Incidence of spread of clinically relevant SARS-CoV2 infection between children in a tertiary emergency department: An evaluation

Dear Editor

Grall and colleagues highlight that asymptomatic carriers are rarely potential viral transmitters in hospital.¹ Their study was in adults and to our knowledge spread in healthcare settings between children has not been reported. Leicester was the first area in the United Kingdom to undergo a localised lockdown with reports of relatively high numbers of children and young people affected.² Our evaluation aimed to identify the number of clinically significant SARS-COV-2 paediatric patients (age <18 years) presenting to our Children's Emergency Department (CED) at the Leicester Royal Infirmary (LRI), to investigate the effectiveness of infection control measures. We determined clinically significant infection to be that which prompted parents or carers to bring their child to the CED and be admitted. We highlight that national guidance in England determines only admitted patients are swabbed for SARS-COV-2. Clinical information was gathered by retrospectively looking at the attendances in Nervecentre^Ⓡ (the University Hospitals of Leicester NHS Trust Electronic Patient Record system, version 6.02). The contact tracing feature on NerveCentre^Ⓡ allowed us to find all patients in the department at the same time as an index case.

The CED at LRI followed national public health guidance when implementing infection control measures. Policies ranged from adopting rigorous hand washing and provision of Personal Protective Equipment (PPE) for patient contacts, to the separation of the department into “red” (suspected COVID) and “blue” (non-suspected COVID) zones (criteria in Fig. 1 ).

Fig. 1.

Criteria for directing patients in into the Red zone from the sieve during data collection period.

Our evaluation was submitted to the University Hospitals of Leicester NHS Trust Audit and Improvement committee (Identifier 10786) and ratified as a service evaluation project. Between 17th March 2020 to 31st July 2020, we saw 10,777 children in the CED. During this period 22 samples tested positive for SARS-COVID-19 by Polymerase chain reaction (PCR) (AusDiagnostics^Ⓡ and Cepheid Genexpert(^Ⓡ) for children admitted from the CED. Nearly all of the patients came through the red zone; 21/22 (95.4%). A 6-year old patient, managed as bullous impetigo with a course of antibiotics, presented with no COVID suspected symptoms and was placed in the blue zone. There was no overlap between any SARS-CoV-2 positive patients with any other patients who subsequently tested positive in the department. Thus, no clinically relevant COVID19 cross infection was noted.

Out of the 22 included patients presenting to the CED, 20 (90.9%) patients were admitted. The two that were discharged from the CED had a sample sent from the CED due to an initial plan to be admitted, which was later changed due to improvement in clinical status (one an infant presenting with suspected fever and inflammatory parameters within normal range and the second due to the referred speciality decision to discharge. All the other 20 patients were eventually discharged from hospital.

Out of the 22 SARS-CoV-2 positive patients presenting to the children's ED, 2 patients were felt to have the novel paediatric Inflammatory Multisystem Syndrome temporally related to SARS-CoV-2 (PIMS-TS), both needing paediatric intensive care stay. Children presented with lower respiratory tract infection (LRTI) (3/22) suspected sepsis (4/22), and Bronchiolitis (2/22). A single patient presented with each diagnosis of infectious gastro-enteritis, seizures, meningo-encephalitis, bullous impetigo, and perforated appendix as the primary diagnosis.

The average length of stay in hospital of the 22 included patients was 120.68 h (range 5–545 h; SD 127.48)

Our evaluation was designed to understand the cross-infection rates amongst paediatric patients presenting to our hospital and ensure we were deploying robust methods of infection prevention. No child who was in the department at the same time as a child who was subsequently found to be positive returned to be admitted with SARS-CoV-2 infection themselves. Therefore, there was no evidence of clinically relevant SARS-CoV-2 infection between patients in our department. However, it is important to note that only patients in whom the decision to admit was made, were the SARS-CoV-2 tests done, therefore the actual incidence of SARS-CoV-2 in our department would be very difficult to obtain. Also, as we did not swab patients unless there was a decision to admit them our results should also not be taken to indicate that any child with SARS-CoV-2 needs admission.

The COVID19 pandemic has presented unprecedented challenges to the healthcare infrastructure. In particular, there is limited number of high quality data on paediatric cases,³ largely due to infrequent symptomatic and severe infection in this population.⁴

In our Paediatric ED, we employed stringent methods of infection prevention. This included standard measures like hand washing, wearing of PPE (gloves, aprons and protective eye gear), and regular training (face-to-face and online) of staff. However, the measure that involved the biggest change in our way of working was a separation of the CED into “red” and “blue” areas based on the presence or absence of, respectively, fever, respiratory complaints (Fig. 1). This led to the creation of a standardised checklist to be used by staff employed in a “sieve”, who would direct patients to different areas using the symptom checklist. This in turn meant a substantial change in the way we work requiring staff allocation amongst the two areas, and challenges to overall oversight of the ED by medical and nursing team leaders as there could potentially be complex patients in both areas at the same time. Given children don't appear to be causing clinically relevant spread within our CED, and the numbers of positive cases are low, we believe that the current measures to split the departments are effective, but also perhaps, unnecessary.

This could be crucial in managing future CED patient flow, especially during the winters when the other seasonal viral infections are likely to overburden the services.

Contributions

DR conceptualised the initial data and MP and SP collected and collated data. MP wrote a first draft to which all authors contributed to and agreed a final version.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors report no competing interests.