7 Minute Infectious Disease Update

My test is negative- Why am I sick?

Everyone knows we are in the midst of a sustained, and massive wave of COVID infections, unlike the Omicron tsunami, but persistent and relatively under the radar as far as official CDC disease counts. Hospitalizations have been on a steady upward trajectory for weeks and are now at 24,000 around the country, with 4,000 new admissions per day. This period of increased disease is likely to last quite a few more weeks, since we have yet to feel the real influence of BA.4/.5, with their increased level of Omicron immunity escape. A more stretched out wave of disease won’t overwhelm the hospital and healthcare system, but since we are likely having 300,000-400,000 new cases a day currently, that will end up being quite a lot of both vaccinated and unvaccinated people, some getting their second or third round of COVID. The word on the street is that rapid antigen tests seem to be less reliable in detecting early disease than they had been. This is discussed by Katherine Wu in her Atlantic article of June 10th, along with various interviewees opining as to the reasons that might explain it. There is of course no hard data to back up this anecdotal impression, so I will just leave it thus; if you’re sick don’t use your negative test as a free pass to some of granny’s home cooking. On the other hand, some might take the opportunity to have an in person meeting with a particularly obnoxious boss. The news feed today reveals that the US will no longer require COVID testing of International travelers, and that New York is no longer going to insist on masks for toddlers in daycare settings. The timing of many decisions in this sphere over the last two and a half years has often perplexed me; after all, five weeks ago we had very, very little COVID and few people in the hospital. But that’s progress, we don’t drag people off planes screaming and kicking because their mask was under their nose anymore, and now we don’t bar people who might, or might not, still be infectious with a positive PCR from returning home to a country where every Tom, Dick and Jane has COVID.

If you have respiratory illness symptoms and your rapid COVID test is negative, then what do you have? First choice would be COVID of course-that wasn’t very helpful but realistic. Next might be one of the four endemic corona viruses which cause the common cold. They cause minimal illness for most people, but are causing a fair amount of havoc right now by forcing people to isolate until they are reasonably sure it’s not COVID. If you are a little sicker, it might be RSV (Respiratory Syncytial Virus). The two strains of this virus can cause disease ranging from a cold to an Influenza like illness and pneumonia. Typically thought of as a significant pathogen of very young children, it also affects adults, and is responsible for a fair amount of hospitalizations, especially anyone with other compromising medical conditions, and the very elderly. RSV used to be extremely predictable with an early winter peak that begins and ends before the end of Influenza season. The Pandemic completely upset this pattern, with RSV disease last year appearing and peaking in the summer into the fall. The CDC Respiratory and Enteric Surveillance System is just beginning to show another summer uptick in RSV. Until now there has been no preventative or treatment for RSV, but today Glaxo-GSK announced positive results in a phase 3 vaccine trial in adults over 60, and has plans to submit this to the FDA for approval later this year.

It appears fairly certain that the FDA will approve an EUA for either one or both of Pfizer’s 3 dose vaccine and Moderna’s 2 dose vaccine for children 6 months to 5 years old. At least they will not bypass their expert committee on vaccines and biologics this time, which is scheduled to meet early next week. The Biden administration is ramping up pre-orders of vaccine from the states in anticipation of both offerings being approved. Please remember that I have spent a good deal of time and energy convincing people of the clear benefit of the COVID mRNA vaccines, but I feel there are some important facts to be considered if you are in charge of making medical decisions for a baby or toddler. In a previous post of April 2, I reviewed some of these issues at (boring) length, and I will keep this succinct. There are approximately 18 million children in this age grouping the US. According to the CDC’s data 177 children per year have died from COVID in this age group. It is an excellent bet, that most of these children had serious underlying medical issues compromising their immune systems, cardio-pulmonary systems, obesity or cancer. According to data from MMWR in September 2020, (which was not stratified to age group) 75% of pediatric deaths to that point were in patients with co-morbidities, and half of those children had two or more significant co-morbidities. 12% of these pediatric COVID deaths were attributed to the Multi-Organ System Inflammatory Syndrome, which is much more common in Black and Hispanic patients than Caucasians. That is a serious illness which will land a child in the hospital for perhaps a week on average, but is rarely fatal.

With regard to the risk side of the equation, the most significant known complication of the mRNA vaccines in children is myo-pericarditis. This inflammation of the heart muscle was initially thought to be exceedingly rare soon after the vaccines were rolled out, but over time, with greater numbers of children vaccinated and heightened awareness of this complication, the frequency was shown to be significantly higher. The following abstract from a recent JAMA Networks article sums up the most current understanding of this side effect. JAMA. 2022;327(4):331-340. doi:10.1001/jama.2021.24110

Findings  In this descriptive study of 1626 cases of myocarditis in a national passive reporting system, (the US VAERS) the crude reporting rates within 7 days after vaccination exceeded the expected rates across multiple age and sex strata. The rates of myocarditis cases were highest after the second vaccination dose in adolescent males aged 12 to 15 years (70.7 per million doses of the BNT162b2 vaccine), in adolescent males aged 16 to 17 years (105.9 per million doses of the BNT162b2 vaccine), and in young men aged 18 to 24 years (52.4 and 56.3 per million doses of the BNT162b2 vaccine and the mRNA-1273 vaccine, respectively).

The majority of these cases are mild, but almost all are briefly hospitalized for observation and treatment, with 87% showing resolution of symptoms within one week of discharge. So far the highest incidence of this has primarily affected mid-teenage boys, but realistically we have no idea exactly what the frequency will be in the infant and toddler group since clinical trials do not include enough participants to ferret this out. It is important to realize that COVID infection itself can cause myocarditis, but after reviewing multiple studies, I find it very hard to ascertain a clear view of the relative risks, and in the age group we are discussing, the data does not exist. Also I would point out that CDC data which has been used to suggest the risk of myocarditis from vaccine is significantly less than the risk from COVID disease was all generated in the pre-Omicron era. It is a fact that current vaccines are far less effective in preventing disease with the newer Omicron lineage variants than against the older COVID strains, which are no longer circulating; while the risk of vaccine side effects remains unchanged. CDC data also shows that a very large proportion of children in the US have already had COVID. In late April the CDC produced the results of the most complete serologic survey of the population so far. They found that during the two months of the Omicron wave an astonishing 30% of children under 17 became infected, and that fully 75% of children had evidence of prior infection. Three months after that survey, another large group of children have certainly been infected. For any child infected during the last 4-5 months, there is an excellent chance they have immunity to the currently circulating variants which would equal or exceed that produced by the vaccines. If you are facing this nuanced decision, I suggest you rely heavily on the advice of your trusted pediatrician.

Now for the Pet Peeves Department. The CDC and the WHO have both stated several times that they are still trying to determine whether the current Monkey Pox virus can be spread by intercourse, or if it is all due to close skin to skin contact— I’ll sleep better when they sort that out, as will no doubt the legions of people who engage in sex fully clothed. The WHO has just announced that they feel further investigation is needed into the possibility that a lab leak in Wuhan was the source of the SARS2-Cov19 Pandemic. As someone who said right from the beginning that this possibility needed to be exhaustively explored, along with a possible zoonotic origin, I’m gratified to see this several years later. I’ll be waiting for my apology from various talking heads at CNN (as I remember Brian Stelter was one of their main experts on the subject) and various academics who labeled me a racist, ill-informed troglodyte for daring to entertaining the possibility. Finally, this past week Politico said that based on several anonymous leakers from the Administration, that there were active discussions within the White House as to what level of daily COVID deaths would be acceptable to the general population, and would be a signal that Biden could declare an end to the Pandemic in the US and tell us to move on. No consensus was reached in the upper eschelons of power, but it seems like the vast majority of people have already moved on, irrespective of what Dr. Fauci or the White House have to say. I’m left wondering if White House Leaker is an official position now in the government or just a freelance gig, and if it comes with one of those plum government 401Ks?

Have a great, safe 4th of July. If you find my quick summaries valuable please forward to you friends and colleagues and of course use the free subscribe button at the bottom.