Jeff Anderson MD, VP: External Medical Affairs

Thanks to all who were able to join our COVID-19 update call for community practices, both the providers in the community and our hospital leaders. Below you will find statements from hospital leadership as well as answers to several of your questions. We will continue to update our external website and send daily emails as information becomes available. Please continue to ask questions so we can support the hard work you are doing serving the children and families of Greater Cincinnati.

Patty Manning, MD: Chief of Staff

We greatly appreciate the front line efforts of community physicians. We know this is a stressful time for all, and the role you play in serving and supporting the children of our community cannot be overstated. As you have likely heard, the overwhelming majority of nonessential outpatient visits have been canceled or converted to a tele-visit format. Volumes at several locations are low enough to permit closure of three sites by end of business on Monday, March 23- Northern KY, Mason, and Eastgate. Services at other satellites will continue currently.

Nathan Timm, MD: Director of Emergency Response Team

We have in place an internal structured approach that provides a framework for all the relevant topics during this type of widespread crisis. The following are those primary areas of focus with some examples: Communications (up to date information on internal sites: Centerlink COVID-19 site; external sites: (www.cincinnatichildrens.org), Resources and Assets (PPE mindful use and testing efforts), Employee/Business Support (work from home, variable pay strategies), Patient/Family Care (visitor restrictions, clinical care algorithms), Facilities (focused social distances strategies, negative air flow rooms) and Safety and Security (visitor/employee screenings, employee exposure algorithms). Your questions and our answers

Question: We do not have a point of care flu test in our office. Should we send symptomatic patients to the lab for it? Are Cincinnati Children's labs open for seeing these patients?

Response from Patty Manning, MD: Chief of Staff

Cincinnati Children's labs are open at this time for testing for patients you feel need to be tested. We strongly encourage you to limit testing requests to those that are urgent, and/or will inform care moving forward. In mildly ill children, flu testing may not be indicated, if treatment plans are not impacted by this information. Question: I have reviewed the CDC guidelines regarding advice to give patients who will not be tested but are symptomatic regarding their return to everyday life. Just wondering if you have any further specific advice as far as when they can leave home? Should children with fever and mild symptoms managed over the phone be quarantined for 7 - 14 days? How should we manage patients with moderate symptoms?

Response from Lara Danziger-Isakov, MD: Infectious Disease/Infection Control

Anyone with symptoms (mild or moderate) should follow the CDC guidelines and stay in self-quarantine until both of the following are satisfied: afebrile for at least 72 hours without antipyretics AND at least seven days since onset of symptoms.

Question: Given that symptoms can be mild and coronavirus testing is not readily available, if a child has fever and cough and tests negative for the flu, should that child be told to quarantine? If so, how long do family members need to quarantine and at what point is it safe for the patient to no longer quarantine?

Response from Lara Danziger-Isakov, MD: Infectious Disease/Infection Control

Yes, See answer above. Family members in the house should stay at home and perform symptom monitoring for 14 days. Common symptoms are fever, dry cough, sore throat.

Question: Any further thoughts about the use of Tylenol or Ibuprofen in our pediatric patients that are going to present with fever and cough?

Response from Lara Danziger-Isakov, MD: Infectious Disease/Infection Control

Any patient who is on NSAIDs for an underlying disease should check with their individual provider. It is not suggested to modify their therapy without a discussion to avoid exacerbation of an underlying disease. We suggest that in patients who were not previously on NSAIDS for an underlying condition that NSAIDs be avoided and that acetaminophen be the preferred choice of antipyretic.

Question: Should staff who have recently traveled by plane be kept out of the office or have additional restrictions? Masks? No patient contact?

Please see exposed employee algorithm here.

Question: Should we actually counsel our older children not due for vaccines not to come in--to reschedule? Including pre-KG 4 & 5 year olds? With the governor's mandate on staying home it seems like well checks except under 18 mos. should be postponed?

Response from Shelly Voet, MD: Executive Community Physician Leader

This will be up to each practice; however, if routine clinical well visits could be deferred if immunizations are not needed or can be delayed.

Question: Do you have specific recommendations for offices in regards to well checks and ill visits. Do all well visits? Only under two years old? All ill visits to telemedicine?

Response from Shelly Voet, MD: Executive Community Physician Leader

Each practice will need to find its own balance. If able, converting as many ill visits safely to telehealth visits – with reflex to other care should the patient appear too ill to stay at home – should be considered. Many practices are using time or location to separate well and necessary ill visits (well visits in morning and ill in the afternoon, or using one location for sick and one for well).

Question: Per the AAP President, I am concerned about infant Wellness Visits for immunizations. Per the AAP President who sent two emails this week about this issue, are you recommending infants and toddlers ages 0-24 months continue to be seen for Wellness Visits especially if immunizations are to be given?

Response from Shelly Voet, MD: Executive Community Physician Leader

We strongly support the continued immunization of infants and toddlers during this time if possible. Strongly suggesting that a single guardian or parent accompany the child and leaving other children home should be encouraged if this is possible for a family to do.

Jeff Simmons, MD: Safety Officer Update on Cincinnati Children's testing for COVID-19: - We have enough testing kits, thanks to our ability of our researchers to make the viral media which is on short supply commercially, to support the CDC/ODH guidelines to test symptomatic, exposed health care workers, and patients who are hospitalized.

- We have tested very few patients to date, but have tested <70 health care workers due to possible exposures with the goal of getting them back to work sooner than the 14 day quarantine they might otherwise face.

- We have piloted this testing through the drive-by model, including a very small tests on some patients this past weekend. We want to have smoothed out challenges in the process so that when we have in-house, rapid turnaround, high throughput testing capability we will be able to roll out a safe, efficient process for patients and staff with the additional goal of also making locations convenient to patients.

Question: How close is Cincinnati Children's to having in house testing capabilities?

Response from Jeff Simmons, MD: Safety Officer

This is uncertain given the technical nature of getting in-house testing approved/validated and the supply chain for approved kits that we could use on existing machines. Earliest availability is likely not till next week, and even then the true scale is unclear. In-house would definitely improve turn-around times though—commercial labs are running 4-7 days.

Question: Is there sensitivity/specificity data on the pcr testing?

Response from Jeff Simmons, MD: Safety Officer

Great question, and while validated tests have to meet standards in this regard, the true test characteristics also likely depend on the patient’s status and the collection technique. Based on the existing known data from other places, PCR is likely to be highly specific regardless (very few false positives), but the patient and collection techniques could impact the sensitivity. CDC is promoting a test of cure/recovery as two negative PCRS collected more than 24 hours apart, but exactly how to operationalize that at the population level is tough. I’m not sure how our local health departments will manage this given the tests are still so limited.

Question: Any data or recommendation on the home testing that is being marketed?

Response from Jeff Simmons, MD: Safety Officer

We’ll have to see. From a pure clinical point-of-view, my guess is the value of testing for this virus won’t end up being that much more useful than viral testing in general, but the fear factor is so high, that I certainly would never fault anyone for seeking testing if it is available. I think home testing could become a critical public health strategy though once we get through this first wave, so that we can more quickly identify cases/clusters and use quarantine to stop community transition.

Question: Is there an antibody test being developed to determine immunity?

Response from Jeff Simmons, MD: Safety Officer

Dr. Fauci talked about that last night on CNN. Sounds like NIH is trying to develop some assays, but likely not ready for clinical use for months. Again, likely not going to do much for us in this phase, but potentially a good public health tool for subsequent waves. Cincinnati Children's is focused internally on the PCR first.