In this video, MedPage Today editor-in-chief Jeremy Faust, MD, sits down with allergist and immunologist Zachary Rubin, MD, of Oak Brook Allergists in Illinois, to discuss the lasting affects of COVID-19 on pediatric health.
Part one of their discussion — where they discuss the pediatric “tripledemic” of flu, respiratory syncytial virus (RSV), and COVID-19 — can be viewed here.
The following is a transcript of their remarks:
Faust: Let me ask you a couple questions about immunology and allergy. I guess I have two questions.
My first one is related to the whole pandemic, like the fact that, for me, I have a little seasonal allergies in the spring and 2020 was my best year ever. There was no pollution, no one was driving, I was masking like crazy, I didn’t have a sniffle. Was that kind of common that people’s allergies got better?
Rubin: Oh yeah. My practice was very quiet at that time.
People were very healthy because they were masking. So, you’re filtering out a lot of the allergens that you’re experiencing. People who had outdoor allergens weren’t really going outside as much. I mean, the foot traffic — if you look at some of the data — people were really staying indoors for quite some time.
Now there was a bump in people with pet allergies because a lot of people were adopting pets, who probably shouldn’t have, and they ended up getting indoor pet allergens and things like that. But overall, between allergies and asthma, we were doing quite well in that year.
But once everybody started opening up again and traveling — more air pollution — pollen counts have been steadily rising; it seems like every year it’s worse and worse and worse now. There’s some long-term data to suggest that we’re going to have pollen seasons lasting for a month longer in the next 50 to 100 years.
Faust: Your patient population is probably the one I’m interested in with this question: long COVID for kids. I imagine that kids who have allergies or kids that have atopic conditions in general might be a little more predisposed. Tell me what you’re seeing with long COVID in terms of how long is it lasting, how common is it? Because, for me, I know this is a major problem, but I also think that the data don’t quite match what I’m seeing on the ground. So I’m curious where you fall.
Rubin: Right. So, every physician who deals with long COVID is seeing a different phenotype. That’s one of the problems. Some people are dealing with brain fog and some of the neurological issues, some people are dealing with the POTS [postural orthostatic tachycardia syndrome] issues, right? It’s not all one clinical entity.
As a pediatric allergist, what I see primarily are skin problems, chronic hives after getting COVID, where it’s lasting for like 6 months, where they’re getting almost daily hives. That’s one phenotype. I have another subset where I just call them COVID coughers, because they get COVID, and they haven’t stopped coughing for months. Usually that’s lasting for about 6 months is what I’m seeing in my population, and I also take care of adults too. About 30% of my practice is actually adults. I’m certified to take care of all ages.
But in terms of kids, I’m putting a lot of kids on inhaled steroids that I wouldn’t have expected, because they didn’t have allergic rhinitis. If you skin test them, a lot of them are negative. They don’t have that kind of allergic disease that’s going on. These aren’t kids who started off with eczema and are dealing with chronic hives or chronic cough. So, they’re not the typical population. That’s what’s a little strange to me with what I’m dealing with.
I do have, I’m not seeing this quite as much, but earlier in the pandemic when we had earlier iterations of the virus that was causing a lot of anosmia or lack of smell, I saw a lot of teens and young adults who had problems with smell — whether they couldn’t smell at all or they had parosmia, where they’re smelling things that are just rancid and it just didn’t quite make sense.
That is something that my ENT colleagues and I have been seeing quite a bit, not quite as much now, because the virus is not really sitting in the nose quite as much, it’s kind of in other areas now. But these are people who are having symptoms anywhere between 6 to 12 months or longer, which is a really, really challenging issue for those patients.
Faust: I’m kind of wondering — let me pursue this just a little bit more because I have two kids and I remember being a kid, there’s always a kid or two who had chronic bronchitis. The kid who always had a cold or sniffle and probably, if you think about it, their body, their immune system was just destined to be that way or they had exposures more than the rest of us.
I just wonder, is this COVID causing this increase itself? In other words, the native pathogen meets person, and COVID is just more likely to cause that? Or is this a reaction to the fact that any virus in this sort of echelon of badness for kids would do this — it’s just that COVID is like 100 times more prevalent and contagious than the other ones? So all of a sudden one in a 100 kids who gets “virus” will get this longer-term thing you’re describing. But guess what folks, it’s just 100 times more common. I mean, which one is it?
Rubin: It’s really hard to say that. I mean, I get what you’re trying to say and that does make sense, but what concerns me is when you see studies where they’re comparing — this is the type 1 diabetes issue that I’m sure you’re familiar with.
So, there are more kids now being diagnosed with type 1 diabetes after COVID compared to if they had another respiratory virus. So we’re seeing studies like that when we compare it. That’s where I start to say, “Oh gosh, I think COVID is actually causing more severe issues when you start comparing these larger data sets of kids who have gotten COVID compared to kids who got just some other respiratory virus.” You age match them and you say, “Okay, actually the diagnosis of type 1 diabetes is higher.”
When you see data like that, that’s when I say, yeah, I think COVID is actually worse just in general.
Faust: Yeah. Well, I mean, we know it’s the mayhem that it’s caused. It’s just the question of — I study excess mortality, meaning how many people die compared to how many are expected to, and we talked about this idea of a mortality product. Is each case out of every 100 cases actually deadlier? Yes. Are there more cases? Yes. So, it’s both. But I just don’t know that for other parts of the spectrum, like for long COVID, for example.
We’re running out of time, but do you sense that long COVID or even medium COVID or whatever you want to call it — 2, 3, 4, or 6 months of misery — do you sense that this is getting better with higher vaccination rates or is it just too soon to tell?
Rubin: I think it’s too soon to tell, honestly. These are things that are going to take the 6- to 12-month, the 24-month range of really just getting larger data and seeing more patients and seeing where this goes, because unfortunately the virus continually mutates, and we are getting these more immune-evasive variants like BQ.1.1 and XBB — as some people coin “Scrabble” COVID because of these letters that are the highest scoring Scrabble letters — more and more infections is not necessarily a good thing. We have to see how that ends up playing out.
There is a higher level of population immunity with more exposure and more vaccinations, but what concerns me is the uptake of this bivalent booster. You know, unfortunately this is a type of virus where we do need to be boosted more regularly until we get a better vaccine coming around to try to help protect especially the most vulnerable population.
Faust: Okay. I’m going to ask one more question. It’s kind of a hypothetical, but I think I want your take on it.
There are a lot of people out there who are really concerned about the lost year of school and the terrible outcomes in terms of that. But I often think about, why don’t we have the outcome of interest for all of our interventions just be days in class, how many days kids are in school? Do you think that if we could test kids weekly for RSV and flu and COVID and have them put masks on during surges that would lead to kids being in school more?
Rubin: I think so. I think if we’re able to try to slow the spread by identifying who’s sick, taking them out, and continually masking when there are surges. Like right now, this would be the time to have masks back in school. I mean now we’re going to be in winter break, right? But in the few weeks that come after winter break, it may be a good idea to do that so that kids don’t come back and spread a bunch of virus — whether it’s COVID, RSV, influenza, or this newer concern that we’re going to start seeing in national media now, the concern of strep A and invasive group A strep.
When I see that it’s 10 times higher in Colorado right now, that is very alarming to me. You don’t want kids getting invasive group A strep in the setting of an antibiotic shortage.
I think we need to pick and choose when we do these types of interventions. They can be short-term, but there’s a lot of potential for success. We have seen in Boston, there was a really good study from the New England Journal, that the schools that held onto those mass mandates longer had lower COVID transmission compared to those that dropped it earlier. I’m sure you probably heard of that study. That was a very impactful one. I think we can take lessons from that and not forget how certain mitigation strategies can be helpful when we pick and choose it.
Unfortunately, we haven’t invested enough in our schools to have improved ventilation, because I think that’s an area that’s not been tapped into well. If we improve ventilation in these older buildings, I actually think that would be a big deal in helping keep kids in school as well.
Faust: Yeah, I think that’s right. I think the simple stuff is actually pretty consensus.
I talked to Joseph Allen about this, if you only open the window for 10 minutes, an hour, you actually have an air change that makes a huge difference. Keep the kids in school, throw the mask on for a week here and there, we don’t have to have the debate about whether having it on for a year hurt them or helped them — I think it probably helped, but at this point that’s in the past.
But if you throw these things on for a week, you can really break a circuit. Then, the teacher’s not out, or then half the class isn’t out. We have had schools where classrooms just shut down, because we’re not doing the things that we know prevent the spread. Actually, slowing these things down is not delaying the inevitable, it’s keeping the overall environment relatively safe. So, I think we see eye-to-eye on a lot of issues.
Zach, tell us where to find you on social media.
Rubin: So my handle is the same for all of my social media. It’s @rubin_allergy. I’m on TikTok, Twitter, Instagram, YouTube. I’m debating about what I’m doing with Twitter with everything going on with Elon Musk, so I have a Med-Mastodon too. It’s the same thing, but I don’t know what I’m going to do with that, but I’m primarily on TikTok and Instagram at this point.
I’m happy to collaborate with you in the future. This has been great. I know we’ve kind of followed each other over the last few years, but it’s nice to be able to finally talk with you.
Faust: Absolutely, and I know this audience will have a lot of questions, so we’ll loop them back to you. I want to thank everyone for joining us, and have a great night.
Rubin: You too. Take care.
Faust: Thanks a lot.