EARLY CHALLENGES IN ISOLATION AND DE-ISOLATION OF CHILDREN DURING THE SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS-2 PANDEMIC.

Dear Editor,

Children frequently have viral acute respiratory illness (ARI) that is clinically indistinguishable from severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) infection. Appropriate investigation and disposition of children suspected of COVID‐19 is important to utilise negative pressure rooms efficiently. A de‐isolation algorithm for suspect adult cases has been described.

In our tertiary paediatric unit, from 22 January to 22 April 2020, we isolated 305 inpatients with ARI in a negative‐pressure or neutral‐pressure single‐bed room depending on ARI severity, epidemiological or contact risk factors and aerosol‐generating procedures. Two nasopharyngeal swabs ≥24 h apart were tested for SARS‐CoV‐2 polymerase chain reaction.

We summarise our isolation challenges early on in the COVID‐19 pandemic.

Active modification of clinical admission workflows for an evolving national case definition, while maintaining consistency with national and institutional guidance, and recognising that children are not little adults.

Some patients downplayed their symptoms and travel/contact history at admission, which were revealed only later during observation. Subsequent isolation of the child generated staff and patient anxiety regarding potential exposure. Exploring the patient's perception of COVID‐19 helped us obtain an accurate history which could otherwise be concealed to avoid testing and isolation.

Children with underlying comorbidities or frequent hospital visits were concerned for their safety and requested use of an isolation room when not required. Clear accurate information was provided to allay anxiety, manage expectations and ensure compliance to infection control practices.

Asymptomatic children required isolation throughout their incubation period if they or their caregivers were under quarantine after close COVID‐19 exposure, to avoid asymptomatic or pre‐symptomatic transmission.

De‐isolation of suspect cases with ongoing ARI symptoms was not straightforward. Polymerase chain reaction can be negative early in illness. Difficulty in obtaining a nasopharyngeal swab in young children affects test sensitivity. Identification of another causative pathogen makes COVID‐19 less likely but cannot exclude it due to possible co‐infection; SARS‐CoV‐2 has been reported with dengue and influenza viruses.2, 3 COVID‐19 respiratory deterioration usually happens at about 1 week ; observation for symptom resolution before de‐isolation may prolong hospital admission unnecessarily, as children may present early in illness, and rhinorrhoea and cough often persist for 2–3 weeks. Efficient inpatient management enabled quick, safe discharge to strict home isolation until recovery. Where bed occupancy allowed, we continued to isolate children with ongoing ARI needing unrelated inpatient care, under droplet instead of airborne precautions.

Optimal use of scarce isolation rooms will require rapid diagnosis and better understanding of SARS‐CoV‐2 transmission.

Conflict of interest

None declared.