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The conundrum of Covid vaccines for children, adolescents and youth

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By Dr B. J. C. Perera

MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL).

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

There is a lot of interest as well as differences of opinion and even misinformation regarding many aspects of vaccination of children, and young people, against Covid-19. This has led to a considerable amount of anxiety in the minds of parents, and even the youth themselves, regarding the different facets of vaccinating these subjects against the coronavirus infection that is running riot, all over the world, including Sri Lanka. Against this background, it is also pertinent to point out that there is a very definite recent increase in the numbers of children who have tested positive for the coronavirus disease, especially in some of the developed countries with facilities available for large scale testing of the general population.

There is a considerable number of differing opinions expressed regarding the need to vaccinate these age groups of subjects. True enough, it is argued that children, and young people, are not as susceptible to major effects. However, there are documented cases, though quite rare, of children, and young people, getting the Multisystem Inflammatory Syndrome (MIS-C) complication of Covid-19. That particular problem could affect several body systems and organs. It is a somewhat delayed but a rather nasty complication which, if it is not properly and promptly treated, could even lead to death. Then, of course, there is the spectacle of ‘Long Covid’, where there are persistent symptoms, particularly of a respiratory nature, for quite some time, after apparent recovery from symptomatic Covid-19. There are some reports of persistent vague symptoms, even in those who were originally not sick with symptomatic disease. It is also noteworthy that there are reports of significant x-ray changes that have been detected in some completely asymptomatic positive cases. It must also be considered that the clinical picture of Covid-19, in children, seems to fluctuate considerably, over different time periods. There is no guarantee that there is no risk at all of the disease suddenly turning quite virulent and starting to produce marked and severe symptoms, even in children. This is particularly of relevance in view of the propensity for the coronavirus to undergo mutations, as it keeps on replicating.

Children rarely become severely ill from Covid-19. However, in the US, in August, 2021, the Delta variant has landed nearly 30,000 of them in hospital. According to the American Academy of Pediatrics, nearly 5.9 million Americans younger than 18, have been infected with the coronavirus. Of the roughly 500 Americans, under 18, who have died, about 125 were aged 5 to 11. “It really bothers me when people say kids don’t die of Covid”, said Dr. Grace Lee, an Associate Chief Medical Officer, at Stanford Children’s Health, who also leads a key Advisory Committee to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. She also said “They die of Covid. It’s heart-breaking”. About one in six Americans infected, since the beginning of the pandemic, was under 18. But with the surge of the Delta variant, children accounted for as many as one in four infections in recent times, according to the American Academy of Pediatrics.

Then, of course, there is the problem of asymptomatic afflicted children carrying the virus around and spreading it, and, perhaps, much more importantly, the scenario of them taking it home and infecting susceptible adults and the elderly. With rather close gatherings during transport, to and from schools, and also in the classrooms themselves, the risks of these children contracting the virus is something quite real. There are some sporadic studies that indicate that there is some protection provided by the vaccines in actually preventing, to a certain degree, the exposed individuals from contracting the virus. This is, of course, is not 100% protection by any means, but is a rather minor but a positive reason for vaccination.

At this point in time, the only coronavirus vaccine that is universally authorised to be administered to children and, young people, over the age of 12, is the mRNA Pfizer – BioNTech Covid-19 (BNT162b2) vaccine, with the brand name “Comirnaty”. The European countries, and Australia, have been provided provisional authorisation for the use of the Moderna mRNA-1273 vaccine with the brand name “Spikevax” in those over 12 years of age. In several studies, the effectiveness of these vaccines, as well as their safety, have been established.

Yet for all that, there are some of the more recent reports of the occurrence of the extremely rare complications of myocarditis and pericarditis occurring, especially in adolescent and young males with all mRNA Covid-19 vaccines, particularly after the second dose of the vaccine, occurring typically within a few days after vaccination. Myocarditis is an inflammation of the heart muscle and pericarditis is an inflammation of the lining that surrounds the heart. Available data suggest that the immediate course of myocarditis and pericarditis, following vaccination, is generally mild and responds to conservative treatment. So far, major problems, with long-term heart functions, have been see in these cases and follow-up is ongoing to determine possible long-term outcomes. All young recipients of mRNA vaccines should be instructed to report for medical attention if they develop symptoms, indicative of myocarditis or pericarditis such as new onset and persisting chest pain, shortness of breath, or palpitations, following vaccination against Covid-19. It has to be reiterated that these complications are extremely rare. In the USA there have been no deaths reported in young people developing myocarditis, following mRNA Covid-19 vaccines.

In a most reassuring publication, released on 22nd October 2021, hot off the oven so to speak, both BNT162b2 (Pfizer-BioNTech) and ChAdOx1 nCoV-19 (AstraZeneca) vaccines offered substantial protection against death from coronavirus disease 2019 (COVID-19) caused by the B.1.617.2 (Delta) variant, according to a study published in The New England Journal of Medicine. Meanwhile, another study, also published recently in The New England Journal of Medicine, suggests that the BNT162b2 (Pfizer-BioNTech) vaccine was highly effective against both documented infection and symptomatic COVID-19 with the Delta variant among adolescents, between the ages of 12 and 18 years. The latest information available to us seem to confirm the benefits of Covid-19 vaccinations in adolescents and young people.

The most recent development, from the standpoint of Covid-19 vaccinations for children, is the application due to be made by Pfizer to the Food and Drugs Administration (FDA) of USA for authorisation for usage of its Covid-19 vaccine for children, 5 to 11 years of age. In a highly anticipated announcement, Pfizer has said that a Phase 2/3 trial showed its Covid-19 vaccine was safe and generated a “robust” antibody response in children, aged 5 to 11.

These are the first such results released for this age group for a USA Covid-19 vaccine.

The trial included 2,268 participants, ages 5 to 11, and used a two-dose regimen of the vaccine, administered 21 days apart. This trial used a 10-microgram dose, which is one third of the 30-microgram dose that has been used for those 12 and older. Pfizer has said that the 10-microgram dose was carefully selected as the preferred dose for safety, tolerability and immunogenicity in children 5 to 11 years of age.

Participants’ immune responses were measured by looking at neutralising antibody levels in their blood and comparing those levels to a control group of 16 to 25-year-olds who were given a two-dose regimen with the larger 30-microgram dose. Pfizer has said the levels compared well with older people who received the larger dose, demonstrating a “strong immune response in this cohort of children, one month after the second dose”. They have further stated that the vaccine was well tolerated, with side effects generally comparable to those observed in participants, 16 to 25 years of age.

However, it is a matter for some concern that this data has not yet been peer-reviewed or published in a reputed medical journal. Pfizer has said that it plans to submit the data directly to the US Food and Drug Administration for emergency use authorisation. Apparently, the FDA officials have said that once the data is submitted, the agency could authorise the vaccine for younger children, in a matter of weeks.

Albert Bourla, Chairman and Chief Executive Officer of Pfizer, said in a statement “Since July 2021, pediatric cases of COVID-19 have risen by about 240 percent in the USA, underscoring the public health need for vaccination. These trial results provide a strong foundation for seeking authorisation of our vaccine for children 5 to 11 years old, and we plan to submit them to the FDA and other regulators with urgency”. Pfizer also said that it is expecting trial data for children as young as six months as soon as the fourth quarter of this year.

In addition, Moderna Incorporated plans for double enrolment in a trial of its Covid-19 vaccine in children under age 12, following a request from U.S. regulators to collect additional safety data. Moderna’s study will enrol an estimated 13,275 participants aged 6 months up to 12 years old, according to a listing on the clinicaltrials.gov website. In a post from late July, the Cambridge, Massachusetts-based company said it would seek to enrol about 7,000.

As things stand now, the scientific information regarding the feasibility of administering the Covid-19 vaccination to very young children is, at best, in a state of flux at the present time. We need to await the results of several on-going Clinical Trials. The Sri Lanka College of Paediatricians will keep a close watch on the developments and would take all necessary steps to advise the authorities on the best course of action, when more tangible evidence from Clinical Trials emerge in the future.

The gut-feeling of a lot of authorities involved in child healthcare is that it would be possible to vaccinate even young children against Covid-19 in the not-too-distant future. The benefits due to be gained seemingly appear to be that much more important and would override the very rare undesirable effects in our quest towards victory over this pandemic that has brought the entire world to its knees.



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Features

ICC arrest warrant; a setback for authoritarian rule

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‘All-weather allies’: President Xi Jinping meets President Vladimir Putin.

As should be expected, the arrest warrant issued by the International Criminal Court (ICC) on Russian President Vladimir Putin on war crimes allegations has given rise to a widespread debate on how effective it would be as an instrument of justice. What compounds the issue is the fact that Russia is not obliged to cooperate with the ICC, given that it is not a signatory to the Rome Statute which outlaws the crimes in question and envisages punitive action for signatory state representatives who act in violation of its provisions.

Predictably, the Russian side has rubbished the ICC allegations and its arrest warrant on the basis that they are totally irrelevant to Russia, considering that it does not recognize the ICC or its rulings. However, the fact remains that important sections of the international community would be viewing Putin and his regime as war criminals who should be shunned and outlawed.

The possibility is great of the Putin regime steadily alienating itself from enlightened opinion the world over from now on. In other words, Putin and his cohorts have incurred a heavy moral defeat as a consequence of the ICC’s arrest warrant and its strictures.

Morality may not count much for the Putin regime and its supporters, locally and internationally, but the long term consequences growing out of this dismissive stance on moral standards could be grave. They would need to take their minds back to the white supremacist regimes of South Africa of decades past which were relentlessly outlawed by the world community, incurring in the process wide-ranging sanctions that steadily weakened apartheid South Africa and forced it to negotiate with its opponents. Moreover, the ICC measures against Putin are bound to strengthen his opponents and critics at home, thereby boosting Russia’s pro-democracy movement.

However, the Putin administration could earn for itself some ‘breathing space’ at present by proving the ICC’s allegations wrong. That is, it would need to establish beyond doubt that it is not guilty of the crime of deporting Ukrainian children to Russia and other war-linked offences. It could liaise with UNICEF and other relevant UN agencies for this purpose since it does not recognize the ICC.

A wise course of action for President Putin would be to pick up this gauntlet rather than ignore the grave allegations levelled against him, in view of the long term consequences of such evasive behavior.

Besides, the Russian President would need to restrict his movements from now on. For, he is liable to be arrested and produced before the ICC by those governmental authorities who are signatories to the Rome Statute in the event of Putin entering their countries. That is, Putin’s head is likely to be increasingly restless as time goes by.

However, the gravest consequence flowing from Putin and his regime ignoring the ICC and its strictures is that later, if not sooner, they could find themselves being hauled up before the ICC. There is ample evidence from recent history that this could be so. All the alleged offenders need to do is take their minds back to the convulsive and bloody Balkan wars of the nineties to see for themselves how the ICC process, though slow and laborious, finally delivered justice to the victims of war crimes in that tempestuous theatre.

All those war criminals who have lulled themselves into believing that it is possible to escape being brought to justice before the world’s tribunals, need to recollect how former Serbian President Slobodan Milosevik and his partners in crime Rodovan Karadzic and Ratko Mladic were brought before the International Criminal Tribunal for the former Yugoslavia (ICTY) in the early years of this century and required to pay the price for their criminality. So confident were they initially that they would never be brought to justice that they agreed, tongue-in-cheek, to fully cooperate with the ICTY.

It is pertinent to also remember that the criminals mentioned were notorious for their ‘ethnic cleansing’ operations and other war-time excesses. Accordingly, those accused of war crimes the world over would be only indulging in wishful thinking if they consider themselves above the law and safe from being held accountable for their offences. Justice would catch-up with them; if not sooner, then later. This is the singular lesson from Bosnia.

Meanwhile, Chinese President Xi Jinping has considered it timely to call on President Putin in Russia. He did so close on the heels of being elected President for a third straight term recently. This is a clear message to the world that Russia could always depend on China to be a close and trusted ally. It is a question of two of the biggest authoritarian states uniting. And the world they see as big enough for both of them.

Interestingly, China is having the world believe that it has a peace plan for Ukraine. While in Russia, though, XI did not spell out in any detail how the crisis in Ukraine would be resolved with China’s assistance. However, China has drafted what is termed its ‘Position on the Ukraine Crisis’. It contains 12 points which are more in the nature of a set of principles.

Seen against the backdrop of the developments in Ukraine, some of these principles merit close scrutiny. For instance, the first principle lays out that the sovereignty of all countries must be respected. Besides, International Law must be universally recognized, including the ‘purposes and principles of the UN Charter’. However, ‘double standards’ must be rejected. Hopefully, the West got the hint.

Principle 4 has it that ‘Dialogue and negotiations are the only viable solution to the Ukraine crisis.’ Principle 8 points out that, ‘Nuclear weapons must not be used and nuclear wars must not be fought’.

Needless to say, all the above principles are acceptable to the international community. What is required of China is to evolve a peace plan for Ukraine, based on these principles, if it is in earnest when it speaks of being a peace maker. The onus is on China to prove its credibility.

However, China could be said to be characteristically pragmatic in making these moves. While further cementing its alliance with Russia, China is placing the latter on notice, though in a subtle way, that its war in Ukraine is proving highly counter-productive and costly, both for the states concerned and the world. The costly economic consequences for the world from the war speak for themselves. Accordingly, nudging Russia in the direction of a negotiated settlement is the wisest course in the circumstances.

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Features

In the limelight again…Miss Super Model Globe 2020

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Those who are familiar with the fashion and beauty pageant setup, in Sri Lanka, would certainly remember Shashi Kaluarachchi.

Three years ago, she was crowned Miss Super Model Globe Sri Lanka 2020 and then represented Sri Lanka at the Miss Super Model Globe International, held in India.

Shashi won two titles at this big event; she was placed second in the finals (1st Runner-up) and took the title of Best National Costume.

Very active in the modelling scene, in the not too distant past, Shashi went silent, after dazzling the audience at the Super Model Globe contest.

Obviously, those who are aware of her talents were kept guessing, and many were wondering whether she had prematurely quit the fashion scene!

Not quite so…and I had a surprise call from Shashi to say that she is ready to do it again.

The silence is due to the fact that she is now employed in Dubai and is concentrating on her office work.

1st Runner-up at Miss Super Model Globe International

“When I came to Dubai, I was new to this scene but now I do have some free time, coming my way, and I want to get back to what I love doing the most – modelling, fashion and beauty pageants,” she said.

Shashi indicated that she plans to participate in an upcoming beauty pageant, to be held in Dubai, and also do some fashion shoots, and modelling assignments.

“Dubai is now buzzing with excitement and I want to be a part of that scene, as well,” said Shashi, who had her early beginnings, as a model, at the Walk with Brian Kerkoven modelling academy.

“I owe my success to Brian. He made me what I’m today – a top model.”

Shashi, who 5’7″ tall, says she loves wearing the sari for all important occasions.

“The sari is so elegant, so graceful, and, I believe, my height, and figure, does justice to a sari,”

Shashi has plans to visit Sri Lanka, in April, for a short vacation, adding that if the opportunity comes her way, she would love to do some photo shoots, and a walk on the ramp, as well.

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Dry Skin

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Shorter Showers

If you have dry skin, do not take long showers, or baths. Staying in the water for a longer time can dry it out more. You should also use warm, instead of hot, water, when you wash. Hot water can strip your skin of the fatty substances that give it hydration. As soon as you finish cleansing yourself, apply a body lotion, all over your body, to moisturize. Don’t wash yourself more than once a day

Moisturizer

Applying a daily moisturizer can do wonders for dry skin, and there are products in your kitchen you can use which are natural and effective. Try coconut oil, olive oil, almond oil, or sunflower seed oil

Scrub

Olive oil and brown sugar have amazing properties for the skin. Both of these substances deeply hydrate. Olive oil is also a known wound-healer, while sugar contains glycolic acid, which allows it to have anti-aging. You can make a natural scrub, using these ingredients which can be as good as the best anti-wrinkle creams.

*  Mix one tablespoon of brown sugar with a teaspoon of olive oil.

*  Blend them, and spread the mixture on your face, and neck, using a circular motion, for a few minutes.

*  Then leave it to sit for another couple of minutes, and wash it off with warm water.

You can do this twice a week for amazing results

Lips

Taking care of your lips is important. Lips can also get dry and chapped, which is why you need to keep them hydrated, daily. If you’re looking for a natural balm, try sugar and lemon, or honey, sugar, and butter.

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