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 As with everything COVID, this is preliminary data and may be out of date or completely contradicted with new data within the month.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

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