Risk Factors for Severity in Children with Coronavirus Disease 2019: A Comprehensive Literature Review

Hybrid immunity after BNT162b2 Covid-19 vaccine administration in children aged 5 to 11 years

BACKGROUND

The immune response to coronavirus disease 2019 (COVID-19) vaccination is stronger among adults with prior infection (hybrid immunity). It is important to understand if children demonstrate a similar response to better inform vaccination strategies. Our study investigated the humoral response after BNT162b2 COVID-19 vaccine doses in SARS-CoV-2 naïve and recovered children (5-11 years).

METHODS

A multi-institutional, longitudinal, prospective cohort study was conducted. Children were enrolled in a case-ascertained antibody surveillance study in Ottawa, Ontario from September/2020-March/2021; at least one household member was severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) positive on RT-PCR. In November 2021, BNT162b2 COVID-19 vaccine was authorized for children aged 5-11 in Canada. Children enrolled in the surveillance study intending to receive two vaccine doses were invited to participate in this study from November 2021-April 2022. Main exposure was prior SARS-CoV-2 infection, defined by positive RT-PCR or SARS-CoV-2 anti-N IgG antibody presence. Primary outcome was spike IgG antibody levels measured following the first vaccine dose (2-3 weeks) and second vaccine dose (3-4 weeks).

RESULTS

Of the 153 eligible children, 75 participants (median age 8.9 IQR (7.4, 10.2) years; 38 (50.7 %) female; 59 (78.7 %) Caucasian) had complete follow-up. Fifty-four (72 %) children had prior SARS-COV-2 infection. Spike IgG antibody levels are significantly higher in SARS-CoV-2 recovered participants after receiving the first dose (p < 0.001) and the second (p = 0.01) compared to infection naïve children.

CONCLUSIONS AND RELEVANCE

SARS-CoV-2 recovered children (5-11 years) demonstrated higher antibody levels following first BNT162b2 vaccine dose compared with naïve children. Most reached antibody saturation two to three weeks after the first dose; a second dose didn't change the saturation level. A single vaccine dose in SARS-CoV-2 recovered children may be equivalent or superior to a 2-dose primary series in naïve children. Further research is needed on the durability and quality of a single vaccine dose in this population.

Airway Management of Critically Ill Pediatric Patients with Suspected or Proven Coronavirus Disease 2019 Infection: An Intensivist Point of View

Advanced airway management of critically ill children is crucial for novel coronavirus disease 2019 (COVID-19) management in the pediatric intensive care unit, whether due to shock and hemodynamic collapse or acute respiratory failure. In this article, intubation is challenging due to the particularities of children's physiology and the underlying disease's pathophysiology, especially when an airborne pathogen, like COVID-19, is present. Unfortunately, published recommendations and guidelines for COVID-19 in pediatrics do not address in-depth endotracheal intubation in acutely ill children. We discussed the caveats and pitfalls of intubation in critically ill children.

Clinical features and virologic lineages of COVID-19-associated encephalitis in Taiwanese children during early epidemic wave of omicron in 2022: Report from a medical center

BACKGROUND

A surge of encephalitis was reported in children during the early wave of the omicron epidemic in Taiwan. Information on the COVID-19-associated encephalitis, including epidemiologic features and factors of unfavorable outcomes, remained unclear.

METHODS

A total of 128 hospitalized Taiwanese children with laboratory-confirmed COVID-19 were enrolled between April 01, 2022, and May 31, 2022. The information on demographics and clinical features was abstracted from the medical records. Virologic lineages were determined by sequences of the spike protein. Factors associated with encephalitis and unfavorable outcomes were identified by comparisons to children without encephalitis and with favorable outcomes, respectively.

RESULTS

The leading syndromes associated with COVID-19 in hospitalized children were febrile seizure (20, 15.7%), fever as the solitary symptom (18, 14.1%), and croup syndrome (14, 10.9%). Encephalitis was diagnosed in nine (7.03%) children. When compared to the three leading syndromes, children with encephalitis were at older ages, had greater rates of hypotension, PICU admissions, use of inotropic agents (P < .001 for all above comparisons), mortality (P = .008), and longer hospital stays (P = .016), but not the underlying comorbidities (P = .376). Unfavorable outcomes were identified in 3 (33.3%) of 9 encephalitis cases and associated with a lower Glasgow coma scale, hypotension, and higher C-reactive protein (P < .05 for all). BA.2.3.7 was the dominant sublineage in children with or without encephalitis.

CONCLUSIONS

Omicron BA.2.3.7 can cause fulminant and lethal encephalitis in healthy children. Depressed consciousness and hypotension at presentation were significant risks of unfavorable outcomes for pediatric COVID-19-associated encephalitis.

Safety of BNT162b2 mRNA COVID-19 vaccine in children with chronic kidney disease: a national population study from South Korea

BACKGROUND

In South Korea, COVID-19 vaccination has been recommended to adolescents aged 12 - 17 since October, 2021. We aimed to assess the rate of adverse events following COVID-19 vaccination in adolescents with chronic kidney disease (CKD) in South Korea, using national cohort data.

METHODS

We retrieved the clinical information of adolescents 12 - 17 years old from the Korea Disease Control and Prevention Agency-COVID19-National Health Insurance Service (K-COV-N) database, to calculate incidence rates of purpura and other hemorrhagic conditions, Guillain-Barré syndrome (GBS), Kawasaki disease/multisystem inflammatory syndrome in children (MIS-C), myocarditis and/or pericarditis, and anaphylaxis in adolescents with CKD, after BNT162b2 vaccination.

RESULTS

Among the 2306 adolescents with CKD, 62.7% (n = 1446) had received the BNT-162b2 vaccine. GBS, Kawasaki disease/MIS-C, and anaphylaxis or anaphylactic shock did not occur during the observation period. Purpura and hemorrhagic conditions were more frequent in the unvaccinated group (7/860 vs. 1/1446), while myocarditis/pericarditis was observed only in the vaccinated group (0/860 vs. 1/1446). Adjusted odds ratio for any of the two adverse events was lower in vaccinated adolescents than in the unvaccinated group which did not reach statistical significance (adjusted odds ratio = 0.14, 95% confidence interval: 0.02, 1.16, P = 0.068).

CONCLUSIONS

In this national cohort study of adolescents with CKD in South Korea, we observed no evidence of increased risk of adverse events following BNT162b2 vaccination. Our finding offers insights into the safety of COVID-19 vaccines, empowering adolescent patients with CKD and their caregivers to make informed decisions.

An Outline of the Immunogenic Potential of Progressing SARSCoV- 2 Vaccine Technologies among Children and Adolescents

BACKGROUND

SARS-CoV-2, a highly dynamic beta-coronavirus, can afflict all age groups. Notably, over 16100 mortalities have been recorded among children as yet. In this regard, many vaccine projects are operational to assess immuno-potency among young cohorts. A bulk of reports have evidenced the efficacy of these immunization technologies in the elderly population, though the impact is yet to be determined among children.

OBJECTIVES

This review is envisioned to outline the current efficacy of contributing vaccine technologies and examine the dose-dependent impact of immunization regimens in lowering the risks of SARS-CoV-2 infections among children and adolescents. Furthermore, the current review exclusively estimated the vaccine impact at current doses.

METHODS

A total of 52 research papers extracted from PubMed, Pubmed Central, Science Direct, Research Gate, Google Scholar and Semantic Scholar were screened along with an emphasis on patents. Inclusion criteria involved all published reports directly or indirectly linked to the contributing vaccine candidates that are operational among the young cohort. Unrelated research papers were excluded from the study. Key search terminologies included information on vaccine identifiers, such as name, type and clinical trial ID, and successively restricted to children and adolscents age groups.

RESULTS

Several vaccine designs, such as mRNA-based vaccinations, viral vector vaccines, DNA vaccines, inactivated vaccines, recombinant vaccines, and protein-based immunizations, are being examined at various stages of clinical trials to gauge the effects on children and adolescents. With reference to the published reports, the mRNA 1273 (1610 GMT; 6-10 yrs, 1401 GMT; 12-15 yrs), BNT162b2 (1407 GMT; 6 months- <2 yrs, 1535 GMT; 2-4 yrs, 4583 GMT; 5-11 yrs, 1239.5 GMT; 12-15 yrs) and Ad5 nCoV (1037.5 GMT; 6-17 yrs) offered relatively high neutralization titers with sharp seroconversion rates compared to MVC-COV1901 (648.5 GMT; 12-17 yrs) and ZyCoV-D (133.49 GMT; 12-17 yrs), which produced modest immune responses.

CONCLUSION

Currently, the WHO is analyzing emerging evidence to issue an emergency use list of vaccines for vaccinating children and adolescents.

Increasing COVID-19 Immunization Rates through a Vaccination Program for Hospitalized Children

Introduction

Inpatient coronavirus disease 2019 (COVID-19) vaccination initiatives offer a novel strategy to eliminate barriers to care, provide access to interprofessional teams, and decrease COVID-19 morbidity and mortality. Our inpatient vaccination initiative aimed to triple the baseline rate of eligible hospitalized children vaccinated against COVID-19 from 0.95% to 2.85% from December 2021 to June 2022.

Methods

We implemented a COVID-19 vaccination program for pediatric inpatients eligible to receive a dose based on age, current guidelines, and prior doses received. Key drivers included immunization counseling training, identification of eligible patients, and a streamlined workflow. The outcome measure was the percentage of eligible patients who received a vaccine dose during hospitalization. The process measures included the percentage of age-eligible patients who were appropriately screened for prior doses on admission. We designed a clinical decision support system to enhance eligibility identification. The team performed a health equity analysis which stratified patients by social vulnerability index.

Results

During the study period, the average percentage of eligible hospitalized patients vaccinated increased from 0.9% to 3.5%, representing special cause variation and a centerline shift. The average percentage of age-eligible patients screened for prior vaccine doses on admission increased from 66.5% to 81.5%. Patients were more likely to be vaccinated if their clinician was exposed to the clinical decision support system (P < 0.01). The social vulnerability index analysis showed no significant differences.

Conclusions

This COVID-19 vaccination initiative highlights how an interprofessional approach can increase vaccination rates in hospitalized children; however, overall inpatient COVID-19 vaccination rates in this setting remained low.

Burden of respiratory failure in pediatric patients: Analysis of a prospective multicenter cohort in Bogotá, Colombia

Background and Aims

The approach to the burden of disease is a demographic, economic, and a health problem, which requires the design and application of specific measures of cost of the disease, such as disability-adjusted life years (DALYs), to establish better public health policies in the pediatric population. The aim of this study is to approach the burden of disease in children with acute respiratory failure (ARF) through the calculation of DALYs.

Methods

This study was conducted in the framework of a prospective, multicenter cohort in Bogotá, Colombia. Inclusion criteria were all pediatric patients admitted to the emergency department, hospitalization, and intensive care unit with respiratory distress; eligible patients were all those who developed ARF between April 2020 and December 2021. They were followed-up during hospitalization, at 30 and 60 days after admission. The Infant/Toddler Quality of Life Questionnaire and KIDSCREEN quality of life scales were applied for follow-up according to the age group. The results were used to calculate DALYs.

Results

Six hundred and eighty-five eligible patients, 296 (43.08%) developed ARF, of these 22 (6.08%) patients died (mortality rate = 7.43%). The total DALYs was 277.164 years. For younger than 9 years, the DALYs were 302.64 years, while for older than 10 years were 40.49 years.

Conclusion

ARF is one of the main causes of preventable mortality in pediatrics, its progression to respiratory failure is a highly prevalent condition in pediatric age, a condition that has a great impact on mortality, morbidity, and disability in our patients.

SARS-CoV-2 excretion kinetics in nasopharyngeal and stool samples from the pediatric population

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for serious respiratory infections in humans. Even in the absence of respiratory symptoms, gastrointestinal (GI) signs were commonly reported in adults and children. Thus, oral-fecal transmission was suspected as a possible route of infection. The objective of this study was to describe RNA shedding in nasopharyngeal and stool samples obtained from asymptomatic and symptomatic children and to investigate virus viability.

Methods

This study included 179 stool and 191 nasopharyngeal samples obtained from 71 children, which included symptomatic (n = 64) and asymptomatic (n = 7) ones. They were collected every 7 days from the onset of the infection until negativation. Viral RNA was detected by real-time RT-PCR, targeting the N and ORF1 genes. Whole-genome sequencing was performed for positive cases. Viral isolation was assessed on Vero cells, followed by molecular detection confirmation.

Results

All cases included in this study (n = 71) were positive in their nasopharyngeal samples. SARS-CoV-2 RNA was detected in 36 stool samples obtained from 15 out of 71 (21.1%) children; 13 were symptomatic and two were asymptomatic. Excretion periods varied from 7 to 21 days and 7 to 14 days in nasopharyngeal and fecal samples, respectively. Four variants were detected: Alpha (n = 3), B.1.160 (n = 3), Delta (n = 7), and Omicron (n = 1). Inoculation of stool samples on cell culture showed no specific cytopathic effect. All cell culture supernatants were negative for RT-qPCR.

Conclusion

Our study demonstrated nasopharyngeal and fecal shedding of SARS-CoV-2 RNA by children up to 21 and 14 days, respectively. Fecal shedding was recorded in symptomatic and asymptomatic children. Nevertheless, SARS-CoV-2 was not isolated from positive stool samples.

Characteristics and Risk Factors Associated with SARS-CoV-2 Pneumonias in Hospitalized Pediatric Patients: A Pilot Study

SARS-CoV-2 pneumonia in children has a lower incidence and severity compared to adults. Risk factors are adolescence and comorbidities. Our aims were to describe the characteristics of children admitted with SARS-CoV-2 pneumonia, identify risk factors associated with severity and compare the cases according to the variant of SARS-CoV-2. This was a descriptive and retrospective study, including patients aged 0-18 years hospitalized in a tertiary-care hospital between 1 March 2020 and 1 March 2022. Epidemiological, clinical, diagnostic and therapeutic data were analyzed. Forty-four patients were admitted; twenty-six (59%) were male and twenty-seven (61%) were older than 12 years. Thirty-six (82%) had comorbidities, the most frequent of which were obesity and asthma. Seven (15.9%) patients required high-flow oxygen, eleven (25%) non-invasive ventilation and four (9.1%) conventional mechanical ventilation. In critically ill patients, higher levels of anemia, lymphopenia, procalcitonin, lactate dehydrogenase (LDH) and hypoalbuminemia and lower levels of HDL-cholesterol were detected (all p < 0.05). Prematurity (p = 0.022) was associated with intensive care unit admission. Patients were younger during the Omicron wave (p < 0.01); no variant was associated with greater severity. In conclusion, pediatric patients with a history of prematurity or with anemia, lymphopenia, elevated procalcitonin, elevated LDH levels, hypoalbuminemia and low HDL-cholesterol levels may require admission and present more severe forms. Apart from age, no notable differences between SARS-CoV-2 variant periods were found.

Unmasking the enigma: An in-depth analysis of COVID-19 impact on the pediatric population

OBJECTIVES

COVID-19, caused by the novel coronavirus, has had a profound and wide-reaching impact on individuals of all age groups across the globe, including children. This review article aims to provide a comprehensive analysis of COVID-19 in children, covering essential topics such as epidemiology, transmission, pathogenesis, clinical features, risk factors, diagnosis, treatment, vaccination, and others. By delving into the current understanding of the disease and addressing the challenges that lie ahead, this article seeks to shed light on the unique considerations surrounding COVID-19 in children and contribute to a deeper comprehension of this global health crisis affecting our youngest population.

METHODS

A comprehensive literature search was conducted to gather the most recent and relevant information regarding COVID-19 in children. Multiple renowned databases, including MEDLINE, PubMed, Scopus, as well as authoritative sources such as the World Health Organization (WHO), the U.S. Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the National Institutes of Health (NIH) websites and others were thoroughly searched. The search included articles, guidelines, reports, clinical trials results and expert opinions published within the past three years, ensuring the inclusion of the latest research findings on COVID-19 in children. Several relevant keywords, including "COVID-19," "SARS-CoV-2," "children," "pediatrics," and related terms were used to maximize the scope of the search and retrieve a comprehensive set of articles.

RESULTS AND CONCLUSION

Three years since the onset of the COVID-19 pandemic, our understanding of its impact on children has evolved, but many questions remain unanswered. While SAR-CoV-2 generally leads to mild illness in children, the occurrence of severe cases and the potential for long-term effects cannot be overlooked. Efforts to comprehensively study COVID-19 in children must continue to improve preventive strategies, identify high-risk populations, and ensure optimal management. By unraveling the enigma surrounding COVID-19 in children, we can strive towards safeguarding their health and well-being in the face of future global health challenges.

Symptom-Specific Hospital Contacts in 12-18-Year-Olds Vaccinated against COVID-19: A Danish Register-Based Cohort Study

In this register-based real-life cohort study, changes in symptom-specific hospital contacts among 12-18-year-olds following two doses of the BNT162b2 COVID-19 vaccine compared to unvaccinated peers were investigated. Using national register data, vaccinated and unvaccinated adolescents were sex and age-matched each week during the inclusion period from May to September 2021. Symptom-specific hospital contacts covering ICD-10 R diagnoses were assessed before first the vaccine dose and after the second vaccine dose. Taking previous rates of symptom-specific hospital contacts into account, differences between vaccinated and unvaccinated adolescents were found. For some hospital contacts, higher rates were seen among the vaccinated, and for others, higher rates were seen among the unvaccinated. Unspecific cognition symptoms may be important to monitor in vaccinated girls, and likewise for throat and chest pain in vaccinated boys within the first months post-vaccination. In perspective, symptom-specific hospital contacts after vaccination against COVID-19 must be assessed by taking the risk of infection and symptoms following COVID-19 infection into account.

Clinical Features of COVID-19 in Pediatric Rheumatic Diseases: 2020-2022 Survey of the Pediatric Rheumatology Association of Japan

Coronavirus disease 2019 (COVID-19) in children can be compounded by concurrent diseases and immunosuppressants. For the first time, we aimed to report the clinical features of concurrent COVID-19 and pediatric rheumatic disease (PRD) in Japan. Pediatric Rheumatology Association of Japan members were surveyed between 1 April 2020 and 31 August 2022. Outcome measurements included the clinical features of concurrent PRD and COVID-19. Questionnaire responses were obtained from 38 hospitals. Thirty-one hospitals (82%) had children with PRD and COVID-19. The female-to-male ratio in these children (n = 156) was 7:3, with half aged 11-15 years. The highest proportion of children with PRD and COVID-19 was accounted for by juvenile idiopathic arthritis (52%), followed by systemic lupus erythematosus (24%), juvenile dermatomyositis (5%), scleroderma (4%), and Takayasu arteritis (3%). Of children with PRD, a significant majority (97%) were found to be asymptomatic (10%) or presented with mild symptoms (87%) of the COVID-19 infection. No severe cases or deaths were observed. Regarding the use of glucocorticoids, immunosuppressants, or biologics for PRD treatment before COVID-19, no significant difference was found between asymptomatic/mild and moderate COVID-19 in children with PRD. Therefore, COVID-19 is not a threat to children with PRD in Japan.

Evaluating COVID-19 vaccination intentions and vaccine hesitancy among parents of children with autism spectrum disorder

As the global vaccination mass campaign against COVID-19 extended to children aged 5 to 11 years, some parents remained hesitant about their children being administered the vaccine despite data supporting its safety. Parent vaccine hesitancy (PVH) may have predisposed certain groups of children, particularly those with autism spectrum disorder (ASD), to COVID-19 when other neurotypical children would have been vaccinated. We investigated the current PVH in 243 parents of children with ASD and 245 controls using the Parent Attitudes about Childhood Vaccines (PACV) scale. The study was conducted in Qatar from May to October 2022. Overall, 15.0% [95% CI 11.7%; 18.3%] of parents were vaccine-hesitant, with no difference (p = 0.054) between groups (ASD children [18.2%] vs. controls [11.7%]). The only sociodemographic factor associated with higher vaccine hesitancy was being a mother (as compared to being a father). The COVID-19 vaccine receipt rate at the time of the study did not differ between ASD (24.3%) and non-ASD groups (27.8%). Around two-thirds of parents of children with ASD refused or were unsure about vaccinating their children against COVID-19. We found that the intent to vaccinate against COVID-19 was higher in parents who were married and in those with a lower PACV total score. Continued public health efforts are needed to address vaccine hesitancy among parents.

Comparing clinical presentation, viremia, and immunological factors at various severity presentations in hospitalized children affected by COVID-19: A cross-sectional study

Background and Aims

Although SARS-CoV-2 infection usually leads to mild COVID-19 in children, sometimes it causes serious complications, especially in those with underlying diseases. Several factors have been identified in determining disease severity in adults, and limited studies have been conducted in children. The prognostic implications of SARS-CoV-2 RNaemia as an important factor in determining disease severity in children are not well understood.

Methods

In this study, we aimed to prospectively assess the relationship between disease severity and immunological factors and viremia in 47 COVID-19 hospitalized children. In this research, 76.5% of children experienced mild and moderate COVID-19, while 23.5% experienced severe and critical forms of the disease.

Results

The presence of underlying diseases in different groups of pediatric patients differed significantly from each other. On the other hand, clinical symptoms such as vomiting and chest pain as well as laboratory parameters including erythrocyte sedimentation rate were significantly different in different groups of patients. Viremia was seen in only two children, and this had no significant relationship with the severity of COVID-19.

Conclusion

In conclusion, our data confirmed that COVID-19 severity differed in SARS-CoV-2 infected children. Some clinical presentation and lab data parameters were different in various presentation of patients. Viremia was not associated with severity in our study.

Paediatric safety assessment of BNT162b2 vaccination in a multistate hospital-based electronic health record system in the USA: a retrospective analysis

BACKGROUND

The emergency use authorisation of BNT162b2 (tozinameran; Comirnaty, Pfizer-BioNTech) for children aged 5-17 years has resulted in rapid vaccination in the paediatric population. However, there are few studies of adverse events associated with vaccination in children. The aim of this study was to systematically assess the adverse events of two-dose BNT162b2 vaccination in the paediatric population.

METHODS

We conducted a retrospective analysis of patient electronic health records (EHRs) of children aged 5-17 years who received the primary two-dose series of the BNT162b2 vaccine between Jan 5, 2021, and Aug 5, 2022, at the Mayo Clinic Health System (MN, FL, AZ, IA, and WI), USA. Using natural language processing, we automatically curated adverse events reported by physicians in EHR clinical notes before and after vaccination. To determine significant adverse events after BNT162b2 vaccination, we calculated risk differences, which was defined as the percentage difference between the rate of children with an adverse event after a vaccine dose and the baseline rate of children with an adverse event before vaccination. 95% CIs and p values were calculated using the Miettinen and Nurminen score method.

FINDINGS

56 436 individuals aged 5-17 years (20 227 aged 5-11 years and 36 209 aged 12-17 years) with EHRs in the Mayo Clinic Health Systems were included in the study. Overall, the reporting of adverse events remained low in passive surveillance. Serious adverse events were rare after the first and second doses of BNT162b2, with rates of anaphylaxis (six [0·01%] of 56 436), myocarditis (five [0·01%]), and pericarditis (three [0·01%]) consistent with previous studies. Among the 20 227 5-11-year-olds, there were increased risks of fatigue (58 after second dose vs 41 before first dose; risk difference [RD]_dose2 0·08% [95% CI -0·01 to 0·18], p=0·044) and fever (104 after second dose vs 77 before first dose; RD_dose2 0·13% [0·00 to 0·27], p=0·022) after the second dose. Among the 36 209 12-17-year-olds, there were increased risks of arthralgia (69 after second dose vs 48 before first dose; RD_dose2 0·06% [-0·00 to 0·12], p=0·026), chills (58 after second dose vs 40 before first dose; RD_dose2 0·05% [-0·00 to 0·11], p=0·034), and myalgia (96 after second dose vs 73 before first dose; RD_dose2 0·06% [-0·01 to 0·14], p=0·038) after the second dose. Although the overall incidence was low, there was an increased risk of myocarditis in males aged 12-17 years after the second dose (five after second dose vs zero before first dose; RD_dose2 0·03% [0·01 to 0·07], p=0·013), with median age being 15 years (IQR 14 to 16).

INTERPRETATION

Overall, this data suggests that vaccination with BNT162b2 in the paediatric population is generally safe and well-tolerated. Further research is warranted to investigate the basis for the increased risk of myocarditis in adolescent males. Additionally, further studies are needed to confirm whether the findings in our study population apply to the whole vaccinated paediatric population.

FUNDING

nference.

Follow-Up of Side Effects throughout the Entire Course of Coronavirus Vaccination

Vaccines are considered the best protective means against coronavirus infection. There is increasing interest in reporting the side effects of vaccines, especially for individuals younger than 18 years old. Accordingly, this analytical cohort study aims to report on the side effects of adult and young individuals who received vaccination within 24 h, 72 h, 5 days, and 1 week through the entire course of vaccination (ECoV). A validated online survey was used to collect information. In total, 1069 individuals were completely followed. Most individuals received the Pfizer vaccine (59.6%). Most individuals had received two doses (69.4%). Very strong and statistically significant associations with side effects (p < 0.05, Phi (Φ) > 0.25) throughout the ECoV were reported for the type of vaccine and female gender. Non-smokers reported weak statistically significant associations. Fatigue and localized pain were the most commonly reported side effect, with onset within 24 h and duration of less than 72 h. The prevalence of reported side effects was statistically significantly higher among young individuals (<18 years old) than among adults (X2 (1) =7.6, p = 0.006. Phi φ = 0.11).

SARS-CoV-2 infection in newborn infants: descriptive epidemiological analysis of cases reported to the Colombian national surveillance system during the first pandemic year, March 2020-February 2021

OBJECTIVE

To describe the clinical and epidemiological characteristics of newborn infants with SARS-CoV-2 infection notified in the Colombian Public Health Surveillance System.

DESIGN

This epidemiological descriptive analysis was conducted using the data of all cases of newborn infants with confirmed SARS-CoV-2 infection notified in the surveillance system. Absolute frequencies and central tendency measures were calculated and a bivariate analysis comparing variables of interest with symptomatic and asymptomatic disease was performed.

SETTING

Population-based descriptive analysis.

PATIENTS

Laboratory-confirmed COVID-19 cases in newborn infants (aged ≤28 days of life) reported to the surveillance system from 1 March 2020 to 28 February 2021.

RESULTS

879 newborns were identified, corresponding to 0.04% of all reported cases in the country. The mean age at diagnosis was 13 days (range 0-28 days), 55.1% were male and most (57.6%) were classified as symptomatic. Preterm birth and low birth weight were identified in 24.0% and 24.4% of the cases, respectively. Common symptoms were fever (58.3%), cough (48.3%) and respiratory distress (34.9%). A higher prevalence of symptomatic newborns was seen in individuals with low birth weight for gestational age (prevalence ratio (PR): 1.51, 95% CI: 1.44 to 1.59) and newborns with underlying conditions (PR: 1.33, 95% CI: 1.13 to 1.55).

CONCLUSIONS

There were a low proportion of confirmed COVID-19 cases in the newborn population. A substantial number of newborns were classified as symptomatic, having low birth weight and being preterm. Clinicians caring for COVID-19-infected newborns should be aware of population characteristics that potentially contribute to disease manifestations and severity.

Evidence-based policies in public health to address COVID-19 vaccine hesitancy

A fundamental basis for effective health-related policymaking of any democratic nation should be open and transparent communication between a government and its citizens, including scientists and healthcare professionals, to foster a climate of trust, especially during the ongoing COVID-19 mass vaccination campaign. Since misinformation is a leading cause of vaccine hesitancy, open data sharing through an evidence-based approach may render the communication of health strategies developed by policymakers with the public more effective, allowing misinformation and claims that are not backed by scientific evidence to be tackled. In this narrative review, we debate possible causes of COVID-19 vaccine hesitancy and links to the COVID-19 misinformation epidemic. We also put forward plausible solutions as recommended in the literature.

Evaluation of BNT162b2 Covid-19 Vaccine in Children Younger than 5 Years of Age

BACKGROUND

Safe and effective vaccines against coronavirus disease 2019 (Covid-19) are urgently needed in young children.

METHODS

We conducted a phase 1 dose-finding study and are conducting an ongoing phase 2-3 safety, immunogenicity, and efficacy trial of the BNT162b2 vaccine in healthy children 6 months to 11 years of age. We present results for children 6 months to less than 2 years of age and those 2 to 4 years of age through the data-cutoff dates (April 29, 2022, for safety and immunogenicity and June 17, 2022, for efficacy). In the phase 2-3 trial, participants were randomly assigned (in a 2:1 ratio) to receive two 3-μg doses of BNT162b2 or placebo. On the basis of preliminary immunogenicity results, a third 3-μg dose (≥8 weeks after dose 2) was administered starting in January 2022, which coincided with the emergence of the B.1.1.529 (omicron) variant. Immune responses at 1 month after doses 2 and 3 in children 6 months to less than 2 years of age and those 2 to 4 years of age were immunologically bridged to responses after dose 2 in persons 16 to 25 years of age who received 30 μg of BNT162b2 in the pivotal trial.

RESULTS

During the phase 1 dose-finding study, two doses of BNT162b2 were administered 21 days apart to 16 children 6 months to less than 2 years of age (3-μg dose) and 48 children 2 to 4 years of age (3-μg or 10-μg dose). The 3-μg dose level was selected for the phase 2-3 trial; 1178 children 6 months to less than 2 years of age and 1835 children 2 to 4 years of age received BNT162b2, and 598 and 915, respectively, received placebo. Immunobridging success criteria for the geometric mean ratio and seroresponse at 1 month after dose 3 were met in both age groups. BNT162b2 reactogenicity events were mostly mild to moderate, with no grade 4 events. Low, similar incidences of fever were reported after receipt of BNT162b2 (7% among children 6 months to <2 years of age and 5% among those 2 to 4 years of age) and placebo (6 to 7% among children 6 months to <2 years of age and 4 to 5% among those 2 to 4 years of age). The observed overall vaccine efficacy against symptomatic Covid-19 in children 6 months to 4 years of age was 73.2% (95% confidence interval, 43.8 to 87.6) from 7 days after dose 3 (on the basis of 34 cases).

CONCLUSIONS

A three-dose primary series of 3-μg BNT162b2 was safe, immunogenic, and efficacious in children 6 months to 4 years of age. (Funded by BioNTech and Pfizer; ClinicalTrials.gov number, NCT04816643.).

Risk and Protective Factors for COVID-19 Morbidity, Severity, and Mortality

The outbreak of the coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become an evolving global health crisis. Currently, a number of risk factors have been identified to have a potential impact on increasing the morbidity of COVID-19 in adults, including old age, male sex, pre-existing comorbidities, and racial/ethnic disparities. In addition to these factors, changes in laboratory indices and pro-inflammatory cytokines, as well as possible complications, could indicate the progression of COVID-19 into a severe and critical stage. Children predominantly suffer from mild illnesses due to COVID-19. Similar to adults, the main risk factors in pediatric patients include age and pre-existing comorbidities. In contrast, supplementation with a healthy diet and sufficient nutrition, COVID-19 vaccination, and atopic conditions may act as protective factors against the infection of SARS-CoV-2. COVID-19 vaccination not only protects vulnerable individuals from SARS-CoV-2 infection, more importantly, it may also reduce the development of severe disease and death due to COVID-19. Currently used therapies for COVID-19 are off-label and empiric, and their impacts on the severity and mortality of COVID-19 are still unclear. The interaction between asthma and COVID-19 may be bidirectional and needs to be clarified in more studies. In this review, we highlight the clinical evidence supporting the rationale for the risk and protective factors for the morbidity, severity, and mortality of COVID-19.

Time course of adverse reactions following BNT162b2 vaccination in healthy and allergic disease individuals aged 5-11 years and comparison with individuals aged 12-15 years: an observational and historical cohort study

We aimed to investigate the type and frequency of adverse events over 7 days following the first and second BNT162b2 vaccination. This observational and historical cohort study included patients aged 5-11 years who received two doses of BNT162b2 and provided consent along with their guardians. We collected data on sex, age, height, weight, blood type, history of Bacille Calmette-Guerin vaccination, allergic disease, medication, history of coronavirus disease 2019 (COVID-19), and adverse reactions 7 days following the first and second BNT162b2 vaccination using a questionnaire. Our results were compared with previously reported results for individuals aged 12-15 years. A total of 421 participants were eligible for this study. Among the 216 patients with allergic disease, 48 (22.2%) had experienced worsening of their chronic diseases, and the frequency of fatigue and dizziness after the second dose was higher than that of healthy individuals. The experience of systemic adverse reactions was associated with asthma. The frequency of headache, diarrhea, fatigue, muscle/joint pain, and fever after the second BNT162b2 vaccination was lower in individuals aged 5-11 years than in those aged 12-15 years. Fever was the only systemic adverse reaction that lasted longer than 5 days (1.0% of participants).

CONCLUSIONS

Individuals with allergic diseases, who are potentially susceptible to COVID-19, may experience worsening of their chronic diseases and more frequent adverse reactions after BNT162b2 vaccination than healthy individuals. To ensure that children with allergic diseases receive the vaccine safely, further information needs to be collected.

WHAT IS KNOWN

• Adverse reactions after BNT162b2 vaccination among individuals aged 5-11 years are generally nonserious, more common after second vaccination, and substantially less common compared to those observed among individuals aged 12-15 years.

WHAT IS NEW

• Individuals with allergic diseases experienced worsening of their chronic diseases and more frequent adverse reactions after BNT162b2 vaccination than healthy individuals. • Systemic adverse reactions were associated with asthma. Fever was the only systemic adverse reaction that lasted longer than 5 days.

SARS-CoV-2 infection and COVID-19 in children

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is common in children, and clinical manifestations can vary depending on age, underlying disease, and vaccination status. Most children will have asymptomatic or mild infection, but certain baseline characteristics can increase the risk of moderate to severe disease. The following article will provide an overview of the clinical manifestations of coronavirus disease 2019 in children, including the post-infectious phenomenon called multisystem inflammatory syndrome in children. Currently available treatment and prophylaxis strategies will be outlined, with the caveat that new therapeutics and clinical efficacy data are constantly on the horizon.

COVID-19 vaccination-related attendance at a pediatric emergency department in Singapore among 12- to 18-year old adolescents

BACKGROUND

Singapore was one of the first countries to begin COVID-19 vaccination with the BNT162b2 vaccine for adolescents aged 12-18 years. This study evaluates the incidence of COVID-19 vaccine related attendances to a Pediatric Emergency Department (PED) to understand post-vaccination health behaviors among adolescents.

METHODS

This was a retrospective review of electronic medical records over a 4 month period, from the start of the adolescent vaccination drive to when more than 85% of this group had been fully vaccinated.

RESULTS

The incidence of COVID-19 vaccination-related presentations to our PED was 3.1% over 4 months (291 of 9387 PED attendances), with a peak daily incidence of 15.4% (14 of 91 attendances). Presentations were characterized by severity into: severe (3.4%), moderate (7.9%) or mild (88.7%) based on predefined criteria. The most common presenting complaints were chest pain (58.8%), dyspnea (28.2%) and palpitations (22.6%). Hospitalization was required in only 6.2% of attendances. Patients with moderate-severe presentations were 0.7 years older (p = 0.030), more likely to have underlying drug allergies (p = 0.048) and had higher rates of hospitalization (p < 0.005) compared to mild presentations. Despite concerns of cardiac inflammation, chest pain related attendances were less likely to be severe (p < 0.005) with reduced hospitalization need (p = 0.043) compared to other presentations. Investigations beyond clinical assessment comprised 91% of attendances, but abnormalities were only found in 6.4% cases.

CONCLUSION

Our study supports current evidence that COVID-19 vaccination is safe amongst adolescents. We highlight the health behaviors among adolescents post-vaccination, which is partly driven by media reports on vaccine side effects and an element of anxiety. While most of the presentations were mild, these can have implications on health resource utilization, particularly in an ongoing pandemic. As healthcare workers, we have an ongoing role to ensure accurate information on vaccine safety is communicated effectively to the public.

Variables Associated With COVID-19 Vaccination Among Israeli Adolescents and the Need for Targeted Interventions

BACKGROUND

We aimed to elucidate variables associated with coronavirus disease 2019 (COVID-19) vaccine compliance in adolescents and devise targeted interventions. Our secondary aim was to compare the rates of severe acute respiratory syndrome coronavirus 2 infection, hospitalizations and deaths between vaccinated and unvaccinated adolescents.

METHODS

A retrospective review of electronic medical records was performed on all adolescents 12-17 years of age registered at Clalit Health District in Israel during January 1, 2021, to November 18, 2021, with characterization by vaccination status against COVID-19. Univariate and multivariable analyses were employed to identify predictors of vaccination.

RESULTS

Of the 43,919 subjects included in the study, 28,207 (64.2%) were vaccinated. Non-ultraorthodox Jewish adolescents had a higher vaccination rate than the minorities Arabs or ultraorthodox Jews (72.5%, 66.2% and 40.5%, respectively, P &lt; 0.001). Adolescents of high socioeconomic status had nearly 2-fold higher vaccination rates than those of low socioeconomic status (80.4% vs 42.3%; P &lt; 0.0001). Adolescents 16-17 years old had a higher rate of COVID-19 vaccination than those 12-15 years old (72.5% vs 60.6%, P &lt; 0.001), as were girls versus boys (64.7% vs 63.8%, P = 0.047). Multivariate analysis identified 3 independent variables that were significantly ( P &lt; 0.001) associated with low vaccination: ultraorthodox sector, Arab population, and underlying obesity (hazard rations 0.42, 0.72 and 0.84, respectively). Vaccination was significantly associated with reduced severe acute respiratory syndrome coronavirus 2 infection, hospitalization and death ( P &lt; 0.001).

CONCLUSION

This study highlights several pediatric populations with low COVID-19 vaccine compliance. Targeted interventions aimed at these populations are suggested with consideration of their special cultural, social and societal characteristics.

Serum Vitamin D Levels in Relation to Development of Multisystem Inflammatory Syndrome in Pediatric COVID-19

Objective The aim of the study is to evaluate vitamin D (vit D) levels in children with and without development of multisystem inflammatory syndrome in children (MIS-C) after coronavirus disease 2019 (COVID-19) and also between those with severe and moderate MIS-C.

Methods This comprises retrospective data of 68 patients including 34 patients with MIS-C and admitted into the pediatric intensive care unit (MIS-C group) and 34 patients without MIS-C (non-MIS-C group) were analyzed for their presenting characteristics, serum vit D levels, ventilatory needs, and prognostic scores.

Results Vit D levels were significantly lower in patients with versus without MIS-C [9 (2–18) vs. 19 (10–43) ng/mL, p <0.001], and also in patients with severe versus moderate MIS-C [7.5 (2–17) vs. 9 (5–18) ng/mL, p = 0.024]. Vit D deficiency (levels <12 ng/mL) was more common in the MIS-C versus non-MIS-C group (79.4 vs. 11.8%, p <0.001) and in severe versus moderate MIS-C (92.9 vs. 70.0%, p <0.001). The severe versus moderate MIS-C was associated with significantly higher levels of procalcitonin [7.6 (0.9–82) vs. 1.7 (0.2–42) ng/mL, p = 0.030] and troponin [211 (4.8–4,545) vs. 14.2 (2.4–3,065) ng/L, p = 0.008] and higher likelihood of reduced ejection fraction (75.0 vs. 15.4%, p = 0.004).

Conclusion Our findings indicate the higher prevalence of vit D deficiency in pediatric COVID-19 patients with versus without MIS-C, as well as in those with severe versus moderate MIS-C. Higher troponin and procalcitonin levels and dyspnea at presentation seem also to be risk factors for severe MIS-C, more pronounced cardiac dysfunction, and poorer prognosis.

Safety after BBIBP-CorV (Sinopharm) COVID-19 Vaccine in Adolescents Aged 10-17 Years in Thailand

Coronavirus disease 2019 affected child health and impacted learning because of the resulting onsite school closures. This prospective cohort study included children aged 10-17 who received two 4 µg doses of BBIBP-CorV administered intramuscularly 21-28 days apart. To assess vaccine safety, 36,808 participants were then followed with paper- and web-based online questionnaire surveys that captured local and systemic reactogenicities following vaccine administration on days 1, 7, and 30. Among participants, 76% (27,880) reported reactogenicity within the first 24 h and 7 days following the first dose. Half (51.41%) of participants experienced pain at the injection site; the majority of cases were mild in severity. Injection site tenderness (37.93%) was another common local reaction. Fatigue (37.89%), myalgia (33.56%), and headache (26.76%) were the most common systemic reactions. On days 2-7 after the first dose, 25.85% of participants experienced adverse reactions. Following the second dose, reactogenicity was 7.6% and 1.09% within 24 h and between days 2-7. The majority of reactions were of mild to moderate severity. We report that two doses of the BBIBP-CorV caused mild to moderate side effects in adolescents in Thailand. The findings confirm the vaccine's safety profile in this age group.

Comparing the expression levels of tripartite motif containing 28 in mild and severe COVID-19 infection

Background

Tripartite motif-containing 28 (TRIM28) is an impressive regulator of the epigenetic control of the antiviral immune response. This study evaluated if the differential expression of TRIM28 correlates with the severity of coronavirus disease 2019 (COVID-19) infection.

Methods

A total of 330 COVID-19 patients, including 188 mild and 142 severe infections, and 160 healthy controls were enrolled in this study. Quantitative real-time polymerase chain reaction (qPCR) was used to determine the expression levels of TRIM28 in the studied patients.

Results

TRIM28 mRNA levels were significantly lower in both groups of patients versus the control group and in the severe group indicated further reduction in comparison to mild infection. The multivariate logistic regression analysis showed the mean age, lower levels of low-density lipoprotein (LDL), high-density lipoprotein (HDL), cholesterol, lower 25-hydroxyvitamin D, and PCR cycle threshold (Ct) value and higher levels of erythrocyte sedimentation rate (ESR) and differential expression of TRIM28 were linked to the severity of COVID-19 infection.

Conclusion

The results of this study proved that the downregulation of TRIM28 might be associated with the severity of COVID-19 infection. Further studies are required to determine the association between the COVID-19 infection severity and TRIM family proteins.

The Impact of Childhood and Parental Vaccination on SARS-CoV-2 Infection Rates in Children

BACKGROUND

The data on the indirect protection of children via the coronavirus disease 2019 (COVID-19) vaccination of household members are insufficient, and analyses to evaluate the efficacy of COVID-19 vaccines are limited.

METHODS

We gathered data on 12,442 patients under the age of 18 regarding the vaccination status of their household members, their vaccine preferences and doses, and their previous history of COVID-19 infection immediately before the patients were administered a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between September 1, 2021 and December 5, 2021.

RESULTS

A total of 18.4% (2289) were vaccinated, 91.4% with BNT162b2mRNA vaccine, 8.6% with inactivated COVID-19 vaccine; 48.7% received a single dose, and 51.3% had 2 doses. Real-time RT-PCR positivity proportions were much higher in older children ( P < 0.001) and were higher in children 12 years of age and older [odds ratio (OR), 1.34; 95% confidence interval (CI): 1.21-1.47] compared with others. SARS-CoV-2 infection was significantly lower in the vaccinated group (fully and incompletely) ( P < 0.001). Unvaccinated (OR, 4.88; 95% CI: 3.77-6.13) and incompletely vaccinated children (OR, 1.83; 95% CI: 1.52-2.12) had a higher risk of COVID-19 infection compared with fully vaccinated patients No significant association was found between the COVID-19 real-time RT-PCR positivity rates of patients and the vaccination status or vaccine preferences of household members ( P > 0.05 each).

CONCLUSIONS

SARS-CoV-2 infection rates were significantly lower in vaccinated children, especially with mRNA vaccines. The indirect protection of unvaccinated children via the vaccination of household members against COVID-19 seems inadequate. The individual vaccination of children remains crucial.

Risk of COVID-19 hospitalizations among school-aged children in Scotland: A national incident cohort study

Background

There is considerable policy, clinical and public interest about whether children should be vaccinated against SARS-CoV-2 and, if so, which children should be prioritised (particularly if vaccine resources are limited). To inform such deliberations, we sought to identify children and young people at highest risk of hospitalization from COVID-19.

Methods

We used the Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II) platform to undertake a national incident cohort analysis to investigate the risk of hospitalization among 5-17 years old living in Scotland in risk groups defined by the living risk prediction algorithm (QCOVID). A Cox proportional hazard model was used to derive hazard ratios (HR) and 95% confidence intervals (CIs) for the association between risk groups and COVID-19 hospital admission. Adjustments were made for age, sex, socioeconomic status, co-morbidity, and prior hospitalization.

Results

Between March 1, 2020 and November 22, 2021, there were 146 183 (19.4% of all 752 867 children in Scotland) polymerase chain reaction (PCR) confirmed SARS-CoV-2 infections among 5-17 years old. Of those with confirmed infection, 973 (0.7%) were admitted to hospital with COVID-19. The rate of COVID-19 hospitalization was higher in those within each QCOVID risk group compared to those without the condition. Similar results were found in age stratified analyses (5-11 and 12-17 years old). Risk groups associated with an increased risk of COVID-19 hospital admission, included (adjusted HR, 95% CIs): sickle cell disease 14.35 (8.48-24.28), chronic kidney disease 11.34 (4.61-27.87), blood cancer 6.32 (3.24-12.35), rare pulmonary diseases 5.04 (2.58-9.86), type 2 diabetes 3.04 (1.34-6.92), epilepsy 2.54 (1.69-3.81), type 1 diabetes 2.48 (1.47-4.16), Down syndrome 2.45 (0.96-6.25), cerebral palsy 2.37 (1.26-4.47), severe mental illness 1.43 (0.63-3.24), fracture 1.41 (1.02-1.95), congenital heart disease 1.35 (0.82-2.23), asthma 1.28 (1.06-1.55), and learning disability (excluding Down syndrome) 1.08 (0.82-1.42), when compared to those without these conditions. Although our Cox models were adjusted for a number of potential confounders, residual confounding remains a possibility.

Conclusions

In this national study, we observed an increased risk of COVID-19 hospital admissions among school-aged children with specific underlying long-term health conditions compared with children without these conditions.

SARS-CoV-2 infection in pediatric population before and during the Delta (B.1.617.2) and Omicron (B.1.1.529) variants era

BACKGROUND

COVID-19, the coronavirus disease that emerged in December 2019, caused drastic damage worldwide. At the beginning of the pandemic, available data suggested that the infection occurs more frequently in adults than in infants. In this review, we aim to provide an overview of SARS-CoV-2 infection in children before and after B.1.617.2 Delta and B.1.1.529 Omicron variants emergence in terms of prevalence, transmission dynamics, clinical manifestations, complications and risk factors.

METHODS

Our method is based on the literature search on PubMed, Science Direct and Google Scholar. From January 2020 to July 2022, a total of 229 references, relevant for the purpose of this review, were considered.

RESULTS

The incidence of SARS-CoV-2 infection in infants was underestimated. Up to the first half of May, most of the infected children presented asymptomatic or mild manifestations. The prevalence of COVID-19 varied from country to another: the highest was reported in the United States (22.5%). COVID-19 can progress and become more severe, especially with the presence of underlying health conditions. It can also progress into Kawasaki or Multisystem Inflammatory Syndrome (MIS) manifestations, as a consequence of exacerbating immune response. With the emergence of the B.1.617.2 Delta and B.1.1.529 Omicron variants, it seems that these variants affect a large proportion of the younger population with the appearance of clinical manifestations similar to those presented by adults with important hospitalization rates.

CONCLUSION

The pediatric population constitutes a vulnerable group that requires particular attention, especially with the emergence of more virulent variants. The increase of symptomatic SARS-CoV-2 infection and hospitalization rate among children highlights the need to extend vaccination to the pediatric population.

Individual genetic variability mainly of Proinflammatory cytokines, cytokine receptors, and toll-like receptors dictates pathophysiology of COVID-19 disease

Innate and acquired immunity responses are crucial for viral infection elimination. However, genetic variations in coding genes may exacerbate the inflammation or initiate devastating cytokine storms which poses severe respiratory conditions in coronavirus disease-19 (COVID-19). Host genetic variations in particular those related to the immune responses determine the patients' susceptibility and COVID-19 severity and pathophysiology. Gene polymorphisms such as single nucleotide polymorphisms (SNPs) of interferons, TNF, IL1, IL4, IL6, IL7, IL10, and IL17 predispose patients to the severe form of COVID-19 or severe acute respiratory syndrome coronavirus-2 (SARS-COV-2). These variations mainly alter the gene expression and cause a severe response by B cells, T cells, monocytes, neutrophils, and natural killer cells participating in a cytokine storm. Moreover, cytokines and chemokines SNPs are associated with the severity of COVID-19 and clinical outcomes depending on the corresponding effect. Additionally, genetic variations in genes encoding toll-like receptors (TLRs) mainly TLR3, TLR7, and TLR9 have been related to the COVID-19 severe respiratory symptoms. The specific relation of these mutations with the novel variants of concern (VOCs) infection remains to be elucidated. Genetic variations mainly within genes encoding proinflammatory cytokines, cytokine receptors, and TLRs predispose patients to COVID-19 disease severity. Understanding host immune gene variations associated with the SARS-COV-2 infection opens insights to control the pathophysiology of emerging viral infections.

SARS-CoV-2 With Concurrent Respiratory Viral Infection as a Risk Factor for a Higher Level of Care in Hospitalized Pediatric Patients

OBJECTIVE

As of early 2021, there have been over 3.5 million pediatric cases of SARS-CoV-2, including 292 pediatric deaths in the United States. Although most pediatric patients present with mild disease, they are still at risk for developing significant morbidity requiring hospitalization and intensive care unit (ICU) level of care. This study was performed to evaluate if the presence of concurrent respiratory viral infections in pediatric patients admitted to the hospital with SARS-CoV-2 was associated with an increased rate of ICU level of care.

DESIGN

A multicenter, international, noninterventional, cross-sectional study using data provided through The Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study database.

SETTING

The medical ward and ICU of 67 participating hospitals.

PATIENTS

Pediatric patients younger than 18 years hospitalized with SARS-CoV-2.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 922 patients were included. Among these patients, 391 required ICU level care and 31 had concurrent non-SARS-CoV-2 viral coinfection. In a multivariate analysis, after accounting for age, positive blood culture, positive sputum culture, preexisting chronic medical conditions, the presence of a viral respiratory coinfection was associated with need for ICU care (odds ratio, 3.6; 95% confidence interval, 1.6-9.4; P < 0.01).

CONCLUSIONS

This study demonstrates an association between concurrent SARS-CoV-2 infection with viral respiratory coinfection and the need for ICU care. Further research is needed to identify other risk factors that can be used to derive and validate a risk-stratification tool for disease severity in pediatric patients with SARS-CoV-2.

Development and validation of the predictive score for pediatric COVID-19 pneumonia: A nationwide, multicenter study

Background

Due to the possibility of asymptomatic pneumonia in children with COVID-19 leading to overexposure to radiation and problems in limited-resource settings, we conducted a nationwide, multi-center study to determine the risk factors of pneumonia in children with COVID-19 in order to create a pediatric pneumonia predictive score, with score validation.

Methods

This was a retrospective cohort study done by chart review of all children aged 0–15 years admitted to 13 medical centers across Thailand during the study period. Univariate and multivariate analyses as well as backward and forward stepwise logistic regression were used to generate a final prediction model of the pneumonia score. Data during the pre-Delta era was used to create a prediction model whilst data from the Delta one was used as a validation cohort.

Results

The score development cohort consisted of 1,076 patients in the pre-Delta era, and the validation cohort included 2,856 patients in the Delta one. Four predictors remained after backward and forward stepwise logistic regression: age < 5 years, number of comorbidities, fever, and dyspnea symptoms. The predictive ability of the novel pneumonia score was acceptable with the area under the receiver operating characteristics curve of 0.677 and a well-calibrated goodness-of-fit test (p = 0.098). The positive likelihood ratio for pneumonia was 0.544 (95% confidence interval (CI): 0.491–0.602) in the low-risk category, 1.563 (95% CI: 1.454–1.679) in the moderate, and 4.339 (95% CI: 2.527–7.449) in the high-risk.

Conclusion

This study created an acceptable clinical prediction model which can aid clinicians in performing an appropriate triage for children with COVID-19.

Clinical and Laboratory Characteristics of the Multisystem Inflammatory Syndrome in Children: A Case Series of 75 Patients

Background: SARS-CoV-2 has been characterized since December 2019 as the etiology of severe pneumonia throughout the world. However, the majority of children and adolescents with the respective infection have mild COVID-19. In April 2020, a warning was issued by the National Health Service (NHS), based on which a multisystem inflammatory syndrome in children (MIS-C) could be associated with COVID-19, presenting with cardiovascular shock, fever, and hyperinflammation. The syndrome presents with fever and organ involvement but with no pathognomonic findings or diagnostic tests, while some of the manifestations are almost the same as those of Kawasaki disease. Objectives: Knowledge of clinical course, demographic data, treatment, and prognosis can contribute to the more efficient management of the patients and, consequently, a decrease in morbidity and mortality. Methods: Seventy-five patients < 18 years from September 22, 2020, to March 10, 2021, in Namazi hospital, Shiraz, Iran, with a diagnosis as per MIS-C defined criteria, were recruited. Results: Median age of the patients was 6.2 years, and 58.6% were male. Of the patients, 46% had positive SARS-CoV-2 RT-PCR, antibody, or both. Thirty percent of the total patients reported contact with proven COVID-19 cases. The abdominal free fluid in 17 patients, hepatitis in one patient, and stasis in both kidneys of one patient were detected. Upon echocardiography on the first day, 77%, 48%, 21%, and one patient were with tricuspid regurgitation, mitral regurgitation, abnormal LV function, and myocarditis, respectively; however, after 5 - 7 days, the repeated echocardiography revealed 44% of patients with tricuspid regurgitation, 30% with mitral regurgitation, and 6% with abnormal LV function. For the treatment, 18% of the patients received inotropes, 60% ASA, 32% IVIG, 84% glucocorticoids, and 25.3% received furosemide. All of the patients received antibiotics as well. Finally, 97% of the patients were discharged alive, while two cases died. Conclusions: The results of this study suggest the importance of cardiac consultation along with early hospital care during the course of MIS-C in order to prevent the associated short-term and long-term complications.

Characteristics and outcomes of acute COVID-19 infection in paediatric and young adult patients with underlying cardiac disease

OBJECTIVE

To describe outcomes of acute coronavirus disease 2019 in paediatric and young adult patients with underlying cardiac disease and evaluate the association between cardiac risk factors and hospitalisation.

STUDY DESIGN

We conducted a retrospective single-institution review of patients with known cardiac disease and positive severe acute respiratory syndrome coronavirus 2 RT-PCR from 1 March, 2020 to 30 November, 2020. Extracardiac comorbidities and cardiac risk factors were compared between those admitted for coronavirus disease 2019 illness and the rest of the cohort using univariate analysis.

RESULTS

Forty-two patients with a mean age of 7.7 ± 6.7 years were identified. Six were 18 years of age or more with the oldest being 22 years of age. Seventy-six percent were Hispanic. The most common cardiac diagnoses were repaired cyanotic (n = 7, 16.6%) and palliated single ventricle (n = 7, 16.6%) congenital heart disease. Fourteen patients (33.3%) had underlying syndromes or chromosomal anomalies, nine (21%) had chronic pulmonary disease and eight (19%) were immunosuppressed. Nineteen patients (47.6%) reported no symptoms. Sixteen (38.1%) reported only mild symptoms. Six patients (14.3%) were admitted to the hospital for acute coronavirus disease 2019 illness. Noncardiac comorbidities were associated with an increased risk of hospitalisation (p = 0.02), particularly chronic pulmonary disease (p = 0.01) and baseline supplemental oxygen requirement (p = 0.007). None of the single ventricle patients who tested positive required admission.

CONCLUSIONS

Hospitalisations for coronavirus disease 2019 were rare among children and young adults with underlying cardiac disease. Extracardiac comorbidities like pulmonary disease were associated with increased risk of hospitalisation while cardiac risk factors were not.

SARS-COV-2 Notable Mutations and Variants: A Review Article

SARS-COV-2 (COVID-19) the virus that caused an epidemic of sever acute respiratory syndrome is what the world has been dealing with since Dec 2019. As the pandemic continues different variants that emerge during mutations have become the latest concern, with notable examples detected in South Africa, Brazil, and UK. Variants are complicated and each one is a collection of several mutations, all of which have the potential to change the virus in unexpected ways. Studying variants is imperative as they can lead the epidemic to the increase of population immunity. In the present study, we reviewed key mutations and concerning variants according to the WHO tracking Sars-Cov-2 program. Databases were searched through Feb to Mar 2022. Overall, 477 studies were extracted from databases, among them 165 studies included mutations, 239 included COVID-19 variants and 43 included both mutations and variants. At the final step of data screening 24 studies associated to mutations, 31 studies with the highlighted information on COVID-19 variants and 31 studies related to both mutations and variants were extracted for this review article. In conclusion, analyses of the genomic sequence of SARS-CoV-2 indicate that structural proteins are key molecules in the assembly of virus while NSPs can have different biochemical properties and possibly cellular functions.

Clinical Characteristics and Outcomes of COVID-19 in Pediatric and Early Adolescent and Young Adult Hematopoietic Stem Cell Transplant Recipients: A Cohort Study

Adult hematopoietic stem cell transplantation (HSCT) recipients are at a high risk of adverse outcomes after COVID-19. Although children have had better outcomes after COVID-19 compared to adults, data on risk factors and outcomes of COVID-19 among pediatric HSCT recipients are lacking. We describe outcomes of HSCT recipients who were ≤21 years of age at COVID-19 diagnosis and were reported to the Center for International Blood and Marrow Transplant Research between March 27, 2020, and May 7, 2021. The primary outcome was overall survival after COVID-19 diagnosis. We determined risk factors of COVID-19 as a secondary outcome in a subset of allogeneic HSCT recipients. A total of 167 pediatric HSCT recipients (135 allogeneic; 32 autologous HSCT recipients) were included. Median time from HSCT to COVID-19 was 15 months (interquartile range [IQR] 7-45) for allogeneic HSCT recipients and 16 months (IQR 6-59) for autologous HSCT recipients. Median follow-up from COVID-19 diagnosis was 53 days (range 1-270) and 37 days (1-179) for allogeneic and autologous HSCT recipients, respectively. Although COVID-19 was mild in 87% (n = 146/167), 10% (n = 16/167) of patients required supplemental oxygen or mechanical ventilation. The 45-day overall survival was 95% (95% confidence interval [CI], 90-99) and 90% (74-99) for allogeneic and autologous HSCT recipients, respectively. Cox regression analysis showed that patients with a hematopoietic cell transplant comorbidity index (HCT-CI) score of 1-2 were more likely to be diagnosed with COVID-19 (hazard ratio 1.95; 95% CI, 1.03-3.69, P = .042) compared to those with an HCT-CI of 0. Pediatric and early adolescent and young adult HSCT recipients with pre-HSCT comorbidities were more likely to be diagnosed with COVID-19. Overall mortality, albeit higher than the reported general population estimates, was lower when compared with previously published data focusing on adult HSCT recipients.

The Effect of Vitamin D Levels in Multisystem Inflammatory Syndrome in Children

Objective Multiple factors being overweight, asthmatic, or being of Asian or black ethnic origins have been reported vis-à-vis the “multisystem inflammatory syndrome in children” (MIS-C). There is an association between these conditions and vitamin D deficiency, which explains why MIS-C is more common in these patients. In the present study, we attempted to retrospective evaluate the 25-hydroxy vitamin D levels of patients with MIS-C, its association with acute phase reactants, its treatment, and clinical status.

Methods Patients aged between 1.5 months to 18 years with MIS-C were included in the study. All of the laboratory parameters, treatment, and response to the treatment were evaluated retrospectively. Two groups were formed. Patients had 25‐hydroxycholecalciferol D vitamin < 20 ng/mL in group 1 and ≥ 20 ng/mL in group 2.

Results A total of 52 patients were included in the study. There was no statistical difference between groups in terms of acceptance of the intensive care unit treatment (p = 0.29) and response to the first-line treatment (p = 0.56). A lower median lymphocyte count (p = 0.01) and a higher median C-reactive protein (p = 0.04) and procalcitonin (p = 0.01) with N-terminal pro-B-type natriuretic peptide (p = 0.025) values were found in group 1.

Conclusion Vitamin D deficiency was associated with an increased inflammatory response in children with MIS-C. More studies are required to determine the potential impact of vitamin D deficiency on the clinical outcome of MIS-C.

Short-Term Side Effects and SARS-CoV-2 Infection after COVID-19 Pfizer-BioNTech Vaccine in Children Aged 5-11 Years: An Italian Real-World Study

Vaccination against COVID-19 is the most effective tool to protect both the individual and the community from this potentially life-threatening infectious disease. Data from phase-3 trials showed that two doses of the BNT162b2 vaccine were safe, immunogenic, and effective against COVID-19 in children aged 5-11 years. However, no surveys in real-life settings have been carried out in this age range. Here, we conducted a cross-sectional study to evaluate the short-term adverse reactions (ARs) and the rate of protection against infection of the BNT162b2 vaccine in children aged 5-11 years by the compilation of two surveillance questionnaires conceived using Google Forms. Five-hundred and ninety one children were included in the analysis. ARs were reported by 68.9% of the children, being mainly local. The incidence of systemic ARs, especially fever, was higher after the second dose. The incidence of infection after completing the immunization accounted for 13.6% of the children. COVID-19 symptoms reported were mild, with the exception of one case of pneumonia. Only 40% of infected participants needed to take medication to relieve symptoms, mostly paracetamol and NSAIDs, and none reported persistent symptoms. The Pfizer-BioNTech vaccine in children aged 5-11 years is safe and well tolerated. The mild clinical course of COVID-19 in immunized children confirmed the favorable risk-benefit ratio, encouraging parents to immunize their children.

Severe Acute Respiratory Syndrome Coronavirus 2 Infections in Children

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in children generally have milder presentations, but severe disease can occur in all ages. MIS-C and persistent post-acute COVID-19 symptoms can be experienced by children with previous infection and emphasize the need for infection prevention. Optimal treatment for COVID-19 is not known, and clinical trials should include children to guide therapy. Vaccines are the best tool at preventing infection and severe outcomes of COVID-19. Children suffered disproportionately during the pandemic not only from SARS-CoV-2 infection but because of disruptions to daily life, access to primary care, and worsening income inequalities.

Caregivers' Intention to Vaccinate Their Children Under 12 Years of Age Against COVID-19: A Cross-Sectional Multi-Center Study in Milan, Italy

The impact of Coronavirus disease 2019 (COVID-19) on the pediatric population is increasingly recognized. A widespread vaccination in childhood would provide benefits for children and might help ending the pandemic by enhancing community protection. Following recent approval by the European Medicines Agency (EMA) of Comirnaty (Pfizer-BioNTech) for children aged 5-11 years, we aimed to investigate caregivers' intention to vaccinate their children <12 years of age against COVID-19. A structured questionnaire was administered to caregivers of children aged <12 years visiting the Emergency Department or the outpatient clinics in three major hospitals of Milan, Italy, from 20 September to 17 October 2021. A total of 612 caregivers were invited to participate and 604 accepted (response rate >98%). Three questionnaires were excluded due to compiling errors and 601 were included in the analysis. A total of 311 (51.7%) caregivers stated they would have their child vaccinated, 138 (23%) would refuse to vaccinate their child and 152 (25.3%) were unsure. The intention to vaccinate the child was higher in caregivers vaccinated against COVID-19, in those with a bachelor's degree or higher level of education, and in those with friends/acquaintances who became ill or died due to COVID-19. This study shows that increasing efforts are necessary to provide evidence-based tailored information to caregivers and to promote vaccination in this pediatric age group.

Epidemiology, Clinical Features, and Outcomes of Multisystem Inflammatory Syndrome in Children (MIS-C) and Adolescents—a Live Systematic Review and Meta-analysis

Purpose of Review

A multisystem inflammatory condition occurring in children and adolescents with COVID-19 has become increasingly recognized and widely studied globally. This review aims to investigate and synthesize evolving evidence on its clinical characteristics, management, and outcomes in pediatric patients.

Recent Findings

We retrieved data from PubMed, EMBASE, Cochrane Library, WHO COVID-19 Database, Google Scholar, and preprint databases, covering a timeline from December 1, 2019, to July 31, 2021. A total of 123 eligible studies were included in the final descriptive and risk factor analyses. We comprehensively reviewed reported multisystem inflammatory syndrome in children (MIS-C) cases from published and preprint studies of various designs to provide an updated evidence on epidemiology, clinical, laboratory and imaging findings, management, and short-term outcomes. Latest evidence suggests that African black and non-Hispanic white are the two most common ethnic groups, constituting 24.89% (95% CI 23.30–26.48%) and 25.18% (95% CI 23.51–26.85%) of the MIS-C population, respectively. Typical symptoms of MIS-C include fever (90.85%, 95% CI 89.86–91.84%), not-specified gastrointestinal symptoms (51.98%, 95% CI 50.13–53.83%), rash (49.63%, 95% CI 47.80–51.47%), abdominal pain (48.97%, 95% CI 47.09–50.85%), conjunctivitis (46.93%, 95% CI 45.17–48.69%), vomiting (43.79%, 95% CI 41.90–45.68%), respiratory symptoms (41.75%, 95% CI 40.01–43.49%), and diarrhea (40.10%, 95% CI 38.23–41.97%). MIS-C patients are less likely to develop conjunctivitis (OR 0.27, 95% CI 0.11–0.67), cervical adenopathy (OR 0.21, 95% CI 0.07–0.68), and rash (OR 0.44, 95% CI 0.26–0.77), in comparison with Kawasaki disease patients. Our review revealed that the majority of MIS-C cases (95.21%) to be full recovered while only 2.41% died from this syndrome. We found significant disparity between low- and middle-income countries and high-income countries in terms of clinical outcomes.

Summary

MIS-C, which appears to be linked to COVID-19, may cause severe inflammation in organs and tissues. Although there is emerging new evidence about the characteristics of this syndrome, its risk factors, and clinical prognosis, much remains unknown about the causality, the optimal prevention and treatment interventions, and long-term outcomes of the MIS-C patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40124-022-00264-1.

Insights into Cardiovascular Defects and Cardiac Epigenome in the Context of COVID-19

Although few in number, studies on epigenome of the heart of COVID-19 patients show that epigenetic signatures such as DNA methylation are significantly altered, leading to changes in expression of several genes. It contributes to pathogenic cardiac phenotypes of COVID-19, e.g., low heart rate, myocardial edema, and myofibrillar disarray. DNA methylation studies reveal changes which likely contribute to cardiac disease through unknown mechanisms. The incidence of severe COVID-19 disease, including hospitalization, requiring respiratory support, morbidity, and mortality, is disproportionately higher in individuals with co-morbidities. This poses unprecedented strains on the global healthcare system. While their underlying conditions make patients more susceptible to severe COVID-19 disease, strained healthcare systems, lack of adequate support, or sedentary lifestyles from ongoing lockdowns have proved detrimental to their underlying health conditions, thus pushing them to severe risk of congenital heart disease (CHD) itself. Prophylactic vaccines against COVID-19 have ushered new hope for CHD. A common connection between COVID-19 and CHD is SARS-CoV-2’s host receptor ACE2, because ACE2 regulates and protects organs, including the heart, in various ways. ACE2 is a common therapeutic target against cardiovascular disease and COVID-19 which damages organs. Hence, this review explores the above regarding CHDs, cardiovascular damage, and cardiac epigenetics, in COVID-19 patients.

Severity of Acute COVID-19 in Children <18 Years Old March 2020 to December 2021

This national study evaluated trends in illness severity among 82 798 children with coronavirus disease 2019 from March 1, 2020, to December 30, 2021.

Adolescent COVID-19 Vaccine Decision-Making among Parents in Southern California

Adolescent COVID-19 vaccination has stalled at 53% in the United States. Vaccinating adolescents remains critical to preventing the continued transmission of COVID-19, the emergence of variants, and rare but serious disease in children, and it is the best preventive measure available to return to in-person schooling. We investigated parent–adolescent COVID-19 vaccine decision-making. Between 24 February and 15 March 2021, we conducted surveys and 12 focus groups with 46 parent–adolescent dyads in Southern California. Parents and adolescents completed a survey prior to participation in a focus group discussion, which focused on exploring COVID-19 vaccine acceptance or uncertainty and was guided by the 5C vaccine hesitancy model. Parents uncertain about vaccinating adolescents expressed low vaccine confidence and high COVID-19 disease risk complacency. Parents who accepted COVID-19 vaccination for adolescents expressed high confidence in health authority vaccine recommendations, high perceived COVID-19 risk, and collective responsibility to vaccinate children. Additionally, unique pandemic-related factors of vaccine acceptance included vaccinating for emotional health, resuming social activities, and vaccine mandates. Among parents, 46% were willing to vaccinate their adolescent, 11% were not, and 43% were unsure. Among adolescents, 63% were willing to vaccinate. Despite vaccine availability, 47% of adolescents remain unvaccinated against COVID-19. Factors associated with vaccine uncertainty and acceptability inform health care practitioner, school, community, and public health messaging to reach parents and adolescents.

COVID-19 Mortality in Children: A Referral Center Experience from Iran (Mofid Children’s Hospital, Tehran, Iran)

Background. The novel coronavirus disease 2019 (COVID-19) started in Wuhan, China, in December 2019. It spread widely around the world and was described as a pandemic by the World Health Organization (WHO). The knowledge regarding the mortality rate and risk factors of COVID-19 among the pediatric population is lacking. In this regard, we aimed to report the clinical and laboratory characteristics of deceased pediatric patients with SARS-CoV-2 infection. Method. This cross-sectional study was conducted in Mofid Children’s Hospital, Tehran, Iran, from February 2020 to April 2021. Recorded documents of 59 pediatric patients (under 18 years old) assumed to have COVID-19 who had died in the COVID-19 ward and COVID-19 intensive care unit (ICU) were retrospectively evaluated. All statistical analyses were performed using SPSS software (v. 26.0, Chicago, IL). A $P$ value of less than 0.05 was considered statistically significant. Results. From 711 COVID-19 definite and suspected patients, 59 children died. Of these deceased pediatric patients, 34 were boys (57.62%) and 25 were girls (42.37%), with a total mean age of 5.6 years. The median length of stay in the hospital was 10 days (range 1–215). 91.52% had underlying comorbidities of which neurological diseases accounted for the largest share. 54 patients were admitted to the ICU and 83.05% of them had intubation during their hospitalization. In addition, the most common reasons for death in our study were related to respiratory and multiorgan failure. Conclusion. According to our knowledge, we are the first team to report such a thorough study in the field of COVID-19 pediatric mortality in Iran. Mortality was observed in all age groups of children, especially in those with previous comorbidities, specifically neurological disease. Abnormally elevated tests of ESR, CRP, LDH, AST, and ALT as well as the presence of proteinuria and hematuria were found in more than 50% of patients in our investigations, and ICU admission between both definite and suspected groups had significant differences, so monitoring and considering these factors may help to control and reduce the progression of the disease to death.

Clinical characteristics and mortality risk factors in patients aged less than 18 years with COVID-19 in Mexico and Mexico City

Introduction

Methods

Results

Conclusion