Vaccine Effectiveness Against Long COVID in Children

Cardiovascular post-acute sequelae of SARS-CoV-2 in children and adolescents: cohort study using electronic health records

The risk of cardiovascular outcomes following SARS-CoV-2 infection has been reported in adults, but evidence in children and adolescents is limited. This paper assessed the risk of a multitude of cardiac signs, symptoms, and conditions 28-179 days after infection, with outcomes stratified by the presence of congenital heart defects (CHDs), using electronic health records (EHR) data from 19 children's hospitals and health institutions from the United States within the RECOVER consortium between March 2020 and September 2023. The cohort included 297,920 SARS-CoV-2-positive individuals and 915,402 SARS-CoV-2-negative controls. Every individual had at least a six-month follow-up after cohort entry. Here we show that children and adolescents with prior SARS-CoV-2 infection are at a statistically significant increased risk of various cardiovascular outcomes, including hypertension, ventricular arrhythmias, myocarditis, heart failure, cardiomyopathy, cardiac arrest, thromboembolism, chest pain, and palpitations, compared to uninfected controls. These findings were consistent among patients with and without CHDs. Awareness of the heightened risk of cardiovascular disorders after SARS-CoV-2 infection can lead to timely referrals, diagnostic evaluations, and management to mitigate long-term cardiovascular complications in children and adolescents.

The COVID-19 pandemic in children and young people during 2022-24: what new did we learn?

The research conducted between 2022 and 2024 has advanced our understanding of COVID-19 in children and young people (CYP), particularly with the emergence of the Omicron variant and its subvariants. The findings have reinforced that, while Omicron infections are often milder compared to earlier variants, the overall seroprevalence of SARS-CoV-2 in children has increased, with notable regional and demographic disparities. COVID-19-related hospitalisation rates in children rose during Omicron waves, especially among infants, unvaccinated individuals, and CYP at higher risk, i.e. with comorbidities such as obesity, diabetes, and neurological or cardiac conditions. Despite this, severe disease and mortality in children remained very low. The observed increases in type 1 diabetes incidence and multisystem inflammatory syndrome in children (MIS-C) have also highlighted the broader systemic effects of SARS-CoV-2 in paediatric populations. Evidence has underscored the protective effect of vaccination in preventing severe disease and MIS-C and vaccine safety, emphasising the need for targeted immunisation strategies, particularly among children who may be at higher risk. Studies have also estimated that a significant proportion of children experienced persistent post-COVID-19 infection symptoms such as fatigue, mood disturbances, sleep disorders, and respiratory difficulties, but the reported prevalence varied widely, from as low as 1.6% to as high as 70%, due to differences in study methodologies, case definitions, and populations studied. Standardised definitions and measurement tools, such as those developed through international consensus processes, are required to improve diagnosis, treatment, and research into this persisting condition. Ethnic disparities in vaccine uptake persist, implying that vaccine hesitancy and accessibility, alongside approaches to countering disinformation, are important areas for future research.

Coronavirus disease 2019 (COVID-19) in children: Evolving epidemiology, immunology, symptoms, diagnostics, treatment, post-COVID-19 conditions, prevention strategies, and future directions

The epidemiology of coronavirus disease 2019 (COVID-19) in children has evolved throughout the pandemic, with initially low infection rates rising significantly as a result of the emergence of the more transmissible Omicron variant. Adolescents, children from ethnic minorities and lower-income households, and those with obesity are at increased risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The immune response in children leads to milder symptoms compared to adults, with fever and cough being most frequent; tough symptoms vary by SARS-CoV-2 variant and age. Diagnostic methods to confirm current or past infection include reverse transcription PCR, rapid antigen tests, and serology. Treatment is mainly supportive, with antivirals and glucocorticoids reserved for severe cases. While serious conditions like multisystem inflammatory syndrome in children and other post-COVID-19 conditions are rare, they require careful management. Vaccination has proven effective in reducing severe disease and protecting against post-COVID-19 conditions. Continued surveillance, including wastewater monitoring and universal or pooled testing, remains crucial for controlling community spread. Key questions remain regarding the duration and quality of immunity after reinfection or vaccination, the impact of coinfections, and optimal treatment protocols for different pediatric populations.

Long-term Sequelae Following Dengue Infection vs SARS-CoV-2 Infection in a Pediatric Population: A Retrospective Cohort Study

Background

Long-term postacute sequelae following SARS-CoV-2 infection in children have been extensively documented. However, while persistence of chronic symptoms following pediatric dengue infection has been documented in small prospective cohorts, population-based studies are limited. We evaluated the risk of multisystemic complications following dengue infection in contrast to that after SARS-CoV-2 infection in a multiethnic pediatric Asian population.

Methods

This retrospective population-based cohort study utilized national COVID-19/dengue registries to construct cohorts of Singaporean children aged 1 to 17 years with either laboratory-confirmed dengue infection from 1 January 2017 to 31 October 2022 or confirmed SARS-CoV-2 infection from 1 July 2021 to 31 October 2022. Cox regression was utilized to estimate risks of new-incident cardiovascular, neurologic, gastrointestinal, autoimmune, and respiratory complications, as identified by national health care claims data, at 31 to 300 days after dengue infection vs COVID-19. Risks were reported by 2 measures: adjusted hazard ratio (aHR) and excess burden.

Results

This study included 6452 children infected with dengue and 260 749 cases of COVID-19. Among children infected with dengue, there was increased risk of any postacute gastrointestinal sequelae (aHR, 2.98; 95% CI, 1.18-7.18), specifically appendicitis (aHR, 3.50; 95% CI, 1.36-8.99), when compared with children infected with SARS-CoV-2. In contrast to cases of unvaccinated COVID-19, children infected with dengue demonstrated lower risk (aHR, 0.42; 95% CI, .29-.61) and excess burden (-6.50; 95% CI, -9.80 to -3.20) of any sequelae, as well as lower risk of respiratory sequelae (aHR, 0.17; 95% CI, .09-.31).

Conclusions

Lower overall risk of postacute complications was observed in children following dengue infection vs COVID-19; however, higher risk of appendicitis was reported 31 to 300 days after dengue infection vs SARS-CoV-2. Public health strategies to mitigate the impact of dengue and COVID-19 in children should consider the possibility of chronic postinfectious sequelae.

Long-term multi-systemic complications after SARS-CoV-2 Omicron and Delta infection in children: a retrospective cohort study

OBJECTIVES

Most studies on long-term sequelae of SARS-CoV-2 infection in children were conducted pre-Omicron and pre-dated vaccination rollout. We examined long-term risk of new-incident multi-systemic sequelae following SARS-CoV-2 Delta/Omicron infection in a multi-ethnic Asian paediatric population.

METHODS

Retrospective cohort study of Singaporean children aged 1-17 years infected during Delta/Omicron BA.1/2 transmission, and contemporaneous test-negative groups. Cox regression was utilized to estimate risks of new-incident sequelae at 31-300 days post-infection.

RESULTS

A total of 267,952 SARS-CoV-2-infected children were included, together with 273,517 test negatives. ≥95 % were infected during Omicron. During Delta, 23.6 % of infected cases were fully vaccinated; during Omicron, 60.4 % were fully vaccinated. ≥98% had mild infection not requiring hospitalization. Overall, there was a modestly increased risk of long-term respiratory sequelae (adjusted hazard ratio [aHR] = 1.09, 95 % CI: 1.01-1.18) and specifically bronchitis (aHR = 1.17, 95 % CI: 1.06-1.29) in the SARS-CoV-2-infected group vs. test negatives. During Delta, an increased risk of endocrine conditions (e.g. diabetes) was observed (aHR = 3.63, 95 % CI: 1.25-10.50); whereas during Omicron, an increased risk of bronchitis (aHR = 1.09, 95 % CI: 1.02-1.20) was observed in COVID-19 cases vs. test negatives. Elevated risk of bronchitis was observed among unvaccinated COVID-19 cases (aHR = 1.17, 95 % CI: 1.06-1.29) vs. test negatives, but not in individuals who had received ≥1 vaccine dose. Risks of chronic sequelae after COVID-19 hospitalization were comparable with those after historical influenza hospitalization; albeit reduced when compared with respiratory sequelae after historical hospitalizations for respiratory syncytial virus.

DISCUSSION

Evidence of chronic sequelae in organ systems other than the respiratory system was limited in a paediatric cohort predominantly infected with mild SARS-CoV-2 Omicron infection. Risks of chronic sequelae in hospitalized COVID-19 cases did not substantially differ from historical influenza hospitalizations. Elevated risk of bronchitis was observed after SARS-CoV-2 infection in children vs. test negatives; an increased risk of respiratory sequelae was documented post respiratory syncytial virus hospitalization versus COVID-19, including children aged under 5 years.

Reinfection with SARS-CoV-2 in the Omicron Era is Associated with Increased Risk of Post-Acute Sequelae of SARS-CoV-2 Infection: A RECOVER-EHR Cohort Study

IMPORTANCE

Post-acute sequelae of SARS-CoV-2 infection (PASC) remains a major public health challenge. While previous studies have focused on characterizing PASC and identifying its subphenotypes in children and adolescents following an initial SARS-CoV-2 infection, the risks of PASC with Omicron-variant reinfections remain unclear. Using a real-world data approach, this study investigates the risks of PASC following reinfections during the Omicron phase in the pediatric population.

OBJECTIVE

To investigate the risks of PASC diagnosis and 24 PASC symptoms and conditions after reinfection of SARS-CoV-2 during Omicron period in the pediatric population.

DESIGN SETTING AND PARTICIPANTS

This retrospective cohort study used data from the RECOVER consortium comprising 40 children's hospitals and health institutions in U.S. between January 2022 and October 2023.

EXPOSURES

A second SARS-CoV-2 infection, confirmed by a positive polymerase-chain-reaction (PCR) or antigen tests, or a diagnose of COVID-19, occurring at least 60 days after the initial infection, compared to the initial infection.

MAIN OUTCOMES AND MEASURES

PASC was identified using two approaches: (1) the ICD-10-CM diagnosis code U09.9 and (2) a symptom-based definition including 24 physician-identified symptoms and conditions. Absolute risks of incident PASC were reported, and relative risks (RRs) were calculated by comparing the second infection episode with the first infection episode groups using a modified Poisson regression model, adjusting for demographic, clinical, and healthcare utilization factors through exact matching and propensity scoring matching.

RESULTS

A total of 465,717 individuals under 21 years old (mean [SD] age 8.17 [6.58] years; 52% male) were included. Compared to the first infection, a second infection was associated with significantly increased risk of an overall PASC diagnosis (RR, 2.08; 95% confidence interval [CI], 1.68-2.59), and with many specific conditions including: myocarditis (RR, 3.60; 95% CI, 1.46-8.86); changes in taste and smell (RR, 2.83; 95% CI, 1.41-5.67); thrombophlebitis and thromboembolism (RR, 2.28; 95% CI, 1.71-3.04); heart disease (RR, 1.96; 95% CI, 1.69 to 2.28); acute kidney injury (RR, 1.90; 95% CI, 1.38 to 2.61); fluid and electrolyte (RR, 1.89; 95% CI, 1.62 to 2.20); generalized pain (RR, 1.70; 95% CI, 1.48 to ; arrhythmias (RR, 1.59; 95% CI, 1.45-1.74); abnormal liver enzyme (RR, 1.56; 95% CI, 1.24 to ; fatigue and malaise (RR, 1.50; 95% CI, 1.38 to 1.64); musculoskeletal pain (RR, 1.45; 95% CI, 1.37 to 1.54); abdominal pain (RR, 1.42; 95% CI, 1.34 to 1.50); postural orthostatic tachycardia syndromes (POTS)/dysautonomia (RR, 1.35; 95% CI, 1.20 to 1.51); cognitive functions (RR, 1.32; 95% CI, 1.15 to 1.50); and respiratory signs and symptoms (RR, 1.29; 95% CI, 1.25 to 1.33). The risks were consistent across various organ systems, including cardiovascular, respiratory, gastrointestinal, neurological, and musculoskeletal systems.

CONCLUSIONS AND RELEVANCE

Children and adolescents face significantly higher risk of various PASC outcomes after reinfection with SARS-CoV-2. These findings suggest a cumulative risk of PASC and highlight the urgent need for targeted prevention strategies to reduce reinfections, which includes an increased emphasis on initial or re-vaccination of children.

A randomized phase I trial of intranasal SARS-CoV-2 vaccine dNS1-RBD in children aged 3-17 years

The intranasal SARS-CoV-2 vaccine dNS1-RBD (Pneucolin®), based on a live-attenuated influenza virus vector, has obtained Emergency Use Authorization in China for individuals aged 18 years and older. Here, we conducted a single-center, double-blind, placebo-controlled, age de-escalation phase 1 clinical trial to evaluate the safety of the dNS1-RBD in children aged 3-17 years (ChiCTR2300068044). Sixty-three participants received 2 intranasal doses of the vaccine or placebo at days 0 and 14. Safety assessments included adverse events/reactions within 30 days and serious adverse events (SAEs) over 12 months. Blood and nasal secretion samples were collected to further monitor blood indices and viral shedding. The vaccine group showed similar adverse reaction rates to the placebo group (39.0% vs 36.4%), with no SAEs related to vaccination. Data suggested that the dNS1-RBD vaccine is well-tolerated in children aged 3-17 years, and warrants further studies on its safety, immunogenicity and efficacy in this population.

Enhancing Pediatric Long COVID Care Through Telementoring: Insights From an ECHO Program

Long COVID affects a significant number of children, yet clinician knowledge gaps and limited access to specialized care hinder effective management. With fewer than 20 pediatric long COVID clinics in the United States, many families must travel long distances for care. To address these challenges, a pediatric long COVID ECHO (Extension for Community Healthcare Outcomes) program was developed to educate health care professionals on evidence-based care. The program engaged 94 participants from the United States and Canada via weekly tele-education sessions, recruited through word of mouth and professional listservs. Pre-surveys (41% response rate) and post-surveys (29% response rate) were sent to attendees. Participants reported statistically significant improvements in knowledge, confidence, competence, and self-efficacy (P < 0.001). This program represents a valuable initiative to facilitate timely interventions and empower primary care and community providers in diagnosing, treating, and managing long COVID in pediatric populations.

Pediatric Coronavirus Disease 2019 Vaccine Experiences, Practices, and Attitudes in Rural Primary Care Clinicians

OBJECTIVE

Pediatric coronavirus disease 2019 (COVID-19) vaccination rates remain low in rural areas. A strong clinician recommendation improves vaccine uptake, but the pediatric COVID-19 vaccine recommendation practices of rural primary care clinicians have not been reported. Our objectives were to describe, among rural Colorado pediatric clinicians: 1) recommendation practices for COVID-19 vaccine compared to influenza and school-entry required vaccines, and 2) personal attitudes.

METHODS

From July to October 2023, surveys were distributed to clinicians in rural Colorado identified as pediatric vaccine providers in counties designated as rural through the Colorado Immunization Information System using mail and email.

RESULTS

Of 89 survey respondents, 37% of clinicians strongly recommended COVID-19 vaccines for children 6 months-5 years old, compared to 79% for influenza (P = 0.05) and 92% for school-entry required vaccines (P = 0.04). For children 6-11 and 12-17 years old, 43% and 44% of clinicians strongly recommended COVID-19 vaccines, respectively, compared to 71% and 70% for influenza (P < 0.01), and 91% for school-entry required vaccines (P < 0.01). Forty four percent of clinicians agreed that COVID-19 vaccines are important for pediatric patients. The most common clinician-perceived challenges to discussing pediatric COVID-19 vaccines included a lack of parent interest in more information (76% "somewhat" or "strongly" agree), lack of ability to change parents' minds (71%), and concerns that the vaccines are too political (40%).

CONCLUSIONS

Most rural Colorado clinicians do not strongly recommend pediatric COVID-19 vaccines compared to influenza and school-entry required vaccines. Efforts to improve pediatric COVID-19 vaccine uptake should aim to strengthen clinicians' recommendations of these vaccines.

COVID-19 Vaccination and Odds of Post-COVID-19 Condition Symptoms in Children Aged 5 to 17 Years

Importance

An estimated 1% to 3% of children with SARS-CoV-2 infection will develop post-COVID-19 condition (PCC).

Objective

To evaluate the odds of PCC among children with COVID-19 vaccination prior to SARS-CoV-2 infection compared with odds among unvaccinated children.

Design, Setting, and Participants

In this case-control study, children were enrolled in a multisite longitudinal pediatric cohort from July 27, 2021, to September 1, 2022, and followed up through May 2023. Analysis used a case (PCC reported)-control (no PCC reported) design and included children aged 5 to 17 years whose first real time-polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infection occurred during the study period, who were COVID-19 vaccine age-eligible at the time of infection, and who completed a PCC survey at least 60 days after infection. From December 1, 2022, to May 31, 2023, children had weekly SARS-CoV-2 testing and were surveyed regarding PCC (≥1 new or ongoing symptom lasting ≥1 month after infection).

Exposures

COVID-19 mRNA vaccination status at time of infection was the exposure of interest; participants were categorized as vaccinated (≥2-dose series completed ≥14 days before infection) or unvaccinated. Vaccination status was verified through vaccination cards or vaccine registry and/or medical records when available.

Main Outcome and Measures

Main outcomes were estimates of the odds of PCC symptoms. Multivariate logistic regression was performed to estimate the odds of PCC among vaccinated children compared with odds of PCC among unvaccinated children.

Results

A total of 622 participants were included, with 28 (5%) case participants and 594 (95%) control participants. Median (IQR) age was 10.0 (7.0-11.9) years for case participants and 10.3 (7.8-12.7) years for control participants (P = .37). Approximately half of both groups reported female sex (13 case participants [46%] and 287 control participants [48%]). Overall, 57% of case participants (16 children) and 77% of control participants (458 children) were vaccinated (P = .05). After adjusting for demographic characteristics, number of acute COVID-19 symptoms, and baseline health, COVID-19 vaccination was associated with decreased odds of 1 or more PCC symptom (adjusted odds ratio [aOR], 0.43; 95% CI, 0.19-0.98) and 2 or more PCC symptoms (aOR, 0.27; 95% CI, 0.10-0.69).

Conclusions and Relevance

In this study, mRNA COVID-19 vaccination was associated with reduced odds of PCC in children. The aORs correspond to an estimated 57% and 73% reduced likelihood of 1 or more and 2 or more PCC symptoms, respectively, among vaccinated vs unvaccinated children. These findings suggest benefits of COVID-19 vaccination beyond those associated with protection against acute COVID-19 and may encourage increased pediatric uptake.

Racial/ethnic differences in post-acute sequelae of SARS-CoV-2 in children and adolescents in the United States

Racial/ethnic differences are associated with the symptoms and conditions of post-acute sequelae SARS-CoV-2 infection (PASC) in adults. These differences may exist among children and warrant further exploration. We conducted a retrospective cohort study with difference-in-differences analyzes to assess these differences in children and adolescents under the age of 21. The study utilized data from the RECOVER Initiative in the United States, which aims to learn about the long-term effects of COVID-19. The cohort included 225,723 patients with SARS-CoV-2 infection or COVID-19 diagnosis between March 2020 and October 2022. The study compared minority racial/ethnic groups to Non-Hispanic White (NHW) individuals, stratified by severity during the acute phase of COVID-19. Within the severe group, Asian American/Pacific Islanders (AAPI) had a higher prevalence of fever/chills and respiratory signs and symptoms, Hispanic patients showed greater hair loss prevalence in severe COVID-19 cases, while Non-Hispanic Black (NHB) patients had fewer skin symptoms in comparison to NHW patients. Within the non-severe group, AAPI patients had increased POTS/dysautonomia and respiratory symptoms, and NHB patients showed more cognitive symptoms than NHW patients. In conclusion, racial/ethnic differences related to COVID-19 exist among PASC symptoms and conditions in pediatrics, and these differences are associated with the severity of illness during acute COVID-19.

Real-world effectiveness and causal mediation study of BNT162b2 on long COVID risks in children and adolescents

Background

The impact of pre-infection vaccination on the risk of long COVID remains unclear in the pediatric population. We aim to assess the effectiveness of BNT162b2 on long COVID risks with various strains of the SARS-CoV-2 virus in children and adolescents, using comparative effectiveness methods. We further explore if such pre-infection vaccination can mitigate the risk of long COVID beyond its established protective benefits against SARS-CoV-2 infection using causal mediation analysis.

Methods

We conducted real-world vaccine effectiveness study and mediation analysis using data from twenty health systems in the RECOVER PCORnet electronic health record (EHR) Program. Three independent cohorts were constructed including adolescents (12-20 years) during the Delta phase (July 1-November 30, 2021), children (5-11 years) and adolescents (12-20 years) during the Omicron phase (January 1-November 30, 2022). The intervention is first dose of the BNT162b2 vaccine in comparison with no receipt of COVID-19 vaccine. The outcomes of interest include conclusive or probable diagnosis of long COVID following a documented SARS-CoV-2 infection, and body-system-specific condition clusters of post-acute sequelae of SARS-CoV-2 infection (PASC), such as cardiac, gastrointestinal, musculoskeletal, respiratory, and syndromic categories. The effectiveness was reported as (1-relative risk)∗100 and mediating effects were reported as relative risks.

Findings

112,590 adolescents (88,811 vaccinated) were included in the cohort for the analysis against Delta variant, and 188,894 children (101,277 vaccinated), and 84,735 adolescents (37,724 vaccinated) were included for the analysis against Omicron variant. During the Delta period, the estimated effectiveness of the BNT162b2 vaccine against long COVID among adolescents was 95.4% (95% CI: 90.9%-97.7%). During the Omicron phase, the estimated effectiveness against long COVID among children was 60.2% (95% CI: 40.3%-73.5%) and 75.1% (95% CI: 50.4%-87.5%) among adolescents. The direct effect of vaccination, defined as the effect beyond their impact on SARS-CoV-2 infections, was found to be statistically non-significant in all three study cohorts, with estimated relative risk of 1.08 (95% CI: 0.75-1.55) in the Delta study among adolescents, 1.24 (95% CI: 0.92-1.66) among children and 0.91 (95% CI: 0.69-1.19) among adolescents in the Omicron studies. Meanwhile, the estimated indirect effects, which are effects through protecting SARS-CoV-2 infections, were estimated as 0.04 (95% CI: 0.03-0.05) among adolescents during Delta phase, 0.31 (95% CI: 0.23-0.42) among children and 0.21 (95% CI: 0.16-0.27) among adolescents during the Omicron period.

Interpretation

Our study suggests that BNT162b2 was effective in reducing risk of long COVID outcomes in children and adolescents during the Delta and Omicron periods. The mediation analysis indicates the vaccine's effectiveness is primarily derived from its role in reducing the risk of SARS-CoV-2 infection.

Funding

National Institutes of Health.

Adolescents with Persistent Symptoms Following Acute SARS-CoV-2 Infection (Long-COVID): Symptom Profile, Clustering and Follow-Up Symptom Evaluation

BACKGROUND

Few studies have evaluated long-COVID in adolescents.

METHODS

Cohort study. Demographics, clinical data, and the presence of 30 symptoms were collected with a modified WHO form. Mean values were compared by Student's t test and proportions by the chi-square test or Fisher test, with trends over time analysed using the chi-square test for trend. Potential risk factors independently associated with persisting symptoms were evaluated in a multivariable logistic regression model. Clustering of cases was analysed by two-step automatic clustering.

RESULTS

A total of 97 adolescents aged 12-17 (54.6% females, 45.4% males) were evaluated. After a mean interval of 96 days (SD 52) from acute infection, the mean number of symptoms (2.8 overall) was higher for pre-Omicron (3.2 vs. 2.5 in Omicron, p = 0.046) and moderate/severe acute infections (4.2 vs. 2.7 in mild, p = 0.023). Fatigue (62.9%) and dyspnea (43.3%) were the most common symptoms, followed by headache (28.9%), thoracic pain (22.7%), diarrhea (20.6%), palpitations/tachycardia (17.5%), articular pain (15.5%), difficult concentration (14.4%), muscle pain (12.4%), taste reduction (8.2%), smell reduction (8.2%), fever (6.2%), and skin disorders (5.2%). The symptom profile was similar in males and females but showed significant differences from that observed in concurrently followed adults. After a mean interval of 340 days from infection, 45.3% still presented symptoms, with persistence associated with higher number of initial symptoms. Two clusters were defined that differed in the phase of acute infection and the number and profile of symptoms.

CONCLUSIONS

Long-COVID manifestations in adolescents may differ from those observed in adults. Polisymptomaticity may predict long-term persistence.

Pediatric SARS-CoV-2 long term outcomes study (PECOS): cross sectional analysis at baseline

BACKGROUND

PECOS is an ongoing study aimed to characterize long-term outcomes following pediatric SARS-CoV-2 infection.

METHODS

This is a cross-sectional analysis of infected and uninfected cohorts at baseline. Participants (0-21 years) with laboratory-confirmed SARS-CoV-2 infection were enrolled as infected. Uninfected were defined as individuals without history or laboratory evidence of SARS-CoV-2 infection. Outcome measures included demographics, medical history, review of symptoms, physical exam, cardiopulmonary evaluation and validated psychological and developmental surveys. Primary outcomes were cohort comparisons for abnormalities on all measures.

RESULTS

654 participants (541 infected, 113 uninfected) completed baseline visits by June 30, 2023. Infected participants were more likely to report constitutional (OR: 2.24), HEENT (OR: 3.74); respiratory (OR: 2.41), or gastrointestinal (OR: 2.58) symptoms. Infected had worse scores in domains of Pain, Fatigue, Global Health, Physical and Cognitive functioning, Mobility and Sleep disturbances when compared to uninfected controls using Patient Reported Outcomes. Cardiopulmonary findings were similar among cohorts.

CONCLUSIONS

The first report of this ongoing longitudinal study demonstrates that infected participants were more likely to report symptoms compared to uninfected controls, which may affect performance and quality of life of these individuals. Longitudinal data will increase understanding of long-term effects of SARS-CoV-2 infection in children.

CLINICALTRIALS

gov Identifier: NCT04830852 IMPACT: This study establishes a large, diverse, prospective, longitudinal, multi-center cohort of children with history of SARS-CoV-2 infection compared to an uninfected cohort to be followed for 3 years. Cross-sectional cohort analysis at study entry showed infected participants were more likely to report constitutional, respiratory, and GI symptoms compared to uninfected controls. Infected participants were more likely to have significantly worse parent-reported performance in 6 of 10 Patient Reported Outcome Measures domains. Continued study of this cohort will help identify clinical sequelae of COVID-19, characterize the immune response to SARS-CoV-2 infection, and identify potential genetic/immunologic factors associated with long-term outcomes.

Persistence of spike protein at the skull-meninges-brain axis may contribute to the neurological sequelae of COVID-19

SARS-CoV-2 infection is associated with long-lasting neurological symptoms, although the underlying mechanisms remain unclear. Using optical clearing and imaging, we observed the accumulation of SARS-CoV-2 spike protein in the skull-meninges-brain axis of human COVID-19 patients, persisting long after viral clearance. Further, biomarkers of neurodegeneration were elevated in the cerebrospinal fluid from long COVID patients, and proteomic analysis of human skull, meninges, and brain samples revealed dysregulated inflammatory pathways and neurodegeneration-associated changes. Similar distribution patterns of the spike protein were observed in SARS-CoV-2-infected mice. Injection of spike protein alone was sufficient to induce neuroinflammation, proteome changes in the skull-meninges-brain axis, anxiety-like behavior, and exacerbated outcomes in mouse models of stroke and traumatic brain injury. Vaccination reduced but did not eliminate spike protein accumulation after infection in mice. Our findings suggest persistent spike protein at the brain borders may contribute to lasting neurological sequelae of COVID-19.

Pediatric COVID-19 vaccine hesitancy among pregnant and post-partum women: A mixed-method study

BACKGROUND

This study aims to understand factors contributing to pediatric COVID-19 vaccine hesitancy among pregnant and postpartum adults.

METHOD

The study used targeted intercept advertising on Facebook, Twitter, and Instagram to recruit a panel of 3600 pregnant and postpartum US adults. Data were collected between December 2021 and April 2022 (i.e., before the introduction of pediatric COVID-19 vaccines in the U.S.). We used logistic regression to understand factors associated with pregnant and postpartum women's hesitancy towards getting children <5 vaccinated against COVID-19. Poststratification weights were applied to analyses to promote the representativeness of the sample. We also conducted a qualitative thematic analysis to determine the reasons for pediatric vaccine hesitancy.

RESULTS

Nearly half (45.6 %) of pregnant or postpartum women were hesitant to vaccinate their child against COVID-19. Vaccine hesitancy was lower among those who had a high perceived susceptibility to COVID-19, had increased perceived severity of COVID-19, and increased perceived benefits of the COVID-19 vaccine. Perceived barriers related to long-term side effects of vaccines were positively associated with hesitancy to vaccinate children. Older women, women in urban areas, and those born outside the US were less likely to be hesitant to vaccinate children <5 against COVID-19. Compared to respondents with a high school education or less, the odds of pediatric vaccine hesitancy were higher among respondents with some college. Pregnant and postpartum women who were hesitant about getting children <5 vaccinated cited the following reasons for hesitancy: concerns about the vaccine, lack of evidence on vaccine safety, and the COVID-19 vaccine is not necessary for children.

CONCLUSION

Our findings suggest that public health messages to promote the COVID-19 vaccine for young children should focus on the risks and consequences of the disease and share data on the effectiveness of the vaccine in preventing severe COVID-19-related outcomes.

Postacute Sequelae of COVID-19 in Pediatric Patients Within the United States: A Scoping Review

A subset of children and adolescents experience recurrent or persistent symptoms following SARS-CoV-2 infection, known as postacute sequelae of COVID-19 (PASC), however, the clinical epidemiology within the United States (US) is not yet well understood. This scoping review aims to synthesize the clinical epidemiology of pediatric PASC in the US. A comprehensive literature search was conducted and databases were queried from inception until January 29, 2024. Studies including US children and adolescents <21 years old were considered. From 1028 studies identified, 29 met the inclusion criteria. Prevalence of PASC ranged from less than 1%-27%. Risk factors included older age, female sex, asthma, obesity, and severe initial infection. Common symptoms were dyspnea, fatigue, headaches, and chest pain. A multidisciplinary approach for diagnosis and management was common across studies. Most studies had a high risk of bias and were limited by a lack of standardized definitions and short follow-up duration. This review establishes a foundation for understanding pediatric PASC and highlights the critical need for continued research to optimize prevention and treatment strategies.

mRNA COVID-19 vaccine safety among children and adolescents: a Canadian National Vaccine Safety Network cohort study

Background

The Canadian National Vaccine Safety Network conducted active safety surveillance for COVID-19 vaccines. This study aimed to characterize the short-to-medium term safety of mRNA COVID-19 vaccines across the pediatric age spectrum.

Methods

In this cohort study, vaccinated and unvaccinated children and adolescents aged 6 months to 19 years from eight Canadian provinces and territories were invited to participate. The outcome was a health event preventing daily activities, resulting in school absenteeism, or requiring medical consultation. Age-stratified multivariable regression models were used to examine health events associated with first and second doses of mRNA COVID-19 vaccines across different age groups: children under 5, children aged 5-11 years and adolescents aged 12-19 years.

Findings

From January 2021 through February 2023, a total of 259,361 individuals from the dose one survey, 131,032 from the dose 2 survey, and 1179 from the control survey were included. In the week following dose two, vaccinated adolescents showed a higher proportion of health events [794 (4.6%) of 17,218 BNT162b2 recipients, 98 (8.5%) of 1153 mRNA-1273 recipients, 49 of (10.6%) of 464 heterologous schedule recipients] than unvaccinated adolescents [9 (3.7%) of 242 controls], but most events were self-limited and resolved within 7 days. No significant differences in proportion of health events following mRNA COVID-19 vaccines were observed between vaccinated and unvaccinated groups among adolescents after dose 1, or among children under 5 or those aged 5-11 years after any dose. Reported myocarditis/pericarditis cases within 0-28 days peaked among male adolescents following dose 2, in three of (0.037%) 8088 homologous BNT162b2 recipients, and two of (0.529%) 378 homologous mRNA-1273 recipients.

Interpretation

Our findings suggest that reported health events, including myocarditis/pericarditis, vary by pediatric age group. Vaccinated adolescents reported health events more frequently following the second mRNA COVID-19 vaccine dose, while younger age groups did not report events more frequently than their unvaccinated counterparts.

Funding

Canadian Immunization Research Network, Canadian Institutes of Health Research; Public Health Agency of Canada; COVID-19 Immunity Task Force.

Consequences beyond acute SARS-CoV-2 infection in children

Although most children are spared from developing complications from SARS-CoV-2 infection, some may suffer consequences including Long Covid and multisystem inflammatory syndrome in children (MIS-C). Although the occurrence of these conditions has decreased over time, they can still occur, and recognition of symptoms and prompt diagnosis is imperative for early intervention.

Characteristics and predictors of Long Covid in children: a 3-year prospective cohort study

Background

Children can develop Long Covid, however long term outcomes and their predictors are poorly described in these patients. The primary aim is to describe characteristics and predictors of Long Covid in children assessed in-clinics up to 36 months post-SARS-CoV-2 infection, as well as investigate the role of vaccines in preventing Long Covid, risk of reinfections and development of autoimmune diseases.

Methods

Children aged 0-18 years old with confirmed SARS-CoV-2 infection were invited for a prospective follow-up assessment at a peadiatric post-covid clinic in Rome, Italy, at serial intervals (3-, 6-, 12-, 18-, 24- and 36-months post-infection onset, between 01/02/2020 and 28/02/2024). Long Covid was defined as persistence of otherwise unexplained symptoms for at least three months after initial infection.

Findings

1319 patients were initially included, 1296 reached the 3 months follow-up or more. Of the patients who underwent multiple follow-ups, 23.2% (301), 169 (13.2%), 89 (7.9%), 67 (6.1%), 47 (7.1%) were diagnosed with Long Covid at 3-6-12-18-24 months, respectively For the primary outcome of Long Covid at three months, age >12 years (P < 0.001, OR 11.33, 95% CI 4.2; 15.15), comorbidities (P = 0.008, OR 1.83, 95% CI 1.06; 2.44), being infected with original variants (P < 0.001, OR 4.77, 95% CI 2.46; 14.47), female sex (P < 0.001, OR 1.62, 95% CI 1.02; 1.89) were statistically significant risk factors. Age >12 years (P = 0.002, OR 9.37, 95% CI 1.58; 8.64), and infection with original (P = 0.012, OR 3.52, 95% CI 1.32; 8.64) and alfa (P < 0.001, OR 4.09, 95% CI 2.01; 8.3) SARS-CoV-2 variants remained statistically significant risk factors for Long Covid duration for at least 18 months. Vaccination was associated with a lower risk of long covid at 3, 6 and 12 months for older children and a lower risk of reinfections. Being infected with the original SARS-CoV-2 variant was associated with a higher risk of new-onset autoimmune diseases ((P = 0.035, 95% CI 1.12; 2.4). One patient was diagnosed with Long Covid after a re-infection.

Interpretation

This is the longest follow-up study of children with SARS-CoV-2 infection, showing a significant and long-lasting burden of Long Covid in the pediatric population. Our findings highlight the urgent need of investing in pediatric Long Covid in order to find effective diagnostic and therapeutic approaches, as well can inform preventive strategies in case of future pandemics.

Funding

This study has been funde by Pfizer non-competitive grant, granted to DB (#65925795).

Pediatric Disaster Science: Understanding Needs, Highlighting Imperatives, and Leveraging Opportunities

The National Academies of Sciences, Engineering, and Medicine (NASEM) Symposium on Pediatric Disaster Science, which was led by the Action Collaborative for Disaster Research, was held August 1st and 2nd, 2022, in Washington, DC. The meeting convened a broad representation of subject matter experts, including federal and nonfederal partners, with the goal of presenting the scope of perspectives, information, and scientific needs related to disasters affecting children. Meeting goals were achieved through formal presentations and facilitated discussions that identified high level pediatric disaster research priorities, opportunities for synergistic scientific efforts, and considerations and strategies to effectively advance pediatric disaster science to improve outcomes for children in disasters. This three-part discussion paper is part of the Symposium collection of works as a compilation of perspectives, ideas, and discussions shared during the Symposium, with follow-on considerations for the field. Part 1 focuses on pediatric disaster science throughout the disaster cycle; Part 2 addresses the scope of translational science in pediatric disaster management; and Part 3 addresses opportunities for building the infrastructure and workforce to support current and future pediatric disaster science efforts. Associated articles in this Symposium collection of works were submitted after the meeting by experts in the field; these pieces augment some of the themes and key concepts identified throughout the Symposium.

Postacute Sequelae of COVID (PASC or Long COVID): An Evidenced-Based Approach

While the acute manifestations of infectious diseases are well known, in some individuals, symptoms can either persist or appear after the acute period. Postviral fatigue syndromes are recognized with other viral infections and are described after coronavirus disease 2019 (COVID-19). We have a growing number of individuals with symptoms that persist for weeks, months, and years. Here, we share the evidence regarding the abnormalities associated with postacute sequelae of COVID-19 (PASC) and therapeutics. We describe physiological and biochemical abnormalities seen in individuals reporting PASC. We describe the several evidence-based interventions to offer patients. It is expected that this growing understanding of the mechanisms driving PASC and the benefits seen with certain therapeutics may not only lead to better outcomes for those with PASC but may also have the potential for understanding and treating other postinfectious sequelae.

Post-vaccination, post-infection and hybrid immunity against severe cases of COVID-19 and long COVID after infection with SARS-CoV-2 Omicron subvariants, Czechia, December 2021 to August 2023

BackgroundCOVID-19 remains a major infectious disease with substantial implications for individual and public health including the risk of a post-infection syndrome, long COVID. The continuous changes in dominant variants of SARS-CoV-2 necessitate a careful study of the effect of preventative strategies.AimWe aimed to estimate the effectiveness of post-vaccination, post-infection and hybrid immunity against severe cases requiring oxygen support caused by infections with SARS-CoV-2 variants BA1/2 and BA4/5+, and against long COVID in the infected population and their changes over time.MethodsWe used a Cox regression analysis with time-varying covariates and calendar time and logistic regression applied to national-level data from Czechia from December 2021 until August 2023.ResultsRecently boosted vaccination, post-infection and hybrid immunity provide significant protection against a severe course of COVID-19, while unboosted vaccination more than 10 months ago has a negligible protective effect. The post-vaccination immunity against the BA1/2 or BA4/5+ variants, especially based on the original vaccine types, appears to wane rapidly compared with post-infection and hybrid immunity. Once infected, however, previous immunity plays only a small protective role against long COVID.ConclusionVaccination remains an effective preventative measure against a severe course of COVID-19 but its effectiveness wanes over time thus highlighting the importance of booster doses. Once infected, vaccines may have a small protective effect against the development of long COVID.

Long COVID management: a mini review of current recommendations and underutilized modalities

Long COVID is a condition that develops in a subset of patients after COVID-19 infection comprising of symptoms of varying severity encompassing multiple organ systems. Currently, long COVID is without consensus on a formal definition, identifiable biomarkers, and validated treatment. Long COVID is expected to be a long-term chronic condition for a subset of patients and is associated with suffering and incapacity. There is an urgent need for clear management guidelines for the primary care provider, who is essential in bridging the gap with more specialized care to improve quality of life and functionality in their patients living with long COVID. The purpose of this mini review is to provide primary care providers with the latest highlights from existing literature regarding the most common long COVID symptoms and current management recommendations. This review also highlights the underutilized interventions of stellate ganglion blocks and low-dose naltrexone, both with well-established safety profiles demonstrated to improve quality of life and functionality for patients suffering with some symptoms of long COVID, and encourages prompt referral to interventional pain management.

Challenges and opportunities in long COVID research

Long COVID (LC) is a condition in which patients do not fully recover from the initial SARS-CoV-2 infection but rather have persistent or new symptoms for months to years following the infection. Ongoing research efforts are investigating the pathophysiologic mechanisms of LC and exploring preventative and therapeutic treatment approaches for patients. As a burgeoning area of investigation, LC research can be structured to be more inclusive, innovative, and effective. In this perspective, we highlight opportunities for patient engagement and diverse research expertise, as well as the challenges of developing definitions and reproducible studies. Our intention is to provide a foundation for collaboration and progress in understanding the biomarkers and mechanisms driving LC.

Exploring the Pathophysiology of Long COVID: The Central Role of Low-Grade Inflammation and Multisystem Involvement

Long COVID (LC), also referred to as Post COVID-19 Condition, Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), and other terms, represents a complex multisystem disease persisting after the acute phase of COVID-19. Characterized by a myriad of symptoms across different organ systems, LC presents significant diagnostic and management challenges. Central to the disorder is the role of low-grade inflammation, a non-classical inflammatory response that contributes to the chronicity and diversity of symptoms observed. This review explores the pathophysiological underpinnings of LC, emphasizing the importance of low-grade inflammation as a core component. By delineating the pathogenetic relationships and clinical manifestations of LC, this article highlights the necessity for an integrated approach that employs both personalized medicine and standardized protocols aimed at mitigating long-term consequences. The insights gained not only enhance our understanding of LC but also inform the development of therapeutic strategies that could be applicable to other chronic conditions with similar pathophysiological features.

Pediatric post COVID-19 condition: an umbrella review of the most common symptoms and associated factors

BACKGROUND

Although the long-term consequences of the Coronavirus Disease-2019 (COVID-19) pandemic are yet to be fully comprehended, a syndrome symptomatically akin to the COVID-19 disease has been defined, for children and adolescents, in February 2023 by the World Health Organization (WHO) as 'post COVID-19 condition' (PCC). Potential consequences of COVID-19 that affect developmental milestones in children and adolescents should be comprehended in their magnitude and duration. The aim is to investigate the most common symptoms and predictors or risk factors for pediatric PCC.

METHODS

In this umbrella review, the population of interest was defined as children and adolescents from 0 to 19 years old presenting PCC symptoms as defined by the WHO in the International Classification of Diseases. The intervention considered was general follow-up activity to monitor the patients' recovery status. No comparator was chosen, and the outcomes were symptoms of PCC and predictors or risk factors of developing PCC. Methodological quality, risk of bias and the level of overlap between studies were assessed. A random-effects meta-analytic synthesis of respective estimates with inverse variance study weighting was carried out, for the primary studies included by the reviews retrieved, regarding predictors or risk factors reported.

RESULTS

We identified six eligible systematic reviews, five with meta-analyses, from three databases. The most common symptoms reported were fatigue and respiratory difficulties; female sex and older age were the most reported factors associated with the development of pediatric PCC.

CONCLUSIONS

A deeper understanding of pediatric PCC requires well-designed and clearly defined prospective studies, symptom differentiation, and adequate follow-up.

Long COVID in Children, Adults, and Vulnerable Populations: A Comprehensive Overview for an Integrated Approach

Long COVID affects both children and adults, including subjects who experienced severe, mild, or even asymptomatic SARS-CoV-2 infection. We have provided a comprehensive overview of the incidence, clinical characteristics, risk factors, and outcomes of persistent COVID-19 symptoms in both children and adults, encompassing vulnerable populations, such as pregnant women and oncological patients. Our objective is to emphasize the critical significance of adopting an integrated approach for the early detection and appropriate management of long COVID. The incidence and severity of long COVID symptoms can have a significant impact on the quality of life of patients and the course of disease in the case of pre-existing pathologies. Particularly, in fragile and vulnerable patients, the presence of PASC is related to significantly worse survival, independent from pre-existing vulnerabilities and treatment. It is important try to achieve an early recognition and management. Various mechanisms are implicated, resulting in a wide range of clinical presentations. Understanding the specific mechanisms and risk factors involved in long COVID is crucial for tailoring effective interventions and support strategies. Management approaches involve comprehensive biopsychosocial assessments and treatment of symptoms and comorbidities, such as autonomic dysfunction, as well as multidisciplinary rehabilitation. The overall course of long COVID is one of gradual improvement, with recovery observed in the majority, though not all, of patients. As the research on long-COVID continues to evolve, ongoing studies are likely to shed more light on the intricate relationship between chronic diseases, such as oncological status, cardiovascular diseases, psychiatric disorders, and the persistent effects of SARS-CoV-2 infection. This information could guide healthcare providers, researchers, and policymakers in developing targeted interventions.