• mortality
• nursing care

The pandemic that is sweeping the globe is extracting its greatest toll on the elderly, the chronically unwell and the healthcare workers who bravely care for them. Children (0–19 years) have been largely spared; at the time of writing, the deaths of only 10 children and adolescents have been reported due to COVID-19, compared with over 115 000 adults, and children account for only 0.9% and 1.7% of infections in China and the USA, from where the strongest epidemiological data have been published.1 2 Relatively spared too at this stage are low-income countries. But the infection is reaching every corner of the globe and will leave no population unscathed. High-income countries have prepared for COVID-19 in many ways—spending billions of dollars on fiscal stimulus, buying hundreds of thousands of mechanical ventilators, restrictive physical distancing and lock-downs, all aimed at prevention, flattening the curve and ensuring sufficient intensive care resources are available to address needs at their anticipated peak.

Populations in low-income countries including children may be hit hard by the pandemic, both indirectly and directly. Key reasons include the high burdens of HIV, tuberculosis and malnutrition; poorly managed non-communicable diseases; overcrowded housing and social congregation, inadequate sanitation and income insecurity; and health system weaknesses spanning such fundamental elements as water, sanitation and hygiene, major workforce deficits and open hospital wards with lack of isolation. These are compounded by lack of personal protective equipment (PPE) and testing capacity. Whether protective factors, such as high rates of BCG vaccine coverage, will mitigate the extent of illness in adults or children in low-income countries is a theory which is evolving but as yet inconclusive.3 Countries’ actions have to be based on what we know today in order to protect the most people.

Evidence from China suggests 5% of children with COVID-19 …