The Impact of COVID-19 in Children

March 24, 2020

Agenda

Introductions

Scientific Update

UNC Children’s Response

How to talk to children about COVID-19

Questions

SCIENTIFIC UPDATE ON COVID-19

Coronavirus Disease 2019: Brief Review and Update

• The Virus - History, Clinical Correlates• COVID-19

» Current epidemiology» Infection & clinical presentation» Confirmation of Dx, management» Prevention

• UNCH COVID-19 Preparations» Overview, Ambulatory, Testing, Inpatient Management

• Resources

Coronavirus:Basic Virology – Clinical Correlates

• Largest positive strand (SS) RNA virus

• Enveloped (from intracellular membranes)

• Spikes are large glycoprotein

» ACE2 is cell receptor for SARS-CoV-2

• Infect humans & animals –respiratory or GI dz

Human Coronaviruses• First identified in 1960s

• Seven known coronaviruses can infect humans

• Common human coronaviruses (endemic coronaviruses)

» 229E & NL63 (alpha coronaviruses)

» OC43 & HKU1 (beta coronaviruses)

» All 4 detected on UNC Respiratory Pathogen Profile test

• Epidemic Coronaviruses

» 3 others more recently evolved / moved from animal species to humans

» SARS-CoV, MERS-CoV, SARS-CoV-2

Epidemiology:COVID-19 Cases: Data as of 3/23-24/2020

• Total world cases: >385,000, deaths >16,500

• Most cases to date: China 81,588; Italy 63,927; US 46,450; Spain 35,212; Germany 30,081

• US: Rapidly increasing, 554 deaths;

• NC 297 (as of 3/23), no deaths.

» Mecklenburg (79), Wake (48), Durham (40) greatest number

March 19, 2020-12:13pm

COVID-19, Infection, Clinical Sx

• Clinical course in adults» Time to symptom onset: average 5-6 days (2-14d)

• Recovery 2 wks; if severe -3-6wks, death 2-8wks (most from ARDS / secondary infx)

» Fever (44-98%)*, cough (46-85%), myalgias/fatigue, short of breath (3-31%)

• *Fever may not be present initially• Symptoms / disease progressive• Other signs /sx: sore throat, diarrhea, other

• Major route of spread droplet» Likely surface contact; possible other

body fluids» Most transmission from symptomatic

people, early in disease

COVID-19: Infection & Clinical Sx• The good news!

» Children have milder disease» Infants and children may be asymptomatic – mild dz» Data on mortality from China:

• Age 0-9yo: 0• Age 10-19: 0.2%• Age 20-29: 0.2%• Vs. 1-3% overall & >14% in highest risk groups• Adult high-risk groups: elderly, co-morbidities of heart

disease, HTN, diabetes, also immunocompromised» Transmission from children –unclear if community spread (usually

household)» But: transmission may occur prior to symptoms onset / if

asymptomatic

Confirmation of Diagnosis & Management

• COVID-19 PCR from NP (nasopharyngeal) swab

• Treatment / Management» Supportive care –currently no FDA-

approved treatment • Investigations with Remdesivir,

Lopinavir/Ritonavir, Chloroquine, et al.

Dr. Melissa MillerDirector-Clinical Molecular

Biology LaboratoryMcLendon Clinical Labs

https://www.today.com/video/new-coronavirus-test-in-north-carolina-takes-only-4-hours-to-see-results-80961605870

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, “social distancing” (6-foot rule), facemask if sick

» During Covid-19 patient contact: Gown, gloves, face mask OR respirator (N95), eye protection (goggles or face shield)

» PPE Stewardship

• Public Health measures

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

Resources for Clinicians• https://epi.dph.ncdhhs.gov/cd/coronavirus/providers.html• https://www.cdc.gov/coronavirus/2019-

nCoV/hcp/index.html• Travel Requirements Announced for UNC Health / UNC

SOM• UNC Health’s COVID-19 Intranet page – Visit for the latest

updates.• External UNC COVID-19 information on our website.• Lib guides - https://guides.lib.unc.edu/COVID19• Daily Briefings:

https://unchcs.intranet.unchealthcare.org/Pages/2020/03-Mar/covid-19-brief/Daily-Briefings.aspx

UNC CHILDREN’S RESPONSE

Inpatient Current State & Updates• Several “rule-outs” but no positive pediatric patients

• Developed 2 teams to cover COVID-19 and rule-out patients:

» Peds COVID Acute (Listed as Peds Surge Acute-PSA)

» Peds COVID ICU (Listed as Peds Surge ICU-PSI)

• Patients will be admitted to PICU or 6CH

• Low risk patients will “test-in place” on isolation but regular teams

• Questions about COVID testing to Peds COVID ID Pager

» Covered by Peds ID attending daily

» Available for questions regarding testing of inpatients

» Can be reached in a similar way as Peds COVID inpatient teams

OR Current State & Updates• Priority/Urgent/Emergent cases only currently

• COVID-19 rule out patients with clear SOP which avoids contact traffic

• Isolated OR and PACU space (Negative Flow)

• Surgical mask conservation- 1-2 masks used per day

• “Cross training” consideration

• Limit staff exposure to airway and high-risk cases

Outpatient Current State & Updates

• Rapid increase in video and phone visits

• In-person visits are down ~70%

• Downsizing the Chapel Hill clinic and moving visits to Raleigh

• Pediatric RDC opened today in Cary

UNC COVID Hotline / HealthLink: 888-850-2684

ED Current State & Updates• Focused on preparedness

• Still potential for surge of adult and pediatric patients

• Actions to date:

• Established separate respiratory and non-respiratory care areas in both the general and pediatric ED to limit spread of infection.

• Tent Tele-Triage ramping up at the medical center to expedite sorting and directing patients

• PEM leadership team working with other Emergency Departments in the Health Care System to establish appropriate ED triage criteria

Links for Clinical Resources for our Providers

https://www.med.unc.edu/pediatrics/covid-19-clinical-resources/

Education Current State & Updates• Policies related to COVID-19

» Family-centered rounding has ceased

» Policies to minimize inpatient rounding group size

» ABMS, ACGME, and ABP have provided some guidance on contingencies

• Reduction in staffing

» Residents have been pulled from outpatient clinics and subspecialty rotations

» Contingency planning developed in anticipation of possible 10%, 25%, and 50% resident workforce reduction

» Medical students temporarily taken out of clinical setting

» Trainees currently not involved in the care of COVID positive or highly-suspected patients.

Research Current State & Updates• Limiting activities according to latest updates from the Vice Chancellor

of Research (VCR) » Visit web site for updates: https://research.unc.edu/covid-19/» Lab-based research restricted to “critical research activities”

• Labs with critical research activities submitted form to be reviewed by VCR

• VCR is responding to labs with OK to proceed, partial approval, no approval

» Human subjects research visits (involving direct contact) should be postponed unless the visit provides immediate benefit to the health or well-being of the participant

• Emergency Preparedness» Personnel working from home unless essential» Developing emergency preparedness documents for

essential human subjects research

Support Resources for our Providers• Taking Care of Our Own

• https://www.med.unc.edu/psych/wellness-initiatives/taking-care-of-our-own/

• Mental Health/Emotional Support Resources for co-workers and providers• https://unchcs.intranet.unchealthcare.org/Pages/2020/03-Mar/Coping-

with-COVID-19.aspx

• UNC Emotional Support Program• https://www.med.unc.edu/psych/wellness-

initiatives/integrated-emotional-support-program/

HOW TO TALK TO CHILDREN ABOUT COVID-19

Talking to Kids about the Virus

American Academy of Child & Adolescent Psychiatry: https://www.aacap.org/App_Themes/AACAP/Docs/latest_news/2020/Coronavirus_COVID19__Children.pdf

• Create an open & supportive environment so children are comfortable expressing their concerns and asking questions

• Explain the virus and the purpose of staying home with words/concepts they can understand based on their age, language, and developmental level

• Answer their questions honestly• Clarify what is known and unknown. Correct misinformation. Help them

find reliable sources. (Fact Sheets CDC/WHO.) Review together but not constantly

• Don’t let them watch too much television with frightening images and messages. This can be disturbing and confusing

Talking to Kids about the Virus: Reassurance and Validation

• Be prepared to repeat info/explanations several times – some will find this whole concept hard to understand. Asking over and over for some children is a way to ask for reassurance

• Be reassuring but don’t make any unrealistic promises

• Acknowledge and validate the child’s thoughts, feelings, reactions. Let them know you think their questions/concerns are important and appropriate

• Remember that children tend to personalize situations-they may worry about their own safety, family, friends, or relatives

American Academy of Child & Adolescent Psychiatry: https://www.aacap.org/App_Themes/AACAP/Docs/latest_news/2020/Coronavirus_COVID19__Children.pdf

Talking to Kids about the Virus: Structure and Self-Care• Balance the importance of flexibility and maintaining

structure• Children benefit from schedule and predictability• Remember old rituals and be open to creating new ones • Children learn from watching and listening to adults.

They will be interested in how you respond to news and will learn through listening to conversations between adults

• It is important in this time that everyone works on self-care (mindfulness, exercise, sleep, limiting electronics/ media, family walks, virtually connecting with family and friends). Direct conversations with children paired with modelling of self-care are very powerful interventions

American Academy of Child & Adolescent Psychiatry: https://www.aacap.org/App_Themes/AACAP/Docs/latest_news/2020/Coronavirus_COVID19__Children.pdf

Talking to Kids about the Virus: Who do we worry about?

• Children with history of psychiatric illness, anxiety, depression, trauma, etc.

• Children who have experienced serious illness or losses in the past are vulnerable to prolonged or intense reactions to news reports/images of illness or death

• Children whose family system is disrupted by illness, parental or financial stress

• Children who are preoccupied with questions/concerns about coronavirus should be evaluated by a mental health professional. Other signs that a child may need more help:

» Ongoing sleep disturbances, intrusive thoughts/worries, recurring fears about illness/death, reluctance to leave parents/return to school

American Academy of Child & Adolescent Psychiatry: https://www.aacap.org/App_Themes/AACAP/Docs/latest_news/2020/Coronavirus_COVID19__Children.pdf

Facilitated Questions and Responses

Thank you all!

Your compassionate, mission-focused, selfless approach to the care of children is heroic and truly appreciated!