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A new episode of our podcast, “Show Me the Science,” has been posted. At present, these podcast episodes are highlighting research and patient care on the Washington University Medical Campus as our scientists and clinicians confront the COVID-19 pandemic.

Whether and how children can return to classrooms has been hotly debated during the past year. Requiring teachers and students to wear masks, spreading out kids in classrooms, and preventing students and staff from coming to school when sick has made most schools safe. With many teachers now vaccinated and more children now eligible, it’s expected that classrooms will be even safer when school resumes in the fall, according to pediatric infectious disease specialist Jason Newland, MD, a professor of pediatrics. As Newland works to prevent infections in kids, his colleague pediatric cardiologist William B. Orr, MD, an assistant professor of pediatrics, has been treating children who have COVID-19 and who have become seriously ill, requiring hospitalization. Much of Orr’s focus has involved children with MIS-C (Multisystem Inflammatory Syndrome in Children), a complication related to COVID-19. These kids can develop issues related to the heart, the gastrointestinal tract, the nervous system or other organs, following COVID-19 infection. Both Newland and Orr said they believe hospitalizations will be much less common for children as more are able to be vaccinated.

The podcast, “Show Me the Science,” is produced by the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis.

Transcript

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Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, we look in this episode at some of the special issues involving children, such as how to keep schools safe and how vaccines may or may not fit into that equation. Although most kids who become infected develop milder disease than many adults, they still face the risk of serious problems.

Jason Newland, MD: If we can vaccinate the whole population, we provide protection for a lot of people beyond just the kids. Additionally, over 400 children have died of COVID-19. Any child death is — any death — is terrible.

Dryden: That’s Dr. Jason Newland, a Washington University infectious diseases specialist who sees patients at St. Louis Children’s Hospital. Working with the Centers for Disease Control and Prevention, Newland and his colleagues have spent much of the last several months trying to make schools and other activities safer for kids and adults. He says he believes vaccines should make schools even safer in the fall. And while he’s been working to keep kids safe from COVID, one of his colleagues, Dr. William Orr, a pediatric cardiologist who sees patients at St. Louis Children’s Hospital, has been working with children who have become infected and had to be hospitalized either because of serious COVID-19 symptoms or because of a problem known as MIS-C: Multisystem Inflammatory Syndrome in Children.

William Orr, MD: It’s a patient under the age of 21. They have to have evidence of some inflammatory process, and two or more organs have to be involved. And that can be GI, which is the most common; cardiac, which is obviously why I have a lot of interest; you name it, any organ really counts. You really need to have some epidemiologic link to the SARS-CoV-2 virus or a COVID-19 infection.

Dryden: Orr says most of the kids he’s treated recover pretty well, but sometimes it’s a slow process. Meanwhile, Newland says that part of keeping kids safe from COVID-19 and related problems when school resumes in the fall will mean getting vaccinations for as many children as possible. And he says it should be safe for almost all kids to go back in person to class. And part of the reason, he says, is because for most kids, schools already were pretty safe.

Newland: Even during the height of the pandemic, in our community of St. Louis there was in-person school happening. In work that has been done with the CDC, we demonstrated that transmission if you had someone — a student or a staff member — with COVID-19 in school, you rarely saw that transmission or the passing of the virus to other children or to staff. That’s not only the St. Louis experience, that was the experience seen in Utah, that was the experience seen in North Carolina. The reason why it was safe, and this is before vaccines, of course, was because of the strategies, the prevention strategies put in place by the schools, including wearing masks, keeping some distance. So the distance of 6 feet is not necessary. Probably one of the biggest things was that we did a much better job of keeping both staff members and children out of the environment when they had illness. And so these things really worked. And I think the question now is — as we move into the summer vacation where cases are really low, which is awesome, I think we’re very all excited, we’re vaccinating large numbers of children and staff — is, “What happens next, as we go into the fall with school?” And I would just say this, that school in the fall will be much safer, and it’s already really, really safe.

Dryden: The current CDC guidelines that have made lots of news the last few weeks are that vaccinated people don’t have to wear masks indoors. But among the younger school-age kids, they can’t be vaccinated yet, so I’m guessing that you are going to recommend that masks continue to be a normal part of school, at least for the first few months next year.

Newland: I would say yes, our unvaccinated children should continue to wear masks. The question becomes really, what do you do about middle and high school? Because it’s easy to, at current, state with CDC guidance to say, “Well, our unvaccinated should wear masks,” but we also know that there’s still a large hesitant population even among middle and high schools. What do you do with them? Should you mandate vaccines in schools? What if you’re a private school and you have the ability to mandate, which I think could happen more than a public school? I mean, these are interesting questions about what’s going to happen. I think currently, even in our hospitals, we still wear masks. This is a big question. But to schools specifically, I think we should all be prepared for the following: Yeah, we might get to a point where the cases are so low and the hospitalizations are so low that we say, “Look, I think it’s OK not to do masks.” That could truly happen. But we should all be prepared to put the mask back on, think about the strategies that we used in the winter when, let’s be honest, is when we often see respiratory viruses, including coronaviruses. Coronaviruses like the winter, just like influenza, just like RSV, some of these other respiratory viruses, and maybe we should be just prepared like, “Oh, we’re seeing more cases. Oh, it’s time we should probably put our mask on because our hospitals are filling, or whatever.”

Dryden: What about testing? So, for example, at WashU the undergrads were tested every couple of weeks during the last school year. Should that sort of surveillance testing maybe be more common, especially if kids aren’t, you know, the younger kids are not vaccinated next year?

Newland: The answer is unknown. I would make one argument that number one, we don’t know. Number two, if we look at our experiences in St. Louis, in schools where there wasn’t weekly testing, their transmission rates were low. I think testing’s helpful. I think when we get to the fall and we get to the winter, testing might be more important because we’re actually looking for signals when virus cases might be rising or COVID-19 cases might be rising for reasons such as we have a variant that’s escaping our vaccination. Right? I think we all have to be in this mindset that the testing programs in the fall are more to indicate when we should be changing our mitigation strategies. The question then remains, to me, is that, yeah, maybe we do have some testing programs in colleges. Maybe we do have testing programs in our schools. I can tell you that we, here and in the group that I work with, we will be doing a study to evaluate what should our testing strategies be? Should it be a weekly screening testing, even among vaccinated groups in a K-12 schools versus, now we don’t need to do weekly screening testing, but we need to make sure testing is available and that it’s easy to get tested so that we see whether or not transmission’s happening or that there’s a rise in cases. We just need to answer that question.

Dryden: Between now and when school starts again in the fall, though, in this area, for instance, a lot of the churches are getting rid of masks and reintroducing singing. The Cardinals are not going to require masks, and they’re not going to have any space between seats. They’re outdoors, but I’m wondering how closely those kinds of things need to be watched for the potential of a rebound.

Newland: As we open society, we have to watch for rebound. Now, we have some examples of places that in our country where states have said, “Hey. Done.” And we haven’t seen rebounds yet. So I think, yes, we will need to watch that. I also say we need to support one another. You’re going to find people at the Cardinals’ games in an outdoor setting that are vaccinated, wearing a mask. Great. There is some individual thinking and risk that we must do and not to just put a blanket over everything. And now we have learned that mask and distancing and these other things have worked really well. I don’t know about you, but I haven’t had a cold in 14 months. It is amazing. I’m still probably going to wear a mask in certain situations where I feel like I’m in a large crowd. We know airports and airplanes are still wearing masks. Great. I’m glad we’re still doing that. And I might be doing that for a long time. Going forward, yes, we need to watch for the rebound. Number two, we need to respect and support one another in people’s decisions. Because I think what we’ve also learned is that the masks had become divisive. And that’s my biggest fear is that the mask-wearing people might be looked upon as that’s a scarlet letter and instead we should be supporting that.

Dryden: We have vaccines now approved for kids as young as 12. The goal from here is to see whether they’re safe for even younger kids. How important is it that kids be able to be vaccinated to get over that hump finally?

Newland: I’m in the camp that kids have to be vaccinated to get over the hump. There’s definitely some folks who says, “Look, I’m not sure we need to have kids vaccinated because, number one, the risk of COVID-19 is less in them and we’ve seen mild disease. Number two, there’s the argument that they don’t transmit it, especially the younger kids as well.” If we look at what’s going on, if we can vaccinate the whole population, we provide protection for a lot of people beyond just the kids. Additionally, over 400 children have died of COVID-19. I mean, any child death, any death is terrible. I think adding another layer of protection to everybody, which is adding kids to being vaccinated, just adds safety to everyone around them.

Dryden: So moving in that direction, I have heard many times over the years that kids are not just little adults. And so with drug trials and I would guess with vaccine trials, it is not just a matter of giving children a slightly lower dose because they’re slightly smaller people.

Newland: Number one, it’s dosing. Number two, it’s safety. And actually, I would probably argue it’s the reverse, right? It’s safety and then it’s the dose that gives you the immune response, and the safety piece is essential. We have learned, as it has been mentioned, about this Multi-System Inflammatory Syndrome, and we’ve seen it more in children. There’s a version in adults, but are we going to see, potentially, kids who are vaccinated, who see the virus and have this kind of inflammatory syndrome, or is the fact that a child sees the spike protein from the vaccine going to trigger an immune response that looks like this multi-inflammatory syndrome? These things have to be looked at.

Dryden: One of the people doing the looking is Dr. William Orr. He works with children who have cardiac issues related to COVID-19 and to Multisystem Inflammatory Syndrome.

Orr: So MIS-C stands for Multisystem Inflammatory Syndrome in Children, which is what the C stands for. And in fact, there is an MIS-A in adults that is more rare. But depending on where you look, you may find some slight variations on the strict definition of it. But the case definition from the CDC says that it’s a patient under the age of 21, hence the children. They have to have evidence of some inflammatory process, and two or more organs have to be involved. And that can be GI, which is the most common organ system; cardiac, which is obviously why I have a lot of interest; neurological, skin, you name it, any organ really counts in the criteria. You also have to have really no other plausible diagnosis. So in a sense, it’s a diagnosis of exclusion. And then the third criteria is that you really need to have some epidemiologic link to the SARS-CoV-2 virus or a COVID-19 infection. So maybe that was either a previous infection with COVID-19, or if you had exposure to somebody with a known COVID-positive person within the last four weeks also counts.

Dryden: And as I understand it, a lot of times what happens here is that a young person or child will have maybe even a mild infection, maybe even asymptomatic. And then a couple of weeks later, they get really sick.

Orr: Most of them are completely asymptomatic. And quite frankly, when you meet these families for the first time, they had no idea that they ever had exposure to COVID or even maybe were positive. And then again, some people, again, may have very mild symptoms. And so they have this delayed reaction roughly four to six weeks after their exposure or they had their initial infection, that they get this kind of robust inflammatory disease process.

Dryden: How dangerous is it?

Orr: Luckily, in kids, the mortality rate and the death rate is extremely low. So most kids are completely recovering from this. There are some concerns for lingering complications, again, because we’re still learning about this. These may be totally different conversations in 20 years. But as we’re learning about them, particularly related to the heart, we want to make sure there’s no kind of lingering effects and cardiac manifestations. Because these kids, while the cardiovascular system may not be the most commonly affected, it’s probably the second most, and those kids can have dysfunction of their heart muscle itself. They can have dilation of their coronary arteries. They could get fluid around the heart itself, and they can develop arrhythmias. And so the list kind of goes on, depending on how sick a kid is. They actually may end up in the pediatric intensive care unit. They may need a breathing tube. They may need multiple continuous medicines to help the heart squeeze. Maybe it’s not squeezing hard enough. And then after they go home, they may have to be on blood thinners because they have dilated coronary arteries. Need to kind of be restricted from sports or play or anything for a few months until we can safely clear them to go back. All that to say is extremely probably scary to hear. But the vast majority, luckily, of kids either respond very well to the different types of treatments that we’re using right now. And most of them also fully recover from any of the cardiac manifestations that they’ve developed.

Dryden: What about vaccination in this population? So, we know that people who have had COVID infection, especially adults, are encouraged to get vaccinated anyway. If there has been this multi-system inflammatory syndrome, are you safe to get vaccinated?

Orr: We have no evidence to believe that you’re not safe. And if a patient asked me right now, I’d say, “By all means, get the vaccine.” Now, there are some reports — actually, if you look at the CDC website, there are mostly just kind of listservs and stuff circulating right now about people developing myocarditis after getting the vaccine. It’s hard to know if there’s a true link to the mRNA vaccines yet and myocarditis. Maybe if it’s a coincidence, it definitely — any complication that you could potentially get from the vaccine still seems to be less than not getting the vaccine and just contracting the virus and developing MIS-C. So I personally, my practice as of right now, is to still recommend the vaccination if it’s available to the child.

Dryden: And you mentioned myocarditis. Could you say what that is, first of all? And number two, my understanding is that that’s a big risk for people who have had COVID-19 as well.

Orr: Yeah, in general, it’s inflammation of the heart muscle itself. And that inflammation can lead to maybe complete resolution, maybe there’s no lingering effects, but it can also lead to dysfunction or scarring of the heart muscle. And so either dysfunction or scarring may lead patients to have a higher risk of an arrhythmia or sudden cardiac arrest or sudden cardiac death. Especially for patients who are competitive athletes, we want to make sure that their heart has healed appropriately before we let them go back and exert themselves as hard as they want to on either the basketball court, soccer field, football field, you name it. And so if you go into the literature, if you look at any major society, the American Academy of Pediatrics, etc., most of them have guidelines based on how you should kind of approach the patient if they’ve had either mild symptoms, moderate symptoms, severe/MIS-C. And if you fall into that severe category, they kind of put you into the algorithm of following the myocarditis guidelines, which the guidelines currently say, not going back to play or sports for about three to six months. And then before going back, evaluating thoroughly with cardiac testing, so an ECG, an echocardiogram, maybe a Holter monitor, which is a 24-hour monitoring system of your heart rhythm, and then even possibly a cardiac MRI. In a sense, some of these recommendations have to be individualized to a certain patient. The good thing about pediatrics, which I love, is that most kids in general want to get back to playing. They’re not like adults and they just want to lay around all day. That’s a very general speculation, obviously. But kids, they just want to get better. And that’s why I love pediatrics, is they want to get out of bed. They want to play with their toys. They want to go home, and they don’t want to just lay around. And so sometimes it’s the opposite. Sometimes we have to break kids’ hearts and tell them they can’t play until we’ve given enough time to kind of make sure there’s no issues. And that, honestly, is probably one of the more unfortunate parts of our job, is to take away something a kid loves or maybe even identifies with. So that way we can make sure they’re safe before going back to play.

Dryden: As Orr and his colleagues continue studying the best ways to help kids who have developed Multisystem Inflammatory Syndrome and COVID-19, Newland says he believes problems related to COVID-19 that require hospitalization and rehabilitation might become a lot less common as more kids are able to be vaccinated. But many, especially younger children, won’t have that chance by the time school starts again in the fall. Regardless, Newland says, in-person school should be safe.

Newland: Yes, I think school will be safe, regardless if they’re vaccinated. Now, that is taking into account the strategies we’ve learned that make schools safe, which includes masking, keeping kids out and staff out that are sick. Those things worked. And so I think adding vaccine on top of that will add another level of COVID-19 protection to schools that we’re all looking for. We already have Pfizer. We’ve learned about Moderna. Moderna recently just says, “Hey, look, the data looks good.” Not surprising, right? Pfizer and Moderna have a similar strategy. They’re using this messenger RNA modality to create an immune response or make our body make those things that will fight against the virus. We will now have two vaccines for the 12- to 17-year-olds, and then eventually we’ll get to the 6- to 11-year-olds, which will come first from Pfizer. I don’t think that’s going to be a shock to anybody. And then Moderna will probably follow suit. And so I think going forward, we will have Moderna and Pfizer for children. And then in the future, we likely will have some other vaccine products that will look at a different way of giving, like intranasally, which we know there’s work done here locally at WashU to develop those sorts of vaccines. And that’ll be probably as we move forward and learn with the vaccine.

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Dryden: Both Newland and Orr say it’s important for all of us to be ready to adjust if things change again. But assuming the vaccines continue to be effective against new strains of the virus, and assuming most of those eligible to get the vaccine actually do so, schools, kids’ sporting events and other activities may look a lot more normal next year than they did this past year.

“Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you heard, please remember to subscribe and tell your friends. Thank you for tuning in. I’m Jim Dryden. Stay safe.

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