A team from CHOC has published original research on the prevalence of COVID-19 infection among its Emergency Department workers during the early stages of the pandemic.
A key finding of the study, called PASSOVER (Provider Antibody Serology Study of Virus in the Emergency Room), suggests that most infections were transmitted through community exposure rather than co-workers, although the study stopped short of drawing a definitive conclusion based on the relatively small sample size of workers who agreed to be tested for SARS-CoV-2.
Researchers observed a seroconversion rate of about one new positive case every two days during the period from April 14-May 13, 2020, during which 143 CHOC ED personnel were repeatedly tested for the virus. They included doctors, physician assistants, nurse practitioners, nurses, medical technicians, secretaries, monitor technicians, and additional administrative staff.
“The acquisition of seropositivity in our study group appeared to follow a linear trend, which is not consistent with the exponential rate of growth that would be expected for transmission within a closely interacting group of people,” the study concludes.
The research project, the results of which were electronically published on April 9, 2021 in the Western Journal of Emergency Medicine, was led by Dr. Theodore Heyming, chair of emergency medicine at CHOC, and Dr. Terence Sanger, a physician, engineer, and computational neuroscientist and vice president, chief scientific officer at CHOC, and vice chair of research for pediatrics at the UCI School of Medicine. The other co-authors of the study are John Schomberg, PhD, CHOC’s Department of Nursing; and Aprille Tongol, Kellie Bacon, and Bryan Lara, all of CHOC’s Research Institute.
The study noted that there is limited data that is publicly available on the seroprevalence of SARS-CoV-2 among healthcare workers. Another of the report’s key findings was that rapid antibody testing may be useful for screening for SARS-CoV-2 seropositivity in high-risk populations such as healthcare workers in the ED.
In the CHOC study, blood samples were obtained from asymptomatic ED workers by fingerstick at the start of each shift from April 14-May 13, 2020. Each worker’s blood sample was obtained every four days until the end of the study period. In addition, a nasopharyngeal swab (NPS) was collected from each participant on the date of study entry.
At the time of the study, 35 percent of the participants had known exposure to a COVID-19-positive individuals within the preceding five days.
Depending on the method used for analysis, the seroprevalence of SARS-CoV-2 among CHOC’s pediatric ED workers ranged from 2 percent to 10.5 percent – levels that were slightly higher than those reported for the local general population, the study found.
“This study would benefit from replication at additional sites that draw from larger samples of ED staff,” the report says.
As the grip of the COVID-19 pandemic continues to weaken, Dr. Jasjit Singh, CHOC’s medical epidemiologist and medical director of infection prevention and control, recalls a ghost of outbreaks past.
Nearly five years ago, a mysterious outbreak of oral infections that eventually was traced to a clinic in Anaheim alarmed parents and dominated the local news.
The health crisis spurred Dr. Singh and a multidisciplinary team at CHOC, working with several community partners, to search for answers – and to provide optimal care for the patients, whose median age was 6.
Over 100 children were admitted to CHOC for evaluation, of whom 70 were confirmed cases, hospitalized for an average of more than a week.
Some suffered permanent tooth loss – as many as six teeth.
The culprit: a Mycobacterial abscessus infection that was detected after each child underwent a pulpotomy procedure, or “baby root canal,” to remove or treat an infected tooth at the Anaheim clinic between Jan. 1 and Sept. 6, 2016.
The outbreak turned out to be the largest ever of invasive Mycobacterial abscessus infections associated with a dental practice. The commonly occurring M. abscessus bacteria is found in water, dust, and soil, but it’s an uncommon cause of healthcare-associated infection.
Between July and September 2016, three patients were admitted to CHOC with atypical infections. All had some combination of facial cellulitis, dental abscess, and/or cervical adenitis that had been present for weeks.
“We had our first child present with what appeared to be a really unusual infection,” Dr. Singh recalls. “Our first thought was, ‘What’s wrong with this child’s immune system?’
“When the second child came in, one of my very astute colleagues, Dr. Negar Ashouri, ascertained that the child had been treated at the same dental clinic. She alerted the OC Health Care Agency immediately, who soon found unexplained symptoms brewing in other kids.”
A mobilized effort
The California Department of Public Health, the Centers for Disease Control and Prevention, and the Dental Board of California worked with the OC Health Care Agency (OCHCA) to investigate the infections.
The team at CHOC helped OCHCA with the epidemiologic and diagnostic probe. Of 1,081 at-risk patients, 71 case patients (22 confirmed; 49 probable) were identified.
Here at CHOC, 27 of the most severely affected children were treated with a complex regimen of antibiotics, including clofazimine, marking the largest number of children to ever receive that medication outside of treatment for leprosy.
Details of the work of Dr. Singh and many others recently was published by Oxford University Press on behalf of the Infectious Disease Society of America.
Publication of the paper, “Invasive Mycobacterium abscessus Outbreak at a Pediatric Dental Clinic,” was delayed a year and a half by the COVID-19 pandemic, Dr. Singh says.
The infections were caused by untreated municipal water the Anaheim clinic was using for drilling and irrigation during pulpotomy procedures. Because pulpotomies are not considered surgical procedure, sterile water is not required.
A change in state water standards
The work of Dr. Singh and an army of others led to a change in water standards for pediatric dental procedures in California.
In September 2018, the governor signed into law a bill that specified as unprofessional conduct the use of water that is not sterile or that does not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.
Dr. Singh is hopeful that the publication of the paper, whose listed authors include 11 CHOC physicians and three officials with the OC Health Care Agency, will lead to similar laws being enacted in other states.
As the paper puts it, “The authors believe the measure adopted in California for the use of sterile water for all pulpotomies is an appropriate standard which we would like to see embraced by the American Dental Association and state dental boards around the country.”
Dr. Singh credits the multi-disciplinary team for caring for the patients. The team included specialists in infectious disease, oral surgeons, ENT doctors, radiologists, dentists, pharmacists, and staff members of Providence Speech and Hearing, among others.
“These were normal, healthy children that were affected,” Dr. Singh says. “The multi-disciplinary coordination was a huge part of the success of this story. Still, many of the patients who lost permanent teeth will need dental rehabilitation in the future. It was a very difficult period for these families.
“We talked to national experts and really delved through whatever literature was out there,” Dr. Singh adds. “We all came together to get the kids and families through this with the least morbidity and the best long-term outcome possible.”
Debunking a fear that was widespread at the beginning of the COVID-19 pandemic, a novel CHOC- and UC Irvine-led study of SARS-CoV-2 infection rates among the K-12 population concludes thatwithin-school transmission of the virus is limited.
The “Healthy School Restart Study,” one of the first to provide essential research on COVID-19 transmission in children and adolescents as schools started reopening last fall, also concludes that although the compliance rate to such mitigation guidelines as wearing face coverings and practicing social distancing at the four Orange County schools directly observed by investigators varied, it averaged about 90 percent.
The seminal research paper is under review and is expected to be published soon, says Dr. Dan Cooper, who treats kids with lung conditions at CHOC and who serves as director of UC Irvine’s Institute for Clinical & Translational Science. Dr. Cooper is a multiple principal investigator of the study along with Dr. Erlinda Ulloa, a CHOC infectious disease specialist and an assistant professor in the Department of Pediatrics at the UCI School of Medicine.
“The number one fear was that, just like influenza, children would be a reservoir for COVID-19 and would spread it to each other at schools and then spread it to adults,” Dr. Cooper says. “The data is showing us, fortunately, that that’s not the case. While such spread can occur, it is limited and when schools follow standard mitigation procedures, spread is minimal.”
The study, a joint effort of CHOC, UCI Health and the Orange County Health Care Agency, found that infection rates at schools reflected those of the community, and that neither remote learning nor highly mitigated onsite school attendance could eliminate SARS-CoV-2 infection.
“It would be disingenuous to say it’s 100-percent safe to return to schools – we’re still in a pandemic,” Dr. Cooper says. “It would be wrong to say there’s absolutely no risk in sending your child back to school, but it would also be wrong to say there’s no risk in not sending your child back to school.”
A total of320 students ages 7 to 17, as well as 99 school staff members, participated in the research project by agreeing to nasal swab and blood testing. Two of the schools in the study serve low-income Hispanic learners. One school serves a high proportion of kids with special needs, and the fourth school serves predominately white kids from upper- and middle-class families. The first three schools mainly provided remote instruction, while the fourth school predominantly provided onsite instruction.
“The four participating schools reflected the enormous diversity of income, community COVID-19 case rates, school type (private, charter, public), and learning status (remote vs. onsite) that face learners, school staff, and policy makers across the United States,” the paper states.
The study was done in two phases – in early fall, when there were lower levels of COVID-19 cases, and a second time during the late fall-winter surge, when there was a tenfold increase in COVID-19 cases. Trained observers studied kids four times a day – during classroom learning, at active recess, during PE, and during communal lunch.
During the first testing phase, no kids tested positive for COVID-19. During the second phase, 17 kids tested positive for the virus, along with six staff members.
School A, which primarily serves lower-income Hispanic students and had 97 percent of its students engaged in remote learning, had the highest infection rate, at 12.9 percent. School D, which serves upper- and middle-class students who primarily attended class in person, had the lowest infection rate, at 1.2 percent.
In the aggregate, there was no statistically significant difference in SARS-CoV-2 positive rates among remote or onsite learners, the study found.
In addition, the study found there was a significant relationship between SARS-CoV-2 positivity and presence of symptoms – data that supports the use of limited symptom screening as a mechanism to enhance healthy school reopening.
Investigators also tested for 21 other circulating respiratory pathogens and turned up no signs of the influenza virus – just the common-cold rhinovirus, which stays functional on surfaces such as desktops for much longer intervals than the coronavirus or influenza virus.
“The mitigation procedures and cleanliness procedures that had been put in place got rid of the flu,” Dr. Cooper notes.
He adds: “This study should make parents feel better and prompt them to ask the right questions to their school. Parents should ask, ‘What are your mitigation plans? How are you making sure people are paying attention to your plan? What happens to a child who reports symptoms during the day? Do you have a plan?’ That’s what I would want to know as a parent.”
Mitigation procedures should remain
With widespread implementation of pediatric COVID-19 vaccination still many months away, it’s likely that adherence to COVID-19 mitigation procedures, including physical distancing and face covering, will need to continue for the near future, the study concluded.
Dr. Cooper notes that some students, mostly from lower-income families, are going on a year without in-classroom learning – an unfortunate situation that comes with many disadvantages, such as more sedentary time at home on the computer and increased obesity and depression.
“We have to weigh the damage to kids of keeping schools closed,” he says. “Who is being impacted most? It’s the low-income kids.”
In addition to Dr. Cooper and Dr. Ulloa, other CHOC and UCI personnel who participated in the “Healthy School Restart Study” included Jessica Ardo, Kirsten Casper, Andria Meyer, and Diana Stephens, clinical research coordinators; Dr. Charles Golden, vice president and executive medical director of the CHOC Primary Care Network; and Dr. Michael Weiss, vice president of population health at CHOC.
The authors of the research paper also acknowledged the “outstanding management” of the complex study by Phuong Dao, director of research operations; Brent Dethlefs, executive director of research; and other staff members of the CHOC Research Institute.
In another research paper, published in late February 2021 in the journal Pediatric Research, Dr. Cooper and Dr. Ulloa addressed the biologic, ethical, research and implementation challenges of SARS-CoV-2 vaccine testing and trials in the pediatric population.
Among others, the paper was co-authored by Dr. Coleen Cunningham, CHOC’s new senior vice president and pediatrician-in-chief, as well as chair of the UCI Department of Pediatrics, and Dr. Jasjit Singh, a CHOC infectious disease specialist.
Children under the age of 12, this paper notes, have yet to be enrolled in COVID-19 vaccine trials.
The paper states that enrolling children in medical research involves a balance between access to experimental but potentially life-saving therapeutics and protection from unsafe or ineffective therapeutics.
The paper notes that in the early stages of the pandemic, a national working group convened and published a commentary outlining the challenges ahead that would inevitably need to be addressed as schools reopened. That commentary, the paper says, included a message that resonates with the immediate challenge of pediatric SARS-CoV-2 vaccine testing and clinical trials:
“This could be accomplished by building public health-focused collaboratives capable of continuous learning and rapid cycles of implementation, as COVID-19 information evolves at breakneck speed. Otherwise, we risk further compounding the incalculable damage already incurred by COVID-19 among children across our country and the world.”
CHOC’s pediatric urology team, in a partnership with UCI Health, has published the largest study of its kind on an emergency condition that afflicts young males, adding to the emerging body of data on how the COVID-19 pandemic has caused patients to delay seeking emergency treatment.
Dr. Davis-Dao leads urology research efforts at CHOC to provide patients and their families with the most current, evidence-based diagnoses and treatments.
The lead author of “A Multicenter Study of Acute Testicular Torsion in the Time of COVID-10,” Dr. Sarah Holzman, a research fellow at UCI-CHOC, says the research paper is the only multicenter urology study and the largest one related to torsion and COVID-19. Most importantly, she adds, it’s the only study that shows patients were delaying presenting to the Emergency Department for testicular torsion.
The study’s key finding: Patients significantly delayed seeking treatment in the Emergency Department following the onset of symptoms of a testicular torsion during the early months of the pandemic, and, as a result, more of them had to have a testicle removed compared to patients with the same condition who sought care before the pandemic.
“This is the largest study of testicular torsion during COVID-19 and the first to show a significantly longer time from symptom onset to presentation (in the Emergency Department),” the paper states.
“Low baseline awareness of torsion may contribute to delays in care that were present even before the pandemic, making patients and their families less likely to present for emergency care during the pandemic when there is concern for exposure to COVID-19.”
Also participating as authors of the study were CHOC pediatric urologists Dr. Heidi Stephany, Dr. Kai-wen Chuang, Dr. Elias Wehbi, and Dr. Antoine Khoury, chief of pediatric urology at both CHOC and UC Irvine Medical Center.
Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the testicle’s blood supply. It presents as acute and severe scrotal pain that quickly worsens, as well as nausea and vomiting.
It’s a relatively rare surgical emergency, with an incidence rate of around 4 per 100,000 males per year in the United States. It most frequently occurs in males between the ages of 10 and 19, with one peak in the neonatal period and the second peak around puberty.
Surgery is required for all patients with testicular torsion.
When torsion is caught early — typically within the first six hours — a detorsion orchiopexy can be performed. In the detorsion surgery, the spermatic cord is untwisted and the blood flow returns to the testicle. The surgeon then secures the testis to the inner scrotum so it can never twist again. However, if patients delay coming to the hospital and the testicle does not have blood supply for several hours, the testicle may have to be removed in a procedure called an orchiectomy.
The CHOC-UCI led study involved a total of 221 patients enrolled at one of seven hospitals in the WPUC (CHOC, Children’s Hospital Los Angeles, Seattle Children’s, UC San Francisco, UCLA, UC San Diego and Western University in Ontario, Canada).
A total of 84 patients with testicular torsion, ages 2 months to 18 years, made up the first cohort. They were studied from March 2020 through July 2020.
The second cohort totaled 137 patients who were treated from January 2019 through February 2020.
The median time it took patients in the COVID-19 cohort to show up at the Emergency Department from the onset of symptoms was 17.9 hours, the study found. This compares to 7.5 hours for patients in the pre-pandemic cohort.
A total of 42 percent of patients in the COVID-19 cohort underwent an orchiectomy (removal of the twisted testicle), compared to 29 percent in the pre-pandemic population.
Other studies have shown that COVID-19 has caused people to delay Emergency Department treatment, including one that examined acute appendicitis from the New York metropolitan region and another similar study in Virginia.
During the last week of June 2020, 41 percent of U.S. adults admitted to avoiding medical care because of COVID-19 exposure concerns and 12 percent avoided urgent or emergent care, according to the Morbidity and Mortality Weekly Report, an epidemiological digest for the United Statespublished by the Centers for Disease Control and Prevention.
Drs. Holzman and Davis-Dao say they plan to continue the study as the pandemic progresses.
While there is less data about pediatric patients, emerging evidence shows that people infected with COVID-19 are at increased risk for myocarditis. Because of this, it is important that pediatricians appropriately evaluate patients before they are cleared to return to play as sports resume after a prolonged COVID-prompted off season.
Patients should be seen in the provider’s office for an in-person, formal evaluation and physical exam to determine clearance, recommend Drs. Kornswiet and Koutures. The following decision tree can aid in triaging patients, as well as providing consistent patient care. This decision tree is applicable to middle and high school athletes, as well as to those who compete in high-exertion activities and to other patients on an individual basis.
The California Interscholastic Federation recommends that if a patient’s infection was over three months ago, they had an asymptomatic, mild or moderate illness, and the patient has regained fitness or is back to full activity without symptoms, then they can return to sports as long as they have an active/recent preparticipation physical exam.
Once an athlete is cleared for a return to sports, Drs. Kornswiet and Koutures recommended that they go through a gradual and step-wise return to play. This is similar to the return-to-play protocol for concussions, and should be performed under the supervision of a physician and athletic trainer, if possible.
Each phase should last at least 24 to 48 hours and should not cause return of symptoms. If the athlete/student experiences a return of symptoms or develops unexpected fatigue, dizziness, difficulty breathing, chest pain/pressure, decreased exercise tolerance, or fainting, then they should stop their return progression and return to their physician for further evaluation.
These protocols are not substitutes for medical judgment, and additional queries should be directed to pediatric cardiologists or sports medicine specialists.
Following are more general return-to-sports guidance for parents and coaches: