Pediatric infectious disease specialist Prachi Singh, DO, presents the evidence on COVID-19 illness and vaccines for children and adolescents, illuminating the current state of the changeable COVID landscape. Her talk arms pediatric providers with answers to questions about the vaccine’s “waning efficacy,” the actual danger of myocarditis or other side effects, protection from “natural immunity,” contraindications to vaccination, and the future of life with COVID.
Thanks everyone for joining. It's great to be here and thank you for giving me the opportunity to talk to you all about this topic that isn't um staying quite relevant despite my best efforts and wishes that it would go away. But I think as pediatricians we're all aware, we're kind of currently in the landscape of just fending off all respiratory illnesses and viruses. And while we are talking about Covid today, um, I just want you to be cognizant that we are seeing an uptick of RSP and we are seeing influenza as well. Not quite as much, but a little bit more RsV. And um what they have found is that RsV is a little bit more virulent um, this year as opposed to years past and of course there's mixed reasons behind that. But We're all aware and continue to encourage vaccines in your pediatric population at least for flu. So planning to talk, we'll just talk about the current epidemiology of COVID-19 examined the efficacy of COVID-19 vaccines and that's the bulk of the talk where I want to spend most of the time in and then describe the need for COVID-19. Um, Blisters in pediatric immuno compromised population just a little bit and then we'll briefly touch upon the identifying some socio economic ethical disparities as a risk factor for COVID-19 disease. Um, so the current landscape national and local outlook is considerably improved since September. United States is currently averaging about 75,000 cases a day. And that's hospitalization continued to decline about 1400 a day and about two thirds of Americans age 12 and older are fully vaccinated just recently, I think um The data came out that about a million doses were administered to ages five and 11. So we're getting up there for even the younger age group globally speaking, this is the current landscape. So you can see the big blue peak over there was India with the delta variant and that kind of um ravaged the country there. And then our two big peaks here where the green lines there. So right after the holidays in january 2021 then over the summer due to the delta variant, we are seeing a little bit more uptake in Germany right now with they're having a outbreak of covid 19 cases. Um and and per reports, it's like the largely unvaccinated group. So in terms of uh mentioned to you before, it's kind of like ups and peaks and traps. But this is from New York Times. They, they do their daily average and then their 14 day average that that kind of changes up and down considerably. So looking at bay Area in particular, um, we saw our big peak over in the summertime and now they're kind of like these a little bit uptick. But then there are also some draws and note that there is some delay in the number of reported cases and such and um on um here you'll see the ICU admissions and hospitalizations from covid 19 and down below the deaths due to covid 19. And what we're starting to see is that even though the cases might be going up, the deaths are not really going up. Which is partly due to the vaccination status. Talking particularly about pediatric population and adolescents. Um This is overall the dark blue line is 0 to 17 years of age and then the dashed lines are several different other age groups. So you can see the lowest age group. There was the 0 to 4 and then the teenagers sort of took the higher peak of the curve and the cases started to rise. But certainly we did see an increase in hospitalization among us, Children and adolescents, particularly obese adolescents since the rise of delta variant. And then this was a particular step it from C. D. C. When they evaluated the data for his hospitalizations for adolescents between june 20th to july 30th. They saw that 68 adolescents in whom that they could assess the vaccination status, 59 of them were unvaccinated. Five were partially vaccinated and four were fully vaccinated. When we look at a cumulative case count between 0 to 4 years, there have been about 1600 cases or hospitalizations secondary to covid and then from 5 to 17 over 2500. This sort of this these statistics I think help inform us as we are talking to families now more and more, particularly in the landscape of the newly um ah approved vaccine for the younger age group. So in terms of proportion of total covid 19 cases by age group, this is obviously no surprise to us. The majority of the age group is the darker gray or the orange shapes here, which is the older population. But you can see that there is an uptick in the, in the 5 to 11 year age group and even the 0 to 4 year age group out of the proportion of what they belong in the society. When we talk about or think about racial and ethnic groups or disparities among that, that covid kind of really highlighted that amongst anything else that our health care system has seen in the past but really brought it to fruition. So you can see that american indian Alaskan natives were highly disproportionate to what they belong or percentage they belong to the population. They had much higher numbers of even deaths. Um, from covid 19 when we think about Children, american indian and Alaskan native Children are 7.6 times as likely to die from covid 19 black Children, about 5.5 times more likely to die. Hispanic for 4.7 times more likely to die. And then asian and pacific islander Children even 2.1% times more likely to die. And these are kind of grave and and somber statistics. But they are reality of what we are living in right now when we think about cases and that's particularly in pediatrics and looking at California in particular, we see the least age group or the lowest number is in the last five age group. And then um, as we go towards the teenager age group is 12.5% or 26. Uh, that's well, this is all Benioff Children's hospital. So including Mission Bay san Francisco and Oakland to date, we have had 297 hospitalization, 96 have required critical care, 27 with mechanical ventilation and three required ECMO. Um, and they're seven day positivity rate is about 1.5%. When you look at covid cases, particularly in pediatrics by region, we saw that there was a very unequal or uneven distribution of cases and that kind of proceeded even what the adults were doing, but certainly kids were the same. So you can see in south back in august and uh october, there was a big peak and we know the vaccination status, there was lower than some of the other regions and the know best where we are. We did see the two peaks but ours were much lower. So speaking or thinking much about the vaccination rates. Um, you know the quartile of states with the lowest vaccination rates. So the oriented to these graphs, the top being the percent of any visits confirmed, COVID-19 cases and the bottom being Um, just admissions from COVID-19 and this is in pediatric population. So you're going from highest vaccination states um to lowest vaccination states. And you can see there's a peak towards the lowest vaccination rates as you go from left to the right in all age groups. This was particularly enlightening to me because what you know, I saw in the hospital was perhaps not the true reality of what was going on. So nationally speaking, COVID-19 hospitalizations and Children and looking at particularly underlying medical conditions. About 46% of them, or almost half of them did not have uh an underlying medical condition. And 35% of them had underlying condition of obesity. And we know during the covid 19 pandemic last year and a half Obese city has increased in pediatric population. So it has Type two diabetes and other things. Um, and you know, other things like asthma and cardiovascular disease or chronic lung disease, they weren't as impressive to me as obesity and perhaps just not having any underlying medical condition. So this informs us a little bit later for when we're going to talk about vaccines. And these are sarah prevalence estimates with different age groups. So, just we're living, we have been living in this pandemic for the past year and a half for almost two years now, what percentage of our population is there a positive or have had the Um natural or you know, the infection. So in terms of the younger age group, it is quite higher. So the 5 to 11. Each group is about 38% 0 positive. And then all age groups. Sarah prevalence in the United States is about 26% soul quarter. Um when you look at California overall in all age groups it's 21% and 0-17 is closer to that as well as about 17.5%. You're all aware of this condition called M. I. S. C. Or a multi system inflammatory syndrome that we see after. Um somebody has had symptomatic or asymptomatic covid about 3 to 4 weeks later you can get this condition the nationally so far there have been about 5000 cases reported and total deaths reported from M. I. S. C. Has been 46. Um The bottom graph here shows the black dotted line is the covid 19 cases and you can see that there's a lag of M. I. S. D. Cases kind of after covid 19 cases peak. And and then there's a few weeks later you'll see M. I. S. C. Cases speaking here again we'll see like the racial disparities that come across and black non hispanic Children really have a higher predisposition to get this M. I. S. C. Condition than any other racial or ethnic minority. So these are sort of like the things that you know I mentioned in the in the um our objectives but we'll kind of go through them So briefly I wanted to touch based on variants. We all know that all infected cells build new coronavirus is these tiny errors lead to mutations. And when there's a lineage track through this branch of viral family tree, a group of these corona viruses that have that shared inherent set of mutations are called variants. So right now, no surprise to us, just don't tell the Delta Airlines that we call it. The delta variant um is about the most predominant um variant that exist in the United States about 94%. How is it different we found out and as the vaccinations were sort of rolling through and and we're seeing more and more delta variant and and that's where sort of like you even recall or maybe remember that there was a little bit of a mixed messaging should be wearing a mask. If you're not if you're vaccinated, should not be wearing a mask. And the delta variant sort of threw a wrench in those things because what we found is that it turned out to be a little bit more transmissible than the original ancestral stain. This first graph in the background was published in new york times back in february 2020 and I remember my very first talk on covid 19 was to a group of E. M. T. S. And I put this box up there and said like okay look you know it's kind of like um spreads so up top is how deadly it is and how linear lee's house faster. It spreads. So you can see measles spreads really fast versus smallpox was very deadly but didn't spread as fast. Um So is it more severe infection? Um as opposed to just being more transmissible, so more people are getting it. Um we saw that there was definitely an increase in hospitalizations with delta variant from 24.7% to almost 36%. And about 80% of these hospitalizations were associated with unvaccinated. Well so that was really um kind of a clue or key in to kind of see when we were parsing through the data. Is that yes there are increased hospitalization but kind of look into how effective vaccines against hospitalizations and um ICU admissions and you can see that down below as ICU admissions and deaths. Um And there was a slight uptick in sort of overall hospitalizations and and deaths. So looking at kids and that's kind of like what who we see in our population and what we could tell at least is that doesn't quite lead to the more severe infection. We were not seeing more kids in the ICU or mechanical event related even though we were seeing more kids in the hospital. Um So this black line here is the percent of icy admissions between 0 to 17 and the dash line here. Down below is the mechanical ventilation and you you see Through August 2022 August 2021 you don't really see a big blip or increase in that black. line. So vaccination versus on vaccination. What do we make of it in the context of delta variant? So right hand side here we you might have heard of things like C. T. Values or cycle threshold essentially what it is is that when the machine or the pcr machine is running, if there's a ton of virus it doesn't take that much cycles for that machine to say hey there's wires present so lower the ct value higher the number of virus or viral count that you have. Um There are some people who argue that this isn't really a good way to measure how much virus is there but that's kind of a surrogate way that we have chosen or most studies have chosen. So you can see fully vaccinated versus not vaccinated. They kind of have the similar cycle threshold of vaccinated versus unvaccinated across different scenarios that they looked at and even symptomatic asymptomatic and then all comers. What the Singapore study found those like okay you carry the same amount of virus, let's say you have a breakthrough infection you were fully vaccinated. So on the left hand side if you see the green is vaccinated individuals and the red is unvaccinated individuals you asked start out with the same cycle threshold. Um as you the vaccinated individuals which had breakthrough infections they tend to lower or higher their ct count much faster than the unvaccinated group. So theoretically you could say that yes you carry the same amount of virus but you're probably not contagious for the same amount of time as an unvaccinated individual in terms of transmission, where is it happening? We know that transmission is there and it's faster than the ancestral variant. This is from a U. K. Study which looked at sort of where the transmission was happening. So I'll highlight the purple here. So the purple is the delta variant, the pink is the alpha. Very in the solid blue line is household transmission and the dotted line is outside non household transmission. And what they found was that the household transmission was certainly much higher than the non hostile transmission. So unlike schools or workplaces and other things. And and that's again what I saw in the hospital, two teenagers who were coming in their entire family unvaccinated. They all got it teenager, got it and now he's in the hospital. So I and and there weren't very many cases that we were saying like oh they work at a grocery store or they were going to school and now there's a big outbreak in the school because of the delta variant. So I think that informs us into a little bit into our vaccine talk here, I don't need to inform you how vaccines work but in general you have an existing antibody toward the pathogen that you you were introduced to either by vaccine or natural infection, maybe chicken pox. If you have a new pathogen, you don't have any antibodies. But what we do is a vaccine creates that anybody for you to give you that uh immunity and the number of vaccines currently in clinical development. I know we talk about two or even one in kids right now is 128 that's globally from the W. H. O. A number of vaccines in pre clinical development. 194. So this is a quick snapshot of different types of vaccines that are available right now. M. R. N. A. Is that uh our Moderna and Pfizer, the viral vector vaccines are astrazeneca and johnson and johnson and sub unit vaccines and novaks, GSK Sanofi the only ones that are available in the United States right now, of course are the Moderna Fighter and the johnson and johnson. And the only ones in kids is Fighter. So people often talk about like this is really new. I'm really hesitant to give a vaccine that just came on the market like maybe a year ago or a year and a half ago. But I want to highlight the history behind the vaccine and and we can't go through the entire history but you can see it dates back almost 4050 years ago when people were talking about these M. R. N. A vector uh M RNA vaccines in in lieu of HIV or even RSP and then slowly progression was made. And you can see um in one of the stories that I'll highlight is that there's a long standing history and I really encourage everybody to read this article down below that I have referenced. But um one of the scientists that has been influential in in um the M. R. N. A. Vaccine is professor Caitlin, chirico or Kati. She goes by um she works for university of pennsylvania and over time she was struggling with grants and kept getting rejected. So the university said well either you can take a pay cut or you can leave the university when she said, okay I'll stay and I'll just take a pay cut. And this is of course before coronavirus before the pandemic. And she continued to work on her bench all this time the vaccine came around developed. We're injecting everybody else. Nobody is kind of paying attention to her influential work that was made it possible. So the journalist went up to her is like don't you feel bad that nobody is kind of like giving you the accolades and and saying like this is her work that we're able to give the vaccine. And what she says is the benches. Their science is good. She struck in a recent interview and says who cares? So there are many many, many scientists who are behind this vaccine and with many, many, many years of hard work. Um and this is a quick sort of scenario of how these vaccines work perhaps elucidating for your families as you're having these discussions with them. So um M. R. N. A. Is packaged into this liquid fat molecule, the lipid nanoparticle or LMP. Um It's injected into the arm taken up by muscle cells. And then these cells make pieces of covid 19 spike protein and put them on their surface and stimulating the immune response. So when the cell makes that spike protein that the immune says okay that doesn't belong there. I'm going to make antibodies to it. So it's essentially giving you the recipe I. E. Your body the recipe and your um machinery is so good that it makes those proteins right away that M. RNA doesn't last in your body for more than I want to say the last time I read and I forget like a few hours or even a day or two. Um It's not long standing. It does not integrate into your DNA. When we think about vaccine efficacy and setting of delta. Um this is where the data comes from. From booster vaccines or other medical conditions and why we started talking about. And I do want to say that personally for me I want to I feel like we should not be using the word booster. I think it's just a third series in this set of vaccines that we're doing. It's not really boosting it. Um Like many other vaccines there are three series for hepatitis therefore series for polio. This is three series for covid. Um When they looked at different studies this is a little bit of a busy slide but 65 over underlying medical conditions, Frontline workers, they saw that there was a decrease in vaccine effectiveness from pre delta to doubt. Tom These again are different studies that looked at different settings or nursing home settings. They looked at fighter, they looked at Moderna, they looked at health care workers and they looked at frontline responders and they saw that okay there was a decrease in vaccine effectiveness in particular when they when the delta was coming around and I would say this is just vaccine effectiveness over time. It's not anything to do with hospitalization or death. Mhm. So when we do look at hospitalization and surprisingly there isn't a much decline or kind of like sharp decline when you look at and this is all age comers over 18 years of age. This isn't data that's pressed out for 65 and over immunized immune compromising conditions or other things. Everybody. So you can see that there's some decline over time when we look at vaccine effectiveness but not a lot, especially in terms of hospitalizations. When you look at hospitalization, vaccine effectiveness over time with adults greater than 16. So five weeks out, 10 weeks out 15 2025 weeks. Um There isn't really a much kind of like a sharp decline in terms of vaccine effectiveness. The M. R. N. A. Vaccine for 16 and over which is in blue went from 100 to maybe 90% and then M. RNA for 50 and over did kind of see some fluctuations and then J. And J. Really came out sort of like at 60 or 70% vaccine effectiveness. And that's why there is a booster of proof for J. And J. Right now. This is a much easier slide to sort of interpret or think about. This is data from Scotland, Canada and Israel. Um The triangle is the delta variant when they looked at confirmed infection. Symptomatic infection or hospitalization or death. You can see that there is 100% almost um 95 over a percent effectiveness in preventing hospitalization or death. So yes you see confirmed or breakthrough infections perhaps in the setting of delta with the vaccines but certainly not severe disease. So why vaccinate kids? Why consider this vaccination and Children there about five million kids who have been infected. Um About 19 20,000 hospitalizations, 4600 cases of M. I. S. C. And it's a little bit more now. Um And then 62% of them are hispanic or black pandemic continues to take a toll in other facets of their lives. Children's mental health, emotional health, social well being educational experience. And one third of adolescents aged 12 to 17, hospitals with covid 19 require intensive care. 5% of them will require mechanical ventilation. And when we look at considering Covid vaccine as opposed to other vaccine, preventable um, infections that we routinely vaccinate again. So this is how civilization burden for 100,000. You can see perhaps a where cela influenza it fluctuates were happy is less than one um where seller is anywhere between 4 to 31 influenza is 30 to 80. So it's a little bit um more for influenza than for covid right now. But if you look at that per year, um, it's significantly higher, 66 versus the other vaccine preventable in uh diseases that we routinely vaccinate against. So looking particularly at the 12 to 15, they were in the trial over 2200 adolescents. They had two doses three weeks apart at 30 micrograms, which is the same as adults. They look for local and systemic reactor Jenness city. And then they also did immunogenicity studies. Um, and about 30% of that population had served positive. Some meeting they had already had the infection So busy slide. But basically the top one says, um, does one, the bottom is those two most common symptoms reported in the study. This is not bears were essentially um, fatigue and headache. And you can see that while there were a higher number of people who reported fever and headache, headache, there wasn't really more severe side effects that were noted. So great for temperature greater than 40. You can see even with those two there weren't really any this is the Moderna. I'm not going to go a whole whole lot into details in the interest of time. But they also published their study. It's not after you approved yet. And then there's which which is the reporting system that parents patients and physicians can use into the CDC. And the most common symptom that was reported adverse event that was reported after the vaccine was dizziness or syncope E. Or nausea. That was between different age groups. So 12 to 15 verses 16 to 25. This is the worry that most parents particularly have and and you know myself included. But the data what has come out has been largely in favor of still vaccinating. So vaccine associated mike arthritis or pericarditis epidemiology. Pre covid era of my card itis. It's a rare condition. You can see it's 0.8 400,000. And in particularly looking at 15 to 18 it's a little higher than the normal population. 1.8 and predominance is with males. There is a low mortality for two for 47% and transplant report um to 9% and you can see with males and females with the Pfizer vaccine dose one and those two between 12 to 15. There was a slightly higher rate or background rate that was reported From males in particular. Um for this vaccine associated myocarditis. So they looked at that there is a reportable thing C. D. C. has been examining it. And they had over 1600 preliminary cases that met their case definition, 77% of them recovered from their symptoms completely. 34 of them. They're not never even hospitalist, they were only seen in the eating. And then they also looked at that's in less than 30 years of age there were total nine reported that's two are still under evaluation. Three were consent. They were not myocarditis. And for three of them they found another potential cause other than the max vaccine causing the myocarditis. They also have published a study um you know about like what's the difference um what I really want to kind of inform everybody and including our patient populations that there's three entities then Yes there is an entity with my card it is associated the vaccine but then you also have my cardiologist or cardiac symptoms. If you get M. I. S. C. And then you also have my card at risk if you get the virus, the covid 19 virus like any virus can trigger myocarditis. Um So compared to classic my card it is this study looked at like what are the abnormalities. What do you see between proponent and lymphocytes and W. B. C. S. And what they found was M. I. S. C. Certainly had more significant human biological arrangements and worse inflammation at presentation but tended to have better clinical outcomes than uh and rapid recovery of cardiac function. So um 91% of the cardiologist or health care providers indicated that the patient was fully or probably recovered from if there was a vaccine associated um uh myocarditis and then the risk of myocardial is after the second dose of fighter and this is an adolescence. Um we'll talk about the 5-11. 54 cases per million doses were administered to males between 12 to 17 years of age. Um so that's quite a high um Tall in 54 cases per million doses. So looking at the 5 to 11, it should say 5 to 11 years of age. So phase one was basically saying like, hey, is the lower dose, Okay, can we do, can the amount of similar vaccine, sort of efficacy or immunogenicity with the lower dose? And that's what they tested against compare with the 12 to 16 years. And they did 12 2010, 20 and 30 micrograms. Remember 30 micrograms is what we do for adolescents and older adults. It was a 2 to 1 randomization with 1500 participants um getting the vaccine 750 getting the placebo. It was across different regions of the United States, being one of the clinical trial sites. Um And then they compared it to the 16 to 25 age group in terms of establishing Baskin FXC does one and then they had seven day reactor Jenna city period where their self reported from an app and then the 21 days later got a dose to, they had a four month, one month follow up for non serious side effects and then serious adverse events, a six month follow up. So this is just kind of highlighting that they were able to generate the same amount of antibodies with a lower dose than the higher dose compared to the 16-25 year old. This is looking at kids who have already had, remember I talked about about 38% of the population. 5 to 11 already have antibodies. So some people say I've already had the infection, I have the immunity. Why do I need to get it? So this highlighted the fact that even though the people or kids who had the vaccine, the natural infection or the COVID-19 infection, they were able to generate a good robust uh, everybody titles or neutralizing antibody titles, which is what we want to fight the infection. Um, the green line here there and then the pink is naive When they looked at vaccine efficacy. So the red line here is placebo and the blue is the vaccine. Um, they had 90.9% efficacy from symptomatic lab confirmed COVID-19 infection. So three cases in the vaccine arm and 16 cases in the placebo arm. No cases of my cardinals were reported though the study was not poverty to detect that in terms of those kind of side effects and other things placebo versus the vaccine. This is where I think it's really important to do placebo controlled trials because you can see that even the placebo group reported fatigue and headache. Um Though of course the vaccine group was a little bit higher. Non some serious side effects. This is just another way of looking at it basically fever between those one and those two placebo versus non placebo slightly higher for the does to than for those one. And then um again for the serious side effects. There in the placebo group there was pancreatitis, abdominal pain and then vaccine group had a limb fracture. I think we can all agree there's nothing to do the vaccine. And then three participants in the vaccine group had infective arthritis, foreign bodies. Some um Kindergartner swallowed a penny and then uh epithelial fracture and 00 side effects from the placebo group. Again you can elucidate that. They're probably not related to the vaccine itself. So again risk versus benefit. Why do it recent incidents looking at the delta variant? We can prevent 57,000 covid cases and females and about the same in males. Um About 100 to 200 hospitalizations. 130 cases of M. I. S. C. And and greater than 50 cases of ICU admissions. Some people will say Delta is going down you know there will be a new variant. So let's just look at the pandemic average. Even still there are about 18,000 covid cases prevented, 80 hospitalizations prevented 42 M. I. S. C. Cases prevented in 26. ICU admissions versus the risks for every million Pfizer covid 19 vaccine. The rates of my card. It is probably unknown. Um but suspected to be much lower because the dose is lower. And then we think that this age group also has a much lower spread election to have that condition. And and like I mentioned before in the study itself, they didn't report any cases. So benefits prevention of covid 19 cases likely prevention of hospitalizations I might see and deaths and post covid conditions, possible prevention of transmission and greater confidence in safety. Return to schools and social interactions, mike arthritis and other rare uh M. RNA back associated M. RNA vaccine events or short term reactive Jenness city like fever, fatigue as as compared to rest. So my whole family had COVID-19 positive in March. We don't need the vaccine since we have natural immunity. And this is where I would say or encourage perhaps using a slightly different terminology than natural immunity versus saying SARS cov two infection, immunity or infection induced immunity. And what I would say is that one is that it prevents if the vaccine would probably prevent you from getting M. I. S. C. Because we know that M. I. S. C. Can also occur even after asymptomatic or mild infection and unvaccinated from adult study. Um That was just published in in mmwr. That unvaccinated with previous infection for five times more likely to look at hospitals compared to the vaccinators. And and this is briefly again from the c. d. c. they look at parental concerns and surveys. So um 57% of patients surveys stated they would definitely or probably get their child vaccinated. The parents who said they are definitely um uh would not they didn't they didn't they would definitely get the vaccine. Most of them worried about long term side effects um followed by short term side effects. Some wanted to just wait and see if it's safe, give it to others first and then I'll say they were worried about allergic reaction and then myocarditis or pericarditis followed that of the parents who were reporting like side effects is sort of a reason of not wanting more of them were worried about allergic reaction fever and myocarditis. Pericarditis is like their top three sinus venous thrombosis. You know it's more associated with the J. And J. Vaccine that has not been reported with the Covid vaccine. So special considerations vaccine after M. I. S. C. Um clinical recovery has been achieved including return to normal cardiac function. It's been more than 90 days since their diagnosis of M. I. S. C. Especially if they're living in a substantial community transmission of SARS cov. Two or otherwise increased risk for transmission. They should consider getting it of course in consultation with the cardiologist and the cardiologist has cleared them out of it. If they received monoclonal or convalescent plasma to avoid potential interference you made 90 days back. I mean other than measles and marathon masala can be administered However I. V. I. G. If they routinely get it as part of their immunodeficiency that you don't need innovating period and if you had a known exposure you wait until the quarantine period has ended and then you can go ahead and get it. So absolute contraindications to the covid 19 M. RNA vaccine is if you have a allergic reaction like anaphylaxis for a previous dose or component of M. R. N. A. Covid 19 vaccine, immediate allergic reaction after a previous dose or no allergy to a component of vaccine. There's no counter indication to M. I. S. C. Or myocarditis but you do need to discuss it with the cardiologist. So in the brief few minutes that we have left. I wanted to spend a little bit of time and diagnostics because I feel like that's kind of like we know that there's different testing that exists out there. How do we interpreted? What do we do? And oftentimes comes up so um we this is sort of where I want. You all are a little familiar with the PcR test and then there's rapidly into two tests that we can get over the counter and then there's antibody tests If you look from day zero to day 25. This is sort of like your exposure to virus, you're infectious period. PcR has the greatest sensitivity. So it will be positive with these yellow dots with the greatest amount of time versus a low sensitivity. Cote and Cote Rapid antigen test will be positive in the highest infectious period. So rapid indigence test you cannot use them for problems of virus in the population. However good for detection of individuals who are likely to be contagious at the time that the test is administered and does have issues with sensitivity and specificity and you need to use it in the right context. PcR is our quote unquote on gold standards and that's why some of these to protest kind of are poo pooed because you're comparing it to the PcR which is really like a very specific and sensitive test. However, you can detect a positive PcR for 20 to 30 days. An infectious period is about 10 days antibody tests. I generally don't recommend them until unless a very specific um uh indication. This is another sort of a slide that I borrowed from Michael Mina. He's epidemiologist at Harvard that talks a lot about rapid antigen test and if there's interest, I'm happy to kind of spend a little bit more time into them. And then briefly the antibody tests they're routinely not recommended. So you'll see to anybody tests that are available or commercially available. There are nuclear caps at anybody's and spike protein antibodies. Nuclear capsule is the infection induced immunity versus the spike protein is vaccinated. However, there's nuances. There are these nuances between the detection and other things. We know that Children tend to have more spike protein antibody tend to be positive than adults. So there's there's a lot of like um gray area and inefficiencies in the antibody testing currently that exists to make it say that we just don't recommend it right now to reliably determine whether the person is protected from an infection or not. All right, this is what I'll end with our endgame. I'm not smart enough to to have a window of how things are going to end. So I gathered some coats and things from other people who are probably smarter than I am. Um scott Godly, the former FDA Commissioner advisor board member. He also published a wrote a book recently said Delta may be our last major wave of infection as covid transitions to a more endemic virus versus Mykelti Ostrom. He's the director of centers of infectious diseases research and Policy at University of Minnesota said, I'm incredibly doubtful. This is our last search. I think some geographic regions are going to be hit again and then Anthony Fauci who needs no introduction. Um, I think people should feel comfortable celebrating the holidays in a reasonable normal way. Um that's the key word, reasonably normal way. Um be trick or treating for Halloween. You can feel the same way about thanksgiving and feel the same way about christmas. Um You heard it first year? Not really they published it on twitter moderna is actually working on a triple vaccine. This is not in humans currently in mice. Um to have flu RsV and Covid booster. So wouldn't that be nice? So I'll end with Children are least as least as likely to be infected with SARS Cov two. As adults infections are less likely to be reported than adults. There are numerous indirect impacts of Covid 19 and Children worsening mental health, emotional health widening existing gaps um decreasing physical activity, increasing BME loss of caregivers and then vaccines are safe and effective against SARS Cov two and the risk of myocardial is small and outweighs the benefits of protective immunity against Covid 19. Um This is how you can refer your patients to ask us in a I will open it up to questions why is the syrup levels higher than this is the first question in 5 to 11 than other age groups. I think there's syrup. Levin's higher because we um there were a lot of kids who had a symptomatic infection probably and they were never really detected and when they were found that they had antibodies kind of like oh turns out that you um have um have anybody for covid so you must have been affected at some point. Um Should there, Sorry just want to let everybody know. Please put your questions in the Q. And A. If you have any further. And also um don't forget at the end of this lecture you please fill out the um your evaluation form so you can all get credit. So go ahead and continue. Sorry? No that's okay. That's good points. Um Should patients who are already infected still get the vaccine? I did touch upon that a little bit right now. The recommendations are yes they should um get get the vaccine. Even if they've had the infection there is some evidence to also say that I didn't go into a whole bunch but the khyber immunity meaning like natural infection plus the vaccine induced immunity or actions in actual the infection induced immunity and the vaccine immunity bring together a more robust response. And it's good if patient has had recent covid infection, how long would you wait before giving the vaccine? Um So the current recommendations are as long as they're out of their quarantine period and window that you can go ahead and give them the vaccine. Um What some parents would argue that look they've just had it like I don't want to give them the vaccine. The natural immunity or infection induced immunity even I can get away from the natural but the infection induced immunity um probably lasts for about 2 to 3 months. Um So if they want to wait a little bit longer like they don't want to go right at the after the 10 days. Um you can wait a little bit longer but you'll see on both ends like somebody who's just got it and they're like, I just don't want it again. I just want to get the vaccine. You can give it to them safely versus others who are a little bit reluctant, hesitant. There is a little bit of window of time. Um Dr Hadley says a lot of parents are asking me about the third dose of fighter for their kids swelling up and anticipate these patients to be eligible for a third time. Does soon. Would it be possibly a lower? That was in ages 5 to 11 And the news about the six months to five years. So the first one, the third dose um right now the most Efficacious data that has come out honestly is with the 65 and over. Um there is a graph that I might have um I will see if I have pulled up um that talks about this very thing. So you kind of have to prevent um I don't, you have to prevent a ton of hospitalizations before before you achieve the benefit of the third dose, particularly in that age room