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Hi, I'm Doctor Buddy Creech, and I'm a pediatric infectious diseases physician here in Nashville, Tennessee. And today, we're gonna talk a little bit about the management of high-risk pediatric COVID-19 patients. Uh, thankfully, the pandemic is over. Uh, we're still living through the PTSD of all of that. But there's still work to be done. This is still a significant respiratory virus for many of our patients. And so today, what we're gonna talk about is how to stratify those kids that are in high-risk categories, how to prioritize their testing, and then what we have both for treatment as well as prevention of severe disease in these kids. Uh, to get started, let me just say I do have some potential conflicts of interest. I received grant funding from the NIH and from the CDC as well as from Pfizer vaccines for a C. difficile vaccine clinical trial. I serve on the data and safety monitoring boards for a, a couple of companies for two specific studies. And then I serve as a consultant to a variety of groups really for the purpose of developing new vaccines and new antibiotics and making sure that the ones we have are safe and effective. So how do we prevent severe disease in the sequelae of COVID-19? Because an ounce of prevention is worth a pound of cure in every one of the diseases we care for. So let's talk a little bit about both vaccination as well as the receipt of passive immunoprophylaxis. So vaccinations available for individuals 6 months of age and older. Uh, the vaccine is most effective at preventing severe illness, hospitalization, and death. And, and current recommendations include prioritizing vaccination for high-risk groups and using shared decision-making that considers the relative benefits and the risks of vaccination. What about pre-exposure prophylaxis? Well, uh, Pitobart is a monoclonal antibody for COVID-19 pre-exposure prophylaxis that's authorized for use in adults and for children, uh, that are at least 12 years of age who weigh at least 40 kg. And patients have to be moderately or severely immunocompromised and therefore unlikely to mount an adequate immune response to COVID vaccination. But it can also be used in conjunction with COVID vaccine, and you would just delay the monoclonal by at least 14 days after receipt of COVID-19 vaccination. Pomivovart is given as an IV infusion over an hour, and it can be repeated every 3 months if the patient remains at high risk for COVID-19. And there's one study called the canopy Study that suggests that in patients that are 18 years of age and older, that this monoclonal may reduce the risk for PCR confirmed symptomatic disease by upwards of 75% in patients who are significantly immunocompromised. So, I think I bring this up to just make sure that we're all aware. For those patients in our care who are unlikely to respond to vaccine, who are immunocompromised, therefore, at high risk for COVID-19 complications, this is still an option that still covers the currently circulating variants that we see. What about severe complications in their long-term sequelae? You know, we talk about these, uh, sometimes together, but they're really obviously different things. Um, severe disease is really primarily respiratory compromise. That's typically what we see. And we know that both vaccination and pre-exposure prophylaxis, but also early initiation of antivirals and immunomodulators reduces this risk substantially. So this is why we need to know who's at risk, test them, treat them, but try to prevent it in the first place through vaccine. What about the complications of COVID-19? So, some of these are acute and some of these are more long-term. Um, we recognize that myopericarditis is a known complication of COVID-19. We dealt with this a whole lot in our athletic population and in tactical warriors like the military when they experienced COVID-19. We recognize that there are neurologic complications, um, that are also associated with long COVID but may be independent of that. Um, young children developing febrile seizures. MISC, which is a multi-system inflammatory condition, we really don't see this anymore. This really seemed to be an early aspect of the pandemic when it was affecting kids for the very first time. Now that we have broad herd-based immunity in our population and kids are seeing uh COVID-19 for the 2nd, 3rd, or 4th time, we're really not seeing MISC like we used to. Now, whether some of these kids are presenting with a Kawasaki-like illness and we're treating them like that, that remains to be seen. But the one that we still see very frequently is long COVID. These are children and especially teenagers who develop acute COVID. It seems to be relatively, uh, it's unfazing them. But then they just develop those post-acute sequelae like chronic fatigue and deconditioning, brain fog, and challenges finding words, and sometimes mood disorders afterwards. And we really wanna talk a little bit about how we can prevent that. So I talked about MIC and how it resembles Kawasaki disease that it's rarely encountered. Myocarditis is really highest in the 1 year following infection and the rate's about 1 in 5000. And we need to recognize and counsel our patients that myocarditis after COVID infection is about 5 times higher than after vaccination, at least 5 times higher. And then long COVID, thankfully, the overall rates are becoming a little bit lower, but as many as 25% of patients will experience some feature of post-COVID-19. So this is one of the reasons we want to be able to vaccinate these children is because if we can prevent infection or prevent the consequences of the complications of infection, we can potentially prevent some of these long-term sequelae. So, what were the goals of this session? It was to identify patients who are at high risk for severe disease, to develop treatment plans for different patient groups and levels of disease severity, and then to know the two primary strategies for the prevention of severe COVID and the sequela of COVID-19. So, From a high-risk standpoint, high risk is age less than 1 year, especially less than 3 months, uh, and at least 1 comorbidity. Those who are less than 1 month of age are at the highest risk of COVID-19. We need to know that. We need to think about those in our practice that meet those criteria and have strategic call-outs to them for both vaccination, but also to know what to do when they develop a respiratory tract infection. The second was to think about how we treat these kids and supportive care is, is necessary for most because less than 5% of COVID-19 cases in children are severe. But if you have an at-risk outpatient kid, um, diabetes, neurologic conditions, cardiac comorbidities, pulmonary disease, although asthma is on the fence, um, early antivirals make a lot of sense for those kids. Um, and so, uh, this is where we prioritize that. We have oral options available if they're Hospitalized, um, then we think about remdesivir, and we think about immunomodulator therapy based on the level of oxygen treatment that they're receiving. If they're on 02 cannula, we start antivirals. If they're going up on their oxygen needs, we think about dexamethasone or these other immunomodulators as we need to. And then third, we recognize that both vaccination and monoclonal antibodies are available to reduce the risk of severe disease and sequelae. And I think we need to really counsel our patients that um vaccines have been used in billions of people, billions of doses, and have proven to be safe and effective for the prevention of COVID. That's not to say that there aren't individual side effects that people may experience following COVID-19 vaccination. And, and we need to spend time talking to families who might, uh, who might express those concerns. And I think we prioritize, and we, and we really work hard to get those who are at high risk. We prioritize them for vaccination. If you are caring for some patients in your clinic or your office that do not have the ability to mount an effective immune response to vaccine, that's where we would use passive immunoprophylaxis with a monoclonal antibody.