Coronavirus: what providers should know

What is coronavirus?

Coronaviruses is one of a large family of viruses worldwide. Many coronaviruses cause mild upper respiratory infections, but coronaviruses that infect animals can evolve and become a new human coronavirus strain. These can cause more severe illness. The current outbreak, which began in Wuhan, Hubei Province, China, is known as 2019-nCoV and has spread to several other countries, including the U.S.

What can I tell patients who are concerned about coronavirus?

If a patient and their family have not recently traveled internationally, the risk of acquiring 2019-nCoV right now is low, says Dr. Jasjit Singh, a pediatric infectious disease specialist at CHOC Children’s.

“Please remind your patients that at this point in our community, influenza is a more immediate concern,” says Dr. Singh. “We are in the midst of influenza season, and thus far in the U.S., the CDC has reported 15 million cases of influenza, including 8,200 fatalities – 54 of which have been children. Therefore, a good way to avoid a severe respiratory illness is to get the influenza vaccine.”

How can patients and families prevent coronavirus infection?

There is no vaccine for 2019-nCoV. The best way to prevent infection is to avoid exposure in the first place. As of Jan. 27, 2020, The CDC has recommended that people avoid all nonessential travel to China.

What was the source of the 2019-nCoV outbreak?

Public health officials are still working to identify the source of the 2019-nCoV outbreak. Many of the earliest patients infected had links to a large seafood and animal market, suggesting animal-to-person spread. However, recent patients have not had exposure to animal markets, suggesting person-to-person spread is occurring. This can happen via respiratory droplets spread when someone with coronavirus coughs or sneezes.

What are symptoms of coronavirus?

Reported illnesses have ranged from people showing little to no symptoms to severe illness and death. Symptoms of coronavirus can include fever, cough and shortness of breath. Symptoms can appear in as few as two days after exposure to as many as 14 days after exposure.

Currently, diagnostic testing for 2019-nCoV can only be done at the CDC. The respiratory pcr panel at CHOC Children’s (RP-pcr) tests for 4 routine strains of coronavirus and does not pick up this strain.

What should I do if I suspect a patient has contracted coronavirus?

Patients in the U.S. who meet the following criteria should be evaluated as a patient under investigation (PUI) in association with the outbreak of 2019-nCoV in Wuhan City, China:

  1. Fever AND symptoms of lower respiratory illness (e.g., cough, shortness of breath), and in the last 14 days before symptom onset:
    • a history of travel from Wuhan City, China
      or
    • close contact with a person who is under investigation for 2019-nCOV while that person was ill
  2. Fever OR symptoms of lower respiratory illness (e.g., cough, shortness of breath), and in the last 14 days before symptom onset:
    • Close contact with an ill laboratory-confirmed 2019-nCoV patient

If a case of nCoV is suspected, providers should notify infection prevention staff at their facility immediately, as well as local or state health officials.

What precautions should providers take when seeing patients?

Providers who care for patients with respiratory illness should take the following precautions:

  • If caring for patients with respiratory symptoms and fever, obtain a detailed travel history.
  • Continue to evaluate for other common respiratory illnesses currently circulating, such as influenza and RSV.
  • In addition to standard precautions, use Airborne and Contact with an N95 mask, eye protection, gown and gloves.
  • If a provider suspects a patient has contracted nCoV, they should notify both infection prevention at their facility and local or state public health authorities immediately.

Leprosy antibiotic is safe treatment for M. abscessus infections, CHOC infectious disease team finds

An oral antibiotic used to treat leprosy is safe and well-tolerated in the treatment of children with challenging-to-treat mycobacterium abscessus infections, the CHOC Children’s infectious disease team has found.

In their study, clofazimine was given to 27 patients during an outbreak of odontogenic mycobacterial infections as part of a multidrug regimen. Though clofazimine performed well in test-tube experiments against M. abscessus, reports in children were previously limited.

This group of patients represents the highest number of children to receive clofazimine outside of leprosy treatment settings.

The study findings were published in the July 2019 Journal of the Pediatric Infectious Disease Society. Its authors are CHOC infectious disease specialists Dr. Felice Adler-Shohet; Dr. Jasjit Singh; Dr. Delma Nieves; Dr. Negar Ashouri; and Dr. Antonio Arrieta; as well as Cathy Flores, a CHOC clinical research nurse coordinator, and Tuan Tran, an infectious disease pharmacist at CHOC.

The patients who received the antibiotic were among a large group of children who underwent pulpotomy procedures at a dental practice with a contaminated water system.

CHOC’s team added clofazimine to its original first-line medication regimen after receiving special use approval from the Food and Drug Administration.

An additional benefit of use of clofazimine was the ability to stop use of an intravenous antibiotic given thrice daily that prompted many side effects, the team found.

Learn how to refer a patient to CHOC Children’s infectious disease specialists.

CHOC Becomes SCID Referral Center

CHOC Children’s is pleased to have recently become a referral center for severe combined immune deficiency (SCID), filling a regional gap that once required Orange County infants to go outside the county for care.

Led by Drs. David Buchbinder, Wan-yin Chan, Diane Nugent and Jasjit Singh, the immunodeficiency program is a multidisciplinary effort crossing multiple specialties at CHOC including allergy and immunology, hematology and infectious disease

Though they appear healthy at birth, infants with this primary immunodeficiency disease lack T lymphocytes, one of the white blood cells that help fight infections. 

Babies with SCID cannot fight even the most innocuous infections and often die. The condition is considered by the medical community as a pediatric emergency.

“Prior to development of SCID newborn screening, the diagnosis would be delayed,” Dr. Chan says. “Often times these patients would not get sick until after 6 months of age. No one would know they were affected until the antibodies from their mother would wane. They end up with life threatening infections with serious complications often resulting in death.”

However, studies show that early bone marrow or stem cell transplants can improve outcomes significantly, Dr. Chan says.

Survival rates increase to 94 percent if administered to an affected infant by age 3 ½ months. However, if transplants occur after that age, survival rates increase to only 70 percent, underscoring the importance of early detection and intervention. 

To that end, California became one of the first states to add SCID to its list of recommended newborn screenings in 2010. In the years since, all states have followed suit. 

Under CHOC’s program, immunodeficiency team physicians review each case of Orange County babies who test positive in newborn screenings for SCID and ask parents to immediately seek a confirmatory blood test for the infant, Dr. Chan says.

If the additional tests confirm the diagnosis, patients are urgently admitted to CHOC for workup and treatment, Dr. Chan says.

Since CHOC’s center was formed in August, more than 20 patients have been flagged in the surrounding communities and each individual case has been reviewed by the immunodeficiency team in collaboration with local pediatricians.

Those urgent blood tests confirmed the presence of SCID or a SCID-like disorder in more than 25 percent of cases thus far. 

Protect Infants from Next Wave of Pertussis

The California Immunization Coalition, along with Dr. Jasjit Singh, director, infection prevention and epidemiology at CHOC Children’s, recommend the following pertussis guidelines for pediatricians and their patients.

As pertussis increases to peak levels every 3- 5 years, California is due for its next epidemic by 2019. Young infants remain at highest risk of hospitalization and death from pertussis. Since 2010, at least 2,800 California infants younger than four months of age have contracted pertussis. Most of these infants have been hospitalized, and at least 18 have died.

Please consider the following measures to protect infants against pertussis:

Prevention

  • Prenatal Interview – Promote Prenatal Immunization! Remind parents and prenatal providers to give prenatal Tdap vaccine to women between 27 and 36 weeks of gestation of each pregnancy, regardless of vaccination history. Encourage vaccination of household and caregivers.
  • Administer the first dose of DTaP vaccine to infants promptly at 6-8 weeks of age. A dose as early as 6 weeks will help protect infants sooner if their mothers did not receive Tdap during pregnancy. Complete the DTaP series without delay.
  • Maternal immunization is associated with infant survival. Receipt of Tdap by mothers between weeks 27 and 36 of pregnancy and receipt of DTaP by infants prior to illness greatly reduce the risk of death from pertussis.

Presentation

Pertussis should be considered in any infant without a documented fever who presents with coryza, cough (especially paroxysmal), apnea, gagging, or post-tussive emesis.

Suspect pertussis in adolescents and adults with prolonged cough, and test and treat promptly to prevent transmission to infants.

Testing

Obtain nasopharyngeal swabs for pertussis PCR testing to confirm the diagnosis. Additional guidance is at www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html.

  • In infants, check white blood cell counts with differential – a leukemoid reaction is associated with life-threatening pertussis. A WBC count greater than 10,000 cells/mm3 with ˃50% lymphocytes should be repeated 24 hours later; increasing lymphocytosis should prompt additional monitoring and treatment. A WBC of >20,000 cells/mm3 with >50% lymphocytosis should be considered as a very strong indication that the infant has pertussis.

Treatment

Azithromycin (10mg/kg/day in a single dose for five days) for infants less than 6 months of age.

Empiric treatment is appropriate while awaiting the results of PCR testing.

Additional clinical guidance and access to consultation can be found at eziz.org/assets/docs/Pertussis-YoungInfants2011.pdf.

Further information, California case counts, and clinical guidance for pertussis can be found here.

 

Nasal Flu Vaccine Not Recommended This Season – What Patients and Families Should Know

An advisory committee of the Centers for Disease Control and Prevention (CDC) recently recommended that the nasal spray influenza vaccine not be used this upcoming flu season. In this Q&A, Dr. Jasjit Singh, medical director of infection prevention and control at CHOC Children’s, offers an explanation for your patients and their families.

Q: What does this mean for influenza vaccine recommendations for the upcoming flu season?

A: All individuals over the age of 6 months are recommended to get the influenza vaccine, and that will continue to be the case.  However, for this season at least, the nasal flu vaccine is not an option. Therefore, parents will need to plan for their children to get the flu shot this upcoming season.

Jasjit Singh, M.D.
Jasjit Singh, M.D.

Q: How does the standard flu shot differ from the nasal spray version in terms of composition and effectiveness?

A: Both the flu shot and the nasal spray contain the anticipated predominant circulating strains of influenza every year, but the nasal spray strains are made of weakened live virus while the flu shot is made of inactivated viral components. The CDC reviewed data from this past season that suggested that the nasal spray did not perform as well as it had in the past.

Q: Besides ensuring their children get a flu shot, what else can parents do to help prevent the flu?

A: In addition to ensuring their child is vaccinated against the flu every year, there are many things parents and other caregivers can do to help prevent the flu. Use proper hand-washing techniques, use respiratory etiquette, and stay home from work or school if you are sick with the flu, to prevent spreading it to others.

Q: What do you anticipate will be parents’ reactions to this recommendation? Is there anything else you’d like them to know? Is there anything else you’d like to share with parents about the importance of vaccinations?

A:  Vaccinations are one of the most effective public health measures that have been developed and they save thousands of lives each year. Influenza vaccinations are important because young children can get quite sick from the flu, and some even require hospitalization. Every year there are pediatric deaths in the U.S. due to influenza, about half of which occur in normal healthy children. Children can pass influenza on to the elderly or other fragile members of our community. It’s important for adults to get the flu shot too, particularly those who are caring for young children. Even though the nasal spray is not an option for vaccinating this particular season, it is still important to have your child vaccinated for this year.