The Impact of COVID-19 in Children March 24, 2020
Agenda Introductions Scientific Update UNC Children’s Response How to talk to children about COVID-19 Questions
SCIENTIFIC UPDATE ON COVID-19
Coronavirus Disease 2019: Brief Review and Update • The Virus - History, Clinical Correlates • COVID-19 » Current epidemiology » Infection & clinical presentation » Confirmation of Dx, management » Prevention • UNCH COVID-19 Preparations » Overview, Ambulatory, Testing, Inpatient Management • Resources
Coronavirus: Basic Virology – Clinical Correlates • Largest positive strand (SS) RNA virus • Enveloped (from intracellular membranes) • Spikes are large glycoprotein » ACE2 is cell receptor for SARS-CoV-2 • Infect humans & animals – respiratory or GI dz
Human Coronaviruses • First identified in 1960s • Seven known coronaviruses can infect humans • Common human coronaviruses (endemic coronaviruses) » 229E & NL63 (alpha coronaviruses) » OC43 & HKU1 (beta coronaviruses) » All 4 detected on UNC Respiratory Pathogen Profile test • Epidemic Coronaviruses » 3 others more recently evolved / moved from animal species to humans » SARS-CoV, MERS-CoV, SARS-CoV-2
Epidemiology: COVID-19 Cases: Data as of 3/23-24/2020 • Total world cases : >385,000, deaths >16,500 • Most cases to date: China 81,588; Italy 63,927; US 46,450; Spain 35,212; Germany 30,081 • US : Rapidly increasing, 554 deaths; • NC 297 (as of 3/23), no deaths. » Mecklenburg (79), Wake (48), Durham (40) greatest number
March 19, 2020-12:13pm
COVID-19, Infection, Clinical Sx • Major route of spread droplet » Likely surface contact; possible other body fluids » Most transmission from symptomatic people, early in disease • Clinical course in adults » Time to symptom onset: average 5-6 days (2-14d) • Recovery 2 wks; if severe -3-6wks, death 2-8wks (most from ARDS / secondary infx) » Fever (44-98%)*, cough (46-85%), myalgias/fatigue , short of breath (3-31%) • *Fever may not be present initially • Symptoms / disease progressive • Other signs /sx: sore throat, diarrhea, other
COVID-19: Infection & Clinical Sx • The good news! » Children have milder disease » Infants and children may be asymptomatic – mild dz » Data on mortality from China: • Age 0-9yo: 0 • Age 10-19: 0.2% • Age 20-29: 0.2% • Vs. 1-3% overall & >14% in highest risk groups • Adult high-risk groups: elderly, co-morbidities of heart disease, HTN, diabetes , also immunocompromised » Transmission from children –unclear if community spread (usually household) » But: transmission may occur prior to symptoms onset / if asymptomatic
Confirmation of Diagnosis & Management • COVID-19 PCR from NP (nasopharyngeal) swab https://www.today.com/video/new-coronavirus-test-in-north-carolina-takes-only-4-hours-to-see-results-80961605870 • Treatment / Management » Supportive care –currently no FDA- approved treatment Dr. Melissa Miller Director-Clinical Molecular • Investigations with Remdesivir, Biology Laboratory Lopinavir/Ritonavir, Chloroquine, et al. McLendon Clinical Labs
COVID-19, Prevention • Usual precautions for respiratory viruses • Personal: » Frequent hand washing (20 seconds soap & water; hand sanitizer); avoid touching eyes nose mouth, avoid ill individuals, stay home if sick, cover mouth if cough / sneeze, “ social distancing ” (6-foot rule), facemask if sick » During Covid-19 patient contact: Gown, gloves, face mask OR respirator (N95), eye protection (goggles or face shield) » PPE Stewardship • Public Health measures » Isolation, quarantine, avoidance of large groups, et al.
Resources for Clinicians • https://epi.dph.ncdhhs.gov/cd/coronavirus/providers.html • https://www.cdc.gov/coronavirus/2019- nCoV/hcp/index.html • Travel Requirements Announced for UNC Health / UNC SOM • UNC Health’s COVID-19 Intranet page – Visit for the latest updates. • External UNC COVID-19 information on our website. • Lib guides - https://guides.lib.unc.edu/COVID19 • Daily Briefings: https://unchcs.intranet.unchealthcare.org/Pages/2020/03- Mar/covid-19-brief/Daily-Briefings.aspx
UNC CHILDREN’S RESPONSE
Inpatient Current State & Updates • Several “rule-outs” but no positive pediatric patients • Developed 2 teams to cover COVID-19 and rule-out patients: » Peds COVID Acute (Listed as Peds Surge Acute-PSA) » Peds COVID ICU (Listed as Peds Surge ICU-PSI) • Patients will be admitted to PICU or 6CH • Low risk patients will “test-in place” on isolation but regular teams • Questions about COVID testing to Peds COVID ID Pager » Covered by Peds ID attending daily » Available for questions regarding testing of inpatients » Can be reached in a similar way as Peds COVID inpatient teams
OR Current State & Updates • Priority/Urgent/Emergent cases only currently • COVID-19 rule out patients with clear SOP which avoids contact traffic • Isolated OR and PACU space (Negative Flow) • Surgical mask conservation- 1-2 masks used per day • “Cross training” consideration • Limit staff exposure to airway and high-risk cases
Outpatient Current State & Updates • Rapid increase in video and phone visits • In-person visits are down ~70% • Downsizing the Chapel Hill clinic and moving visits to Raleigh • Pediatric RDC opened today in Cary UNC COVID Hotline / HealthLink: 888-850-2684
ED Current State & Updates • Focused on preparedness • Still potential for surge of adult and pediatric patients • Actions to date: • Established separate respiratory and non-respiratory care areas in both the general and pediatric ED to limit spread of infection. • Tent Tele-Triage ramping up at the medical center to expedite sorting and directing patients • PEM leadership team working with other Emergency Departments in the Health Care System to establish appropriate ED triage criteria
Links for Clinical Resources for our Providers https://www.med.unc.edu/pediatrics/covid-19-clinical-resources/
Education Current State & Updates • Policies related to COVID-19 » Family-centered rounding has ceased » Policies to minimize inpatient rounding group size » ABMS, ACGME, and ABP have provided some guidance on contingencies • Reduction in staffing » Residents have been pulled from outpatient clinics and subspecialty rotations » Contingency planning developed in anticipation of possible 10%, 25%, and 50% resident workforce reduction » Medical students temporarily taken out of clinical setting » Trainees currently not involved in the care of COVID positive or highly-suspected patients.
Research Current State & Updates • Limiting activities according to latest updates from the Vice Chancellor of Research (VCR) » Visit web site for updates: https://research.unc.edu/covid-19/ » Lab-based research restricted to “critical research activities” • Labs with critical research activities submitted form to be reviewed by VCR • VCR is responding to labs with OK to proceed, partial approval, no approval » Human subjects research visits (involving direct contact) should be postponed unless the visit provides immediate benefit to the health or well-being of the participant • Emergency Preparedness » Personnel working from home unless essential » Developing emergency preparedness documents for essential human subjects research
Support Resources for our Providers • Taking Care of Our Own • https://www.med.unc.edu/psych/wellness-initiatives/taking-care-of-our- own/ • Mental Health/Emotional Support Resources for co-workers and providers • https://unchcs.intranet.unchealthcare.org/Pages/2020/03-Mar/Coping- with-COVID-19.aspx • UNC Emotional Support Program • https://www.med.unc.edu/psych/wellness- initiatives/integrated-emotional-support- program/
HOW TO TALK TO CHILDREN ABOUT COVID-19
Talking to Kids about the Virus • Create an open & supportive environment so children are comfortable expressing their concerns and asking questions • Explain the virus and the purpose of staying home with words/concepts they can understand based on their age, language, and developmental level • Answer their questions honestly • Clarify what is known and unknown. Correct misinformation. Help them find reliable sources. (Fact Sheets CDC/WHO.) Review together but not constantly • Don’t let them watch too much television with frightening images and messages. This can be disturbing and confusing American Academy of Child & Adolescent Psychiatry: https://www.aacap.org/App_Themes/AACAP/Docs/latest_news/2020/Coronavirus_COVID19__Children.pdf
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