CHEST Physician

CHEST has been informed of the following deaths of CHEST members.

We extend our sincere condolences.

Noe Zamel, MD (2020)

Stuart Craig Lennox, MD (2018)

Teruo Hirose, MD, PhD, FCCP

Priscilla S. A Sarinas, MD, FCCP

Stephen Jenkinson, MD, FCCP (2021)

CHEST has been informed of the following deaths of CHEST members.

We extend our sincere condolences.

Noe Zamel, MD (2020)

Stuart Craig Lennox, MD (2018)

Teruo Hirose, MD, PhD, FCCP

Priscilla S. A Sarinas, MD, FCCP

Stephen Jenkinson, MD, FCCP (2021)

CHEST has been informed of the following deaths of CHEST members.

We extend our sincere condolences.

Noe Zamel, MD (2020)

Stuart Craig Lennox, MD (2018)

Teruo Hirose, MD, PhD, FCCP

Priscilla S. A Sarinas, MD, FCCP

Stephen Jenkinson, MD, FCCP (2021)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused by the novel coronavirus of the year 2019 (COVID-19) has had a major impact on global health and economy. United States reported a total caseload of 28,998,834 patients and total mortality of 525,031 as of March 2021 (NPR.org; worldometer. Accessed March 8, 2021). The beginning of 2021 ushered positivity with the development of multiple highly effective SARS-CoV-2 vaccines. Although the medical world has gained much knowledge about this deadly disease, there are many unknowns and still much to be learned.

Two early landmark studies from Italy (Lombardy) and United States (New York City area) provided initial insight on comorbid conditions associated with increased risk of severe COVID-19 infection (Richardson S, et al. JAMA. 2020;323[20]:2052; Grasselli G, et al. JAMA Intern Med. 2020;180[10]:1345). In the United States cohort, hypertension (HTN), obesity, and diabetes (DM) were independent risk factors for severe disease, while in the Italy cohort, older age, male, COPD, hypercholesterolemia, and diabetes were independent risk factors for increased mortality. Obstructive sleep apnea (OSA) was not mentioned as a comorbid risk factor.

There is much speculation regarding OSA as an independent risk factor for severe COVID-19 infection. OSA is a common sleep-related breathing disorder with increased prevalence in men, older age, and higher body mass index (BMI); and OSA is associated with hypertension, obesity, and diabetes, all of which are risk factors for severe COVID-19. Because of the shared similarities in pathophysiology between OSA and COVID-19 (Tufik S, et al. J Clin Sleep Med. 2020;16[8]:1425), and shared comorbid conditions associated with increased risk of severe COVID-19 disease, OSA has been suggested as an independent risk factor for unfavorable COVID-19-related outcomes.

SARS-CoV-2 triggers a severe inflammatory response involving type-II pneumocytes and angiotensin-converting enzyme 2 pathway. OSA is characterized by intermittent hypoxia and sleep fragmentation, leading to a cascade of systemic inflammatory response involving oxidative stress, pro-inflammatory cytokines, endothelial dysfunction, and consequent cardiovascular injury (Jose RJ, et al. Lancet Respir Med. 2020;8[6]:e46; Saxena K, et al. Sleep Medicine. 2021;79:223). In this regard, OSA may contribute to COVID-19 “cytokine storm” by causing or exacerbating endothelial dysfunction, inflammation, and oxidative stress.

Multiple studies have recently been published on the impact of OSA on COVID-19 outcomes. The Coronavirus SARS-CoV-2 and Diabetes Outcomes (CORONADO) study was one of the initial studies that analyzed the relationship between OSA and COVID-19-related outcomes. This was a multicenter observational study involving diabetic patients hospitalized with COVID-19. The primary outcome was mechanical ventilation and/or death within 7 days of admission. Multivariate adjustment showed that age, BMI, and OSA, among other factors, were independently associated with risk of death on day 7 (Cariou B, et al. Diabetologia. 2020;63[8]:1500). Strausz and colleagues also evaluated OSA as an independent risk factor for severe COVID-19 in a large registry of hospital discharge patients (FinnGen study). The authors reported that although the risk of contracting COVID-19 was the same for patients with or without OSA, after adjusting for age, sex, and BMI, OSA was associated with higher risk of hospitalization (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845). Similar findings were confirmed by the Maas et al. study, which utilized a large socioeconomically diverse database composed of 10 hospital systems. Diagnoses and outcomes were identified by ICD-10 coding and medical record data. After adjustments for diabetes, HTN, and BMI, OSA conferred an eight-fold risk for COVID-19 infection, was associated with increased risk of hospitalization, and doubled the risk of developing respiratory failure (Maas MB, et al. Sleep Breath. 2020 Sep; 29:1-3. doi: 10.1007/s11325-020-02203-0).

Peker and colleagues conducted a prospective multicenter observational study comparing clinical outcomes of severe COVID-19 infection in patients with low vs high pretest probability of having OSA based on the Berlin questionnaire. The authors reported a clinically significant risk of poorer clinical outcomes in the high pretest probability OSA group after adjustments for age, sex, and comorbidities (Peker Y, et al. Ann Am Thorac Soc. 2021. Feb 17. doi: 10.1513/AnnalsATS.202011-1409OC). A timely meta-analysis including 21 studies (19 with retrospective design) with 54,276 COVID-19 patients and 4,640 OSA patients concluded poor composite outcomes including severe COVID-19, intensive care unit admission, mechanical ventilatory support, and death in association with OSA (OR – 1.72 95% CI 1.55-1.91, P< .00001). In patients with obesity, OSA is a highly prevalent co-morbid condition. BMI, however, was not adjusted in this model (Hariyanto TI, et al. Sleep Med. 2021. doi: 10.1016/j.sleep.2021.03.029).

Other studies have concluded the opposite with OSA not being an independent risk factor for severe COVID-19 infection. Cade and colleagues conducted a retrospective analysis from a comprehensive electronic health dataset using ICD codes to identify OSA patients with severe COVID-19 infection. A significant association between OSA and COVID-19 death was noted after adjustment for demographics (ethnicity, age, sex). However, when fully adjusted for demographics, BMI, asthma, COPD, HTN, or DM, OSA was not an independent risk factor for COVID-19-related mortality and hospitalization (Cade BE, et al. Am J Respir Crit Care Med. 2020;202[10]:1462). The FinnGen study (Strausz et al.) was part of a meta-analysis examining the association between OSA and severe COVID-19 with and without adjustments for BMI. This meta-analysis consisted of 15,835 COVID-19 patients including 1,294 with OSA. The authors found that OSA was a risk factor with a two-fold increased risk of severe COVID-19 infection (OR = 2.37, P = .021). However, after adjustments were made for BMI, this finding lost statistical significance (OR=1.55, P=.13) (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845).

It is worth noting that a majority of studies identified OSA by indirect and imperfect methods through chart review, ICD codes, and databases. Confirmed OSA based on formal testing with a sleep study in COVID-19 patients remains a challenge. Perhaps well performed screening questionnaires, such as STOP-Bang, Berlin, or NoSAS, can be utilized as was the case in one study. It is also unclear if outcomes of COVID-19 infection differ in patients with treated or untreated OSA, as raised by the CORONADO study. A recent cross-sectional telephone interview survey of patients with confirmed OSA in Iran alluded to higher prevalence of COVID-19 in patients with severe OSA with suggestion of lower prevalence in patients who were currently receiving OSA treatment with positive airway pressure (PAP) therapy (Najafi A, et al. Sleep Health. 2021 Feb;7[1]:14). This is a crucial question as PAP therapy is considered an aerosol-generating procedure (Lance CG. Cleve Clin J Med. 2020 May 5. doi: 10.3949/ccjm.87a.ccc003). Studies have suggested continued use of PAP therapy with additional measures to mitigate the spread of virus, since failure to use PAP could be deleterious to the patient’s quality of life. Interestingly, PAP adherence seemed to have improved during the pandemic as evidenced by a telephonic survey done in New York City that showed 88% of patients with OSA used a PAP device consistently (Attias D, et al. Eur Respir J. 2020 Jul 30;56[1]:2001607. doi: 10.1183/13993003.01607-2020).

In summary, the jury is still out on whether OSA is a facilitator for viral replication, or an independent risk factor for poor prognosis related to COVID-19 infection, or has no clinical relevance to COVID-19. COVID-19 and OSA share comorbidities and pathways leading to a systemic inflammatory cascade. Theoretically, it would make sense that OSA is a risk factor for severe COVID-19 infection; however, it remains to be proven. The recent studies are limited by retrospective and observational nature, imprecise OSA classification/diagnostic criteria, and confounded by difficult to control variables. Further research is needed to expand our understanding of OSA -induced intermittent hypoxemia, inflammation, and endothelial dysfunction that may play a role in COVID-19 morbidity and mortality. Until we have more clarity, close monitoring of OSA patients infected with COVID-19 is recommended along with implementation of safe protocols for continuation of PAP usage during the infectious phase. Identifying underlying comorbid conditions that contribute to worsening of a COVID-19 infectious course is a crucial step in improving clinical outcomes.
 

Dr. Sahni is Assistant Professor of Clinical Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago. Dr. Cao is Clinical Associate Professor, Division of Sleep Medicine and Division of Neuromuscular Medicine, Department of Psychiatry and Department of Neurology, Stanford (Calif.) University.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused by the novel coronavirus of the year 2019 (COVID-19) has had a major impact on global health and economy. United States reported a total caseload of 28,998,834 patients and total mortality of 525,031 as of March 2021 (NPR.org; worldometer. Accessed March 8, 2021). The beginning of 2021 ushered positivity with the development of multiple highly effective SARS-CoV-2 vaccines. Although the medical world has gained much knowledge about this deadly disease, there are many unknowns and still much to be learned.

Two early landmark studies from Italy (Lombardy) and United States (New York City area) provided initial insight on comorbid conditions associated with increased risk of severe COVID-19 infection (Richardson S, et al. JAMA. 2020;323[20]:2052; Grasselli G, et al. JAMA Intern Med. 2020;180[10]:1345). In the United States cohort, hypertension (HTN), obesity, and diabetes (DM) were independent risk factors for severe disease, while in the Italy cohort, older age, male, COPD, hypercholesterolemia, and diabetes were independent risk factors for increased mortality. Obstructive sleep apnea (OSA) was not mentioned as a comorbid risk factor.

There is much speculation regarding OSA as an independent risk factor for severe COVID-19 infection. OSA is a common sleep-related breathing disorder with increased prevalence in men, older age, and higher body mass index (BMI); and OSA is associated with hypertension, obesity, and diabetes, all of which are risk factors for severe COVID-19. Because of the shared similarities in pathophysiology between OSA and COVID-19 (Tufik S, et al. J Clin Sleep Med. 2020;16[8]:1425), and shared comorbid conditions associated with increased risk of severe COVID-19 disease, OSA has been suggested as an independent risk factor for unfavorable COVID-19-related outcomes.

SARS-CoV-2 triggers a severe inflammatory response involving type-II pneumocytes and angiotensin-converting enzyme 2 pathway. OSA is characterized by intermittent hypoxia and sleep fragmentation, leading to a cascade of systemic inflammatory response involving oxidative stress, pro-inflammatory cytokines, endothelial dysfunction, and consequent cardiovascular injury (Jose RJ, et al. Lancet Respir Med. 2020;8[6]:e46; Saxena K, et al. Sleep Medicine. 2021;79:223). In this regard, OSA may contribute to COVID-19 “cytokine storm” by causing or exacerbating endothelial dysfunction, inflammation, and oxidative stress.

Multiple studies have recently been published on the impact of OSA on COVID-19 outcomes. The Coronavirus SARS-CoV-2 and Diabetes Outcomes (CORONADO) study was one of the initial studies that analyzed the relationship between OSA and COVID-19-related outcomes. This was a multicenter observational study involving diabetic patients hospitalized with COVID-19. The primary outcome was mechanical ventilation and/or death within 7 days of admission. Multivariate adjustment showed that age, BMI, and OSA, among other factors, were independently associated with risk of death on day 7 (Cariou B, et al. Diabetologia. 2020;63[8]:1500). Strausz and colleagues also evaluated OSA as an independent risk factor for severe COVID-19 in a large registry of hospital discharge patients (FinnGen study). The authors reported that although the risk of contracting COVID-19 was the same for patients with or without OSA, after adjusting for age, sex, and BMI, OSA was associated with higher risk of hospitalization (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845). Similar findings were confirmed by the Maas et al. study, which utilized a large socioeconomically diverse database composed of 10 hospital systems. Diagnoses and outcomes were identified by ICD-10 coding and medical record data. After adjustments for diabetes, HTN, and BMI, OSA conferred an eight-fold risk for COVID-19 infection, was associated with increased risk of hospitalization, and doubled the risk of developing respiratory failure (Maas MB, et al. Sleep Breath. 2020 Sep; 29:1-3. doi: 10.1007/s11325-020-02203-0).

Peker and colleagues conducted a prospective multicenter observational study comparing clinical outcomes of severe COVID-19 infection in patients with low vs high pretest probability of having OSA based on the Berlin questionnaire. The authors reported a clinically significant risk of poorer clinical outcomes in the high pretest probability OSA group after adjustments for age, sex, and comorbidities (Peker Y, et al. Ann Am Thorac Soc. 2021. Feb 17. doi: 10.1513/AnnalsATS.202011-1409OC). A timely meta-analysis including 21 studies (19 with retrospective design) with 54,276 COVID-19 patients and 4,640 OSA patients concluded poor composite outcomes including severe COVID-19, intensive care unit admission, mechanical ventilatory support, and death in association with OSA (OR – 1.72 95% CI 1.55-1.91, P< .00001). In patients with obesity, OSA is a highly prevalent co-morbid condition. BMI, however, was not adjusted in this model (Hariyanto TI, et al. Sleep Med. 2021. doi: 10.1016/j.sleep.2021.03.029).

Other studies have concluded the opposite with OSA not being an independent risk factor for severe COVID-19 infection. Cade and colleagues conducted a retrospective analysis from a comprehensive electronic health dataset using ICD codes to identify OSA patients with severe COVID-19 infection. A significant association between OSA and COVID-19 death was noted after adjustment for demographics (ethnicity, age, sex). However, when fully adjusted for demographics, BMI, asthma, COPD, HTN, or DM, OSA was not an independent risk factor for COVID-19-related mortality and hospitalization (Cade BE, et al. Am J Respir Crit Care Med. 2020;202[10]:1462). The FinnGen study (Strausz et al.) was part of a meta-analysis examining the association between OSA and severe COVID-19 with and without adjustments for BMI. This meta-analysis consisted of 15,835 COVID-19 patients including 1,294 with OSA. The authors found that OSA was a risk factor with a two-fold increased risk of severe COVID-19 infection (OR = 2.37, P = .021). However, after adjustments were made for BMI, this finding lost statistical significance (OR=1.55, P=.13) (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845).

It is worth noting that a majority of studies identified OSA by indirect and imperfect methods through chart review, ICD codes, and databases. Confirmed OSA based on formal testing with a sleep study in COVID-19 patients remains a challenge. Perhaps well performed screening questionnaires, such as STOP-Bang, Berlin, or NoSAS, can be utilized as was the case in one study. It is also unclear if outcomes of COVID-19 infection differ in patients with treated or untreated OSA, as raised by the CORONADO study. A recent cross-sectional telephone interview survey of patients with confirmed OSA in Iran alluded to higher prevalence of COVID-19 in patients with severe OSA with suggestion of lower prevalence in patients who were currently receiving OSA treatment with positive airway pressure (PAP) therapy (Najafi A, et al. Sleep Health. 2021 Feb;7[1]:14). This is a crucial question as PAP therapy is considered an aerosol-generating procedure (Lance CG. Cleve Clin J Med. 2020 May 5. doi: 10.3949/ccjm.87a.ccc003). Studies have suggested continued use of PAP therapy with additional measures to mitigate the spread of virus, since failure to use PAP could be deleterious to the patient’s quality of life. Interestingly, PAP adherence seemed to have improved during the pandemic as evidenced by a telephonic survey done in New York City that showed 88% of patients with OSA used a PAP device consistently (Attias D, et al. Eur Respir J. 2020 Jul 30;56[1]:2001607. doi: 10.1183/13993003.01607-2020).

In summary, the jury is still out on whether OSA is a facilitator for viral replication, or an independent risk factor for poor prognosis related to COVID-19 infection, or has no clinical relevance to COVID-19. COVID-19 and OSA share comorbidities and pathways leading to a systemic inflammatory cascade. Theoretically, it would make sense that OSA is a risk factor for severe COVID-19 infection; however, it remains to be proven. The recent studies are limited by retrospective and observational nature, imprecise OSA classification/diagnostic criteria, and confounded by difficult to control variables. Further research is needed to expand our understanding of OSA -induced intermittent hypoxemia, inflammation, and endothelial dysfunction that may play a role in COVID-19 morbidity and mortality. Until we have more clarity, close monitoring of OSA patients infected with COVID-19 is recommended along with implementation of safe protocols for continuation of PAP usage during the infectious phase. Identifying underlying comorbid conditions that contribute to worsening of a COVID-19 infectious course is a crucial step in improving clinical outcomes.
 

Dr. Sahni is Assistant Professor of Clinical Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago. Dr. Cao is Clinical Associate Professor, Division of Sleep Medicine and Division of Neuromuscular Medicine, Department of Psychiatry and Department of Neurology, Stanford (Calif.) University.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused by the novel coronavirus of the year 2019 (COVID-19) has had a major impact on global health and economy. United States reported a total caseload of 28,998,834 patients and total mortality of 525,031 as of March 2021 (NPR.org; worldometer. Accessed March 8, 2021). The beginning of 2021 ushered positivity with the development of multiple highly effective SARS-CoV-2 vaccines. Although the medical world has gained much knowledge about this deadly disease, there are many unknowns and still much to be learned.

Two early landmark studies from Italy (Lombardy) and United States (New York City area) provided initial insight on comorbid conditions associated with increased risk of severe COVID-19 infection (Richardson S, et al. JAMA. 2020;323[20]:2052; Grasselli G, et al. JAMA Intern Med. 2020;180[10]:1345). In the United States cohort, hypertension (HTN), obesity, and diabetes (DM) were independent risk factors for severe disease, while in the Italy cohort, older age, male, COPD, hypercholesterolemia, and diabetes were independent risk factors for increased mortality. Obstructive sleep apnea (OSA) was not mentioned as a comorbid risk factor.

There is much speculation regarding OSA as an independent risk factor for severe COVID-19 infection. OSA is a common sleep-related breathing disorder with increased prevalence in men, older age, and higher body mass index (BMI); and OSA is associated with hypertension, obesity, and diabetes, all of which are risk factors for severe COVID-19. Because of the shared similarities in pathophysiology between OSA and COVID-19 (Tufik S, et al. J Clin Sleep Med. 2020;16[8]:1425), and shared comorbid conditions associated with increased risk of severe COVID-19 disease, OSA has been suggested as an independent risk factor for unfavorable COVID-19-related outcomes.

SARS-CoV-2 triggers a severe inflammatory response involving type-II pneumocytes and angiotensin-converting enzyme 2 pathway. OSA is characterized by intermittent hypoxia and sleep fragmentation, leading to a cascade of systemic inflammatory response involving oxidative stress, pro-inflammatory cytokines, endothelial dysfunction, and consequent cardiovascular injury (Jose RJ, et al. Lancet Respir Med. 2020;8[6]:e46; Saxena K, et al. Sleep Medicine. 2021;79:223). In this regard, OSA may contribute to COVID-19 “cytokine storm” by causing or exacerbating endothelial dysfunction, inflammation, and oxidative stress.

Multiple studies have recently been published on the impact of OSA on COVID-19 outcomes. The Coronavirus SARS-CoV-2 and Diabetes Outcomes (CORONADO) study was one of the initial studies that analyzed the relationship between OSA and COVID-19-related outcomes. This was a multicenter observational study involving diabetic patients hospitalized with COVID-19. The primary outcome was mechanical ventilation and/or death within 7 days of admission. Multivariate adjustment showed that age, BMI, and OSA, among other factors, were independently associated with risk of death on day 7 (Cariou B, et al. Diabetologia. 2020;63[8]:1500). Strausz and colleagues also evaluated OSA as an independent risk factor for severe COVID-19 in a large registry of hospital discharge patients (FinnGen study). The authors reported that although the risk of contracting COVID-19 was the same for patients with or without OSA, after adjusting for age, sex, and BMI, OSA was associated with higher risk of hospitalization (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845). Similar findings were confirmed by the Maas et al. study, which utilized a large socioeconomically diverse database composed of 10 hospital systems. Diagnoses and outcomes were identified by ICD-10 coding and medical record data. After adjustments for diabetes, HTN, and BMI, OSA conferred an eight-fold risk for COVID-19 infection, was associated with increased risk of hospitalization, and doubled the risk of developing respiratory failure (Maas MB, et al. Sleep Breath. 2020 Sep; 29:1-3. doi: 10.1007/s11325-020-02203-0).

Peker and colleagues conducted a prospective multicenter observational study comparing clinical outcomes of severe COVID-19 infection in patients with low vs high pretest probability of having OSA based on the Berlin questionnaire. The authors reported a clinically significant risk of poorer clinical outcomes in the high pretest probability OSA group after adjustments for age, sex, and comorbidities (Peker Y, et al. Ann Am Thorac Soc. 2021. Feb 17. doi: 10.1513/AnnalsATS.202011-1409OC). A timely meta-analysis including 21 studies (19 with retrospective design) with 54,276 COVID-19 patients and 4,640 OSA patients concluded poor composite outcomes including severe COVID-19, intensive care unit admission, mechanical ventilatory support, and death in association with OSA (OR – 1.72 95% CI 1.55-1.91, P< .00001). In patients with obesity, OSA is a highly prevalent co-morbid condition. BMI, however, was not adjusted in this model (Hariyanto TI, et al. Sleep Med. 2021. doi: 10.1016/j.sleep.2021.03.029).

Other studies have concluded the opposite with OSA not being an independent risk factor for severe COVID-19 infection. Cade and colleagues conducted a retrospective analysis from a comprehensive electronic health dataset using ICD codes to identify OSA patients with severe COVID-19 infection. A significant association between OSA and COVID-19 death was noted after adjustment for demographics (ethnicity, age, sex). However, when fully adjusted for demographics, BMI, asthma, COPD, HTN, or DM, OSA was not an independent risk factor for COVID-19-related mortality and hospitalization (Cade BE, et al. Am J Respir Crit Care Med. 2020;202[10]:1462). The FinnGen study (Strausz et al.) was part of a meta-analysis examining the association between OSA and severe COVID-19 with and without adjustments for BMI. This meta-analysis consisted of 15,835 COVID-19 patients including 1,294 with OSA. The authors found that OSA was a risk factor with a two-fold increased risk of severe COVID-19 infection (OR = 2.37, P = .021). However, after adjustments were made for BMI, this finding lost statistical significance (OR=1.55, P=.13) (Strausz S, et al. BMJ Open Resp Res. 2021;8:e000845).

It is worth noting that a majority of studies identified OSA by indirect and imperfect methods through chart review, ICD codes, and databases. Confirmed OSA based on formal testing with a sleep study in COVID-19 patients remains a challenge. Perhaps well performed screening questionnaires, such as STOP-Bang, Berlin, or NoSAS, can be utilized as was the case in one study. It is also unclear if outcomes of COVID-19 infection differ in patients with treated or untreated OSA, as raised by the CORONADO study. A recent cross-sectional telephone interview survey of patients with confirmed OSA in Iran alluded to higher prevalence of COVID-19 in patients with severe OSA with suggestion of lower prevalence in patients who were currently receiving OSA treatment with positive airway pressure (PAP) therapy (Najafi A, et al. Sleep Health. 2021 Feb;7[1]:14). This is a crucial question as PAP therapy is considered an aerosol-generating procedure (Lance CG. Cleve Clin J Med. 2020 May 5. doi: 10.3949/ccjm.87a.ccc003). Studies have suggested continued use of PAP therapy with additional measures to mitigate the spread of virus, since failure to use PAP could be deleterious to the patient’s quality of life. Interestingly, PAP adherence seemed to have improved during the pandemic as evidenced by a telephonic survey done in New York City that showed 88% of patients with OSA used a PAP device consistently (Attias D, et al. Eur Respir J. 2020 Jul 30;56[1]:2001607. doi: 10.1183/13993003.01607-2020).

In summary, the jury is still out on whether OSA is a facilitator for viral replication, or an independent risk factor for poor prognosis related to COVID-19 infection, or has no clinical relevance to COVID-19. COVID-19 and OSA share comorbidities and pathways leading to a systemic inflammatory cascade. Theoretically, it would make sense that OSA is a risk factor for severe COVID-19 infection; however, it remains to be proven. The recent studies are limited by retrospective and observational nature, imprecise OSA classification/diagnostic criteria, and confounded by difficult to control variables. Further research is needed to expand our understanding of OSA -induced intermittent hypoxemia, inflammation, and endothelial dysfunction that may play a role in COVID-19 morbidity and mortality. Until we have more clarity, close monitoring of OSA patients infected with COVID-19 is recommended along with implementation of safe protocols for continuation of PAP usage during the infectious phase. Identifying underlying comorbid conditions that contribute to worsening of a COVID-19 infectious course is a crucial step in improving clinical outcomes.
 

Dr. Sahni is Assistant Professor of Clinical Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago. Dr. Cao is Clinical Associate Professor, Division of Sleep Medicine and Division of Neuromuscular Medicine, Department of Psychiatry and Department of Neurology, Stanford (Calif.) University.

Feeling lonely is one of the biggest challenges that we are faced with during this pandemic. It doesn’t matter who you are – a patient, a caregiver, or a physician – it affects us all.

Social distancing practices make it almost impossible to host in-person gatherings, which is hard on everyone, but as a philanthropic organization that focuses on community events, it’s down-right devastating. Not only does the Foundation look to events to help form a sense of camaraderie among our donors, we rely on them to help fund our projects.

That’s why we had to get creative last year and quickly reimagine our events in a totally new space ... cyberspace to be exact.
 

New takes on old favorites

We’re proud to say that we hosted seven online events in 2020, including Irv Feldman’s Poker Tournament, one of our most popular fundraisers. “We wanted to continue our traditions but knew we had to do it in a different format. We learned to pivot quickly and get everything online, but we then had to cross our fingers that our donors would get onboard,” said Angela Perillo, Director, Development & Foundation Operations. To the Foundation’s delight, the events not only piqued people’s interest, they brought in more than $150,000!

The impact of your ticket purchase

The Foundation has a new motto in 2021: “When you attend an event, you tend to our mission.” In other words, every event we host raises funds for our initiatives. “We want our donors to know that while they’re having a great time, they’re also doing their part in helping the Foundation enable more people to get access to the resources they need. A ticket sale today might help a patient get better care tomorrow, “ said Perillo.

Now’s the time to attend

Several events have been planned for this spring and summer. We hope you’ll join us by registering at chestfoundation.org and following #CHESTFoundation25 on social media:

• Irv’s Spring Splash Poker Tournament: Thursday, May 20 at 7 pm CT
• Belmont Stakes Reception & Auction: June 5 at 5 pm CT
• Irv’s Spring Splash Poker Tournament: June 18 at 7 pm CT
• Wine Tasting: June 24 at 7 pm CT
• Trivia Night: July 21 at 7 pm CT

Chestfoundation.org

Feeling lonely is one of the biggest challenges that we are faced with during this pandemic. It doesn’t matter who you are – a patient, a caregiver, or a physician – it affects us all.

Social distancing practices make it almost impossible to host in-person gatherings, which is hard on everyone, but as a philanthropic organization that focuses on community events, it’s down-right devastating. Not only does the Foundation look to events to help form a sense of camaraderie among our donors, we rely on them to help fund our projects.

That’s why we had to get creative last year and quickly reimagine our events in a totally new space ... cyberspace to be exact.
 

New takes on old favorites

We’re proud to say that we hosted seven online events in 2020, including Irv Feldman’s Poker Tournament, one of our most popular fundraisers. “We wanted to continue our traditions but knew we had to do it in a different format. We learned to pivot quickly and get everything online, but we then had to cross our fingers that our donors would get onboard,” said Angela Perillo, Director, Development & Foundation Operations. To the Foundation’s delight, the events not only piqued people’s interest, they brought in more than $150,000!

The impact of your ticket purchase

The Foundation has a new motto in 2021: “When you attend an event, you tend to our mission.” In other words, every event we host raises funds for our initiatives. “We want our donors to know that while they’re having a great time, they’re also doing their part in helping the Foundation enable more people to get access to the resources they need. A ticket sale today might help a patient get better care tomorrow, “ said Perillo.

Now’s the time to attend

Several events have been planned for this spring and summer. We hope you’ll join us by registering at chestfoundation.org and following #CHESTFoundation25 on social media:

• Irv’s Spring Splash Poker Tournament: Thursday, May 20 at 7 pm CT
• Belmont Stakes Reception & Auction: June 5 at 5 pm CT
• Irv’s Spring Splash Poker Tournament: June 18 at 7 pm CT
• Wine Tasting: June 24 at 7 pm CT
• Trivia Night: July 21 at 7 pm CT

Chestfoundation.org

Feeling lonely is one of the biggest challenges that we are faced with during this pandemic. It doesn’t matter who you are – a patient, a caregiver, or a physician – it affects us all.

Social distancing practices make it almost impossible to host in-person gatherings, which is hard on everyone, but as a philanthropic organization that focuses on community events, it’s down-right devastating. Not only does the Foundation look to events to help form a sense of camaraderie among our donors, we rely on them to help fund our projects.

That’s why we had to get creative last year and quickly reimagine our events in a totally new space ... cyberspace to be exact.
 

New takes on old favorites

We’re proud to say that we hosted seven online events in 2020, including Irv Feldman’s Poker Tournament, one of our most popular fundraisers. “We wanted to continue our traditions but knew we had to do it in a different format. We learned to pivot quickly and get everything online, but we then had to cross our fingers that our donors would get onboard,” said Angela Perillo, Director, Development & Foundation Operations. To the Foundation’s delight, the events not only piqued people’s interest, they brought in more than $150,000!

The impact of your ticket purchase

The Foundation has a new motto in 2021: “When you attend an event, you tend to our mission.” In other words, every event we host raises funds for our initiatives. “We want our donors to know that while they’re having a great time, they’re also doing their part in helping the Foundation enable more people to get access to the resources they need. A ticket sale today might help a patient get better care tomorrow, “ said Perillo.

Now’s the time to attend

Several events have been planned for this spring and summer. We hope you’ll join us by registering at chestfoundation.org and following #CHESTFoundation25 on social media:

• Irv’s Spring Splash Poker Tournament: Thursday, May 20 at 7 pm CT
• Belmont Stakes Reception & Auction: June 5 at 5 pm CT
• Irv’s Spring Splash Poker Tournament: June 18 at 7 pm CT
• Wine Tasting: June 24 at 7 pm CT
• Trivia Night: July 21 at 7 pm CT

Chestfoundation.org

COVID-19 vaccination efforts were initially restricted to health department control, and physician practices were not often included as vaccination sites. However, as vaccine availability improves ,physician offices will become a place where vaccines can be delivered conveniently and efficiently. It is important to understand the current and future coding and billing requirements for COVID-19 vaccination so that one’s practice may be appropriately reimbursed.

The provision of COVID-19 vaccination in an office setting is not as simple as influenza or pneumonia vaccination. One can find useful information about all vaccines and specifically about COVID-19 vaccines at https://www.cdc.gov/vaccines/ed/index.html. This site includes video training modules and downloadable resources for clinical use, as well as patient education. This information is important as providing vaccinations may require a change in infrastructure, equipment, and clinical flow. It may not be financially advantageous for one’s practice to provide COVID-19 vaccination.

If the decision is made to provide COVID-19 vaccinations, there are specific CPT codes for each vaccine and its administration (Table 1). These codes are valid for the vaccines with emergency use authorization (Pfizer, Moderna, Janssen) but not yet for as yet unauthorized vaccines (AstraZeneca). Should additional vaccines be authorized, it is expected that new CPT codes will be added.

When a patient is vaccinated, only the administration code is used at this time. The CPT codes for the vaccine (91300-3) should not be used because the cost of the vaccine is currently born by the federal government. When the vaccines are available for purchase by a practice, it will then be appropriate to use the vaccine CPT code. If an evaluation and management (E/M) service is performed, the appropriate E/M service code should be reported in addition to the vaccine administration code.

For payment of the vaccine administration by Medicare, either a single claim or roster claim can be submitted. When five or more patients are vaccinated using the same vaccine on the same day, one may submit a roster claim. Instructions on how to appropriately bill the various Medicare plans can be found at https://tinyurl.com/hfya8888. Guidelines for payment by private insurers should also be reviewed as well, as they will have their own requirements. If a vaccine is given to an individual who does not have any insurance coverage, reimbursement may be available through the Provider Relief Fund. These funds were made available by legislation, including the CARES act and information about claim submittal for the uninsured can be found at https://www.hrsa.gov/CovidUninsuredClaim.

COVID-19 vaccination efforts were initially restricted to health department control, and physician practices were not often included as vaccination sites. However, as vaccine availability improves ,physician offices will become a place where vaccines can be delivered conveniently and efficiently. It is important to understand the current and future coding and billing requirements for COVID-19 vaccination so that one’s practice may be appropriately reimbursed.

The provision of COVID-19 vaccination in an office setting is not as simple as influenza or pneumonia vaccination. One can find useful information about all vaccines and specifically about COVID-19 vaccines at https://www.cdc.gov/vaccines/ed/index.html. This site includes video training modules and downloadable resources for clinical use, as well as patient education. This information is important as providing vaccinations may require a change in infrastructure, equipment, and clinical flow. It may not be financially advantageous for one’s practice to provide COVID-19 vaccination.

If the decision is made to provide COVID-19 vaccinations, there are specific CPT codes for each vaccine and its administration (Table 1). These codes are valid for the vaccines with emergency use authorization (Pfizer, Moderna, Janssen) but not yet for as yet unauthorized vaccines (AstraZeneca). Should additional vaccines be authorized, it is expected that new CPT codes will be added.

When a patient is vaccinated, only the administration code is used at this time. The CPT codes for the vaccine (91300-3) should not be used because the cost of the vaccine is currently born by the federal government. When the vaccines are available for purchase by a practice, it will then be appropriate to use the vaccine CPT code. If an evaluation and management (E/M) service is performed, the appropriate E/M service code should be reported in addition to the vaccine administration code.

For payment of the vaccine administration by Medicare, either a single claim or roster claim can be submitted. When five or more patients are vaccinated using the same vaccine on the same day, one may submit a roster claim. Instructions on how to appropriately bill the various Medicare plans can be found at https://tinyurl.com/hfya8888. Guidelines for payment by private insurers should also be reviewed as well, as they will have their own requirements. If a vaccine is given to an individual who does not have any insurance coverage, reimbursement may be available through the Provider Relief Fund. These funds were made available by legislation, including the CARES act and information about claim submittal for the uninsured can be found at https://www.hrsa.gov/CovidUninsuredClaim.

COVID-19 vaccination efforts were initially restricted to health department control, and physician practices were not often included as vaccination sites. However, as vaccine availability improves ,physician offices will become a place where vaccines can be delivered conveniently and efficiently. It is important to understand the current and future coding and billing requirements for COVID-19 vaccination so that one’s practice may be appropriately reimbursed.

The provision of COVID-19 vaccination in an office setting is not as simple as influenza or pneumonia vaccination. One can find useful information about all vaccines and specifically about COVID-19 vaccines at https://www.cdc.gov/vaccines/ed/index.html. This site includes video training modules and downloadable resources for clinical use, as well as patient education. This information is important as providing vaccinations may require a change in infrastructure, equipment, and clinical flow. It may not be financially advantageous for one’s practice to provide COVID-19 vaccination.

If the decision is made to provide COVID-19 vaccinations, there are specific CPT codes for each vaccine and its administration (Table 1). These codes are valid for the vaccines with emergency use authorization (Pfizer, Moderna, Janssen) but not yet for as yet unauthorized vaccines (AstraZeneca). Should additional vaccines be authorized, it is expected that new CPT codes will be added.

When a patient is vaccinated, only the administration code is used at this time. The CPT codes for the vaccine (91300-3) should not be used because the cost of the vaccine is currently born by the federal government. When the vaccines are available for purchase by a practice, it will then be appropriate to use the vaccine CPT code. If an evaluation and management (E/M) service is performed, the appropriate E/M service code should be reported in addition to the vaccine administration code.

For payment of the vaccine administration by Medicare, either a single claim or roster claim can be submitted. When five or more patients are vaccinated using the same vaccine on the same day, one may submit a roster claim. Instructions on how to appropriately bill the various Medicare plans can be found at https://tinyurl.com/hfya8888. Guidelines for payment by private insurers should also be reviewed as well, as they will have their own requirements. If a vaccine is given to an individual who does not have any insurance coverage, reimbursement may be available through the Provider Relief Fund. These funds were made available by legislation, including the CARES act and information about claim submittal for the uninsured can be found at https://www.hrsa.gov/CovidUninsuredClaim.

Recognizing that caring for patients with COVID continues to be the focus of many physicians, in March, the American Board of Internal Medicine (ABIM) announced that it extended all MOC requirement deadlines until 12/31/22. For those ABIM Board Certified in Critical Care Medicine, Hospital Medicine, Infectious Disease, or Pulmonary Disease, MOC requirements have been extended until the end of 2023.

In a letter to the internal medicine community, Richard J. Baron, MD, MACP, ABIM President and CEO; and Marianne M. Green, MD, Chair of the ABIM Board of Directors, said, “We know internists and internal medicine subspecialists have been on the front lines meeting the country’s needs, many experiencing the tragedy of COVID in deeply personal ways…We also recognize the high levels of stress you may have faced over the last 12 months, and that it will likely be some time until it subsides…We hope this gives you one less thing to worry about.”

The decision means that nobody will lose ABIM certification if they are unable to complete MOC requirements this year. Recognizing every physician’s situation is different, all ABIM MOC exams will be administered as scheduled in 2021 for those who wish to take one.

In January 2022, ABIM will launch a new Longitudinal Knowledge Assessment (LKATM) (www.abim.org/lka/), a more flexible and convenient way to maintain certification. Physicians who decide to delay their 2021 assessment will be able to enroll in the LKA when it rolls out (pending availability), or can choose to take the traditional, 10-year MOC exam if they prefer.

The LKA for Critical Care, Hospital Medicine, Infectious Disease, and Pulmonary Disease will launch in January 2023. As these were among the disciplines most impacted by COVID, additional time is needed to create the requisite content for a high-quality assessment and is why MOC requirement deadlines for these specialties is extended an additional year to provide a transition pathway to the LKA.

Through the LKA, questions can be answered on almost any internet-connected device at any time, and physicians can access all the resources used in practice (except another person). ABIM will release 30 questions each quarter that can be answered a few at a time, or all at once. Immediate feedback with rationale and reference will be provided. As long as at least 500 of the 600 questions are answered over the 5-year cycle, the LKA Participation Requirement will be met.

ABIM is in the process of updating the Physician Portal in light of the MOC requirements deadline extension. If you have any questions about your requirements, call 1-800-441-ABIM or email [email protected]. For further information about the LKA, visit abim.org/lka/.

Recognizing that caring for patients with COVID continues to be the focus of many physicians, in March, the American Board of Internal Medicine (ABIM) announced that it extended all MOC requirement deadlines until 12/31/22. For those ABIM Board Certified in Critical Care Medicine, Hospital Medicine, Infectious Disease, or Pulmonary Disease, MOC requirements have been extended until the end of 2023.

In a letter to the internal medicine community, Richard J. Baron, MD, MACP, ABIM President and CEO; and Marianne M. Green, MD, Chair of the ABIM Board of Directors, said, “We know internists and internal medicine subspecialists have been on the front lines meeting the country’s needs, many experiencing the tragedy of COVID in deeply personal ways…We also recognize the high levels of stress you may have faced over the last 12 months, and that it will likely be some time until it subsides…We hope this gives you one less thing to worry about.”

The decision means that nobody will lose ABIM certification if they are unable to complete MOC requirements this year. Recognizing every physician’s situation is different, all ABIM MOC exams will be administered as scheduled in 2021 for those who wish to take one.

In January 2022, ABIM will launch a new Longitudinal Knowledge Assessment (LKATM) (www.abim.org/lka/), a more flexible and convenient way to maintain certification. Physicians who decide to delay their 2021 assessment will be able to enroll in the LKA when it rolls out (pending availability), or can choose to take the traditional, 10-year MOC exam if they prefer.

The LKA for Critical Care, Hospital Medicine, Infectious Disease, and Pulmonary Disease will launch in January 2023. As these were among the disciplines most impacted by COVID, additional time is needed to create the requisite content for a high-quality assessment and is why MOC requirement deadlines for these specialties is extended an additional year to provide a transition pathway to the LKA.

Through the LKA, questions can be answered on almost any internet-connected device at any time, and physicians can access all the resources used in practice (except another person). ABIM will release 30 questions each quarter that can be answered a few at a time, or all at once. Immediate feedback with rationale and reference will be provided. As long as at least 500 of the 600 questions are answered over the 5-year cycle, the LKA Participation Requirement will be met.

ABIM is in the process of updating the Physician Portal in light of the MOC requirements deadline extension. If you have any questions about your requirements, call 1-800-441-ABIM or email [email protected]. For further information about the LKA, visit abim.org/lka/.

Recognizing that caring for patients with COVID continues to be the focus of many physicians, in March, the American Board of Internal Medicine (ABIM) announced that it extended all MOC requirement deadlines until 12/31/22. For those ABIM Board Certified in Critical Care Medicine, Hospital Medicine, Infectious Disease, or Pulmonary Disease, MOC requirements have been extended until the end of 2023.

In a letter to the internal medicine community, Richard J. Baron, MD, MACP, ABIM President and CEO; and Marianne M. Green, MD, Chair of the ABIM Board of Directors, said, “We know internists and internal medicine subspecialists have been on the front lines meeting the country’s needs, many experiencing the tragedy of COVID in deeply personal ways…We also recognize the high levels of stress you may have faced over the last 12 months, and that it will likely be some time until it subsides…We hope this gives you one less thing to worry about.”

The decision means that nobody will lose ABIM certification if they are unable to complete MOC requirements this year. Recognizing every physician’s situation is different, all ABIM MOC exams will be administered as scheduled in 2021 for those who wish to take one.

In January 2022, ABIM will launch a new Longitudinal Knowledge Assessment (LKATM) (www.abim.org/lka/), a more flexible and convenient way to maintain certification. Physicians who decide to delay their 2021 assessment will be able to enroll in the LKA when it rolls out (pending availability), or can choose to take the traditional, 10-year MOC exam if they prefer.

The LKA for Critical Care, Hospital Medicine, Infectious Disease, and Pulmonary Disease will launch in January 2023. As these were among the disciplines most impacted by COVID, additional time is needed to create the requisite content for a high-quality assessment and is why MOC requirement deadlines for these specialties is extended an additional year to provide a transition pathway to the LKA.

Through the LKA, questions can be answered on almost any internet-connected device at any time, and physicians can access all the resources used in practice (except another person). ABIM will release 30 questions each quarter that can be answered a few at a time, or all at once. Immediate feedback with rationale and reference will be provided. As long as at least 500 of the 600 questions are answered over the 5-year cycle, the LKA Participation Requirement will be met.

ABIM is in the process of updating the Physician Portal in light of the MOC requirements deadline extension. If you have any questions about your requirements, call 1-800-441-ABIM or email [email protected]. For further information about the LKA, visit abim.org/lka/.

A little over a year ago, none of us imagined we’d be where we are right now. The pandemic has deeply affected us all, and there have been so many losses, both professional and personal. I’m proud of how our CHEST community responded to the pandemic. The incredibly rapid pace of knowledge acquisition and the speed at which we disseminated that knowledge took a lot of combined effort, but that’s nothing new to our CHEST community.

Throughout the pandemic, CHEST pushed digital education with an array of webinars, podcasts, bite-sized educational modules, and infographics. We held a highly successful, well-received CHEST 2020 online conference with just a few months of planning. I’m so excited to take what we learned about offering high-quality, digital education and turn that into a hybrid meeting for CHEST 2021 that meets the educational needs of every participant!

At CHEST 2021, you will be presented with the latest in pulmonary, critical care, and sleep medicine for clinicians at all levels. Whether you are a trainee or an experienced clinician, there is something to learn at CHEST 2021. We are packing the agenda with experiences from live learning and simulation to high-quality education sessions and smaller problem-based learning classes.

On top of this, you have an amazing opportunity to network and reconnect with colleagues you haven’t seen in months! Whether at Experience CHEST, in the gaming area, the Trainee and Transition Lounge, and more, CHEST 2021, as always, is the best at providing top-tier education, team-based learning, and community connections.

This will be the first hybrid meeting put on by CHEST. We came to the decision knowing that while some people are hungry to get back to having an in-person experience, others found that an online conference better fits their needs. I strongly encourage you to join us October 17-20 in Orlando, Florida, to experience the networking and growth opportunities that come from attending in person. We are following strict protocols, as recommended by the CDC, and will be requiring all attendees to attest to being vaccinated. However, if travel isn’t possible, join us for livestreamed, immersive digital learning from wherever you are in the world. Regardless of your choice, both options will allow you to engage in fun experiences, learn, and connect.

As Co-Chair of CHEST 2021, I’d like to personally invite you to participate, whether this is your first time or you’ve lost count how many times you’ve attended our annual meeting. The community at CHEST is what makes the CHEST conference special, and we are proud to be able to keep you all connected despite geographic restrictions.

Looking forward to seeing you there and connecting on Twitter at #CHEST2021.

Chris Carroll, MD

Co-Chair, CHEST 2021

A little over a year ago, none of us imagined we’d be where we are right now. The pandemic has deeply affected us all, and there have been so many losses, both professional and personal. I’m proud of how our CHEST community responded to the pandemic. The incredibly rapid pace of knowledge acquisition and the speed at which we disseminated that knowledge took a lot of combined effort, but that’s nothing new to our CHEST community.

Throughout the pandemic, CHEST pushed digital education with an array of webinars, podcasts, bite-sized educational modules, and infographics. We held a highly successful, well-received CHEST 2020 online conference with just a few months of planning. I’m so excited to take what we learned about offering high-quality, digital education and turn that into a hybrid meeting for CHEST 2021 that meets the educational needs of every participant!

At CHEST 2021, you will be presented with the latest in pulmonary, critical care, and sleep medicine for clinicians at all levels. Whether you are a trainee or an experienced clinician, there is something to learn at CHEST 2021. We are packing the agenda with experiences from live learning and simulation to high-quality education sessions and smaller problem-based learning classes.

On top of this, you have an amazing opportunity to network and reconnect with colleagues you haven’t seen in months! Whether at Experience CHEST, in the gaming area, the Trainee and Transition Lounge, and more, CHEST 2021, as always, is the best at providing top-tier education, team-based learning, and community connections.

This will be the first hybrid meeting put on by CHEST. We came to the decision knowing that while some people are hungry to get back to having an in-person experience, others found that an online conference better fits their needs. I strongly encourage you to join us October 17-20 in Orlando, Florida, to experience the networking and growth opportunities that come from attending in person. We are following strict protocols, as recommended by the CDC, and will be requiring all attendees to attest to being vaccinated. However, if travel isn’t possible, join us for livestreamed, immersive digital learning from wherever you are in the world. Regardless of your choice, both options will allow you to engage in fun experiences, learn, and connect.

As Co-Chair of CHEST 2021, I’d like to personally invite you to participate, whether this is your first time or you’ve lost count how many times you’ve attended our annual meeting. The community at CHEST is what makes the CHEST conference special, and we are proud to be able to keep you all connected despite geographic restrictions.

Looking forward to seeing you there and connecting on Twitter at #CHEST2021.

Chris Carroll, MD

Co-Chair, CHEST 2021

A little over a year ago, none of us imagined we’d be where we are right now. The pandemic has deeply affected us all, and there have been so many losses, both professional and personal. I’m proud of how our CHEST community responded to the pandemic. The incredibly rapid pace of knowledge acquisition and the speed at which we disseminated that knowledge took a lot of combined effort, but that’s nothing new to our CHEST community.

Throughout the pandemic, CHEST pushed digital education with an array of webinars, podcasts, bite-sized educational modules, and infographics. We held a highly successful, well-received CHEST 2020 online conference with just a few months of planning. I’m so excited to take what we learned about offering high-quality, digital education and turn that into a hybrid meeting for CHEST 2021 that meets the educational needs of every participant!

At CHEST 2021, you will be presented with the latest in pulmonary, critical care, and sleep medicine for clinicians at all levels. Whether you are a trainee or an experienced clinician, there is something to learn at CHEST 2021. We are packing the agenda with experiences from live learning and simulation to high-quality education sessions and smaller problem-based learning classes.

On top of this, you have an amazing opportunity to network and reconnect with colleagues you haven’t seen in months! Whether at Experience CHEST, in the gaming area, the Trainee and Transition Lounge, and more, CHEST 2021, as always, is the best at providing top-tier education, team-based learning, and community connections.

This will be the first hybrid meeting put on by CHEST. We came to the decision knowing that while some people are hungry to get back to having an in-person experience, others found that an online conference better fits their needs. I strongly encourage you to join us October 17-20 in Orlando, Florida, to experience the networking and growth opportunities that come from attending in person. We are following strict protocols, as recommended by the CDC, and will be requiring all attendees to attest to being vaccinated. However, if travel isn’t possible, join us for livestreamed, immersive digital learning from wherever you are in the world. Regardless of your choice, both options will allow you to engage in fun experiences, learn, and connect.

As Co-Chair of CHEST 2021, I’d like to personally invite you to participate, whether this is your first time or you’ve lost count how many times you’ve attended our annual meeting. The community at CHEST is what makes the CHEST conference special, and we are proud to be able to keep you all connected despite geographic restrictions.

Looking forward to seeing you there and connecting on Twitter at #CHEST2021.

Chris Carroll, MD

Co-Chair, CHEST 2021

Numerous advances in diagnosis, staging, and treatment have evolved over the past several years for non-small cell lung cancer (NSCLC) patients. Because of the new developments, input from a team of specialists is required to treat each patient. Many hospitals have implemented a multidisciplinary team approach to treat these complex cases.

In this ReCAP, Dr Nicole Tanner, a pulmonary critical care specialist from the Medical University of South Carolina, hosts thoracic oncologist Dr Carrie Lee and thoracic surgeon Dr Jason Long, colleagues from the UNC Lineberger Comprehensive Cancer Center, in a discussion of the advantages of multidisciplinary teams in the treatment of NSCLC patients.

Their discussion ranges from identifying key multidisciplinary team members, individual practitioner responsibilities, benefits of multidisciplinary teams to patients and clinicians alike, and the advantages of incorporating telehealth visits into standard practice after the pandemic.

--

Jason M. Long, MD, MPH, FCCP, Associate Professor, Department of Surgery, University of North Carolina School of Medicine; Staff Physician, Department of Surgery, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina

Jason M. Long, MD, MPH, FCCP, has disclosed no relevant financial relationships.

Carrie B. Lee, MD, MPH, Associate Professor, Department of Medicine, University of North Carolina, Chapel Hill; Medical Director, Clinical Protocol Office, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina

Carrie B. Lee, MD, MPH, has disclosed the following relevant financial relationships:
Serve(d) as the chair of the Data and Safety Monitoring Board for: Delcath, Inc.

Nichole T. Tanner, MD, MSCR, FCCP, Associate Professor, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina

Nichole T. Tanner, MD, MSCR, FCCP, has disclosed no relevant financial relationships.

Numerous advances in diagnosis, staging, and treatment have evolved over the past several years for non-small cell lung cancer (NSCLC) patients. Because of the new developments, input from a team of specialists is required to treat each patient. Many hospitals have implemented a multidisciplinary team approach to treat these complex cases.

In this ReCAP, Dr Nicole Tanner, a pulmonary critical care specialist from the Medical University of South Carolina, hosts thoracic oncologist Dr Carrie Lee and thoracic surgeon Dr Jason Long, colleagues from the UNC Lineberger Comprehensive Cancer Center, in a discussion of the advantages of multidisciplinary teams in the treatment of NSCLC patients.

Their discussion ranges from identifying key multidisciplinary team members, individual practitioner responsibilities, benefits of multidisciplinary teams to patients and clinicians alike, and the advantages of incorporating telehealth visits into standard practice after the pandemic.

--

Jason M. Long, MD, MPH, FCCP, Associate Professor, Department of Surgery, University of North Carolina School of Medicine; Staff Physician, Department of Surgery, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina

Jason M. Long, MD, MPH, FCCP, has disclosed no relevant financial relationships.

Carrie B. Lee, MD, MPH, Associate Professor, Department of Medicine, University of North Carolina, Chapel Hill; Medical Director, Clinical Protocol Office, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina

Carrie B. Lee, MD, MPH, has disclosed the following relevant financial relationships:
Serve(d) as the chair of the Data and Safety Monitoring Board for: Delcath, Inc.

Nichole T. Tanner, MD, MSCR, FCCP, Associate Professor, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina

Nichole T. Tanner, MD, MSCR, FCCP, has disclosed no relevant financial relationships.

Numerous advances in diagnosis, staging, and treatment have evolved over the past several years for non-small cell lung cancer (NSCLC) patients. Because of the new developments, input from a team of specialists is required to treat each patient. Many hospitals have implemented a multidisciplinary team approach to treat these complex cases.

In this ReCAP, Dr Nicole Tanner, a pulmonary critical care specialist from the Medical University of South Carolina, hosts thoracic oncologist Dr Carrie Lee and thoracic surgeon Dr Jason Long, colleagues from the UNC Lineberger Comprehensive Cancer Center, in a discussion of the advantages of multidisciplinary teams in the treatment of NSCLC patients.

Their discussion ranges from identifying key multidisciplinary team members, individual practitioner responsibilities, benefits of multidisciplinary teams to patients and clinicians alike, and the advantages of incorporating telehealth visits into standard practice after the pandemic.

--

Jason M. Long, MD, MPH, FCCP, Associate Professor, Department of Surgery, University of North Carolina School of Medicine; Staff Physician, Department of Surgery, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina

Jason M. Long, MD, MPH, FCCP, has disclosed no relevant financial relationships.

Carrie B. Lee, MD, MPH, Associate Professor, Department of Medicine, University of North Carolina, Chapel Hill; Medical Director, Clinical Protocol Office, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina

Carrie B. Lee, MD, MPH, has disclosed the following relevant financial relationships:
Serve(d) as the chair of the Data and Safety Monitoring Board for: Delcath, Inc.

Nichole T. Tanner, MD, MSCR, FCCP, Associate Professor, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina

Nichole T. Tanner, MD, MSCR, FCCP, has disclosed no relevant financial relationships.

Six months after mild SARS-CoV-2 infection in a representative health care workforce, no long-term cardiovascular sequelae were detected, compared with a matched SARS-CoV-2 seronegative group.

“Mild COVID-19 left no measurable cardiovascular impact on LV structure, function, scar burden, aortic stiffness, or serum biomarkers,” the researchers reported in an article published online May 8 in JACC: Cardiovascular Imaging.

“We provide societal reassurance and support for the position that screening in asymptomatic individuals following mild disease is not indicated,” first author George Joy, MBBS, University College London, said in presenting the results at EuroCMR, the annual CMR congress of the European Association of Cardiovascular Imaging (EACVI).

Briefing comoderator Leyla Elif Sade, MD, University of Baskent, Ankara, Turkey, said, “This is the hot topic of our time because of obvious reasons and I think [this] study is quite important to avoid unnecessary further testing, surveillance testing, and to avoid a significant burden of health care costs.”
 

‘Alarming’ early data

Early cardiac magnetic resonance (CMR) studies in patients recovered from mild COVID-19 were “alarming,” Dr. Joy said.

As previously reported, one study showed cardiac abnormalities after mild COVID-19 in up to 78% of patients, with evidence of ongoing myocardial inflammation in 60%. The CMR findings correlated with elevations in troponin T by high-sensitivity assay (hs-TnT).

To investigate further, Dr. Joy and colleagues did a nested case-control study within the COVIDsortium, a prospective study of 731 health care workers from three London hospitals who underwent weekly symptom, polymerase chain reaction, and serology assessment over 4 months during the first wave of the pandemic.

A total of 157 (21.5%) participants seroconverted during the study period.

Six months after infection, 74 seropositive (median age, 39; 62% women) and 75 age-, sex-, and ethnicity-matched seronegative controls underwent cardiovascular phenotyping (comprehensive phantom-calibrated CMR and blood biomarkers). The analysis was blinded, using objective artificial intelligence analytics when available.

The results showed no statistically significant differences between seropositive and seronegative participants in cardiac structure (left ventricular volumes, mass, atrial area), function (ejection fraction, global longitudinal shortening, aortic distensibility), tissue characterization (T1, T2, extracellular volume fraction mapping, late gadolinium enhancement) or biomarkers (troponin, N-terminal pro–B-type natriuretic peptide).

Cardiovascular abnormalities were no more common in seropositive than seronegative otherwise healthy health care workers 6 months post mild SARS-CoV-2 infection. Measured abnormalities were “evenly distributed between both groups,” Dr. Joy said.

Therefore, it’s “important to reassure patients with mild SARS-CoV-2 infection regarding its cardiovascular effects,” Dr. Joy and colleagues concluded.
 

Limitations and caveats

They caution, however, that the study provides insight only into the short- to medium-term sequelae of patients aged 18-69 with mild COVID-19 who did not require hospitalization and had low numbers of comorbidities.

The study does not address the cardiovascular effects after severe COVID-19 infection requiring hospitalization or in those with multiple comorbid conditions, they noted. It also does not prove that apparently mild SARS-CoV-2 never causes chronic myocarditis.

“The study design would not distinguish between people who had sustained completely healed myocarditis and pericarditis and those in whom the heart had never been affected,” the researchers noted.

They pointed to a recent cross-sectional study of athletes 1-month post mild COVID-19 that found significant pericardial involvement (late enhancement and/or pericardial effusion), although no baseline pre-COVID-19 imaging was performed. In the current study at 6 months post infection the pericardium was normal.

The coauthors of a linked editorial say this study provides “welcome, reassuring information that in healthy individuals who experience mild infection with COVID-19, persisting evidence of cardiovascular complications is very uncommon. The results do not support cardiovascular screening in individuals with mild or asymptomatic infection with COVID-19.”  

Colin Berry, PhD, and Kenneth Mangion, PhD, both from University of Glasgow, cautioned that the population is restricted to health care workers; therefore, the findings may not necessarily be generalized to a community population .

“Healthcare workers do not reflect the population of individuals most clinically affected by COVID-19 illness. The severity of acute COVID-19 infection is greatest in older individuals and those with preexisting health problems. Healthcare workers are not representative of the wider, unselected, at-risk, community population,” they pointed out.

Cardiovascular risk factors and concomitant health problems (heart and respiratory disease) may be more common in the community than in health care workers, and prior studies have highlighted their potential impact for disease pathogenesis in COVID-19.

Dr. Berry and Dr. Mangion also noted that women made up nearly two-thirds of the seropositive group. This may reflect a selection bias or may naturally reflect the fact that proportionately more women are asymptomatic or have milder forms of illness, whereas severe SARS-CoV-2 infection requiring hospitalization affects men to a greater degree.

COVIDsortium funding was donated by individuals, charitable trusts, and corporations including Goldman Sachs, Citadel and Citadel Securities, The Guy Foundation, GW Pharmaceuticals, Kusuma Trust, and Jagclif Charitable Trust, and enabled by Barts Charity with support from UCLH Charity. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Six months after mild SARS-CoV-2 infection in a representative health care workforce, no long-term cardiovascular sequelae were detected, compared with a matched SARS-CoV-2 seronegative group.

“Mild COVID-19 left no measurable cardiovascular impact on LV structure, function, scar burden, aortic stiffness, or serum biomarkers,” the researchers reported in an article published online May 8 in JACC: Cardiovascular Imaging.

“We provide societal reassurance and support for the position that screening in asymptomatic individuals following mild disease is not indicated,” first author George Joy, MBBS, University College London, said in presenting the results at EuroCMR, the annual CMR congress of the European Association of Cardiovascular Imaging (EACVI).

Briefing comoderator Leyla Elif Sade, MD, University of Baskent, Ankara, Turkey, said, “This is the hot topic of our time because of obvious reasons and I think [this] study is quite important to avoid unnecessary further testing, surveillance testing, and to avoid a significant burden of health care costs.”
 

‘Alarming’ early data

Early cardiac magnetic resonance (CMR) studies in patients recovered from mild COVID-19 were “alarming,” Dr. Joy said.

As previously reported, one study showed cardiac abnormalities after mild COVID-19 in up to 78% of patients, with evidence of ongoing myocardial inflammation in 60%. The CMR findings correlated with elevations in troponin T by high-sensitivity assay (hs-TnT).

To investigate further, Dr. Joy and colleagues did a nested case-control study within the COVIDsortium, a prospective study of 731 health care workers from three London hospitals who underwent weekly symptom, polymerase chain reaction, and serology assessment over 4 months during the first wave of the pandemic.

A total of 157 (21.5%) participants seroconverted during the study period.

Six months after infection, 74 seropositive (median age, 39; 62% women) and 75 age-, sex-, and ethnicity-matched seronegative controls underwent cardiovascular phenotyping (comprehensive phantom-calibrated CMR and blood biomarkers). The analysis was blinded, using objective artificial intelligence analytics when available.

The results showed no statistically significant differences between seropositive and seronegative participants in cardiac structure (left ventricular volumes, mass, atrial area), function (ejection fraction, global longitudinal shortening, aortic distensibility), tissue characterization (T1, T2, extracellular volume fraction mapping, late gadolinium enhancement) or biomarkers (troponin, N-terminal pro–B-type natriuretic peptide).

Cardiovascular abnormalities were no more common in seropositive than seronegative otherwise healthy health care workers 6 months post mild SARS-CoV-2 infection. Measured abnormalities were “evenly distributed between both groups,” Dr. Joy said.

Therefore, it’s “important to reassure patients with mild SARS-CoV-2 infection regarding its cardiovascular effects,” Dr. Joy and colleagues concluded.
 

Limitations and caveats

They caution, however, that the study provides insight only into the short- to medium-term sequelae of patients aged 18-69 with mild COVID-19 who did not require hospitalization and had low numbers of comorbidities.

The study does not address the cardiovascular effects after severe COVID-19 infection requiring hospitalization or in those with multiple comorbid conditions, they noted. It also does not prove that apparently mild SARS-CoV-2 never causes chronic myocarditis.

“The study design would not distinguish between people who had sustained completely healed myocarditis and pericarditis and those in whom the heart had never been affected,” the researchers noted.

They pointed to a recent cross-sectional study of athletes 1-month post mild COVID-19 that found significant pericardial involvement (late enhancement and/or pericardial effusion), although no baseline pre-COVID-19 imaging was performed. In the current study at 6 months post infection the pericardium was normal.

The coauthors of a linked editorial say this study provides “welcome, reassuring information that in healthy individuals who experience mild infection with COVID-19, persisting evidence of cardiovascular complications is very uncommon. The results do not support cardiovascular screening in individuals with mild or asymptomatic infection with COVID-19.”  

Colin Berry, PhD, and Kenneth Mangion, PhD, both from University of Glasgow, cautioned that the population is restricted to health care workers; therefore, the findings may not necessarily be generalized to a community population .

“Healthcare workers do not reflect the population of individuals most clinically affected by COVID-19 illness. The severity of acute COVID-19 infection is greatest in older individuals and those with preexisting health problems. Healthcare workers are not representative of the wider, unselected, at-risk, community population,” they pointed out.

Cardiovascular risk factors and concomitant health problems (heart and respiratory disease) may be more common in the community than in health care workers, and prior studies have highlighted their potential impact for disease pathogenesis in COVID-19.

Dr. Berry and Dr. Mangion also noted that women made up nearly two-thirds of the seropositive group. This may reflect a selection bias or may naturally reflect the fact that proportionately more women are asymptomatic or have milder forms of illness, whereas severe SARS-CoV-2 infection requiring hospitalization affects men to a greater degree.

COVIDsortium funding was donated by individuals, charitable trusts, and corporations including Goldman Sachs, Citadel and Citadel Securities, The Guy Foundation, GW Pharmaceuticals, Kusuma Trust, and Jagclif Charitable Trust, and enabled by Barts Charity with support from UCLH Charity. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Six months after mild SARS-CoV-2 infection in a representative health care workforce, no long-term cardiovascular sequelae were detected, compared with a matched SARS-CoV-2 seronegative group.

“Mild COVID-19 left no measurable cardiovascular impact on LV structure, function, scar burden, aortic stiffness, or serum biomarkers,” the researchers reported in an article published online May 8 in JACC: Cardiovascular Imaging.

“We provide societal reassurance and support for the position that screening in asymptomatic individuals following mild disease is not indicated,” first author George Joy, MBBS, University College London, said in presenting the results at EuroCMR, the annual CMR congress of the European Association of Cardiovascular Imaging (EACVI).

Briefing comoderator Leyla Elif Sade, MD, University of Baskent, Ankara, Turkey, said, “This is the hot topic of our time because of obvious reasons and I think [this] study is quite important to avoid unnecessary further testing, surveillance testing, and to avoid a significant burden of health care costs.”
 

‘Alarming’ early data

Early cardiac magnetic resonance (CMR) studies in patients recovered from mild COVID-19 were “alarming,” Dr. Joy said.

As previously reported, one study showed cardiac abnormalities after mild COVID-19 in up to 78% of patients, with evidence of ongoing myocardial inflammation in 60%. The CMR findings correlated with elevations in troponin T by high-sensitivity assay (hs-TnT).

To investigate further, Dr. Joy and colleagues did a nested case-control study within the COVIDsortium, a prospective study of 731 health care workers from three London hospitals who underwent weekly symptom, polymerase chain reaction, and serology assessment over 4 months during the first wave of the pandemic.

A total of 157 (21.5%) participants seroconverted during the study period.

Six months after infection, 74 seropositive (median age, 39; 62% women) and 75 age-, sex-, and ethnicity-matched seronegative controls underwent cardiovascular phenotyping (comprehensive phantom-calibrated CMR and blood biomarkers). The analysis was blinded, using objective artificial intelligence analytics when available.

The results showed no statistically significant differences between seropositive and seronegative participants in cardiac structure (left ventricular volumes, mass, atrial area), function (ejection fraction, global longitudinal shortening, aortic distensibility), tissue characterization (T1, T2, extracellular volume fraction mapping, late gadolinium enhancement) or biomarkers (troponin, N-terminal pro–B-type natriuretic peptide).

Cardiovascular abnormalities were no more common in seropositive than seronegative otherwise healthy health care workers 6 months post mild SARS-CoV-2 infection. Measured abnormalities were “evenly distributed between both groups,” Dr. Joy said.

Therefore, it’s “important to reassure patients with mild SARS-CoV-2 infection regarding its cardiovascular effects,” Dr. Joy and colleagues concluded.
 

Limitations and caveats

They caution, however, that the study provides insight only into the short- to medium-term sequelae of patients aged 18-69 with mild COVID-19 who did not require hospitalization and had low numbers of comorbidities.

The study does not address the cardiovascular effects after severe COVID-19 infection requiring hospitalization or in those with multiple comorbid conditions, they noted. It also does not prove that apparently mild SARS-CoV-2 never causes chronic myocarditis.

“The study design would not distinguish between people who had sustained completely healed myocarditis and pericarditis and those in whom the heart had never been affected,” the researchers noted.

They pointed to a recent cross-sectional study of athletes 1-month post mild COVID-19 that found significant pericardial involvement (late enhancement and/or pericardial effusion), although no baseline pre-COVID-19 imaging was performed. In the current study at 6 months post infection the pericardium was normal.

The coauthors of a linked editorial say this study provides “welcome, reassuring information that in healthy individuals who experience mild infection with COVID-19, persisting evidence of cardiovascular complications is very uncommon. The results do not support cardiovascular screening in individuals with mild or asymptomatic infection with COVID-19.”  

Colin Berry, PhD, and Kenneth Mangion, PhD, both from University of Glasgow, cautioned that the population is restricted to health care workers; therefore, the findings may not necessarily be generalized to a community population .

“Healthcare workers do not reflect the population of individuals most clinically affected by COVID-19 illness. The severity of acute COVID-19 infection is greatest in older individuals and those with preexisting health problems. Healthcare workers are not representative of the wider, unselected, at-risk, community population,” they pointed out.

Cardiovascular risk factors and concomitant health problems (heart and respiratory disease) may be more common in the community than in health care workers, and prior studies have highlighted their potential impact for disease pathogenesis in COVID-19.

Dr. Berry and Dr. Mangion also noted that women made up nearly two-thirds of the seropositive group. This may reflect a selection bias or may naturally reflect the fact that proportionately more women are asymptomatic or have milder forms of illness, whereas severe SARS-CoV-2 infection requiring hospitalization affects men to a greater degree.

COVIDsortium funding was donated by individuals, charitable trusts, and corporations including Goldman Sachs, Citadel and Citadel Securities, The Guy Foundation, GW Pharmaceuticals, Kusuma Trust, and Jagclif Charitable Trust, and enabled by Barts Charity with support from UCLH Charity. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients who receive the mRNA COVID-19 vaccines are experiencing a variety of skin rashes, a dermatologist told colleagues, and some lesions don’t appear until several days after an injection. The good news is that these side effects tend to be minor and vanish within a few days, Esther Freeman, MD, PhD, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

“The reality is actually very reassuring,” Dr. Freeman said, especially in light of what is currently known about when the rashes occur and how anaphylaxis is extremely uncommon. Now, she added, dermatologists can tell patients who had reactions to their initial vaccination that “we know you had this big reaction, and we know that it was upsetting and uncomfortable. But it may not happen the second time around. And if it does, [the reaction is] probably going to be smaller.”

Dr. Freeman, associate professor of dermatology at Harvard Medical School, Boston, highlighted a study published in the Journal of the American Academy of Dermatology that she coauthored with dermatologists across the United States. The researchers tracked 414 cutaneous reactions to the Moderna (83%) and Pfizer (17%) COVID-19 vaccines in a group of patients, which was 90% female, 78% White, and mostly from the United States. Their average age was 44 years. The cases were reported to the AAD–International League of Dermatological Societies registry of COVID-19 cutaneous manifestations.

While most were women, “it’s a little hard to know if this is really going to end up being a true finding,” said Dr. Freeman, the registry’s principal investigator and a member of the AAD’s COVID-19 Ad Hoc Task Force. “If you think about who got vaccinated early, it was health care providers, and the American health care workforce is over 70% female. So I think there’s a little bit of bias here. There may also be a bias because women may be slightly more likely to report or go to their health care provider for a rash.”

Delayed large local reactions were the most common, accounting for 66% (175 cases) of the 267 skin reactions reported after the first Moderna vaccine dose and 30% (31 cases) of the 102 reactions reported after the second dose. These reactions represented 15% (5 cases) of the 34 skin reactions reported after the first Pfizer vaccine dose and 18% (7 cases) of the 40 reactions after the second dose.

There are two peaks with that first dose, Dr. Freeman said. “There’s a peak around day 2 or 3. And there’s another peak around day 7 or 8 with some of these reactions. Only 27% who had a reaction with the first dose had the same reaction with the second.” She added that these reactions “are not cellulitis and don’t require antibiotics.”

Other more common reactions included local injection-site reactions (swelling, erythema, and pain), urticaria (after 24 hours in almost all cases, occurring at a higher rate in patients who received the Pfizer vaccine), and morbilliform eruptions.

Dr. Freeman said that patients may experience redness and swelling in the hands and feet that can be “very uncomfortable.” She described one patient “who was having a hard time actually closing his fist, just because of the amount of swelling and redness in his hand. It did resolve, and it’s important to reassure your patients it will go away.”

According to this study, less common reports of other cutaneous findings with both vaccines included 9 reports of swelling at the site of cosmetic fillers, 8 reports of pernio/chilblains, 10 reports of varicella zoster, 4 reports of herpes simplex flares, 4 pityriasis rosea–like reactions, and 4 rashes in infants of vaccinated breastfeeding mothers.

The study noted that “patients responded well to topical corticosteroids, oral antihistamines, and/or pain-relieving medications. These reactions resolved after a median of 3-4 days.”

It’s important to understand that none of the patients developed anaphylaxis after the second dose even if they’d had a reaction to the first dose, Dr. Freeman said. “But I should point out that we’re talking about reactions that have started more than 4 hours after the vaccine. If a rash such as a urticaria specifically starts within 4 hours of vaccination, that’s in a different category. Those are considered more immediate allergic reactions, and those patients need to be seen by allergy before a second dose.”

Dr. Freeman added that “it’s really interesting to think about how our bodies are really reacting to the vaccine in a way that’s mimicking our body’s reactions to COVID-19.” For example, some patients who got vaccinated developed chilblains similar to the “COVID toes” described in infected patients, apparently as part of the body’s immune response to the virus. “We’ve seen this in patients who actually had COVID and had prior COVID toes and then actually got a flare with their vaccine. And then we’ve also seen it in patients who never had COVID.”

In regard to general advice for patients, she said, “I do still encourage my patients who previously had COVID to go ahead and get the vaccine even if they had a skin manifestation with COVID.”

Shari Lipner, MD, PhD, associate professor of clinical dermatology, Weill Cornell Medicine, New York, said she has have seen only a handful of cases of delayed large local reactions and local injection site reactions after COVID-19 vaccination. “I have seen a significant number of cases of acute urticaria following the first and second doses,” she said in an interview. “However, it is important to keep in mind that we cannot determine cause and effect for the cases of acute urticaria. They may or may not be vaccine related.”

Fortunately, none of the adverse effects she’s seen have been severe. “It is important that dermatologists educate the public and their patients that most people do not develop any skin reaction in response to the vaccine,” she said. In the minority who do, “reactions tend to be mild and are not life-threatening. Many of these skin reactions resolve on their own without treatment.”

She added that “patients with pernio/chilblains or herpes zoster following vaccination should be referred by a board-certified dermatologist for prompt treatment and to avoid sequelae.”


 

‘COVID vaccine arm’

Delayed local reactions to the Moderna vaccine were also described in a report published online on May 12, 2021, in JAMA Dermatology, after the AAD meeting, in 16 patients referred to the Yale New Haven (Conn.) Hospital Dermatology service who experienced delayed localized cutaneous hypersensitivity reactions a median of 7 days after receiving the vaccine (range, 2-12 days), from Jan. 20 to Feb. 12, 2021. No such cases were reported in Pfizer vaccine recipients.

Of the 16 patients, whose median age was 38 years and who were mostly women, 15 developed the reaction after the first dose, described as “pruritic and variably painful erythematous reactions near the injection site,” which lasted a median of 5 days (range, 1-21 days). After the second dose, 12 of the 16 patients developed injection-site reactions (including one patient who had no reaction after dose 1), a median of 2 days after the vaccine was administered (range, 0-5 days). Histologic results of a biopsy in one patient with a reaction to the second dose “ demonstrated mild predominantly perivascular and focal interstitial mixed infiltrate with lymphocytes and eosinophils consistent with a dermal hypersensitivity reaction,” wrote Alicia J. Little, MD, PhD, of the department of dermatology, Yale University, New Haven, and coauthors.

Compared with immediate hypersensitivity reactions, occurring within 4 hours of vaccination, such as anaphylaxis and urticaria, they concluded that “these delayed localized hypersensitivity reactions are not a contraindication to subsequent vaccination,” and they proposed that they be named “COVID vaccine arm.”

Dr. Freeman reported no disclosures. Dr. Lipner also had no relevant disclosures. Dr. Little reported receiving a grant from the National Center for Advancing Translational Science and a Women’s Health Career Development Award from the Dermatology Foundation while the study was conducted; another author reported equity in Johnson & Johnson in his spouse’s retirement fund outside the submitted work.
 

Patients who receive the mRNA COVID-19 vaccines are experiencing a variety of skin rashes, a dermatologist told colleagues, and some lesions don’t appear until several days after an injection. The good news is that these side effects tend to be minor and vanish within a few days, Esther Freeman, MD, PhD, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

“The reality is actually very reassuring,” Dr. Freeman said, especially in light of what is currently known about when the rashes occur and how anaphylaxis is extremely uncommon. Now, she added, dermatologists can tell patients who had reactions to their initial vaccination that “we know you had this big reaction, and we know that it was upsetting and uncomfortable. But it may not happen the second time around. And if it does, [the reaction is] probably going to be smaller.”

Dr. Freeman, associate professor of dermatology at Harvard Medical School, Boston, highlighted a study published in the Journal of the American Academy of Dermatology that she coauthored with dermatologists across the United States. The researchers tracked 414 cutaneous reactions to the Moderna (83%) and Pfizer (17%) COVID-19 vaccines in a group of patients, which was 90% female, 78% White, and mostly from the United States. Their average age was 44 years. The cases were reported to the AAD–International League of Dermatological Societies registry of COVID-19 cutaneous manifestations.

While most were women, “it’s a little hard to know if this is really going to end up being a true finding,” said Dr. Freeman, the registry’s principal investigator and a member of the AAD’s COVID-19 Ad Hoc Task Force. “If you think about who got vaccinated early, it was health care providers, and the American health care workforce is over 70% female. So I think there’s a little bit of bias here. There may also be a bias because women may be slightly more likely to report or go to their health care provider for a rash.”

Delayed large local reactions were the most common, accounting for 66% (175 cases) of the 267 skin reactions reported after the first Moderna vaccine dose and 30% (31 cases) of the 102 reactions reported after the second dose. These reactions represented 15% (5 cases) of the 34 skin reactions reported after the first Pfizer vaccine dose and 18% (7 cases) of the 40 reactions after the second dose.

There are two peaks with that first dose, Dr. Freeman said. “There’s a peak around day 2 or 3. And there’s another peak around day 7 or 8 with some of these reactions. Only 27% who had a reaction with the first dose had the same reaction with the second.” She added that these reactions “are not cellulitis and don’t require antibiotics.”

Other more common reactions included local injection-site reactions (swelling, erythema, and pain), urticaria (after 24 hours in almost all cases, occurring at a higher rate in patients who received the Pfizer vaccine), and morbilliform eruptions.

Dr. Freeman said that patients may experience redness and swelling in the hands and feet that can be “very uncomfortable.” She described one patient “who was having a hard time actually closing his fist, just because of the amount of swelling and redness in his hand. It did resolve, and it’s important to reassure your patients it will go away.”

According to this study, less common reports of other cutaneous findings with both vaccines included 9 reports of swelling at the site of cosmetic fillers, 8 reports of pernio/chilblains, 10 reports of varicella zoster, 4 reports of herpes simplex flares, 4 pityriasis rosea–like reactions, and 4 rashes in infants of vaccinated breastfeeding mothers.

The study noted that “patients responded well to topical corticosteroids, oral antihistamines, and/or pain-relieving medications. These reactions resolved after a median of 3-4 days.”

It’s important to understand that none of the patients developed anaphylaxis after the second dose even if they’d had a reaction to the first dose, Dr. Freeman said. “But I should point out that we’re talking about reactions that have started more than 4 hours after the vaccine. If a rash such as a urticaria specifically starts within 4 hours of vaccination, that’s in a different category. Those are considered more immediate allergic reactions, and those patients need to be seen by allergy before a second dose.”

Dr. Freeman added that “it’s really interesting to think about how our bodies are really reacting to the vaccine in a way that’s mimicking our body’s reactions to COVID-19.” For example, some patients who got vaccinated developed chilblains similar to the “COVID toes” described in infected patients, apparently as part of the body’s immune response to the virus. “We’ve seen this in patients who actually had COVID and had prior COVID toes and then actually got a flare with their vaccine. And then we’ve also seen it in patients who never had COVID.”

In regard to general advice for patients, she said, “I do still encourage my patients who previously had COVID to go ahead and get the vaccine even if they had a skin manifestation with COVID.”

Shari Lipner, MD, PhD, associate professor of clinical dermatology, Weill Cornell Medicine, New York, said she has have seen only a handful of cases of delayed large local reactions and local injection site reactions after COVID-19 vaccination. “I have seen a significant number of cases of acute urticaria following the first and second doses,” she said in an interview. “However, it is important to keep in mind that we cannot determine cause and effect for the cases of acute urticaria. They may or may not be vaccine related.”

Fortunately, none of the adverse effects she’s seen have been severe. “It is important that dermatologists educate the public and their patients that most people do not develop any skin reaction in response to the vaccine,” she said. In the minority who do, “reactions tend to be mild and are not life-threatening. Many of these skin reactions resolve on their own without treatment.”

She added that “patients with pernio/chilblains or herpes zoster following vaccination should be referred by a board-certified dermatologist for prompt treatment and to avoid sequelae.”


 

‘COVID vaccine arm’

Delayed local reactions to the Moderna vaccine were also described in a report published online on May 12, 2021, in JAMA Dermatology, after the AAD meeting, in 16 patients referred to the Yale New Haven (Conn.) Hospital Dermatology service who experienced delayed localized cutaneous hypersensitivity reactions a median of 7 days after receiving the vaccine (range, 2-12 days), from Jan. 20 to Feb. 12, 2021. No such cases were reported in Pfizer vaccine recipients.

Of the 16 patients, whose median age was 38 years and who were mostly women, 15 developed the reaction after the first dose, described as “pruritic and variably painful erythematous reactions near the injection site,” which lasted a median of 5 days (range, 1-21 days). After the second dose, 12 of the 16 patients developed injection-site reactions (including one patient who had no reaction after dose 1), a median of 2 days after the vaccine was administered (range, 0-5 days). Histologic results of a biopsy in one patient with a reaction to the second dose “ demonstrated mild predominantly perivascular and focal interstitial mixed infiltrate with lymphocytes and eosinophils consistent with a dermal hypersensitivity reaction,” wrote Alicia J. Little, MD, PhD, of the department of dermatology, Yale University, New Haven, and coauthors.

Compared with immediate hypersensitivity reactions, occurring within 4 hours of vaccination, such as anaphylaxis and urticaria, they concluded that “these delayed localized hypersensitivity reactions are not a contraindication to subsequent vaccination,” and they proposed that they be named “COVID vaccine arm.”

Dr. Freeman reported no disclosures. Dr. Lipner also had no relevant disclosures. Dr. Little reported receiving a grant from the National Center for Advancing Translational Science and a Women’s Health Career Development Award from the Dermatology Foundation while the study was conducted; another author reported equity in Johnson & Johnson in his spouse’s retirement fund outside the submitted work.
 

Patients who receive the mRNA COVID-19 vaccines are experiencing a variety of skin rashes, a dermatologist told colleagues, and some lesions don’t appear until several days after an injection. The good news is that these side effects tend to be minor and vanish within a few days, Esther Freeman, MD, PhD, said in a presentation at the American Academy of Dermatology Virtual Meeting Experience.

“The reality is actually very reassuring,” Dr. Freeman said, especially in light of what is currently known about when the rashes occur and how anaphylaxis is extremely uncommon. Now, she added, dermatologists can tell patients who had reactions to their initial vaccination that “we know you had this big reaction, and we know that it was upsetting and uncomfortable. But it may not happen the second time around. And if it does, [the reaction is] probably going to be smaller.”

Dr. Freeman, associate professor of dermatology at Harvard Medical School, Boston, highlighted a study published in the Journal of the American Academy of Dermatology that she coauthored with dermatologists across the United States. The researchers tracked 414 cutaneous reactions to the Moderna (83%) and Pfizer (17%) COVID-19 vaccines in a group of patients, which was 90% female, 78% White, and mostly from the United States. Their average age was 44 years. The cases were reported to the AAD–International League of Dermatological Societies registry of COVID-19 cutaneous manifestations.

While most were women, “it’s a little hard to know if this is really going to end up being a true finding,” said Dr. Freeman, the registry’s principal investigator and a member of the AAD’s COVID-19 Ad Hoc Task Force. “If you think about who got vaccinated early, it was health care providers, and the American health care workforce is over 70% female. So I think there’s a little bit of bias here. There may also be a bias because women may be slightly more likely to report or go to their health care provider for a rash.”

Delayed large local reactions were the most common, accounting for 66% (175 cases) of the 267 skin reactions reported after the first Moderna vaccine dose and 30% (31 cases) of the 102 reactions reported after the second dose. These reactions represented 15% (5 cases) of the 34 skin reactions reported after the first Pfizer vaccine dose and 18% (7 cases) of the 40 reactions after the second dose.

There are two peaks with that first dose, Dr. Freeman said. “There’s a peak around day 2 or 3. And there’s another peak around day 7 or 8 with some of these reactions. Only 27% who had a reaction with the first dose had the same reaction with the second.” She added that these reactions “are not cellulitis and don’t require antibiotics.”

Other more common reactions included local injection-site reactions (swelling, erythema, and pain), urticaria (after 24 hours in almost all cases, occurring at a higher rate in patients who received the Pfizer vaccine), and morbilliform eruptions.

Dr. Freeman said that patients may experience redness and swelling in the hands and feet that can be “very uncomfortable.” She described one patient “who was having a hard time actually closing his fist, just because of the amount of swelling and redness in his hand. It did resolve, and it’s important to reassure your patients it will go away.”

According to this study, less common reports of other cutaneous findings with both vaccines included 9 reports of swelling at the site of cosmetic fillers, 8 reports of pernio/chilblains, 10 reports of varicella zoster, 4 reports of herpes simplex flares, 4 pityriasis rosea–like reactions, and 4 rashes in infants of vaccinated breastfeeding mothers.

The study noted that “patients responded well to topical corticosteroids, oral antihistamines, and/or pain-relieving medications. These reactions resolved after a median of 3-4 days.”

It’s important to understand that none of the patients developed anaphylaxis after the second dose even if they’d had a reaction to the first dose, Dr. Freeman said. “But I should point out that we’re talking about reactions that have started more than 4 hours after the vaccine. If a rash such as a urticaria specifically starts within 4 hours of vaccination, that’s in a different category. Those are considered more immediate allergic reactions, and those patients need to be seen by allergy before a second dose.”

Dr. Freeman added that “it’s really interesting to think about how our bodies are really reacting to the vaccine in a way that’s mimicking our body’s reactions to COVID-19.” For example, some patients who got vaccinated developed chilblains similar to the “COVID toes” described in infected patients, apparently as part of the body’s immune response to the virus. “We’ve seen this in patients who actually had COVID and had prior COVID toes and then actually got a flare with their vaccine. And then we’ve also seen it in patients who never had COVID.”

In regard to general advice for patients, she said, “I do still encourage my patients who previously had COVID to go ahead and get the vaccine even if they had a skin manifestation with COVID.”

Shari Lipner, MD, PhD, associate professor of clinical dermatology, Weill Cornell Medicine, New York, said she has have seen only a handful of cases of delayed large local reactions and local injection site reactions after COVID-19 vaccination. “I have seen a significant number of cases of acute urticaria following the first and second doses,” she said in an interview. “However, it is important to keep in mind that we cannot determine cause and effect for the cases of acute urticaria. They may or may not be vaccine related.”

Fortunately, none of the adverse effects she’s seen have been severe. “It is important that dermatologists educate the public and their patients that most people do not develop any skin reaction in response to the vaccine,” she said. In the minority who do, “reactions tend to be mild and are not life-threatening. Many of these skin reactions resolve on their own without treatment.”

She added that “patients with pernio/chilblains or herpes zoster following vaccination should be referred by a board-certified dermatologist for prompt treatment and to avoid sequelae.”


 

‘COVID vaccine arm’

Delayed local reactions to the Moderna vaccine were also described in a report published online on May 12, 2021, in JAMA Dermatology, after the AAD meeting, in 16 patients referred to the Yale New Haven (Conn.) Hospital Dermatology service who experienced delayed localized cutaneous hypersensitivity reactions a median of 7 days after receiving the vaccine (range, 2-12 days), from Jan. 20 to Feb. 12, 2021. No such cases were reported in Pfizer vaccine recipients.

Of the 16 patients, whose median age was 38 years and who were mostly women, 15 developed the reaction after the first dose, described as “pruritic and variably painful erythematous reactions near the injection site,” which lasted a median of 5 days (range, 1-21 days). After the second dose, 12 of the 16 patients developed injection-site reactions (including one patient who had no reaction after dose 1), a median of 2 days after the vaccine was administered (range, 0-5 days). Histologic results of a biopsy in one patient with a reaction to the second dose “ demonstrated mild predominantly perivascular and focal interstitial mixed infiltrate with lymphocytes and eosinophils consistent with a dermal hypersensitivity reaction,” wrote Alicia J. Little, MD, PhD, of the department of dermatology, Yale University, New Haven, and coauthors.

Compared with immediate hypersensitivity reactions, occurring within 4 hours of vaccination, such as anaphylaxis and urticaria, they concluded that “these delayed localized hypersensitivity reactions are not a contraindication to subsequent vaccination,” and they proposed that they be named “COVID vaccine arm.”

Dr. Freeman reported no disclosures. Dr. Lipner also had no relevant disclosures. Dr. Little reported receiving a grant from the National Center for Advancing Translational Science and a Women’s Health Career Development Award from the Dermatology Foundation while the study was conducted; another author reported equity in Johnson & Johnson in his spouse’s retirement fund outside the submitted work.
 

State health officials have shared plans to distribute Pfizer’s COVID-19 vaccine to 12- to 15-year-olds after the Food and Drug Administration authorized its use in this age group May 10.

Some states hope to start the vaccinations as early as May 13, officials said at an Association of State and Territorial Health Officials news conference.

There are, however, two more steps before shots can reach younger arms. On May 12, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is expected to recommend use of the vaccine in this age group. Then CDC Director Rochelle Walensky, MD, must make a final decision to begin vaccinating 12- to 15-year-olds.

Some hoping to start this week

Both the CDC panel and Dr. Walensky are expected to sign off on the vaccine’s use. States have been making plans on how to tailor the vaccination message not just to the patient this time, but to parents and guardians as well, some of whom are hesitant to consent.

Some schools, assuming approval May 12, are ready to start vaccinating in cafeterias and gyms.

Anne Zink, MD, president-elect of the Association of State and Territorial Health Officials and Alaska chief medical officer, told reporters that many of her state’s boroughs and districts have booked in-person vaccines for their schools May 12 as the state has dismissal for summer as early as this week.

Maine is readying four types of distribution sites for the vaccines: primary care offices, Walgreen’s and CVS pharmacies, mass vaccination sites, and schools, said Nirav Shah, MD, current ASTHO president and director of the Maine Center for Disease Control and Prevention.

Starting later this week, he said, the state hopes to host large vaccination clinics for people age 12 and over.

Eliminating barriers

States are working to break down barriers through education and improving access.

In Alaska, many of the drive-through evening vaccination sites are being changed to Pfizer sites so parents just getting off work can take their kids.

It’s also important to get young people to speak to their peers about the importance of vaccines, she said. Some teen groups in Alaska are hosting Zoom calls where they share with children and families why they chose to get vaccinated.

In Maine, Dr. Shah said, “the notion of informed consent applies with equal force to adults as it does with adolescents.” But at least in Maine, it is not required that a parent be on site and present during the vaccination itself.

A parent could sign a form allowing the child to be vaccinated in a school-based clinic. Maine also allows verbal consent so a parent can give consent over the phone, Dr. Shah said.

Dividing vaccine trays

Vaccines going to pediatrician and family medicine offices presents a challenge in that smaller numbers of doses are needed for those venues than at large vaccination sites that get trays of 1,170 Pfizer doses each.

Dr. Shah says states have been talking with federal authorities on the need for smaller packaging.

“Breaking the trays up into smaller lot sizes takes a fair amount of effort,” Dr. Shah said. “We understand that later this month the lot size will be going down to 450.”

But even that will be too much for small offices, he said.

Similarly, an effort is being made in Maine to make sure doctors’ offices are not limited by their refrigeration capabilities. The Pfizer vaccine must be kept at ultra-cold temperatures that many primary care doctors’ offices may not have.

“If they need a cool cube with dry ice, we can furnish that to them,” Dr. Shah said.

Should they be mandated?

Dr. Zink said Alaska generally has high acceptance for recommendations around COVID-19 and has no plans to mandate the COVID-19 vaccines for children.

Umair A. Shah, MD, secretary of health at the Washington State Department of Health, said, “Our number one ability to get people vaccinated is for them to be encouraged to do so, to be incentivized to do so, to do everything we can to make the vaccine choice the easy choice,” including eliminating language, cultural and access barriers.

However, he said, “in higher education, University of Washington and Washington State University have indicated they are going to require COVID vaccines for kids to come back to school. I do think that is something that is increasingly being looked at.”

Though the messages will be tailored differently across the states the bottom line will be the same, Dr. Shah said: The vaccines work and they are safe.

But most critically, “Vaccines are our pathway to moving forward and once and for all ending this pandemic,” he said.

A version of this article first appeared on Medscape.com.

State health officials have shared plans to distribute Pfizer’s COVID-19 vaccine to 12- to 15-year-olds after the Food and Drug Administration authorized its use in this age group May 10.

Some states hope to start the vaccinations as early as May 13, officials said at an Association of State and Territorial Health Officials news conference.

There are, however, two more steps before shots can reach younger arms. On May 12, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is expected to recommend use of the vaccine in this age group. Then CDC Director Rochelle Walensky, MD, must make a final decision to begin vaccinating 12- to 15-year-olds.

Some hoping to start this week

Both the CDC panel and Dr. Walensky are expected to sign off on the vaccine’s use. States have been making plans on how to tailor the vaccination message not just to the patient this time, but to parents and guardians as well, some of whom are hesitant to consent.

Some schools, assuming approval May 12, are ready to start vaccinating in cafeterias and gyms.

Anne Zink, MD, president-elect of the Association of State and Territorial Health Officials and Alaska chief medical officer, told reporters that many of her state’s boroughs and districts have booked in-person vaccines for their schools May 12 as the state has dismissal for summer as early as this week.

Maine is readying four types of distribution sites for the vaccines: primary care offices, Walgreen’s and CVS pharmacies, mass vaccination sites, and schools, said Nirav Shah, MD, current ASTHO president and director of the Maine Center for Disease Control and Prevention.

Starting later this week, he said, the state hopes to host large vaccination clinics for people age 12 and over.

Eliminating barriers

States are working to break down barriers through education and improving access.

In Alaska, many of the drive-through evening vaccination sites are being changed to Pfizer sites so parents just getting off work can take their kids.

It’s also important to get young people to speak to their peers about the importance of vaccines, she said. Some teen groups in Alaska are hosting Zoom calls where they share with children and families why they chose to get vaccinated.

In Maine, Dr. Shah said, “the notion of informed consent applies with equal force to adults as it does with adolescents.” But at least in Maine, it is not required that a parent be on site and present during the vaccination itself.

A parent could sign a form allowing the child to be vaccinated in a school-based clinic. Maine also allows verbal consent so a parent can give consent over the phone, Dr. Shah said.

Dividing vaccine trays

Vaccines going to pediatrician and family medicine offices presents a challenge in that smaller numbers of doses are needed for those venues than at large vaccination sites that get trays of 1,170 Pfizer doses each.

Dr. Shah says states have been talking with federal authorities on the need for smaller packaging.

“Breaking the trays up into smaller lot sizes takes a fair amount of effort,” Dr. Shah said. “We understand that later this month the lot size will be going down to 450.”

But even that will be too much for small offices, he said.

Similarly, an effort is being made in Maine to make sure doctors’ offices are not limited by their refrigeration capabilities. The Pfizer vaccine must be kept at ultra-cold temperatures that many primary care doctors’ offices may not have.

“If they need a cool cube with dry ice, we can furnish that to them,” Dr. Shah said.

Should they be mandated?

Dr. Zink said Alaska generally has high acceptance for recommendations around COVID-19 and has no plans to mandate the COVID-19 vaccines for children.

Umair A. Shah, MD, secretary of health at the Washington State Department of Health, said, “Our number one ability to get people vaccinated is for them to be encouraged to do so, to be incentivized to do so, to do everything we can to make the vaccine choice the easy choice,” including eliminating language, cultural and access barriers.

However, he said, “in higher education, University of Washington and Washington State University have indicated they are going to require COVID vaccines for kids to come back to school. I do think that is something that is increasingly being looked at.”

Though the messages will be tailored differently across the states the bottom line will be the same, Dr. Shah said: The vaccines work and they are safe.

But most critically, “Vaccines are our pathway to moving forward and once and for all ending this pandemic,” he said.

A version of this article first appeared on Medscape.com.

State health officials have shared plans to distribute Pfizer’s COVID-19 vaccine to 12- to 15-year-olds after the Food and Drug Administration authorized its use in this age group May 10.

Some states hope to start the vaccinations as early as May 13, officials said at an Association of State and Territorial Health Officials news conference.

There are, however, two more steps before shots can reach younger arms. On May 12, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is expected to recommend use of the vaccine in this age group. Then CDC Director Rochelle Walensky, MD, must make a final decision to begin vaccinating 12- to 15-year-olds.

Some hoping to start this week

Both the CDC panel and Dr. Walensky are expected to sign off on the vaccine’s use. States have been making plans on how to tailor the vaccination message not just to the patient this time, but to parents and guardians as well, some of whom are hesitant to consent.

Some schools, assuming approval May 12, are ready to start vaccinating in cafeterias and gyms.

Anne Zink, MD, president-elect of the Association of State and Territorial Health Officials and Alaska chief medical officer, told reporters that many of her state’s boroughs and districts have booked in-person vaccines for their schools May 12 as the state has dismissal for summer as early as this week.

Maine is readying four types of distribution sites for the vaccines: primary care offices, Walgreen’s and CVS pharmacies, mass vaccination sites, and schools, said Nirav Shah, MD, current ASTHO president and director of the Maine Center for Disease Control and Prevention.

Starting later this week, he said, the state hopes to host large vaccination clinics for people age 12 and over.

Eliminating barriers

States are working to break down barriers through education and improving access.

In Alaska, many of the drive-through evening vaccination sites are being changed to Pfizer sites so parents just getting off work can take their kids.

It’s also important to get young people to speak to their peers about the importance of vaccines, she said. Some teen groups in Alaska are hosting Zoom calls where they share with children and families why they chose to get vaccinated.

In Maine, Dr. Shah said, “the notion of informed consent applies with equal force to adults as it does with adolescents.” But at least in Maine, it is not required that a parent be on site and present during the vaccination itself.

A parent could sign a form allowing the child to be vaccinated in a school-based clinic. Maine also allows verbal consent so a parent can give consent over the phone, Dr. Shah said.

Dividing vaccine trays

Vaccines going to pediatrician and family medicine offices presents a challenge in that smaller numbers of doses are needed for those venues than at large vaccination sites that get trays of 1,170 Pfizer doses each.

Dr. Shah says states have been talking with federal authorities on the need for smaller packaging.

“Breaking the trays up into smaller lot sizes takes a fair amount of effort,” Dr. Shah said. “We understand that later this month the lot size will be going down to 450.”

But even that will be too much for small offices, he said.

Similarly, an effort is being made in Maine to make sure doctors’ offices are not limited by their refrigeration capabilities. The Pfizer vaccine must be kept at ultra-cold temperatures that many primary care doctors’ offices may not have.

“If they need a cool cube with dry ice, we can furnish that to them,” Dr. Shah said.

Should they be mandated?

Dr. Zink said Alaska generally has high acceptance for recommendations around COVID-19 and has no plans to mandate the COVID-19 vaccines for children.

Umair A. Shah, MD, secretary of health at the Washington State Department of Health, said, “Our number one ability to get people vaccinated is for them to be encouraged to do so, to be incentivized to do so, to do everything we can to make the vaccine choice the easy choice,” including eliminating language, cultural and access barriers.

However, he said, “in higher education, University of Washington and Washington State University have indicated they are going to require COVID vaccines for kids to come back to school. I do think that is something that is increasingly being looked at.”

Though the messages will be tailored differently across the states the bottom line will be the same, Dr. Shah said: The vaccines work and they are safe.

But most critically, “Vaccines are our pathway to moving forward and once and for all ending this pandemic,” he said.

A version of this article first appeared on Medscape.com.