Moving toward a pandemic endgame

As Practice Improvement section editor for Contemporary Pediatrics®, over the past 2 years I’ve written many articles detailing how pediatricians can best modify their practices to cope with the COVID-19 pandemic. In the spring of 2021, COVID-19 cases were declining, adults and children aged 12 years and older were being vaccinated, and school children were returning to classes. My colleagues and I were looking forward to SARS-CoV-2 transitioning from pandemic to endemic status. But it was not to be.

Last fall, the SARS-CoV-2 Omicron variant began to infect individuals who were fully vaccinated and proved very contagious. In addition, unlike the delta variant, Omicron was frequently infecting children in schools and daycares, but fortunately most pediatric patients had a mild illness, with few children requiring hospitalizations. Contagious children were however bringing COVID-19 home, infecting vaccinated and unvaccinated family members, some with high-risk medical conditions.

As I write this in January of 2022, here in New Hampshire we are seeing 2000 cases per day (a state with a population of 1.4 million), a positivity rate of 20%, with 30% of those infected being 19 years of age or younger.1

I’d like to offer some recommendations for coping with the Omicron surge and suggest how we can play our best strategic “endgame” with the COVID-19 pandemic. As the eternal optimist, I believe in the spring of this year (or no later than summer), Omicron will decline and although other variants will likely emerge, we will at long last see COVID-19 transitioning to endemic status.

Testing for COVID-19 infections

Omicron infection rates are so high in New Hampshire that close to half of patients tested by my clinic because of symptom or exposure history are producing positive results.Given that these infections are presently mild, and symptoms resolve with supportive care, one can easily justify not testing suspect cases.However, one can consider in office testing given the following:

The backlog of drive-through and mail-in RT-PCR COVID-19 tests is so long in some states that patients sometimes get notified days after the test was performed, long after they have spread the infection to susceptible individuals.

Pediatricians should offer point of care testing in our offices as rapid results limit spread of COVID-19 in schools and within households. Point of care testing can guide return to schools and work, and limit exposure to high-risk individuals who are most likely to require hospitalization. Pediatricians should not fear performing in office testing as over the past few years there have been no reports of staff contracting COVID-19 from sample collection or testing.Prior to the pandemic, staff members did not contract influenza from performing point of care testing in pediatric offices.

Influenza point of care testing is performed with the same swab used to test for COVID-19 and ruling out COVID-19 infection or co-infection, allows pediatricians to consider antiviral therapy for influenza patients early in the course of their illness. The BD Veritor and Quidel Sofia antigen systems offer the ability to test for both viruses. This may have the benefit of limiting duration of influenza as well as limiting its spread.Similar benefit is expected for COVID-19 infections once anti-viral oral medications become available.

Keep in mind that the CDC recommends COVID-19 infected individuals isolate for 5 days and can return to work/school if they have been fever and symptom free without antipyretics for 24 hours after this period if they continue to wear an appropriate mask for 5 days further.This is not-unlike the CDC’s recommendations regarding when children can return to school following influenza.In many communities currently with elevated Omicron infection rates, testing is often required by schools and employers before allowing individuals to return to school and work.Antigen tests are generally considered reliable if performed within 5 days of symptoms onset, while office NAAT tests are more sensitive and can detect infections if performed within 7 to 10 days of symptom onset.Many believe that once the viral load falls below the threshold for detection by rapid antigen tests, infected individuals are very unlikely to transmit disease.

In my 2021 Tech Supplement to Contemporary Pediatrics® published in September I wrote about point-of-care COVID-19 antigen and nucleic acid amplification tests providing advice regarding which tests to use for screening patients for COVID-19 infection and detailing their relative accuracy. I noted that it is advantageous to diagnose a COVID-19 infection before a patient leaves the office and recommended that all pediatricians utilize an inexpensive SARS-CoV-2 antigen test as a first-line test. Consider a positive test a true positive, but also consider that a negative antigen may need serial antigen testing or testing with a more sensitive office nucleic acid amplification test (NAAT) or with a hospital or lab service real time PCR (RT-PCR) assay. If you already have a NAAT in your office that you use for influenza, RSV, and strep testing, purchase a quantity of the SARS-CoV-2 cartridges to be used if the antigen test is negative, but still suspect a COVID-19 infection.

Evaluating ill patients

Fortunately, most patients with Omicron have flu like symptoms, affecting the upper airway, and will benefit from symptomatic treatment with antipyretics and reassurance.A small number will have secondary ear infections and pneumonia, while a few will have wheezing or stridor. Practices need to be selective in how they see patients in the office, recognizing that many presenting with upper respiratory tract symptoms and/or sore throats will have Omicron. Many patients can be evaluated easily via telehealth visits.Parents can purchase an inexpensive high-resolution otoscope on Amazon.com for approximately $40 (with expedited delivery), and pulse oximeters are similarly priced. Using these devices and sharing images with physicians can help us make more precise recommendations re: when a child needs to be seen in the office, the emergency room - or just monitored at home. In many situations utilizing these tools will help physicians determine if antibiotics need to be prescribed.

One needs to be cautious if such patients are seen in the office.When rooming a patient with known or possible COVID-19, staff needs to wear appropriate personal protective equipment (PPE), including N95 masks. The Centers for Disease Control and Prevention (CDC) recently reported that not all KN95 from overseas manufactures have been evaluated and may be unreliable.2 Alternatively, many patients can be evaluated easily via telehealth visits.

Supporting parents and patients

It has been my experience that parents are requesting clearance letters for return to school or daycare following COVID-19 infections.In many situations it is beyond our ability to provide clearance without evaluating the patient without testing, or assurance that the patient is symptom free.In most circumstances your office can help direct parents to the most appropriate COVID-19 tests in the community or provide testing in your office.

Many adolescent pediatric patients are experiencing severe mental health (MH) issues exacerbated by the pandemic, and community MH services are inadequate to provide counseling.One solution is to advocate for our patients and formally request via letter that anxious or depressed adolescents receive counseling via the school psychologist or guidance counselor.Pediatricians need to be able to provide medication management where appropriate.

Reinventing pediatric practice

Once COVID-19 becomes endemic, we should look back at the past few years and consider the many lessons learned.We need to harden our practices against financial difficulties, continue to use telehealth to care for patients, and improve community MH resources. We must keep an ample supply of PPE for use in times of need, promote vaccination, and continue to practice good infection control when rooming ill patients.

References
1. NH.gov. COVID-19 New Hampshire. Accessed January 21, 2022. https://www.covid19nh.gov/

2. Centers for Disease Control and Prevention. Types of masks and respirators. January 14, 2022. Accessed January 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html