Study collecting the views of young people, parents of children with long COVID, and doctors, finds that long COVID in children is poorly understood by doctors

Posted on July 21, 2021July 20, 2021 by lindsey.pike

Dr Katharine Looker

‘Enhancing the utilization of COVID-19 testing in schools’, is a study which will look at the characteristics of long COVID and COVID-19 infection in children. ‘Long COVID’ is commonly used to describe signs and symptoms that continue or develop after acute COVID‑19. The study is being funded as a result of a rapid funding call by Health Data Research UK (HDR UK), the Office for National Statistics (ONS) and UK Research and Innovation (UKRI). The study forms part of the larger Data and Connectivity National Core Study, which is led by HDR UK in partnership with ONS.

The COVID-19 testing in schools study is related to the CoMMinS (COVID-19 Mapping and Mitigation in Schools) study being undertaken by the University of Bristol in partnership with Bristol City Council, Public Health England [PHE] and Bristol schools. CoMMinS aims to give us an understanding of COVID-19 infection dynamics centred around school pupils and staff and onward transmission to family contacts, using regular testing. Our study will jointly analyse data from CoMMinS, along with information from Electronic Patient Records, and data from the COVID-19 Schools Infection Survey (SIS; jointly led by the London School of Hygiene & Tropical Medicine [LSHTM], PHE, and ONS). The SIS is a study similar to CoMMinS but carried out nationally.

To help inform research questions and methods for the study, members from the University of Bristol study team gathered views about long COVID in children between 9 March and 30 April 2021 from:

seven young people from the NIHR Bristol Biomedical Research Centre Young People’s Advisory Group (YPAG)
five families whose children have long COVID or suspected long COVID, recruited through two online UK campaign groups for long COVID, and
a survey completed by four GPs and one paediatrician, and an online meeting with two paediatricians.

It is important to note that the opinions gathered were based on small samples which may not be representative.

Through the meeting and survey with the doctors, the study team found that clinical understanding of long COVID in children is currently very limited.

The doctors said that it may be hard to distinguish between long COVID and other conditions with similar symptoms. Many of the symptoms of long COVID, like fatigue and feeling sick, aren’t very specific, and are common to many different conditions. Long COVID in children currently lacks a clinical definition, making diagnosis difficult. It isn’t yet properly understood whether long COVID is a new condition in itself, or a group of conditions like post viral fatigue, which is already recognised.

Young people, and families of children with long COVID or suspected long COVID, who were also asked for their opinion, said that feeling sick or stomach pain, extreme tiredness, and headaches were the symptoms they would rank as most ‘harmful’. For young people, this was based on them imagining having the symptoms. For the families, this was based on their first-hand experience.

The families also said that the symptoms their children were experiencing were numerous, often very severe, and more wide-ranging than those currently listed on the NHS website for long COVID. It is not yet clear what is causing the unusual symptoms.

The families said that they had struggled to get a diagnosis and treatment for their children. They also said that long COVID symptoms were having a significant impact on their children’s day-to-day lives both physically and psychologically, and that some of the children had missed school because of the symptoms. Some of the families also found fevers difficult to manage because their children had to miss school to self-isolate every time they had a fever. They wanted to know why the set of symptoms were being experienced, and why their children in particular had developed them.

It is not known how many children have or will develop long COVID. So far, studies which have tried to measure the rate of long COVID in children suggest it is rare. However, quantifying the number of cases is made difficult by a lack of clinical understanding of long COVID including the lack of an agreed clinical definition. The opinions collected suggest that relying on clinical diagnoses alone will under-estimate cases. On the other hand, there needs to be a cautious approach to estimating the number of cases based on non-specific symptoms, as other conditions which cause similar symptoms may be counted as well.

Caroline Relton, Professor of Epigenetic Epidemiology and Director of the Bristol Population Health Science Institute at the University of Bristol, joint lead for CoMMinS and one of the lead authors of the report, said: “The opinions we gathered further highlight that it is difficult to count the number of children with long COVID on the basis of diagnoses alone while long COVID in children remains poorly defined.

“There are added complications of studying long COVID in children, when it is sometimes difficult to disentangle what might be the result of experiencing infection from what might result from the wider impact of experiencing the pandemic. Isolation, school closures, disrupted education and other influences on family life could all have health consequences. Defining the extent of the problem in children and the root causes will be essential to helping provide the right treatment and to aid the recovery of young people who are suffering.”

The findings highlight that examining GP and hospital visits, and school attendance, might currently be a more useful and feasible way of assessing how COVID-19 has affected children, rather than relying only on diagnoses of long COVID. However, the study researchers also need to be aware how often healthcare is accessed according to need, and absence from school due to self-isolation, which will affect what is being measured.

Feeling sick or stomach pain, extreme tiredness, and headaches will be important symptoms to consider in the study.

Read the full report

Find the full report on the CoMMinS study news page.

COVID19 – should schools close early for Christmas?

Posted on December 15, 2020July 1, 2024 by lindsey.pike

Sarah Lewis, Marcus Munafo and George Davey Smith

We have previously written about the limited risk posed to pupils, teachers and the community by schools being open during the Covid19 pandemic. Schools have now been open for almost a full academic term (3 months), so it is time to take another look at the evidence.

School re-openings have coincided with an increase in Covid19 infection rates across all UK nations. This rise in infection rates was anticipated, given the annual pattern of rising respiratory infections in the autumn term. There was also a rapid increase in Covid19 testing rates as children returned to school and presented with mild symptoms. Rates of positivity among children were very low at first, but a rise was observed over the autumn. This corresponded with an increase in rates among adults, and there seems to be a strong correlation between Covid19 positivity in schools and rates in the local community.

But has transmission of Covid19 in schools driven the second wave? And should schools be closed again to reduce infection in the community?

This post argues that there is little case for closing schools, as

Schools don’t seem to drive transmission in the community
The risk of the virus to most school children is very low
The harms of school closures are wide ranging.

Infection rates among children have been low

Since September children with COVID19 symptoms have been asked to stay at home and have a test before returning to school. Tests equating to 10% of the school pupil population were carried out during first half term in Scotland; only 0.2% of pupils tested positive during this period. Similarly high volumes of testing have been carried out in Wales, but only 0.6% of pupils tested positive between 1^st September and 9^th December 2020. Pupils made up 3.5% of cases in Wales over that period, despite making up 16% of the population.

However, the weekly Covid19 incidence among 12-16 year olds in Wales was similar to the national average for the week ending 9^th December 2020, suggesting a change in the age demographic of cases.

Transmission levels in school have been low

It is unclear what proportion of children who tested positive contracted the infection in school – many children have similar social circles both in and out of school. When infections are found in schools, most schools have only 1 or 2 cases within a 2-week period (unless levels in the local community are high). This suggests low levels of transmission in schools.

Children and adults have different symptoms

Comparisons of rates of infection between children and adults should be treated with caution. Cases are diagnosed using recognised Covid19 symptoms, and are influenced by the volume of testing in the community. Younger children seem to be less likely to have symptoms – around 50% of infected children tend to be completely asymptomatic. They also may have somewhat different pattern of symptoms to adults – fatigue, gastrointestinal symptoms, and changes in sense of smell or taste, but only rarely a cough. Therefore, studies relying on symptoms in children may be unreliable.

Random testing is the best way to find out level of infection

Surveys show that while young adults had the highest levels of infection in September, secondary school pupils now have the highest rates.

Studies which test individuals at random in the community are more reliable indicators of the levels of infection among children compared to adults. The UK Office of National Statistics (ONS) infection survey has been randomly testing people from the community since early May. It showed that young adults (school year 11 to age 24) had the highest positivity rates in September. This became more pronounced in early October when universities re-opened to students. By the end of October, rates among secondary school pupils were similar to those in young adults, at around 2%. Secondary school pupils now have the highest rates. Covid19 positive rates among primary school children are about half those in secondary school children and have barely changed since the beginning of the academic year.

Infection rates among teachers

There is no evidence that teachers are more at risk of death from COVID19, and infection rates among teachers do not seem higher than other professions.

ONS data from the first wave of the COVID19 epidemic in the UK showed that teachers were not at increased risk of death from the disease compared to other professionals. Based on ONS data, during October those working in the education sector had an antibody positivity rate of 8.1% (95% CI 5.9-10.8) compared with 6.5% (95% CI 5.9-7.3) among those working in other professions. This suggests perhaps slightly higher infection rates, but this is estimated with uncertainty.

Infection positivity rates – also measured by the ONS survey – from 2^nd September to 16th October showed that teachers were no more likely to test positive than other professions, although again there was a lot of uncertainty in these estimates*. The Swedish Public Health Agency have linked data on Covid19 infection to occupational data and found no increase in infection rates among teachers, although there was some evidence of an increase in infection rates among teaching assistants, school counsellor and headteachers. However, infection rates may have been inflated relative to other profession if there is increased testing among asymptomatic people in the education sector.

Could infections in schools be driving community infection rates?

The evidence suggests this is unlikely.

Infection rate increases appear to coincide with school openings, but the R-number was increasing in Scotland and England before school openings. Hospital admissions due to Covid19 had also started to rise before this point. In September, positivity rates were initially highest among young adults, not among children of school age, suggesting that perhaps infections among school children were not driving community rates. The ONS data showed infection rates levelling off over October half term, and climbing again among young adults and secondary school children after half term. However, this trend was not as marked in primary school children, and was not observed in adults, even amongst the 35-49 year age group, to which many parents of school aged children belong. Another study of community-based testing – the REACT-1 study – found a greater decrease in infections among younger children compared with older children following the October half term holiday, but again there was a lot of uncertainty in this estimate.

Contact mixing patterns show that people tend to have the most contacts within the same age group, followed by the age group closest to them. Children have more opportunities to pass on the infection to other children and young adults, and are not significantly influencing rates in older adults.

The current R-number in England is currently estimated to be slightly below 1 despite schools being open. This shows that it is possible to drive down infection rates in the community whilst keeping schools open. Furthermore, when everything else but schools are closed – such as in the case of the national lockdown which occurred in England in November, school children will have more contacts than anyone else and schools will contribute to relatively more transmissions in the community even if transmission rates are low overall.

Closing schools is not the answer

Rates have recently fallen among adults in England, despite schools remaining open and secondary school rates increasing. The evidence suggests low levels of virus transmission within schools. First Minister of Wales Mark Drakeford recently said that behavioural evidence suggests closing schools could place some children “in even riskier environments”. Children being looked after by their grandparents rather than being in school would be more dangerous in terms of the virus being transmitted to a higher risk group.

Any public health intervention should consider the costs as well as the benefits. We know that school closures have wide ranging adverse consequences for children and families as outlined by UNESCO, and such costs are particularly pronounced for the poorest and most vulnerable children in society. Children:

who do not have access to technology to participate in online learning
whose parents who do not have the resources or the educational background to help

have been shown to fall further behind following school closures. Evidence suggests that children’s mental health deteriorated during the first lockdown, and that vulnerable children were at greater risk of violence and exploitation. School closures can also cause economic hardship due to parents being unable to work. This has prompted Robert Jenkins Global Chief of Education at UNICEF to issue a statement over the last few days saying:

“Evidence shows that schools are not the main drivers of this pandemic. Yet, we are seeing an alarming trend whereby governments are once again closing down schools as a first recourse rather than a last resort. In some cases, this is being done nationwide, rather than community by community, and children are continuing to suffer the devastating impacts on their learning, mental and physical well-being and safety”.

If schools being open are not major drivers of transmission in the community (which they don’t appear to be), given that the risk of the virus to most school children is very low, there is very little case for closing them given the potential harm this could cause.

Footnote: Secondary schools in Wales were closed early for Christmas on the 11^th December 2020

*(estimates ranged from 0.2% (95%CI=0.07-0.53) for primary school teachers to 0.5% teachers of unknown type (95% CI=0.36-0.69) compared with 0.4% (95%=0.39-0.49) for all other professions)

Are schools in the COVID-19 era safe?

Posted on July 1, 2020July 1, 2024 by lindsey.pike

Sarah Lewis, Marcus Munafo and George Davey Smith

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The COVID-19 pandemic caused by the SARS-COV2 virus in 2020 has so far resulted in a heavy death toll and caused unprecedented disruption worldwide. Many countries have opted for drastic measures and even full lockdowns of all but essential services to slow the spread of disease and to stop health care systems becoming overwhelmed. However, whilst lockdowns happened fast and were well adhered to in most countries, coming out of lockdown is proving to be more challenging. Policymakers have been trying to balance relaxing restriction measures with keeping virus transmission low. One of the most controversial aspects has been when and how to reopen schools.

Many parents and teachers are asking: Are schools safe?

The answer to this question depends on how much risk an individual is prepared to accept – schools have never been completely “safe”. Also, in the context of this particular pandemic, the risk from COVID-19 to an individual varies substantially by age, sex and underlying health status. However, from a historical context, the risk of death from contracting an infectious disease in UK schools (even in the era of COVD-19) is very low compared to just 40 years ago, when measles, mumps, rubella and whooping cough were endemic in schools. Similarly, from a global perspective UK schools are very safe – in Malawi, for example, the mortality rate for teachers is around five times higher than in the UK, with tuberculosis causing more than 25% of deaths among teachers.

In this blog post we use data on death rates to discuss safety, because there is currently better evidence on death rates by occupational status than, for example, infection rates. This is because death rates related to COVID-19 have been consistently reported by teh Office for National Statistics, whereas data on infection rates depends very much on the level of testing in the community (which has changed over time and differs by region).

Risks to children

Thankfully the risk of serious disease and death to children throughout the pandemic, across the UK and globally, has been low. Children (under 18 years) make up around 20% of the UK population, but account for only around 1.5% of those hospitalised with COVID-19. This age group have had better outcomes according to all measures compared to adults. As of the 12^th June 2020, there have been 6 deaths in those with COVID-19 among those aged under 15 years across England and Wales. Whilst extremely sad, these deaths represent a risk of around 1 death per 2 million children. To place this in some kind of context, the number of deaths expected due to lower respiratory tract infections among this age group in England and Wales over a 3 month period is around 50 and 12 children would normally die due to road traffic accidents in Great Britain over a 3-month period.

Risks to teachers

Our previous blog post concluded that based on available evidence the risk to teachers and childcare workers within the UK from Covid-19 did not appear to be any greater than for any other group of working age individuals. It considered mortality from COVID-19 among teachers and other educational professionals who were exposed to the virus prior to the lockdown period (23^rd March 2020) and had died by the 20^th April 2020 in the UK. This represents the period when infection rates were highest, and when children were attending school in large numbers. There were 2,494 deaths among working-age individuals up to this date, and we found that the 47 deaths among teachers over this period represented a similar risk to all professional occupations – 6.7 (95% CI 4.1 to 10.3) per 100,000 among males and 3.3 (95% CI 2.0 to 4.9) per 100,000 among females.

The Office for National Statistics (ONS) has since updated the information on deaths according to occupation to include all deaths up to the 25^th May 2020. The new dataset includes a further 2,267 deaths among individuals with COVID-19. As the number of deaths had almost doubled during this extended period, so too had the risk. A further 43 deaths had occurred among teaching and education professionals, bringing the total number of deaths involving COVID-19 among this occupational group to 90. It therefore appears that lockdown (during which time many teachers have not been in school) has not had an impact on the rate at which teachers have been dying from COVID-19.

As before, COVID-19 risk does not appear greater for teachers than other working age individuals

The revised risk to teachers of dying from COVID-19 remains very similar to the overall risk for all professionals at 12.9 (95% CI 9.3 to 17.4) per 100,000 among all male teaching and educational professionals and 6.0 (95% CI 4.2 to 8.1) per 100,000 among all females, compared with 11.6 (95%CI 10.2 to 13.0) per 100,000 and 8.0 (95%CI 6.8 to 9.3) per 100,000 among all male and female professionals respectively. It is useful to look at the rate at which we would normally expect teaching and educational professionals to die during this period, as this tells us by how much COVID-19 has increased mortality in this group. The ONS provide this in the form of average mortality rates for each occupational group for same 11 week period over the last 5 years. The mortality due to COVID-19 during this period represents 33% for males and 19% for females of their average mortality over the last 5 years for the same period. For male teaching and educational professionals, the proportion of average mortality due to COVID-19 is very close to the value for all working-aged males (31%) and all male professionals (34%). For females the proportion of average mortality due to COVID-19 is lower than for all working-aged females (25%) and for female professionals (25%). During the pandemic period covered by the ONS, there was little evidence that deaths from all causes among the group of teaching and educational professionals were elevated above the 5-year average for this group.

Teaching is a comparatively safe profession

It is important to note that according to ONS data on adults of working age (20-59 years) between 2001-2011, teachers and other educational professionals have low overall mortality rates compared with other occupations (ranking 3^rd safest occupation for women and 6^th for men). The same study found a 3-fold difference between annual mortality among teachers and among the occupational groups with the highest mortality rates (plant and machine operatives for women and elementary construction occupations among men). These disparities in mortality from all causes also exist in the ONS data covering the COVID-19 pandemic period, but were even more pronounced with a 7-fold difference between males teaching and educational professionals and male elementary construction occupations, and a 16-fold difference between female teachers and female plant and machine operatives.

There is therefore currently no indication that teachers have an elevated risk of dying from COVID-19 relative to other occupations, and despite some teachers having died with COVID19, the mortality rate from all causes (including COVID19) for this occupational group over this pandemic period is not substantially higher than the 5 year average.

Will reopening schools increase risks to teachers?

One could argue that the risk to children and teachers has been low because schools were closed for much of the pandemic, and children have largely been confined to mixing with their own households, so that when schools open fully risk will increase. However, infection rates in the community are now much lower than they were at their peak, when schools were fully open to all pupils without social distancing. Studies which have used contract tracing to determine whether infected children have transmitted the disease to others have consistently shown that they have not, although the number of cases included has been small, and asymptomatic children are often not tested. Modelling studies estimate that even if schools fully reopen without social distancing, this is likely to have only modest effects on virus transmission in the community. If infection levels can be controlled – for example by testing and contact tracing efforts – and cases can be quickly isolated, then we believe that schools pose a minimal risk in terms of the transmission of COVID, and to the health of teachers and children. Furthermore, the risk is likely to be more than offset by the harms caused by ongoing disruption to children’s educational opportunities.

Sarah Lewis is a Senior Lecturer in Genetic Epidemiology in the department of Population Health Sciences, and is an affiliated member of the MRC Integrative Epidemiology Unit (IEU), University of Bristol.

Marcus Munafo is a Professor of Biological Psychology, in the School of Psychology Science and leads the Causes, Consequences and Modification of Health Behaviours programme of research in the IEU, University of Bristol.

George Davey Smith is a Professor of Clinical Epidemiology, and director of the MRC IEU, University of Bristol.

Are teachers at high risk of death from Covid19?

Posted on May 26, 2020July 1, 2024 by lindsey.pike

Sarah Lewis, George Davey Smith and Marcus Munafo

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Due to the SARS-CoV-2 pandemic schools across the United Kingdom were closed to all but a small minority of pupils (children of keyworkers and vulnerable children) on the 20^th March 2020, with some schools reporting as few as 5 pupils currently attending. The UK government have now issued guidance that primary schools in England should start to accept pupils back from the 1^st June 2020 with a staggered return, starting with reception, year 1 and year 6.

Concern from teachers’ unions

This has prompted understandable concern from the teachers’ unions, and on the 13^th May, nine unions which represent teachers and education professionals signed a joint statement calling on the government to postpone reopening school on the 1st June, “We all want schools to re-open, but that should only happen when it is safe to do so. The government is showing a lack of understanding about the dangers of the spread of coronavirus within schools, and outwards from schools to parents, sibling and relatives, and to the wider community.” At the same time, others have suggested that the harms to many children due to neglect, abuse and missed educational opportunity arising from school closures outweigh the small increased risk to children, teachers and other adults of catching the virus.

What risk does Covid19 pose to children?

Weighing up the risks to children and teachers

So what do we know about the risk to children and to teachers? We know that children are about half as likely to catch the virus from an infected person as adults, and if they do catch the virus they are likely to have only mild symptoms. The current evidence, although inconclusive, also suggests that they may be less likely to transmit the virus than adults. However, teachers have rightly pointed out that there is a risk of transmission between the teachers themselves and between parents and teachers.

The first death from COVID-19 in England was recorded at the beginning of March 2020 and by the 8^th May 2020 39,071 deaths involving COVID-19 had been reported in England and Wales. Just three of these deaths were among children aged under 15 years and only a small proportion of the deaths (4416 individuals, 11.3%) were among working aged people. Even among this age group risk is not uniform; it increases sharply with age from 2.6 in 100,000 for 25-44 years olds with a ten fold increase to 26 in 100,000 individuals for those aged 45-64.

Risks to teachers compared to other occupations

In addition, each underlying health condition increases the risk of dying from COVID-19, with those having at least 1 underlying health problem making up most cases. The Office for National Statistics in the UK have published age standardised deaths by occupation for all deaths involving COVID-19 up to the 20^th April 2020. Most of the people dying by this date would have been infected at the peak of the pandemic in the UK prior to the lockdown period. They found that during this period there were 2494 deaths involving Covid-19 in the working age population. The mortality rate for Covid-19 during this period was 9.9 (95% confidence intervals 9.4-10.4) per 100,000 males and 5.2 (95%CI 4.9-5.6) per 100,000 females, with Covid-19 involved in around 1 in 4 and 1 in 5 of all deaths among males and females respectively.

Amongst teaching and education professionals (which includes school teachers, university lecturers and other education professionals) a total of 47 deaths (involving Covid-19) were recorded, equating to mortality rates of 6.7 (95%CI 4.1-10.3) per 100,000 among males and 3.3 (95%CI 2.0-4.9) per 100,000 among females, which was very similar to the rates of 5.6 (95%CI 4.6-6.6) per 100,000 among males and 4.2(95%CI 3.3-5.2) per 100,000 females for all professionals. The mortality figures for all education professionals includes 7 out of 437000 (or 1.6 per 100,000 teachers) primary and nursery school teachers and 17 out of 395000 (or 4.3 per 100,000 teachers) secondary school teachers. A further 20 deaths occurred amongst childcare workers giving a mortality rate amongst this group of 3.4 (95%CI=2.0-5.5) per 100,000 females (males were highly underrepresented in this group), this is in contrast to rates of 6.5 (95%CI=4.9-9.1) for female sales assistants and 12.7(95%CI= 9.8-16.2) for female care home workers.

Covid-19 risk does not appear greater for teachers than other working age individuals

In summary, based on current evidence the risk to teachers and childcare workers within the UK from Covid-19 does not appear to be any greater than for any other group of working age individuals. However, perceptions of elevated risk may have occurred, prompting some to ask “Why are so many teachers dying?” due to the way this issue is portrayed in the media with headlines such as “Revealed: At least 26 teachers have died from Covid-19” currently on the https://www.tes.com website. This kind of reporting, along with the inability of the government to communicate the substantial differences in risk between different population groups – in particular according to age – has caused understandable anxiety among teachers. Whilst, some teachers may not be prepared to accept any level of risk of becoming infected with the virus whilst at work, others may be reassured that the risk to them is small, particularly given that we all accept some level of risk in our lives, a value that can never be zero.

Likely impact on transmission in the community is unclear

As the majority of parents or guardians of school aged children will be in the 25-45 age range, the risk to them is also likely to be small. Questions remain however around the effect of school openings on transmission in the community and the associated risk. This will be affected by many factors including the existing infection levels in the community, the extent to which pupils, parents and teachers are mixing outside of school (and at the school gate) and mixing between individuals of different age groups. This is the primary consideration of the government Scientific Advisory Group for Emergencies (SAGE) who are using modelling based on a series of assumptions to determine the effect of school openings on R₀.

George Davey Smith is a Professor of Clinical Epidemiology, and director of the MRC IEU, University of Bristol

How might fathers influence the health of their offspring?

Posted on September 30, 2019 by lindsey.pike

Dr Gemma Sharp, Senior Lecturer in Molecular Epidemiology

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A novel thing about the Exploring Prenatal influences On Childhood Health (EPoCH) study is that we’re not just focusing on maternal influences on offspring health, we’re looking at paternal influences as well.

One of the reasons that most other studies have focused on maternal factors is that it’s perhaps easier to see how mothers might have an effect on their child’s health. After all, the fetus develops inside the mother’s body for nine months and often continues to be supported by her breastmilk throughout infancy. However, in a new paper from me and Debbie Lawlor published in the journal Diabetologia, we explain that there are lots of ways that fathers might affect their child’s health as well, and appreciating this could have really important implications. The paper focuses on obesity and type two diabetes, but the points we make are relevant to other health traits and diseases as well.

The EPOCH study will look at how much paternal factors actually causally affect children’s health. Image by StockSnap from Pixabay

How could fathers influence the health of their children?

These are the main mechanisms we discuss in the paper:

Through paternal DNA. A father contributes around half of their child’s DNA, so it’s easy to see how a father’s genetic risk of disease can be transmitted across generations. Furthermore, a father’s environment and behaviour (e.g. smoking) could damage sperm and cause genetic mutations in sperm DNA, which could be passed on to his child.
Through “epigenetic” effects in sperm. The term “epigenetics” refers to molecular changes that affect how the body interprets DNA, without any changes occurring to the DNA sequence itself. Some evidence suggests that a father’s environment and lifestyle can cause epigenetic changes in his sperm, that could then be passed on to his child. These epigenetic changes might influence the child’s health and risk of disease.
Through a paternal influence on the child after birth. There are lots of ways a father can influence their child’s environment, which can in turn affect the child’s health. This includes things like how often the father looks after the child, his parenting style, his activity levels, what he feeds the child, etc.
Through a father’s influence on the child’s mother. During pregnancy, a father can influence a mother’s environment and physiology through things like causing her stress or giving her emotional support. This might have an effect on the fetus developing in her womb. After the birth of the child, a father might influence the type and level of child care a mother is able to provide, which could have a knock-on effect on child health.

There are lots of ways in which fathers might influence the health of their offspring. This figure was originally published in our paper in Diabetologia (rdcu.be/bPCBa).

What does this mean for public health, clinical practice and society?

Appreciating the role of fathers means that fathers could be given advice and support to help improve offspring health, and their own. Currently hardly any advice is offered to fathers-to-be, so this would be an important step forward. Understanding the role of fathers would also help challenge assumptions that mothers are the most important causal factor shaping their children’s health. This could help lessen the blame sometimes placed on mothers for the ill health of the next generation.

What’s the current evidence like?

In the paper, we reviewed all the current literature we could find on paternal effects on offspring risk of obesity and type 2 diabetes. We found that, although there have been about 116 studies, this is far less than the number of studies looking at maternal effects. Also, a lot of these studies just show correlations between paternal factors and offspring health (and correlation does not equal causation!).

What is needed now is a concerted effort to find out how much paternal factors actually causally affect offspring health. This is exactly what EPoCH is trying to do, so watch this space!

This content was reposted with permission from the EPOCH blog.

Depression: where we’re at and where we’re going

Posted on May 13, 2019May 20, 2019 by lindsey.pike

To mark Mental Health Awareness Week, IEU PhD researcher Alex Kwong takes us on a tour of the research on depression in young people.

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What is depression and why should we care?

Depression is one of the biggest public health challenges we’re currently facing and is expected to be the highest global burden of disease by 2030. The world health organisation (WHO) estimates that around 300 million people worldwide currently experience depression and that at least one in five people will experience depression at some stage of their life. Treatment is not always successful with only around 40-60% of individuals responding positively to antidepressant medication, and other forms of treatment such as cognitive behavioural therapy (CBT) or other talking based therapies requiring long waiting times of up to two years. It’s no surprise to see that depression and other mental health treatments are considered to be in a ‘crisis’ as we continually look for new and effective ways to combat this disease.

Research suggests that depression may first begin to manifest early in adolescence and young adulthood. This may have serious downstream consequences as depression during adolescence is related to both concurrent and later self-harm and suicide, corresponding mental health problems (like anxiety, addiction and psychosis) and impaired social functioning (reduced cognitive functioning and reclusiveness), to name a few. It also appears that depression during adolescence and young adulthood may actually be getting worse. Now whether or not this is because young people are talking more about their mental health than before remains to be seen, but that has not stopped researchers identifying potential causes for depression in adolescence in the hope of developing new and effective treatments and interventions. The message seems to be clear: by stopping/reducing depression in young people, we can potentially improve the quality of life later on.

What is responsible for depression in young people?

The lived experience of depression between young people differs from one person to the next, meaning there is no ‘one-size-fits-all’ approach. But with the help of research, we have begun to identify things that individuals experiencing depression have in common, that could be useful for treating and even preventing depression in young people. What follows is a whistle stop tour of some of the findings of potential causes of depression in young people.

Bullying

It may seem obvious, but childhood and adolescent bullying is one of the strongest predictors of current and later depression. One recent study found that individuals who had been bullied during adolescence were almost 3 times more likely to be depressed at age of 18. Bullying is particular prevalent during school years but can also occur well into the workplace or later education, which can have lasting effects on an individual’s mental health. Stopping bullying from occurring will be difficult, but that does not mean we cannot support individuals who have been bullied in order to help prevent depression from occurring or getting more severe.

Parental Depression

A lot of research has focused on the role of parental mood and later depression in young people. The role of parenting cannot be understated as numerous studies have shown that children of depressed parents are more likely to go on to have depression themselves, see research by Pearson et al, Stein et al and Gutierrez-Galve et al. However, it’s not clear if this is passed on genetically from the parent to child, or if there is something in the “environment” that transmits depression from parent to child. Whilst we don’t know for sure, the answer looks like it could be a bit of both. Parents may pass on depression genetically to their children, but depressed parents may also create an environment that makes the child more liable to depression. It is even possible that the parent passes on their genetics and the child then creates an environment for themselves that makes them more liable to depression. This is a form of gene-environment correlation that I won’t discuss in detail, but research is beginning to tease this apart with regard to parent and childhood depression.

Genetics

Interest in the genetics of depression has been heightened in the last few years. We always knew from twin studies that depression was likely to be heritable (i.e., that depression can be passed on from generation to generation), but convincing some that depression could have a strong genetic basis was tough (for a really good debate on this involving Professor Marcus Munafò, you can listen to this episode of BBC Start the Week). Most recently it has been shown that common genetic variants associated with depression in adulthood seem to predict greater levels of depression in children and adolescents, as well as varying patterns of depressive mood across adolescence. Importantly, it’s clear that there is no ‘one gene’ for depression. Instead, there are multiple genes which can be referred to as ‘polygenicity’ or ‘polygenic risk scores’; “poly” meaning multiple and “risk” indicating that individuals carrying multiple risk genes are more liable or ‘at risk’ to depression. By using polygenic risk scores we can begin to identify individuals experiencing depression early by using knowledge of their genetic make-up. However, it is really important to state here that genetic liability to depression does not equal genetic determinism. Just because someone is more genetically liable to depression, does not mean they will get depressed. There are multiple other factors at play, and we do not know how genetic liability to depression impacts on other pathways (i.e., does having genetic liability make you more likely to seek out an environment that could leave you more depressed?); but many researchers are beginning to ask these questions.

Taken together, these findings highlight how diverse depression is and how many factors could underlie depression in adolescence. There are a ton of other factors that have been related to adolescent depression that I have not had time/space to talk about. That is not to say they are not important, because most likely some are. As research develops and we are able to utilise different methods, we will get a better picture of what underpins depression in adolescence and what can be done to prevent and treat it.

What can we do?

Well for one, we have to keep up the research. We don’t know nearly enough about the underlying mechanisms and pathways that truly underlie adolescent depression. Researchers are beginning to examine this further with novel and promising techniques, but we also have to streamline the time it takes for research to be put into practise. The prolific mental health blog “The Mental Elf” states that it takes 17 years for research to reach clinical practise. That’s a long time and means a lot of people could miss out on the treatment they deserve.

Secondly, we have to be more forthright in how we talk about depression. You may have heard the expression ‘it is ok to be not be ok”. Avoiding telling people to “man-up” when they’re feeling depressed, speaking out and campaigns will only drive this forward. We have to normalise the fact that depression is a disease and like any other disease, it is good to talk about it. Only by talking about depression can we really move forward to end the stigma that being depressed is some kind of weakness. In fact one of my favourite instances of this recently was well explained by the England international Danny Rose.

Where do we go from here?

We appear to be reaching a turning point where more and more people are discussing mental health issues. This may be celebrities, royals or just your average Jo from down the street. But what is important is that we recognise the problem. That depression is a global burden that may be getting worse and requires our utmost attention and action. We are beginning to understand the causes of depression and how we might tackle it through research and reducing the social stigma that surrounds depression. However, the question is whether or not we can take advantage of these changes to really make a difference. Can we build on the progress we have made to finally one day beat depression? Yes. I really believe we can.

Resources for if you’re feeling down

If you’re ever feeling low, then I cannot speak highly enough for these guys: https://www.samaritans.org/

There are a lot of charities who specialise in mental health and depression who provide some excellent resources and information:
https://www.mqmentalhealth.org/
https://www.mind.org.uk/

There are some awesome twitter feeds out there who I have always found to be really helpful and supportive of mental health issues. These people really get depression and are leading the charge in one way or another so do please give them a follow:

MENtalHealth
Paul McGregor
Gareth Griffith
Miguel Cordero Vega
Louise Arseneault
Dr Erin C Dunn

It’s the mother! Is there a strong scientific rationale for studying pregnant mothers so intensively?

Posted on May 7, 2019May 8, 2019 by lindsey.pike

Dr Gemma Sharp, University of Bristol

For many years, researchers have been studying how our early life experiences, including those that happen before we are born, can affect our lifelong health. In an article we wrote last year, Debbie Lawlor (University of Bristol), Sarah Richardson (Harvard University) and I show that most of these studies have focused on the characteristics and behaviours of mothers around the time of pregnancy. In a recent paper published in the Journal of Developmental Origins of Health and Disease, Debbie Lawlor, Sarah Richardson, Laura Schellhas and I show that there have been more studies of maternal prenatal influences on offspring health than any other factors (read more here).

We argue this is because people assume that mothers, through their connection to the developing fetus in the womb, are the single most important factor in shaping a child’s health. This assumption runs deep and is reinforced at every level, from researchers, to research funders, to journalists, to policy makers, to health care professionals and the general public (see figure 1).

In our article, we question the truth behind this assumption.

Is there a strong scientific rationale for studying pregnant mothers so intensively?

Well, no actually. Although a lot of studies have found correlations between maternal characteristics and offspring health, the evidence that these characteristics actually have a causal effect is pretty weak. And since there haven’t been many studies of the effects of fathers and other factors, it’s difficult to say how important any maternal effect might be compared to any other early life experience.

Focusing so intensively on pregnant mothers, and interpreting all evidence as causal (if a mother does X, their unborn child will have Y), can have very damaging effects. Complex, nuanced scientific findings are being rushed into simplified advice that, although well-meaning, places the burden of blame on individual pregnant women. For example, there has been very little research on the effects of low-level drinking during pregnancy, but the current advice in the United States is for all sexually active women of reproductive age to avoid alcohol completely if they are not using birth control, for fear of fetal harm.

Fig. 1 Assumptions that the health, lifestyle and behaviours of mothers around the time of pregnancy have the largest causal influence on their children’s health and risk of disease drives research at all stages, from study design to research translation, and is also reinforced by research itself.

A culture of blame

The culture of blame is more overt in the media, where articles are often guilty of scaremongering. This feeds into public beliefs about how pregnant women should and shouldn’t behave, which can limit pregnant women’s freedom and even lead to questions around whether their behaviour is criminal. For example, pregnant women have reportedly been refused alcoholic drinks in bars, and taking drugs during pregnancy is legally classed as child abuse in many US states.

In our article, we make a number of recommendations that we hope will create more of a balance. In particular, we call for more research on how child health might be influenced by fathers and other factors, including the social conditions and inequalities that influence health behaviours. We also call for greater attention to be paid to how health advice to pregnant women is constructed and conveyed, with clear communication of the supporting scientific evidence to allow individuals to form their own opinions.

The EPoCH study

In June, I’ll begin work on a new project to investigate how both mothers and fathers’ lifestyles might causally affect the health of their children. Funded by the Medical Research Council, the EPoCH (Exploring Prenatal influences on Childhood Health) study will highlight whether attempts to improve child health are best targeted at mothers, fathers or both parents. I’m excited to work closely with the people behind WRISK to help ensure that findings from this project are communicated effectively and responsibly.

I hope that, along with the rest of the research community, we can produce high quality evidence to support health care and advice that maximises the health of all family members and stops blaming women for the ill health of the next generation.

The original article can be accessed (open access) here, and the authors’ full list of recommendations can be found below.

Full recommendations

Our full recommendations, which apply variously to researchers, journalists, policy makers and clinicians:

Collect more and better quality data on partners of pregnant women.
In addition to studying the effects of mothers, study and compare the effects of partners/fathers, social and other factors on child health.
Look for causal relationships between these factors and child health, not just (potentially spurious) correlations.
Publish all results, including negative results, to give a balanced view of the evidence.
Be aware and critical of the current imbalance in the scientific literature and how this will bias our overall understanding of the truth.
Collaborate with social scientists to consider the social implications of this research and the role of cognitive bias and social assumptions when interpreting findings.
When communicating findings, put the risk in context: compare findings to the broader scientific literature and the social environment.
Avoid language that suggests individual mothers are responsible for direct harm to their foetuses (most of the evidence will be based on averages in a population and can’t be assumed to apply to all individuals).
Where there is evidence of a paternal effect, aim public health advice at both parents.
Explain the level of risk in a way that empowers people to assess the evidence and form their own opinions (i.e. avoid over simplification).

This blog post is an edited version of one originally posted on the WRISK project website.