by Dr. Debbie-Ann Shirley, MD
The pandemic and children. Nearly 7.6 million child cases of COVID-19 have been reported in the United States as of December 23rd, with nearly 200,000 new cases in the past week, a 50% increase compared to earlier in December. Children account for 21% 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 has resulted in increased hospitalizations, but preliminary observations suggest that infection does not appear more to be more severe in children than previous waves. Some centers such as UVA are also noting new trends in younger aged children among those hospitalized but not necessarily requiring oxygen. What has not changed though is that children who are unvaccinated or under vaccinated continue to account for the overwhelming majority of those hospitalized from COVID-19. Continue to follow Virginia-specific data through the Virginia Department of Health website, which also includes cases among children in their COVID-19 dashboard page.
Variants of concern. Omicron (lineage B.1.1.529), which quickly took over as the predominant variant in the United States after being originally identified in Botswana on November 11, 2021. This variant, which has several mutations in the receptor binding protein, is highly contagious, and accounts for more than 60% of the SARS-COV-2 infections locally and nationally. Circulating SARS-CoV-2 viral variants may be associated with resistance to monoclonal antibodies, which may further impact availability of increasingly 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. Both the standard and pediatric formulations of the Pfizer vaccine authorized by the FDA for children 5 to 11 years are now available to offer patients during their patient visits in the Battle Building. Booster vaccine doses for everyone 16+ are recommended, including new mix and match options for those 18+. The FDA is set to discuss expansion of the EUA to adolescents 12 to 15 years of age as well as high-risk children 5 to 11 years old on January 3, 2022. The Pfizer vaccine may not be available for younger age groups <5 years until spring of this year, as the company reported in December 2021 that the immunogenicity goal for those to 2 to <5 years of age was not met and so they are testing a three dose series to see if this improves immunogenicity.
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