WHY you need (or don’t need) a booster shot (part 1)

Hot topic these last couple weeks is news about the availability of a booster shot against COVID19. Due to some delays and further reviews by the FDA, the availability of these shots is again – confusing. What’s new? In this post (and the next), I will review what is known and currently recommended and run through some scenarios with my recommendations. As always, please make these decisions hand in hand with your healthcare provider. My opinions are my own and not necessarily those of the organizations I work for.

First, a pandemic update (i.e. the stats I find important). Currently in the United States, 80 million people remain unvaccinated. The latest health department data shows a 300-fold risk of hospitalization if you are unvaccinated. That is terrifying. There are some areas of the country that have seemed to peak, i.e. Florida. However, the kids just went back to school last week mostly unmasked, so let’s see how long it takes for the numbers to go back up.

Over 80% of all ICU beds across the country are full. That means, potentially, no room in the inn for your heart attack or COVID infection. I’m hearing stories of families driving from hospital to hospital looking for a bed. In more than 1 out of 4 states (25% of our country), more than 90% of ICU beds are full. That includes mine, Nevada, along with Oregon and Idaho. We are now overflowing into our surrounding states. In Idaho, where the governor is opposed to mask mandates, the state is completely overrun and is now transporting patients out of state for care, stressing neighbors like Spokane, Washington (all story links below).

For most of the vaccinated, there is a feeling of helplessness and now, even anger, building against the unvaccinated. All of the current stress and death could have been avoided if a greater number of our population had done the right thing (as they did with polio and smallpox, for instance). So if we can’t control the unvaccinated filling our hospitals, how do we avoid breakthrough infections? Booster shots? Maybe, and maybe not.

Let’s start with the positive – as of Sept 7, 2021, more than 176 million Americans have been vaccinated (out of a total population of about 330 million). That’s not bad… but not great (and, by the way, not enough to achieve “herd immunity” if you have been waiting for that!). There are many studies currently underway or freshly published that show that the immunity achieved from the current recommended dosing is more than adequate. The vaccinated continue to be protected from severe disease, ICU admission, and death. Yes, breakthrough infection is real, and now feels very common. But if you have had the vaccine and get COVID, you are most likely going to have a crappy couple days or week and then get back to work.

The vaccinated that are actually ending up in the ICU have so far been the very frail or those with underlying serious health conditions. The latest report (link below) shows that 87% of the 2675 reported deaths in vaccinated people were in people > 65 years of age. This isn’t comforting for anyone, but we also understand that with increasing age, comes increasing risk and health issues. 21% of those reported deaths (493 of the 2675) didn’t have COVID symptoms and/or were not due to the actual infection. There have been 665,000 deaths reported due to COVID19 in the United States so far — just to give you a perspective on that 2675 number in vaccinated people.

For most adults, the protection has been reliable. In South Africa, they have now reported some really good news about the one-dose J&J vaccine:  

“ In the trial, called Sisonke, the researchers evaluated one dose of the Johnson & Johnson vaccine in nearly 500,000 health care workers, who are at high risk of Covid-19. The vaccine has an efficacy of up to 95 percent against death from the Delta variant, and up to 71 percent against hospitalization, the researchers reported.”

However, we are also continuing to see evidence of waning immunity over time (though this is also the subject of much discussion/argument!). Because of these concerns, the discussion around boosting immunity with a third (or second) shot started early on. Here are the current recommendations:

  • No booster shot is currently recommended for adolescents or adults with healthy immune systems.
  • For adolescents and adults over the age of 12 years with moderate to severe immune compromise (autoimmune diseases requiring medication, chronic steroid use, cancer patients, etc), a third dose of the Pfizer vaccine is available (announced Aug 12, 2021 through an amendment to the Emergency Use Authorization)
  • For adults over the age of 18 years with severe immune compromise, a third dose of Moderna is available
  • Third shots should be given at least 28 days after the second dose

That’s it. That’s the official word right now (today, September 15, 2021).

Okay, so what qualifies as “immunocompromised”? According to the CDC, people with immune compromise make up about 3% of the population. This population is at risk of getting and dying from COVID19 as their infection-fighting cells don’t work well. This includes:

  • Solid organ transplant patients
  • Patients receiving cancer treatment or chemotherapy for other diseases
  • Patients with inherited or acquired immunodeficiency (DiGeorge Syndrome, HIV)
  • Patients requiring long term steroid treatment or other medications that suppress the immune system

The CDC has reported that many of the breakthrough infections in vaccinated people that have required hospitalization have included many of the people in this category. That’s why we are absolutely recommending vaccination for this group along with a third shot.

For the rest – stay tuned for my next post!

References:

Idaho outbreak: https://www.nytimes.com/2021/09/13/us/coronavirus-hospitals-washington-idaho.html

CDC info on breakthrough cases: https://www.cdc.gov/vaccines/covid-19/health-departments/breakthrough-cases.html

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness/why-measure-effectiveness/breakthrough-cases.html

Unsure if J&J will need booster: https://www.nytimes.com/2021/08/06/science/johnson-delta-vaccine-booster.html

WHY are children getting chest pain after the COVID19 vaccine?

This post is the best summary I can create from the data currently available regarding myocarditis after COVID19 vaccination in children. As with everything COVID, this is preliminary data and may be out of date or completely contradicted with new data within the month. That being said, I would like to present the current data and opinions being published. As always, my opinions are my own, and my conclusion after reading through all currently available information is that teenagers age 12 to 18 years of age should get the 2-dose Pfizer vaccine series.

As previously discussed, the Pfizer/BioNTech vaccine is currently the only series approved through an emergency use authorization (EUA) for teenagers ages 12 to 17 years. Moderna is applying for approval to be given to teens, but their authorization is currently only for age 18 and above. Johnson & Johnson is just beginning trials of their vaccine in children. Full FDA authorization of the Pfizer vaccine was just granted today, but only for teens and adults 16 years and older. Younger teens will still be offered the Pfizer vaccine under the EUA.

Pfizer received its EUA in December 2020 and immunization campaigns quickly took off while they were beginning to study their vaccine in teenagers. On May 10, 2021, they received authorization from the FDA to offer the vaccine to teens age 12 years and over. Soon after, reports of adults and teens presenting for care with chest pain began to hit the media, medical discussion boards, and journals. One of the first large studies in Israel reported 275 cases of myocarditis in 5 million vaccinated people. What was unique about this report was that this adverse effect appeared mostly in men aged 16 to 19 years and occurred mostly after the second dose. A similar report affecting a young, healthy military population soon followed with 23 male patients reporting myocarditis (20 after second vaccine dose) out of a total of 2.8 million doses given to this group. I have included more references below along with a Washington state report from May and updated VAERS reporting (national vaccine side effect reporting). Though these are small numbers, the adverse effect got attention as there have been more people affected than researchers expected.

Most authors speculate that a “hyperimmune” response to the second dose of the vaccine is a plausible cause for the myopericarditis. Symptoms typically occur within 4 days after receiving the second dose of an mRNA vaccine and are almost always mild. For most patients, symptoms resolve within 1-3 days. Many hospitals are now implementing protocols in their emergency rooms to evaluate and arrange for outpatient follow-up for affected patients as we are learning that most of these cases are mild. The DHHS, CDC and other medical organizations recently released a joint statement on myocarditis and pericarditis: 

An exceedingly small number of people will experience myocarditis or pericarditis after vaccination. Importantly, for the young people who do, most cases are mild, and individuals recover often on their own or with minimal treatment. Myocarditis and pericarditis are more common if one gets COVID-19, and the risks to the heart from COVID-19 infection can be more severe.

Back to my opinions. Yes, this is concerning, and as I discussed in previous blogs, myocarditis can be serious. As we learn more about these patients and the reports, there has been some discussion about modifying the vaccine series for young males. This might mean spacing the two shots further apart or decreasing the doses given. As with all good research, this is going to take some time to study and sort out. In the meantime, what I KNOW to be true, is that the heart problems that we are seeing in patients who have active COVID infection are much more serious with a much higher risk of mortality than what is being described after vaccine. Unvaccinated people put everyone around them at risk and are potentially causing others to get sick.

Young men and their parents have a difficult decision to make. Young women also have to consider the risks involved with the Aztra Zeneca and J&J vaccines as we continue to review reports of blood clots in this population after vaccination. It is incredibly important to keep up on the latest news and read as much as you can in order to help you make these decisions.

Almost everything I do in the ICU carries risk. Every day I have to weigh the risks and benefits of a medicine, imaging order, or treatment as I partner with my patients to care for them. Even Tylenol has side effects! It is always important to consider risks in light of the possible benefits to make decisions about care. So far, to date, everything I know about the benefits of getting a COVID vaccine outweighs the risks for MOST people. As always, please discuss your own health and risk factors with your physician in order to help you make the best decision for yourself (and your children).

Teenagers and adults who experience chest pain after COVID19 vaccination should immediately speak with their healthcare provider and/or seek emergent medical care to evaluate. Emergency providers must stay informed about these reports and have a low threshold for considering myocarditis and pericarditis in vaccinated patients.

As always, please send me any questions, comments, or corrections! We are all doing our best to stay on top of the latest information available, and I want to make sure that what I am sharing is relevant and accurate.

Photo credit: Getty Images

References (more always available on request!):

Israeli study: https://www.gov.il/en/departments/news/01062021-03

Military report: https://jamanetwork.com/journals/jamacardiology/fullarticle/2781601?alert=article

Washington State Health Dept: https://www.doh.wa.gov/Newsroom/Articles/ID/2803/Statement-from-Washington-State-Department-of-Health

VAERS reports: Preliminary reports of myocarditis/pericarditis

As of June 11, 2021, the Vaccine Adverse Event Reporting System (VAERS) had received 1226 (0.000038%) preliminary reports of myocarditis and pericarditis after about 300 million doses of the Pfizer and Moderna vaccines. There were 233 (0.006427%) cases of myocarditis or pericarditis after 3,625,574 second doses administered to men aged 18-24. Based on population cohort studies 2 to 25 cases would have been expected.

After 5,237,262 doses administered to women in this age group, 27 (0.000516%) cases were reported; 2 to18 would have been predicted.

A similar pattern of risk was seen in children 12-17 years old. The crude reporting rates of myocarditis or pericarditis decreased with increasing age as did the gender differences.

CDC/HHS statement: https://www.hhs.gov/about/news/2021/06/23/statement-following-cdc-acip-meeting-nations-leading-doctors-nurses-public-health-leaders-benefits-vaccination.html

AAP letter Aug 5: https://downloads.aap.org/DOFA/AAP%20Letter%20to%20FDA%20on%20Timeline%20for%20Authorization%20of%20COVID-19%20Vaccine%20for%20Children_08_05_21.pdf

Schauer J, Buddhe S, Colyer J, Sagiv E, Law Y, Chikkabyrappa SM, Portman MA, Myopericarditis after the Pfizer mRNA COVID-19 Vaccine in Adolescents, The Journal of Pediatrics (2021), doi: https://doi.org/10.1016/j.jpeds.2021.06.083

Long SS, Important insights into myopericarditis following Pfizer mRNA COVID-19 vaccination in adolescents, The Journal of Pediatrics (2021), doi: https://doi.org/10.1016/ j.jpeds.2021.07.057

Understanding the different types of COVID19 vaccine

There is so much confusion, information, and misinformation on the web and in the media that I felt compelled to post a more detailed blog reviewing (for some) and explaining (for others) the basics of the COVID19 vaccines currently available. At the end of this post, I have included some recent news about waning effectiveness and variants.

Current vaccination options for children

As a reminder from my last post, Pfizer is currently the only vaccine approved (for emergency use) in teenagers ages 12 to 17 years. Moderna is applying for approval to be given to teens, but their authorization is currently only for age 18 and above. Pfizer has applied for full FDA authorization for age 16 and up with expected approval within the next month. Similarly, Moderna has applied for full authorization for age 18 and up. Both companies have been conducting trials in younger children as young as 6 months old. The dose being given to younger kids is smaller, so these studies will take longer to determine the minimum effective dose and possible side effects in this population. The latest updates from the Pfizer team state that they hope to apply for emergency use for children age 5 and up by the end of September with results for the youngest age group, down to 6 months of age, released by November.

The Johnson & Johnson (Janssen) vaccines are further behind in their pediatric trials. The J&J vaccine received EUA (emergency use authorization) in February 2021 for adults age 18 and up. They plan to start testing their vaccine “in the fall” in teens 12 to 17 years, and based on those trials, plan to then start further staged testing in children: first age 6 and up, then age 2 to 5, and finally age 0-2. The final study they have planned will involve immunocompromised and high-risk children age 1 to 17 years.

DNA-based vaccines

There are some differences between these vaccines. The J&J vaccine is made of an inactivated virus that carries genetic material — double stranded DNA. The virus used is actually an adenovirus that usually causes cold symptoms. Because it is inactivated, the vaccine made of adenovirus will not cause infection with adenovirus – the capsule is only a carrier for genetic material. Once the vaccine material is injected, the adenovirus carrier gets picked up by cells in the vaccinated person. The DNA carried inside the adenovirus then gives instructions to some of the recipient’s cells to make spike proteins similar to the ones we see on the outside of the COVID19 virus. These spike proteins are then presented to the recipient’s immune system which causes creation of antibodies (memory cells) to target the spike proteins. These antibodies will then recognize the actual COVID19 virus if it enters the vaccinated person’s bloodstream. This will set off an immune response in the vaccinated person that will eliminate the COVID19 virus. I’ve included a reference from the NY Times below that has some great pictures that help explain this process.

This inactivated-viral-DNA-carrying-type vaccine has been around for years and is the same type used by the Aztra Zeneca company in their vaccine. The benefit of a DNA vaccine is that the actual genetic material is fairly durable and so it does not require the same deep freeze as other vaccines. It can be refrigerated for 3 months and still be effective. Another benefit of the J&J vaccine is that is currently being released as one shot (Aztra Zeneca is two shots). A downside to both the J&J and Aztra Zeneca vaccines is that they have both been found to cause blood clots in a small number of mostly women age 14 to 50 years. Because of this, both vaccines now carry warnings and these risks should be discussed with your provider to help determine if this is a safe vaccine for you.

mRNA-based vaccines

The Pfizer and Moderna vaccines are made a bit differently. They do not use an inactivated virus as a carrier. Instead, the vaccines are made up of mRNA, or messenger RNA, wrapped in a coating (not a virus carrier). Messenger RNA is a single strand of genetic material that “teaches” your cells how to make proteins. Once injected into your arm muscle, the mRNA gives your cells instructions to make the spike protein that we see on the COVID19 virus. The mRNA is then destroyed and eliminated from the body. Once those spike proteins are created, the rest of the immune response (creating antibodies) is similar to that caused by the J&J vaccine detailed above. If the vaccinated person is exposed to COVID19, their immune system should recognize the spike proteins on the real virus and protect the vaccinated person from getting symptoms.

A weakness of the mRNA vaccines is that they are considered to be more fragile than the DNA vaccines.  Because of this, the vaccine must be transported and initially stored (unmixed) in an ultra-cold freezer for up to 2 months (or a regular freezer for up to 2 weeks), then a refrigerator for up to a month. Once mixed, the vaccine must be discarded after 6 hours. Though this type of vaccine is new to most of us, it has actually been studied for decades and is being used to develop vaccines for the flu, Zika, and CMV. This technology has also been used to fight specific types of cancer.

After vaccination, your body can take a few weeks to make enough antibody to fight infection. With the mRNA vaccines, you should be fully protected two weeks after your second shot. J&J reports that you should be fully protected two weeks after their one shot. Until that time, you need to be vigilant about protecting yourself and others with masks, hand washing, and social distancing in order to prevent infection. One other detail — the Pfizer injections are given 21 days apart, whereas the Moderna series is given 28 days apart (decision made based on how the injections were initially studied!).

Side effects are more common after the second injection and are only a sign that your immune system is working correctly – some people develop fever, chills and body aches a day after receiving the vaccine, but these symptoms typically resolve within 48 hours.

It is important to note here that the CDC has advised that the Pfizer and Moderna shots are NOT interchangeable. If you received a Pfizer for shot #1, you should receive a Pfizer for shot #2. There have been no studies to date investigating whether you can mix the vaccines. So don’t (!!!).

Effectiveness

Another historical concern with the J&J vaccine is that it is not as effective as the other vaccines in preventing mild to moderate COVID19 disease. In the initial trials submitted to the FDA for EUA, it was reported that the J&J vaccine was 67% effective at preventing disease (with the original alpha strain of COVID19) whereas Pfizer reported 95% effectiveness. Moderna reported about 94% protection.The initial Pfizer trials enrolled over 23,000 people over 12 years of age before they obtained their EUA. Moderna reported use in over 15,000 subjects.

And then there was Delta…

Data about these vaccines continues to be collected. Over time, and with new variants in our environment, the reported effectiveness is falling. In a recent review in Israel, Pfizer was found to only be 64% effective in preventing symptoms with the Delta variant, though still had 94% effectiveness against severe disease. A brand new study being released by the Mayo clinic has been a surprise as they have found in their study population that the Pfizer vaccine may only be 42% effective against the Delta variant. In this review of a Minnesota population, the Moderna vaccine held against Delta with a 76% effectiveness. Pfizer has previously released data that a third (or “booster”) shot may significantly increase immunity, and they are in the process of seeking authorization for this booster program.

I will be reviewing a more concerning side effect of the vaccines, myocarditis, in my next blog, so stay tuned!

References:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html

Latest update on J&J plans for testing children

Great visual of how the J&J vaccine works

Pfizer storage information

Two studies of effectiveness of Pfizer vaccine against Delta variant:

Israeli study in July 2021

New England Journal Aug 2021

Pfizer’s push for booster shots:

NY Times July 28

Hot off the presses from Mayo clinic (though not yet peer reviewed):

https://www.medrxiv.org/content/10.1101/2021.08.06.21261707v1

Photo credit: news-medical.net / Wikipedia

WHY should teens get a COVID19 vaccine?

Fully appreciating that vaccination is a hot topic nationally and internationally, I am writing these next blogs to summarize the latest facts regarding COVID vaccination in children. I believe in vaccination, but the concerns about myocarditis after vaccine in kids are real. I wanted to take some time to summarize what we currently know and help parents and adolescents make their own decisions about this. THIS IS NOT A POLITICAL STATEMENT, and my opinions are my own.

Between March, 2020 and April, 2021, there were approximately 1.5 million cases of COVID-19 reported in children. As you have likely heard, the disease has been milder in most children than in adults, with most experiencing little to no symptoms when infected. There are most likely thousands more children that developed COVID19 antibodies over the past year, but these kids remain uncounted as they either did not have symptoms or were not counted by local health departments. Unfortunately, around 2% of all children becoming infected with COVID19 require hospitalization, and of those, about a third (33%) require the ICU (intensive care unit).

There have been 335 deaths of children aged 0-17 years old related to COVID19 reported through July, 2021. Approximately 77% of children hospitalized with COVID had underlying medical problems, like chronic lung disease, obesity, heart disease, and immune suppression. So, the number of healthy children ending up in the hospital or dying from COVID is EXTREMELY low, but there is a still a possibility of this happening.

More concerning is the syndrome discussed in my last post, MIS-C, which we believe is a hyper-immune response to COVID19 that presents a few weeks after COVID infection or exposure. We think that some children have an amped up response to the virus which results in their own immune systems attacking their own organs. While this is scary, it is also very rare with about 4200 cases and 37 deaths due to MIS-C reported by June, 2021. Again, this is out of the more than 1.5 million cases of COVID19 reported by this time. This works out to about a 0.3% chance of a child getting MIS-C after having been infected with COVID. In a study released by major children’s hospitals in June, 2020 (see reference below), they found an even lower rate of infection with 316 MIS-C cases per 1 million COVID19 infections which equals a 0.03% chance of disease. This rate tends to be higher in children (median age of 9 years) and in Black and Hispanic populations.

There have also been reports of children experiencing “long COVID” or a persistent cough, fatigue, headache, joint pain or other symptoms for weeks after infection. We are seeing reports of up to 15% of all children infected continuing to have these symptoms, though the data collection for long COVID is still very new.

Because of the risks, morbidity and mortality associated with children getting COVID19 infection, healthcare providers and scientists have been working hard to evaluate vaccine safety and effectiveness in children. In December, 2020 the Pfizer vaccine received emergency use approval for children over the age of 16 years. On May 10th, 2021, this emergency use authorization was extended to children over 12 years of age. Pfizer is the only vaccine that currently carries this FDA approval. This was based on data that showed that 7 days after the second dose, the Pfizer vaccine was 95% effective in preventing disease in children.

The FDA authorization reports state that 2,260 teens aged 12 to 15 were followed in the most recent trial with half of these (1,131) receiving the vaccine and the other half receiving a saline placebo (fake shot). The adverse events in this group have been very low and similar to the adult population with no “serious” adverse events reported related to the vaccine. Based on these safety reports, the vaccine was released for use in children over 12 years of age. Trials are ongoing to evaluate vaccine safety (and dose) in younger children with rumors that at some point in this school year, the vaccine may be released to younger children. Note that for all age groups, there is only an FDA “emergency use” authorization. Full FDA approval of these vaccines is expected in the fall of this year.

Any side effects of vaccines can be reported by patients and/or health care providers to the Vaccine Adverse Event Reporting System (VAERS). There are many mild adverse events after vaccine being reported, including anaphylaxis. Currently, VAERS reports that about 1 in 5 million injections has caused mild to severe anaphylaxis (severe allergic response). Because the VAERS system works so well, researchers and the CDC were able to quickly note an increase in blood clots associated with the Johnson & Johnson (“one shot”) vaccine earlier this year and put out guidance and alerts around this (almost all clots were found in women aged 14 to 50 years of age).

One of the signals noted by the VAERS system and providers is concern for children presenting after vaccination with chest pain. My next post will be dedicated to reviewing our current understanding of this concern.  In the meantime, I will offer my opinion as to “Why should teens get a COVID19 vaccine?” – THEY SHOULD. Infection in children can be devastating both to their own health and to those around them. The adverse events reported in children are minimal and much less scary than getting COVID19 itself. We need to get kids back to school, socializing, and safely visiting with their grandparents and family. We have lost so much this year…. We don’t need to lose any more of us.

Please vaccinate your teen. It’s the right thing to do for them and for their community.

Follow my blog, “like” if you like what I’m doing, and please send any questions or comments to me so that I can continue to build on this content!

References:

Payne AB, Gilani Z, Godfred-Cato S, et al. Incidence of Multisystem Inflammatory Syndrome in Children Among US Persons Infected With SARS-CoV-2. JAMA Netw Open. 2021;4(6):e2116420. doi:10.1001/jamanetworkopen.2021.16420

https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html

https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm#SexAndAge

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392074/

https://journals.lww.com/ajnonline/Fulltext/2021/06000/NewsCAP__Growing_concern_about_the_risk_of__long.11.aspx

https://vaers.hhs.gov/data.html

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html

I also love this Nebraska Medicine site which is working to counter misinformation around vaccines:

https://www.nebraskamed.com/COVID/you-asked-we-answered-do-the-covid-19-vaccines-contain-aborted-fetal-cells

Photo credit: gettyimages.com, AAP

WHY is myocarditis making children sick after COVID19 infection?

In my last blog, I discussed a post-COVID19 inflammatory condition being seen in children called MIS-C (Multisystem Inflammatory Syndrome in Children). Full disclosure – this syndrome is also being seen in adults and has now been defined in the over age 21 age group as MIS-A (Adult). MIS-C is a rare complication of COVID19 infection that usually presents 4-6 weeks after COVID19 infection or exposure and causes inflammation of the heart, GI system, skin, lungs, and kidneys. While we still don’t know the cause or risk factors for MIS-C, we do believe that it is likely due to an excessive immune response to the virus (SARS CoV-2) that causes COVID19 infection.

When the inflammatory response attacks the muscle of the heart, it is called myocarditis. Myo = muscle, carditis = heart. We also see pericarditis with viral infections which is inflammation of the covering around the heart: peri = around, like “perimeter”. When the heart muscle becomes inflamed, the muscle can have a more difficult time coordinating the trigger to squeeze and the squeeze itself. This causes weakness of the heart and decreased efficiency of squeezing blood out to the body. When the heart muscle is stressed, a cardiac marker called troponin, will acutely increase. This is a common lab that we collect when patients present with chest pain or concern for cardiac dysfunction, or heart failure. We can follow this lab, or “troponin leak”, to have a general idea (not specific) of whether the function is getting worse or improving. More importantly, an echocardiogram (involving a probe and some gel on the chest) is needed to determine overall heart function and cause. Cardiologists read these “echos” and report back on whether the function is normal or not, and if the muscle (myocardium), a valve, or the lining of the heart (pericardium) is the problem.

Myocarditis, if caught early, can be treated with supportive care, steroids, IV antibodies from other people (IVIG), and other anti-inflammatories depending on the hospital and the severity. If severe on presentation, or unresponsive to treatment, myocarditis can develop into total heart failure, cardiac arrest, and death. Most of the deaths due MIS-C so far are believed to be due to heart failure.

It is impossible to predict at this time which children will get MIS-C and which of those children will go on to develop myocarditis. MIS-C can present as altered mental status, as in encephalitis (inflammation of the brain), vomiting and diarrhea, or skin rashes. We don’t have enough cases, yet, to fully define, but we believe the number of MIS-C patients who develop myocarditis may be quite high. Healthcare providers must understand this and look for it. As the number of Delta-variant COVID19 infections increases, we fully expect to see another surge of MIS-C cases one to two months later in each community that sees a spike of adult infections. We must be diligent and aware in order to prevent any further mortality in children!

In my next blog in this series, I will be reviewing what we know about myocarditis in children after receiving a COVID19 vaccine. Follow my blog and leave any comments or questions below!

Image Credit: Kateryna Kon / Shutterstock.com

WHY do kids get sick a month after getting COVID19?

COVID-19 and all of the questions around mask mandates, vaccines, treatments and variants has caused immense confusion, distrust, and even anger. Though it has become absolutely obvious to most of us that COVID is spread by droplets, prevented by masks, and significantly decreased by vaccines, there is still misinformation and fear throughout the social media cosmos. As if all of that wasn’t enough, the nasty virus then morphs itself into new variants and causes later side effects that none of us were ready for.

I completely appreciate the confusion and the questions. We have many of the answers now, but we continue to learn more as the population affected grows and real research (randomized controlled studies, etc) can finally be done to get more answers. You can’t do a study on ten people (usually) – it’s always better to have hundreds, thousands, or millions to weed out the random effects and confounders and come to significant conclusions.

I’m focused on this today because of rare later effect of COVID19 that we have discovered and are diligently trying to define and describe. Because of all the incredible databases and hospital reporting that were rapidly deployed during this pandemic, scientists began to note “signals” – symptoms and side effects reported to these databases that did not fit the common pattern seen in the typical patient infected with COVID19. One of the biggest signals was noted last year in children.

The reports caught attention early on because:

  1. The symptoms were occurring in children (who were initially considered to be “immune” from COVID19)
  2. Illness was reported 4-6 weeks after suspected or confirmed COVID exposure
  3. Most of these children never had symptoms with the acute COVID infection that made their adult contacts sick
  4. The symptoms were often not respiratory, but instead GI (gastrointestinal), neurologic, and cardiac

With further investigation and awareness, we soon found and described a syndrome in children that we now call “MIS-C”, or Multisystem Inflammatory Syndrome in Children. Until we got our arms around this new disease, many children died or were left with severe disabilities due to MIS-C. By rapidly sharing and distributing information, pediatric providers quickly began trialing treatments and were able to improve outcomes for kids with MIS-C. The mortality for this disease has now dropped close to zero.

MIS-C is still under investigation, as with everything pediatric, there are many barriers to doing research on children and the numbers involved are very small. The initial reports out of England in March of 2020 involved 23 children. Then in New York, between April and May 2020, another 15 children were described. The numbers and investigation capabilities have continued to increase. According to the CDC, as of June 28, 2021 there have been 4196 reported MIS-C cases and 37 deaths. We still do not understand why some children develop this syndrome while millions of others do not. The regions with the highest reported numbers of MIS-C mirror the number of cases of COVID19 (figure from CDC website, link).

We know from our current research that the median age for MIS-C is 9 years, and half of the cases occur in children between the ages of 5 and 13 years. 99% of these patients had a positive test for SARS CoV-2 (the virus that causes COVID19), and the other 1% had an exposure to someone with COVID19 infection. 60% of the cases have been male, and 62% of the cases have occurred in children who are Hispanic, Latino, or Black. There have most likely been hundreds of other cases, but they were either not reported or missed due to milder symptoms.

The number of MIS-C cases dropped rapidly after the first surge of COVID19, but are now being seen in an increasing number with the rise of the Delta variant across the world. As I mentioned before, we cannot do good research on a small number of patients, but with thousands now affected, and good scientists working hard to answer the questions, we will hopefully gain a greater understanding of this disease over the next year.

As pediatricians and scientists, our goal is NOT to spread misinformation, but instead to prevent death and injury to children.

If you would like to learn more about MIS-C, start with the CDC definitions: https://www.cdc.gov/mis/about.html

One of the most serious side effects of MIS-C is myocarditis, which is inflammation of the muscle of the heart. I will be discussing this more along with vaccine side effects in my next post, so follow me and send me any requests for more or comments!

A lot of Peloton, and a little bit of “Eco”

Please tolerate my shift from medical topics to work-life balance (usually imbalance) for my musings today. This week, I have been fortunate enough to finally go on a real vacation – a big vacation – to Croatia. Some friends of mine have been wanting to do this for over a year now. It has been a very long, stressful year, so we’ve all been looking for something to heal our souls. As Croatia was one of the few countries that remained “open” through most of the pandemic, we realized that this could be a reality if we all had our vaccines and jumped through lots of paperwork hoops. I honestly cannot believe that the stars aligned, the plane landed, and this country welcomed us with open arms.

The tour we picked is a bike-sail adventure through the islands of South Dalmatia, just across the pond from Italy and Greece. So far, we have had the opportunity to visit and eat the gelato of: Trogir, Hvar, Vis, Korčula, Solta, and Split. We have biked up and down mountains, jumped into the ocean on “swim stops”, stuffed ourselves with fish and salads, and rafted down a mountain river. I have stepped out of my comfort zone many times so far – jumping off a cliff (a short one), diving into freezing ocean water, and eating new foods (still not an octopus fan). Our ship, the Melody, is gorgeous – a beautiful yacht with about 16 rooms and a crew of seven. Our three guides have been friendly, inspiring, and attentive.

I love biking, but I always struggle with the climb. My road bike, a Scott Contessa, and I are pretty well bonded as I have put her through sprint triathlons, hot humid rides in Florida, and serious climbs around Lake Tahoe. She has been modified to transition from the flat roads of Fort Lauderdale to the hills of Mt Rose by adding gears and a new derailleur. Over the last twelve years, I have changed her countless flat tires, oiled up her chain, and added electronics to track my efforts. Despite the new gears, I continue to struggle on the hills almost having panic attacks when the road continues to rise without a break in sight.

I added a Peloton to my life when I moved to Reno as I was concerned about even leaving my home on a bike and the hill that would be encountered to get back to my garage. I have worked out with Cody, Emma, and Alex in my living room to improve my sprints and my climbs. I know my heart and my legs are strong (beyond grateful for this), but I continue to panic when friends want to take me out and over the big hills.

My bike and I may be at a turning point now. These wonderful guides (www.islandhopping.com) handed me an e-bike on my arrival. I don’t think I want to give it back! I have been worried about “turning to the dark side” as I believe that exercise is so important for both physical and emotional health. I’ve had a moped before – I worried an e-bike would defeat the whole point of putting on bike shorts. I WAS 100% WRONG. It’s fabulous!!! You still have a variety of gears to target, you still need to shift down when you approach your hill, and you still need to be proficient in steering and the rules of the road. But when you need a little help… when that panic starts to kick in… you can turn on the power and push through.

My bike has a few new settings: Off, Eco, Tour, Sport, and Turbo. I’m finding that once you get over about 16 mph, the boost no longer helps – you are on your own to ride as fast as you can. But when you are climbing and your speed begins to drop – 10 mph…7 mph… 4 mph… before you fall off, you can give yourself a little boost. Powering up a hill even at 10 to 15 mph is an incredible feeling. No more panic attacks. I’m enjoying the ride and even looking around at the scenery.

I’m still pushing and pedaling to ride near the front of my pack, or our “Peloton” as the guide calls us. All of that training with my stationary bike friends has absolutely made me stronger. But a little bit of Eco is sure going a long way. The lingering feeling is there in my heart that I am cheating – cheating myself out of the massive pushes and cheating on my road bike. But I am having an incredible time! So, I think I’ll get over it soon.

WHY is there soda in that baby bottle???

My first job after pediatric training was in a Federally Qualified Health Center (FQHC) in Texas. I had taken a primary care scholarship from the government to help minimize my student loans, and this was my opportunity to pay back this debt. The clinic served a very underserved population in south San Antonio. Most of my patients and their families were Spanish-speaking only. Unfortunately, I had chosen to take French in high school. For that and so many other reasons, this was one of the most challenging jobs I have ever had, but it was also one of the most rewarding.

Though I had been prepared to do pediatric physicals, treat common medical problems, and give incredible advice (?!?) in residency, I was not prepared for the social-emotional component of having to earn trust and build relationships with families. For most of my first year, I was treated like an outsider and stranger. With and without an interpreter, I felt fairly disconnected to my patients as I tried to tell them what to do, how to raise their kids, how to take “dos pastillas par la boca dos veces al dia”. They smiled at me, nodded quietly, sometimes shook my hand, and sometimes came back. That was likely only because, for most of them, I was their only option.

Early in my first year, I vividly remember a young mother coming in with her toddler. The kid was walking, saying a few words, and seemed happy and very bonded to his mother—somewhere between one and two years of age. But he was carrying a bottle. A bottle filled with a bright red liquid. And he was carrying a bag. A bag of Cheetos. I was horrified.

I was not unfamiliar with this diet after my three years of pediatric training. I knew that the red stuff was a sugary sweet strawberry soda called “Big Red” that was very popular in the South. There were so many things wrong with this picture. I immediately jumped in: “Why is there soda in that bottle?”  “Why is he still using a bottle?”  “Why are you letting him eat Cheetos???” “Do you realize that this is going to rot his teeth?”.  I was questioning and judging harshly as this young mother just looked at me very quietly. I don’t remember why she was there with her child, but I do remember quickly understanding that I had lost her. She had brought her child to see me – she was likely worried about something or needed help. And instead of being a helper, I was being mean.

She was probably twenty years old. I think that she spoke enough English to understand what I was saying, but she had nothing to say to me. Sometimes, the answers are harder than the questions. Instead of talking to her and asking what I could do to help, I had immediately attacked her and made her feel like a bad mom. I will never forgive myself for that. I don’t remember if she ever came back.

Everyone has a story, and most people will engage if you ask them questions and extend a helping hand. I totally screwed up that visit by starting with my agenda. I was young and dumb enough to think that my job was to fix everything and tell parents what they could do better. What I did not understand then was that my job was actually to comfort, heal, and gently guide. It took me years of practice and feedback from my coworkers and my families to begin to understand that, and it has taken me an entire career to get a little closer to doing that well.

In the ICU, it doesn’t help anyone to make a parent feel guilty or responsible for what is happening to their child. Instead, the opposite is what helps to build a relationship. Letting a terrified mom or dad know that this is not their fault, that sometimes life happens, that sometimes… bad things happen to kids – that is my job. I look them in the eye, ask questions, attempt to figure out what is going on, try to give them answers —  and then let them know that I am going to be there to help them get through it. Then we partner and do our best.

Sometimes the answers are harder than the questions.

WHY is texting and driving so dangerous?

Admit it. You’ve done it. I’ve done it. You might not do it very often, or you might be a chronic offender, but either way, know that you have put yourself and others in harm’s way every time you do it. I’m absolutely preaching, but I’m also working through the challenges myself.

We are all important. We all have important tasks and people who need to contact us all of the time. My phone might as well be super glued to my palm. When I have a moment that I look around and don’t immediately see my phone, I panic. This is pathologic. But this is where our society, culture, jobs, and families have driven us to. As an old person, I will say, this is our new normal. For our kids, this is the way it has always been.

The complicating factor is that we have also become a car-focused, commuting culture. Many of us spend hours of our day in our cars. I remember living in New York City and being able to function and thrive without a car. I didn’t realize at the time how great that was! For most of us, unfortunately, our cars are a necessity – to drive ourselves, our kids, and our pets to all of the places that we need to go for life to continue.

We forget this sometimes as our brains program common routes and allow us to drive places without much thought, but driving actually requires acute observation skills in order to stay out of trouble and keep those around us safe. The moment that we add in non-driving activities (adjusting the radio, putting on mascara, unwrapping a hamburger) we become distracted drivers. Add in a cell phone with its notifications, calls, texts, tweets, and emails, and we are no longer paying enough attention to the road enough to stay out of trouble.

The teen brain is not fully mature. For many, full abstract thinking does not develop until their early 20s (no matter how smart they think they are). Research has shown that teens are less able than mature adults to focus on more than one thing at a time. Add into this deficit the fact that they are new drivers and still mastering all of the subtleties, challenges, and rules around driving. A new driver must be vigilant and focused on their environment. We know that you are more likely to get into an accident during your first two years of driving than at any other time in your life.

I will say to you that if you haven’t been in an accident (yet) while attending to your cell phone, you are LUCKY. You are LUCKY—not amazingly competent and a pro-multi-tasker! Managing your phone traffic while driving in traffic is not a skill you should be proud of! You have been LUCKY, but your luck will run out. The data around motor vehicle accidents and cell phone use is getting more and more terrifying by the day.

The National Safety Council reports that cell phone use leads to 1.6 million crashes per year. 3142 people were killed in 2019 due to distracted driving. Twenty-one percent (21%) of teen fatalities while driving were due to cell phone use. One fourth of teens report responding to at least one text message every time they drive. 202 teens were killed in 2018 due to cell phone use. 1 out of 4 accidents in America are caused by cell phone use.

https://www.nhtsa.gov/risky-driving/distracted-driving

Is it worth it to risk being a distracted driver? Is anything dinging on your phone that important? You must answer that question for yourself. As I noted at the start, I am just as guilty as everyone reading this. What changed for me over the last few years is that I realized that I usually have an audience in my car. I have two little girls who watch everything I do and imprint all of my behaviors in their own protoplasm. I became acutely aware that not only was I teaching them to be distracted drivers, but I also was promoting this behavior and teaching them how to do it. More and more, I started putting my phone away while I drove – in the glove compartment, in my briefcase, on the floor. I have personally found that the further away from my reach, the better. That phone is an addiction – it calls to us (literally). We must figure out how to create a little distance when other things (my kids’ lives) are more important.

I am proud to say that my youngest will now shriek at me and grab my phone away when she notices me going for it while driving. Both of my girls now have their own cars and their own phones. I hope that I have at least created an awareness that distracted driving is dangerous. My girls will now also have to answer the question for themselves:

Is it worth it?

Picture credit: CarSurance

WHY are we worried about winter viruses in the summer?

Every winter, children’s hospitals across the country fill with babies and toddlers fighting respiratory viruses. Most of these viruses also infect adults, but due to our built-up immunity, big noses, and nostrils, we can blow out our mucus and fight the infections. Small babies have tiny nasal passages, so any virus that causes the mucus to collect can completely block their ability to breathe. Most babies up to around 3 or 4 months of age actually rely completely on their noses to breathe. They have not developed the reflex that allows them to breathe through their mouth. This does allow them to feed well from their moms or a bottle while maintaining an open nose, but a virus can quickly make this more difficult. Babies are admitted to the hospital to help them get more oxygen and to help them maintain hydration and nutrition while they are unable to coordinate feeding and breathing.

In the wintertime, most of us come indoors and have more direct close contact with each other allowing viruses to rapidly be transmitted from person to person. Many viruses also tend to prefer cold weather as they have a gel coating that breaks down in warm weather. Because of this, most viruses have a “season”. Flu shots are given out in September and October (in the Northern Hemisphere) as “the flu”, the influenza virus, hits its peak between December and February. The flu shot does not protect us against other common winter viruses, like rhinovirus (the “common cold”), enterovirus, adenovirus, and coronavirus (a common pre-COVID19 strain). There are currently no vaccines available for these viruses, though this might change soon due to the work being done on the COVID19 strain.

One of the most common viruses that brings babies into the hospital is RSV, or respiratory syncytial virus. Most of us were exposed to RSV by the time we were two years of age, though as immunity wanes over time, we can get it again when we are older. For infants, RSV infections make up more than 30% of respiratory illness with over 50,000 babies being admitted nationally every year and 100-500 infant deaths. It causes blockage of the nasal passages, decrease in oxygen levels, and decreased feeding. The virus is especially hard on premature babies, babies under 6 months of age, babies with heart or lung conditions, and babies with weakened immune systems. We currently do not have an effective treatment for RSV other than saline suctioning of the nose to keep it open, and respiratory devices to help the baby breathe. There is a monoclonal antibody injection, Synagis (palivizumab), available for very premature babies that is given as a shot every month during the respiratory season. Synagis has been very effective at preventing hospitalizations for our most vulnerable population. More information here: https://www.synagis.com/rsv-resources.html

As with everything else this year, all bets are off when it comes to understanding respiratory viruses in 2021. During our winter, 2020-2021, we were all wearing masks, washing our hands, and keeping our distance. RSV is usually spread through a cough in droplets, but it can also land on surfaces and survive for hours. This is why it can be spread so easily to children. Because of all of our precautions this past year, RSV was almost nonexistent! In my Nevada hospital, we had ZERO RSV admissions between November and March. Normally, our unit and floor are full with RSV babies during this time. Then, in April 2021, our county reported its first case. The numbers have slowly grown, and in June we were already up to 40+ cases.

The concern this year is that the virus is causing more severe symptoms and affecting even younger babies than usual. We had a warning that this might happen when Australia reported a bizarre peak in RSV infections a few months ago during their summer (Southern Hemisphere = our winter). The CDC recently reported:

“Due to reduced circulation of RSV during the winter months of 2020–2021, older infants and toddlers might now be at increased risk of severe RSV-associated illness since they have likely not had typical levels of exposure to RSV during the past 15 months.”

The graph below depicts this off-season rise in infections across the country in 2020-2021 (source: National Center for Immunization and Respiratory Diseases (NCIRD)Division of Viral Diseases).

The message is this: be careful this summer if you have small children! Keep washing your hands, keep your distance from people with colds, and keep your babies’ noses clear. If you are worried that your baby is not feeding well, if they are having a funny breathing pattern or breathing fast, or if they get a fever, please bring them in to be checked. This summer, they may be at risk of getting a winter virus!

I had the opportunity to be interviewed by the Wall Street Journal this month. Along with other national experts, we shared this information with the public:

https://www.wsj.com/articles/another-respiratory-virus-is-spreading-as-u-s-gets-back-to-pre-covid-19-life-11625140800

Photo credit: Getty Images