The AAAAI has compiled the following resources so that you have the latest information to inform you as you continue to treat your allergy/immunology patients during the ongoing pandemic. This includes a section specific to pediatric patients due to the increase of COVID-19 cases in children.
An Update on COVID-19 for the Practicing Allergist/immunologist (Updated 12/19/22)
Treating Your A/I Patients
Caring for Pregnant Patients with Asthma during the COVID-19 Pandemic (Updated 12/14/22)
- The CDC recommends urgent action to increase COVID-19 vaccination among people who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future. As of September 27, 2021, more than 125,000 laboratory-confirmed COVID-19 cases have been reported in pregnant people, including more than 22,000 hospitalized cases and 161 deaths.
- The COVID 19 Task Force does not anticipate any contraindication with the COVID-19 vaccine for patients on allergen immunotherapy (AIT). However, it would be best to not get the 2 shots within 48 hours of each other to avoid confusion should a reaction occur.
Vaccines for Moderately to Severely Immunocompromised Patients Age 12 and Above
- On October 25, 2021 the CDC recommended that immunocompromised people aged 18 years and older who completed an mRNA COVID-19 vaccine primary series and received an additional mRNA vaccine dose may receive a single COVID-19 booster dose (Pfizer-BioNTech, Moderna, or Janssen) at least 6 months after completing their third mRNA vaccine dose. In such situations, people who are moderately and severely immunocompromised may receive a total of four COVID-19 vaccine doses.
- On August 19, 2021, the CDC made the recommendation that immunocompromised patients should receive a third COVID-19 dose in order to improve their chances of protective immunity. They specifically recommended that patients with moderate to severe primary immunodeficiency disorders should be among those who receive a third dose.
- The AAAAI Primary Immunodeficiency Diseases (PIDD) Committee has reviewed available evidence on SARS-CoV-2 vaccine responses in patients with inborn errors of immunity (IEI), and acknowledge that information regarding the types of IEI that represent higher risk of either severe COVID-19 and/or suboptimal response to current SARS-CoV-2 vaccinations is still emerging. The AAAAI PIDD committee endorses the third dose for people with immune deficiencies as it believes most patients will benefit from the extra dose. However, the timing and specifics should be discussed with one’s own immunologist.
- Reactions to a third dose of an mRNA COVID-19 vaccine are similar to reactions after the second dose. (MMWR, October 2021)
Mild Disease Associated With Long-Term Cardiac Pathology
A prospective cohort study in 346 previously well individuals with mild initial COVID-19 disease found that 57% had persistent cardiac symptoms at follow-up 329 days after infection. Symptoms included exertional dyspnea (62%), palpitations (28%), atypical chest pain (27%) and syncope (3%). Structural heart disease or high levels of biomarkers of cardiac injury or dysfunction were rare, but imaging indicated ongoing cardiac inflammation.
Resources for Respiratory and Cardiovascular Symptoms Associated With Long COVID (PCC, PASC)
A recent CDC Clinician Outreach and Communication Activity (COCA) call presented a good overview of cardiovascular symptoms following COVID-19 with suggestions on evaluation and support. These patients may present with cough and dyspnea. Females, older age and more severe disease are risk factors, but can occur even with asymptomatic infection. The incidence is 17%, 8-14% with some activity limitation. As allergists, we need to evaluate possible pulmonary co-morbidities that might be contributing. Slides from the call can be found here. PASC Consensus Guidance statements from the American Academy of Physical Medicine and Rehabilitation on breathing discomfort and respiratory sequelae can be found here and on cardiovascular disease here. Get information here on the NIH Recover Initiative to learn more about long-term effects of COVID, find a study near you or to encourage your patients with long-COVID to volunteer.
Preinfection Psychological Distress Associated With Increased Risk of Post-COVID Conditions
Depression, anxiety, perceived stress, loneliness and worry about COVID-19 were prospectively associated with a 1.3- to 1.5-fold increased risk of self-reported post-COVID-19 conditions, as well as increased risk of daily life impairment related to post-COVID-19 conditions, in this cohort study involving primarily females.
As of September 2021, cases of COVID-19 in children are surging due to the ongoing spread of the Delta variant. Allergists need to remember that children, who have returned to school, may not be required to wear masks, are not currently eligible to be vaccinated if they are younger than 12, and thus could be a risk to other children and immunocompromised adults. Be aware of your local school district requirements and be an advocate for your patients’ safety.
CDC Recommends Pfizer-BioNTech COVID-19 Vaccine for Children Ages 5-11
The FDA’s Vaccines and Related Biologics Advisory Committee (VRBAC) voted unanimously with one abstention to recommend Pfizer-BioNTech’s mRNA vaccine for children ages 5-11 at one-third the normal dose. The FDA followed VRBAC’s recommendation and granted an emergency use authorization on October 29, and the ACIP agreed by unanimous vote during their meeting on November 2. You can find all of the presentations from the November 2 meeting here.
Children will get two injections of the Pfizer vaccine containing 10 micrograms of antigen given 21 days apart. Moderna’s application for approval for children ages 12-18 is still pending.
FDA and AAP Warn Against Off-Label Use of the Pfizer Vaccine
There have been a significant number of children in the United States younger than 12 years who have been given this vaccine. Both the FDA and the AAP strongly advise against this. Studies are currently ongoing to determine the proper dose and to evaluate the response. Giving this vaccine off-label could threaten your liability protection.
Vaccine Safety and Efficacy in Adolescents
Despite the earlier approval for the mRNA vaccines in adolescents, only a minority have received the vaccine. This update from the ongoing phase 2-3 placebo-controlled trial of the mRNA-1273 (Moderna) shows that local reactions (primarily injection site pain, swelling and erythema) occurred in 93.1% and 92.4% after the first and second dose respectively. 95% of these reactions were mild to moderate. Systemic reactions (headache, fatigue, chills were the most common) occurred in 68.5% and 86.1% respectively, with 85% being mild to moderate. Efficacy was similar to that in young adults. You can use this information to help convince your adolescent patients and their parents to consent to the vaccine. In another study, cardiologists report that in a small study of adolescents with myocarditis following the mRNA vaccine most tended to have a mild course, similar to young adults.
Case and Hospitalization Rates
Hospital Data Compared with Vaccination Coverage
This study demonstrated that ER visits and hospitalizations are four times greater in areas with low vaccine coverage compared to those with high vaccine coverage. (MMWR, Sept 10, 2021)
Hospitalization Among Children and Adolescents
A case-control study involving 464 patients 12-18 years in 19 pediatric hospitals from June-September 2021 found that vaccination reduced risk for hospitalization by 93%. Of adolescents hospitalized for COVID-19, 97% were unvaccinated, and no vaccinated adolescents hospitalized with COVID-19 were admitted to the ICU. (MMWR, October 22, 2021)
Weekly COVID-19-associated hospitalization rates among children and adolescents rose nearly five-fold during late June to mid-August 2021, coinciding with increased circulation of the highly transmissible SARS-CoV-2 Delta variant. The proportions of hospitalized children and adolescents with severe disease were similar before and during the period of Delta predominance. Hospitalization rates were 10 times higher among unvaccinated than among fully vaccinated adolescents.
Importance of Vaccines and Masks in the School Setting
The CDC reported an outbreak in Marin County, California in May-June of 2021 associated with an unvaccinated, symptomatic elementary teacher who was periodically unmasked, where 55% of her students were subsequently infected. The secondary attack rate was 80% in the rows closest to the teacher. The school had high adherence to masks among the students, six foot separation of desks and increased ventilation.
Pediatric Household Transmission of SARS-CoV-2 Infection
This study is particularly relevant as school reopens across the United States. It did take place prior to the dominance of the Delta variant. The study was done in Ontario, Canada and involved 6,280 households with pediatric index cases. 1,717 households (27.3%) experienced secondary transmission. The age group with the highest odds of transmitting the infection to household contacts compared with children aged 14-17 was the 0-3 year age group (1.43, 95% CI 1.17-1.75). Children in the 4-8 year age group also had a higher odds ratio (1.40, 95% CI 1.18-1.67). Since these age groups cannot be vaccinated, it is important for parents to take other precautions and be sure that the school or daycare is doing the same. As allergists who care for pediatric patients or young adults with children, we need to be aware of the family dynamics, childcare and school status in order to counsel our patients about prevention and precaution.
External Resources for Pediatric Patients
Your Local Epidemiologist Blog: Top Seven Parental Concerns Answered; COVID-19 Vaccine Update Table (Your Local Epidemiologist blog and COVID-19 Vaccine Update table are credited to Katelyn Jetelina, PhD, MPH, Assistant Professor in the Department of Epidemiology, Human Genetics and Environmental Sciences at the University of Texas School of Public Health, and are linked with permission.)
Ask the AAAAI
See what other AAAAI members are asking the COVID-19 Task Force about their patients and practices:
- An interactive, mobile-friendly online tool which complements CDC Testing Guidelines. Topics covered include whether to order testing, what kind of test to order, how to interpret the result, what to do with conflicting results, whether confirmatory testing is necessary and how vaccination affects decisions for testing
- Schools and child care programs
Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review JAMA Netw Open. 2021;4(9):e2126456