Pandemic Times

As we sit in lockdown silence with empty hospitals and consulting rooms, a word or two on Cape Town winters is worth sharing.
No doubt the lockdown is protecting kids from exposure to other viruses and other pathogens which are so freely shared at crèches and schools, but a time of “opening” will come and like with Corona, a period of isolation will have slowed down the spread and annual herd immunity of other important pathogens, most notably, influenza and RSV. Will we see an explosion of these as well, as, it is unprecedented and not often considered, but a very real possibility?

As frontline healthcare professionals, particularly Family Practitioners, or as they should be better known, those who still remember most of what 6 years taught us doctors, who will we see and how? As coronavirus spreads through the community, questionnaires to help tease out travellers will be a waste of time and yet we will need to decide who needs to be seen, and in paediatrics like veterinary medicine, teasing out signs and symptoms can be tough, and missing things have even more severe consequences.

As we know, kids get sick quickly, but more importantly with good care do extremely well. From leukaemia to diabetes, children are arriving late in centres where the Corona Pandemic has taken hold. Communications locally and in the UK show a reduction of 40-50% in emergency room paediatric arrivals due to lock down and fear of exposure, which in this recent review from Italy shows in many cases lethal consequences.

Throw into the equation our fear of contracting the virus ourselves, transferring it to our staff and colleagues or even worse our patients or other members of the public sitting in waiting rooms; this whole process of decision making becomes almost impossible. The HPCSA is considering its options regarding telemedicine, currently not practical at all, and insurers are equally unsure. Let’s face it, examining a child is a unique experience, not just with every child but with every visit with the same child.

Is it right, or even possible, not to examine their chests or throats when a source for temperature is being saught? Do we hand out antibiotics like lollies and hope we catch most things in our net? Add to this, incomplete vaccination will, for the next few months/years, be the norm; food supplies and reliance on left-over food common; flu vaccine “hoarding” away from the neediest routine and parental fear even more heightened, all while winter creeps into the southern hemisphere.

So where are the advice and the good news? Well, this pandemic, if nothing else, has been kind to the kids, and as the pandemic emerges in Cape Town, it will as in most centres show up in kids as part of family clusters. This in itself is a clue already.

Anecdotally, my first COVID-19 positive child presented with croup, atypical in that there was no preceding coryza but a father with flu-like symptoms and fever already commenced on Tamiflu. So we can look out for “family” illnesses but this holds true for Influenza, parainfluenza and many other winter viral illnesses. The same pattern was seen by Chinese clinicians with children “gradually presented with fever, fatigue, dry cough, accompanied by other upper respiratory symptoms including nasal congestion, runny nose, and seldom gastrointestinal symptoms such as nausea, vomiting and diarrhoea.”

So let’s quickly try and analyze why kids are doing so well; we know RSV attacks the youngest and most vulnerable with severe morbidity and mortality to the point of us fighting for Synagis (passive immunization) for the at-risk ex-prem, cardiacs and other vulnerable kids. But it does seem that it is the immune weakness, particularly of underproduction of Interferon(IFN) in children, that though making them susceptible to viral U/LRTIs does specifically in this Corona seem to lessen the immune destruction/reaction or cytokine storm in the lower airways as seen in adults. Saying this though, it must be qualified that beyond, the by now well-known risk factors of age, diabetes, hypertension, ischaemic heart disease, asthma and obesity there is a phenotype and heavy initial viral load that does increase the risk of ARDS/pulmonary (HUS-like) microvasculopathy. In small Chinese reviews of paediatric patients, “35% of patients had a previously diagnosed congenital or acquired diseases”. So what are you supposed to do?

I suggest sticking to the basics we all know:

• • Remember firstly that 30-40% of Covid-19 + children are asymptomatic, so treat everyone as infected.
    Covid-19 disease in children will be mild/moderate (90%) and 60% + will present classically with fever and a dry cough. There seems to be a shortened incubation time in children.
  • Try and be available for your practice. It will free up other hands. Get familiar with WhatsApp, Skype, Zoom and Clickdoc for consultations.
  • Know the codes/costs and inform patients, take consent and allow them to discuss with their medical aids where necessary.
  • Take a good telephonic history, record it or take careful notes and get the parents to have growth charts and vaccine information ready.
  • Parents can take a photo and WhatsApp this information through.
  • Use cellphone cameras at home or with parents in your rooms to assess rashes and throats.
  • Make a summary and email/WhatsApp this to the patient to confirm the plan.
  • Provide your patient group with access to simple healthcare info and resources. I have an A to Z of items on my website. Feel free to copy.
  • Make sure patients understand the risks and benefits of where and which doctors to visit.
  • Provide masks for staff. Ensure safe areas with regular and appropriate cleaning. Full PPE is not practical for everyday duties, but a mask (+/- eye protection) and scrubs to change before exposure to a family is essential, as is hand hygiene, glove-wearing and disposable apron use.
  • Try and work in a team, seek advice, wear full PPE if an infection is suspected OR any aerosol producing procedure.
  • DO NOT NEBULISE.
  • Be prepared to administer MDI bronchodilators to the maximum dose.
  • Avoid (DO NOT) look into throats!
  • Observe chests rather than listen to them.
  • Oxygen saturation can help make many decisions right now, from Corona to RSV.
  • Remember 2 basic principles of “do no harm” and you are not medically useful sick or dead.

Written by Dr Paul Sinclair (Paed. Vincent Pallotti) Edited and contributions Dr Karin Van Niekerk (Paed. Milnerton Mediclinic) UK experience Dr Colin Bernstein (Manchester)