ESPN Newsletter on Coronavirus

Dear Colleagues

We are all already facing or will very soon be facing a huge challenge from COVID-19. Italy has been unfortunate to be first to get this experience in Europe on a large scale.

Giovanni Montini and Licia Peruzzi have both agreed to share their experiences so far. Their reports are very interesting to read.

ESPN Newsletter on Coronavirus
The city of Milan, and the rest of Italy, is experiencing such a surreal situation at present that one can only liken it to a scene from a science fiction film. All commercial activity has been temporarily closed with the exception of essential services, the streets are deserted, the train stations and airports at a standstill. The most recent statistics (March 12th) tell us that over 8000 people have tested positive in our Region, Lombardia, more than 15.000 nationwide, with 1016 deaths and many new cases being registered every day. In this terrible scenario, fortunately there are only circa 50 confirmed pediatric cases of Covid-19, asymptomatic or with only mild symptoms including low-grade fever. To date, no transplanted or dialysed children have been infected.
However, the situation inside our hospitals is critical and all units, both adult and pediatric, carry a high risk of transmission of the virus. Due to the imminent overload of our ICUs, the enormous burden of work for the healthcare staff who have not yet tested positive but who are literally working around the clock, stringent measures have been undertaken in order to try and offer continuity of care to all patients while at the same time protect staff. These measures include suspending all routine clinical activity and elective surgeries and sending non-critical patients home in order to convert wards, operating theatres and whatever space is available into makeshift intensive care areas. Pediatricians are being called on to work on adult wards where staff shortages due to infection are increasing.

In our unit, in addition to cancelling routine check ups and organising a telephone consultation service for parents with any queries or worries, we have adopted the following measures. Firstly, any member of staff who has symptoms or who has tested positive for Covid-19 is sent home immediately. However, as resources are so limited, if a member of staff has had contact with a confirmed case, but is asymptomatic, the test is not performed until there is a clinical reason to do so. We have organised a triage system in order to guarantee as best possible a clean environment for whoever enters the unit, either for dialysis or any other essential treatment. Patients and chaperones are initially evaluated by only one medical professional, a nurse or a doctor. If their triage evaluation is negative, they can access the unit, whereas if there are any doubts regarding their clinical condition they are sent for a mucal swab test.  As a precautionary measure, we have also organised an isolated area in the adult unit, with a filter, where children on chronic hemodialysis who could possibly be infected can be sent with the support of one of our pediatric nurses, but fortunately, to date, there has not been the need to make use of this.

My advice to you would be to plan ahead. Devise a system by which access to your units is reduced to a minimum and is safe for the children who require essential treatment. Set up a telephone service so patients can contact you if need be. Make sure there is a dedicated area where children who have tested positive can undergo dialysis. Be prudent. Staff members who have had possible contact with a confirmed case or who show any sign of infection should self-isolate at home until they have been given the all clear to return to work. The situation is critical, drastic measures are necessary, however if we have a strategy in place and that strategy is implemented correctly, it can be overcome.

Giovanni Montini
Pediatric Nephrology Dialysis and Transplant Unit
Milano, Italy


News from the Italian Society of Pediatric Nephrology

The Covid-19 emergency in Italy has exploded and created a difficult and challenging situation for the country and particularly for the sanitary service as a global.
We are experiencing an outbreak of infection of incredible proportion and all the professional involved in the care of all types of patients have been recruited to assist the new cases coming day by day to our observation, particularly among adults and older people.
The fear was very high for immune-depressed patients and particularly for the fragile population of children carriers of a transplant, taking multiple immunodepressive drugs and for other generally critical like those on dialysis or with several comorbidities: strict measures for home isolation, reduced access to the hospital and tele-monitoring were immediately adopted after case “one” in Italy was identified.
The Italian Society of Pediatric Nephrology (SINePe) is daily monitoring the situation acquiring data form all the Regions, all centers of Pediatric Nephrology and of Pediatrics involved in the care of these children:  until today March 13th, 2020 no cases of Covid-19 infection were relevated.

We received many requests upon immunosuppressive therapy withdrawal: at the moment basing on the data obtained so far we have no evidences to recommend any modification of the ongoing therapy.
We strongly recommend however that strict measures of home isolation as well as reduction of hospital admittance of patient and visitors are taken.
Basing on the Italian experience we recommend moreover that sanitary professionals are efficiently protected and organized to work in team to avoid simultaneous coinfection of operators.
Some concerns finally were raised on the use of ACE-I: at the moment there are no strong evidences to recommend to interrupt the use of the drug in all patients however it might be cautious to withdraw ACE-I when used as a renoprotective or antiproteinuric, when feasible.
The Italian Society of Pediatric Nephrology continues to monitor the situation and will be happy to share any useful information.

Licia Peruzzi
Italian Society of Pediatric Nephrology on behalf of all the Italian pediatric nephrologists
Ana Teixeira                        Kjell Tullus                      Rezan Topaloglu