cough or sneeze.
  • Stay home if you are unwell. If anyone has a fever, cough or breathing difficulty, they should stay home, seek medical attention (call in advance), and follow the local health authority instructions. Self-isolation is required if contact has been made with someone with COVID-19 symptoms, or symptoms develop following contact with someone who has COVID-19 (see details below). Quarantine of 14 days is required for people who have travelled from overseas, even if they do not feel unwell.
  • Follow government advice and restrictions. It is important that everyone complies with government restrictions, that include the actions listed above and physical/social distancing measures

When is self-isolation required?

Self-isolation is required if contact has been made with someone with COVID-19 symptoms, or symptoms develop following contact with someone who has COVID-19. Information on how to self-isolate is on the following websites:

www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/how-to-protect-yourself-and-others-from-coronavirus-covid-19/isolation-for-coronavirus-covid-19

www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-novel-coronavirus-health-advice-general-public/covid-19-novel-coronavirus-self-isolation  

Further information

The ASCIA COVID-19 webpage www.allergy.org.au/members/covid-19 is regularly reviewed and updated, with links to the following information:

ASCIA COVID-19 information | Information from other organisations and governments Publications COVID-19 and Telehealth | Medical product supply updates | IUIS  COVID-19 Primary Immunodeficiency Survey | COVID–19 Global Rheumatology Alliance Registry | ASCIA COVID-19 Working Party | COVID-19 Symptom Checker | COVID-19 Dashboard

© ASCIA 2020

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology research go to www.allergyimmunology.org.au

Content updated May 2020

Common Variable Immunodeficiency (CVID)

Common Variable Immunodeficiency (CVID) is one of the most common primary immunodeficiency diseases (PID), and affects both males and females.  Many people with CVID are not diagnosed until they are adults, however, symptoms of CVID may appear in childhood. 

pdfASCIA PCC Common Variable Immune Deficiency CVID113.43 KB

CVID is a primary immunodeficiency

CVID and other PIDs are caused by defects in cells of the immune system, and are usually inherited. PIDs are different to AIDs (acquired immunodeficiency syndrome), that is due to human immunodeficiency virus (HIV).

In most cases the causes of CVID are not known. Studies have identified a small number of abnormal genes that are involved in immune cell development in around one in ten people with CVID.

How is the immune system different in people with CVID?

The main role of the immune system is to defend against infections and other invaders (such as cancer cells) whilst protecting the body’s own cells. Antibodies, also known as immunoglobulins, are proteins made by specialised white blood cells, called B cells (B lymphocytes). Antibodies recognise germs so they can be removed by the rest of the immune system.

For B cells to work effectively they usually need help from other immune cells such as the T cells (T lymphocytes), which are another type of specialised white blood cell in the immune system. Most people with CVID have normal numbers of B cells.  However, these B cells do not mature normally to produce effective antibodies or they don’t receive the help needed from T cells to develop normal antibody responses.

People with CVID will vary in their ability to make effective antibody responses, due to decreased levels of:

  • All three major types of immunoglobulins (IgG, IgA, IgM) or
  • Immunoglobulins G and A (IgG and IgA) or
  • Only Immunoglobulin G (IgG) is reduced.

Diagnosis of CVID is usually confirmed by abnormal blood test results and medical history.

Reduced antibody responses in CVID lead to infections

Most people with CVID have frequent infections due to their reduced antibody responses.  These infections usually occur in the ears, sinuses, nose and lungs.  Other common infections in CVID include conjunctivitis, and persistent diarrhoea. Unusual infections may also occur, including meningitis and blood stream infection.

Although people who don’t have CVID can also suffer from these infections, the difference in people with CVID is that the infections are unusually frequent, prolonged, severe or resistant to normal treatment.

Chronic infections can lead to organ damage

Infections that are not treated properly in people with CVID, can result in damage to organs in the body, such as the sinuses, causing chronic sinusitis, or the airways of the lung (bronchi), causing bronchiectasis.

This organ damage can lead to tissue damage, causing ongoing mucus secretion and the persistent need to clear phlegm (sputum) or thick white, yellow or green mucus from the nose.  Once tissue damage is established, infection tends to become more persistent and difficult to clear.

Non-infectious complications of CVID

Autoimmune disease can affect some people with CVID. Autoimmunity occurs when the body doesn’t recognise its own cells and attacks them.  This can damage normal cells, including blood cells, skin, hair, bowel and hormone producing glands. 

Granulomatous disease can cause organ damage that results from immune cells which form small nodules in different tissues. These include the lungs, lymph nodes, liver and spleen.

Tumours of the immune system including lymphoma may occur in some people with CVID.

Treatment options for CVID

Treatment plans for CVID should consider several factors. These include antibody levels and responses, severity and range of infections and symptoms, and the ongoing need for treatment to prevent infections. 

Treatment options include:

  • Immunoglobulin replacement therapy (IRT), which is given as intravenous immunoglobulin (IVIg) or subcutaneous immunoglobulin (SCIg) infusions.
  • Antibiotics combined with IRT can greatly improve the health and wellbeing of people with CVID, by reducing infections and preventing development of chronic lung disease.
  • Clearance of airway secretions.
  • Corticosteroid therapy for control of autoimmune disease.
  • Management of gastrointestinal inflammation.

Patient support organisations

The following organisations provide support for people with CVID and their families: 

To donate to immunology research go to www.allergyimmunology.org.au

 

© ASCIA 2019

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

 

Immunodeficiencies

Immunoglobulin Replacement Therapy in Primary Immunodeficiencies

Immunoglobulin (antibody) replacement therapy (IRT) is one of the most effective and commonly used therapies for some primary immunodeficiency diseases (PIDs).  Many people with PIDs have insufficient antibodies to adequately fight infections, and this therapy can be life saving.   

pdfASCIA PCC Immunoglobulin Replacement Therapy in PID141.75 KB

Why is IRT used?

In people with PIDs, IRT can: 

  • Treat existing infections
  • Prevent new infections from occurring
  • Prevent long term damage from chronic infections (such as bronchiectasis in the lung)

How is IRT made?

Immunoglobulin products are purified from pooled plasma of many healthy blood donors. Plasma is the liquid part of blood that remains when all red blood cells have been removed.  When donors give blood, the red cells and plasma are separated. The plasma is pooled together and processed in highly specialised and regulated facilities to produce immunoglobulin, which contains a wide variety of antibodies.

How is IRT given?

There are two ways that IRT can be given: 

  • Intravenous immunoglobulin (IVIG) infusions are delivered directly into the person's vein, usually in a hospital day clinic. The infusion can take approximately 2 to 4 hours. The dose and frequency vary, and depend on the person's weight and immunoglobulin levels. Most people receive IVIg doses once every month.
  • Subcutaneous immunoglobulin (SCIg) - This involves slowly infusing the antibody preparation directly under the skin, which can be done at home, often by using a pump. This is usually done once or more each week, as only 10-15mL can be infused into any one site. A 10mL infusion can be delivered in half an hour. It may be necessary in some cases for infusions to be more frequent, particularly during introduction to therapy. When beginning SCIg therapy, red lumps may form under the skin. These usually disappear quite quickly and after a few weeks of therapy usually stop appearing.     

Are there any side effects of IRT?

IRT is normally very well tolerated and serious side effects are very rare.  However, there are some side effects that people receiving IRT should be aware of:

  • Risk of blood-borne infections
    Current preventative measures have been greatly enhanced so that the risk of infection from antibody therapy is now close to zero. Nevertheless, you may wish to discuss this risk with your medical team.
  • Other side effects
    Some people get minor side effects such as low grade fevers or headaches, which can usually be reduced by a slower infusion rate or treated with paracetamol. Occasionally people experience hives or wheezing or rarely severe headaches. Severe allergic reactions and abnormal kidney function due to IRT are rare.
  • IgA reactions
    In rare cases, when a person lacks Immunoglobulin A (IgA) antibodies, reactions similar to severe allergic reactions may occur when receiving blood products containing IgA. However, most IgA deficient people receive blood products without difficulty. These reactions are less likely with current IgA depleted Immunoglobulin products.

You should notify your doctor of any side effects you might experience.

Limitations of IRT

IRT does not cure the antibody deficiency, and does not usually reverse long term organ injury from chronic infections. IRT contains only one of the important components of the immune system's response to infection. For these reasons it is best to start IRT before organ damage has occurred.

Availability of IRT

IRT is derived from blood (plasma), are in limited supply, and access is restricted. Doctors must follow specific guidelines to ensure that the product goes to people most in need.

IRT should only be used in these cases where scientific and clinical evidence supports its use, and where other therapies are considered less favorable.

IRT is reserved for those people with confirmed abnormalities in antibody production, and who experience recurrent infections.

IRT is also of great benefit for patients with certain autoimmune diseases (such as immune thrombocytopenia and Guillain Barre syndrome), where it is used to alter the course of the disease (immunomodulation) rather than to replace antibodies that are deficient.

© ASCIA 2019

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology research go to www.allergyimmunology.org.au

Content last updated March 2019

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