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CDC World Health Organization Canadian Paediatric Soceity LitCovid Cochrane Library Oxford Evidence Service

Infection control for children with chronic conditions in the COVID-era

April 23rd, 2020

Children’s Healthcare Canada and Paediatric Project ECHO have, once again, partnered to bring you this webinar, which will focus on COVID-19, infection control, and children with chronic disease. During the webinar you will have opportunities to ask (and receive answers to) your questions related to infection control, particularly in the home care and ambulatory settings, COVID-19, and the care of the child with chronic disease. Paediatric Project ECHO is a virtual community of practice that aims to connect healthcare providers to share knowledge and best practice of care for children and youth with medical complexities.

Session Information

Speaker: Dr. Michelle Science, Infectious Disease Consultant and Pediatrician, The Hospital for Sick Children; Assistant Professor, University of Toronto. Dr. Michelle Science is an Academic Clinician in the Division of Infectious Diseases at The Hospital for Sick Children and an Assistant Professor at the University of Toronto. Since 2012, she has been the Medical Advisor for Infection Prevention and Control (IPAC) and the co-lead of the Antimicrobial Stewardship Program (ASP) at SickKids. More recently, she joined Public Health Ontario as a consulting IPAC physician. She has been involved in the response to the COVID-19 pandemic both locally and provincially and is currently leading a multicenter study testing healthcare workers for antibodies to COVID-19. This study aims to get a better understanding of the natural history of COVID-19, in particular whether the antibody response is protective and the duration of this protection, and describe how the seroprevalence is changing through the course of the pandemic. 

Moderators: Dr. Eyal Cohen, Program Head, Child Health Evaluative Sciences, SickKids Research Institute; Co-founder, Complex Care Program, Division of Pediatric Medicine, The Hospital for Sick Children; Professor, Pediatrics and co-Executive Director, Leong Centre for Healthy Children, University of Toronto Dr. Catherine Diskin, Academic Paediatric Fellow in Complex Care 

The recording, presentation slides and keytakeways will be up shortly. Register for Paediatric Project ECHO here to be notified of any follow-ups regarding our COVID-19 sessions 

Learning Objectives

  • Discuss current status of the COVID-19 outbreak worldwide, Canada, and Ontario 
  • To provide an overview of COVID-19 in children, including the presenting features and risk factors for severe disease
  • To review the infection prevention and control recommendations related to COVID-19 in the hospital and community settings

Paediatric Project ECHO for Complex Care co-leads Dr. Eyal Cohen, MD, M.Sc, FRCP(C), and Dr. Catherine Diskin, MD, host Infection control in children with chronic conditions in the COVID-eraby Dr. Michelle Science, MD, M.Sc. Presentation slides coming soon. 

Key Takeaways

This information is accurate to the best of our knowledge on April 23, 2020 and in line with recommendations provided by Public Health Ontario and Health Canada. We recommend staying up-to-date with information which is evolving day-by-day.  Although there is plenty of information, there is also much that we do not know or fully understand yet – e.g. role of asymptomatic transmission, aerosolization. Society is navigating new questions including the resumption of activity including school and non-essential services. We encourage you to continue to explore the resources above.

Clinical presentation of COVID-19 in children

Of all the cases worldwide, a very small proportion are reported in children. Presentation in those children can include fever, cough, sore throat, rhinorrhea, diarrhea and vomiting1. Presentation appears to be more non-specific compared with adults. Isolated gastrointestinal symptoms have been reported along with extremity findings.

Route of transmission

The World Health Organization (WHO) Joint Mission on Coronavirus Disease 2019 (COVID-19) reports that the route of transmission is droplet during close, unprotected contact2. The majority of cases were linked to person-to-person transmission through close direct contact to someone with respiratory symptoms.

Recommendations for families who require nursing support

We emphasize with all family’s public health recommendations including hand hygiene, physical distancing, cough etiquette, and cleaning and disinfecting high touch objects and areas. Screening individuals prior to entering your home to ensure they are asymptomatic is strongly recommended.

Our experience through this COVID-19 pandemic period suggests that there is need to work across the sector from hospital to community to confirm that children with medical complexity are recognized as among the most vulnerable to disease. We are asking for and offering to support rapid development of policies, procedures and processes that prioritize safe and sustainable care for children with medical complexity across all sectors, including community (e.g. group homes, respite facilities)/and home care.

Review of children with non-COVID-19 in the community setting

Recommendations currently for primary care and general office settings is to ensure appropriate screening approaches and triaging, using virtual care when possible and to see only those children that require essential appointments such as for newborn care or vaccinations. Indeed, attendance for vaccinations should be encouraged and facilitated.

Many offices have included signs on the door with screening questions as well as pre- clinic phone calls and physical plexiglass barriers.  The maintenance of physical distancing measures in waiting room and during routine care is important. Have alcohol hand rub available.

In advance of a family attending an appointment, informing them of new procedures including that the number of people accompanying patients is being minimized is important.

References
1. Chan K et al. The acute management of paediatric coronavirus disease 2019 (COVID-19). Canadian Paediatric Society

2. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 [cited 2020 Mar 6]. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

Q&A Period Summary (Video Time Stamps)

Time Stamp Question
39:20 Are there any specific recommendations for families who have nursing support in the home, recognizing the need to physically distance?
42:01 How do we support families when information is evolving so quickly?
45:57 How does the recent evidence of asymptoatic cases in children effect how we should see that are not COVID related in the community setting?
47:50 Could you comment on the use of MDI epinepherine in the setting of croup, which is a change in practice? 
The acute management of paediatric coronavirus disease 2019 (COVID-19)
50:00 Should we be disinfecting boxes/deliveries? 
51:27 Should we wash our food with soap and water? 
52:35  As healthcare providers, what should we be doing about our clothes to prevent spread to our families?
54:10 How do I stay up-to-date with all the changing nuances and recommendations?   

COVID-19 and the care of children with chronic diseases

April 2nd, 2020

During this unprecedented time, Paediatric Project ECHO and Children’s Healthcare Canada have partnered to bring this webinar, primarily tailored to paediatric healthcare providers in Canada to answer questions about COVID-19 and the care of children with chronic disease on April 2nd, 2020. Participants learned about the current epidemiology on COVID-19 as it applies to pediatrics and data/evidence available to-date in terms of management (e.g.,novel therapeutics and pharmacological management). Click on the video below to watch the webinar. 

Session Information

Dr. Upton Allen, MBBS, MSc, FAAP, FRCPC, is a Professor of Paediatrics at the University of Toronto. He is Chief, Division of Infectious Diseases, and interim director of the Transplant and Regenerative Medicine Centre, Hospital for Sick Children. He is a Senior Associate Scientist in the Research Institute, Hospital for Sick Children. His primary appointment is with the Division of Infectious Diseases, Department of Paediatrics at the Hospital for Sick Children. He is cross-appointed as a professor in the Institute of Health Policy, Management and Evaluation, University of Toronto. Dr. Allen is a past director of the Infectious Diseases Society of America and Fellow of the Society. He is a Fellow of the American Academy of Pediatrics, Fellow of the Royal College of Physicians and Surgeons of Canada and Fellow of the Royal College of Physicians (UK). He is a past Chair of the Infectious Diseases Specialty Training Committee, Royal College of Physicians and Surgeons of Canada (RCPSC). Past awards include the Clinical Science Established Investigator Award from the American Society of Transplantation. In 2018, he was awarded the Order of Ontario, the highest honor awarded by the province. He is a general infectious diseases specialist, and actively involved in clinical and research activities relating to immuno-compromised patients, notably those who have undergone organ and stem cell transplantation and cancer therapies. He has had numerous invited lectures internationally, visiting professorships, more than 300 scientific publications and 190 scientific abstracts, several book chapters and peer-reviewed research grants.

Moderators:

  • Dr. Julia Orin, Complex Care Medical Lead
  • Michelle Ho, Nurse Practitioner

Panel Members:

  • Dr. Eyal Cohen, Complex Care Medical Lead
  • Dr. Zia Bismilla, Staff Physician 
  • Dr. Catherine Diskin, Clinical Fellow 
  • Jas Otal, Clinical Pharmacist
  • Kathy Netten, Social Worker
  • Ashley Edwards, Social Worker
  • Erika Gibson, Registered Dietitian
  • Jordan Beaulieu, Registered Dietitian

Presentation Outline

  • The Coronavirus family
  • Transmission
  • Epidemic curve
  • Clinical presentation
  • Risk factor for severe disease in children 
  • Defining & protecting high-risk patients

Learning Objectives

  • Understand the current epidemiology on COVID-19 as it applies to pediatrics
  • Understand the data/evidence available to-date in terms of management (e.g.,novel therapeutics and pharmacological management).

Paediatric Project ECHO for Complex Care co-leads Dr. Julia Orkin, MD, MSc, FRCPC and Michelle Ho, RN(EC), CPNP-PC, MN, MA host COVID-19 and the care of children with chronic diseasesby Dr. Upton Allen, MBBS, MSc, FAAP, FRCPC. View presentation slides here >>> 

Key Takeaways

This advice relates to what was known about COVID-19 on April 2nd 2020. We encourage you to continue to explore the resources above.

General Points

  • Flattening the curve refers to measures undertaken to slow the spread of infection so as to avoid a steep increase in the number of cases that would overwhelm the capacity of the health care system. These efforts to flatten the curve include physical distancing (keeping 2 metres away from others), frequently washing hands well, disinfecting surfaces and high touch objects and correct cough and sneeze etiquette (using elbow or tissue rather than hands).
  • In children and young adults, mortality is low. Preschool children and infants were more likely to have severe clinical manifestations than older children.

What should we be recommending our families do in terms of medications at home and being prepared for the coming future?

  • Canadian Pharmacy Association and Ministry of Health (Ontario) have recommended that no more than 30 days supplies be dispensed to avoid future shortage. We are encouraging families to have a 4-week supply of medication and formula on hand and to be proactive in seeking refills.
  • We are not actively recommending avoiding non-steroidal anti-inflammatory medication (NSAIDs including ibuprofen) although do suggest using alternatives e.g. Acetaminophen (Tylenol) first.
  • We advise patients to continue current medication including ACE inhibitors. In the event, a child contracts COVID-19, treatment decisions would be taken on a case by case basis.
What is the Complex Care team doing to plan for important care that is currently deemed non-essential and may become essential if left unattended?
  • Whilst in-person visits have been reduced at this time, the Complex Care team similar to many clinicians continue to provide care during this time, typically using telehealth.  This includes actively considering what is considered essential and what can be deferred. For example, whilst a G/J-tube change may not be essential at this moment but should something change, it will be prioritized.
  • Hospitals have developed clear procedures for protecting children, families and staff from getting an infection. Additional measures include screening on entry and reduction in visitors. It is important to attend a hospital, if a child requires emergent medical care or as directed by clinician.
  • Is there research/data individual outcomes specific to certain disease populations (ie. cystic fibrosis, type I diabetes, congenital heart disease etc.)?

    There are not specific published studies that take into account certain disease populations.

    The Canadian Paediatric Surveillance Program (CPSP), in collaboration with the Public Health Agency of Canada are conducting rapid surveillance on COVID-19 in Canadian children. They are contacting Paediatricians weekly with a COVID-19 reporting link to facilitate online reporting. Any questions about the CPSP study can be directed to:  cpsp@cps.ca. That account is monitored multiple times a day, and will be re-directed immediately to the appropriate person.

    Feel free to contact the Paediatric Project ECHO team if you have any otherr any other queries or suggestion at project.echo@sickkids.ca

    Q&A Period Summary (Video Time Stamps)

    Time Stamp Question
    25:52 Does this novel corona virus have the same seasonal peaks as the other human corona virus? Can we expect to be improvement as the weather warms over the summer?
    27:34 What should we be recommending our families do in terms of medications at home and being prepared for the coming future?
    29:01 What is the current role of some of the new pharmacological management options that have been put forward in terms of research study design? Is there any validation or trials being put forward for the use of that children?
    31:23 What is the role of ACE-inhibitors? Should we be discontinuing that for patients who are regularly on ACE-inhibitors for regular routine care?
    32:34 What is the current status of COVID-19 testing at the Hospital for Sick Children?
    36:14 How should we be protecting individuals visiting the hospital for regular and/or routine outpatient care?
    37:47 Are there any plans for mass testing for asymptomatic vulnerable groups like complex children and their caregivers?
    39:20 Some families have had trouble getting enough formula for care in their home. Is something that an issue across the board and are there any recommendations for what we should be advising families? 
    40:45 Is there enough evidence to support to possibly extend the RSV syncytial vaccine to at-risk NICU babies in light of the pandemic?
    43:02 Should we be washing our groceries; our fresh fruits and vegetables to prevent infection?
    44:49 What is the Complex Care team doing to plan for important care that is currently deemed non-essential and may become essential if left unattended? For example, routine G/J-tube changes and other things that children may need preventatively that may be “non-essential”.
    45:51 What PPE is required for chest physio?
    46:49 Are there any plans for serological testing for those maybe immune to the virus?
    48:28 What would you advise for healthcare workers who are in the acute care environment to keep their families and their homes as safe as possible? What should they be wearing, washing and should they be social distancing at home?
    51:32 Do you know if there is any possible immune response to the regular corona virus that individuals may have against the novel corona virus that would allow them to be more able to fight or even prevent this?
    53:01 Concerns around home care nursing.
    54:29 Is there research/data individual outcomes specific to certain disease populations (ie. cystic fibrosis, type I diabetes, congenital heart disease etc.)?
    56:08 What is the recommendation around home-made PPE for the general public at this time?