Briefing by UCT Children’s Institute on impact of Covid-19 pandemic on children in the province

Meeting report

The Chairperson welcomed all in attendance. Apologies were tabled and the agenda for the meeting was stated.

Children and Covid-19 Advocacy Briefs: Prioritise children from response to recovery

Ms Lori Lake, Communication and Education Specialist at the Children's Institute, stated that children have mostly been spared from severe infection, yet government's efforts to curb the spread of the virus, and the associated lockdown and economic recession have deepened levels of poverty and hunger, intensified pressures and the threat of violence within the home, and limited women and children’s access to schools, health care, early childhood development and social services.

Children are particularly vulnerable to both the immediate shock and enduring impacts of COVID-19: This is especially the case during sensitive and rapid periods of development such as the first 1,000 days of life and adolescence when exposure to hunger, violence and adversity can cause irreparable harm to children’s immune systems, their developing brains and their education and employment prospects.

She outlined the series of advocacy briefs calls on government to put children at the heart of our COVID-19 response and recovery plans.  They document the impact of the pandemic on children and children's services and identify opportunities to strengthen systems, improve outcomes and better support children in future waves and crises. They draw on administrative data from the Western Cape, as even in this relatively well-resourced province, children's needs were initially overlooked.

Seven domains
Child-centred Covid-19 care
Routine health services
Nutrition
Violence and injury
Mental health
Early childhood development
Education


Briefing on Child-centred Covid-19 Care

Dr Heloise Buys, Head Clinical Unit: Ambulatory and Emergency Paediatrics, Red Cross Children’s Hospital, stated that in the first year of the pandemic, there were over 284 000 cases of COVID-19 in the Western Cape, with 12 300 of those being children. 1 500 Children were admitted to hospital and 59 children died of COVID-19.

Since the start of the pandemic, there were over 658 0445 cases of COVID-19 in the Western Cape, with 46 455 of those being children under 18 years of age. 3 924 Children were admitted to hospital and 123 children died of COVID-19.

Thousands of children have been affected by the illness, loss of income and death of family members, with five million children around the world estimated at having lost a primary caregiver from March 2020 to October 2021. As health services prepared for the first wave, children’s needs were side-lined, resources were diverted from paediatrics to adult COVID-19 care, and concerns around infection led to the separation of infants and children from much needed family support.

Did the health system provide child-centred Covid-19 care?

Quarantine and Isolation facilities were set up with adults in mind;
Children over 12 were put into single rooms without much support or supervision;
Intermediate care facilities for children were not an option as the risk of superspreading to other vulnerable children and staff was real;
Social workers working feverishly, were reluctant to place children without testing - so PHC facilities were capacitated to do this;
All hospitals with paediatric wards ‘made a plan’

Did the health system provide child-centred COVID-19 care to newborns and their mothers?

Available research indicated that transmission to new-borns was rare;
General preventive measures with screening and targeted testing were put in place;
Spacing in KMC rooms was controlled;
Breastfeeding continued to be promoted;
COVID-19 positive mothers and baby were kept together if both well;
COVID-19 exposed and positive babies were managed in closed incubators;
Mothers had 24/7 access, and video calls were encouraged for fathers(excluded)

Multisystem inflammatory syndrome MIS-C

In the first ten months of the pandemic, Red Cross and Tygerberg Children's Hospitals saw about 70 children with MIS-C, of whom approximately 40% required ICU admission and blood pressure support.
Mimics Kawasaki-disease features, MIS-C children are generally more ill, -heart muscle, gastro-intestinal tract, brain and kidneys.
Frequently require intensive care and expensive special investigations and treatment – only available at tertiary centres (pandemic exposes local and global inequities)

Care and Protection when caregivers are hospitalised

Children are profoundly affected when their caregivers fall ill, or get admitted, or go into Q&I or worst still … die
They need intensive support during this period of anxiety, separation and bereavement
Therefore we need to put systems in place to ask if there are children in need of support when adults are admitted with COVID

Long COVID-19 in children?

Limited data available, uniform paediatric definition still awaited
Emerging data suggest that some children, as with adults with long COVID, experience similar lingering symptoms weeks to months after infection, including fatigue or insomnia, muscle and joint pain, headache and inability to concentrate, persistent nasal congestion and weight loss.
One Italian study reported that more than 40% of children had at least one problem >2 months after infection
We need to raise awareness with families and colleagues as ongoing supportive care is needed

Lesson Learned and Key recommendations
 
Provide access to child-friendly information and safe platforms to talk about experiences and express concerns
Provide care and protection to children when their caregivers are hospitalised with COVID-19
Each child admitted to hospital needs their bedside caregiver
Keep mother-infant/young child dyads together, and promote breastfeeding
Advocate for affordable medicines and diagnostic tests for children
Protect resources and essential non-COVID-19 paediatric care
Ensure that there are child health reps supported by clinical governance teams to guide on national and provincial command structures

Briefing on disruption to routine health services

Dr Thandi Wessels, District Paediatrician, Cape Town Metro East, Department of Paediatrics and Child Health, Tygerberg Hospital, stated that maintaining routine child health services was essential to ensure overall health was not compromised and positive gains made over the past years had not been lost. Covid-19 had an uneven impact on child health services in the Western Cape, with relatively few cases in children.  While maternal and child health services were deemed ‘essential’, the high burden of adult diseases required:

Reallocation of resources
De-escalation of some child health services
Cancellation of non-urgent OPD
Cancellation of elective surgery/procedures

What was the impact on hospital services?

Paediatric hospital beds re-allocated to adult COVID-19 care
Intermediate care facilities opened but directed towards adult care
De-escalation of services impacted children with LTHC

What was the impact on under-five mortality?

Although fewer hospital admissions, In Hospital Mortality Rate (IHMR) was higher than in 2019
Pneumonia IHMR from 2 to 2.8 deaths per 1000 admissions
Diarrhoea IHMR from 1.8 to 3 deaths per 1000 admissions
Raising concerns about late presentations and delays in seeking care

Adolescent health

School-based support groups for young mothers in the Eastern sub-district 2018 to provide emotional support, promote nurturing care of children, helps mothers stay in school, prevent further pregnancies, and improve breastfeeding and immunisation rates.
Yet over the past year, the number of newly pregnant moms at one of the schools increased dramatically with about 20 pregnancies during lockdown.
There have also been reports from teenagers of increased anxiety and suicidal ideation
We therefore need to make greater efforts to improve access to adolescent-friendly healthcare during pandemics such as COVID-19 – including access to contraception and mental health services

Recommendations

Leadership and advocacy for child health is needed at every level of the health care system to protect, sustain and rebuild child health services
Strengthen surveillance systems to identify children at risk
Optimise the use of community health workers in maternal and child health to reach out and bridge the gap between communities and health services.

Briefing on Nutrition and Food Security

Ms Lake stated that one in ten children lived in households where children went hungry. One in three children lived below the food poverty line. One in four children was stunted or short for age. One in eight young children was overweight or obese. Forty-eight percent (48%) of child hospital deaths were associated with moderate or severe acute malnutrition – done on a study of causes of death in children under five years of age. Forty-seven percent (47%) of households ran out of money to buy food during the hard lockdown. Child hunger has remained unacceptably high with 1-in-7 households reporting a child went hungry in April 2021.

The disruption of routine health services made it harder to identify and support children at risk of acute malnutrition.
Despite the rise in child hunger, there was a decrease in the incidence of severe acute malnutrition cases presenting to facilities and in hospital admissions in the WC.
Yet there may have been an increase in malnutrition and stunting at community level that was not reflected in administrative data because the cases were not seen, recorded or treated.
And in recent months, facilities in the WC have started to see more severe cases of acute malnutrition.

Social assistance

Child hunger is expected to intensify in the coming months due to a decrease in the real value of the Child Support Grant (valued at R460 a month or R15 a day) which has failed to keep pace with food price inflation – and continues to fall way below the food poverty line

Specific recommendations

Increase the CSG to the food poverty line and address barriers to early uptake through Regulation 11(1) of the Social Assistance Act
Use taxes, subsidies and price controls to limit food price inflation.
Sustain and enhance the quality of ECD and school feeding
Strengthen surveillance and referral systems to identify and support children at risk of malnutrition.
Ensure measures introduced to alleviate hunger (such as school meals and food parcels) are nutritionally balanced and do not increase the burden of overnutrition and micronutrient deficiencies
Use licencing and zoning regulations to ensure a more equitable spatial distribution of healthy food retailers and limit the number of unhealthy food outlets.

Discussion

Mr A Van der Westhuizen (DA) thanked the presenters for their really valuable presentation. He wanted to know from the delegation what lessons they believed the Committee should take from their reports and summary of the situation. With some children suffering a lot more than others, he sought to know how to identify those who have suffered and were still in need of remedial action, and what could be done to aid them. Expansion on the topic of the school feeding scheme was sought.

The Chairperson stated that a study had indicated that breast milk could transfer antibodies against Covid-19 if the mother had been with Covid-19, but also if the mother had been vaccinated. Information was sought as to whether there had been any local studies indicating whether breast milk could help protect small children and babies from more severe Covid-19 outcomes.

Ms R Windvogel (ANC) stated that she was really touched by the brilliant presentations. She was really grateful for the role which the institutions played in helping society as a whole. Appreciation was given for the recommendations.

Regarding the Slide which gave information about the 123 children who died due to Covid-19, information was sought as to which variant they had died from, including the ages of the 123 victims. The current situation on the ground in schools was sought, considering that schools were operating at full capacity. Information was requested as to the number of child-headed homes which had been created as a result of the pandemic within the Western Cape and South Africa as a whole. What support was given to children when parents were hospitalised or even died as a result of Covid-19? Lastly, Ms Windvogel asked as to what role community health workers could play in maternal and child health.

Mr M Xego (EFF) wanted to know whether children subjected to IMS Services were directly or indirectly affected, explaining that he sought clarity as to whether it was children who had been affected as a result of their guardians or parents being infected or whether it was the children themselves who had been hospitalised as a result of Covid-19 related illnesses. Regarding the closure of the Paediatric Hospital, Mr Xego sought information regarding the turnaround strategy to deal with that closure which directly affected children who needed to recover under various circumstances. What would be done to ensure that the hospital is brought back to functionality?

Mr P Marais (FF+) stated that he was depressed after hearing that children’s facilities were being closed, and those beds were being ripped away from children and being given to adults.

He said ‘Are we playing God here when we close children’s facilities and give the beds to adults? Are we saying that children five and under that are very ill are less in need of a bed than someone over 60? We cannot play God!’

He sought information as to whether it was a budgeting issue that led to the needs of children being deemed less important than those of adults.

Responses
Dr Wessels responded that unfortunately, as soon as numbers increased, they have had to cut back on outpatient services as they could not meet the demands they faced with their current pool of staff. She believed that going forward; no services during the forthcoming waves of the pandemic ought to be cut, whilst funding should be ring-fenced specifically for child health to ensure that children did not suffer as a result of funding.

The transfer of beds from children to adults was a difficult situation to deal with when faced with people who were dying, they needed to try and secure or firstly assist the dying or critical patients. She stated, however, that as a health group, they have been advocating for the need to ringfence certain services for children. They needed to be a lot more vocal in their communication campaigns to ensure people that it was safe to access services. Communication forms such as radio were being used to encourage people to go for their routine check-ups and services; however, the internal fear of people remained an obstacle.

Dr Michael Hendricks, emeritus associate professor, Department of Paediatrics at the University of Cape Town (UCT), explained that there was no clear evidence regarding the vertical transmission of Covid-19 through breastfeeding. He emphasised that breastfeeding generally protected children against mortality, respiratory infections, diarrheal disease and many other forms of health risks. He took the stance that a mother ought to continue breastfeeding exclusively despite being Covid-19 positive, however, whilst taking the necessary medical precautions.

Ms Lake responded that it had been incredibly challenging to maintain programs such as the NSNP (National Schools Nutrition Programme) whilst schools were still rotating. While it has not been easy, it was absolutely vital to prioritise children, with schools being another way of identifying children in need of care and support. She emphasised that what had been clearly presented in the presentations was the fact that child services had been stretched thin and perhaps disadvantaged during the pandemic period – which was not right.

Dr Buys responded that the graph indicated the number of children who had died since the pandemic. The light blue indicated children who died outside of hospitals, while the dark blue indicated those who died inside hospitals.

What was unclear was whether those children died of Covid-19 or not. They suspected that many of those children who died, had serious underlying chronic conditions such as heart disease, general heart conditions, chronic lung disease, immune deficiencies, cancer, cerebral palsy, etcetera.

They were currently awaiting a full report so that they could inform everybody as to why and how those children died, along with what the exact underlying conditions were if there were any.

Ms Lake responded that approximately five million children had lost their primary caregiver worldwide due to Covid-19 in the first year and a half of the pandemic. A clear cause for concern was the fact that South Africa had no clear systems in place to identify what the exact impact had been on children in South Africa. One of the strongest recommendations which came from the briefings as a whole was the need to strengthen referral systems between the Departments of Health, Education and Social Development. To track the numbers would be an extremely onerous task which required a great deal of collaboration between the various departments. According to a study, the proportion of child-headed households in South Africa was very small and generally amounted to less than one percent of the population.

Dr Wessels responded that at the moment there was no turnaround strategy. Management was aware of the various issues being faced, however, what was needed was the political power and will which would take the matter further to ringfence resources provided for children.

Dr Hendricks responded that concerning malnutrition, they were unaware of the number of children who died outside the hospital from acute or severe malnutrition. He believed that it was critical that support was given to community-based services in terms of that. Regarding high-risk mothers, he stressed the importance of community health workers being able to identify and engage with those mothers in the antenatal arena. They have been trying to establish a programme in the metro whereby they could actually engage community health workers in offering support to mothers.

Briefing on violence and injury 

Ms Shanaaz Mathews, Director, Children’s Institute, stated that in South Africa, one in two women have experienced physical and sexual IPV in their lifetime. 34-45% children experienced violence in their homes.

Impact of Covid-19

Early in the COVID-19 pandemic, child rights activists raised concerns about how rising unemployment, food insecurity and the stresses of lockdown increased the risk of violence and injury in the home
Poverty-related stress and economic insecurity and poor coping strategies (for example substance abuse) can lead to increases in intimate partner violence and child maltreatment.
Therefore, the rapid increase in unemployment was likely to trigger the increase in VAW/C and leave women increasingly trapped in violent relationships.
From 2019 to 2020, there was a 15% decrease in children admitted to Red Cross War Memorial Children’s Hospital with unintentional injuries.
This was driven by a 56% decrease in road traffic injuries during the hard lockdown, while injuries in the home – such as burns and falls – increased over the same period.
There was a 10% decrease in children presenting with non-accidental injuries driven by a sharp 50% decrease during the hard lockdown and the alcohol ban - after which cases climbed to pre-pandemic levels.

What are the numbers telling us?

The Minister of Police announced a 37% increase of GBV reports to SAPS at end of the first week of lockdown
But a month later the SAPS statistics showed a decrease of complaints – domestic violence down by 69,4% and rape by 87%
Similarly, services like Rape Crisis saw a 50% decrease in rape and sexual assault cases
While Childline reported an increase in the number of calls.
Shelters reported a drop in women and children accessing safety

Effects of social isolation

Living in confined spaces increases stress, fear, and poor mental health, which can, in turn, increase the risk of VAW/C.
Lockdown and quarantine also increase day-to-day exposure to perpetrators and can reinforce abuse tactics as a result of social isolation.
Usual support systems for women and children like family, friends and school were not available – increasing the risk for the escalation of violence
Disruption of social and child protection services made it harder for women and children to access the SAPS, courts and social services and anecdotal evidence points to delays in following up.

Specific recommendations

Prioritise child protection services in crisis response plans
Designate child protection as an essential service and establish local response teams to facilitate access to support services at community-level
Strengthen collaboration between health, education and child protection services making use of every point of contact - including schools, ECD programmes, health facilities and contact tracing teams - to identify and respond to cases of violence and abuse.
Limit the sale of alcohol to prevent injuries and interpersonal violence


Briefing on Covid-19, child and adolescent well-being, the future

Prof Mark Tomlinson, Co-Director, Institute of Life Course Health Research at Stellenbosch University, in his opening statement, explained that while Covid-19 was a new emergent pandemic, child and adolescent wellness and mental health was not new or emergent. Mental Health has been a longstanding care crisis.

Child and adolescent health

Parental mental health and child development
Poor parental mental health – subsequent emotional and behavioural problems in children
Poverty and mental health
Social drift and social causation (or both)
Self-harm and suicidal ideation
UK study - abuse, self-harm and suicidal ideation during the pandemic:
29% of 18–29-year-olds surveyed had self-harm or suicidal thoughts
UK - 43% of young people reported that the first lockdown had made their life worse
25% of young people reported that it made their lives better

Other factors that jeopardise mental health were sleep disruption, loneliness and alcohol

Recommendations

Specialised child and adolescent mental health services remain extremely limited in South Africa
Women have been particularly hard hit by unemployment, food insecurity, domestic violence and an increased burden of childcare
Essential to build the capacity of families and frontline workers in schools, ECD programmes and health care services to help children cope
Establish integrated systems and clear referral pathways between the DoH, DSD, DoJ and the SAPS to ensure the safety of women and children
Designate child protection as an essential service and establish local response teams to facilitate community access
Limit the sale of alcohol to prevent injuries and interpersonal violence


Briefing on Schools as nodes of care and support

Dr Patti Silbert, Senior Education Specialist, Schools Development Unit, UCT, stated that the rotational system disrupted teachers’ ability to complete the curriculum, negatively affecting learners’ mastery of core skills and content knowledge, particularly in the younger grades where children learnt foundational concepts. Learner absenteeism, particularly in the youngest grades, was a key factor driving learning losses – with learners in historically disadvantaged schools learners losing 50% - 75% of contact time. School dropout tripled during the pandemic with an estimated 750 000 children dropping out of school. Despite Matriculants continuing to attend classes in full, grade 12 learners from low SES schools were estimated to have lost around 35% of contact time. Online learning during the pandemic amplified socioeconomic divisions. While 90% of South African households have access to a mobile phone, only 60% could access the internet via their mobile phone. Over 2000 or 0.6% of teachers lost their lives between March 2020 and late May 2021. It was predicted that learners would be an entire year of learning behind their pre-pandemic peers.

Beyond the curriculum: Impact of COVID-19

In many schools silence is conflated with coping, with the result those children and adolescents are becoming increasingly disconnected from themselves, their peers and their teachers. This often leads to avoidant, aggressive and/or high-risk behaviour.
Even before the pandemic, it was estimated that one in three people would be affected by mental health illness in their lifetime. Typically, these issues manifest in poor academic performance, with the schooling system mostly unable (not necessarily unwilling) to help youngsters address underlying issues of depression and anxiety.
Research in countries across the world during and after large-scale situational crises has shown that in schools that encouraged immediate adult-led discussion of the crisis, children had measurably better signs of behavioural health than those in schools that avoided adult-led discussion.
The health of a child influences the extent to which they can fully attain their personal and educational potential.
The threats posed by the COVID-19 pandemic to both the health and education of school-going youth are likely to have devastating long-term impact on children and our broader society.
The role of the school & educator becomes more critical in the context of fragile family systems, in creating opportunities for children to feel safe and secure.
Given the absence of psychosocial support for the majority of young South Africans, the school becomes critical in mainstreaming and promoting mental health, particularly during periods of adversity
Teachers need to have a basic understanding of mental illness to grasp how trauma affects self-esteem, behaviour and interpersonal relationships. We need to move away from the stigma and ignorance of trauma, towards normalising children's experiences associated with mental illness.
Creating emotionally safe spaces: children need to learn the language of self-expression and be taught the skills of emotional literacy.

Psycho-social support and teacher wellbeing

Build the capacity of teachers to support learners who are struggling with emotional and psychosocial issues.
Provide psychosocial support for teachers who are experiencing their own emotional distress.
Strengthen & centralise the role of School-Based Support Teams within these collaborations (referrals).
Strengthen partnerships between schools, universities, districts.

Discussion
 
The Chairperson wanted to know how government could adequately utilise the information given to create better outcomes. Similarly, for the Department of Education, advice was sought on how the information on children and teachers could be used to integrate work across academia, government and civil society to tackle those issues presented.

Ms Windvogel, in reference to Slide 3, sought information as to what kind of psychological and social support was needed to support families suffering from poverty-related stresses, and whether those were available in the Western Cape. She asked as to what the reasons were for the school dropouts and how many cases were due to bullying. Lastly, a view of the poor and ineffective psychological and social support offered to teachers and learners in schools was asked for.

Ms Mathews responded that one of the widest available interventions of psychological support would be ‘Parenting’, which was delivered through different NGOs, including through the Department of Social Development.

She emphasised that ‘parenting' on its own would not reduce the vulnerability of families. She did a review of interventions that were successful in reducing both violence and the intersections of violence against women and children – which would be made available to the Committee.

She believed that they needed to think about multi-component interventions, as a single strand intervention would be insufficient to reduce the magnitude of the problems which families and children were experiencing. As researchers and academics, more collaboration and interaction needed to occur between government and NGO counterparts, to think as to how they could target their programs more effectively.

Prof Tomlinson responded that the Western Cape had been quite innovative in its approach to the psychological and overall concept of wellness. He believed, however, that it was incredibly important as to who sat at the table when discussions occurred. He suggested getting every single person and stakeholder to the table – explaining that it was an entire government and society as a whole collaborative approach and concept. He apologised that unfortunately, he did not have the data for bullying in South Africa, as the data he had pertained to the United Kingdom's statistics.

In terms of psychologists and social workers, he believed that they were a vital part of the solution. There should never be psychologists and social workers in his opinion. Government needed to think as to how best to utilise their psychologists and social workers to minimise their caseload to prevent them from burning out.

Dr Silbert stated that she would like to acknowledge the role of the Western Cape Education Department during the 2020/21 period and their efforts made to integrate different sectors of society to address children who were out of school. The enormous amount of work done and those piloted by Mr Haroon Mohammed who was the Chief Director: Curriculum Management and Teacher Development, and others which integrated the psychological components needed to be acknowledged

Ms Tembeka Mzozoyana, Social Worker & School Wellness Centre Coordinator, Schools Development Unit, UCT, responded that besides bullying, there were several other factors that contributed to students dropping out of school. Financial and psychological factors played a big role in that students’ moods were low due to the pandemic and many found themselves unable to get out of bed and find the motivation to go to school. Financial aspects took the form where students were on rotation and therefore needed to only go to school a few times a week. Sometimes transport money was diverted or utilised for other things by either students or parents themselves.

It remained extremely important that children remained at the centre of community organisations, as it helped to foster the relationship between the various stakeholders and helped to improve on providing resources where needed – be it mental, psychological or financial.

The Chairperson thanked the delegation and assured them that the meeting had no less than 10 Standing Committee Chairpersons in attendance, hence the presentations reached a vast number of Committees across the legislature. Further conversations would most likely occur across Committees as a result. The delegation was thanked for their attendance.

Resolutions

The Chairperson requested that since the meeting ran over schedule, any resolutions or recommendations be forwarded in writing by no later than Monday, 7 March at 12 pm.

Minutes

The Committee considered and adopted its minutes of 1 December 2021.

Committee Report for December 2021

The report was considered and adopted.

The Chairperson thanked Members for their attendance. The next meeting would be on 10 March 2022.

The meeting was adjourned.