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Experts at an AAP town hall discussed topics related to COVID-19, including the risk of myocarditis after vaccination. They agreed the best approach pediatricians can take when counseling patients and families on COVID-19 continues to be:
- encouraging vaccination for all eligible children ages 12 and older and adults, and
- urging families with younger children to continue wearing masks, maintaining physical distance and choosing activities with lower risk from transmission preferably outdoors.
Stuart Berger, M.D., FAAP, chair of the AAP Section on Cardiology and Cardiac Surgery Executive Committee, Yvonne “Bonnie” Maldonado, M.D., FAAP, chair of the AAP Committee on Infectious Diseases (COID), and Sean T. O’Leary, M.D., M.P.H., FAAP, vice chair of COID, answered questions collated from AAP members by Anne R. Edwards, M.D., FAAP, AAP chief population health officer.
As of June 23, 7.7 million U.S. children under age 18 had received at least one dose of the COVID-19 vaccine, representing 42% of 16- to 17-year-olds and 29% of 12- to 15-year-olds. This includes 5.4 million children who are fully vaccinated and represents 32% of 16- to 17-year-olds and 19% of 12- to 15-year-olds, according to data from the Centers for Disease Control and Prevention (CDC).
“We do notice some trends, where (vaccination rates) may be already plateauing,” Dr. Edwards said.
Most myocarditis cases observed after COVID-19 vaccination have been “garden variety myocarditis,” Dr. Berger said. Symptoms may include significant chest pain about two to four days after vaccination, EKG changes, a troponin “bump” and MRI findings of “late gadolinium enhancement.” He observed that patients often improved after receiving nonsteroidal anti-inflammatory medications, and troponin levels came down quickly.
“What we’re seeing at least in my world as a cardiologist is (that) the potential side effects or safety issues are relatively mild compared to what we’re seeing in kids from a cardiac standpoint from the acute viral infection and certainly from MIS-C (multisystem inflammatory syndrome),” Dr. Berger said.
There is no evidence that pretreatment with anti-inflammatory medication before immunization will prevent myocarditis. The panelists also said the mechanism for myocarditis after vaccination is not yet understood.
Following are some of the questions panelists answered.
What should pediatricians do if a parent calls about an adolescent who is experiencing chest pain after receiving COVID-19 vaccine?
Dr. Berger suggested sending the patient to the emergency department to ensure the patient will receive urgent care inclusive of an EKG a troponin test, as well as close monitoring.
He said pediatricians should follow general myocarditis guidelines on returning to sports or activities if patients had myocarditis after COVID-19 vaccine. The recommendation includes avoiding sports and physical activities for three to six months if the patient has evidence of inflammation of the myocardium by troponin (test) and cardiac MRI.
Should a patient with a history or family history of congenital heart disease get the mRNA vaccine?
Just as immunizations are recommended for the prevention of influenza or respiratory syncytial virus, the same holds true for preventing COVID-19 infection, Dr. Berger said.
When counseling families on the vaccine, Dr. O’Leary said pediatricians should acknowledge unknowns and remind families that hundreds of people in the U.S. are still dying from the virus every day. Because the world has focused on the severity and prevalence of COVID-19 illness in adults, children have been overlooked, he said.
COVID-19 is one of the Top 10 causes of death for U.S. children this year, according to the CDC. Adolescents have been hospitalized for COVID-19 at nearly three times the typical hospitalization rate for influenza, according to a report covering 14 states.
“We know that the death rate from COVID is two-and-a-half to three times higher than the death rate for flu in kids. That in and of itself is really an important issue, and yet we recommend vaccination easily for flu for all kids over six months of age,” Dr. Maldonado added. “We can vaccinate our way out of this.”
As misinformation and disinformation circulate online about the vaccine, town hall attendees asked for ways to explain why it is important to get vaccinated even if the patient already had COVID-19. A few participants asked how to quell the persistent misinformation about the vaccine and infertility. (See Associated Press fact check: https://bit.ly/3zWSRH0.)
The AAP strongly encourages all eligible people ages 12 and older to get vaccinated and signed onto a statement Wednesday alongside leaders of the Department of Health and Human Services, CDC and other medical and public health groups.
Although COVID-19 cases are going down, pediatricians should remind parents that there remains a risk for unvaccinated children, especially in parts of the country where vaccination rates are low.
“Unless we can really get better vaccination coverage by the fall, we’re almost certainly going to see a fall surge,” Dr. O’Leary said.
According to Dr. Maldonado, the Delta variant is 60% more transmissible than the Alpha variant. “The vast majority of cases right now are occurring in unvaccinated individuals around the country,” she said. “If you want to prevent Delta from affecting your community, it really does make sense to vaccinate.”