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Constantin T, Pék T, Horváth Z, Garan D, Szabó AJ. Multisystem inflammatory syndrome in children (MIS-C): Implications for long COVID. Inflammopharmacology 2023; 31:2221-2236. [PMID: 37460909 PMCID: PMC10518292 DOI: 10.1007/s10787-023-01272-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 09/26/2023]
Abstract
The COVID-19 pandemic caused by the coronavirus 2 of the severe acute respiratory syndrome (SARS-CoV-2) has significantly affected people around the world, leading to substantial morbidity and mortality. Although the pandemic has affected people of all ages, there is increasing evidence that children are less susceptible to SARS-CoV-2 infection and are more likely to experience milder symptoms than adults. However, children with COVID-19 can still develop serious complications, such as multisystem inflammatory syndrome in children (MIS-C). This narrative review of the literature provides an overview of the epidemiology and immune pathology of SARS-CoV-2 infection and MIS-C in children. The review also examines the genetics of COVID-19 and MIS-C in children, including the genetic factors that can influence the susceptibility and severity of the diseases and their implications for personalized medicine and vaccination strategies. By examining current evidence and insights from the literature, this review aims to contribute to the development of effective prevention and treatment strategies for COVID-19, MIS-C, and long COVID syndromes in children.
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Affiliation(s)
- Tamás Constantin
- Department of Pediatrics, Semmelweis University, Tűzoltó u. 7-9., Budapest, 1094, Hungary.
| | - Tamás Pék
- Department of Pediatrics, Semmelweis University, Tűzoltó u. 7-9., Budapest, 1094, Hungary
| | - Zsuzsanna Horváth
- Department of Pediatrics, Semmelweis University, Tűzoltó u. 7-9., Budapest, 1094, Hungary
| | - Diána Garan
- Department of Pediatrics, Semmelweis University, Tűzoltó u. 7-9., Budapest, 1094, Hungary
| | - Attila J Szabó
- Department of Pediatrics, Semmelweis University, Tűzoltó u. 7-9., Budapest, 1094, Hungary
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2
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Hamad Saied M, van der Griend L, van Straalen JW, Wulffraat NM, Vastert S, Jansen MHA. The protective effect of COVID-19 vaccines on developing multisystem inflammatory syndrome in children (MIS-C): a systematic literature review and meta-analysis. Pediatr Rheumatol Online J 2023; 21:80. [PMID: 37550719 PMCID: PMC10405572 DOI: 10.1186/s12969-023-00848-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 06/18/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVE To review whether the current COVID-19 vaccines can prevent the occurrence of multisystem inflammatory syndrome in children (MIS-C) and adolescents. METHODS A systematic literature review and meta-analysis were performed. The data were abstracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was the efficacy of COVID-19 vaccination in preventing MIS-C development. The search was performed in PubMed and Embase. RESULTS The review yielded 13 studies, which were included for critical appraisal and data extraction. The available studies showed a reduced incidence of MIS-C after mRNA COVID-19 vaccination in children aged 12-18 years. Four studies were eligible for meta-analysis and the pooled odds ratio for MIS-C in vaccinated children compared to unvaccinated children was 0.04 (95% confidence interval: 0.03-0.06). Additionally, the risk of MIS-C as an adverse effect of vaccination was much lower compared to the risk of MIS-C post-infection. CONCLUSIONS Our systematic review highlights the current available evidence on the efficacy of COVID-19 vaccination in preventing MIS-C. The published studies so far - mainly conducted during the Delta wave - indicate that (original strain) COVID-19 mRNA vaccines in children are safe and associated with significantly less development of MIS-C. These findings further reinforce the recommendation for COVID-19 vaccination in children, which should be promoted and largely supported.
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Affiliation(s)
- Mohamad Hamad Saied
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. box 85090, Utrecht, 3508 AB, The Netherlands.
- Department of Pediatrics, Carmel Medical Center, Technion Faculty of Medicine, Haifa, Israel.
| | | | - Joeri W van Straalen
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. box 85090, Utrecht, 3508 AB, The Netherlands
| | - Nico M Wulffraat
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. box 85090, Utrecht, 3508 AB, The Netherlands
| | - Sebastiaan Vastert
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. box 85090, Utrecht, 3508 AB, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc H A Jansen
- Department of Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. box 85090, Utrecht, 3508 AB, The Netherlands
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3
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Soriano-Arandes A, Brett A, Buonsenso D, Emilsson L, de la Fuente Garcia I, Gkentzi D, Helve O, Kepp KP, Mossberg M, Muka T, Munro A, Papan C, Perramon-Malavez A, Schaltz-Buchholzer F, Smeesters PR, Zimmermann P. Policies on children and schools during the SARS-CoV-2 pandemic in Western Europe. Front Public Health 2023; 11:1175444. [PMID: 37564427 PMCID: PMC10411527 DOI: 10.3389/fpubh.2023.1175444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/26/2023] [Indexed: 08/12/2023] Open
Abstract
During the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), mitigation policies for children have been a topic of considerable uncertainty and debate. Although some children have co-morbidities which increase their risk for severe coronavirus disease (COVID-19), and complications such as multisystem inflammatory syndrome and long COVID, most children only get mild COVID-19. On the other hand, consistent evidence shows that mass mitigation measures had enormous adverse impacts on children. A central question can thus be posed: What amount of mitigation should children bear, in response to a disease that is disproportionally affecting older people? In this review, we analyze the distinct child versus adult epidemiology, policies, mitigation trade-offs and outcomes in children in Western Europe. The highly heterogenous European policies applied to children compared to adults did not lead to significant measurable differences in outcomes. Remarkably, the relative epidemiological importance of transmission from school-age children to other age groups remains uncertain, with current evidence suggesting that schools often follow, rather than lead, community transmission. Important learning points for future pandemics are summarized.
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Affiliation(s)
- Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ana Brett
- Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Milan, Italy
| | - Louise Emilsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Sweden
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Isabel de la Fuente Garcia
- Pediatric Infectious Diseases, National Pediatric Center, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Despoina Gkentzi
- Department of Paediatrics, Patras Medical School, Patras, Greece
| | - Otto Helve
- Department of Health Security, Institute for Health and Welfare, Helsinki, Finland
- Pediatric Research Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kasper P. Kepp
- Section of Biophysical and Biomedicinal Chemistry, DTU Chemistry, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Maria Mossberg
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Epistudia, Bern, Switzerland
| | - Alasdair Munro
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, Institute of Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Aida Perramon-Malavez
- Computational Biology and Complex Systems (BIOCOM-SC) Group, Department of Physics, Universitat Politècnica de Catalunya (UPC·BarcelonaTech), Barcelona, Spain
| | | | - Pierre R. Smeesters
- Department of Pediatrics, University Hospital Brussels, Academic Children’s Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium
- Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Petra Zimmermann
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Department of Paediatrics, Fribourg Hospital, Fribourg, Switzerland
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4
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La Torre F, Taddio A, Conti C, Cattalini M. Multi-Inflammatory Syndrome in Children (MIS-C) in 2023: Is It Time to Forget about It? CHILDREN (BASEL, SWITZERLAND) 2023; 10:980. [PMID: 37371212 PMCID: PMC10297102 DOI: 10.3390/children10060980] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/31/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is defined as a clinically serious condition requiring hospitalization involving fever, multi-system organ dysfunction, and an increase in inflammatory biomarkers. The syndrome was originally described as a post-infectious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which usually causes COVID-19. During the COVID-19 pandemic, not only did the virus undergo mutations but vaccines against SARS-CoV-2 were also developed. Both these conditions led to a decrease in the incidence of MIS-C. This narrative review summarizes the recent updates for MIS-C, particularly regarding the change in incidence, the link between the SARS-CoV-2 vaccine and MIS-C, and new updates of MIS-C treatments.
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Affiliation(s)
- Francesco La Torre
- Pediatric Rheumatology Center, Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, 70121 Bari, Italy
| | - Andrea Taddio
- Institute of Child and Maternal Health–IRCCS “Burlo Garofolo”, University of Trieste, 34127 Trieste, Italy
| | - Chiara Conti
- Pediatrics Clinic, Department of Experimental and Clinical Sciences, University of Brescia, 25121 Brescia, Italy
| | - Marco Cattalini
- Pediatrics Clinic, Department of Experimental and Clinical Sciences, University of Brescia, 25121 Brescia, Italy
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5
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Ludwikowska KM, Popiel A, Matkowska-Kocjan A, Olbromski MJ, Biela M, Wójcik M, Szenborn F, Wielgos K, Pielka-Markiewicz E, Zaryczański J, Kursa MB, Szenborn L. COVID-19 mRNA BNT162b2 vaccine safety and B-cell and T-cell reactogenicity among children with a history of paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS) - preliminary study. Vaccine 2023; 41:2289-2299. [PMID: 36870876 PMCID: PMC9977623 DOI: 10.1016/j.vaccine.2023.02.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
To assess the safety of Pfizer-BioNTech COVID-19 mRNA BNT162b2 vaccine (Comirnaty®) among patients with the anamnesis of paediatric inflammatory syndrome temporally associated with COVID-19 (PIMS-TS), we conducted a prospective cohort study of 21 patients with history of PIMS (PIMS group, median age 7.4 years, 71% male) and 71 healthy controls without such an anamnesis (CONTROL group, median age 9.0 years, 39% male) aged 5-18 years. Among them, 85 patients (all PIMS patients and 64 CONTROL patients) completed the two dose schedule of vaccination administered 21 days apart and 7 children in the CONTROL group received a single, age appropriate dose of a COVID-19 mRNA BNT162b2 vaccine during the study period. The frequency and character of reported adverse events (AEs) after each dose and results of flow cytometry (FC) 3 weeks after a second dose were compared between those groups. COVID-19 mRNA BNT162b2 vaccine safety profile was very good and comparable in both groups. No severe AEs were observed. 30% of all patients reported some general AE after any vaccine dose and 46% - some local AE. Frequency of reported AEs did not differ between groups except for local hardening at injection site, more common in PIMS group (20% vs 4% after any vaccine dose, p = 0,02). All AEs were benign, general AEs lasted up to 5 days and localised - up to 6 days after a vaccine dose. COVID-19 mRNA BNT162b2 vaccine did not induce any PIMS-like symptoms in any patient. We did not observe any significant T cells or B cells subset abnormalities in the PIMS group compared to the CONTROL group three weeks after a second dose except for terminally differentiated effector memory T cells that were higher in PIMS group (p < 0.0041). To sum up COVID-19 mRNA BNT162b2 vaccine in children with PIMS-TS was safe. Further studies are required to support our findings.
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Affiliation(s)
- Kamila M Ludwikowska
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland.
| | - Aneta Popiel
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland; Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Agnieszka Matkowska-Kocjan
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Mateusz J Olbromski
- Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Mateusz Biela
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Marta Wójcik
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Filip Szenborn
- Faculty of Electronics, Wroclaw University of Science and Technology, Stanisława Wyspiańskiego 27, 50-370 Wrocław, Poland
| | - Katarzyna Wielgos
- Department of Paediatrics, J. Gromkowski Regional Specialist Hospital in Wroclaw, Koszarowa 5, 51-149 Wroclaw, Poland
| | - Ewa Pielka-Markiewicz
- University Clinical Hospital in Opole Pediatric Ward, Wincentego Witosa 26, 46-020 Opole, Poland
| | - Janusz Zaryczański
- Department of Paediatrics, Institute of Medical Sciences, University of Opole, Wincentego Witosa 26, 46-020 Opole, Poland
| | - Miron B Kursa
- Interdisciplinary Centre for Mathematical and Computational Modelling, University of Warsaw, Pawinskiego 5A, 02-106 Warsaw, Poland
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
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6
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Haq K, Anyalechi EG, Schlaudecker EP, McKay R, Kamidani S, Manos CK, Oster ME. Multiple MIS-C Readmissions and Giant Coronary Aneurysm After COVID-19 Illness and Vaccination: A Case Report. Pediatr Infect Dis J 2023; 42:e64-e69. [PMID: 36729556 PMCID: PMC9935235 DOI: 10.1097/inf.0000000000003801] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) rarely involves delayed giant coronary aneurysms, multiple readmissions or occurrence after COVID-19 vaccination. METHODS We describe a child with all 3 of these unusual features. We discuss his clinical presentation, medical management, review of the current literature and CDC guidance recommendations regarding further vaccinations. RESULTS A 5-year-old boy had onset of MIS-C symptoms 55 days after COVID-19 illness and 15 days after receiving his first BNT162b2 COVID-19 vaccination. He was admitted 3 times for MIS-C, and twice after his steroid dose was tapered. On his initial admission, he was given intravenous immunoglobulin and steroids. During his second admission, new, moderate coronary dilation was noted, and he was treated with intravenous immunoglobulin and steroids. At his last admission, worsening coronary dilation was noted, and he was treated with infliximab and steroids. During follow-up, he had improvement in his coronary artery dilatation. However, his inflammatory markers increased after steroid wean, and his steroid taper was further extended, after which time his inflammatory markers improved. This is the only such reported case of a patient who was admitted 3 times for MIS-C complications after COVID-19 vaccination. CONCLUSION MIS-C rarely involves delayed giant coronary aneurysms, multiple readmissions, or occurrence after COVID-19 vaccination. Whether our patient's COVID-19 vaccine 6 weeks after COVID-19 illness contributed to his MIS-C is unknown. After consultation with the CDC-funded Clinical Immunization Safety Assessment Project, the patient's care team decided against further COVID-19 vaccination until at least 3 months post normalization of inflammatory markers.
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Affiliation(s)
- Khadija Haq
- From the Children’s Healthcare of Atlanta
- Department of Pediatrics, Morehouse School of Medicine
| | - E. Gloria Anyalechi
- Clinical Immunization Safety Assessment, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth P. Schlaudecker
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel McKay
- From the Children’s Healthcare of Atlanta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Satoshi Kamidani
- From the Children’s Healthcare of Atlanta
- Clinical Immunization Safety Assessment, Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Cynthia K. Manos
- From the Children’s Healthcare of Atlanta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew E. Oster
- From the Children’s Healthcare of Atlanta
- Clinical Immunization Safety Assessment, Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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7
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Pino R, Antoñanzas JM, Paredes-Carmona F, Perramon A, Rivière JG, Coma M, Martínez-Mejías A, Ripoll F, López N, Conti R, Sala-Castellví P, Ruiz M, Brio S, García-Lorenzo M, Esteller M, Carreras-Abad C, Herrero-Hernando C, Schneider SO, Gatell A, Aguilar I, Cantero J, Ruiz G, Fenollosa T, Lobato Z, Villalobos P, Mora E, Anton J, Visa-Reñé N, Soler-Palacin P, Calavia O, Esquirol-Herrero C, Guarch-Ibañez B, García-García JJ, Coma E, Fina F, Prats C, Soriano-Arandes A. Multisystem inflammatory syndrome in children and SARS-CoV-2 variants: a two-year ambispective multicentric cohort study in Catalonia, Spain. Eur J Pediatr 2023; 182:1897-1909. [PMID: 36801975 PMCID: PMC9937862 DOI: 10.1007/s00431-023-04862-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/20/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare but severe disease temporarily related to SARS-CoV-2. We aimed to describe the epidemiological, clinical, and laboratory findings of all MIS-C cases diagnosed in children < 18 years old in Catalonia (Spain) to study their trend throughout the pandemic. This was a multicenter ambispective observational cohort study (April 2020-April 2022). Data were obtained from the COVID-19 Catalan surveillance system and from all hospitals in Catalonia. We analyzed MIS-C cases regarding SARS-CoV-2 variants for demographics, symptoms, severity, monthly MIS-C incidence, ratio between MIS-C and accumulated COVID-19 cases, and associated rate ratios (RR). Among 555,848 SARS-CoV-2 infections, 152 children were diagnosed with MIS-C. The monthly MIS-C incidence was 4.1 (95% CI: 3.4-4.8) per 1,000,000 people, and 273 (95% CI: 230-316) per 1,000,000 SARS-CoV-2 infections (i.e., one case per 3,700 SARS-CoV-2 infections). During the Omicron period, the MIS-C RR was 8.2 (95% CI: 5.7-11.7) per 1,000,000 SARS-CoV-2 infections, which was significantly lower (p < 0.001) than that for previous variant periods in all age groups. The median [IQR] age of MIS-C was 8 [4-11] years, 62.5% male, and 80.2% without comorbidities. Common symptoms were gastrointestinal findings (88.2%) and fever > 39 °C (81.6%); nearly 40% had an abnormal echocardiography, and 7% had coronary aneurysm. Clinical manifestations and laboratory data were not different throughout the variant periods (p > 0.05). Conclusion: The RR between MIS-C cases and SARS-CoV-2 infections was significantly lower in the Omicron period for all age groups, including those not vaccinated, suggesting that the variant could be the main factor for this shift in the MISC trend. Regardless of variant type, the patients had similar phenotypes and severity throughout the pandemic. What is Known: • Before our study, only two publications investigated the incidence of MIS-C regarding SARS-CoV-2 variants in Europe, one from Southeast England and another from Denmark. What is New: • To our knowledge, this is the first study investigating MIS-C incidence in Southern Europe, with the ability to recruit all MIS-C cases in a determined area and analyze the rate ratio for MIS-C among SARS-CoV-2 infections throughout variant periods. • We found a lower rate ratio of MISC/infections with SARS-CoV-2 in the Omicron period for all age groups, including those not eligible for vaccination, suggesting that the variant could be the main factor for this shift in the MISC trend.
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Affiliation(s)
- Rosa Pino
- Paediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Catalonia, Spain
| | - Jesús M Antoñanzas
- Department of Physics, Universitat Politècnica de Catalunya, Barcelona, Catalonia, Spain
| | | | - Aida Perramon
- Department of Physics, Universitat Politècnica de Catalunya, Barcelona, Catalonia, Spain
| | - Jacques G Rivière
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Passeig de La Vall d'Hebron, 119-129, 08035, Barcelona, Catalonia, Spain
| | - Maria Coma
- Hospital Universitari Joan XXII, Tarragona, Catalonia, Spain
| | | | - Francesc Ripoll
- Unitat d'Infectologia Pediàtrica de Girona ICS-IAS, Hospital Universitari Josep Trueta, Girona, Catalonia, Spain
| | - Núria López
- Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Romina Conti
- Consorci Sanitari Parc Taulí, Sabadell, Catalonia, Spain
| | - Pere Sala-Castellví
- Hospital Universitari General de Catalunya, Sant Cugat del Vallés, Barcelona, Catalonia, Spain
| | - Montserrat Ruiz
- Hospital Universitari de Vic, Vic, Barcelona, Catalonia, Spain
| | - Sonia Brio
- Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | | | | | - Clara Carreras-Abad
- Paediatric Infectious Diseases Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Catalonia, Spain
| | - Carlos Herrero-Hernando
- Department of Pediatrics, Hospital de Barcelona, Societat Cooperativa d'Instal·Lacions Assistencials Sanitàries (SCIAS), Barcelona, Catalonia, Spain
| | | | - Anna Gatell
- Equip d'Atenció Primària de Pediatria Garraf, Institut Català de La Salut, Vilanova I La Geltrú, Catalonia, Spain
| | - Isabel Aguilar
- CAP Camps Blancs, Institut Català de La Salut, Sant Boi de Llobregat, Barcelona, Catalonia, Spain
| | - Javier Cantero
- Corporació de Salut del Maresme I La Selva, Barcelona-Girona, Catalonia, Spain
| | - Gloria Ruiz
- Pediatria Dels Pirineus SCCLP, Lleida, Catalonia, Spain
| | | | - Zulema Lobato
- Althaia, Xarxa Assistencial Universitària de Manresa (Fundació Althaia), Catalonia, Barcelona, Spain
| | | | - Emiliano Mora
- Hospital Mútua de Terrassa, Barcelona, Catalonia, Spain
| | - Jordi Anton
- Paediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Catalonia, Spain
| | - Núria Visa-Reñé
- Hospital Universitari Arnau de Vilanova, Lleida, Catalonia, Spain
| | - Pere Soler-Palacin
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Passeig de La Vall d'Hebron, 119-129, 08035, Barcelona, Catalonia, Spain
| | - Olga Calavia
- Hospital Universitari Joan XXII, Tarragona, Catalonia, Spain
| | | | - Borja Guarch-Ibañez
- Unitat d'Infectologia Pediàtrica de Girona ICS-IAS, Hospital Universitari Josep Trueta, Girona, Catalonia, Spain
| | - Juan-José García-García
- Paediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Catalonia, Spain
| | - Ermengol Coma
- Sistemes d'Informació Dels Serveis d'Atenció Primària (SISAP), Institut Català de La Salut (ICS), Barcelona, Catalonia, Spain
| | - Francesc Fina
- Sistemes d'Informació Dels Serveis d'Atenció Primària (SISAP), Institut Català de La Salut (ICS), Barcelona, Catalonia, Spain
| | - Clara Prats
- Department of Physics, Universitat Politècnica de Catalunya, Barcelona, Catalonia, Spain
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Passeig de La Vall d'Hebron, 119-129, 08035, Barcelona, Catalonia, Spain.
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8
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Milito C, Cinetto F, Garzi G, Palladino A, Puca M, Brambilla E, De Vitis C, Costanzo G, Scarpa R, Punziano A, Lagnese G, Del Giacco S, Spadaro G, Quinti I, Firinu D. Safety of mRNA COVID-19 Vaccines in Patients with Inborn Errors of Immunity: an Italian Multicentric Study. J Clin Immunol 2023; 43:299-307. [PMID: 36374363 PMCID: PMC9662105 DOI: 10.1007/s10875-022-01402-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Little is known about vaccine safety in inborn errors of immunity (IEI) patients during the current vaccination campaign for COVID-19. To better investigate the reactogenicity and adverse event profile after two, three, and four doses of mRNA vaccines, we conducted an observational, multicentric study on 342 PID patients from four Italian Referral Centres. METHODS We conducted a survey on self-reported adverse reactions in IEI patients who received mRNA vaccine by administering a questionnaire after each dose. RESULTS Over the whole study period, none of the patients needed hospitalization or had hypersensitivity reactions, including anaphylaxis and delayed injection site reaction. After two vaccination doses, 35.4% of patients showed only local reactogenicity-related symptoms (RrS), 44.4% reported both systemic and local RrS, and 5% reported only systemic RrS. In more than 60% of cases, local or systemic RrS were mild. After the first and second booster doses, patients showed fewer adverse events (AEs) than after the first vaccination course. Patients aged 50 years and older reported adverse events and RrS less frequently. Among AEs requiring treatment, one common variable immune deficiency patient affected by T cell large granular lymphocytic leukemia developed neutropenia and one patient had Bell's paralysis perhaps during herpes zoster reactivation. CONCLUSION Although our follow-up period is relatively short, the safety data we reported are reassuring. This data would help to contrast the vaccine hesitancy often manifested by patients with IEI and to better inform their healthcare providers.
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Affiliation(s)
- Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Cinetto
- Department of Medicine-DIMED, University of Padova, Padua, Italy
- Rare Diseases Referral Center, Internal Medicine I, Ca' Foncello Hospital, AULSS2 Marca Trevigiana, Treviso, Italy
| | - Giulia Garzi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Palladino
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Puca
- Department of Medical Sciences and Public Health, University of Cagliari, Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Elena Brambilla
- Department of Medicine-DIMED, University of Padova, Padua, Italy
- Rare Diseases Referral Center, Internal Medicine I, Ca' Foncello Hospital, AULSS2 Marca Trevigiana, Treviso, Italy
| | - Camilla De Vitis
- Department of Medicine-DIMED, University of Padova, Padua, Italy
- Rare Diseases Referral Center, Internal Medicine I, Ca' Foncello Hospital, AULSS2 Marca Trevigiana, Treviso, Italy
| | - Giulia Costanzo
- Department of Medical Sciences and Public Health, University of Cagliari, Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Riccardo Scarpa
- Department of Medicine-DIMED, University of Padova, Padua, Italy
- Rare Diseases Referral Center, Internal Medicine I, Ca' Foncello Hospital, AULSS2 Marca Trevigiana, Treviso, Italy
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Gianluca Lagnese
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy.
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9
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Feleszko W, Okarska-Napierała M, Buddingh EP, Bloomfield M, Sediva A, Bautista-Rodriguez C, Brough HA, Eigenmann PA, Eiwegger T, Eljaszewicz A, Eyerich S, Gomez-Casado C, Fraisse A, Janda J, Jiménez-Saiz R, Kallinich T, Krohn IK, Mortz CG, Riggioni C, Sastre J, Sokolowska M, Strzelczyk Z, Untersmayr E, Tramper-Stranders G. Pathogenesis, immunology, and immune-targeted management of the multisystem inflammatory syndrome in children (MIS-C) or pediatric inflammatory multisystem syndrome (PIMS): EAACI Position Paper. Pediatr Allergy Immunol 2023; 34:e13900. [PMID: 36705045 DOI: 10.1111/pai.13900] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare, but severe complication of coronavirus disease 2019 (COVID-19). It develops approximately 4 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and involves hyperinflammation with multisystem injury, commonly progressing to shock. The exact pathomechanism of MIS-C is not known, but immunological dysregulation leading to cytokine storm plays a central role. In response to the emergence of MIS-C, the European Academy of Allergy and Clinical Immunology (EAACI) established a task force (TF) within the Immunology Section in May 2021. With the use of an online Delphi process, TF formulated clinical statements regarding immunological background of MIS-C, diagnosis, treatment, follow-up, and the role of COVID-19 vaccinations. MIS-C case definition is broad, and diagnosis is made based on clinical presentation. The immunological mechanism leading to MIS-C is unclear and depends on activating multiple pathways leading to hyperinflammation. Current management of MIS-C relies on supportive care in combination with immunosuppressive and/or immunomodulatory agents. The most frequently used agents are systemic steroids and intravenous immunoglobulin. Despite good overall short-term outcome, MIS-C patients should be followed-up at regular intervals after discharge, focusing on cardiac disease, organ damage, and inflammatory activity. COVID-19 vaccination is a safe and effective measure to prevent MIS-C. In anticipation of further research, we propose a convenient and clinically practical algorithm for managing MIS-C developed by the Immunology Section of the EAACI.
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Affiliation(s)
- Wojciech Feleszko
- Department of Pediatric Pneumology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | | | - Emilie Pauline Buddingh
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marketa Bloomfield
- Department of Immunology, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic.,Department of Pediatrics, 1st Faculty of Medicine, Thomayer University Hospital, Charles University, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Carles Bautista-Rodriguez
- Pediatric Cardiology Services, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Helen A Brough
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, St. Thomas' Hospital, King's College London, London, UK.,Children's Allergy Service, Evelina Children's Hospital, Guy's and St.Thomas' Hospital NHS Foundation Trust, London, UK.,Paediatric Allergy Group, Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Guys' Hospital, King's College London, London, UK
| | - Philippe A Eigenmann
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Thomas Eiwegger
- Karl Landsteiner University of Health Sciences, Krems, Austria.,Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Andrzej Eljaszewicz
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland
| | - Stefanie Eyerich
- Center for Allergy and Environment (ZAUM), Technical University and Helmholtz Center Munich, Munich, Germany
| | - Cristina Gomez-Casado
- Department of Dermatology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alain Fraisse
- Pediatric Cardiology Services, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Jozef Janda
- Faculty of Science, Charles University, Prague, Czech Republic
| | - Rodrigo Jiménez-Saiz
- Department of Immunology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain.,Department of Immunology and Oncology, Centro Nacional de Biotecnología (CNB-CSIC), Madrid, Spain.,Faculty of Experimental Sciences, Universidad Francisco de Vitoria (UFV), Madrid, Spain.,Department of Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Tilmann Kallinich
- Pediatric Pneumology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin and Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, Berlin, Germany
| | - Inge Kortekaas Krohn
- SKIN Research Group, Vrije Univeristeit Brussel (VUB), Brussels, Belgium.,Department of Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Carmen Riggioni
- Allergy, Immunology and Rheumatology Division, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joaquin Sastre
- Fundacion Jimenez Diaz and CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne - Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Ziemowit Strzelczyk
- Department of Pediatric Pneumology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Gerdien Tramper-Stranders
- Department of Paediatric Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Neonatology, Erasmus MC-Sophia, Rotterdam, The Netherlands
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10
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Aykac K, Ozturk K, Demir OO, Gumus DD, Aslan S, Cem E, Celebi MY, Karabacak MD, Alkan G, Aksoy FD, Yayla BCC, Kepenekli E, Celebi S, Emiroglu M, Devrim I, Cengiz AB, Ceyhan M, Ozsurekci Y. Frequency and safety of COVID-19 vaccination in children with multisystem inflammatory syndrome: a telephonic interview-based analysis. World J Pediatr 2022; 18:700-705. [PMID: 35972716 PMCID: PMC9379241 DOI: 10.1007/s12519-022-00604-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 10/25/2022]
Affiliation(s)
- Kubra Aykac
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Kubra Ozturk
- Goztepe Prof. Dr. Suleyman, Department of Pediatric Rheumatology, Yalcın City Hospital, Istanbul, Turkey
| | - Osman Oguz Demir
- Faculty of Medicine, Department of Pediatric Diseases, Hacettepe University, Ankara, Turkey
| | - Dilan Demir Gumus
- Faculty of Medicine, Department of Pediatric Diseases, Hacettepe University, Ankara, Turkey
| | - Sevgi Aslan
- Department of Pediatric Infectious Diseases, Marmara University School of Medicine, Istanbul, Turkey
| | - Ela Cem
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Miray Yilmaz Celebi
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Mustafa Dogan Karabacak
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Gulsum Alkan
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Selcuk University, Konya, Turkey
| | - Fatma Dilsad Aksoy
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Uludag University, Bursa, Turkey
| | - Burcu Ceylan Cura Yayla
- Department of Pediatric Infectious Diseases, University of Health Science Ankara Training and Research Hospital, Ankara, Turkey
| | - Eda Kepenekli
- Department of Pediatric Infectious Diseases, Marmara University School of Medicine, Istanbul, Turkey
| | - Solmaz Celebi
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Uludag University, Bursa, Turkey
| | - Melike Emiroglu
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Selcuk University, Konya, Turkey
| | - Ilker Devrim
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Ali Bulent Cengiz
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Mehmet Ceyhan
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey
| | - Yasemin Ozsurekci
- Faculty of Medicine, Department of Pediatric Infectious Diseases, Hacettepe University, Ankara, Turkey.
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11
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Minoia F, Lucioni F, Heshin-Bekenstein M, Vastert S, Kessel C, Uziel Y, Lamot L, Ruperto N, Gattorno M, Bracaglia C, Toplak N. Approaches to SARS-CoV-2 and other vaccinations in children with a history of multisystem inflammatory syndrome (MIS-C): An international survey. Front Pediatr 2022; 10:1030083. [PMID: 36440337 PMCID: PMC9682234 DOI: 10.3389/fped.2022.1030083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Francesca Minoia
- Pediatric Immuno-Rheumatology Unit, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Lucioni
- Pediatric Immuno-Rheumatology Unit, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Merav Heshin-Bekenstein
- Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Sebastiaan Vastert
- Division of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Christoph Kessel
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
| | - Lovro Lamot
- University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Nicolino Ruperto
- UOSID Centro Trial, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Claudia Bracaglia
- Division of Rheumatology and Laboratory of Immuno Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Natasa Toplak
- Department of Pediatric Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre, MF, UL, Ljubljana, Slovenia
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