Information on COVID-19 for Clinicians:

Additional Guidelines for Outpatient Pediatric Care in the Philippine Setting

The Philippine Department of Health (DOH) has recently announced new confirmed cases of COVID-19. Unlike the
previous cases, several of these new patients have no history of travel, marking them as cases of local
transmission. This particular detail is important to highlight: the public health response has now expanded its
strategies, no longer focusing on just containment, but also mitigation (identification of those at highest risk and
prioritizing this group for prevention and management).

With containment, the goal was to exclude those with infection, likely to be acquired from other countries where
most of the cases were being reported. At that time, travel-based restrictions were thought to be helpful and in
fact proved effective: no new cases were reported locally for almost a month, as travelers were being screened
when they presented with symptoms.

The rapid spread of infection globally, however, meant that it would only be a matter of time before new cases
would be detected. Because of this, a sampling of patients presenting to local hospitals with severe acute
respiratory infections was being tested through the SARI surveillance system. Through this, two of the more recent
cases without a history of travel were detected.

With local transmission being documented, COVID-19 is now a consideration whenever a patient presents with the
following symptoms, alone or in combination: 1) fever; 2) acute respiratory illness (whether this takes the form of
mild cough and cold illness, or difficulty breathing that requires more intensive support); and 3) diarrhea.
i
Based on limited available data, SARS-CoV-2 infections in children appear to be milder in general. The most
common presenting symptoms include fever, cough, congestion, and rhinorrhea. Vomiting and diarrhea were also
ii,iii,iv,v
reported in a case, and one infant was reported to develop ARDS and septic shock. . There is also no evidence
to date that children are any more or less susceptible to SARS-CoV-2 infections compared to adults. Data show that
vi,vii
intrafamilial transmission is the most common way they are infected.

In the Philippines, the most common causes of Influenza-Like Illnesses (ILI) among children are influenza virus,
respiratory syncytial virus (RSV), and human rhinovirus (HRV), while the most common causes of acute diarrhea in
viii,ix,x
children remain to be rotavirus, enterotoxigenic E. coli (ETEC) and salmonella.

The Department of Health – Philippine Society of Microbiology and Infectious Diseases Coronavirus Disease 2019
(COVID-19) Task Force has released an Algorithm for Triage of Patients with Possible COVID-19 Infection on March
9, 2020 (see Annex). The Philippine Pediatric Society (PPS) and the Pediatric Infectious Disease Society of the
Philippines (PIDSP) fully support this initiative and commend the DOH-PSMID COVID-19 Task Force for its prompt
action.

To supplement the above approach, the following are additional reminders for those who care for children:
1. Children and households should practice stringent infection control measures to prevent the spread of
respiratory pathogens, including frequent handwashing, cough etiquette, use of hand sanitizers, and
social distancing (including avoidance of crowded places and non-essential gatherings/celebrations).
2. Infection control measures and frequent disinfection should also be done in outpatient clinics. Consider
triaging through pre-clinic calls, scheduling of well-baby consults separately from sick consults, re-
structuring of waiting areas to limit exposure to other patients, and so on.
3. Children with underlying medical conditions may be at increased risk for more severe COVID-19 disease,
similar to their increased risk for other respiratory infections. Thus, rigorous practice of infection
prevention measures, including immunization for high risk groups, must be reinforced.
 Information on COVID-19 for Clinicians:
Additional Guidelines for Outpatient Pediatric Care in the Philippine Setting
from the Philippine Pediatric Society and the
Pediatric Infectious Disease Society of the Philippines
10 March 2020

4. Provide routine childcare and immunizations to your patients, as these are important for their wellness
and help prevent future health problems or outbreaks. Children should be updated with their
immunizations, especially against respiratory and diarrheal pathogens like influenza virus, measles virus,
polio virus, rotavirus, Streptococcus pneumoniae, and Haemophilus influenzae.
5. Use diagnostic exams whenever possible to determine etiologic diagnosis of ARI or diarrhea to identify
other possible causes of disease (e.g. culture, rapid diagnostic tests/panels, PCR, etc.).
6. Children exhibiting mild symptoms and who have no co-morbid conditions may be managed at home with
supportive measures such as adequate hydration and fever control, after appropriate testing is done (see
Taskforce Algorithm). Home quarantine measures must be enforced for mild cases that are positive for
SARS-CoV-2 (refer also to DOH Clinical Management Guidelines). Should there be a need to request
testing, please be reminded to fill up the Case Report Form with complete information, as this is critical
for contact tracing.
7. Listen to reputable and scientific resources, specially to the Department of Health, for updates and
guidance, and adhere to the Algorithm provided by the COVID-19 Taskforce. Additional sources of
information are the WHO and US CDC websites. Do not spread unverified information.

i
[Link]
accessed 3/10/2020
ii
Kam KQ, Yung CF, Cui L, Lin Tzer Pin R, Mak TM, Maiwald M, Li J, Chong CY, Nadua K, Tan NWH, Thoon
KC. A Well Infant with Coronavirus Disease 2019 (COVID-19) with High Viral Load. Clin Infect Dis. 2020
Feb 28. pii: ciaa201. doi: 10.1093/cid/ciaa201. [Epub ahead of print]
iii
Cai J, Xu J, Lin D, Yang Z, Xu L, Qu Z, Zhang Y, Zhang H, Jia R, Liu P, Wang X, Ge Y, Xia A, Tian H, Chang H,
Wang C, Li J, Wang J, Zeng M. A Case Series of children with 2019 novel coronavirus infection: clinical
and epidemiological features. Clin Infect Dis. 2020 Feb 28. pii: ciaa198. doi: 10.1093/cid/ciaa198. [Epub
ahead of print]
iv
Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang ZJ. Novel Coronavirus Infection in Hospitalized Infants Under 1
Year of Age in China. JAMA. 2020 Feb 14. doi: 10.1001/jama.2020.2131. [Epub ahead of print]
v
Chen F, Liu ZS, Zhang FR, Xiong RH, Chen Y, Cheng XF, Wang WY, Ren J. [First case of severe childhood
novel coronavirus pneumonia in China].Zhonghua Er Ke Za Zhi. 2020 Feb 11;58(0):E005. doi:
10.3760/[Link].0578-1310.2020.0005. [Epub ahead of print] Chinese.
vi
[Link] accessed 3/10/2020
vii
Liao X, Qian S, Yuan J, Wang F, Liu Y, et al. Community transmission of severe acute respiratory
syndrome coronavirus 2, Shenzhen, China, 2020. Emerg Infect Dis. 2020 Jun [date cited].
[Link]
viii
Carlos C. and Saniel M. Etiology and Epidemiology of Diarrhea. Phil J Microbiol Infect Dis 1990;
19(2):51-53.
ix
Carlos C. et al. The Burden of Hospitalizations and Clinic Visits for Rotavirus Disease in Children Aged !5
Years
in the Philippines. The Journal of Infectious Diseases 2009; 200:S174–81.
x
Otomaru H, Kamigaki T, Tamaki R, Opinion J, Santo A, Daya E, et al. (2015) Influenza and Other
Respiratory Viruses Detected by Influenza-Like Illness Surveillance in Leyte Island, the Philippines, 2010–
2013. PLoS ONE 10(4): e0123755. doi:10.1371/[Link].0123755
ANNEX. Algorithm for Triage of Patients with Possible COVID-19 Infection
March 9, 2020