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.
Treating Your A/I Patients
Caring for Pregnant Patients with Asthma during the COVID-19 Pandemic (Updated 10/4/21)
- 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.
- On August 19th 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 Committee (PIDD) have 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)
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.
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
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: 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