COVID-19 in Pediatrics

Cape Fear Valley Medical Center

Grand Rounds – Pediatrics

May 6, 2020

Tom Belhorn, MD, PhD

UNC Pediatrics – Infectious Diseases

COVID-19 in Pediatrics

Tom Belhorn, MD, PhD

UNC Pediatrics – Infectious Diseases

No disclosures or conflicts of interest in relation to this

presentation

“Off-label” use of medications and diagnostic studies

will be identified during this presentation

COVID-19 in Pediatrics

» Basic Virology –History, Clinical Correlates

» COVID-19

• Current epidemiology

• Infection & clinical presentation

• Confirmation of Dx, management

• Prevention

» COVID-19 Management

• Overview, Ambulatory, Testing, Inpatient Management

» Resources

» Disclaimer: Please refer to current, updated references from CDC, State Health Department, for details regarding definitions for PUI, testing, management!

Coronavirus:

Basic Virology – Clinical Correlates

• Largest positive strand

(SS) RNA virus

• Enveloped (from

intracellular membranes)

• Spikes are large

glycoprotein

• Infect humans & animals

–respiratory or GI dz

Human Coronaviruses

• First identified in 1960s

• Four main sub-groupings of coronaviruses, known as alpha, beta, gamma, and delta.

• Seven coronaviruses can infect humans

• Common human coronaviruses (on UNC Respiratory Pathogen Profile) » 229E & NL63 (alpha coronaviruses)

» OC43 & HKU1 (beta coronavirus)

• Three others more recently evolved / moved from animal species to humans

» SARS-CoV, MERS-CoV, COVID-19

Recent Coronavirus History

• SARS-CoV (the beta coronavirus that caused severe acute respiratory syndrome, or SARS)» First detected in China November 2002

» From 2002 to 2003 >8000 cases confirmed, 774 deaths

» No cases detected since 2004

• MERS-CoV (the beta coronavirus that caused Middle East Respiratory Syndrome, or MERS)» First detected in Saudi Arabia in 2012

» Multiple cases, most in neighboring countries

» Still being monitored

• Late 2019 Novel Coronavirus = COVID-19 (some still say “SARS-CoV2”)

Epidemiology: COVID-19

• Link to the data visualization site from Johns Hopkins; live tracking of

number of cases and deaths:

• https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740f

d40299423467b48e9ecf6

Epidemiology:

COVID-19 Cases: Data as of 5/4/2020

• Total world cases: >3.5 million, deaths >250,000

• Country with most cases to date: USA >1.2 million,

deaths >69,000

• NC cases: >12,000, deaths >460

COVID-19 Transmission

• Major route of spread likely

droplet

» Most transmission from

symptomatic individuals, early in

disease

» Likely also via surface contact;

possible other body fluids (not likely

from stool)

» Extent of transmission from pre-

symptomatic individuals unclear –

likely important in community

spread

» Transmission may also occur from

asymptomatic individuals (those

who never develop symptoms)

» Other sources?? – animals (likely

no)

COVID-19 Clinical Signs & Symptoms

• Clinical course in adults

» Time to symptom onset: average 5-6 days

(2-14d)

» Fever (44-98%)*, cough (46-85%),

difficulty breathing (3-31%)

• *Fever may not be present initially

• Symptoms / disease progressive

• Other signs /sx: sore throat, shaking

chills, myalgias, HA, loss of taste or

smell

• Adult high-risk groups: elderly, co-

morbidities of heart disease, HTN,

diabetes, also immunocompromised

COVID-19: Infection & Clinical Sx

• The Good News (Still!)

» Children have milder disease

» Early data on mortality from China:• Age 0-9yo: 0

• Age 10-19: 0.2%

• Age 20-29: 0.2%

• (compared with 2.9% overall; >14% in highest risk groups)

» Mild disease can include range of mild respiratory

disease

(including cold symptoms, minor sore throat; also vomiting & diarrhea)

» Infants and children more likely to be asymptomatic

» Low morbidity and mortality –except…

COVID-19: Infection & Clinical Sx

• Examples of increased morbidity and mortality in children

» Children with underlying health conditions (heart / lung

disease, immunocompromised, etc.); young infants

• Sporadic reports of severe disease

» Neonates – early onset COVID-19 (mode of transmission

unclear)

• Reports of symptoms in first few days of life

• Vertical vs horizontal transmission

• Implications for management of the neonate

• An old term…Koch’s postulates (?cause – effect)

» Reports of Kawasaki Disease-like illness, “cytokine storm”

COVID-19: Confirmation of Diagnosis

• COVID-19 Diagnostics

» COVID-19 PCR

• NP (nasopharyngeal) swab

• OP (oropharyngeal) swab

• Other sources

» Serology (IgG, IgM, other)

• Hot topics…

» Test sensitivity

» If antibody positive – are you protected?

» Need for more tests!

• Role of Imaging: CXR, CT

COVID-19: Management / Treatment

• Management of Infected Patients

» Evolving recommendations for

management

» Supportive care

» Supplemental oxygen

» Mechanical ventilation

» Specific therapeutics…

COVID-19 Therapeutics

• Antiviral Agents

» Remdesivir –

• Adenosine analog, broad in vitro activity against RNA viruses

• Good safety profile in Ebola trials; pediatric dosing is available

• Reports in past week:

» The Lancet:

https://www.thelancet.com/lancet/article/s0140673620310229

• 237 patients, randomized 2:1 drug treatment, adults, no

effect

» But: https://www.niaid.nih.gov/news-events/nih-clinical-trial-

shows-remdesivir-accelerates-recovery-advanced-covid-19

» NIH trial, >1000 pts, more rapid improvement and decreased

mortality (small but statistically significant)

• Compassionate use program, now FDA EUA (emergency use

authorization)

COVID-19 Therapeutics

• Other Agents

» Hydroxychloroquine and chloroquine

• Press release / study on Hydroxychloroquine and azithromycin

for COVID

• HCQ malaria /anti-inflammatory drug, in vitro activity against

several viral pathogens

• No efficacy against other viruses in vivo

• Major problems with clinical study

• Additional studies showing no effect

» VA Hospital study – no positive effect, increased mortality

» Others: Lopinavir –ritonavir (Kaletra), Ribavirin, other

antivirals; Anti-inflammatory drugs (Tocilizumab –mAb

against IL6 receptor); convalescent serum

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, “physicaldistancing” (6-foot rule), facemask

» PPE Stewardship» Gown, gloves, face mask OR respirator (N95), eye

protection (goggles or face shield)

• Public Health measures:

» Isolation, quarantine, avoidance of large groups, et al.

COVID-19: Prevention

COVID-19 Vaccines

>100 vaccine candidates

8 (?more) in clinical trials

Protection shown by 2 vaccines in

primates

Multiple vaccine types

Time-line -challenges

Overview

Ambulatory & Inpatient Patient Management

Healthcare Providers

Issues in COVID-19 Management

Issues in COVID-19 Management

Goals during / dealing with a pandemic

Optimal patient care

Preventing the spread of infection

Ambulatory settings

Inpatient settings

Expect all plans / protocols be fluid in response to changing

epidemiology, new data, testing availability, and rapidly

changing factors

Ambulatory / Outpatient Care

• Ambulatory Care Goals:

» Provide effective patient care while minimizing patient contact with

other patients and staff

» Provide evidence-based screening of potentially infected patients

• Select Issues / Challenges / Solutions

» Effective triage (for risk / sx of COVID, degree of illness)

• COVID Hotline

» Testing –RDC (Respiratory Diagnostic Centers), other

• Limiting resources: supplies / reagents for testing, PPE

» Telehealth

» In-person visits –protocols (screening / limiting care givers)

» Care of Staff

Inpatient Care

• Inpatient Care Goals:

» Provide effective patient care while minimizing patient contact with

other patients and staff

» Provide evidence-based screening of potentially infected patients

• Select Issues / Challenges / Solutions

» Effective triage (for risk / sx of COVID, degree of illness)

» Testing: Limiting resources: supplies / reagents for testing, PPE

» Preparing for a surge

• Patient location(s), staffing (COVID team)

» Decisions on medical / surgical services provided

» Visitor policies

» Care of Staff

Addressing morale during this time of ambiguity and fear

UNC Children’s has a team dedicated to implementing tools to keep everyone well-connected and support emotional well-being; examples are outlined below:

» Developed an Instagram account dedicated to uplifting and encouraging photos

» Implemented virtual gatherings (e.g., zoom happy hours)

» Established a 1:1 buddy system for internal support

» Created list of wellness tools to help with increased screen time (e.g., Headspace)

» Scheduled daily check-ins between the Chair and Division Chiefs to discuss any immediate needs or to answer questions

COVID Surge: Flattening the Curve

Resources for Clinicians

• CDC

» https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

• NC Department of Health

» https://epi.dph.ncdhhs.gov/cd/coronavirus/providers.html

• AAP COVID Site

• IDSA (Infectious Disease Society of America)

COVID-19 in Pediatrics

» Basic Virology –History, Clinical Correlates

» COVID-19

• Current epidemiology

• Infection & clinical presentation

• Confirmation of Dx, management

• Prevention

» COVID-19 Management

• Overview, Ambulatory, Testing, Inpatient Management

» Resources

» Disclaimer: Please refer to current, updated references from CDC, State Health Department, for details regarding definitions for PUI, testing, management!

Questions?