Clinical Features and Follow-up of Referred Children and Young People With Long COVID

BACKGROUND

Patient-level data on the clinical features and outcomes of children and young people referred for possible long coronavirus disease (COVID) can guide clinicians on what to expect in managing patients and advising families.

METHODS

A Post-Acute COVID Clinic for persons <21 years of age was established in October 2020. Intake was standardized and management was tailored to presenting symptoms. Data were abstracted from the charts of all patients evaluated through December 2021, and the study cohort consisted of patients who had a history of confirmed severe acute respiratory syndrome coronavirus 2 infection, had ≥1 symptom persisting for ≥12 weeks and had no pre-existing diagnosis that explained the symptoms. A structured follow-up interview was conducted in early 2022.

RESULTS

A total of 104 patients were referred, 81 of whom met inclusion criteria. The median age was 14 years (interquartile range, 13-16), and most were female, White/Caucasian and had commercial health insurance. Patients reported previously good health but over half reported moderate-to-severe disability at their first visit. Two clusters of presenting symptoms-fatigue with multiple symptoms, and fatigue and headache with cardiopulmonary symptoms-were identified. Extensive routine testing did not affirm alternative diagnoses. Incident conditions-most commonly anxiety, depression and/or panic disorder; migraines; and autonomic dysfunction-were diagnosed on clinical grounds. Telephone interviews (N = 55) revealed that 78% of patients were improved by about 6 months.

CONCLUSIONS

Within the limits of a single-center, referral-based, observational cohort, this study provides reassurance to patients and parents in that most cases of long COVID were self-limited. Extensive evaluations may be more useful in ruling out alternative diagnoses than in affirming specific physiologic disturbances.

Spotting a potential threat: Measles among pediatric solid organ transplantation recipients

BACKGROUND

Low-vaccination rates worldwide have led to the re-emergence of vaccine-preventable infections, including measles. Immunocompromised patients, including pediatric solid organ transplant (SOT) recipients, are at risk for measles because of suboptimal vaccination, reduced or waning vaccine immunity, lifelong immunosuppression, and global re-emergence of measles.

OBJECTIVES

To review published cases of measles in pediatric SOT recipients to heighten awareness of its clinical manifestations, summarize diagnostic and treatment strategies, and identify opportunities to optimize prevention.

METHODS

We conducted a literature review of published natural measles infections in SOT recipients ≤21 years of age, summarizing management and outcomes. We describe measles epidemiology, recommended diagnostics, treatment, and highlight prevention strategies.

RESULTS

There are seven published reports of measles infection in 12 pediatric SOT recipients, the majority of whom were unvaccinated or incompletely vaccinated. Subjects had atypical or severe clinical presentations, including lack of rash and complications, most frequently with encephalitis and pneumonitis, resulting in 33% mortality. Updated recommendations on testing and vaccination are provided. Treatment options beyond supportive care and vitamin A are limited, with no approved antivirals.

CONCLUSION

While measles is infrequently reported in pediatric SOT recipients, morbidity and mortality remain significant. A high index of suspicion is warranted in susceptible SOT recipients with clinically compatible illness or exposure. Providers must recognize this risk, educate families, and be aware of both classic and atypical presentations of measles to rapidly identify, isolate, and diagnose measles in pediatric SOT recipients. Continued efforts to optimize measles vaccination both pre- and post-SOT are warranted.

1083. Clinical Features and Long-Term Follow-up of Children Evaluated for Persistent Unwellness Following Acute COVID-19

Background

Few data exist on the clinical features and outcome of pediatric patients with persistent unwellness following acute COVID.

Methods

Norton Children’s and the University of Louisville School of Medicine opened a Post-COVID Clinic (PCC) in Oct 2020. The study cohort included all 104 patients referred to the PCC through Dec 2021. Clinical data were collected using a standardized template during routine care. Diagnostic tests and subspecialty referrals were ordered at the discretion of clinic physicians. A telephone interview in 2022 assessed long-term outcomes.

Results

The median age at first visit was 14 y (IQR=12,16); the age distribution of PCC patients was different from that of Pediatric Infectious Diseases Clinic (PIDC) patients in that there were few patients under 10 y. Males and females were equally represented. The racial distribution was similar to that of PIDC, but patients were more often from mid/upper socioeconomic status (using commercial insurance as a surrogate; p=0.001). The median interval from onset of COVID to the first PCC visit was 2 mo (IQR=1.5,4.4), and an increase in referrals was seen 2 mo after each COVID wave in the community (Figure 1). Most PCC patients reported good health prior to COVID. Fifty-four percent of patients experienced moderate or severe disability according to Modified Functional Disability Inventory scores at the first PCC visit (Figure 2; median score 14, IQR=6,19). Common symptoms were fatigue or lethargy (73%), headache (60%), shortness of breath or difficulty breathing (48%), exercise intolerance (47%), and chest pain (39%). Few abnormalities were found on routine diagnostic tests. Common subspecialty referrals were to Neurology, Cardiology, Pulmonology, Physical Therapy, and Psychiatry; the total number and types of referrals varied widely among patients. Most patients did not receive a specific diagnosis other than post-COVID syndrome. Sixty-three follow-up interviews were completed a median of 6 mo after the initial PCC visit; 79% of patients were improved or back to normal. Figure 1Reported COVID-19 cases in persons &lt;20 years of age in Jefferson County, KY and number of new patients seen in Norton Children’s Infectious Diseases Post-COVID Clinic, by 2-week intervals.

Figure 2 Box and whisker plot of Modified Functional Disability Inventory scores at first visit to Post-COVID Clinic.

Upper and lower quartiles are marked by the top and bottom of the boxes. The median is marked by a horizontal line inside the box and the mean is shown by the “x.” Top whiskers indicate the largest value ≤ the 3rd quartile plus 1.5 times the interquartile range; bottom whiskers indicate the smallest value ≥ the 1st quartile minus 1.5 times the interquartile range. Open circles extending beyond the whiskers represent outliers. Disability categories are from Kashikar-Zuck S, et al. Pain 2011;152:1600-1607.

Conclusion

This large experience with a PCC established early in the pandemic demonstrates that symptoms of post-COVID unwellness are non-specific and varied, routine tests are seldom diagnostic, and the natural history is one of gradual recovery.

Disclosures

Shanna M. Barton, M.D., M.Sc., Sanofi Pasteur: Grant/Research Support Victoria A. Statler, M.D., M.Sc., Astellas: University Research Support|Gilead: University Research Support|Pfizer: Advisor/Consultant|Sanofi: University Research Support|Seqirus: Advisor/Consultant Gary S. Marshall, MD, GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support|GlaxoSmithKline: Honoraria|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi: Honoraria|Seqirus: Advisor/Consultant|Seqirus: Grant/Research Support|Seqirus: Honoraria.

573. AIMS-trained Residents Exhibit Specific Communication Skills During Virtual Encounters with Standardized Vaccine-Hesitant Parents Following an Online Training Program

Background

There are no accepted best practices for counseling vaccine-hesitant parents, and training in this area is not required in residency. In a prior study (J Pediatr 2022;241:203-11), we demonstrated that in-person training in a structured communication strategy called AIMS (Announce, Inquire, Mirror, Secure) resulted in behaviors of interest during live encounters with standardized patients (SPs) portraying vaccine-hesitant parents. We investigated whether similar effects would be seen if training and SP encounters occurred in a virtual environment.

Methods

Pediatrics and Medicine-Pediatrics residents were randomized to receive either AIMS or control training. Subjects underwent pre- and post-training SP encounters simulating an immunization visit for a 4-month-old. SP case materials were modified to more closely approximate well-intentioned reluctance to vaccinate and allow for more authentic interaction. Encounters were video-recorded and assessed by 3 raters using the Vaccine Hesitancy Communication Assessment (VHCA), developed and characterized in the initial study but modified based on factor analysis to improve reliability and validity. Subject confidence and SP evaluations of the encounter were assessed pre- and post-training. Investigators, subjects, SPs, and video raters were blinded to treatment allocation.

Results

Fifty-three subjects completed the protocol and 47 had complete video files. Subject confidence improved in both groups (Panel A). No differences in SP evaluations were detected between groups (B). Preliminary analysis demonstrated that AIMS behaviors were more commonly detected among AIMS-trained subjects than control, as evidenced by an increase in VHCA score (C).

Conclusion

Communication training and assessment using SPs were both successfully transitioned to a virtual environment; this opens the possibility of efficient training and assessment of residents who are not located on site. Training increased confidence non-specifically. Encounters with SPs can serve as a model to detect learned vaccine-specific communication behaviors among resident providers, but post-encounter assessments by SPs remained insensitive to differences in those behaviors despite modification of the case materials.

Disclosures

Shanna M. Barton, MD, M.Sc., Sanofi Pasteur: Grant/Research Support Aaron W. Calhoun, MD, FSSH, Sanofi-Pasteur: Grant/Research Support|Society for Simulation in Healthcare: Board Member|Society for Simulation in Healthcare: Honoraria Victoria A. Statler, M.D., M.Sc., Astellas: University Research Support|Gilead: University Research Support|Pfizer: Advisor/Consultant|Sanofi: University Research Support|Seqirus: Advisor/Consultant Gary S. Marshall, MD, GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support|GlaxoSmithKline: Honoraria|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi: Honoraria|Seqirus: Advisor/Consultant|Seqirus: Grant/Research Support|Seqirus: Honoraria.

Return to School and COVID-19 Vaccination for Pediatric Solid Organ Transplant Recipients in the United States: Expert Opinion for 2021-2022

The COVID-19 pandemic continues to generate challenges for pediatric solid organ transplant (SOT) recipients and their families. As rates of COVID-19 fluctuate, new SARS-CoV-2 variants emerge, and adherence to and implementation of mitigation strategies vary from community to community, questions remain about the best and safest practices to prevent COVID-19 in vulnerable patients. Notably, decisions about returning to school remain difficult. We assembled a team of specialists in pediatric infectious diseases, transplant infectious diseases, public health, transplant psychology, and infection prevention and control to re-address concerns about school re-entry, as well as COVID-19 vaccines, for pediatric SOT recipients in the United States in 2021. Based on available literature and guidance from national organizations, we generated expert statements specific to pediatric SOT recipients focused on school attendance in 2021.

Standardized Vaccine-Hesitant Patients in the Assessment of the Effectiveness of Vaccine Communication Training

OBJECTIVES

To determine if training residents in a structured communication method elicits specific behaviors in a laboratory model of interaction with vaccine-hesitant parents.

STUDY DESIGN

Standardized patients portraying vaccine-hesitant parents were used to assess the effectiveness of training in the Announce, Inquire, Mirror, Secure (AIMS) Method for Healthy Conversations. Blinded pediatric residents were pseudorandomized to receive AIMS or control training and underwent pre- and post-training encounters with blinded standardized patients. Encounters were assessed by blinded raters using a novel tool. Participant confidence and standardized patient evaluations of the participants' general communication skills were assessed.

RESULTS

Ratings were available for 27 AIMS and 26 control participants. Statistically significant increases in post-training scores (maximum = 30) were detected in AIMS, but not in control, participants (median, 21.3 [IQR, 19.8-24.8] vs 18.8 [IQR, 16.9-20.9]; P < .001). Elements (maximum score = 6) with significant increases were Inquire (0.67 [IQR, 0-1.76] vs -0.33 [IQR, -0.67 to 0.33]; P < .001); Mirror (1.33 [IQR, 0 to 2] vs -0.33 [IQR, -0.92 to 0]; P < .001) and Secure (0.33 [IQR, 0 to 1.67] vs -0.17 [IQR, -0.67 to 0.33]; P = .017). Self-confidence increased equally in both groups. Standardized patients did not detect a difference in communication skills after training and between groups. Internal consistency and inter-rater reliability of the assessment tool were modest.

CONCLUSIONS

Standardized patients proved useful in studying the effectiveness of structured communication training, but may have been limited in their ability to perceive a difference between groups owing to the predetermined encounter outcome of vaccine refusal. AIMS training should be studied in real-world scenarios to determine if it impacts vaccine acceptance.

1116. AIMS-trained Residents Exhibit Specific Communication Skills in a Standardized Patient Model of Vaccine Hesitancy

Background

Vaccine hesitancy (VH) is one of the top 10 threats to global public health. While VH is common among parents, there are no accepted best practices for counseling, and training in this area is not required in residency. Strategies are needed to help providers address VH in practice.

Methods

The AIMS (Announce, Inquire, Mirror, Secure) Method for Healthy Conversations is a structured communication strategy that attempts to build trust between provider and patient (or parent), inviting receptivity to healthcare recommendations. To assess whether relatively inexperienced providers exhibit AIMS behaviors after training, blinded pediatric residents were pseudo-randomized to receive either AIMS or control training. Subjects underwent pre- and post-training clinical encounters with blinded standardized patients (SPs) portraying vaccine-hesitant parents; encounters were video-recorded and assessed by 3 blinded raters using the Vaccine Hesitancy Communication Assessment (VHCA) tool, which was developed by an iterative process and validated in pilot testing. Subject confidence was assessed pre- and post-training.

Results

Overall VHCA intraclass correlation was 0.273 for pre and 0.681 for post encounters (2-way mixed averages); reliability varied with AIMS phases. Fifty-eight subjects completed the protocol, and VHCA ratings for 29 subjects were available for this analysis. AIMS behaviors were more commonly detected among AIMS-trained subjects than control (median change in score [scale 0–30]=4.5 versus 0 for control) (Figure 1). Confidence improved in both groups (Figure 2). SPs perceived no differences between groups, nor between pre and post within groups, in aspects of subject performance such as respect, empathy, and promotion of trust (P=0.936 [ANCOVA]; partial eta-squared 0.0).

Figure 1

Figure 2

Conclusion

Pediatric residents can be trained in AIMS behaviors, and an SP model of VH can be used to assess performance. AIMS training results in similar gains in self-confidence compared to control training. SP perceptions may be colored by their script, which in this case was to exhibit adamant vaccine refusal. Testing of AIMS training in longitudinal experimental scenarios and in real-world settings is warranted.

Disclosures

Kristina A. Bryant, MD, Pfizer (Research Grant or Support, Investigator on multi-center clinical trials) Gary S. Marshall, MD, GlaxoSmithKline (Consultant, Scientific Research Study Investigator)Merck (Consultant, Scientific Research Study Investigator)Pfizer (Consultant, Scientific Research Study Investigator)Sanofi Pasteur (Consultant, Grant/Research Support, Scientific Research Study Investigator, Honorarium for conference lecture)Seqirus (Consultant, Scientific Research Study Investigator)

Management of Hepatitis C in Children and Adolescents

The management of hepatitis C virus (HCV) infections has changed dramatically in recent years with the use of direct antiviral agents (AADs). New AADs have excellent safety profile and demonstrated to be highly effective. Interferon free regimens are now recommended for children and adolescents but significant barriers for treatment exist. Overcoming those barriers will facilitate HCV elimination. This review covers varied topics to familiarize providers with the current status of pediatric HCV management in light of newly available DAAs medications.

Return to School for Pediatric Solid Organ Transplant Recipients in the United States During the Coronavirus Disease 2019 Pandemic: Expert Opinion on Key Considerations and Best Practices

The coronavirus disease 2019 (COVID-19) pandemic has created many challenges for pediatric solid organ transplant (SOT) recipients and their families. As the pandemic persists, patients and their families struggle to identify the best and safest practices for resuming activities as areas reopen. Notably, decisions about returning to school remain difficult. We assembled a team of pediatric infectious diseases (ID), transplant ID, public health, transplant psychology, and infection prevention and control specialists to address the primary concerns about school reentry for pediatric SOT recipients in the United States. Based on available literature and guidance from national organizations, we generated consensus statements pertaining to school reentry specific to pediatric SOT recipients. Although data are limited and the COVID-19 pandemic is highly dynamic, our goal was to create a framework from which providers and caregivers can identify the most important considerations for each pediatric SOT recipient to promote a safe return to school.

Long-term Health Outcomes of Patients Evaluated for Unexplained Fever in a Pediatric Infectious Diseases Clinic

A telephone interview was conducted with parents of 120 children seen in a pediatric infectious diseases clinic for unexplained fever who received no definitive diagnosis or were thought to have recurrent self-limited illnesses. Only 3 were diagnosed with a fever-related condition after 8 years of follow-up. The majority remained well.

Immunization Adherence in Children With Sickle Cell Disease: A Single-Institution Experience

OBJECTIVES

The Advisory Committee on Immunization Practices (ACIP) recommends additional immunizations for people with asplenia or functional asplenia, such as children with sickle cell disease. Adherence rate to the recommended immunization schedule for functional asplenia remains low for children with sickle cell disease. The purpose of this study was to assess the immunization adherence for this population at a single institution in Kentucky and to evaluate the use of the Kentucky Immunization Registry (KYIR) by providers.

METHODS

A single-center retrospective chart review was conducted for 107 children with sickle cell disease ages 2 through 18 years. Immunization histories were obtained from the hospital EMRs, the sickle cell clinic EMR, the KYIR, and by requesting records from primary care physicians. Each patient was documented as either missing or having complete records in the KYIR.

RESULTS

The complete adherence rate to the ACIP-recommended immunization schedule for children with functional asplenia was 6% (6 of 107). Nearly all children were compliant with the Haemophilus influenzae type B vaccination, whereas the adherence rate for the meningococcal and pneumococcal vaccines ranged from 25% to 77%. The lowest immunization rate was observed in children eligible for the meningococcal B vaccine (25%). Only 3 patients had a complete immunization history documented in the KYIR.

CONCLUSIONS

Adherence to the ACIP-recommended immunization schedule for functionally asplenic patients is poor among children with sickle cell disease included in this study. Quality improvement measures should focus on increasing immunization adherence and improving documentation of immunization records in the KYIR for this patient population.

Evaluation of Prolonged and Recurrent Unexplained Fevers

Fever is a common symptom in children. Some children may present to their primary care physician with undifferentiated fever; that is, fever for which there is no obvious source from the history or physical examination. Undifferentiated fevers may be prolonged or recurrent. Distinguishing between the two is helpful for narrowing the differential diagnosis, which can be broad and include infections and inflammatory diseases and, rarely, malignancies and autoinflammatory disorders. The evaluation of such children requires a step-wise approach. Taking a detailed history, performing a thorough physical examination, and reviewing a fever and symptom diary is crucial in recognizing clues that may ultimately lead to a diagnosis. Some children who look good and whose fever disappears may never have a diagnosis, whereas referral to a specialist may be prudent for others. [Pediatr Ann. 2018;47(9):e347-e353.].

Immunogenicity and safety of a quadrivalent inactivated influenza vaccine in children 6-59 months of age: A phase 3, randomized, noninferiority study

BACKGROUND

In the Southern Hemisphere 2010 influenza season, Seqirus' split-virion, trivalent inactivated influenza vaccine was associated with increased reports of fevers and febrile reactions in young children. A staged clinical development program of a quadrivalent vaccine (Seqirus IIV4 [S-IIV4]; Afluria® Quadrivalent/Afluria Quad™/Afluria Tetra™), wherein each vaccine strain is split using a higher detergent concentration to reduce lipid content (considered the cause of the increased fevers and febrile reactions), is now complete.

METHODS

Children aged 6-59 months were randomized 3:1 and stratified by age (6-35 months/36-59 months) to receive S-IIV4 (n = 1684) or a United States (US)-licensed comparator IIV4 (C-IIV4; Fluzone® Quadrivalent; n = 563) during the Northern Hemisphere 2016-2017 influenza season. The primary objective was to demonstrate noninferior immunogenicity of S-IIV4 versus C-IIV4. Immunogenicity was assessed by hemagglutination inhibition (baseline, 28 days postvaccination). Solicited, unsolicited, and serious adverse events were assessed for 7, 28, and 180 days postvaccination, respectively.

RESULTS

S-IIV4 met the immunogenicity criteria for noninferiority. Adjusted geometric mean titer ratios (C-IIV4/S-IIV4) for the A/H1N1, A/H3N2, B/Yamagata, and B/Victoria strains were 0.79 (95% CI: 0.72, 0.88), 1.27 (1.15, 1.42), 1.12 (1.01, 1.24), and 0.97 (0.86, 1.09), respectively. Corresponding values for differences in seroconversion rates (C-IIV4 minus S-IIV4) were -10.3 (-15.4, -5.1), 2.6 (-2.5, 7.8), 3.1 (-2.1, 8.2), and 0.9 (-4.2, 6.1). Solicited, unsolicited, and serious adverse events were similar between vaccines in both age cohorts, apart from fever. Fever rates were lower with S-IIV4 (5.8%) than C-IIV4 (8.4%), with no febrile convulsions reported with either vaccine during the 7 days postvaccination.

CONCLUSION

S-IIV4, manufactured with a higher detergent concentration, demonstrated noninferior immunogenicity to the US-licensed C-IIV4, with similar postvaccination safety and tolerability, in children aged 6-59 months. This completes the program demonstrating the immunogenicity and safety of S-IIV4 in participants aged 6 months and older.

FUNDING

Seqirus Pty Ltd; ClinicalTrials.gov identifier:NCT02914275.

Characteristics of Patients Referred to a Pediatric Infectious Diseases Clinic With Unexplained Fever

BACKGROUND

Older case series established diagnostic considerations for children meeting a priori definitions of fever of unknown origin (FUO). No recent study has examined the final diagnoses of children referred for unexplained fever.

METHODS

This study was conducted with a retrospective chart review of patients referred to a pediatric infectious diseases clinic from 2008 to 2012 for unexplained fever.

RESULTS

Sixty-nine of 221 patients were referred for "prolonged" unexplained fever. Ten of these were not actually having fever, and 11 had diagnoses that were readily apparent at the initial visit. The remaining 48 were classified as having FUO. The median duration of reported fever for these patients was 30 days; 15 had a diagnosis made, 5 of which were serious. None of the serious FUO diagnoses were infections. Of 152 patients with "recurrent" unexplained fever, 92 had an "intermittent" fever pattern, and most of these had sequential, self-limited viral illnesses or no definitive diagnosis made. Twenty of the 60 patients with a "periodic" fever pattern were diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Overall, 166 patients either were not having fever, had self-limited illnesses, or ultimately had no cause of fever discovered. Only 12 had a serious illness, 2 of which were infections (malaria and typhoid fever).

CONCLUSIONS

Most children referred with unexplained fever had either self-limited illnesses or no specific diagnosis established. Serious diagnoses were unusual, suggesting that these diagnoses rarely present with unexplained fever alone, or that, when they do, the diagnoses are made by primary care providers or other subspecialists.