Evaluation of the BNT162b2 Covid-19 Vaccine in Children 5 to 11 Years of Age

The SARS-CoV-2 vaccination campaign in Brazil and the invisibility of science evidences

This paper reflects on the vaccination campaign against COVID-19 in Brazil in light of the consideration of scientific evidence in the decision-making process. Brazil has one of the largest and most complete vaccination programs in the world, the National Immunization Program (Programa Nacional de Imunizações or PNI). Unfortunately, in the current context, with the political interference of the federal government, the PNI lost its role in conducting the vaccination campaign against COVID-19. Despite being a vaccination campaign with a lot of potential and one of the most accepted by the population among countries in the world, it presented many problems and left several gaps in the Brazilian scenario. In this sense, it is essential that the quality scientific evidence produced during this period can guide a constant remodeling of the vaccination strategy. Four points deserve to be highlighted: 1) the interval between doses; 2) the interchangeability between vaccines; 3) vaccination in children and adolescentes; and 4) the need for better evidence to define the vaccination strategy in certain groups and age groups.

Myocarditis Following the Second Dose of COVID-19 Vaccination in a Japanese Adolescent

As COVID-19 vaccines continue to be deployed worldwide, countries are now planning to vaccinate their pediatric populations as well. However, several vaccine-related adverse events, including myocarditis, have been reported. Although the incidence of myocarditis after BNT162b2 vaccination is low, it is higher, particularly after receiving the second dose, among young male recipients. A 13-year-old male adolescent presented with chest pain after the second dose of the BNT162b2 vaccination. Electrocardiography, echocardiography, cardiac magnetic resonance imaging, and blood examinations were consistent with myocarditis. He was treated conservatively because his symptoms were relatively mild. In Japan, it is expected that the chances of diagnosing vaccine-related myocarditis will increase as more children are getting vaccinated. Our case report raises concerns to physicians that the COVID-19 vaccination may cause rare cases of myocarditis, which must always be considered as a differential diagnosis.

Consensus on COVID-19 Vaccination in Pediatric Oncohematological Patients, on Behalf of Infectious Working Group of Italian Association of Pediatric Hematology Oncology

Vaccines represent the best tool to prevent the severity course and fatal consequences of the pandemic by the new Coronavirus 2019 infection (SARS-CoV-2). Considering the limited data on vaccination of pediatric oncohematological patients, we developed a Consensus document to support the Italian pediatric hematological oncological (AIEOP) centers in a scientifically correct communication with families and patients and to promote vaccination. The topics of the Consensus were: SARS-CoV-2 infection and disease (COVID-19) in the pediatric subjects; COVID-19 vaccines (type, schedule); who and when to vaccinate; contraindications and risk of serious adverse events; rare adverse events; third dose and vaccination after COVID-19; and other general prevention measures. Using the Delphi methodology for Consensus, 21 statements and their corresponding rationale were elaborated and discussed with the representatives of 31 centers, followed by voting. A high grade of Consensus was obtained on topics such as the potential risk of severe COVID-19 outcome in pediatric oncohematological patients, the need for vaccination as a preventative measure, the type, schedule and booster dose of vaccine, the eligibility of the patients for vaccination, and the timing, definition, and management of contraindications and serious adverse events, and other general prevention measures. All 21 of the statements were approved. This consensus document highlights that children and adolescents affected by hematological and oncological diseases are a fragile category. Vaccination plays an important role to prevent COVID-19, to permit the regular administration of chemotherapy or other treatments, to perform control visits and hospital admissions, and to prevent treatment delays.

The Potential of Nanomedicine to Unlock the Limitless Applications of mRNA

The year 2020 was a turning point in the way society perceives science. Messenger RNA (mRNA) technology finally showed and shared its potential, starting a new era in medicine. However, there is no doubt that commercialization of these vaccines would not have been possible without nanotechnology, which has finally answered the long-term question of how to deliver mRNA in vivo. The aim of this review is to showcase the importance of this scientific milestone for the development of additional mRNA therapeutics. Firstly, we provide a full description of the marketed vaccine formulations and disclose LNPs' pharmaceutical properties, including composition, structure, and manufacturing considerations Additionally, we review different types of lipid-based delivery technologies currently in preclinical and clinical development, namely lipoplexes and cationic nanoemulsions. Finally, we highlight the most promising clinical applications of mRNA in different fields such as vaccinology, immuno-oncology, gene therapy for rare genetic diseases and gene editing using CRISPR Cas9.

mRNA Vaccine Development for Emerging Animal and Zoonotic Diseases

In the prevention and treatment of infectious diseases, mRNA vaccines hold great promise because of their low risk of insertional mutagenesis, high potency, accelerated development cycles, and potential for low-cost manufacture. In past years, several mRNA vaccines have entered clinical trials and have shown promise for offering solutions to combat emerging and re-emerging infectious diseases such as rabies, Zika, and influenza. Recently, the successful application of mRNA vaccines against COVID-19 has further validated the platform and opened the floodgates to mRNA vaccine's potential in infectious disease prevention, especially in the veterinary field. In this review, we describe our current understanding of the mRNA vaccines and the technologies used for mRNA vaccine development. We also provide an overview of mRNA vaccines developed for animal infectious diseases and discuss directions and challenges for the future applications of this promising vaccine platform in the veterinary field.

Evolution of SARS-CoV-2 IgG Seroprevalence in Children and Factors Associated with Seroconversion: Results from a Multiple Time-Points Study in Friuli-Venezia Giulia Region, Italy

Data on the effective burden of the SARS-CoV-2 pandemic in the pediatric population are limited. We aimed at assessing the prevalence of SARS-CoV-2 IgG antibodies in children at three subsequent time-points. The study was conducted between January 2021 and July 2021 among children referring to the Research Institute for Maternal and Child Health “Burlo Garofolo” in Trieste, a referral regional hospital in Friuli Venezia Giulia, Italy. A multivariate analysis was conducted to assess factors independently associated with seroconversion. A total of 594 children were included. Anti-SARS-CoV-2 trimeric Spike protein IgG antibodies were found in 32 (15.4%) children tested in April-May and in 20 (11.8%) in June–July 2021, compared with 24 (11.1%) of those tested in January–February 2021 (p = 0.37, Armitage exact test for trend over time p = 0.76). A subgroup analysis and a multivariate logistic regression analysis were performed considering sociodemographic, clinical, and historical variables. Three categories of children showed statistically significant increased odds of positive anti-SARS-CoV-2 IgG antibodies: children previously positive to a nasopharyngeal swab (AdjOR 15.41, 95%CI 3.44–69.04, p < 0.001), cohabitant with a person with an history of a previous positive nasopharyngeal swab (AdjOR 9.95, 95%CI 5.35–18.52, p < 0.001), and children with a foreign citizenship (AdjOR 2.4, 95%CI 1.05–5.70, p = 0.002). The study suggests that seroprevalence studies may be of limited help in estimating the prevalence of the COVID-19 pandemic in children. Further studies are needed to identify other markers of previous SARS-CoV-2 infection in children, such as CD4+ T cells or memory B-cells.

Model-Estimated Association Between Simulated US Elementary School-Related SARS-CoV-2 Transmission, Mitigation Interventions, and Vaccine Coverage Across Local Incidence Levels

Importance

With recent surges in COVID-19 incidence and vaccine authorization for children aged 5 to 11 years, elementary schools face decisions about requirements for masking and other mitigation measures. These decisions require explicit determination of community objectives (eg, acceptable risk level for in-school SARS-CoV-2 transmission) and quantitative estimates of the consequences of changing mitigation measures.

Objective

To estimate the association between adding or removing in-school mitigation measures (eg, masks) and COVID-19 outcomes within an elementary school community at varying student vaccination and local incidence rates.

Design, Setting, and Participants

This decision analytic model used an agent-based model to simulate SARS-CoV-2 transmission within a school community, with a simulated population of students, teachers and staff, and their household members (ie, immediate school community). Transmission was evaluated for a range of observed local COVID-19 incidence (0-50 cases per 100 000 residents per day, assuming 33% of all infections detected). The population used in the model reflected the mean size of a US elementary school, including 638 students and 60 educators and staff members in 6 grades with 5 classes per grade.

Exposures

Variant infectiousness (representing wild-type virus, Alpha variant, and Delta variant), mitigation effectiveness (0%-100% reduction in the in-school secondary attack rate, representing increasingly intensive combinations of mitigations including masking and ventilation), and student vaccination levels were varied.

Main Outcomes and Measures

The main outcomes were (1) probability of at least 1 in-school transmission per month and (2) mean increase in total infections per month among the immediate school community associated with a reduction in mitigation; multiple decision thresholds were estimated for objectives associated with each outcome. Sensitivity analyses on adult vaccination uptake, vaccination effectiveness, and testing approaches (for selected scenarios) were conducted.

Results

With student vaccination coverage of 70% or less and moderate assumptions about mitigation effectiveness (eg, masking), mitigation could only be reduced when local case incidence was 14 or fewer cases per 100 000 residents per day to keep the mean additional cases associated with reducing mitigation to 5 or fewer cases per month. To keep the probability of any in-school transmission to less than 50% per month, the local case incidence would have to be 4 or fewer cases per 100 000 residents per day.

Conclusions and Relevance

In this study, in-school mitigation measures (eg, masks) and student vaccinations were associated with substantial reductions in transmissions and infections, but the level of reduction varied across local incidence. These findings underscore the potential role for responsive plans that deploy mitigation strategies based on local COVID-19 incidence, vaccine uptake, and explicit consideration of community objectives.

Estimating the cost of COVID-19 vaccine deployment and introduction in Ghana using the CVIC Tool

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Current COVID-19 vaccine supply market means LMICs will have to rely on a combination of different sources/types of vaccines to meet their demand.

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Deployment of COVID-19 vaccine plans in Ghana will cost $348.7–$436.1 million for coverage of 17.5 million of eligible Ghanaians.

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Vaccine cost constitute 78–83% of total cost whereas the total vaccination cost is 0.48–0.60% of the country’s 2020 GDP.

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The WHO-UNICEF CVIC tool is useful for comprehensive COVID-19 vaccine deployment costing and resource planning.

Background

This study estimated cost of COVID-19 vaccine introduction and deployment in Ghana.

Methods

Using the WHO-UNICEF COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool Ghana’s Ministry of Health Technical Working Group for Health Technology Assessment (TWG-HTA) in collaboration with School of Public Health, University of Ghana, organized an initial two-day workshop that brought together partners to deliberate and agree on input parameters to populate the CVIC tool. A further 2–3 days validation with the Expanded Program of Immunization (EPI) and other partners to finalize the analysis was done. Three scenarios, with different combinations of vaccine products and delivery modalities, as well as time period were analyzed. The scenarios included AstraZeneca (40%), Johnson & Johnson (J&J) (30%), Moderna, Pfizer, and Sputnik V at 10% each; with primary schedule completed by second half of 2021 (Scenario 1); AstraZeneca (30%), J&J (40%), Moderna, Pfizer, and Sputnik V at 10% each with primary schedule completed by first half of 2022 (Scenario 2); and equal distribution (20%) among AstraZeneca, J&J, Moderna, Pfizer, and Sputnik V with primary schedule completed by second half of 2022 (Scenario 3).

Results

The estimated total cost of COVID-19 vaccination ranges between $348.7 and $436.1 million for the target population of 17.5 million. These translate into per person completed primary schedule cost of $20.9–$26.2 and per dose (including vaccine cost) of $10.5–$13.1. Again, per person completed primary schedule excluding vaccine cost was $4.5 and $4.6, thus per dose excluding vaccine also ranged from $2.2 – $2.3. The main cost driver was vaccine doses, including shipping, which accounts for between 78% and 83% of total cost. Further, an estimated 8,437–10,247 vaccinators (non-FTEs) would be required during 2021–2022 to vaccinate using a mix of delivery strategies, accounting for 8–10% of total cost.

Conclusion

These findings provide the estimates to inform resource mobilization efforts by government and other partners.

School Asthma Care During COVID-19: What We Have Learned and What We Are Learning

The focus of this article is to review school asthma care during coronavirus disease 2019 (COVID-19). Asthma is listed as a risk factor in some guidelines, although children with asthma appear to not be at increased risk of severe respiratory outcomes compared with children without asthma during the pandemic. Differentiating COVID-19 from allergic disease is very difficult in the school-aged children. For school management, there is firm evidence that masks do not exacerbate underlying lung conditions including asthma, and evidence to date supports that children with asthma can learn in-person at school because they do not appear to be at increased risk of COVID-19 morbidity or mortality. For children and adolescents, the COVID-19 vaccine has been demonstrated to be safe and well tolerated. School asthma management includes remaining on prescribed asthma medications. Asthma management, as with management of all pediatric conditions, must also factor in the impact of adverse social determinants and health disparities. Broadly, the pandemic has also served as a call to resource stewardship and innovation and allowed practitioners to consider how this may impact asthma care moving forward.

Three exposures to the spike protein of SARS-CoV-2 by either infection or vaccination elicit superior neutralizing immunity to all variants of concern

Infection-neutralizing antibody responses after SARS-CoV-2 infection or COVID-19 vaccination are an essential component of antiviral immunity. Antibody-mediated protection is challenged by the emergence of SARS-CoV-2 variants of concern (VoCs) with immune escape properties, such as omicron (B.1.1.529) that is rapidly spreading worldwide. Here, we report neutralizing antibody dynamics in a longitudinal cohort of COVID-19 convalescent and infection-naive individuals vaccinated with mRNA BNT162b2 by quantifying anti-SARS-CoV-2-spike antibodies and determining their avidity and neutralization capacity in serum. Using live-virus neutralization assays, we show that a superior infection-neutralizing capacity against all VoCs, including omicron, developed after either two vaccinations in convalescents or after a third vaccination or breakthrough infection of twice-vaccinated, naive individuals. These three consecutive spike antigen exposures resulted in an increasing neutralization capacity per anti-spike antibody unit and were paralleled by stepwise increases in antibody avidity. We conclude that an infection-plus-vaccination-induced hybrid immunity or a triple immunization can induce high-quality antibodies with superior neutralization capacity against VoCs, including omicron.

Omicron variant susceptibility to neutralizing antibodies induced in children by natural SARS-CoV-2 infection or COVID-19 vaccine

The novel SARS-CoV-2 Omicron variant may increase the risk of re-infection and vaccine breakthrough infections as it possesses key mutations in the spike protein that affect neutralizing antibody response. Most studies on neutralization susceptibility were conducted using specimens from adult COVID-19 patients or vaccine recipients. However, since the paediatric population has an antibody response to SARS-CoV-2 infection that is distinct from the adult population, it is critical to assess the neutralization susceptibility of pediatric serum specimens. This study compared the neutralization susceptibility of serum specimens collected from 49 individuals of <18 years old, including 34 adolescent BNT162b2 (Pfizer-BioNTech) vaccine recipients, and 15 recovered COVID-19 patients aged between 2 and 17. We demonstrated that only 38.2% of BNT162b2 vaccine recipients and 26.7% of recovered COVID-19 patients had their serum neutralization titre at or above the detection threshold in our live virus microneutralization assay. Furthermore, the neutralizing antibody titer against the Omicron variant was substantially lower than those against the ancestral virus or the Beta variant. Our results suggest that vaccine recipients and COVID-19 patients in the pediatric age group will likely be more susceptible to vaccine breakthrough infections or reinfections due to the Omicron variant than previous variants.

Coronavirus Disease 2019 (COVID-19) Vaccination for Children: Position Statement of Indian Academy of Pediatrics Advisory Committee on Vaccination and Immunization Practices

JUSTIFICATION

Data generated after the first wave has revealed that some children with coronavirus 19 (COVID-19) can become seriously ill. Multi-inflammatory syndrome in children (MIS-C) and long COVID cause significant morbidity in children. Prolonged school closures and quarantine have played havoc with the psychosocial health of children. Many countries in the world have issued emergency use authorisation (EUA) of selected Covid-19 vaccines for use in children. In India, a Subject Expert Committee (SEC) has recommended the use of Covaxin (Bharat Biotech) for children from the ages of 2-18 years. The recommendation has been given to the Drugs Controller General of India (DCGI) for final approval.

OBJECTIVE

To provide an evidence-based document to guide the pediatricians on the recommendation to administer COVID vaccines to children, as and when they are available for use.

PROCESS

Formulation of key questions was done by the committee, followed by review of literature on epidemiology and burden of Covid-19 in children, review of the studies on COVID vaccines in children, and the IAP stand on Covid-19 vaccination in children. The available data was discussed in the ACVIP focused WhatsApp group followed by an online meeting on 24 October, 2021, wherein the document was discussed in detail and finalized.

RECOMMENDATIONS

The IAP supports the Government of India's decision to extend the COVID-19 vaccination program to children between 2-18 years of age. Children with high-risk conditions may be immunized on a priority basis. The IAP and its members should be a partner with the Government of India, in the implementation of this program and the surveillance that is necessary following the roll-out.

Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare

There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.

Limited Additive Diagnostic Impact of Isolated Gastrointestinal Involvement for the Triage of Children with Suspected COVID-19

The strategy for the selection of patients with a suspected SARS-CoV-2 infection is relevant for the organization of a children’s hospital to provide optimal separation into COVID-19 and non-COVID-19 areas and pathways. We analyzed the proportion of children with COVID-19 presenting with gastrointestinal (GI) symptoms in 137 consecutive patients admitted between January 2020 and August 2021. GI symptoms were present as follows: diarrhea in 35 patients (26%), vomiting in 16 (12%), and both of them in five (3%); the combination of fever, respiratory symptoms, and diarrhea was observed in 16 patients (12%). Of the 676 adult patients with COVID-19 admitted to our hospital in the same time interval, 62 (9.2%) had diarrhea, 30 (4.4%) had vomiting, and 11 (1.6%) had nausea; only one patient, a 38-year-old male, presented with isolated GI symptoms at the diagnosis. Although diarrhea was observed in one quarter of cases, one-half of them had the complete triad of fever, respiratory syndrome, and diarrhea, and only five had isolated diarrhea, of which two were diagnosed with a Campylobacter infection. The occurrence of either respiratory symptoms or gastrointestinal symptoms in our patients was not related to the patient age, while younger children were more likely to have a fever. Of the 137 patients, 73 (53%) could be tested for their serum level of SARS-CoV-2 specific IgG antibodies. The observed titer ranged between 0 (n = 3) and 1729 BAU/mL (median, 425 BAU/mL). Of 137 consecutive patients with COVID-19 admitted to our referral children’s hospital, only three presented with an isolated GI manifestation. It is interesting to note that this finding turned out to be fully in keeping with what was observed on adult patients with COVID-19 in our hospital. The additive diagnostic impact of gastrointestinal involvement for the triage of children with suspected COVID-19 appears limited.

Risk factors for admission to the pediatric critical care unit among children hospitalized with COVID-19 in France

BACKGROUND

COVID-19 infection is less severe among children than among adults; however, some patients require hospitalization and even critical care. Using data from the French national medico-administrative database, we estimated the risk factors for critical care unit (CCU) admissions among pediatric COVID-19 hospitalizations, the number and characteristics of the cases during the successive waves from January 2020 to August 2021 and described death cases.

METHODS

We included all children (age < 18) hospitalized with COVID-19 between January 1st, 2020, and August 31st, 2021. Follow-up was until September 30th, 2021 (discharge or death). Contiguous hospital stays were gathered in "care sequences." Four epidemic waves were considered (cut off dates: August 11th 2020, January 1st 2021, and July 4th 2021). We excluded asymptomatic COVID-19 cases, post-COVID-19 diseases, and 1-day-long sequences (except death cases). Risk factors for CCU admission were assessed with a univariable and a multivariable logistic regression model in the entire sample and stratified by age, whether younger than 2.

RESULTS

We included 7,485 patients, of whom 1988 (26.6%) were admitted to the CCU. Risk factors for admission to the CCU were being younger than 7 days [OR: 3.71 95% CI (2.56-5.39)], being between 2 and 9 years old [1.19 (1.00-1.41)], pediatric multisystem inflammatory syndrome (PIMS) [7.17 (5.97-8.6)] and respiratory forms [1.26 (1.12-1.41)], and having at least one underlying condition [2.66 (2.36-3.01)]. Among hospitalized children younger than 2 years old, prematurity was a risk factor for CCU admission [1.89 (1.47-2.43)]. The CCU admission rate gradually decreased over the waves (from 31.0 to 17.8%). There were 32 (0.4%) deaths, of which the median age was 6 years (IQR: 177 days-15.5 years).

CONCLUSION

Some children need to be more particularly protected from a severe evolution: newborns younger than 7 days old, children aged from 2 to 13 years who are more at risk of PIMS forms and patients with at least one underlying medical condition.

Social Media Interventions Strengthened COVID-19 Immunization Campaign

BACKGROUND

Since The Italian Medicines Agency (AIFA) has recommended the COVID-19 vaccine Comirnaty in children aged 5-11, the immunization campaign faced vaccine hesitancy in parents. Social media are emerging as leading information source that could play a significant role to counteract vaccine hesitancy, influencing parents' opinions and perceptions. Our aim was to evaluate the coverage of the COVID-19 vaccine Comirnaty in a cohort of children aged 5-11 whose families have been counseled to use Social Media to counteract vaccine hesitancy.

METHODS

All parents of children aged 5-11 in a primary care setting were instructed by their pediatrician to get accurate information about the COVID-19 vaccine from a Facebook page. Active calls to vaccinate children were also scheduled through messaging services Pediatotem and Whatsapp. Vaccination rates of children in the study were assessed with an electronic database and compared to both regional and national child vaccination rates.

RESULTS

Coverage of 277 children aged 5-11 was analyzed from 16 December 2021 to 31 January 2022. A total of 62.4% (173/277) of enrolled children received the 1st dose of COVID-19 vaccine Comirnaty and 39.7% (110/277) the 2nd dose. Coverage rates were higher compared both to the regional population (1st dose: 48.8%, 2nd dose: 24.6%; p = 0.001) and national population (1st dose: 32.1%, 2nd dose: 13.8%; p < 0.001).

CONCLUSION

Increasing vaccine confidence using Social Media interventions have a positive impact on vaccination acceptance of parents.

SARS-CoV-2 B.1.1.529 (Omicron) Variant Causes an Unprecedented Surge in Children Hospitalizations and Distinct Clinical Presentation Compared to the SARS-CoV-2 B.1.617.2 (Delta) Variant

BACKGROUND

In the midst of successive waves of SARS-CoV-2 variants, the B.1.1.529 (omicron) variant has recently caused a surge in pediatric infections and hospitalizations. This study aimed to describe and compare the symptoms, explorations, treatment and evolution of COVID-19 in hospitalized children during the successive B.1.617.2 (delta) and B.1.1.529 (omicron) waves.

METHODS

This observational study was performed in the Pediatric Pulmonology Department of a University Hospital in Paris, France. All hospitalized children aged between 0 and 18 years who tested positive for SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) in nasopharyngeal swabs from July 15th to December 15th 2021 (delta wave), and from December 15th 2021 to February 28th 2022 (omicron wave) were included.

RESULTS

In total, 53 children were included, 14 (26.4%) during the delta wave and 39 (73.6%) during the omicron wave (almost three times as many hospitalizations in half the time during the latter wave). During the omicron wave, hospitalized patients were mostly aged < 5 years (90 vs. 71% of all the children during omicron and delta waves, respectively), and tended to have fewer underlying conditions (56 vs. 79% during omicron and delta waves, respectively, p = 0.20). The omicron variant was also responsible for a different clinical presentation when compared to the delta variant, with significantly higher and often poorly tolerated temperatures (p = 0.03) and increased digestive symptoms (p = 0.01). None of the three patients who were older than 12 years were fully vaccinated.

CONCLUSION

The dramatic increase in the hospitalization of children with COVID-19 and the modification of the clinical presentation between the latest delta and omicron waves require pediatricians to remain vigilant. It should also encourage caregivers to ensure vaccination in children older than 5 years, for whom the BNT162b2 COVID-19 vaccine has been deemed safe, immunogenic, and effective.

Approaches to SARS-CoV-2 and other vaccinations in children with a history of multisystem inflammatory syndrome (MIS-C): An international survey

BACKGROUND

Following the Coronavirus Disease-19 (COVID-19) pandemic outbreaks, the hyperinflammatory condition termed Multisystem Inflammatory Syndrome in Children (MIS-C) became a healthcare issue worldwide. Since December 2020 the mRNA vaccine against SARS-CoV-2 has become available with a good safety profile. However, evidence regarding safety and vaccination strategies in children with previous MIS-C is still lacking. The aim of our study was to investigate the current approach of international centers to anti-SARS-CoV-2 and other vaccinations in children with a history of MIS-C.

METHODS

Physicians who care for patients with MIS-C were invited to anonymously complete a 15-question, web-based survey. The survey was open from October 6 to December 31, 2021.

RESULTS

A total of 290 replies from 236 centers in 61 countries were collected. Most respondents (86%) were pediatric rheumatologists. The anti-SARS-CoV-2 vaccine was available in 85% of the countries. Sixty-seven centers (28%) in 22 countries already vaccinated MIS-C patients without adverse reactions in most cases (89%). Six reported complications: 2 not specified, 3 mild symptoms and 1 reported a MIS-C-like reaction. Most centers (84%) favored vaccinating MIS-C patients against SARS-CoV-2, after 3-6 months (40%), 6-12 months (52%) or >12 months (8%). The survey revealed broad heterogeneity of responses among healthcare providers within the same country and within the same center. The variable with the greatest impact on the decision not to vaccinate MIS-C patients was the current lack of evidence (51%), followed by patient/parent objection (40%). The most relevant parameters in the vaccination strategy were time from MIS-C episode (78%), immunosuppressive treatment (35%), SARS-CoV-2 serologic status (32%), and MIS-C features (31%). Almost all centers favored continuing regular vaccination with non-live (99%) and live (93%) vaccines; however, with high variability in suggested timelines.

CONCLUSION

To date, the experience of the international pediatric rheumatology community in vaccinating MIS-C patients against SARS-CoV-2 is overall reassuring. However, lack of evidence causes broad heterogeneity in vaccination strategy worldwide.

Case report: Myocarditis with nonsustained ventricular tachycardia following COVID-19 mRNA vaccination in a female adolescent

Children with underlying medical conditions potentially develop severe illness from Coronavirus disease 2019 (COVID-19). The use of vaccines against COVID-19 is currently recommended for the pediatric population. The COVID-19 vaccine has a temporal association with the occurrence of myocarditis. Although most patients with COVID-19 vaccination-associated myocarditis (C-VAM) exhibit a mild clinical course and rapid recovery, C-VAM potentially causes electrical instability and sudden cardiac death. Herein, we report the case of a 17-year-old woman who presented with chest pain and syncope following the first dose of the messenger RNA COVID-19 vaccine. The patient's heart function was impaired, and nonsustained ventricular tachycardia was frequent. Cardiac magnetic resonance (CMR) imaging satisfied the criteria for myocarditis. Despite the administration of immunomodulatory drugs, the patient's heart function was not fully restored, and the concentration of cardiac enzymes remained above the normal range. Persistence of late gadolinium enhancement was observed on short-term follow-up CMR imaging. Although most patients with C-VAM exhibit mild symptoms, significant cardiac arrhythmias potentially occur. Furthermore, some patients with C-VAM demonstrate prolonged impaired heart function and sustained late gadolinium enhancement on follow-up CMR imaging. Therefore, monitoring of electrical and functional cardiac abnormalities in patients with C-VAM is crucial and the long-term outcomes and prognosis of patients with C-VAM require further investigation.

La myocardite et la péricardite après un vaccin à ARN messager contre la COVID-19

Question

À la suite de l’approbation d’un vaccin contre la maladie à coronavirus 2019 (COVID-19) pour les enfants de 5 à 11 ans et compte tenu de préoccupations de parents au cours de la dernière année face à des cas rapportés de myocardite et de péricardite chez des adolescents, ma clinique devrait-elle continuer à encourager tous les enfants et les jeunes adultes à recevoir le vaccin à ARN messager contre la COVID-19?

Réponse

Depuis avril 2021, des rapports ont documenté des cas de myocardite et de péricardite chez des adolescents et des jeunes adultes ayant reçu un vaccin à ARN messager contre la COVID-19, et plusieurs centaines de signalements semblables ont été documentés au Canada. Les schémas cliniques étaient majoritairement bénins, avec quelques rares hospitalisations, et les cas touchaient habituellement des adolescents masculins de 16 ans et plus dans les quelques jours suivant la deuxième dose du vaccin. Après la vaccination, les enfants et les adolescents qui présentent des symptômes comme des douleurs thoraciques, de la dyspnée ou des palpitations devraient être évalués en procédant à un examen physique et à un électrocardiogramme, et en mesurant les taux de troponines cardiaques. Si les résultats sont anormaux, il y a lieu d’envisager un échocardiogramme ou une imagerie cardiaque par résonance magnétique. La myocardite et la péricardite subséquentes à la vaccination sont bien moins courantes et beaucoup moins graves que les complications cardiaques d’une infection à la COVID-19, et les vaccins devraient continuer à être recommandés auprès de toutes les personnes admissibles.

Myocarditis and pericarditis after COVID-19 messenger RNA vaccines

QUESTION

With the approval of coronavirus disease 2019 (COVID-19) vaccine for children 5 to 11 years of age and concerns among parents in the past year following reported cases of myocarditis and pericarditis in adolescents, should my office continue to encourage all children and young adults to receive the COVID-19 messenger RNA vaccine?

ANSWER

Since April 2021 reports have documented cases of myocarditis and pericarditis in adolescents and young adults after messenger RNA COVID-19 vaccination, and several hundred such reports were documented in Canada. Clinical presentations were mostly mild, with rare instances of admission to the hospital, and were typically among male adolescents 16 years of age and older within several days after the second dose of the vaccine. After vaccination, children and adolescents with symptoms of chest pain, shortness of breath, or palpitations should be evaluated with a physical examination, an electrocardiogram, and measurement of cardiac troponin levels. If results are abnormal, an echocardiogram or cardiac magnetic resonance imaging should be considered. Myocarditis and pericarditis after vaccination are much less common, and much milder, than cardiac complications of COVID-19 infection, and vaccines should continue to be recommended to all those eligible.

COVID-19 Vaccine Safety in Children Aged 5-11 Years - United States, November 3-December 19, 2021

On October 29, 2021, the Food and Drug Administration (FDA) amended the Emergency Use Authorization (EUA) for Pfizer-BioNTech COVID-19 (BNT162b2) mRNA vaccine to expand its use to children aged 5-11 years, administered as 2 doses (10 μg, 0.2mL each) 3 weeks apart (1). As of December 19, 2021, only the Pfizer-BioNTech COVID-19 vaccine is authorized for administration to children aged 5-17 years (2,3). In preauthorization clinical trials, Pfizer-BioNTech COVID-19 vaccine was administered to 3,109 children aged 5-11 years; most adverse events were mild to moderate, and no serious adverse events related to vaccination were reported (4). To further characterize safety of the vaccine in children aged 5-11 years, CDC reviewed adverse events after receipt of Pfizer-BioNTech COVID-19 vaccine reported to the Vaccine Adverse Event Reporting System (VAERS), a passive vaccine safety surveillance system co-managed by CDC and FDA, and adverse events and health impact assessments reported to v-safe, a voluntary smartphone-based safety surveillance system for adverse events after COVID-19 vaccination,* during November 3-December 19, 2021. Approximately 8.7 million doses of Pfizer-BioNTech COVID-19 vaccine were administered to children aged 5-11 years^† during this period; VAERS received 4,249 reports of adverse events after vaccination with Pfizer-BioNTech COVID-19 vaccine in this age group, 4,149 (97.6%) of which were not serious. Approximately 42,504 children aged 5-11 years were enrolled in v-safe after vaccination with Pfizer-BioNTech COVID-19 vaccine; after dose 2, a total of 17,180 (57.5%) local and 12,223 systemic (40.9%) reactions (including injection-site pain, fatigue, or headache) were reported. The preliminary safety findings are similar to those from preauthorization clinical trials (4,5). The Advisory Committee on Immunization Practices (ACIP) recommends the Pfizer-BioNTech COVID-19 vaccine for children aged 5-11 years for the prevention of COVID-19 (6). Parents and guardians of children aged 5-11 years vaccinated with Pfizer-BioNTech COVID-19 vaccine should be advised that local and systemic reactions are expected after vaccination. Vaccination is the most effective way to prevent COVID-19. CDC and FDA will continue to monitor vaccine safety and will provide updates as needed to guide COVID-19 vaccination recommendations.

Can a combination of vaccination and face mask wearing contain the COVID-19 pandemic?

The COVID‐19 pandemic is going into its third year with Europe again being the focus of major epidemic activity. The present review tries to answer the question whether one can come to grip with the pandemic by a combination of vaccinations and non‐pharmaceutical interventions (NPIs). Several COVID‐19 vaccines are of remarkable efficacy and achieve high protection rates against symptomatic disease, especially severe disease, but mathematical models suggest that the current vaccination coverage in many countries is insufficient to achieve pandemic control. NPIs are needed as complementary measures because recent research has also revealed the limits of vaccination alone. Here, we review the evidence for efficacy of face mask wearing in various settings. Overall pooled analysis showed significant reduction in COVID‐19 incidence with mask wearing, although heterogeneity between studies was substantial. Controlled trials of mask wearing are difficult to conduct, separating mask wearing effects in population studies from the impact of other NPIs is challenging and the efficacy of masks depend on mask material and mask fit. The combination of vaccination and mask wearing is potentially synergistic since vaccination protects so far well from disease development (the omicron variant is currently an unknown) but immunity from infection wanes over few months after vaccination. In comparison, masks interfere with the virus transmission process at a level of a physical barrier independent of coronavirus variant. Vaccination and masks are much less costly to apply than other NPI measures which are associated with high economic and social costs, but paradoxically both measures are the target of a vocal opposition by a sizable minority of the society. In parallel with biomedical research, we need more social science research into this opposition to guide political decisions on how to end the pandemic.

The present review tries to answer the question whether one can control the pandemic by a combination of vaccinations and non‐pharmaceutical interventions. The combination of vaccination and mask wearing is potentially synergistic since vaccination protects so far well from disease while masks interfere with the virus transmission process as a physical barrier against any type of coronavirus variant.

Adults' Acceptance of COVID-19 Vaccine for Children in Selected Lower- and Middle-Income Countries

Since emergency approval of COVID-19 vaccines for children aged between 12 and 15 years old was recently obtained in the United States and Europe, we aimed to assess the willingness to vaccinate children with a COVID-19 vaccine in lower- and middle-income countries (LMICs). Therefore, we launched an online cross-sectional survey in several LMICs. Questions relating to socio-demographic information, knowledge of COVID-19, level of fear/worry of being infected with COVID-19, and willingness to vaccinate children with the COVID-19 vaccine at 50%, 75% and 95% effectiveness levels, were asked. Of the 6571 participants (mean age = 39 ± 14 years), 64.0%, 72.6%, and 92.9% were willing to vaccinate children at 50%, 75%, and 95% effectiveness levels, respectively. Respondents who were undergraduates, who were more worried/fearful about COVID-19, had higher knowledge scores regarding COVID-19, and a higher belief that COVID-19 vaccination is important to protect others, were more willing to accept COVID-19 vaccination of children. COVID-19 vaccination of children will limit the spread of the virus, especially in schools; it may decrease the need for school closures which has a negative effect on child development. Findings from this study are useful for health promotion strategies during COVID-19 vaccination implementation among children in LMICs.

A randomized study to evaluate safety and immunogenicity of the BNT162b2 COVID-19 vaccine in healthy Japanese adults

We report interim safety and immunogenicity findings from an ongoing phase 1/2 study of BNT162b2 in healthy Japanese adults. Participants were randomized 3:1 to receive 2 intramuscular injections of 30 μg BNT162b2 or placebo 21 days apart. Overall, 160 individuals were randomized: 119 received BNT162b2, and 41 received placebo. Participants were stratified by age: 20–64 years (n = 130) and 65–85 years (n = 30). More than 97% of BNT162b2 recipients received 2 doses. Local reactions and systemic events were generally transient and mild to moderate. Severe adverse events were uncommon; there were no serious adverse events. One month after dose 2, SARS-CoV-2 50% serum neutralizing geometric mean titers were 571 and 366, and geometric mean fold rises were 55.8 and 36.6, in the younger and older age groups, respectively. In summary, BNT162b2 has an acceptable safety profile and produces a robust immune response, regardless of age, in Japanese adults. (ClinicalTrials.gov, NCT04588480).

Here the authors provide the interim analysis of an ongoing phase 1/2 study of the BNT162b2 vaccine in healthy Japanese adults. They report mainly mild to moderate local reactions and no serious adverse events as well as good antibody induction one month after the second dose.