Novel Coronavirus (COVID-19) Resource Guide for Employees & Healthcare Providers

Coronaviruses are a large family of viruses that typical cause a mild illness like the common cold. From time to time new coronaviruses emerge and have the potential to cause severe disease and global epidemics. Coronavirus Disease 2019, or COVID-19, is caused by a new respiratory virus, which is also sometimes referred to as SARS-CoV-2. This virus is different than SARS and MERS that caused previous outbreaks of respiratory illness. This virus was first identified as the cause of an outbreak in Wuhan, Hubei Province, China and has subsequently spread to more than 100 countries on several continents. Early cases were believed to be animal-to-human spread linked to a large seafood and animal market, but it is now known that person-to-person spread is occurring. 

Symptoms of those confirmed to have COVID-19 include fever, cough and shortness of breath. While most cases are relatively mild, some patients have had a severe respiratory illness. Severe respiratory disease is more common in the elderly and patients with medical co-morbidities. It is believed that symptoms may appear in as few as 2 days or as long as 14 days after exposure.

Coronaviruses are mostly spread from person-to-person through:

• Respiratory droplets produced from coughing or sneezing (especially within six feet of another person)
• Close personal contact such as touching or shaking hands

A person may also get infected by touching a surface with the virus on it, and then touching their mouth, nose or eyes before cleaning their hands. 

The general risk to those living in the US and Chicago remains low. The severity of illness of COVID-19 and risk of dying is less than other epidemics of new coronaviruses (SARS and MERS) over the past 20 years. Children and young adults are particularly likely to only have mild disease. However, reported cases of COVID-19 have already surpassed the prior SARS and MERS epidemics. At higher risk are those older than 60 years old and those with chronic medical conditions. 

We advise to take general measures that are effective for preventing all causes of respiratory viral illness, including:

• Wash hands with soap and water often. When soap and water is not available, use alcohol-based hand sanitizer. 
• Avoid touching your eyes, nose and mouth with unwashed hands.
• Avoid close contact with individuals who are sick.
• Stay away from public places such as work, school and daycare when sick. 
• Cover your cough and sneeze.
• Clean and disinfect frequently touched objects and surfaces such as phones, tables and doorknobs. 
• Also, teach your children to do the above.

At this time, laboratory diagnostic testing for COVID-19 is being conducted at the IDPH laboratory. CDC currently recommends collecting and testing clinical specimens from lower respiratory (sputum, tracheal aspirate, BAL) and upper respiratory (NP/OP swab) specimens only. Testing should not be ordered until IP&C has been contacted who will provide further recommendations. The COVID-19 strain can only be detected at a public health laboratory. The respiratory viral panel PCR test at Lurie Children's detects some coronavirus strains that cause the common cold but does not detect COVID-19. There is no cross reactivity between COVID-19 and the coronavirus strains on the respiratory viral panel PCR test.

There is no current antiviral treatment recommended for COVID-19 infection. However, scientists and public health officials are assessing whether certain antivirals and monoclonal antibodies can be effective treatments. Individuals who have been infected with COVID-19 will receive supportive care to help manage symptoms.

For all patients with a febrile and/or respiratory illness, staff need to ask whether they or their close contacts have travelled internationally within the past 2 weeks, with a particular concern for the countries with travel advisories as listed in the section below. Infection Prevention and Control will provide guidance for healthcare workers seeing ill patients with this travel history and who are suspected of having 2019-nCoV. If you suspect a patient may have COVID-19 based on their symptoms and travel history (i.e., a febrile respiratory illness and travel to China, South Korea, Italy, Iran, Japan, or Hong Kong in the past 14 days), please place on airborne/contact isolation (with additional use of eye protection). Additionally at this time, irrespective of travel history, we are advising that any child with a severe (i.e., requiring admission to the critical care unit) acute febrile respiratory illness of unknown etiology also be placed on airborne/contact isolation (with additional use of eye protection). This level of isolation would require gowns, gloves, eye protection, and either an appropriately sized N95 mask (based on fit testing results) or powered air purifying respirator (PAPR). If these scenarios arise, please contact Infection Prevention and Control at 7-4290 immediately.

If you are called by a patient with a history of travel to China, South Korea, Italy, Iran or other area with COVID-19 activity in the past 2 weeks, please ask about signs/symptoms of respiratory illness and/or exposure to someone known to have COVID-19. If a patient with a significant travel or exposure history has symptoms of a respiratory illness, the patient will require medical evaluation.

If a patient was exposed, but not yet symptomatic, additional education may be needed. Healthcare providers should report suspected symptomatic COVID-19 cases or known COVID-19 exposures immediately to Infection Prevention & Control via the 24 hours pager 7-4290 to guide plans for evaluation. Known COVID-19 exposures in an asymptomatic patient can be reported to Infection Prevention & Control within 1 business day. Please do not refer the patient to a medical facility without contacting them ahead of time so that steps can be taken to minimize exposure.

In addition to being a pandemic that none of us have experienced in our lifetimes, the recommendations for workplace safety are changing rapidly, leading to confusion. Initial recommendations were made out of a substantial abundance of caution until risk assessments could be completed and better understood. Now with a better understanding of risk to healthcare workers, we can now provide more streamlined recommendations for PPE that are fortunately more operational in ambulatory settings.

These recommendations are made with the expectation that eventually COVID-19 could be widespread in the community. Thus, these recommendations will keep you safe if or when children with COVID-19 present to your clinic. Currently, the prevalence of COVID-19 in the general community is very low but increasing. The prevalence of COVID-19 in the general pediatric community is even lower. We know in Seattle, where there is community transmission, the prevalence of COVID-19 among children tested for COVID-19 has been less than 1%. However, out of a desire to keep you as protected as possible, while also limiting unnecessary use of PPE, a real-time risk assessment is needed by providers. That risk assessment is based on likelihood of COVID-19 and the types of procedures that are performed. This is why there are some differences in PPE suggestions based on risk.  Current PPE guidance can be found here:

• Initial PPE Algorithm in Ambulatory Settings
• Initial PPE Algorithm in Inpatient Settings

The bottom line for the ambulatory setting:

1. Patients with respiratory symptoms who are masked pose a substantially lower risk to other patients and providers. Efforts to mask symptomatic patients and family members.
2. The types of procedures done in clinic (i.e., nasal/oral swabs, nebulizers, nasal suction) are lower-risk aerosol generating procedures than those that have airway manipulation below the vocal cords. Nonetheless, avoiding procedures may further reduce an already low risk.
3. In general, in the ambulatory setting, a procedural/surgical facemask and eye protection alone will substantially reduce risk to providers in nearly every situation. Other PPE will be situation dependent.
4. In addition to PPE, additional measures can be taken to reduce risk.

Please consider the following: 

1. Does my patient need to be seen?
   
   We have developed FAQs for families to reference.
   
   Message to parents and families prior to appointments about deferring routine care until respiratory symptoms have resolved. Also message to them criteria for being seen in clinic with respiratory symptoms and tested for COVID-19. Most patients with respiratory symptoms do not require evaluation or testing for COVID-19 at this time. Expectant guidance is essential.
   
   
2. Does my patient need a nebulizer therapy?
   
   Although nebulizer therapy is a low-risk aerosol generating procedure, avoiding nebs may provide an additional layer of protection. For example, advise asthmatics to bring their MDI and spacer to clinic to try and avoid nebulizers if possible. Consider using albuterol MDI instead of Xopenex nebs for the time being. Avoid nebulizer therapy for bronchiolitis.
   
   
3. Does my patient need to be swabbed?
   
   Although oral and nasal swabs are a low-risk aerosol generating procedures, avoiding swabs may provide an additional layer of protection. Please be familiar with clinical indications for swabbing for group A strep and influenza. For example, cough and lack of exudates are low risk for group A strep. In the outpatient setting, patients with more than 48 hours of symptoms and who are at low risk for complications do not need influenza testing. You can consider empirically prescribing Tamiflu to high-risk children without testing; currently likelihood of influenza in children with a compatible illness is around 35-40%, but this will continue to decline. RSV is rapidly declining in the community, reducing need for RSV testing. In terms of COVID-19 testing, confirming the diagnosis is unnecessary in many instances of mild illness in otherwise healthy children. Additional guidance for COVID-19 testing of outpatients will be available to providers shortly.

The susceptibility of pregnant women to COVID-19 is largely unknown but initial reports suggest risk is relatively low. While pregnancy is not necessarily an exclusion for providing care to a patient with suspected or confirmed COVID-19, it is prudent for pregnant healthcare workers to limit exposure, especially during aerosol generating procedures. 

We anticipate travel restrictions will continue to change rapidly over the next several weeks to months. Thus, it is possible that travel and return-to-work restrictions may be expanded to other countries in the future. If you anticipate any future international travel, please stay abreast on travel advisories here: https://wwwnc.cdc.gov/travel/notices.

When considering spring travel, make sure you can check off all the following items:

• All travelers and their close contacts do not have underlying high-risk conditions
• All travelers have received the flu shots
• You're not traveling to destinations "restricted" by the Centers for Disease Control and Prevention or the U.S. State Department
• Your trip is not a cruise 5. There are no major events after the trip that would be problematic if travelers were quarantined for a period of time.
• Anxiety about COVID-19 will not ruin the trip.
• Travelers are reasonably able to implement common preventative measures such as washing hands and keeping hands away from the face.
• Your regret will be manageable if you or a family member were to get COVID-19.

Level 3 travel advisories are currently in place for mainland China, and now additionally South Korea, Iran and most of Europe. This means that you should avoid ANY non-essential travel to these countries. Thus, the following policies are effective immediately:

• Staff returning from mainland China, South Korea, Italy, or Iran will need to be under self-quarantine (i.e., home monitoring) for 14 days before returning to work, starting from the first day of return home from travel. Staff who traveled to China or South Korea before this updated policy went into effect will be on paid leave during these 14 days and will not need to use their PTO hours.
• Staff are temporarily restricted from traveling to mainland China, South Korea, Italy, or Iran for any professional, job-related activities without prior approval from the Medical Center via the Chief Executive Officer.
• Staff who choose to travel to mainland China, South Korea, Italy, or Iran for personal reasons will need to use PTO for their 14-day self-quarantine before returning to work, unless prior approval from the Medical Center via the Chief Executive Officer is obtained. 

To optimize safety in the setting of a rapidly evolving public health issue, if you have travelled internationally anywhere outside of North America, South America, or the Caribbean in the past 14 days and develop fever or respiratory illness, please DO NOT report to work. Additionally, if a household contact has travelled internationally (outside of North America, South America, or the Caribbean) AND becomes ill with fever or respiratory symptoms, also please DO NOT report to work. If these situations occur, please then call the Return from Travel Abroad telephone line at 312.227.2300 for a telephone triage health screening. Employee and Corporate Health will work with Infectious Prevention and Control to define return-to-work status.

Our number one priority is to keep patient/families, healthcare workers, and staff safe. At Lurie Children’s, since 2014, we have had a High Consequence Infectious Diseases (HCID) team that focuses exclusively on preparedness efforts for rare pathogens of high clinical and/or public health significance. We prepare healthcare workers throughout the organization by providing information about how to rapidly identify patients at risk for coronavirus and prepare protocols for safely evaluating and treating those patients. We monitor epidemiology of coronavirus daily and get debriefings from the Chicago Department of Public Health weekly. This information is crucial for rapidly modifying policy and clinical practice recommendations in real time. We communicate important updates to our patients/families, healthcare workers, and staff promptly as needed. By doing the above, we are confident that we can continue provide safe, effective, and compassionate care, even during an infectious diseases outbreak.

As of March 10, 2020, all events to be held at Lurie Children's Facilities including the main hospital involving non-employed staff should be cancelled. The duration of this policy will be based on COVID-19 epidemiology but current CDC estimates are that this could go for three months.

These meetings and events can be moved to a non-Lurie Children's facility outside of the main hospital and/or have a dial-in option to avoid large numbers of outside personnel at the hospital.  

When moving meetings to a non- Lurie Children's facility with non-hospital personnel, please request that attendees have no respiratory symptoms and have not travelled internationally to high risk areas in the last 14 days. As always, remember to use proper hand hygiene and sensible social distance.

As we see an increase of confirmed COVID-19 patients in Illinois and across our health system, we have, and will continue to implement policy changes to ensure we effectively care for patients and maintain the safety of our workforce.

Effective March 12, we are implementing a temporary foreign and domestic business-related travel ban for all faculty and staff, and suspension of external events or conferences in all Lurie Children's facilities through April 15th or sooner, if conditions warrant.

Please contact the Accounts Payable Department regarding changes to your business travel plans. We are aware that many organizations have cancelled or are contemplating cancelling upcoming meetings and conferences due to the ongoing travel concerns. The Medical Center has elected to reimburse fees incurred due to these unforeseen business travel changes and/or cancellations.

For business travel arrangements made through our travel partner, Uniglobe Travel Designers, please contact them directly to process any changes and/or cancellations needed. Uniglobe works with the major airlines including United, Delta, and American Airlines to waive change fees on our behalf. They will also work with the hotels to have fees waived when possible. They can be reached Monday thru Friday from 9:30am – 4:00pm at luriechildrens@uniglobetd.com  or 614.237.4488 and after hours at afterhours@uniglobetd.com or 800.966.6512.