 afternoon. Good evening, everyone nasaaman mo kayo sa mundo. Welcome to the 59th installment of the Stop COVID-19 webinar series brought to you by the University of the Philippines. We are glad that you can join us today as we continue on with our fifth season of our COVID-19 learning journey together. So commonly, when people talk about vulnerable sector society, usually they refer to the senior citizens, pregnant women, mga indigent population po, no? But we wanted to put a focus today on the topic really on a sector really close to our hearts and that's COVID-19 and how it has been affecting our children po. So maraming salamat po sa inyong pagsubay-bay at pagdalo po dito po sa ating webinar number 59. I'm Dr. Raymond Francis Sarmiento, Director of the National Telehealth Center National Institutes of Health, University of the Philippines, Manila. It's always a pleasure to be with all of you during our regular Friday lunch date and always look forward to our Fridays because I get to share my hosting duties with my partner in crime and my mentor, also our adjunct research faculty at the National Telehealth Center and really one of the international renown public health communications experts. She's none other than Dr. Susie Pineda Mercado. Dr. Susie? Kamusta ka nag? Good afternoon. Magandang happen. Kusinin dahat. Good afternoon to everyone who's watching from all around the country and from other parts of the world. I can see that there are people who are. We have people watching from PG and Raymond's gonna tell us where the others are watching from but to our Metro Manila Hospitals that are watching, to all of our regulars. Also babating natin yung mga nanonod from the Department of Education because you're under Secretary Eusek. Dads is here with us today. We're going to talk about children and COVID and I think we all have a lot of questions, a lot of things that we want to know as the pandemic is not yet really over and we are really honored and privileged that this webinar today is co-hosted, co-sponsored by the Philippine Pediatric Society. So binambati pa natin natin mga pediatrician nanonod from all over the country. Welcome po. And I think we're all here to take care of our children to make sure that everyone's safe and to learn. There's so much to learn. So it's a Friday and I hope you will enjoy this session today. Over to you Raymond. Thank you Dr. Susie and as mentioned po, very very important topic for today and that's why we have invited really, they are co-sponsoring this webinar, the Philippine Pediatric Society and also representatives from its regional chapters po. We want to take a closer look on the Philippine data specifically in COVID-19 and children, yung pung-ris symptoms and management and as mentioned po and for those who have seen our poster we have also invited someone from the Department of Education kasi alam po po, alam po namin na yung pung mga katanungan really will be kailang po babalik ang mga bata sa eskualahan. So please join us today for this very important informative session. We will sit through all of the data, pano po ba ang pagkaka-inset ng mga bata kumpara sa mga matatanda, what's the epidemiology behind it, yung symptoms po ba nila, lumalala katulad ng sa mga matatanda or primarily ba mild ang kailang mga symptoms or asymptomatic. But for those who are joining us for the very first time ang structure po ng ating webinar, mayro po tayong main discussion or presenter and then also a set of reactors po, that's how we have been doing it. Really a lot of our discussion, the rich discussion will be during the panel discussion po so we hope that you'll be able to join us up until the end of our webinar. And before we continue on, I think there are many meter instructions from Dr. Suzie especially for those who are joining us outside of Zoom. Okay so as you know you can watch through Zoom but you can also watch through Facebook and YouTube and for our audience who are watching us on Facebook and YouTube. When we have our little opinion poll or our fun quiz, you can participate, if you're not in the Zoom poll, you can participate by going to www.menti.com and use the code 59641081. So that's on your screen, let's take a look at it again 59641081. So we will give the question later now. For those of you who are on Zoom, you're just going to go into the opinion poll. Okay over to you Raymond. Thank you Dr. Suzie. Olitin ko lang din po, lagay po nang mga nakaraang mga webinar, yung po mga katanungan sa ating Mentimeter sa www.menti.com, yun din po ang very same questions na naitita po of those attendees po na nandito po sa ating Zoom webinar. But before we continue on, I would like to take this opportunity para pasalamatan po ang really ang napakasipag at masino po na miembro ng ating webinar series team. Maraming-maraming salamat ko to each and every one of you and really we endeavor each and every week to bring you quality content and something that's valuable especially in terms of clinical and public health management of COVID-19 cases. Lapusing ko lang po also for those who are asking kung ano po ang ityuran ng mga certificates kasi it looks like there are still those na very first time na uma-attend po sa ating webinar. But for those who are asking po ano po ang ityura especially for those who have not seen or received a certificate of attendance, eto po ang really a copy of the image that you will be receiving for certificates of attendance and only those who have spent at least 50% of the webinar duration will be given this certificate along with a copy or copies of the presentations po of our resources speakers. Over to you Dr. Susey. Okay thank you very much Reymond and um at this point we'd like to go to a very special guest who's going to give our introductory remarks and as I mentioned earlier we are very fortunate and honored and privileged that Philippine Pediatric Society's with us in Cool Force. I know we are all concerned about our children during the pandemic and it's great to have the president of the Philippine Pediatric Society Dr. Joseline Nusebio. Very lovely Dr. Rao who is going to give the opening remarks. Ma'am go ahead. Dr. Rao go ahead. Thank you so much Dr. Susey Mercado. Good day to everyone. The COVID-19 phenomenon has undoubtedly changed the world upside down. It has transformed our daily existence into an experience we never thought we will encounter in this lifetime. This pandemic has brought us in the world of what we probably enjoyed watching in sci-fi thrillers that kept us at the edge of our seats. Yes this unprecedented situation has indeed kept us at the edge of everything. The healthcare system is always constantly threatened by collapse. The economy has suffered setbacks in proportions comparable to a recession. The workplace has shifted from outside to inside people's homes. Classes have moved from mainstream to online. Human relations transform from physical to virtual. As we find balance in this new normal, we look at our children and wonder how they coped up with everything that has transpired for over a year now. Aside from our fear that they may contract the disease, we must also manage our deep concerns about how they have adopted so far and seal our worries with fervent prayers that these two shall pass and that better days are distinct ahead. The Philippine Pediatric Society has continuously collaborated with other professional medical organizations in our collective goal of surviving this pandemic with a new mindset that focuses on resilience, agility and self-sustainability. The Philippine Pediatric Society has for the past year contributed guidelines, policy statements, educational webinars, data registries and scientific expertise in the field of pediatric medicine in any and every opportunity it can. The Philippine Pediatric Society through its recognized sub-specialty pediatric associations have made themselves ready and available resources and references for COVID-19 related infectious, immunologic, cardiac, metabolic, behavioral and unital concerns providing timely and accurate information to help the general public. Likewise, the PPS has generously shared its rich banks of experts to serve as advisors, policymakers and decision shapers in government-initiated pandemic response institutions like the IATF, NITUG and NIP. Allow me to thank the University of the Philippines for recognizing the role of the Philippine Pediatric Society in this continuing saga as it becomes part of yet another innovative webinar on COVID-19 in children. In behalf of the more than 6,000 strong Philippine Pediatric Society members, allow me to reiterate our commitment to be at the forefront of promoting, protecting and preserving the best interest of the Filipino child before, during and beyond this pandemic. Thank you and good day. Hey, thank you very much. Let's talk to Dr. Jocelyn Yusefyo, the President of the Philippine Pediatric Society and Dr. Adriana Slater for the panel discussion. We really appreciated your talking about not just COVID and children but really what is the effect of the pandemic on the well-being of all of our children. Anyway, we have a little surprise for the audience later. We actually have two young people who are joining us and Dr. Adriana Slater for our panel discussion. Alright, so Raymond, over to you for our fun quiz. Go ahead. Thank you, Dr. Jocelyn. Thank you also to Philippine Pediatric Society President Dr. Yusefyo for that wonderful opening remarks. We are seeing on the screen, especially for those attending po, numbering a little over 1,000 attendees dito po sa ating Zoom. Two questions dito po sa ating Zoom polls and they are the same that are being seen here dito po sa ating mentee meter. So for those, again uliti lang po, no? For those who want to participate, please go to www.mentee.com and enter the code 59641081. That's 59641081. For the two questions, question number one, ano po ang most common presentation ng COVID-19 in children, medyo halo halo po ang mga kasagutan, merupong fever, fever and cough, but the options are fever, cough, itchy throat, body aches, headaches, loss of spell and fever and cough. For our next question ano po ba ang first line of management for mild COVID-19, medyo ayan as we are trying to get more of our attendees to join in the and participate dito po sa ating fun opinion poll. I'd like to take this opportunity also to greet those who are attending all the way from Basko Provincial Health Office in Basko Batanes from the Commission on Population and Development Region 3 San Fernando Pampanga, Newborn Screening Center in Southern Luzon in Tanawan Batangas, the Child Neurology Society of the Philippines. Maraming salamat po. Dr. Pablo Otto, Rememorial Hospital in Pakolod City, Leyte Provincial Hospital, Palawate, and Sambuanga City Medical Center, Sambuanga Pining Sula. Internationally, we also have those very first attendee po natin ito, neural federal university from Yekaterinburg, I hope I pronounce that correctly, in Russia. The University of Fiji and Laotoka, Fiji, Laotoka Hospital, also in Fiji, Neptune City in New Jersey, Doha, Qatar, Alcobar, Saudi Arabia, Niagara Falls, and Geneva, Switzerland. Okay, so what is the first line of management? At least nila po sa ating zoom poll and also parang nalim po sa ating Mentimeter. Medyo kong tingal ang po sa mentimeter natin. The options are hydration, enough rest, parasetamol, nutritious diet, consult your pediatrician, all of the above. Sundo po sila na all of the above ang mga kasagutan po. Also for those who are asking, we have quality distributed certificates for all previous 58 episodes. Please let us know if you have not received any and you can play it back again, rewind it, watch it again po sa YouTube channel ng TVUP for all 58 episodes. And then after this episode, we will also be putting it there to archive as well as the fifth book pages of TVUP, the University of Philippines, and stop COVID-19. Over to you, Dr. Susie. Thank you very much for that, Ramon. And I think right now what we're going to do is we're going to watch some opinions from persons on the street that have been interviewed by TVUP. Please take it away. I will be taking the COVID-19 because this is based from my personal experience or in my needs but infected by the virus po. She is seven years old. Palagay ko talaga pwede po sila magkakaroon ng COVID-19. Dila man natin kasi masabi na na-hati na dito sa loob ng bahay. May mga bata kasing na-sigilan po sila sa labas. Sa tingin ko lahat ng mga bata, pwede-ng-pwede ng tamaan ng COVID-19 kasi tayong mga malalaki na di ba, hindi tayo accepted eh. I think children are also at risk in being infected with COVID-19. Personally, tako-tako sa COVID-19 lalo-lalo na sa mga anak ko. I am sure that with a kind of immune system that children has, they haven't built that kind of immune system that adult people has so it will be harder for them. There will be a greater impact when it comes to their health. Maka-a-bilang man ay po kasi it is beyond my control kasi it whether ma-infect ang anak ko or hindi kasi ako yung tiktak ko yung malabaseng. Sa narin po ko, ano yung pinapraktis natin napag-i-ingat, kailangan sa sabihin din natin sa mga bata, yung sinasabi ko sa mga bata na kailangan sumundin kayo. Ang gat-wala po silang vaccine eh, parang nakukulangan ko ako na, wala akong peace of mind kung ma-ahawaan sila o yung nakakaroon ng COVID-19. I have to make sure na sila ay full vaccinated. So in my case, I made sure na sila ay merong pneumonia vaccine and flu vaccine and talagong proper diet. Extra dose is a vitamin C. If they were taking it once a day before, they would normally take it now twice a day. I think ko this time nagiging helpful yung pagiging paranoid din. Ang paranoid ko kasi, piling ko mas extra careful ka. Dibang alam natin mas mga maging paranoid, pero in this case, kailangan paranoid tayo. So just to be extra careful. Learning should be kept virtually. I mean, face-to-face classes is more effective, but right now with the situation that we have, I don't think that it's a risk that we should take. Ok din po yung night, pero mas prefer dito ko iba sa yung face-to-face sana. Mas mading matutu eh, ang bata sa face-to-face, ang problema lang, kailangan patupad yung protocol talaga. Yung pinatawag natin mu normal method of learning, medyo na hirapan kami jane, especially ako. Kasi kami ng husband ko, hindi talaga namin sinane yung mga bata sa mga gadgets. Sa apat kasi silang nag-aaral, so laging nilang si-iniinda sa akin, maming sakit ang ulo ko. Syempre, di ba alam naman natin na masama yung nakatutukulagi sa tablet? Yung naging angasame, naging nag-ingat, pagbabagos sa aming when it comes to education. So in dalawang kids ko ko, in-home school ko sila. Ang sabi ko, after the pandemic, gusto ko, tolito may home school na lang kami forever. Mas ok siya para sa aming. Mas maraming, ano, mas magkaroy ng time ako sa anak ko, to low him more. Mas nakapag-focus kami sa mga bagay na hindi nakapocus ng isang traditional school. There would be a vaccine for children. I would certainly give my child a vaccine. If ever naman ko na meron ang vaccination na para sa mga bata, willing naman po kami na pabakunahan yung aming mga anak para sa parmas legdas sila na makalabas ng bahay at makapag-aaral face-to-face. Ako po, believer ko ako ng vaccine niya. So kung ito naman ay dumaan sa kamang paga-aaral, then why not? Duma ting ang panahon meron ng vaccine ready and ready for children. Ako talaga, I will support 100%. Tulad ng sinasabi ko dito sa bahay naman, sa mga anak ko, sabi ko sa kanila, ingatan mo yung sarili mo. Kasi sa pag-iingat mo sa sarili mo, ini-ingatan mo na rin yung buong pamilya ko. Okay, thank you very much, TVUP, for that very interesting person on the street polation. I think it always helps us to have a little context, get the pulse, and try to understand what people are thinking about COVID and children. So we go to our main presenter today and I think early in the pandemic we were already seeing cases of what's called multi-system inflammatory syndrome in children or MIS-C. Now we've seen recent reports from India that there are more children who are getting COVID and also hearing about children who are long-haulers. We'll be hearing about Philippine data on COVID-19 and we do actually have two young people who will be with us on the panel today. But our main presenter is one of our leading pediatricians in the country. She has been with us before so she's very familiar to you. She is also the associate dean for the faculty and students at the U.P. College of Medicine. It is my honor and privilege to welcome Dr. Maria Lisa Antoinette Gonzales or Chet. Chet, welcome back to the webinar. Hello, good afternoon Dr. Susi, Dr. Raymond, and good afternoon of course to all the viewers of the Stop COVID Deaths webinar. Okay, so Chet please go ahead with your presentation. Okay, so just allow me to share my screen. Can you now see it, Dr. Susi? Yep, very clear. Go ahead please. Let's go to PowerPoint or presentation. Or at the bottom there's a little icon there or you can go to slideshow. Sorry, is it already in slideshow? No, it is both. Okay na Chet, go ahead. Okay, so the topic given to me is COVID-19 in children. And I actually have no conflict of interest in relation to this present although for COVID-19 vaccines and nature, for this afternoon I'm focusing on vaccines of course we may touch on that a little bit later. The first presentation to present the epidemiology of COVID-19 among Filipino children discussed the COVID-19 registry data, discussed the risk factors for COVID-19 and management and outcome of children with COVID-19. So as of June 30, 2021, there were 182 million cases of COVID-19 worldwide, 3.95 million deaths and the case fatality rate of 2.17%. In the Philippines, as of June 30, 2021, we had the total of 1.4 million COVID-19 cases of which 48,649 are active cases. Among the active cases approximately 95% are asymptomatic or have mild disease, 1.56% have moderate COVID-19 and 3.5% would have critical or severe COVID-19. The death rate is reported at 1.75%. Among those who tested positive, 142,663 or approximately 10% are below the age of 20 years old and 6% are less than 15 years old. So this is consistent with the reports from other countries with regards to the cases of COVID-19 in children and consistent also with global reports, the death rates are low in the younger age groups and increase with increasing age, particularly in the elderly 60 years and older. Our current knowledge about SARS-CoV-2 transmission has been updated. So we now know that there are three principal modes by which people are infected with SARS-CoV-2. The first is inhalation of very fine respiratory droplets and aerosol particles less than five micrometers. Deposition of respiratory droplets and particles on exposed mucus membranes of the mouth, nose, and eyes and touching mucus membranes with soiled hands contaminated with respiratory fluids containing the virus. The CDC maintains that COVID-19 most commonly spreads through close contact within the infected respiratory droplets. Children with COVID-19 are more likely than adults to have operator-track involvement at nasocaryngeal carriage with higher SARS-CoV-2 viral loads at presentation. However, children are unlikely to be the major source of transmission in the community. Family clusters of confirmed COVID-19 cases showed a greater number of adult index cases who developed symptoms first before any other household contact, including children. So contrary to earlier assumptions, children are not a major source of COVID-19 and they are more likely to contract the disease from close contact with infected adults than from other children. So children comprise 1-10% of the diagnosed COVID-19 cases across countries. However, due to lack of more systematic testing of children, including children with mild symptoms as part of contract tracing or seroprevalent studies, the true burden of pediatric SARS-CoV-2 infection remains unclear. And it's very likely that we are missing many cases of mild or asymptomatic children. Several systematic reviews of pediatric COVID-19 have described the disease to be milder in children with better outcomes compared to adults. However, a small percentage of children may require hospitalization, develop severe or critical disease and require ICU admission due to underlying comorbidities. Several studies have reported that children with underlying medical conditions are more likely to develop severe illness and of dying following infection with COVID-19. Post one in these reports in children COVID-19 include cardiovascular disease, which includes congenital heart disease, neurological conditions, chronic lung disease, including asthma, in these reports. Children who have a history of medical complexity due to neurologic impairment, developmental delays, or genetic syndromes, including trisomy 21, a increased risk for severe disease. Other underlying conditions are hematologic, metabolic, or endocrine disorders, obesity, and prematurity. COVID-19 is a respiratory disease presenting with a range of clinical manifestations. Most children will develop mild or nonspecific respiratory symptoms and will not require any specific therapy, can be managed with supportive care alone. Approximately 40-60% will develop moderate disease that requires hospitalization and oxygen support, and approximately 10% will develop severe and critical manifestations. Critical disease are those complicated by the acute respiratory distress syndrome, sepsis and septic shock, multi-organ failure, including acute kidney injury and cardiac injury. Both worthy also is that approximately 15-30% of COVID-19. I think we're losing you, Chet. Chet, we're losing you a bit. You're a bit choppy. Can you hear me now? Yeah, now it's good. We lost you for like 20 seconds. So good. So inflammatory multi-system syndrome known as the multi-system inflammatory with an estimated incidence of two per 100,000, but it may increase severe inflammatory syndrome. Kawasaki, this is like teacher with coronal disinfection with SARS-CoV-2. They tend to occur in older children. Now, there are several signs for this syndrome, but while slightly different, they all include the presence of fever, elevated inflammatory markers, and manifestations of effect on one or more of more than one organ system. Several theories are mainly explained by adults. This is a good expression in the respiratory tract of the ACE2, our Genshin Converting Enzyme Receptor for SARS-CoV-2, viral interference and pre-existing cross-reactive Anthony from previous respiratory infections, a vigorous early mucosal immune response, and active in ACE2, the thousand and half circulating naive. Sorry, can you see my slides now? Not yet, ma'am. There we go. Okay. Okay. So as I was mentioning, there are several theories on why there is decreased severity and susceptibility. Okay. Chat, we're losing you. I suggest that you can turn off your video, no? Because if you do, we won't see the slides. Pwede bayon, Raymond, remove the video. Turn off the video, but still share slide. We'll try to turn off her video po, but you can still share her screen, so that should not be uprope. Chat, try to turn off lang your stop video lang. Kasi it's choppy. We're picking up only parts of the... Okay, please try. Okay, nawala si Chat. Okay. Okay, let me stop my video. Is it okay? Yes, ma'am. Go ahead and share your screen again, ma'am. Okay. Share your screen. Okay, got it. As I was saying, there are several theories to explain the difference in severity and susceptibility of children compared to adults. And these include reduced expression of the ACE2 in the respiratory trap, viral interference, and the pre-existing cross-reactive antibodies from respiratory infections, a vigorous early mucosal immune response, an active innate immune system, the presence of the thymos and higher circulating T cells, an adaptive immune system in children, and the absence of age-related comorbidities such as hypertension and diabetes, as well as lower levels of various pro-inflammatory cytokines. Now, the lower level and immature development of these ACE2 receptors expressed in the nasal mucosa of children may explain also the differences in some clinical presentations, such as the lower incidence of olfactory dysfunction such as adjusya and anosmia. So, if present, these are more common actually in adolescence. So, a recent review which to date is the largest in terms of published studies on pediatric COVID-19 included more than 9,300 children enrolled in 129 studies. And the findings were consistent with previous reviews that identify the predominance of infection in school age children with slight male predominance and low hospitalization and low mortality rates. Comorbidities were reported in approximately 30% of cases with immunosuppression and lung disease as the most common comorbidities reported. The most common presenting symptoms from the various studies were fever and cough, followed by nausea or vomiting and diarrhea. The other symptoms included dyspnea, nasal symptoms, rashes, kawasaki-like symptoms, conjunctivitis, fatigue, abdominal pain and neurological symptoms. 13% were asymptomatic and they presented primarily through exposure in family clusters or household contact. Out of 3,670 children with regiologic findings were reported for 7% regiogical abnormalities with ground gas opacities reported as the most commonly as the most common abnormality. For the laboratory markers, pooled analysis of the studies that provided details revealed increased CRP, serum ferritin, lactate dehydrogen as the most common abnormalities. Abnormalities included elevated ESR, lymphopoeia, procalcitonin, treatment of COVID-19 in children largely supportive. Patients with mild to moderate symptoms can be managed at home with isolation while patients having severe symptoms require hospitalization and intensive care. Oxygen supplementation may be given and mechanical ventilation may be required in some patients. In addition to standard supportive therapy, commonly used therapy among hospitalized children included antimicrobials, intravenous immunoglobulin and systemic steroids. Other treatment regimens included aspirin, inotropic drugs, inhaled interferon, antimalariels and antiviral such as remdesivir, oseltami beer, and lapinaviritonavir. Now none of these drugs have been demonstrated to improve outcome and have no clear recommendations the treatment of COVID-19 in children because of insufficient evidence. Hence, they are only given if the benefits outweigh the risks. For hospital outcomes, about one in four children were admitted to the ICUs. A high proportion of children with severe disease had symptoms consistent with MISC and received antimicrobials, inotropes, and anti-inflammatory agents compared with those with non-severe disease. Approximately 89% were discharged and 3.6% died. So with regards to the outcome, several studies have reported a U-shaped curve of severity in children diagnosed with COVID-19 in infants under one year of age and adolescents 10 to 14 years of age at higher risk of developing severe COVID-19. There are regional differences that were seen in the comparison of clinical features, treatment, and outcome between high and low income countries. Studies in high income countries showed higher proportion of cases with fever, neurologic symptoms, abdominal symptoms, and other symptoms consistent with MISC. Studies from high income countries also showed that more children with comorbidities, ICU admissions, and mechanical ventilation and administration of treatment with various drug regiments. Whereas studies from low income countries and other symptoms are angelic and retema work. There was a higher proportion of children hospitalized in lower income countries compared to high income countries and also higher mortality rates seen. Due to insufficient data, we don't know if the observed differences in this mortality rates were related to differences in available hospital resources or differences in severity of illness or higher baseline rates of death in lower income countries. So now let's take a look at our local data. The Salvation Study which stands for Surveillance and Analysis of COVID-19 in children wide is an online registry that aims to capture epidemiologic and clinical data on COVID-19 in the pediatric population. The Salvation Study is an initiative of the Pediatric Infectious Disease Society of the Philippines in cooperation with PPS, the Philippine Pediatric Society, and in partnership with the University of the Philippines Manila National Telehealth Center and 101 Health Research. Data on the epidemiologic profile, clinical and laboratory features, treatment, and outcome of children less than 18 years old with probable or confirmed COVID-19 and admitted or are collected retrospectively is the actual yan on esteem pediatric infectious disease specialist and a staunch vaccination advocate whom we lost due to COVID-19. So from July 2020 to April 3, 2021, the registry had a total of 972 patients reported, which is actually just a small proportion of the over 142,000 pediatric cases below 20 years old that has reported by the Department of Health. Now data collection and analysis is ongoing and information is expected to evolve as more patients are enrolled. Majority of the reported cases are patients admitted in hospitals with a small number of reported patients managed on an outpatient basis. There were slightly more males at 56 percent and disease severity was classified as mild in 38 percent, moderate in 25 percent, severe in 7 percent, and critical in 10 percent. Among the age groups, children 1 to 5 years old had the greatest number of cases followed by the 11 to 15 years old, up to 55 percent in each of these age groups had mild cases. Majority of COVID-19 patients were symptomatic because in general the children were tested for SARS-CoV-2 only when they had symptoms while a small number are incidentally tested as part of contact tracing or as part of workup for another condition. The most common clinical manifestations were fever, cough, and difficulty breathing. Other symptoms were colds, gastrointestinal symptoms like diarrhea, vomiting, and abdominal pain. The laboratory results showed greater elevation of inflammatory markers such as procalcitonin, ESR, D-dimer, ferritin, LVH, and IL-6 with the elevations more marked in those with severe and critical COVID-19 compared to those with mild or moderate disease. The chest x-ray was abnormal in 53 percent and the most common findings were unilateral peripheral ground glass opacities. The proportion of those with abnormal CT scan was significantly higher, which indicates that the CT scan was more sensitive in demonstrating long abnormalities even in those with normal chest x-rays. Consistent with the other studies, comorbidities were present in 26 percent of cases while co-infection was present in 13.9 percent of cases. There were no cases of immunosuppression detected, but the other comorbidities that were reported were hematologic disorders, cardiac disease, neurodevelopmental disorders, and kidney disease. The most common co-infection was dengue and hospital acquired pneumonia. It is not shown here, but there were 11 cases of MISC in this series ranging from eight months to 11 years of age, all recovered except for one mortality. Given the typically mild course of COVID-19 in children, supportive care alone was administered for most cases. Only 27 percent required oxygen support and of those who required oxygen support, 64 percent were non-invasive mechanical ventilation while 36 percent required mechanical ventilation. At this time, there is no evidence-based therapy effective against COVID-19 for children and in this study, only a few of those who received at least one treatment aimed at modulating the course of the infection. The most commonly used drugs were corticosteroids, IVIG, and only a few were given remdesivir and interferon. Convalescent plasma was given in six patients. The outcome is generally good with 82 percent who recovered. There were 93 deaths, most of whom were admitted to the hospitals with severe or critical COVID-19. In addition to the registry, I would also like to present our experience in the Philippine General Hospital. As you may be aware, PGH was designated as one of four COVID-19 referral centers in the early part of the pandemic last year. The hospital was divided into COVID and non-COVID zones. The pediatric COVID areas were located in the fifth floor of the central block buildings. Initially, there was a COVID ward which was able to accommodate nine to 12 patients and to separate NICO COVID area where infants born to mothers with confirmed or suspect COVID-19 were cohorted separately. Currently, all SARS-CoV-2 positive pediatric and neonatal patients are admitted in the same COVID area separate from the non-COVID patients. So from April 2020 until April 2021, a total of 195 pediatric COVID-19 patients were admitted in TGH, 169 with PCR confirmed COVID-19 and 26 with probable COVID-19. Of these, 60% were asymptomatic or had mild COVID-19, 20% were moderate and 20% each were severe or critical. The increased prevalence of severe or critical cases in TGH could be explained because PGH is a referral center. For the age distribution of the admitted patients, most of the confirmed cases were 11 to 19 years old, followed by the zero to five months old. So in our institution, the admitted cases were older than those in the Salvation Online Registry. The most common clinical presentation was respiratory distress, fever and cough or colds. This is consistent with the other studies and with the online registry. Now unlike findings in the online registry where only 26% had comorbidities, in those who were admitted in TGH, majority or about 60% of the patients had comorbidities, hematologic disorders, neurologic disorders, cardiac and venal disorders were the most common underlying diseases reported. The general outcome was good with majority being discharged, however there were 21 deaths, mostly due to the underlying condition. What about infants born to COVID positive mothers? One study in TGH showed that majority of pregnant women with COVID-19 infection and their neonates had good outcomes. Of 209 pregnant women with confirmed COVID-19 infection admitted in TGH from April to August 2020, there were 196 deliveries. 63% were delivered abdominally due to an obstetric indication. There were four maternal deaths and of these four maternal deaths, one was a direct maternal death due to pulmonary embolism during the second stage of labor and the three remaining cases had comorbidities such as sepsis, diabetes mellitus and ASD with Eisenmanger syndrome that made them at risk for fatal COVID-19 infection. For the neonatal outcome, there were 192 live-born infants, all singletons except for one set of twins. Almost all of the infants in this study were born term, exhibited good apgar scores and dead birth weights appropriate for gestational age with apgar scores 8.6 and 8.8 at one and five minutes on the average. So only two neonates so that's 1% tested positive for COVID-19 infection. One was a 31-week-old preterm who eventually succumbed to sepsis with DIC and the other a stable term infant who was eventually discharged. So overall labor, delivery and the immediate postpartum course were generally uneventful and the prognosis was good. However, this generally good outcome in neonates born to COVID-19 mothers is contrary to findings from other studies. In this multinational cohort study comparing the risk for maternal and neonatal complications in pregnant women diagnosed with and without COVID-19, this study included more than 2,100 pregnant women in 18 countries and found that COVID-19 infection during pregnancy was associated with substantial risk, comorbidity and mortality in postpartum mothers as well as for their infants worldwide compared with their not infected pregnant counterparts especially if these individuals were symptomatic or had comorbidity. So for the next few slides, I would like to show you our guidelines for the management of COVID-19 in children. However, because of lack of time, you can watch the replay of this video if you want to see details. So in our management, we classify the patients having suspect probable and confirmed COVID-19 as well as classifying them based on severity. So based on severity, then there is a corresponding treatment regimen. So this is for mild to moderate, then we have for moderate to severe wherein we start them on steroids and then also we also start them on the antiviral remdesivir. For children also with severe or critical COVID, we also give them tocilizumab and convalescent plasma or IVIG. Now of course, we know that these drugs are investigational drugs. So before we give them, we make sure that we get the informed consent first before initiation of the treatment. And we also have treatment guidelines for MISC. All right, so what about the long-term outcomes of children? So there remains possibility of studies reporting the long-term prognosis of COVID-19 in children, including those who report mild symptoms of infection. A small proportion has been shown to develop prolonged symptoms, meaning more than two months and symptoms may last up to six to eight months. Majority of these patients with prolonged symptoms were pre or adolescents nine to 15 years old and there were more females who will develop prolonged symptoms. The most frequent manifestations were extreme fatigue or weakness, dyspnea, heart palpitations, chest pain, severe headache, persistent low-grade fever. So children may also experience long COVID symptoms similar to adults with females being more affected than males. So long-term follow-up of children with prolonged COVID symptoms is important to monitor their health and well-being including mental and psychosocial support. So in this last slide, I would like to present some important challenges and issues concerning COVID-19 in children. So in addition to the risk of disease and illness, COVID-19 has led to changes in schooling, health services delivery, and other disruptions of normal routine that are likely to affect children's health and well-being regardless of whether they are infected. So the challenges and issues that could negatively impact the health and well-being of children can be grouped under three broad categories. Social isolation due to social distancing policies and school closures. Second is disruptions in medical care and social services and third, economic and societal disruptions. So social distancing policies and school closure has resulted in reduced social connections and physical activity for children. And to address this concern, it is important to recognize and address the fear, stress and behavioral changes, offer mental health and psychosocial support through telehealth, and help children stay socially connected as well as finding alternate ways to connect and support each other at a distance. Health risk due to disruptions in medical or health care has occurred during the pandemic. And we know that continued acute and chronic well-child visits is important, particularly for children with special health care needs such as those with intellectual or developmental disabilities, those with underlying comorbidities, immunosuppression, and those with ongoing illnesses such as tuberculosis, HIV, and other diseases. This can be carried out through telemedicine or telehealth with complete in-person elements once the community circumstances allow. So we need to remember from the previous slides that the presence of these underlying comorbidities, in fact, increase the risk for severe COVID-19 disease and poor outcomes and hence the importance of continued health care services. And then last but not least, health risk due to loss of family income. So COVID-19 has led to a surge in unemployment and income declines for many families with children. So many families are now experiencing loss of income, food insufficiency, or problems in paying rent since the pandemic. So now is the time to maintain a trustworthy relationship and open communications with children, even as it becomes the duty of the government to provide security to those family who need economic and social support. So to end, let me summarize my talk on COVID-19 in children. So children represent less than 10% of diagnosed COVID-19 cases. Children predominantly contract mild form of infection, but they still could be at risk of more severe outcomes. The local data are generally consistent with published data and further studies are needed to determine optimal treatment for children, including those with prolonged symptoms. So thank you very much for your attention. Okay, thank you very much. Let's talk to Chef Gonzalez, who is the associate dean for faculty and students at the University of the Philippines and one of our leading pediatricians in the country today. Thank you, Chet. So we're going to go now into a series of reactions. And as we mentioned earlier, we have a little surprise for you. We thought because we're talking about children and COVID-19 that we should actually bring some young people into this conversation and not just have adults talking among themselves. So we do have two very, very special guests who are youth coming from two different parts of the world to talk about COVID. And let me turn you over to Raymond, who will introduce our first young speaker. Go ahead, Raymond. Thank you, Dr. Susie, and thank you to associate dean Chet Gonzalez for that really informative data and how it compares to the global data, at least for the published ones. At this point, we'll call on our first youth speaker po. Actually, all the way from the East Coast in the United States, Mili Rose Walker. Welcome to the webinar. I think it's a little past midnight over there. We hope that you still have the energy to keep up with us. So thank you. And thank you to your mom, Cecilia Walker. Go ahead with your reaction. So I had COVID in early March of 2021. And so I had it from, I think I contracted COVID on March 8. And before I had COVID, I, like the week before I tested positive for COVID, I was feeling really tired and exhausted, which I thought was from school and I had like kind of a sore throat. And then the Saturday after school, I like, I woke up and I felt so exhausted and I was lethargic. And like, I just, I couldn't think and I was really unmotivated to do anything. I had headaches and I had aches like on my body and I just, I really wasn't feeling well. And I thought I was like going to have a fever. So I talked to my mom and then on Monday I tested for COVID and an hour after my test, I got, I tested positive. So then during COVID I, I was actually really surprised because it was a lot more mild than I thought it was going to be. I had a stuffy nose, but I didn't experience any coughing or like tightness in my chest. I didn't have a fever. It was, it was really mild for me. I just, I thought it was like more mild for me than like I thought the common cold is and it lasted for like about two weeks. And then after my stuffy nose went away, I realized I couldn't smell. And currently, Millie has still has no sense of smell four months later. So is that something that Millie, at least in your age group, have you heard any similar experiences to yours? I know a bunch of my friends have had COVID and but I don't think any of them have lost their smell or have like, have had lingering symptoms. Okay, okay. So how is it in the Boston area? Have you gone back to school for face to face or how is it generally over there? It is actually, it's pretty good over here. So school just ended for me, but we did go back in, in person, like all of my classmates and I, we were in school. We did have to wear masks, but we were there like full day. And now nobody has to wear masks outside anymore. But if you're like in federal buildings or using public transportation, you do have to wear a mask. How about for PE classes? Is that something that, I don't know, if you have to do it at the gym or outdoors, how about the mask requirement? So we did, we did, we did do PE outdoors, but then like our teachers who are vaccinated and they didn't actually, they allowed the kids to take off their masks outside as long as we stayed six feet apart. Okay. First, do you see any questions? Yeah. Mili, what was the first thing that came to your mind when you were told that you were COVID-19 positive? I really just didn't want to infect my sisters because like I was around them at the time because we like do everything together. So I was just like, I really didn't want to like infect anyone in my family. And I was also really worried about like how I would be. Like I didn't want to go to the hospital and get sick, like I've seen people on the news. Yeah, I'm going to ask your mom a question, same question for Mili's mom. What came to your mind? I understand you come from a family of doctors and when you found out you tested positive, what was going through your head? Initially, I thought, oh my gosh, we've gone a year and have avoided COVID and all of a sudden we were so close to the vaccine being available and someone in the family tested positive. So I thought immediately Mili's a triplet and she shares her room with her two sisters, I thought we're all going to get it. It's in the house. So there's no way that we and luckily her sisters didn't get it and everyone seemed fine. It was surprising to me actually how we were able to avoid it. Initially, once Mili tested positive, we had to isolate her in the house. So she was in a separate bedroom and had to eat in the kitchen. We took shifts so that when everyone had left the kitchen, Mili could come down and eat in the kitchen. So people, she was using her own bathroom and so that was challenging but I think shortly when Mili had the lingering symptoms and I was surprised that she still had no sense of smell a month later and we took her back to the pediatrician and she had said that only recently in 2021 in the past month, so in the month of March, they had seen a higher case of children with myocarditis. So because Mili had the lingering symptoms, she had asked Mili to stop any physical activity and go get an EKG. So Mili had an EKG and it came back abnormal. Her resting heart rate was 120 beats per minute and she had a little bit of like a little bit of, I think it was like inverted T-waves and a little bit of atrial enlargement but we followed up with a pediatric cardiologist who said who did an ultrasound and repeated the EKG and said that it was temporary, that Mili would just have to recondition her heart. So slowly do ten, five minutes of walking, then increase to ten minutes and try to and just kind of recondition her heart but she assured us that nothing was wrong with Mili's heart. It was just a matter of, you know, it was just temporary. So Mili, can we go back, we'll follow up every six, in another two months or three months we follow up with the cardiologist. Thank you. Mili, how did your friends react to hearing that you had COVID? They were all surprised and then they were all asking me like if my sisters had got COVID and I told them no and yeah, they were just really surprised that I'd gotten it and they were like asking me how it was and I just, I told them like it was mild and then I also told them that I still can't smell. Okay, so thank you Mili. Please stay, we're going to have a panel discussion Raymond. Did you have a last question Raymond? I think we have something from the audience. No, I think one of the last questions was, has Mili or anybody among your siblings been vaccinated? No, only like my mom and my dad have been vaccinated. Yeah, in the United States their children age 12 to 17 are eligible. They did last week actually put a pause or had some concern about myocarditis with the vaccine but we heard that the risk of myocarditis is greater if you contract COVID than if you get the vaccine. So that was just a few cases. Mili, they're telling everyone if you've had COVID you have to wait 90 days before you're eligible for vaccine but because of now some of the new studies coming back with children getting myocarditis from the vaccine they've asked Mili to wait. So the girls have not gotten the vaccine yet. Okay, thank you very much and please stay, we're waiting to have you in the panel. All right, our next speaker is a young man from the Philippines. My pleasure to welcome Patrick de Guzman who is a very outstanding student and leader in his school and I'll turn the mic over to you Patrick so you can talk a little about, well, what did you want to say? And then we'll, Raymond and I have some questions for you. So go ahead Patrick, the floor is yours. Hello, can you hear me? Yes. Yes, loud and clear Patrick. Hello, hello. I'm Patrick and as a person who stayed in like the household time for around 17 months now, I find it tough. It's a bit restrictive. It's, you know, I mainly have to stay at home and two weeks ago I just started my eighth grade. I had to have online class at home because I'm part of the, I'm vulnerable to the virus and essentially in, essentially my family, I'm the home body, you know, that I see at home all the time. Even before the pandemic, I always like staying at home and during my free time, I have a lot of free time in the pandemic especially for the summer, I play games, watch YouTube, chat with my friends of course online, chat with my friends online and the only really outdoor activity I do is just watering the plants outside my house and at times where my parents and my sister would go outside my house and attend important events and businesses, I would stay behind at my house with guardians because again, I am vulnerable and my parents and my sisters also vaccinated. They already fully vaccinated, they just recently got their second dose but except for me, there's no vaccine for my age or for at least here in the Philippines. I did here, they were testing vaccines in America for like people might like my age and the vaccine really is just the best protection for people and since I don't have the vaccine yet, you know, I have to be careful inside my house. My mom is a baker, she has like staff, like customers come in the house every once in a while and even inside the house, I have to wear a mask and wash my hands more often and I really started taking it seriously like last year at November, my dad got COVID, luckily none of us, my sister, my mom, me, no one else got infected and that's when I really started washing my hands more and like social distancing even with my sibling and my parent and online schooling, it's, compared to physical school, it's very restrictive like for example in physical school, you know, we can interact with our classmates, you know, we can talk to them, you can talk to the teachers and online there's a lot of problems like internet connection and we're very limited to talking to each other in Zoom classes and at school, you know, we all like at lunch, we do lots of games, like, you know, I play lots of sports like football, baseball, but in online we can't really do that, you know, I can't really meet up with my friends as much, especially the workload in online school and then like in online school like there's PE classes, you know, in physical school it's more fun, you know, we have like these games and then we exercise together and then online it's like, it's, it feels isolating, you know, like you only see your friends and classmates through a screen and, you know, it can have a, it can really have a mental impact to me and that's, I really miss my classmates and my school physically and like, you know, I can't really talk to my classmates again because you know, we can't really go out, you can't like have birthday parties, you can't have play dates, I can't even meet with my relatives, we only resort to Zoom classes or Skype and we, it isn't as much as fun as in physical because, you know, we can do all sorts of games but at least there's always a positive things to everything, like for example, my parents stay at home, my parents stay at home more than compared to before the pandemic, right, now they have their own Zoom meetings too and we get to have mass every Sunday watching, we watch the mass in YouTube. I really hope there's more interesting things we could do at home because, you know, we can do only so much until it, you know, things get boring if you do something too much it really gets boring and honestly, the only thing that keeps me saying is just talking to my friends and I really hope the pandemic will end soon but in the end we should all look forward to a healthier and safer future for all of us, thank you. Thank you Patrick, thank you Patrick for sharing that. Before we let you go because we're going to have a panel discussion I'm just going to ask you, what do you do Patrick when you're feeling that it's affecting you mentally? What would you do? I would usually talk to my parents, my friends, maybe try to, you know, get it out of my head by doing my hobbies, you know, like watching YouTube, playing games and maybe even try to find new hobbies to, like, distract myself from what's happening outside in the world, yeah. In the world, yeah. Okay, thank you Patrick. Raymond, did you have a question for Patrick? No, I just want, I just wanted to ask Patrick, he seems like a very, very mature kid and just wanted to ask him, how soon would you wish to go back to school or maybe be able to interact with your friends again? Like at first when the pandemic started and then they announced online school, you know, I was celebrating because, you know, I didn't have to go out but then over time I just miss my friends, I just miss them, you know, seeing them physically, also my teachers and, you know, like playing, you know, those, yeah, those playdays and parties and all that stuff, yeah. Okay, thank you very much, Patrick. No, go away. We're going to have you on the panel and let me turn it over to Raymond for next speaker. Raymond. Thank you, Patrick and thank you, Dr. Suzie, our, well, our last reactor as mentioned, that we have a representative from the Department of Education. He is the Undersecretary for Curriculum and Instruction, none other than Dr. Justdados San Antonio to give his reaction from the Department of Education's perspective. Usag dado. Good afternoon. Okay, there we go. Usag dado, go ahead, sir. Thank you very much, Raymond. Thank you very much, Dr. Suzie. Good afternoon everyone. Of course, we all know that in the Department of Education, we are not yet able to provide the face-to-face classes that all of us would want to have. We understand from the presentation of Dr. Chet Gonzales that indeed the kids may not be so like prone to getting infected, but we also respect the decision of the President particularly in putting premium to the health and safety of the children and of the Filipinos. Much as we, personally, I've been a teacher myself for more than 36 years, I feel that if we would want to really make sure that the youngsters would be able to continue to learn the component of face-to-face, like blending the delivery of basic education services, could also be possible considering the data that we also knew even at the start of this COVID-19 pandemic. But as I've said, we are respectful and we agree that the health and safety of the children and of all fellow teachers is of better importance than making happen our dream of a face-to-face class for everyone, even if they are done on a limited scale. Thank you. Okay, thank you, Yusek Dado. Thank you so much. At this point, I think we'd like to call on all of our speakers for today. We have, well, obviously we have Yusek Dado, but we'd like to call on Patrick again and maybe Executive Director of the Climate Change Commission, Sekmani de Guzman, can also join Patrick, Mili, and her mom, Cecilia. We also have Dr. Chet, obviously, and Dr. Yusebio. Okay, but before we start, let us go first, TVUP on our fun quiz. Just to go through the questions, there we go. Okay, so for the two questions that we have, what are the most common presentation of COVID-19 in children? 66% of responders selected fever and cough followed by 42% fever and then 26 and 27% itchy throat and cough. And then for the second question, what is the first line of management for mild COVID-19? An overwhelming 78% chose all of the above followed by 8% hydration, 6% pediatric consultation, and then 5% paracetamol. Okay, Dr. Susie. Okay, so we've got everyone on the panel now and we're going to have questions from the audience too. We actually have two of our pediatricians from outside of Metro Manila who are going to be part of our discussion this afternoon but before we go into that, I was going to ask, maybe I'll ask Milly and then Patrick first, you know, if they had any questions for each other because you're, you know, and there are questions in the chat, you know, Patrick is 13 and Milly is 14 and they're on two different parts of the world but I think you can hear similar threads in what they're talking about but I just wanted to ask either Milly or Patrick to start off with a conversation between you two. I guess it must be interesting to learn more about somebody or age in another part of the world. So I'll start with Patrick. Do you have a question for Milly? Actually, how did you feel when you, like when you learned you got COVID and, you know, how you're being treated and when you were recovering and how did you cope, how did you cope mentally and emotionally? So when I tested positive for COVID, I was really nervous, like how my body was going to react and I didn't want to like, I really didn't want to like be in the hospital and like be on a ventilator like I've seen a bunch of people on the news and then I was really, really relieved when like all of my symptoms were mild and then after COVID when I learned that I was having like trouble with my heart, I started to get nervous again because I didn't want to like have a heart attack at being in the hospital and I just, I just wanted to like be back to normal and like be able to play sports and like just like be healthy like my sisters were. So I was just like really nervous the whole time but then when my doctor told me that I was all right and I just needed to like recondition, I, you know, I felt really glad and relieved. Milly, do you have a question for Patrick? Patrick has been in the country with the longest lockdown in the history of the world, so do you have a question for Patrick? I was wondering like when or like would you feel comfortable, like if, you know, you get vaccines in the Philippines, would you feel comfortable comfortable like going outside again, like being in public, being in school, being around people, like would you feel comfortable? Like if you haven't gone, if you haven't gone outside in a long time thinking and thinking that the virus is still there, you know, of course I'll still get scared even if I get a vaccine that I'll still probably social distance because I'm probably gonna be paranoid, I'm gonna be paranoid but, you know, at least I can see, you know, people physically and interact with them. Okay, great. Okay, so you guys, Patrick and Milly, take a look in the chat. People are, Milly, a lot of people are cheering for you, you didn't really go through a difficult, you didn't really go through an easy time, I mean this is a difficult, difficult situation for you and people are cheering you on in the chat box. So, okay, so let's go to our question. So I don't know, you said that did you want to ask Dr. Chet anything in relation to her presentation? Dr. Chet, so what do you recommend if asked? Is it safe to have like limited face-to-face observing social distancing, fewer learners in a classroom, especially in far-blang areas? Sir, thank you for the question. I think that that's been going on in the minds of many people. Personally po, I would have to say that if ever we open, it has to be like, it cannot be nationwide, it has to be like taste or in just selected areas because there are many things to consider. Although we do know that children get mild disease or are not as susceptible, still they can get the infection. And so before we open, we have to consider like, is there ongoing community transmission? Are the teachers vaccinated? Are the schools, the infrastructure, are you prepared? Do you have enough ventilation? Can you like, is there enough space to be able to ensure that the children are distance, appropriate distance, they have appropriate physical space. So there are so many things to consider. But having said that, there are so many advantages also of starting schooling because of the mental effect that the prolonged lack of schooling has cost to our children. So we have to consider that. And I was just thinking, if we are able to open our malls and business establishments, I think we also have to consider opening our schools at one time or another. So maybe once we are ready, we can like make open a few areas at a time knowing the situation in that area. So I hope that helps, sir. I know it's a difficult situation to have, whether to open or not, because I agree safety of everybody concerned, our teachers, our school, the community, the children are, of course, of utmost importance. Thank you. Thank you, Chet. And thank you, Doctor. Thank you, Yusef Dads for that question. And I think we've got two pediatricians from the Philippine Pediatric Society that Raymond's going to introduce them. And they are coming from different parts of the country, both very different contexts. And I think, really, I agree with Chet, this is really about understanding what's happening in terms of the community and looking at community transmission as something that we need to strongly consider when we're thinking of going back to school. So Raymond, over to you for our two doctors from the Philippine Pediatric Society. Thank you, Doctor Susie. So for our first representative, he is a chapter president for Southern Mindanao of the Philippine Pediatric Society, Doctor Sheldon Paragas. And our other guest is the chapter president for Northern Luzon of the Philippine Pediatric Society, non-other than Doctor Efren Balanag. So Doctor Balanag and Doctor Paragas, welcome po to our webinar. Any, like, brief reactions to the topic, sirs, or anything that you'd like to share to our audience? Let's start with Doctor Balanag and then Doctor Paragas. Thank you very much for inviting me to be a reactor so far. It has been a very fruitful interaction, especially with the feedback coming from our children themselves. So I would just like to give a little background on our situation here in Baguio. Basically, we have the same demographics with that of what is reported by Doctor Etshet from PGH. In my place of practice here in Baguio, General Hospital, which is also an identified COVID referral center, here in the Cordillera Administrative Region, we have 200 expedientic cases of COVID so far. And half of the total cases are around 105 patients of which have mild symptoms, followed by moderate of around 48 and seven cases presented as severe and seven cases were critical. And around 39 children, though, were asymptomatic. Of the 206 pediatric cases, more than half or 112 cases belong to zero to four years old, followed by five to nine years old with 37 patients and 15 to 18 years old with 32 cases. The least number of cases belong to 10 to 14 years old bracket around 25 cases. And the top five clinical presentations are also respiratory symptoms such as cough and colds, fever, diarrhea, seizures, and sore throat. And the most common comorbidities are those patients with malignancies or cancers, patients with dengue, surgical and neonatal complications, and urologic symptoms or patients. And of the 206 cases, we have 11 deaths. So far, most common comorbidities for this mortality are two cases of dengue severe and two cases of severe RDS and one of which with epilepsy, hyranencephaly, bronchial asthma, lymphoma, DIC, and meconium aspiration syndrome and obesity. So, those are the demographics here at BGH and Baguio in general. One common problem I would just like to ask Dr. Chet is that the most common dilemma is the question of separation from the caregiver. Like if a pediatric patient is positive and immediate caregiver is negative, how do we go about it? Do we sacrifice the negative caregiver just to be with a sick positive child? Because I believe this is one of the costs of underreporting. They don't want to get separated for the fear of being taken away from their primary caregiver. Okay. So, usually what we do in PGH is we test both the patients and the caregiver. So, if the patient is positive and I think it's a matter of whether we have a proper isolation room for them, if there is no other caregiver, then if, wait, if the caregiver is, your situation is the caregiver is exactly okay. As long, and there's no other caregiver who can take care of the patient, is that the condition? Yes, especially if you are very young patients who need to be breastfed like that. Okay. I would, if there is no other caregiver who will take care of the patient, especially if the caregiver is also at risk, like elderly or has a home, but they take the risk and I would not recommend that. If there is no other caregiver, I think if, I think that it should be clear to the caregiver about the risks of getting the infection. If the caregiver is fully aware that he might be, or he or she might be at risk, especially if this patient is elderly or has comorbid conditions, then he has to be informed and then having said that it would be important for this caregiver to practice the appropriate standards of prevention. So wear mask, face shield, wash hands always. So, I think that's the only way that we can go about it because of course we cannot separate the primary caregiver from the child. So, I think that's the best that we can do. Yeah, I really, I really like that question, Dr. Efren, because it's a very special situation for children and it just brings me, maybe we're going to ask Dr. Yuseb you to also comment on this and you say that, but once we open school and you have a child who has symptoms, then the school will probably have to have some kind of facility and some health workers who would be able to manage possible infections. So, I was going to ask Dr. Yuseb you from the point of view of PPS, is it possible that our pediatricians could be working with our schools to just to prepare because again, we don't know, not everything is isolation in a hospital and a lot of cases are mild, but there could be instances when we open up where you have a child who you find out that the person tested, that the child tested positive and the school then has to make a decision on what it's going to do. So, is PPS, what are your thoughts on how PPS could be helping our schools when we start opening? Yeah, well actually just for the information of everyone, about two days ago the DOH convened the child health experts together with I mean with the educators and some other stakeholders and we discuss about this reopening of classes and as mentioned by Dr. Gonzales, there were a lot of our recommendations that were set and presented to the body in order for it to more or less happen, but we always have to start from maybe piloting initially in certain areas that are of low risk and to ensure and make sure that the school will have provisions for all the health safety measures that need to be followed and together with that also is how to identify if I mean what will, what needs to be provided for or done if ever that the child will have the sickness or the illness and what are the support system that has to be provided for by caregivers but and so on and so on. So in other words, if I'm going to answer your question, yes, the pediatricians have very important roles in more or less helping the families understand and even the educators at that in more or less emphasizing to them the importance of the health safety measures and to support the mental health of the children. Yeah. Thank you very much, Dr. Yusef. Yusef Dads, did you want to add to that conversation? Of course, we are grateful that Dr. Chet and Dr. Yusef, you have practically affirmed what we are trying to do in the Department of Education as we prepare for the limited face-to-face. It will really be in faces and of course, while we know that the trend is becoming like harder in the areas originally identified as low risk, but we are also aware that there are certain areas. For example, in Calabarzon, there's a town that's on an island into itself where like COVID transmission from outsiders may be very difficult, then this is something we can perhaps explore. But yes, we have taken note of those things and those are the things that we are trying to look into now, especially the risk levels at the communities where limited face-to-face classes may be done. I understand our original list of the pilot schools was more than 1000, but lately I think we have to reduce it to about 300 across the country. But yes, we also wanted to do this in faces because we have to monitor and learn from our experience and find out how we can do it in bigger scales later on. So the inputs from the professionals would also be very important to us so that the decisions made will be consistent with the opinions of our experts in terms of this COVID-19 disease among children. So we're very grateful. Yes, there's a strand in the Department of Education that actually works with our partners. And unfortunately, I don't belong to that strand. It's on, I think, the USEC in charge of administration and health services. Okay. Thank you very much, USEC. I mean, talking about low risk and high risk areas, let's talk to somebody who is in a very high risk area. So Dr. Sheldon Paragas from Davao. Please, hi, welcome Sheldon. And yeah, please take the floor. Tell us what's happening in Davao and what you're thinking. And if you have any question for Chet or for our young folks on fall, go ahead, Sheldon. Okay. Thank you very much, Dr. Susi and as well as Dr. Raymond and for the rest of the team with this webinar. So I represented Davao's other mineral chapter, the Philippine Pediatric Society. And to give you an overview, let me walk you through what happened when we started the pandemic last year. So in March 2020, we started gathering data and numbers as to how many of these children were affected. And then what is unique in Davao City because we have a one hospital command. We're in Southern Philippines Medical Center. All of these suspects as well as confirmed cases across all ages will be admitted only to that hospital. So it's a dedicated hospital. The rest of the private hospitals, for example, when the pandemic started, they are not allowed to admit these types of patients. So all patients are we are seeing patients in Southern Philippines Medical Center since March 2020. And among these for the census for the whole year of 2020, we had about 569 confirmed COVID positive patients, children. And then 254 up to this date starting from January to June of 2021. If you're going to sum it all up, the total of 823 confirmed COVID patients, children, are admitted at Southern Philippines Medical Center. And if you're going to look into the greater picture, the total number of COVID cases in SBMC for the whole year from March 2020 up to this point, around 709 hundred, 790. So it means we have only 3.8% of the total number of cases admitted in that institution. But we have to understand that since we had two surges in Davao in the last quarter of 2020, and now the second surge. So we are now opening other private hospital to cater these patients. And these private hospitals are now allowed to cater mild as well as asymptomatic to some extent, moderate cases. And then we are also having these temporary transient medical facility or TTMS across the Davao region, wherein all of these patients will be admitted, whether they are asymptomatic or mild. So it means that given the census of 823 cases of children with COVID, we don't know exactly the true census because we are only catering the moderate, the severe as well as the critical. So we don't know who among these children who are asymptomatic and mild cases. So that's the scenario of our cases in our city. So we are now trying to consolidate, make policies, review policies, and make new guidelines regarding how to combat these surges. We noted that when the National Capital Region had its surge, we are pretty much expecting that Davao will follow. So true enough, when the number of cases in the NCR went down, Davao cases went up. So yun yung nangyari sa atin. So it means that for the Davao region, I think we have a total of 43,000. And then at present, we have 9,657 active cases as of today. And in southern Philippines Medical Center, we have at least around, I think around, in Davao region, we have 4,000, Davao city rather, we have 4,000 active cases. So that is pretty much a bad picture, especially if you are dealing this one. Again, the policies and guidelines set by the government, the DOH, as well as the IITF. And we actually continue to educate people to get their vaccines among these, especially among the priority groups. So that's the clear picture. And regarding children with COVID, we had a total mortality of, I think, if I'm not mistaken, 31 patients in SPMC alone. So given that data, so at least we have only, I rather, the mortality rate are less than 5% of the total cases. So the same data presented by Dr. Chet among this mortality, they have serious comorbidity. So HEMA oncologic comorbid conditions, cardiovascular, renal as well as respiratory. And then we are also seeing patients with dengue fever. So that's the picture in our setting. And probably with this data, I think we can also work hand in hand with UPTGA to consolidate this one and then include in the Salvation Trial probably. One of the questions I've frequently been asked since I am a pediatric cardiologist by practice is that recent reports about a myocardial involvement or myocarditis regarding these types of vaccines, especially with the mRNA platforms shared by these vaccines, rather. A lot of parents are very much concerned whether these children should accept this type of vaccine. So the same sentiments were raised regarding in one of our panels. So I usually answer them back that, yes, it's true, there have been reports about myocarditis. But again, as the other cardiologists from the other part of the world have said that, the risk of having cardiovascular involvement, ventricular dysfunction or myocarditis are much higher when you will be having COVID than through the vaccines. I don't know about if my perceptions are accepted by Dr. Chet. Can Dr. Chet share your thoughts about this one? Chet, go ahead. Okay. This is regarding myocarditis, right? I think still in those who develop myocarditis from what I've read, they're usually mild and self-limiting. And so as was mentioned earlier, the risk of myocarditis from COVID-19 infection itself is actually high. It's higher than the risk of myocarditis from the vaccine. So still, the benefits of vaccination would still outweigh the risk. And so if it becomes available, then surely, I think, vaccination would still be a better option. Yeah, you know, I don't know if I heard this correctly, but Mili, you had myocarditis, right? Or you have myocarditis, am I correct? I didn't have myocarditis, but they wanted to make sure I didn't because kids around my age who were having like lingering symptoms of COVID were developing myocarditis. So that's why I had an EKG and an ultrasound. But you didn't, it turned out that you were negative. Yeah, I was all right. She just has an elevated heart rate, so that will take time to recondition her heart by slowly building up the exercise and not stress. Yeah, good. So that's something I think we need to watch out for. Raymond, did you have a question you wanted to... Yes, very, very, very interesting question. Thank you, Dr. Suzy, just because it has already touched on by Dr. Paragas and Dr. Ratchett, I'd like to continue on. We'll address this to Dr. Ratchett again. And this is from our pediatric dentistry colleagues po, no? I'll just read the question. Have we seen, based on the Philippine data, have we seen cases of COVID-19 in children that manifest oral lesions? Our pediatric dentist colleagues, especially from the international community, have been seeing lesions in the oral cavity in COVID-19 children cases. Okay, that's interesting. I have not seen any in the report, but maybe having mentioned that, maybe it should be specifically observed or looked for in patients with COVID. I'm just wondering what type of lesions are we talking about, ulcers? I haven't seen personally, I haven't seen. Unless we're talking about oral ulcers in relation to MIS-C, because I have seen, like, chaplips and, you know, lungs and things like that. But in relation to children with MIS-C, not the ordinary COVID infect. Yeah, thanks, Chet. Dr. Efren Balanag wanted to say something. Efren, go ahead. I would just like to ask the young adults regarding their feedbacks. One of the possible backlash of being COVID positive is the stigma attached with one way or the other. If other children knew a classmate, had the COVID, is it a possible cause of bullying or avoidance from other classmates or parents of other classmates? That's one. And another question is what are the feedback of children regarding the swab test? How traumatic is the experience for them to be poked inside their noses? Okay, great. I think let's start with Patrick. Patrick, you think somebody who got COVID would be discriminated or would receive stigma? And did you ever get tested? What was it like for you? Go ahead, Patrick. I would say, yeah, because first day they want to stay away from the person who got the disease. And also, I heard news in America, you know, those like Asian hate, I think, because China, you know, the virus. Actually, I did get the swab test and for me it wasn't really traumatizing or anything. And it didn't really hurt that much. If anything, it was just ticklish. Ticklish. Okay, that's nice. Let's go to Millie. Millie, have you sensed that because you tested positive your friends, so you think people are avoiding you? Well, I know a bunch of people didn't say anything about having COVID because they didn't want to be shamed for going against restrictions or seeing people and doing all that stuff. But I don't think people necessarily wanted to avoid me. I think they were more interested in how the whole process was. But definitely, there were a lot of people who really didn't mention having COVID until like the end of the year because they were afraid of what other people would think. Yeah, and how about testing? How has testing been for you? Um, yeah, like Patrick said with the nasal swabs, I didn't mind it. Like, I know some people have a hard time with it, but yeah, I thought it was like ticklish. Okay, so I think it's the adults don't like it. The kids seem to like it. Alright, Reima, did we need to go to the answers to the questions before we do something else or? No, no, I think we're okay and most of the questions have already been addressed, Dr. Suzie. I think at this point, you'd like to ask TVU people to show our evaluation poll. There we go. Okay, so I'll just read off the list as our resource speakers composed themselves for their final statements. The five questions are as follows. The panelists demonstrated thorough knowledge of the topic. The panelists were well prepared and organized. Number three, the panelists spoke clearly and audibly. Number four, the panelists used appropriate language with technical medical standards adequately explained. And then finally, the panelists contributed to new perspectives and knowledge on managing various COVID-19 health issues. Over to you, Dr. Suzie. Okay, thank you very much. We're approaching the top of the hour and we're going to share a little public service announcement during which time we're going to ask our panelists, our guests, our reactors to formulate a very short message for the audience before they go. So, we'll give you a minute or so to do that while we share a public service announcement from the University of Philippines. Go ahead, TVU people. Sigurado ka na ba si Reservations natin? Oh, naman. Bakit bis na bis ka? Oh, magiging escort moko eh. Mokong may date si Lola-plolo. Ilagay mukaya ito. Ang ganda naman. Maganda yan. Special anulakan natin. Ano, ready ka na? Reading ready na. Mom, dad, alisi Lola-plolo. Oh, anak, after lunch. Sana lakad nyo ko. Para sa atin lahat ito, magpapapakuna kami dahil mahal namin kayo. Dahil mahal ko kayo, magpapapakuna ako. Okay. Thank you very much, TVU people. Just another reminder for our seniors. And to our audience that we have to get our seniors vaccinated. We still, I think the numbers are going up but we really have to share this message that let's do it out of love for our family. Okay. So let's go now to our closing remarks. And I'm going to start in reverse. So we're going to start with under secretary of the Department of Education. Yusik, let's go ahead please. Of course, we're very grateful to the organizers for the opportunity to be a part of this important initiative. And us in the Department of Education, we are very grateful to the whole country. Everyone has shown that Bayanihan is alive in the Department of Education. Everyone who cares. It's not just the end that has done its part in providing learning continuity for our youngsters. So thank you very much again to everyone. Mabuhay po kayo. Thank you very much, Yusik Dats. Let's go to Dr. Yusebyo from President of the Philippine Pediatric Society. Yes. Also, I would like to express my deepest gratitude for this forum. And that despite the fact that children are less affected, we know that its impact on our children is very, very much more than that because it can even be lifelong because of the mental, social emotional impact it has on them. But as I have emphasized earlier on, we at the Philippine Pediatric Society is always at the forefront and is committed to promote, protect and preserve the best interests of the Filipino child. So whether this is before, during or even after the pandemic. So thank you. Thank you very much, Dr. Yusebyo of the Philippine Pediatric Society, President. We're going to ask also Dr. Efren and Dr. Sheldon to give some parting words. So Dr. Efren first. Go ahead, please. I would like to thank this opportunity to be able to impart our knowledge, especially to our caregivers and to our pediatric patients because we all know that the Filipino children is this, they're the future of our country. So we have to take care of them. Thank you very much to Dr. Efren Balanagob Bagyo City. And let's go to Dr. Sheldon Maragas. Okay, thank you very much. So I would like to take this opportunity to send a message that protecting our children starts when we are protecting ourselves, the adults. So do not be afraid to be tested, especially when we have influenza-like illnesses or systemic viral infections. Do not wait for the rest of the household to be transmitted with this disease and also likewise, do not be afraid to be vaccinated. That's all, Dr. Yusebyo. Thank you very much, Dr. Sheldon. Let's go to Mili Velasquez Walker from Boston, Massachusetts. Go ahead, Mili. I just want to say, please listen to all the COVID restrictions, wear your masks, stay six feet apart, stay at home. Ask your doctor if you have questions, do your research, get tested. And don't lose hope, things will get better. They did where I am and I'm sure they will get better in the Philippines. Thank you very much, Mili. Patrick de Guzman from Santa Rosa in the Philippines. Hi, I just want to say thank you again for inviting me. And I believe this pandemic will be in the past and eventually we will learn from our own experiences and we will all work out for a better normal. Just stay safe, like what Mili said, wear your mask, all the health protocols, wash your hands. And it will all be over soon. Thank you, Patrick. Dr. Chet Gonzalez. Okay, I think it has already been mentioned by several speakers also that although children contract the mild forms of the disease and the outcomes are generally good, there is still a small proportion of children, especially those with comorbidities that can develop severe COVID. Aside from that, we also know and we heard from our young people, our young reactors that the effect of COVID is not just physical, it's also mental and social. And I think as pediatricians and as physicians, we have to consider that also. May I just mention, there were several questions with regards to vaccination. Go ahead. So, I think just briefly, should children be vaccinated? Yes, eventually, of course, because when we say herd immunity, that does not mean 70 to 80% of people more than 60 years old. It means the entire population. So, eventually, yes. And just like school opening, face-to-face, I think vaccination, there's a perfect time for that. That's it. Thank you. Thank you very much, Chet. Yes, I do realize there are many questions about vaccination. And maybe at some point in time when we're ready, we will talk about vaccination for kids. But, yeah, thank you so much for your presentation, Chet. Okay, to close our program, we are going to have a brief summary by the Chancellor VP Manila, Dr. Carmen Sita Padilla Menchit. Go ahead. Yeah, okay, thank you. So, well, good afternoon. Good afternoon. So, our webinar 59 was opened by Dr. Jocelyn Giuseppeo, the President of the Philippine Pediatric Society. Our COVID experience was likened by Dr. Giuseppeo to a sci-fi thriller with all of us at the edge of our seats. And I think that's exactly what we're feeling right now. But we are just worried whether the children will contract COVID, but we're now concerned how the children are coping up with this condition. We have to start looking at the mental component of COVID. PPS is committed to collaborating with the Department of Health, the Department of Education and all the agencies to make sure that we come up with policies working towards resilience, agility and self-sustainability. I'm really happy to be part of PPS too and I know that they've been contributing guidelines, policy statements, registries and scientific information. The PPS has also contributed, shared their expertise actually is members of IATF and some committees of the Department of Health. And for that, we are thankful to PPS. Our main presenter, Dr. Gonzalez, worked on the epidemiology, the registry and the risk factors. So allow me just to give the highlights in the interest of time. It was clear that Dr. Gonzalez said that the children represent less than 10% of the diagnosed cases. Children are unlikely to be the major source of transmission. They predominantly contract the mild form but still a certain percentage will have severe outcomes due to underlying medical conditions. I'd like you to review in the replay her discussion on the multisystem inflammatory syndrome in children. And likewise, the theories regarding the reduced severity and susceptibility of children, those issues very interesting. Now, just to mention a few, some of the data that you might be, you'd like to bring home to your community in your echo seminars. The biggest collection in the literature has 9,000 children in their collection and still the most common symptoms will be fever, cough, nausea and vomiting, diarrhea and rashes. But generally, the management is still supportive. And of course, for a moderate and severe, they will need hospitalization. Now, what I found interesting in the presentation of Dr. Gonzalez is that she said that the risk of severe COVID-19 in children showed a U-shaped curve of severe COVID-19. That means infants under one year of age and adolescents 10 to 14 years and note the regional difference. The high income countries have a higher proportion of abdominal symptoms. The co-morbidities were as the low income countries at a higher proportion that was asymptomatic with cough and barangile arritima. But a high proportion of hospitalized children with higher hospital mortality. I think that is one part that's worth reviewing why it is that that is a situation in the differences. As she mentions, DiSalva Sean pediatric COVID-19 registry which is named after our president in PPS who died who succumbed to COVID. Presenting data, well documented data of 972 patients showing that still 80% are asymptomatic. But the most common, the majority will still be asymptomatic and those who are symptomatic at fever, cough and difficulty of breathing. Chest x-ray was abnormal only in 53% because it can't be more sensitive. Further on, she said that majority actually recovered and then she discussed the PGH data. Now in the PGH with 195 patients, it is interesting that the symptoms are actually similar and majority are actually discharged and that for the mothers who, the COVID-19 mothers who were actually delivered that the newborns actually had good outcome and only two neonates actually tested positive. I think with all of this information now, it has guided our societies to come up with better guidelines and better protocols so that we pediatricians and other sub-specialists will be able to manage our patients better. Now, in closing she actually talked about the issues for children that impact health and well-being. I think this is something that we should really take home. Number one is the social isolation eating social distancing policies. Number two is the disruption of routine services where in chronic children illnesses must continue their follow-up with the doctors using telehealth and the third will be the health risk due to the loss of family income. Now, we had two young reactors Milly from Boston USA and Patrick from Manila who shared their feelings about the situation and they both of them were concerned with their families. Milly is in a hybrid situation in a modified educational setup and Patrick is still in a remote setup and the two of them actually exemplified highlighted exactly what Dr. Gonzalez said were in social distancing policies must be given attention. We must we should offer mental health and psychosocial support and we have to find alternate ways to connect and support each other at the distance and I think for us in the Philippines this is going to be very important because everything is still on remote whereas Milly in the U.S. started already the face-to-face with limited interaction. For USEC for USEC dads it was good to hear that the Department of Education recognizes a difficult situation and we're so happy to hear that you're now exploring limited opening of classes and by piloting in certain areas and as you said Mayanian is alive in the country because there is a desire for continuity of learning. We have two reactors, we have two of our PPS presidents Dr. Efrem Belamed from Baguio and Dr. Sheldon Paragas from Davao and I'm really happy that they're also working on the registries Baguio with 206 cases and Davao with 823 children with COVID-2 and yes we have to be merged with the Salvation Registry data so that we can get more information and work better on policies. I think the important thing now is hearing from Dr. Gonzales, from Dr. Yusebio, Dr. Sheldon Paragas and Dr. Belamed data is very important so that we can actually come up with better policies that will affect the general population of children so allow me to just end with a couple of shall I say it, food for thought? Well number one, children are not spared from the mental effects of the lockdown. As a matter of fact, we must remember that the impact of the children may be lifelong and despite the desire to prioritize public safety we must consider mental health effects of the lockdown. Mental health must also be given equal priority in planning together with public safety so yes we recognize and appreciate the efforts of all sectors in assisting government in arriving on the decision for the limited opening of classes we look forward to that one. In interspersed in our discussion, we cannot overemphasize the importance of vaccination. We need it and this has been shown in the sharing of nearly from the USA wherein the vaccination rate is high. They have all opened their doors their schools, their malls and their parks. Now this realization this relaxation of the lockdown has improved the mental health status on their end. So in other words here in the Philippines we have to move towards increasing our vaccination rate so that we can actually also relax our rules for lockdown. So maybe at the end as we leave this webinar today let us just remember that the impact of the children may be lifelong and we as a whole as a community, as a society we have to protect the future of our country and as the young our two young reactors today said it will be over soon and we just have to take care of each other at this time. Magandan hapon po sa yung lahat and back to you Susie. Thank you very much. I will never mention Padilla the Chancellor of UP Manila and before we close of course I would also like to thank our two young guests Milly and Patrick and their parents Cecil and Manny for allowing allowing the kids to join us today and I hope Milly and Patrick that this experience will make you stronger advocates for good public health in the future and as you grow up okay so next week don't miss it we have a very exciting webinar is COVID-19 air born or is it spread by aerosol join us next week we've got great presenters we have actually people in engineering who will talk about how particles are suspended in the air what is the current thinking on suspension of viral particles and how COVID-19 is being transmitted so imitahin nyo po I know there are a lot of watch parties in the hospitals not just one person watching but groups please don't miss next week's webinar Raymond over to you Thank you so much Doctor Susie and thank you also for that excellent synthesis next week not just engineers po we also have a physicist who will help us out and also an infectious disease specialist as well as a communications expert po to help us well understand the whole thing how to communicate it to our lay people Gaya po nang nasabi maraming salama po we still have a little over 1110 bees over in our zoom and I'm pretty sure in youtube also in the live streaming pages po of tvup stop COVID-19 deaths and the University of the Philippines makita kita po tayo ulit next week same time same channel Friday's 12 noon to 2pm it's a date together we can stop COVID-19 deaths so keep safe keep healthy and see you online I know you long for home but I am here you're not alone I'll stay with you until the coast is clear the other Spain before my fears the other lives before my tears my pride behind the mask I look into myself and ask do I have strength to carry on oh God our Lord and leave you here to keep me strong I'm here to hold the line I'll keep my way until my time say his name to realize it's fine to be afraid just hold on to the word he gave this time we'll come to pass because this salvation just makes it last you'll carry you to see the break of day the other Spain before my fears the other lives before my tears my pride behind the mask I look into myself and ask do I have strength to carry on oh God our Lord and leave you here to keep me strong I'm here to hold the line I'll keep my way until my time my fears the other lives before my tears my pride behind the mask I look into myself and ask do I have strength to carry on oh God our Lord and leave you here to keep me strong I'm here to hold the line I'll keep my way until my time say