COVID-19

• COVID-19 infection is spread by droplet transmission much like flu is. A virus may travel from person to person through respiratory fluids when they cough, breathe, speak, sing, sneeze etc.  Masks and handwashing are important in stopping disease spread.
• Disease in children is often mild but can be severe in some, especially the immune suppressed and chronically ill.  Mildly infected children can infect others
• Illness may be acute (short lived) or long.  There is still a lot to be learned about “Long Covid” in children.  Even mild disease can have long term consequences in some.

What is COVID-19

COVID is a respiratory disease caused by a coronavirus.  We are constantly learning about the virus and how it affects different aged individuals and how effective vaccines are.  Will it someday be an infectious disease, we learn to live with like the flu or other corona viruses that cause the common cold? When a disease circulates in the population year after year it is said to be endemic. It looks like COVID will evolve to become a milder endemic disease, but how long that will take is still pretty much guesswork. There is much we don’t know about COVID and children, however the assumption that children do not get sick or do not die from COVID, is not based in fact.

The Vaccine

Currently there is only one approved COVID vaccine for children and adolescents and that is the Pfizer/BioNTech vaccine. Dosing recommendations and booster requirements are frequently being updated as new studies and information comes in. Refer to your provider or the CDC for the most recent recommendations. There are more rigorous requirements to approve vaccines for children than for adults so COVID vaccines for kids will always lag behind those of adults.

A note on vaccine effectiveness:  As a vaccine moves from the somewhat controlled environment of a phase III trial and out into the real world, the marker we use to judge how well it works is “effectiveness”.  Effectiveness of a vaccine will vary due to several factors.  Age, immune history, and pregnancy are just some of the human factors that come into play.  The percentage associated with effectiveness is for an individual and not for a group.  For example, if a vaccine is 85% effective that means those who received the vaccine are at a 85% lower risk of developing disease not that 15% of a group will get the disease.

How did they make the vaccine so quickly?

The technology for mRNA is not new.  It just hasn’t worked on other diseases in the past.  At no point in our history has so much money, brain power, and political will been directed toward one disease.

Scientists had been studying coronaviruses for over 50 years and a lot was already known about their structure, genome and their life cycle or reproduction.  Most importantly, they knew about the “S” or spike protein on the virus which plays a key role in how the virus attaches to our cells and makes its way inside to carry out replication.  That spike protein was a good starting place for vaccine development and treatment.

But that doesn’t fully explain how we got a vaccine to fight against a virus we had only met a year before.  Most vaccines are developed more slowly for a few different reasons.

1. The research and development process used by companies, primarily large pharmaceutical companies, takes a long time. There are permits, and recruiting, and FDA hoops to jump through and it takes a lot of money.  In addition, when a vaccine is being developed, the company may not want to share a new technology or process.  It may not be very transparent with its competitors.
2. In the non-emergency version of vaccine development, the process happens step by step. Much like a relay race is run. Each phase in the process is like a runner who runs a full lap before handing off the baton.

With the COVID vaccine the runners ran in sprint fashion.  All at once.  Especially unique to this vaccine, is the vaccines were manufactured before the clinical safety trials were completed.

What?!?!   Yes, it was a huge gamble to take.  If the vaccine had proven to be unsafe or not effective against preventing severe disease, then they would have had to toss it all.  And with so many reputable scientists and groups watching the process so carefully it would have been pretty impossible to slip a dangerous or ineffective vaccine through the approval process.

The vaccine itself is fairly easy to make but the small jars, the rubber stoppers, the syringes and labels all take more time.  With factories shut down due to outbreaks, getting the vaccine as quickly as we did really is a miracle.

Infection versus disease versus severe disease.

The medical community sometimes seems obsessed with pointing out that the vaccine doesn’t prevent infection it prevents severe disease.  What is the difference and why does it matter?

Asking a vaccine to prevent against infection, meaning the virus can’t enter the body or enter cells, is a pretty tall order given how the immune system responds to invading organisms.  It takes a little bit of time for the immune system to respond and attack a virus before it enters cells (antibodies do this) or to train killer T-cells to attack infected cells.  The vaccine gives the body a heads up and starts this process ahead of time. So while “infection” might still happen the immune system is ready to mobilize quickly and shut down the virus.  Without the vaccine training in place, the body takes longer giving the virus more time to replicate (reproduce) and damage more cells. This can lead to “disease” or “severe disease” which leads to hospitalization in some cases.

A simpler way to put it is infection is when the virus enters your cells.  Disease is when you show signs and symptoms of that infection.  Symptoms such as fever and inflammation are results of the immune system attacking the invading virus.  Sometimes this response can get out of control and a child might experience Multi-system Inflammatory Syndrome (MIS-C).  See below for more information.

What about medications?

Antivirals either make it harder for the virus to get into a cell or they prevent the virus from reproducing once they are inside of your cells. Antivirals, and other treatments such as monoclonals, are still being developed.

COVID and Mental Health in children

There is still much to learn about the mental health effects of COVID on children.  It is fairly easy to assume that the social and mental health impacts of social distancing and pandemic restrictions would have on children.

For most children being isolated from friends, school and extended family is not conducive to social and mental well-being. There are of course exceptions to every rule, but to say children, especially adolescents, have not fared well during the pandemic would be an understatement.  New research is beginning to shed light on how a COVID infection may cause neurological damage that impacts children and adult mental health.

Multi-systemic Inflammatory Syndrome (MIS-C) 

MIS-C is a rare but serious complication of a COVID infection. In the simplest terms it is an immune response against your own blood vessels causing organs (heart, kidneys, brain, skin, eyes, intestinal system) in the body to become inflamed.  What actually causes MIS-C to occur is unknown but children with MIS also have blood tests indicating an infection by the virus that causes COVID-19.

The most commonly affected age group is school aged children, specifically 8-9 year old’s.  Infants and older children can also develop MIS-C although less commonly.

The symptoms of MIS-C, high fever, fatigue, stomach pain, rash, red eyes, diarrhea, dizziness, commonly show up about 4 weeks (anywhere from 2-6 weeks) after a COVID infection.   During this time there is no virus shedding. May occur after a mild or severe infection.

Kids showing symptoms of MIS should be seen by a doctor promptly to avoid long term damage to organs.  The condition is treatable and full recovery occurs in most children.

It is too early to make definitive statements regarding vaccine protection against MIS-C but early indicators and study do show that most of the children who develop this particular complication of COVID are unvaccinated.

Common Questions

Can children get long COVID?

Long Covid, or post-acute sequelae of SARS CoV-2 infection, refers to a condition in people who experience 4 or more weeks of ongoing problems or symptoms following a COVID infection.  For some people these conditions may last 9 months or longer. It is still unknown how the coronavirus can impair the heart, lungs, skin, kidneys and brain, but it does.  The symptoms are not all physical.  Mental health is also affected in many children and adolescents who may experience anxiety or depression or what is becoming known as COVID Brain Fog.

Long COVID can be especially hard for parents as well.  There is not much known about why it happens, why it only occurs in some children and adults or how to cure it.

The best way to prevent the suffering of long COVID is to prevent COVID.  Preventing COVID is done through vaccines.

What about myocarditis associated with the vaccine?

Simply put, myocarditis is an inflammation of the heart muscle.  You may have never heard of this condition until recently but it is diagnosed in thousands of people every year.  The most commonly affected population is young adult males often otherwise young and healthy. Several different viral infections cause myocarditis including flu, colds and COVID.

Symptoms can range from mild to severe, with severe cases requiring hospitalization and sometimes resulting in permanent damage to the heart.  The symptoms of myocarditis might be the same as the illness that brought it on such as fever, shortness of breath and chest pain.  Most cases resolve on their own.

Myocarditis is an excellent example of comparing risk of vaccine side effects versus risk for possibility of a complication of a disease.  CDC has identified myocarditis as a rare, but real, side effect of the mRNA vaccine, specifically in young adult males. About 4-7 out of 100,000 vaccinated kids. Exactly why this happens is not clear but most likely related to a hyper immune response. Current observations suggest that myocarditis after a vaccination tends to be mild and resolves quickly.

It’s difficult to compare numbers in these situations but people who are infected with COVID are much more (17 x more) likely to have myocarditis than someone who is not.  If you took the group of 100,00 from above where 4-7 have risk of vaccine side effect and didn’t vaccinate them about 5,500 would become infected with COVID in a 3 month time-frame.  Of those 5,500, about 50 would end up hospitalized due to serious disease.  (Example taken from CHOP: Myocarditis Get the Facts)

Choosing to not vaccinate your child is not how you prevent myocarditis.