key: cord-0028121-t8ocloh9 authors: Botan, Edin; Uyar, Emel; Öztürk, Zeynelabidin; Şevketoğlu, Esra; Sarı, Yusuf; Dursun, Oğuz; Sincar, Şahin; Duyu, Muhterem; Oto, Arzu; Celegen, Mehmet; Özçiftçi, Gökçen; Havan, Merve; Nilüfer Öztürk, Makbule; Ağın, Hasan; Yener, Nazik; Yaman, Ayhan; Gün, Emrah; Yılmaz, Merve; Şimşek, Naile; Özdemir, Halil; Yıldızdaş, Dinçer; Kendirli, Tanıl title: COVID-19 Transmission and Clinical Features in Pediatric Intensive Care Health Care Workers date: 2021-01-01 journal: Turk Arch Pediatr DOI: 10.5152/turkarchpediatr.2021.21205 sha: dfdefd7ef9a8aad6c58231e7ccc4432e9b880f49 doc_id: 28121 cord_uid: t8ocloh9 OBJECTIVE: This study aims to investigate modes of transmission and clinical features of coronavirus disease 2019 in healthcare workers in pediatric intensive care units. MATERIALS AND METHODS: This multicenter descriptive study was conducted between March and November 2020. Patient demographics, clinical characteristics, origin of coronavirus disease 2019, treatment modalities, and loss of workdays were recorded. RESULTS: Seven hundred and sixty-eight healthcare workers from 16 pediatric intensive care units were enrolled and 114 (14.8%) healthcare workers with a mean age of 29.7 ± 6.7 years became coronavirus disease 2019 patients. Seventy-six (66.7%) patients were female. Approximately half (54.3%) of the patients were physicians, 34.2% were nurses, and 11.4% were ancillary staff. Transmission was deemed to occur through patient contact in 54.3% of the patients. Comorbid illness was present 10.5% of the patients. Transmission occurred during endotracheal intubation in 21%, cardiopulmonary resuscitation in 9.6%, and non-invasive ventilation in 12.2% of patients, while transmission was a result of multiple possible procedures in 43.8%. Intensive care admission was needed for 13.1% of the patients. Five patients needed oxygen by cannula, 7 needed oxygen with a non-rebreathing mask, 5 needed high-flow nasal cannula support, 5 needed non-invasive ventilation, and 3 needed invasive mechanical ventilation. Fortunately, no infected healthcare workers died. CONCLUSION: Coronavirus disease 2019 in healthcare workers is a significant problem in pediatric intensive care units. Transmission seems to occur particularly frequently during patient care procedures such as intubation, ventilation and aerosol therapy, which highlights the importance of proper use of full sets of personal protective equipment during all procedures during care of coronavirus disease 2019 patients. • Transmission of SARS-CoV- 2 to HCWs occurs mainly during procedures such as intubation, ventilation, and aerosol therapies. What this study adds on this topic? The coronavirus disease 2019 (COVID-19) pandemic brought life all over the world to a standstill and posed serious problems in provision of health care. Many healthcare workers (HCWs) got infected at work and lost their lives, and healthcare facilities had difficulty in providing ample service during local surges. 1, 2 Healthcare workers have to treat COVID-19 patients, which puts them at the frontline in this global war. Use of personal protective equipment (PPE) reduces transmission of COVID-19 even in critical care. Recommendations on the use of PPE by HCWs have been published by the World Health Organization (WHO) and the Center for Disease Control (CDC). 3 During the severe acute respiratory syndrome (SARS) epidemic in 2003, 21% (1706 / 8096) cases were HCWs. 4 In a single-center case series of 138 COVID-19 patients hospitalized in Wuhan, China, in January 2020, 29% (40/138) were HCWs. 5 One report states that about 10 000 HCWs were infected and 74 died in Italy. 6 In this study, we aimed to investigate COVID-19 in PICU staff with respect to role at work, mode of transmission, symptoms, treatment modalities, lost workdays, and outcome. To our best knowledge, this is the first multicenter study of COVID-19 in PICU. This was a descriptive multicenter study conducted between March and November 2020 in 16 An online questionnaire was sent to all participating centers. All medical personnel had contact with COVID-19. All those who filled out the questionnaire were included in the study. Demographic data, role in the PICU, comorbidity, pregnancy, type of contact with SARS-CoV2, symptoms, extent of PPE use, diagnostic methods, and laboratory results were recorded. The history of contact with COVID-19 (+) based on the statements of the participants was taken into account. Staff who underwent testing for contracting COVID-19 were included, regardless of whether or not they were symptomatic. Treatment modalities were recorded as home quarantine only, medication at home, ward admission, or ICU admission. Need for respiratory support and the type of respiratory support needed (oxygen by nasal cannula, nonrebreathing oxygen mask, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) were recorded. Days off from PICU, time to symptom resolution, sequalae, and deaths were recorded. The Statistical Package for Social Sciences, version 16.0 software (SPSS Inc.; Chicago,IL, USA) was used to interpret data. Shapiro-Wilk test was used to check for normality. Normally distributed data were expressed as mean ± standard deviation (SD), while data without normal distribution were expressed as median (minimum to maximum). A P value less than .05 was considered significant. Most of the infected HCWs (62/114, 54.4%) were exposed to SARS-CoV-2 during patient contact. Twenty-one percent of transmissions occurred during endotracheal intubation, 9.6% occurred during cardiopulmonary resuscitation (CPR), 12.2% occurred during NIV, and there were multiple possible procedures for 43.8% of episodes of transmission ( Figure 1 ). Transmission occurred due to factors other than patient contact in 45.6% of the patients. Twenty (38.1%) HCWs contracted the disease from colleagues outside the patient care area, 15 (28.8%) contracted the disease at home, and 17 (32.7%) staff contracted the disease at mall or public transport situations. Clinical features of the patients and data on personal protective equipment (PPE) usage are summarized on Table 2 . Among the PICU personnel infected by SARS-CoV-2, PCR tests in 108 (92.3%), thorax computerized tomography (CT) findings in 28 (23.9%), and anti-SARS-Cov-2 immunoglobin M (IgM) in 15 (12.8%) were positive. Also, CRP in 85.7%, white blood cell in 83.3%, hemoglobin in 78.6%, activated partial thromboplastin time in 47.6%, international normalized ratio in 50%, brain natriuretic peptide in 9.5%, prothrombin time in 45.2%, procalcitonin in 45.2%, troponin T in 33.3%, and ferritin in 50% were checked during the disease period in infected HCWs. No, n (%) 101 (88.5) Yes, n (%) 13 (11.5) Chronic bronchitis, n (%) 2 (1.8) Heart disease + DM, n (%) 1 (0.9) Hypertension + DM, n (%) 1 (0.9) Ulcerative colitis, n (%) 1 (0.9) Immunodeficiency, n (%) 1 (0.9) Tumor, n (%) 1 (0.9) Renal diseases, n (%) 1 (0.9) Familial Mediterranean fever, n (%) 1 (0.9) Morbid obesity, n (%) 1 (0.9) Hypertension, n (%) 1 (0.9) Profession Attending/professor, n (%) 3 (2.6) PICU fellow, n (%) 12 Healthcare workers are at high risk of exposure to infectious diseases, including COVID-19, which spreads through respiratory secretions, body fluids, and contaminated surfaces. 7 The rapid rise in the number of patients with COVID-19 resulted in many HCWs contracting the disease. 8 Prompt diagnosis of COVID-19 in HCWs is crucial in prevention of the spread of COVID-19 throughout the hospital. 9 In our multicenter study of 768 healthcare staff, 114 (14.8%) had COVID-19. One singlecenter study reports that 16.3% of 432 healthcare personnel were found to be symptomatic for COVID-19 and were positive on testing. 1 In another study of 1353 HCWs, 6% were found to be symptomatic and positive for COVID-19. 2 On April 8, 2020, the incidence of COVID-19 among HCWs was reported to be 11% in Italy, 10 13.6% in Spain, 11 and 3.8% in China. 10 Sahu et al 3 published a meta-analysis of 11 studies in which the rate of SARS-CoV-2 infection was reported to be 10.1%. The rate of COVID-19 positivity among PICU staff was found to be similar in our study Publications on COVID-19 situation among PICU staff are scarce. To our best knowledge, this is the first multicenter study of COVID-19 in PICU staff in Turkey. Contracting SARS-CoV 2 during the pandemic is intrinsic to the nature of the job for HCWs. Fortunately, PPE use was proven to be very effective in preventing infection of HCWs, particularly when used during airway management procedures and aerosol therapies. Studies suggest that in order to control an outbreak of COVID-19 in the hospital, patients need to be isolated in negative pressure room or units. Should that be unavailable, naturally ventilated rooms with continuous air flow need to be used. If possible, there should be 1 patient per room, all patients should wear masks, and healthcare staff should wear complete sets of PPE at all times. 12 Medical and surgical masks should cover the mouth and nose, and this option is safe during standard patient care and outside of patient care area. Healthcare workers should use N95 filtering facepiece respirator (N95), Filtering facepiece2 (FFP2), and Filtering facepiece3 (FFP3) masks during invasive procedures such as intubation, endotracheal aspiration, CPR, and aerosol therapies (HFNC, inhaler therapies, NIV). These masks protect from 95% of particles with a radius larger than >0.3 µm. 13 FFP3 masks, the European counterpart to the US N95 masks, are recommended for protection against SARS-CoV-2 laden aerosols. 14 An FFP3 mask, goggles or face shield, waterproof gown, and gloves were recommended for healthcare staff in another study. If waterproof gowns are not widely available, single-use plastic gowns are recommended. 15 In our study, when contact with patients who wore surgical masks in accordance with guidelines published by the Turkish Ministry of Health, a full set of PPE was used appropriately in 59.8% of encounters. Centers with a low number and ratio of COVID-19 positive personnel despite high numbers of staff, the low incidence of COVID-19 in HCWs may be due to proper use of PPE. Severe acute respiratory syndrome coronavirus-2 is known to spread through respiratory droplets, but the virus has also been demonstrated in blood and other bodily fluids. 14-17 Ran et al 16 19.5% were found positive in one study, 1 while among 14 staff on a neurosurgical ward, 85.7% were found to be PCR-positive and 86% were found to be positive on CT. 8 Significant developments occurred in the field of COVID-19 vaccination globally. All healthcare staff were vaccinated in January and February 2021 in our country with the Chinese coronavirus vaccine (Sinovac Biotech®, CHINESE). However, there was no vaccine during our study, therefore our participants were not vaccinated at the time. We have observed a significant decrease in infected HCWs after widespread vaccination of HCWs in Turkey. Our study is the first multi-center study of COVID-19 in PICU staff in Turkey, but it is limited in that it is a retrospective study conducted as an online questionnaire, which may have missed some cases. In conclusion, COVID-19 is a significant problem among PICU staff. Infection tends to occur particularly frequently during invasive procedures such as intubation, ventilation, and aerosol therapy. Caution should be exercised throughout the workday, particularly during these aforementioned procedures. Insufficient use of PPE by PICU staff, working and interacting with colleagues without masks, and lack of social distancing increase the rate of SARS-CoV-2 infection. Ethics Committee Approval: This study was approved by Ethics committee of Ankara University, (Approval No: İ1-70-21). Informed Consent: Written informed consent was obtained from the patients who agreed to take part in the study. 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Geneva: WHO; 2020 Spain's coronavirus death toll surpasses China as world struggles with containment. Global News China Website Protecting healthcare workers from SARS-CoV-2 infection: practical indications Respiratory Protection for Airborne Exposures to Biohazards COVID-19 coronavirus: recommended personal protective COVID-19 in Pediatric Intensive Care Health Workers Turk Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages Risk factors of healthcare workers with coronavirus disease 2019: a retrospective cohort study in a designated hospital of Wuhan in China Clinical characteristics of 54 medical staff with COVID-19: a retrospective study in a single center in Wuhan Case report: recurrent clinical symptoms of COVID-19 in healthcare professionals: a series of cases from brazil The authors thank the pediatric intensive care specialists in the participating units who were members of the Turkish PICU-Covid Study Group for their collaboration in our survey. We created a list of acknowledgement by their surnames: Nihal Akçay, MD, Anar Gurbanov MD, Burak Balaban MD, Fevzi Kahveci MD, Hasan Özen MD, Ali Genco Gencay MD, Hacer Uçmak MD, Feyza İnceköy Girgin MD, Alper Köker MD, Pınar Seven MD, Muhammed Üdürgücü MD. Also the data were taken from the hospital database established by Ankara University Hospitals and the database of other hospitals participating in the study. The authors have no conflict of interest to declare. The authors declared that this study has received no financial support.