key: cord-252574-7oh0k139 authors: Nicastro, Emanuele; Mazza, Angelo; Gervasoni, Annalisa; Di Giorgio, Angelo; D’Antiga, Lorenzo title: A Pediatric Emergency Department Protocol to Avoid Intra-Hospital Dispersal of SARS-CoV-2 during the Outbreak in Bergamo, Italy date: 2020-04-21 journal: J Pediatr DOI: 10.1016/j.jpeds.2020.04.026 sha: doc_id: 252574 cord_uid: 7oh0k139 The pandemic of coronavirus SARS-CoV-2 disease affected Northern Italy, spreading from the Bergamo province to the entire country. During reorganization of our emergency department to support patients presenting with coronavirus SARS-CoV-2 disease, we aimed to evaluate whether children play a role in intrahospital spread of the infection. occurred in Northern Italy, and rapidly spread to the entire country (1) . Due to the impracticability of any containment measure, mitigation and suppression policies to reduce self-sustaining community outbreak amplification were promulgated by the Italian government. This entailed three steps: 1) local confinement confirmed cases of COVID-19 and 8,169 fatalities, of which 36% and 59%, respectively, were in the Lombardy region (2). The province of Bergamo became the most affected territory outside mainland China. In Lombardy, the main outbreak of the infection was located in a community hospital in the Bergamo province, suggesting that the community spread of the infection probably arose from a large cohort of subjects who were in contact with SARS-CoV-2 infected patients attending health care facilities, and who were probably unrecognized at that time., so far pediatric services have not experienced the COVID-19 burden experienced in adults. The few known infected children seem to have a mild disease or are asymptomatic (4-7). However, we do not know whether infected children play a substantial role as drivers of the epidemic. Children hospitalized for reasons other than lower respiratory tract infections could carry the virus and represent an occult threat for healthcare workers and other vulnerable patients. To address these issues, we developed a protocol addressing reception, risk-management and hospitalization of suspected SARS-CoV-2 cases at the pediatric emergency department and medical-surgical units aimed at containing intra-hospital transmission of the infection, considering that currently our hospital is the largest referral site in the primary outbreak area in Italy. Testing for SARS-CoV-2 was performed using real-time PCR for SARS-CoV-2 nucleic acids on nasal-/oropharyngeal swab (NO/OP swab). Close contact was defined according to ECDC/WHO definition (https://www.ecdc.europa.eu/sites/default/files/documents/nove-coronavirus-infection-prevention-controlpatients-healthcare-settings.pdf). Three meetings, which took place on February 27, February 28 and March 6, 2020, finalized the protocol, included a representative member from the hospital executive board. The protocol was adopted on March 6, 2020 and consisted of three parts: triage optimization, risk assessment and management in the emergency room, and patient management on the pediatric unit. Spatial reorganization of the emergency department with the creation of separate routes access for suspected COVID-19 and standard patients was completed on March 13, 2020 ( Figure 1 ). Children and caretaker with acute RTI with or without fever are approached with a FFP2/N95 masked staffmember and receive a 2-item questionnaire, addressing the risk of community or intrafamilial transmission. Answering "yes" to at least one of the questions (with symptoms of RTI AND/OR previous contact with a confirmed or probable case of SARS-CoV-2 infection), marks the case as suspect. Patients triaged as suspected cases receive a yellow identification bracelet, are accepted into the Department via a separate route, have a separate waiting room, and undergo protected transfers ( Figure 1 ). Patients enter the emergency department through a separate path, are evaluated by healthcare personnel protected according to the COVID-19 World Health Organization recommendations (FFP2/N95 respirator + eye protection goggles or face shield + isolation gown + face mask + gloves) (8) . Physical examination takes place in isolated single rooms. The pediatrician assesses additional elements of suspicion (e.g., presence of a household contact with history of LRTI within the last 14 days; presence of LRTI/community acquired pneumonia not responding to standard antibiotic therapy in children >14 years of age). Patients requiring oxygen, receive non-humidified gas through a nasal cannula or Venturi mask, in order to reduce aerosol formation. Those requiring chest imaging reach the emergency radiology department through a dedicated hallway. All transfers are operated with the patient wearing a surgical mask, including transfer to the pediatric unit for children requiring hospitalization. Patients not requiring hospitalization are discharged to domestic isolation, and undergo medical monitoring by the local health services handling the clinical aspects and the infectious risk ( Figure 1 ). Patients accessing the emergency department for non-respiratory problems and without history of contact with a COVID-19 patient, are accepted into a separate area and managed according to the standard procedure, with contact and droplet precautions. Suspected COVID-19 patients requiring hospitalization are managed by health care personnel (HCP) using personal protective equipment (PPE) (FFP2/N95 respirator + eye protection goggles or face shield + 5 isolation gowns + face mask + gloves), who perform the acquisition of an NP/OP swab for SARS-CoV-2 real time-PCR testing. The beds for COVID-19 suspected cases are located in an isolated, clearly marked area. Blood samples are collected according to HCP recommendations, and patients undergo evaluation for other etiologies according to HCP clinical judgment. If SARS-CoV-2 testing yields a negative result, standard protective precautions are adopted. If COVID-19 is confirmed, subsequent management takes place with HCP using PPE in tight cooperation with infectious diseases specialists. Patients admitted for non-respiratory problems and without history of contact with COVID-19 patients also undergo diagnostic NP/OP swab for SARS-CoV-2, to detect asymptomatic carriers, and are managed with COVID-19 precautions until the swab result is available. Therefore universal NP/OP screening is carried out in all admitted patients, on first day of admission (Figure 1 ). Due to the shortage of virological diagnostic reagents and laboratory consumables, the following hospital policy for management of HCP was used for personnel with mild respiratory symptoms without fever: continuation of regular activity, continuous donning of a surgical masks and for personnel with symptoms preventing work activity (fever, cough, evidence of LRTI, gastrointestinal symptoms, malaise): domestic isolation until 14 days from the disappearance of symptoms, before returning to work. Routine use of diagnostic NP/OP swabs for SARS-CoV-2 testing in asymptomatic or mildly symptomatic HCP was not adopted. Remarkably, during the SARS-CoV-2 epidemic, the number of pediatric patients presenting to the emergency department decreased from a mean of 62/day to a mean of 8/day (Figure 2 Remarkably, among the patients admitted electively to the hemato-oncology unit, 3/15 (20%) tested positive (2 with hepatoblastoma and 1 with rhabdoid tumour, all with fever and neutropenia following chemotherapy). In the hepatology, gastroenterology and transplantation unit none of the15 tested children had a positive NP/OP swab (9/15 had a liver transplant, 1/15 an intestinal transplant, 1 had Coombs' positive anemia with giant cell hepatitis, 4 had chronic liver disease and no immunosuppressive treatment). The mother of one child who was admitted for a biliary stricture following liver transplantation had a positive test for SARS-CoV-2. Only two children were admitted for respiratory problems (uncomplicated pneumonia), and 6 children had no or very mild respiratory symptoms. Six newborns/infants had fever without signs of localization. Unfortunately, before the adoption of a dedicated protective protocol, 6 confirmed and 16 suspected COVID- Despite risk assessment beginning at triage, the proportion of infected physicians and nurses was high before the implementation of strict protocols. Remarkably, only four cases of COVID-19 occurred among HCP after spatial separation of a dedicated area for suspect cases, which allowed timely adoption of PPE. We believe it is likely that the infection of these four persons may have occurred outside the hospital. It is likely that a proportion of infected HCP, if insufficiently protected, acquire infection in the hospital environment, and others can be infected through community contacts. If this hypothesis is correct, the only way to prevent intra-hospital transmission of infection (and possible spread to the community during an epidemic) is to perform consistent hand hygiene and use of universal PPE, and to perform wide NP/OP screening of the admitted patients and possibly the HCP, regardless of symptoms (9) . It is noteworthy that we did not experience severe forms of COVID-19 in our pediatric patients, including children with malignancies and pediatric solid organ transplant recipients (three patients under chemotherapy were SARS-CoV-2 positive when admitted for fever and neutropenia, but had no respiratory symptomatology). This supports data gathered from previous coronavirus outbreaks (SARS, MERS), suggesting that immunosuppression per se does not seem to be an additional risk factor for COVID-19 (10). A major limitation of our study is the small number of children tested and cases detected. Intra-hospital spread of SARS-CoV-2 appears to be a major threat during this pandemic, and should not be European Centre for Disease Prevention and Control. Outbreak of novel coronavirus disease 2019 (COVID-19): situation in Italy -23 Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention Epidemiological Characteristics of 2143 Pediatric Patients With Coronavirus Disease in China Infection prevention and control during healthcare when novel coronavirus (nCoV) infection is suspected. Interim Guidance Geneva 2020. 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