The coronavirus disease 2019 (COVID-19) pandemic has urged countries to control severe acute respiratory syndrome (SARS)-CoV-2 transmission and to provide care for all affected persons. On January 30, 2020, the World Health Organization (WHO) announced that the COVID-19 outbreak was a public health emergency of international concern, and on 11 March, the WHO described the COVID-19 outbreak as a pandemic.1 As of April 14, 2020, 1,873,265 cases of COVID-19 have been reported worldwide, including 118,854 deaths.2 Europe is currently the most affected continent in terms of detected COVID-19 cases and deaths.2
Italy was the first country to be affected in Europe, with the first autochthonous patient diagnosed on February 20, 2020.3 National response actions to contain the pandemic upgraded from strict social distancing measures in 11 municipalities in Northern Italy, on February 23, 2020, to national social distancing and school closures on March 4, 2020 and culminated with the national lockdown on March 11, 2020. As of March 24, 2020, all of Italy’s regions had reported at least 1 locally acquired case of COVID-19, and all age groups have been affected; of 15,940 cases, 1.5% were children.3 Children accounted for about 2% of the diagnosed cases in China4 and 5% of the COVID-19-positive cases in the United States.5 In the United States, the percentage of children with COVID-19 needing hospitalization was between 1.6% and 2.5%.5
Healthcare facility preparedness is a key component of the response to the COVID-19 pandemic,6 and must ensure appropriate space, supplies and personnel, prioritize care, activate triage procedures, and train staff about infection prevention and control (IPC) and clinical management for COVID-19. In this article, we describe how the pandemic affected a tertiary care children’s hospital with a dedicated COVID-19 regional center in Italy.
MATERIALS AND METHODS
The Bambino Gesù Children’s Hospital [Ospedale Pediatrico Bambino Gesù (OPBG)] is an academic tertiary care children’s hospital located in the Lazio region, Italy, with 607 inpatient beds. The emergency department (ED) provides free urgent medical care on a 24/7 basis. In 2019, there were 89,558 ED visits, and 11,519 urgent inpatient admissions.
On January 24, 2020, OPBG was designated as the Lazio regional hub for children with COVID-196; ED flows were organized to separate children with fever and respiratory symptoms from other patients and IPC measures were enforced. At the regional level, individuals with fever and respiratory symptoms were discouraged from directly going to ED, and encouraged to call their general practitioners or the regional health emergency center, and follow the instructions given based on clinical history, signs and symptoms. If COVID-19 was suspected and the patient’s conditions were suggestive of clinical deterioration, the regional ambulance service was in charge of transporting the patient to the hospital. Starting from February 23, 2020, all patients and their parents were actively screened when entering the hospital using a structured questionnaire checking for fever, respiratory symptoms and possible contacts with COVID-19 cases, pretriage tents were set up, only one parent or relative per patient was allowed to enter the hospital and nonurgent outpatient visits except for hemodialysis and chemotherapy were suspended. In March, a two-floor building was dedicated to COVID-19 patients, with 1 unit for suspected cases and 1 for confirmed cases. Suspected patients transported by the regional ambulance service were admitted directly to the COVID center. Telemedicine tools for general practitioners and primary-care pediatricians were implemented.
Patients with fever and respiratory symptoms or those who had close contacts with COVID-19 cases underwent nasopharyngeal aspirates for SARS-CoV-2 qRT-PCR. The parents of these patients were also tested for SARS-CoV-2. Since February 28, 2020, nasopharyngeal aspirates for SARS-CoV-2 qRT-PCR had been performed for hematopoietic stem cell transplant and solid organ transplant recipients and donors8; since April 7, 2020, SARS-COV-2 nasopharyngeal aspirates had been performed in all children requiring surgery under general anesthesia. COVID-19 infection prevention measures9,10 were adopted for all individuals undergoing the SARS-CoV-2 qRT-PCR test, until COVID-19 diagnosis was excluded. If the SARS-CoV-2 infection was confirmed, these measures were continued until the patient was cured or was discharged home. Patients were considered cured after the resolution of symptoms and 2 negative tests for SARS-CoV-2 at ≥24-hour intervals.11 Patients and parents who were SARS-CoV-2 qRT-PCR positive and discharged home were instructed to maintain infection transmission precautions.
We analyzed (1) the number of ED visits and urgent hospitalizations and their distribution over time and patient characteristics (age: <1, 1–4, 5–9, 10–14, ≥15 years; sex; main diagnosis: respiratory tract infections, fever and infectious diseases; trauma and accidents; other diseases); (2) the number of individuals tested for SARS-COV-2, and their distribution according to test results [reverse transcription-polymerase chain reaction (RT-PCR) negative or positive], time and characteristics (age; sex; type of ward: ED, Covid center, other wards); and (3) characteristics of COVID-19 patients (age; sex; underlying chronic diseases; known exposure to COVID-19; access to hospital, by regional ambulance, through ED, or for transplant screening, symptoms; in-hospital admission; length of stay and outcome).
We considered 3 time-intervals, based on the different phases of COVID-19 pandemic in Italy, that is: (1) from January 1 to February 19, 2020, before the first COVID-19 Italian case; (2) from February 20 to March 10, 2020, before the national lockdown; and (3) from March 11 to April 20, 2020, during the lockdown.
Categorical data were summarized as counts and percentages, while continuous data were expressed as means and SDs or medians and ranges. To take into account the different duration of the three time periods, the numbers of visits and urgent hospitalizations were expressed in daily mean numbers. To determine statistical differences when comparing the three time-intervals of the study, we used the χ2 test or Fisher exact test for categorical variables, and ANOVA model for continuous variables.
Starting from February 20, 2020, ED visits dramatically decreased (Fig. 1), from a mean number of 239.1 visits per day in the period 1 January–19 February, to a daily mean of 180.2 visits in the period February 20–March 10, 2020 (Table 1). Since the lockdown, the mean number of ED visits had been reduced further to 79.6 per day, which was 66.7% lower than before the pandemic. The decrease of ED visits was statistically significant in all age groups and diagnoses, but was most evident in children <10 years of age, and for visits due to fever or infectious diseases (Table 1). The lowest decrease in ED visits was for home accidents (from 9.6 to 6.5 mean daily visits) (Table 1).
The decrease of urgent hospitalizations was less sharp than ED visits (Fig. 1), from a daily mean of 30.6 hospitalizations before February 20, 2020, to 21.2 during the lockdown (ie, a 30.7% reduction) (Table 1). The mean daily number of urgent hospitalizations for traumas and accidents did not significantly decrease over time; home accidents accounted for 24% of the urgent hospitalizations in this category.
The first suspected patient was tested for SARS-CoV-2 on January 29, 2020; as of April 20, 2020, 1970 individuals were tested, the daily number of tested individuals sharply increased after the national lockdown and continued to increase thereafter (Fig. 2). Overall, 1035 (52%) individuals were tested in the ED, 170 (9%) in the COVID center and 765 (38.8%) in other wards.
All the patients were negative to SARS-COV-2 RT-PCR until March 12, 2020, when a 1-year-old child associated with a family cluster was diagnosed positive for COVID-19 (Fig. 2). As of April 20, 2020, 52 individuals resulted positive (2.6%), including 33 patients and 19 parents. The proportion of confirmed infections was 1.2% for persons tested in the ED (12/1035), 21.1% in the COVID center (36/171) and 0.5% in other wards (4/764). The patients’ characteristics are described in Table 2; 26 patients (79%) were transported to hospital by the regional ambulance service because they were suspected cases, 3 (9%) followed the ED flow for suspected cases and one (2%) was tested within the screening program for transplant recipients. The median age was 6.7 years (range: 10 days–17 years), and 9 children (27%) had a coexisting chronic disease. Almost all the children (85%) had a known exposure, mostly linked to family clusters. Twenty-eight children had symptoms (91.2%) and 31 were hospitalized (94%), while the remaining 2 were discharged home. The median length of hospital stay was 7 days (range: 7–21 days).
As of April 24, 2020, 11 children were cured (33%); none required respiratory support. During hospitalization, all the children remained with 1 parent or relative, who were negative to SARS-COV-2 RT-PCR in 7 cases (21%).
Hospital physicians performed 875 telemedicine consultations, 745 (85.1%) of which with patients and families, and 130 (14.9%) with primary care pediatricians.
The COVID-19 pandemic has dramatically challenged healthcare systems and people’s daily life. To optimize the healthcare response, hospitals have been reorganized, elective activities drastically reduced and COVID hospitals opened. We found that measures taken to limit the pandemic have had a profound impact on the use of hospital services, with a 68% reduction in the mean daily ED visits and a 31% reduction in the urgent hospitalizations compared with the period before the confirmation of the first Italian case. This drop may be partly due to the lower risk of acquiring infectious diseases because of social distancing; in fact, respiratory tract infections, fever and other communicable diseases were the most frequent cause of ED visits before the pandemic and decreased by 90% during the lockdown. A less striking decrease in daily ED accesses regarded accidents, and in particular home accidents. The home quarantine during the lockdown may have been a risk factor for these events not only because children remained at home, but also because isolation increases the risk of domestic violence and neglect.12 In this unprecedented situation, pediatricians need to provide families with adequate education on home accident prevention, and to monitor the risk of domestic violence during all visits and telemedicine consultations.
In this study, we did not analyze appropriateness of ED access; it is possible that the reduction of ED visits was partly due to a decrease of hospital use for conditions that could be safely managed at home, consulting by phone the treating physician or with telemedicine tools. Further studies are needed to assess the use of phone consultations and telemedicine, and how the reduction in emergency and hospital use affected children healthcare needs during the pandemic. In fact, a delay in accessing ED has been documented for children during the lockdown in Italy,13 and is a reason of concern because postponing necessary urgent care for conditions such as acute appendicitis, diabetic ketoacidosis, abdominal or intracranial mass may have serious consequences.
The fear of exposing children to SARS-CoV-2 in the hospital setting may play an important role in limiting ED access. Parents’ fear of COVID-19 transmission should not be denied and must therefore be addressed by providing families with accurate information on the hospital’s actions of infection prevention and control.
SARS-Cov-2 PCR testing is a cornerstone of the COVID-19 response, because it enables to identify infected individuals and appropriately isolate them. We tested either children who were suspected for SARS-CoV-2 infection or were screened because of transplants or surgery under general anesthesia. In the COVID center, where suspected cases were hospitalized, the proportion of confirmed infections was 20.5%, slightly lower than reported by the fever clinic in Wuhan, China, where 25% of the people between 18 and 29 years of age were positive.14 However, in this study, there were no children, and the rate of positive cases increased significantly with higher age.14 In wards other than the COVID center, the proportion of infected individuals was 0.5%, comparable with the 0.6%–0.8% rate detected in the general population in Iceland in April 2020,15 which showed a slow spread of SARS-CoV-2 through the population. We can thus confirm that patient flows that separate children with fever and respiratory symptoms or known COVID contacts from all other patients, and the centralization of suspected and confirmed cases in dedicated COVID centers are essential to control the risk of SARS-CoV-2 in-hospital transmission.
According to our findings, the majority (67%) of the children with COVID-19 were linked to family clusters, as was observed in China where strict social distancing measures were implemented and 77% of the pediatric cases were exposed in the household.16 The incidence of transmission through school or community exposure could change when lockdown will end and restrictions will be reduced and will therefore need to be closely monitored.
As a crucial component of COVID-19 preparedness and response, hospitals that provide care to children should establish criteria for in-hospital stay of parents or family members. We allowed only one family member to remain with each suspected or confirmed patient, ensuring adequate IPC training. In most cases, parents of affected children were also positive to SARS-CoV-2. Disease in family members may profoundly affect children’s lives, because the mobility of other family members or friends is limited and there may be no adults who can remain with hospitalized children. Although our case series confirms that COVID-19 in children is rarely severe,16–18 the short- and long-term impacts of the pandemic on children’s health will deserve in-depth investigation.
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