COVID-19 Vaccinations: Potential Adverse Event with Vaccination in Adolescents

June 3, 2021 by
Sanjivan V. Patel, MD, FAAP

Sanjivan V. Patel, MD, FAAP

Sanjivan Patel, MD, FAAP
Chairman, Department of Pediatrics
Wyckoff Heights Medical Center

Kyle Russell DO, PGY3
Chief Pediatric Resident
Wyckoff Heights Medical Center

Myocarditis and Pericarditis following COVID-19 vaccination: Reviewing Risk and Recommendations

On May 10, 2021, Pfizer-BioNTech COVID-19 vaccines became approved to be given to adolescent teens by the Food and Drug Administration (FDA) after trials showed good efficacy in the ages of 12-15.  This marked the first available vaccination for this age group as the Moderna and Johnson and Johnson vaccines were still in the trial phase.  Amidst the current COVID-19 pandemic, the widening of access to vaccinations to younger and younger age groups marks the next stage in the fight towards controlling the spread of COVID-19.  However, in a recent release from the Centers for Disease Control and Prevention (CDC), news of increased incidence of myocarditis and pericarditis following COVID-19 vaccination was reported around the time of the expansion of availability to this age group.1  This information has caught the eyes of many pediatricians who can now offer their adolescent patients the vaccine.  In this post, it is important to review the reported risks of myocarditis and pericarditis associated with the COVID-19 vaccine as well as the CDC recommendations to administering the vaccine to our adolescent population.

With the multitude of complications that occur with COVID-19 infections, acute cardiovascular complications are not excluded. In both adults and children affected by COVID-19, myocarditis and pericarditis are two of the included complications.  In a case series study by Tao Guo et al, myocardial injuries resulting from COVID-19 were shown to result in fatal consequences due to cardiac dysfunction and arrhythmias.2  In a meta-analysis by Raghavan et al. looking at 1,527 patients over 6 studies, it was found that around 8% of inpatients were reported with acute cardiomyopathy.3  In children, there have been studies showing increased risk of myocarditis after COVID-19 infections due to the “multisystem inflammatory syndrome in children” (MIS-C).  In a review article by Yuyi et al. collecting 48 articles on MIS-C, it was found that myocarditis was the most found radiologic finding on echocardiogram with 61% of the cases examined.4

With increased availability for adolescent teens to the COVID-19 vaccine, the news of increased incidence of myocarditis and pericarditis especially in the male population has been brought to light.  As of June 23, 2021, the CDC listed more than 1000  reports of myocarditis and pericarditis, with 616 of the cases seen among people ages 30 and younger who received COVID-19 vaccines with confirmation of 393 of these cases.5  These cases were found after one of the two mRNA COVID-19 vaccines, Pfizer and Moderna vaccines. CDC further found that cases were reported:

  • Mostly in male adolescent and young adults age 16 years and older.
  • More often after the second dose of one of the two COVID-19 mRNA vaccines than after the first dose
  • Typically within several days after COVID-19 vaccination1

CDC also reported that patients who did receive care for this adverse effect responded well to medicine and rest and quickly recovered.

Despite these current findings of increased incidence of myocarditis and pericarditis potentially due to the COVID-19 mRNA vaccines, CDC recommendations remain firm for offering the vaccine to the adolescent population. In the latest virtual town hall held by the U.S. Surgeon General Vivek H. Murphy, M.D., M.B.A, stated that the overall number of cases did not outweigh the benefits of vaccination, stating that “when you compare the risk of cardiac complications among adolescents who have had COVID-19 vs. the numbers that we’re seeing here, it is very clear to us at this point in time that the benefits still outweigh the risk when it comes to vaccination.”6

Recommendations from the CDC include:

  • Continue to recommend COVID-19 vaccination for everyone 12 years of age and older given the greater risk of other serious complications related to COVID-19, such as hospitalization, MIS-C, or death.
  • Report all cases of myocarditis and pericarditis post COVID-19 vaccination to Vaccine Adverse Event Reporting System (VAERS)
  • Consider myocarditis and pericarditis in adolescent or young adults with acute chest pain, shortness of breath, or palpitations as coronary events are less likely to be a source of symptoms
  • Ask about prior COVID-19 vaccination if you identify these symptoms
  • For initial evaluation, consider an Electrocardiogram, troponin level, and inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate. In the setting of normal ECG, troponin, and inflammatory markets, myocarditis or pericarditis are unlikely.
  • For suspected cases, consider consultation with cardiology for assistance with cardiac evaluation and management.
  • For follow-up of patients with myocarditis, consult the recommendations from the American Heart Association and the American College of Cardiology
  • Rule out other potential causes of myocarditis and pericarditis. Consider consultation with infectious disease and/or rheumatology to assist in evaluation1

References:

  1. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2021, May 27). Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination.  Retrieved June 23, 2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
  2. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020 Jul 1;5(7):811-818. doi: 10.1001/jamacardio.2020.1017.  Erratum in: JAMA Cardiol. 2020 Jul 1;5(7):848. PMID: 32219356; PMCID: PMC7101506.
  3. Raghavan S, Gayathri R, Kancharla S, Kolli P, Ranjitha J, Shankar V. Cardiovascular Impacts on COVID-19 Infected Patients.  Front Cardiovasc Med. 2021;8:670659. Published 2021 May 13. doi:10.3389/fcvm.2021.670659
  4. Tang Y, Li W, Baskota M, et al. Multisystem inflammatory syndrome in children during the coronavirus disease 2019 (COVID-19) pandemic: a systematic review of published case studies. Transl Pediatr. 2021;10(1):121-135. doi:10.21037/tp-20-188
  5. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2021, June 11). Selected Adverse Events Reported after COVID-19 Vaccination.  Retrieved June 23, 2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html
  6. Korioth T. (2021, June 11). Surgeon general addresses myocarditis, pediatricians’ role in COVID-19 vaccination efforts Retrieved June 14, 2021, https://www.aappublications.org/news/2021/06/11/townhall061121
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