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?
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