by Dr. Debbie-Ann Shirley, MD
The pandemic and children. Nearly 11.4 million child cases of COVID-19 have been reported in the United States since the start of the pandemic, with a staggering 808,000 new child cases reported in the past week, accounting for 22.8% of all weekly COVID-19 cases. While children continue to be less likely to be hospitalized or die from COVID-19, severe outcomes continue to occur with pediatric deaths in the US now surpassing 1,000 deaths from COVID-19 reported to date. The recent increase in COVID-19 cases in children during December and January has resulted in increased hospitalizations, but observations continue to suggest that infection does not appear more to be more severe in children than previous waves. Children who are unvaccinated or under vaccinated still account for the overwhelming majority of those hospitalized from COVID-19. Masks serve as an important layer of protection for children, including in school settings, see the Virginia Chapter of the AAP statement here for more details.
Variants of concern. The highly contagious Omicron (lineage B.1.1.529) variant, which quickly took over as the predominant variant in the United States now accounts for more than 99% of the SARS-COV-2 infections nationally. The Omicron subvariant, known as BA.2, which spreads even faster than the original has recently been reported in the United States. Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies, which may further impact availability of limited supplies. In vitro neutralization studies indicate it is unlikely that bamlanivimab-etesevimab or casirivimab-imdevimab are active against the omicron variant, while sotrovimab remains active. New outpatient COVID-19 therapies with expected activity against the omicron were FDA authorized under EUA in December, including nirmatrelvir-ritonavir (paxlovid). Nirmatrelvir-ritonavir is authorized for treatment of mild to moderate COVID-19 in adults and pediatric patients (≥12 years of age and ≥ 40 kg) with a positive test for COVID-19 who are within 5 days of symptom onset and at high risk for progression to severe COVID-19. Nirmatrelvir inhibits the main protease of the virus, preventing viral replication. Ritonavir increases (‘boosts’) the activity of nirmatrelvir by inhibiting CYP3A-mediated metabolism, but also causes a number of significant drug interactions, which could be severe or life-threatening. It is prescribed as a 5-day treatment course and a list of growing pharmacy locations in Virginia where it is available can be found here: therapeutics webpage. This option is not recommended for those with significant hepatic impairment. Clinicians who are not experienced in prescribing ritonavir-boosted drugs should refer to the EUA fact sheet and the Liverpool COVID-19 Drug Interactions website for additional guidance.
COVID-19 vaccines and children. The Pfizer vaccine may soon be available for children <5 years sometime around mid-March to mid-April as a lower dose maroon colored pediatric formulation of 3 mcg per dose. Pfizer announced in December 2021 that the non-inferiority outcome for immunogenicity had been meet for children 6 months-2 years but not for those 3 and 4 years of age, so they are testing a 3-dose series in this age group. Several other important updates to COVID-19 vaccination where made last week at the February 4th CDC advisory group meeting (CDC Presentation) including a booster dose can be given after 3 months instead of waiting 5 months in immunocompromised patients 12+ years. The 90-day COVID-19 vaccine deferral period after administration of a COVID-19 monoclonal antibody product for treatment or post-exposure is no longer required. Patients should still wait 2 weeks after COVID-19 vaccination before administering pre-exposure prophylaxis with tixagevimab/cilgavimab. Based on data presented by health officials from Canada, it is also possible that in the future the interval between dose 1 and 2 of mRNA vaccines may be increased to 8 weeks to improve vaccine efficacy and decrease risk of myocarditis, but no official changes have yet been made to the dosing interval. Planning is underway at UVA in preparation for these updates.
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