WHY the masks are going back on

It’s back, people. It slipped in when we had our guard down. We had a good run there of feeling like life was getting back to normal. We have been out and around, flying without masks, gathering at parties, going to concerts. Most of us are vaccinated now, even boosted once or twice. The fear of the vaccine has decreased as more and more people miraculously survive the shot (it’s safe, really!). We are less nervous to be around strangers as it is now more likely they are vaccinated. Additionally, many of us have had Covid19 this year (2022), so we have embraced our natural immunity. But guess what? It turns out BA.5 doesn’t care. It is taking us down.

The latest Covid19 Omicron strain, BA.5, was discovered in South Africa earlier this year. Spreading faster than the speed of light, it is now the most prevalent strain in the U.S. just a month after gracing our shores. Mayo Clinic just called it “hypercontagious”. Confirming our suspicions, a new study published in Nature this week (see all refs below) found that BA.5 is four times more resistant to our current vaccines than any other previous strain. These variants are different due to mutations in the spike proteins which make it more difficult for the antibodies (that many of us carry against Covid19) to neutralize (stop) the virus.

It’s still worse for the unvaccinated. According to Dr Gregory Polland, head of Mayo Clinic’s Vaccine Research Group:

“… among the unvaccinated with this variant, they’re about fivefold more likely to get infected than people who have been vaccinated and boosted, about 7½ times more likely to be hospitalized, and about 14 to 15 times more likely to die if they get infected.”

Dr Poland also notes that even though vaccinated people are more likely to get mild to moderate symptoms from BA.5, they are still well protected against hospitalization. As before, even with vaccination, there are still high risk populations who have a really hard time with this virus and may quickly develop severe symptoms. Hospitalizations are up 23% just in the past week and have doubled since May. There are still people dying every day in our country due to Covid19, though not at the same rate we saw with previous variants. We always see cases peak, then hospitalizations, then deaths. We don’t know, yet, what the impact of BA.5 will be. (See Florida reference below–they have had BA.5 for a while and are now seeing an increase in deaths). The other challenging part of recent statistics is that so many people are doing home tests. A positive home test doesn’t show up in the local and national numbers. This means that we actually have no idea what the current rate of infection is — it might be much higher than we think.

The best way to prevent getting sick at all is to put a mask on. In my hospital, masks are still required in all hallways and clinical (patient) areas– we never stopped wearing them. Based on CDC guidelines, however, I did stop wearing my mask out in public. Of course, as soon as I went on my first trip without a mask (a dude ranch in Arizona!), I came home with Omicron. I thought I would be safe after vaccination and a booster, but I was very wrong. Since then, I have even had a second booster — about 90 days after my infection. I’m disappointed to hear that BA.5 might still get me despite all of that!

CDC guidance has been confusing and has changed so many times that many people have given up trying to follow the current guidelines.

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If you are one of those people, then let me get you up to date with the current recommendations. Instead of putting the whole country on lockdown at once, the CDC has now officially recognized that different areas of the country are seeing surges in infection at different times. Because of this, they now have an easy tool and traffic light warning system for people to follow depending on where they live.

As an example, I live in Washoe County in the state of Nevada. I can go to the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html

I pick “Nevada” on their drop down menu, then “Washoe County”, and I currently find this:

On the same website, you can see the three levels of recommendation which are determined by evaluating the number of Covid cases being reported to the local county health department, the number of local hospital beds being used, and the number of hospital admissions. These are the current traffic lights depending on the level of activity in your county:

It’s a good idea to check this website before you travel. I might be more comfortable walking into a restaurant without a mask in a town that is “green” then in my current neighborhood.

My last thought today – this is HARD. We’ve had our masks off in Washoe County for a long time. Now, I’m putting it back on to go to Walmart or waiting at the airport. I had Covid in February, and it kicked my ass. I really don’t want it again. There are many cases of people who had Covid in March and April getting BA.5 now and getting just as sick as the first time around. I repeat, I don’t want it again. So, I put on my mask and dust off my bottles of hand sanitizer to carry around again. I don’t need anyone else to tell me to do this. I can see the writing on the wall.

I also do this so that I don’t get my elderly parents sick or anyone else around me that might not have the nice immune system that I have. We know that we can spread Covid a day before we even get symptoms. I feel like it is inevitable at this point to get Covid every once in a while, but I don’t want to be responsible for getting someone else really sick. I will wear my mask again.

Please “like” or comment with any questions or concerns. Share with others who need all of this info summarized every once in a while! Let me know what you would like to hear more about, and I will do my best to post about it. Thanks for reading and for all of your support!

References:

Wang, Q., Guo, Y., Iketani, S. et al. Antibody evasion by SARS-CoV-2 Omicron subvariants BA.2.12.1, BA.4, & BA.5. Nature (2022).

https://www.nature.com/articles/s41586-022-05053-w

https://newsnetwork.mayoclinic.org/discussion/what-you-need-to-know-about-the-ba-5-omicron-variant/

https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html

https://www.cnbc.com/2022/07/12/covid-hospitalizations-have-doubled-since-may-as-omicron-bapoint5-sweeps-us-but-deaths-remain-low.html

https://www.floridatoday.com/story/news/local/2022/07/16/brevard-county-florida-covid-deaths-hospitalizations-increase/10027275002/

WHY do some people get long COVID?

As if it isn’t bad enough to get sick with COVID (caused by the SARS-CoV-2 virus) and have to take a few days off work or school, more and more people are reporting ongoing symptoms lasting for weeks and even months. These symptoms can range from body aches to fatigue, chronic cough, “brain fog”, loss of taste and smell, and heart problems. This is being called “long Covid” in the press, or post-acute sequelae of Covid (PASC) by physicians. With the big volume surge of Omicron, I am predicting that more people will be diagnosed with long Covid in the next couple months.

First of all, if this is happening to you right now — YOU ARE NOT CRAZY! Many of these symptoms are noted in other autoimmune and poorly researched diseases like chronic fatigue syndrome, fibromyalgia, and POTS (postural orthostatic tachycardia syndrome). Many of us in medicine have been skeptical of these diseases in recent years, but I am ready to stand corrected. Something about the Covid virus seems to be setting off our own immune systems and causing many inflammatory and autoimmune-type diseases. As I have said before – it’s not always the cancer that kills you, but often the chemo. Same with Covid – it’s not always the virus, but instead, your body’s reaction to it, that makes you sick. Yes – that means that in the end, the cancer and the Covid started everything. But some of us respond differently to the initial insult than others. Some reports state that 10-30% of people who get infected with Covid will experience chronic symptoms. This equates to about 15 million people in the US and even more globally. The average age of these patients, according to the CDC, is 40 years old.

So why do some of us get so sick while others just get a runny nose? Researchers are currently scrambling to figure this out. Hot off the presses this week is a study published in the journal, Cell (all references below), that is proposing that there may be four factors that put some people more at risk for long Covid than others:

1. Having type 2 diabetes
2. Having EBV (Epstein Barr Virus – causes “mono”) in your system – either a recent infection or reactivated one when you are sick with Covid
3. Having a high viral load at time of Covid diagnosis – most of us just test positive or negative, but labs can determine your “viral load” on a PCR test, if requested
4. Having a strong autoantibody response to Covid infection – the strongest factor of all of these

Obviously, there is nothing that you can control about any of these things. It is what it is. If you have type 2 diabetes, or have a family history of autoimmune disease, you may be more at risk for more chronic symptoms. What is interesting about this study is the new understanding that if you have a patient with this underlying risk factor, and you then make the effort to measure their viral load at time of diagnosis, then you may be able to recognize an “at risk” patient. Or maybe we need to measure everyone’s viral load (not just those with autoimmune disease) and their autoantibody levels to determine if they are “at risk”.

The next research question could then be: what if your “at risk” patient was then able to receive additional therapies to decrease their risk of chronic infection? We have yet to do the outcomes research (study of the data) on this, but I can only imagine the impact that long Covid is having on individuals, their families, the companies they work for, and the national economy. As of this month, over 100 million people worldwide and over 15 million in the US have been reported with and are being followed or treated for long Covid. This number likely underestimates the actual number as not everyone is seeking care for their symptoms. 15 million people who are previously young and healthy suddenly having symptoms that disrupt their ability to work or care for their families is a devastating blow to our workplaces and households. The financial impact of this must be compared to the cost of lab testing of patients at time of diagnosis and providing them with novel therapies. My guess is that we could save a lot of money at the local and national level by determining and treating “at risk” patients.

Of course, the treatment of long Covid is still being researched and trialed. There are teams treating long Covid patients with everything from vitamin supplements to Covid vaccines to monoclonal antibodies. There has been some research that shows that with or without treatment, long Covid symptoms are improving after three to four months. Other studies show a much longer duration of disability.

Per the CDC: As of July 2021, “long COVID,” also known as post-COVID conditions, can be considered a disability under the Americans with Disabilities Act (ADA). Learn more: https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html#footnote10_0ac8mdc

References:

https://www.cell.com/cell/fulltext/S0092-8674(22)00072-1

Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in adults at 6 months after COVID-19 infection. JAMA Netw Open 2021;4(2):e210830-e210830

https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

New journal on PASC: https://www.medrxiv.org/content/10.1101/2021.11.15.21266377v1.full.pdf

https://www.webmd.com/lung/news/20211118/millions-worldwide-long-covid-study

WHY is Omicron an issue for kids?

With so much information coming out every day, I have started this blog multiple times and had to immediately give up as something new hit my Twitter feed. I don’t believe that there is any reason for me at this point to educate about Omicron as so much has been posted and argued over already. Instead, today, I would like to summarize a couple of my own opinions and important facts, and leave you with a list of media reports that can help to answer specific questions. I have been grateful to be interviewed for many of these — grateful for the opportunity to share important information and hopefully help parents, schools, and physicians make good decisions for our kids.

First of all… this is what I know:

— Omicron is much more contagious than previous strains, so masks are even more important to protect you as you walk by strangers inside or outside.

— Omicron is a big problem for two specific populations: hospitals (due to the sheer volume of infections) and the un/undervaccinated.

— Omicron is getting into our bodies differently and causing a different type of infection than previous strains. Delta went directly to your lungs and caused a “pneumonitis”, or inflammation of the lungs that was difficult to treat. Patients experienced respiratory failure and often ended up on ventilators. Omicron is causing some upper airway inflammation — this means, congestion, sore throat, slight cough, maybe headache and body aches. Even for those of us that are vaccinated, we can experience many of these symptoms, but we are protected from severe disease and hospitalization. The unvaccinated and undervaccinated are still at risk for severe disease — mostly the high risk immunocompromised and elderly population.

— The first two vaccinations appear to offer some protection, but people who have had a third (“booster”) shot have the best protection against severe disease.

— Even though the sheer numbers of children testing positive for SARS-CoV2 is much higher with Omicron than previous strains, kids continue to fare better than their adult counterparts. Yes, there are more kids being hospitalized. Yes, some of these kids are even ending up in the ICU. Many of these kids, however, are coming into the hospital for different reasons (wintertime is always busy in the PICU) but end up testing positive for COVID. Most of us in the PICU are not seeing the high numbers of acute illness that we were worried about.

— I believe that keeping our children in school is absolutely crucial to their academic potential and emotional health. This pandemic has been unprecedented in the damage it has done to our school age kids — from preschool through college. We are already seeing standardized testing scores fall and mental health admissions surge. Our children deserve to be the focus of ongoing intervention, funding and protection. Otherwise, this will truly be a “lost generation”.

— Each district and school will need to make individual decisions based on support available from their state, county, and community. County supervisors and principals will need to make decisions for their schools based on testing available, space available, and staff available to carry out local mandates. There are school districts who have prioritized aggressive testing (i.e. LA County, SF) and have had very low levels of positivity and almost no school closures or virtual classes required. There are other counties, like mine, who are doing their best but do not have the resources to routinely test. These schools have been more likely to see higher numbers of infections and have more often had to transition to virtual learning.

— The pediatric COVID vaccine is safe. Millions of children have received the vaccine with incredibly low reports of side effects with the lower dose given. However, only 17% of children 5 – 11 years old have been vaccinated nationally (14% in my area, Washoe County). If we can support and educate and promote pediatric vaccination, then schools will stop being a focus of controversy and instead return to centers of learning and socialization. Kids will be able to take their masks off and be kids together again.

— Politicians and political parties have created a black and white spectrum of truth and lies with both sides exaggerating at times to make their points. The truth is usually in the gray. Educate yourself and listen to the science. Ask a doctor, if you know one, to answer your questions. If you don’t know one, feel free to ask me! I will continue to do my best to post the latest science and research in the most unbiased way that I can.

Those are my thoughts today.

I offer more information through these recent media stories:

Good Morning America — I was interviewed by reporter Katie Kendelan about isolation and quarantine for kids with COVID infection or symptoms, Jan 14, 2022: https://www.goodmorningamerica.com/wellness/story/pediatricians-answer-parents-questions-covid-19-isolation-testing-82250739

Low rates of vaccination in kids, Jan 12, 2022, PBS news: https://www.pbs.org/newshour/nation/covid-19-rates-for-children-are-low-experts-say-parents-are-taking-an-enormous-risk

Healthline, Jan 6, 2022 — Julia Ries (@namesjules) on how Omicron is affecting kids:

https://www.healthline.com/health-news/heres-what-experts-are-seeing-in-kids-during-the-omicron-wave?utm_content=193732269&utm_medium=social&utm_source=linkedin&hss_channel=lcp-19688

From Asher Lehrer-Small (@small_asher) in the 74 (@The74) on school issues: https://www.the74million.org/ask-the-doctor-navigating-the-new-math-of-omicron-in-schools/

Medpage today, Jan 12, 2022 — excellent interview with Dr Paul Offit (CHOP, Peds ID) by Emily Hutto (@EmAndEdits): https://www.medpagetoday.com/publichealthpolicy/healthpolicy/96635

Official updates to CDC guidelines on when to isolate and quarantine, Jan 13, 2022:

Click to access 011322_slides.pdf

Parents magazine, Dec 2021 — What Parents need to know about Omicron by Nicole Harris:

https://www.parents.com/health/what-parents-need-to-know-about-the-omicron-variant/?utm_content=190367313&utm_medium=social&utm_source=linkedin&hss_channel=lcp-19688

Side effects of Covid vaccine for kids in VeryWell Family, Nov 2021 by Wendy Wisner (@WendyWisner): https://www.verywellfamily.com/what-are-the-side-effects-of-the-kids-covid-vaccine-5209790

References:

https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html

https://www.theatlantic.com/health/archive/2022/01/should-teens-get-booster-omicron/621222/

https://www.reuters.com/business/healthcare-pharmaceuticals/jj-booster-85-effective-against-omicron-1-2-months-safrican-study-2022-01-14/

https://www.medicalnewstoday.com/articles/covid-19-mrna-booster-vaccine-offers-best-protection-against-omicron

https://www.nytimes.com/2021/12/28/health/omicron-kids-hospitalizations.html

https://www.usatoday.com/story/news/health/2022/01/13/hospital-bed-shortages-covid/9176531002/?gnt-cfr=1

https://www.npr.org/2022/01/03/1069907437/officials-are-determined-to-keep-schools-open-despite-omicron

Picture credit: https://acs-h.assetsadobe.com/is/image//content/dam/cen/99/44/WEB/09944-leadcon-variant-new.jpg/?$responsive$&wid=700&qlt=90,0&resMode=sharp2

WHY are so many people afraid of the COVID19 vaccine?

As millions of people across the world are gaining access to and choosing to receive the COVID19 vaccine, I remain hopeful that at some point soon, we will be able to dial back many of the lockdowns and social restrictions that remain in place due to our fear of infection. This fear is real – over 770,000 people in the US have died due to COVID19 infection, and we know that many more died of other causes likely exacerbated by recent infection. This number is the same as the entire population of Northern Nevada (outside of Las Vegas). Every one of those who have died left behind family and friends. Many were elderly and frail, but many were young and healthy, and some were children.

For those of us who have lost, or have been around the losses, the rapid development of a vaccine nine months after initial reports of infection in the US was an absolute miracle. Or at least, incredibly impressive. Many of us in healthcare were the first in line to get the vaccine – I received mine on December 19, 2020. For all of us that chose the jab, the benefits of this new vaccine outweighed the risks of the vaccine and the risks of not being protected. Of course we were concerned – a new vaccine, what was mRNA doing in our bodies?, stories of fever and even allergic reactions – it was all scary. But what we were doing and taking care of in the hospital every day was even scarier. It was a leap of faith, but I chose to trust science and trust the vaccine. As millions of people have now received COVID19 vaccines (over 200 million in the US alone), we continue to learn more about it. For those of us in healthcare, this data has been reassuring. The vaccine is just as safe, or safer, than any of the other vaccines, medications, or therapies that we dispense daily.

Yet, there are still millions of people who are choosing not to get the vaccine. I have chosen to try to understand what the concerns are in an effort to provide facts and education around those fears. Initially, many people felt like this was a political divide. I no longer feel that way as I know intelligent people on both edges of the political spectrum who have decided not to vaccinate. When I ask why, the answers are usually based in fears – fears about the ingredients, the side effects, the long-term effects, and fears around personal health issues. This I can understand. I face these fears every day as I take care of individual patients with lots of questions about their medicines, chemotherapy, antibiotics, radiation, etc. So today, I would like to address some of these fears. Here are some of the concerns:

Medical Reasons. First of all, there is a very small population of people who should not get the shot. Yes, I said that. There are specific diseases and conditions that are absolutely high risk for a reaction to a vaccine. For instance:

• If you have ever had anaphylactic shock after receiving a vaccine, then you should probably not get this one. I would direct you to your physician to have an important conversation about your specific risks.
• If you had an acute allergic reaction (anaphylaxis) to a COVID vaccine, then you should not get the same version again – talk to your doc about options.
• If you just had COVID and had an antibody product (like Regeneron) then you should defer vaccination for 90 days.
• If you developed myocarditis after your first dose, then you should not get the second.
• If you are currently acutely ill, then you should wait until you are well.

Religious exemptions. I’m hearing that thousands are checking the “religious exemption” box when faced with an employer mandate. I didn’t realize so many people were Scientologists. Not judging. Just saying that most churches and church leaders nationally are supporting the vaccine to enable their parishioners to safely return to church! There is a specific list of religions here that do object: https://www.vumc.org/health-wellness/news-resource-articles/immunizations-and-religion

Ingredient concerns. Well, I have watched A LOT of videos in the past few months of campaigns, talks, interviews, etc, that are anti-vaccine and warn their audiences of all kinds of badness in the shots. I’ve really tried to listen and understand. I hear some really good information and some really bad information. Some of these speakers found a medical textbook and put a bunch of words together that absolutely make no sense. Others express real concerns about specific ingredients, but don’t seem to understand the dosing or use of these ingredients.

Let’s go through a couple:

• mRNA. This is the only “active” (meaning has any effect on your body) ingredient in the Pfizer and Moderna vaccines. The few other ingredients (below) are “inactive” and have no impact on your body and are quickly cleared. One of the better descriptions of the mRNA component is here:

“There are rumors that mRNA vaccines will alter our DNA because the RNA molecule can convert information stored in DNA into proteins. That’s simply, not true. It’s critical to note that the mRNA vaccines never enter the nucleus of the cell, where our DNA is stored. After injection, the mRNA from the vaccine is released into the cytoplasm of the cells. Once the viral protein is made and on the surface of the cell, mRNA is broken down and the body permanently gets rid of it, therefore making it impossible to change our DNA.” (ref below)

• Lipids are used a as a fatty layer to protect the mRNA piece and help it enter the cell. One of the four lipids used is a small piece of cholesterol.

lipid structure

• The one that has received the most attention is a form of polyethylene glycol. Yes, it’s in the Pfizer shot. A similar substance, polysorbate 80, is in the J&J vaccine. Most of us know it as “PEG” or Miralax. When concentrated, it works well as a laxative. It has thousands of other uses (check Wikipedia!) including thickening uses in toothpaste and shampoo and binding to proteins as a carrier to last longer in the bloodstream. There is a tiny amount used in the lipid wall surrounding the mRNA piece to deliver it to the cells. There was initially concern that people allergic to PEG (or Miralax) may be the ones who have an allergic reaction to the vaccine. I have not found any follow up data on this, but if you have allergies to any medications, please discuss this with your doctor to determine if the vaccine is safe.
• One of the other lipids used by Moderna that has received A LOT of attention is SM-102. I’ve seen accusations that SM-102 is somehow able to carry GPS signals and even magnets and electrical charges. Pretty impressive, and completely untrue. SM-102 is another little tiny lipid that forms the wall of a coating around the mRNA to protect it from immediate destruction. It’s just not that cool… More info here: https://www.factcheck.org/2021/05/scicheck-vaccine-ingredient-sm-102-is-safe/

SM-102

• Salts and sugar. That’s it.

The vaccine does NOT contain:

• Fetal cells
• Blood products, like red blood cells, white blood cells, plasma or platelets
• COVID-19 virus cells
• Mercury
• Egg
• Latex stoppers
• Pork products
• Preservatives
• Microchips      

— Sometimes there are microchips on the outside of a syringe (usually in a bar code), so the health care professional can scan it quickly for digital records. The world’s tiniest microchip is still much too big to insert into an immunization shot.

The oldest and newest fear has been infertility. The doubts came up early and fast due to the possibility that a protein on the placenta, syncytin-1, could be could have a similar spike protein that would cause the body to attack it after vaccine. This miniscule possibility has been evaluated by multiple reproductive health teams and found to be near impossible (one study ref below). I placed a nice article from Missouri below addressing this concern if you would like more references.

Most significant to me, I have had parents tell me that they are worried the vaccine will make their children infertile long-term. Again, I understand the fear — my 18yo and 20yo daughters received the vaccine, and I had to do my research. There is no scientific away, no mechanism of the vaccine, no rare mutation of the mRNA, that can cause infertility in our kids. You know what can cause infertility? Infections. STDs, bacterial sepsis, and …. COVID19. So, if you want to help protect your children’s reproductive future, then educate them appropriately and get them the COVID19 vaccine.

Lastly, the CDC has added a nice “Myths and Facts” page to their website. Check it out: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html

I hope this helps! Happy to take any questions or comments below. If you like this material, I encourage you to hit the “Follow” button as I have been trying to keep up and post weekly. Thanks so much for all of your encouragement!

References:

Full CDC site with ingredients listed in “Appendix C”: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html?s_cid=10492:covid%2019%20vaccine%20ingredients:sem.ga:p:RG:GM:gen:PTN:FY21#Appendix-C

Ingredient breakdown:  https://www.hackensackmeridianhealth.org/HealthU/2021/01/11/a-simple-breakdown-of-the-ingredients-in-the-covid-vaccines/

PEG concerns:  https://www.science.org/doi/full/10.1126/science.371.6524.10

SM-102: https://www.nebraskamed.com/COVID/sm-102-moderna-vaccine

https://www.nebraskamed.com/COVID/you-asked-we-answered-are-covid-19-vaccine-ingredients-public

Infertility: https://www.muhealth.org/our-stories/does-covid-19-vaccine-affect-fertility-heres-what-experts-say

syncytin-1 study: https://www.nature.com/articles/s41577-021-00525-y

https://www.nbcnews.com/health/sexual-health/covid-vaccine-doesnt-cause-infertility-disease-might-rcna2868

COVID and pregnancy: https://www.ama-assn.org/delivering-care/public-health/what-doctors-wish-patients-knew-about-covid-19-vaccines-and-pregnancy

Photo credit: Creator: AndreyPopov | Credit: Getty Images/iStockphoto

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 10^th, 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!