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COVID-19 Pandemic ResponseRecommendations for Modified Enteric Precautions KU Pediatric Hospital MedicineRecommendation:All patients with vomiting or diarrhea should be placed on enteric precautions. During this pandemic, patients otherwise on enteric precautions should instead be on full Contact/Droplet Precautions with Eye Precautions to follow the “Blue Sign” precaution recommendationsGownGlovesSurgical maskFace Shield or gogglesClean stethoscope between each roomLimit exposure to all staffDue to risk of transmission through urine/stool, parent or caregiver encouraged to change all diapers. Due to risk of aerosolization with toilet flushing, we will encourage parents to perform all flushing duties. If staff flushes toilet they should be wearing full contact/droplet precautions with eye protection, the hallway door should be shut and the bathroom door should be shut immediately after flushing. Rationale:In a case series of 20 pediatric patients with confirmed COVID-19 positive test, 15% had diarrhea and 10% had vomiting1.Characteristics of 2143 pediatrics patients with confirmed or suspected COVID-19. Described that some cases may only have digestive symptoms of nausea, vomiting, abdominal pain and diarrhea2.Study of 204 patients with confirmed COVID-19. longer time from onset to admission than patients without digestive symptoms (9.0 days vs. 7.3 days). Patients with digestive symptoms had a variety of manifestations, such as anorexia (83 [83.8%] cases), diarrhea (29 [29.3%] cases), vomiting (8 [0.8%] cases), and abdominal pain (4 [0.4%] cases). In 7 cases there were digestive symptoms but no respiratory symptoms. As the severity of the disease increased, digestive symptoms became more pronounced. Patients without digestive symptoms were more likely to be cured and discharged than patients with digestive symptoms (60% vs. 34.3%)3. Case series of 10 pediatric patients with confirmed COVID-19. They the pattern of viral excretion from respiratory and gastrointestinal tracts in all ten patients by a chronological series of nasopharyngeal and rectal swab samples using real-time RT–PCR.). Patient 4 was asymptomatic but tested positive on multiple occasions. Patient 6 was asymptomatic on the day his nasopharyngeal swab tested positive and then developed nasal congestion and rhinorrhea the following day. The remaining eight patients had positive tests soon after the onset of symptoms. In addition, eight of ten patients also had real-time RT–PCR-positive rectal swabs, suggesting potential fecal viral excretion. Moreover, eight of ten patients (patients 1–6, 8 and 10) demonstrated persistently positive real-time RT–PCR tests of rectal swabs after their nasopharyngeal testing had become negative. Swab remained positive in 1 patient even 13 days after discharge4.Thirty-five aerosol samples of three different types (total suspended particle, size segregated and deposition aerosol) were collected in Patient Areas and Medical Staff Areas of hospitals in Wuhan, China. The ICU, CCU and general patient rooms inside Renmin, patient hall inside Fangcang had undetectable or low airborne SARS-CoV-2 concentration but deposition samples inside ICU and air sample in Fangcang patient toilet tested positive. This raises concern that the highest risk of aerosolization of viral pathogens may be from urine/feces from flushing toilets5. Room ventilation, open space, proper use and disinfection of toilet and protocols for safe flushing can effectively limit aerosol transmission of SARS-CoV-2.Please see source #6 for charactertics of lab-tested viral pathogens in aerosol and droplet forms and prolonged life span of pathogens as fomites on different surfaces. If we decrease the aerosolization or spread of pathogens from toilet to the rest of the patient restroom, patient room, hallway, then it may decrease pathogens on surrounding fomites and spread throughout the floor and hospital. Support:Xia, W,?Shao, J,?Guo, Y,?Peng, X,?Li, Z,?Hu, D.?Clinical and CT features in pediatric patients with COVID‐19 infection: Different points from adults.?Pediatric Pulmonology.?2020;?1–?6.?, y, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics. DOI: 10.1542/peds.2020-0702Lei Pan, et al. Characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. , Y., Li, X., Zhu, B.?et al.?Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding.?Nat Med?(2020). Y, Ning Z, Chen Y, et al. Aerodynamic Characteristics and RNA Concentration of SARS-CoV 2 Aerosol in Wuhan Hospitals during COVID-19 Outbreak. bioRxiv. January 2020:2020.03.08.982637. doi:10.1101/2020.03.08.982637Doremalen, N, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. March 17, 2020. DOI: 10.1056/NEJMc2004973 ................
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