key: cord-0794300-satufg9w authors: Devrim, İlker; Bayram, Nuri title: Infection control practices in children during COVID-19 pandemic: differences from adults date: 2020-05-26 journal: Am J Infect Control DOI: 10.1016/j.ajic.2020.05.022 sha: 7e0caaae03c62b3eef9f9b422d0a88daeba98f8e doc_id: 794300 cord_uid: satufg9w BACKGROUND: Limited studies have been published on practices and management of COVID-19 in children. Despite the fact that COVID-19 rarely caused any severe disease in children, the asymptomatic children might be playing an important role for spreading COVID-19 in healthcare facilities. This review aimed at sharing our experience of how to handle patients with COVID-19 in a pediatric referral and tertiary care hospital to prevent the possible transmissions to the healthcare workers (HCWs). METHODS: This review sought to identify infection control practices measures during COVID-19 pandemic comes from our daily practice combined with the most recent guidelines with the new experience and information. RESULTS: Prevention the transmission of COVID-19 to the HCWs, four primary themes should be taken into consideration; (1) ongoing education and importance of the organization of the healthcare facility, (2) proper clinical triage and isolation of the suspected or confirmed COVID-19 patients in the outpatient clinics and in the emergency departments, (3) necessity of the organization of the COVID-19 wards, and (4) utilization of personal protective equipment. CONCLUSIONS: Infection control precautions to prevent the possible transmissions to HCWs as well as the other patients and their caregivers from children with COVID-19 are very critical. If sufficient precautions are not taken, healthcare settings may serve as additional source of transmission and spread of COVID-19 in the society. pathogenicity for humans, result in severe respiratory diseases and high mortality rates as in the case of SARS-CoV-2 (8, 9) In Turkey, the first case of COVID-19 was announced on March 11, 2020 and the first death was reported on March 17, 2020 (10) . While reported fatality rate remains relatively low, Turkey has one of the rapidly rising numbers of confirmed cases in the world. The Turkish Ministry of Health confirmed that the total number of documented cases increased to 150,593 and the numbers of deaths reached 4,171 on May 18, 2020 (5) . However, there is still no sufficient data on pediatric population in Turkey. Although some clinical studies of adult COVID-19 exist (11) (12) (13) , very limited studies have been published on COVID-19 in children so far. Currently, the data on children is accessible in studies on adult population with limited information on children (14) (15) (16) (17) (18) (19) (20) (21) (22) . In a review of 45 relevant scientific papers and letters, it was observed that only 1-5% of diagnosed COVID-19 cases were children, who generally had milder disease than adults and deaths had been extremely rare (23) . Transmission of SARS-CoV-2 seems to be primarily through respiratory secretions on droplets of an infected individual by coughing or sneezing (24, 25) . There is not any available evidence of airborne spread for COVID-19, however this possibility must be taken into consideration while conducting certain aerosol-generating procedures in health care facilities (26, 27) . Recent studies showed the viability of SARS-CoV-2 on environmental surfaces (26, 27) that may indicate that the transmission of SARS-CoV-2 through contaminated surfaces might be possible. And although viable virus associated with fecal shedding has been demonstrated in a limited number of cases (28) , yet, its role in transmission of COVID-19 is still controversial. Data on individuals aged 18 years old and under suggest that there is a relatively low attack rate in this age group (about 2% of all reported cases) (29) . Published data from Italy reported that only 1.2% of COVID-19 cases were children (30) . And early reported cases in the United States demonstrated that 1.7% occurred in children (31) . In addition to the previous reports, a recent study from pediatric intensive care units at United States and Canada, including 48 COVID-19 patients hospitalized at pediatric intensive care units, 18 (38%) required invasive ventilation, and the hospital mortality rate was reported to be 4.2%, supporting the favorable outcomes of the children compared to adults (32) . The largest child case series published previously demonstrated that 5.2% had severe disease and 0.6% had critical disease with respiratory failure, signs of multi-organ failure, encephalopathy, heart failure, abnormal coagulation, or acute renal failure (33) . However, it should be noted that approximately 40% of the children with critical COVID-19 in this study were less than 5 years of age (33) . Based on available data, it is possible to conclude that COVID-19 has been less severe among children compared to adults. However, these findings should be interpreted with caution as a high percentage of children might have remained undiagnosed due to the asymptomatic pattern of the disease in this age of group (22, 33) , which makes it not feasible to determine the full extent of infection among children. A recent study reported that 86% of all early COVID-19 infections in China remained undiagnosed (34) . According to the same study, despite the lower transmission rate of such asymptomatic cases, their greater number suggested that these might have been the source of 79% of all early cases (34) . This may pose a problem since the undiagnosed children can be a major source of transmission and spread of COVID-19 in the society. Since the onset of this pandemic, health care workers (HCWs) have been exposed to SARS-CoV-2 in different clinical settings. The Chinese Center for Disease Control and Prevention reported that among the 44,672 confirmed cases in mainland China, 3,019 HCWs were infected and 14.8% of the infected HCWs had severe and critical disease which led to five deaths (35) . The initial infections of HCWs might be due to the contact with a new contagious disease, and thus can be attributed to limited knowledge. However, approximately 3 months after the beginning of COVID-19 outbreak, 94 doctors and 26 nurses had died due to SARS-CoV-2 in Italy, and a total of 12,681 HCWs got infected with SARS-CoV-2 according to the Italian Institute of Health (36) . Currently, up to 9% of overall cases in Italy are among healthcare workers (38) . A study from the Netherlands, where the first COVID-19 cases were reported on 27th February, state that 86 (6%) of the HCWs tested for COVID-19 were found to be positive (39) . All of these reports reveal the vulnerability of the HCWs to COVID-19. Moreover, Centers for Disease Control and Prevention (CDC) COVID-19 response team reported 9,282 HCW were infected with COVID-19 in the United States (40) , and it will not be surprising to expect more COVID-19 infected HCWs all around the World as long as this pandemic remains uncontrolled. The COVID-19 pandemic has several aspects that need to be addressed. These include the patients' health and treatment, the risk for HCWs and their protection, and the public health aspects and measures to reduce the impact of the pandemic. Despite the fact that COVID-19 rarely caused any severe disease in children, as mentioned above, the asymptomatic children might be playing an important role in spreading COVID-19 in health facilities as well as in outpatient clinics. In this review, we aimed at sharing our experience of how to handle patients with COVID-19 at the …. Hospital and of the infection control committee measures to prevent the possible transmission to the healthy children and HCWs from the children with COVID-19. The current hospital is a 400-bed pediatric referral and tertiary care hospital in İzmir, Turkey. The hospital is a dedicated pediatric hospital with 24-bed pediatric intensive care unit, 80-bed neonatal intensive care unit, 30-bed pediatric hematology unit, 12-bed hematopoietic bone marrow transplantation unit, 6-bed pediatric cardiovascular, 12-bed pediatric surgery intensive care units in addition to general pediatric wards, pediatric orthopedics, cases were hospitalized at the center. To the date this review was submitted, four of the HCWs were diagnosed with COVID-19, while no one was attributable to hospital exposure (the source of infection was generally their spouse or roommates). The following are the main infection control measures that were taken during the COVID-19 pandemic which came from our daily practice combined with the most recent guidelines. Keeping in mind that with more experience and newly available information, the practices as well as guidelines will eventually change. Under these unusual circumstances, potential transmission was a crucial problem considering the relatively high rate of asymptomatic children or children with milder presentation of COVID-19 and additionally the potentially asymptomatic parents (31, 43) . Therefore, reducing the number of the HCWs exposed to possible or confirmed COVID-19 patients was prioritized by the hospital management and organizing a more proper triage was a great challenge for the infection control committee (44) . The clinical triage, especially in the case of COVID-19 pandemic, is an evolving process requiring a high level of institutional preparedness and includes evaluating outpatients during the first admission to the hospital, the pediatric emergency admissions and the referrals from other hospitals as well. i. A front desk was set up for triage on the ground floor at the only entrance of the hospital (the other entrances were closed) with two fully-equipped nurses and one pediatrician who measured the temperature of the child and the parents or caregivers and also who applied a specially designed questionnaire to screen on the symptoms of COVID-19 (e.g.; fever, cough, difficulty to breath), information on whether the patient had any relatives infected with COVID-19 and also the symptoms that occurred within the last two days. In the first twenty days of the pandemic in Turkey, medical masks were only given to the parents and children with fever, whereas later everyone entering the outpatient clinics was requested to wear medical masks. Additionally, only one caregiver with medical mask was allowed to enter the examination room. iv. The organization of the COVID-19 wards: Three specific wards were arranged and classified according to the risks of COVID-19 patients as high, moderate and low. The other remaining wards were designated COVID-19 free pediatric wards where only patients without fever and any respiratory symptoms were admitted. Pediatric infectious diseases ward was the only ward that confirmed or suspected COVID-19 cases were hospitalized. The patients with respiratory symptoms and fever in which COVID-19 possibility was nullified by molecular assays were transferred to the other two low-risk wards. Despite the fact that most children with COVID-19 do not require hospitalization, certain precautions should be taken to prevent nosocomial infections in the wards. Unlike the general hospitals, the children's hospital may require certain specific measures worth mentioning: i. Before the pandemic, there was only one entrance to the ward used both by the patients and the HCWs. A second entrance dedicated for use by HCWs was built. ii. Healthcare workers were made to wear scrubs which were washed at the hospital after use and they were not allowed to go out with scrubs on. iii. In the clinical practice, after the first examination of the children with COVID-19, the parent/caregiver and the child were immediately transferred to the patient's room and all information required to fill the forms such as additional information about family history, complaints of the child, etc. were taken by the nurse on the phone. iv. Healthcare workers wore full PPE including N95 masks. vi. In every patient room, patient-specific stethoscopes were placed to prevent possible transmission via fomites and wall-clocks (for evaluating the patients' heart rate as well as respiratory rate) were installed as HCWs were not allowed to use their personal belongings in the COVID-19 patient rooms. vii. The children who require high-flow nasal cannula or conventional oxygen therapy were immediately transferred to negative pressure isolation room when available. As there was only one such room at the hospital, aerosol-generating procedures had to be conducted in regular rooms taking the necessary measures such as fullyequipped HCWs donning N95 or N99 masks (45) . viii. Before the COVID-19 pandemic, the young children and infants who required salbutamol inhalation via nebulizer were kept together in the same area in the emergency service. During the pandemic, this practice was discontinued and a metered dose inhaler via a holding chamber or spacer was used instead. The reusable holding chambers and the outer parts of the nebulizer were sterilized with vaporized hydrogen peroxide and stored as a sterile package (image 1). ix. Living spaces and resting areas of HCWs were strictly separated from the patients' area and no personal belongings were allowed in the patients' area. x. When a child with suspected or confirmed COVID-19 was discharged from the ward, firstly disinfection was performed with a multifunctional UV disinfection robot with air-cleaning properties and then all surfaces in the room were physically cleaned (image 2). All furniture, equipment, and frequently touched surfaces (e.g., door handles) were cleaned with a physical cleaning agent using 1,000 ppm bleach solution (2 in 1) made up daily from a concentrated solution. This cleaning technique was applied in all rooms where suspected or confirmed COVID-19 cases were hospitalized. All HCWs, including doctors, nursing and administrative staff having contact with patients were required to use PPE during the current pandemic. Moreover for every HCW, a form including possible exposure and presence of PPE during contact with COVID-19 was filled by the HCWs to determine the risk score. i. All HCWs were required to follow standard precautions including rigorous handwashing practices using water and soap or alcohol-based hand rub. ii. Surgical masks were provided for all HCWs. Particularly for the HCWs performing aerosol generating procedures, N95 respirators were provided. Aerosol generating procedures were listed as procedures including collecting diagnostic respiratory samples (e.g. nasopharyngeal swab), endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, physical prone positioning of the patient, disconnecting the patient from the ventilator, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation including tracheal intubation, bronchial suctioning, bronchoscopy, and sputum induction (45) . According to the guidelines, these masks were allowed to be used for 8 hours for multiple patients without removing, unless the respirator is damaged, soiled or contaminated (46) . iii. Healthcare workers collecting diagnostic respiratory samples were required to wear gloves, gowns and N95 masks at COVID-19 wards. The HCWs at the other remaining wards were required to wear surgical masks while managing the COVID-19 free patients. Stock levels of PPEs were daily monitored by an inventory management software program. According to the use of PPEs, new products obtained immediately once the stocks declined to a certain level v. Availability of PPEs for all HCWs was assessed at the point-of-care. Five sets of equipment of PPE including N95 masks, gowns, gloves, and face shields were prepared for the emergency department, outpatient clinics and wards that COVID-19 patients admitted. These sets are ready to use sets reserved for resuscitation. 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Licence: CC BY-NC-SA 3.0 IGO Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care WHO Guidelines Presymptomatic transmission of SARS-CoV-2-Singapore Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Recommended guidance for extended use and limited reuse of N95 filtering facepiece respirators in healthcare settings We thank to Işıl Demirakın for her help in language editing. Figure 1 . Clinical triage and isolation of the suspected or confirmed COVID-19 patients at the center.