To the Editor—As of 23 April 2020, there have been 104 confirmed paediatric cases of coronavirus disease 2019 (COVID-19) in Hong Kong.1 Fortunately, all cases were mild or asymptomatic with no fatalities.1 The proportion of patients with COVID-19 who are aged ?19 years is 14.1% in Hong Kong, which is higher than other countries (Table).1 2 3 4 5 6 This may be attributable to high numbers of overseas students returning to Hong Kong; even those who are asymptomatic are tested as part of the current border controls. Mortality for patients aged ?19 years is very low, with less than 10 reported cases, mostly teenagers.7 8 9

Current clinical management of COVID-19 is mainly supportive and there are currently no definite antiviral drugs recommended for the treatment of paediatric patients with COVID-19.7 The Hong Kong College of Paediatricians and The Hong Kong Society of Paediatric Immunology Allergy and Infectious Disease have taken a leading role in paediatric public health promotions, and published a very clear and informative guidance for parents to refer to in prevention of COVID-19, with links to educational materials that will help children understand the current situation of this epidemic.10 Children should be engaged in usual preventive actions to avoid infection, including cleaning hands often using soap and water or alcohol-based hand sanitiser, avoiding contact with others who display COVID-19 symptoms, and staying up to date on vaccinations, including influenza vaccine.

In response to the COVID-19 pandemic, schools in Hong Kong were closed from 25 January 2020, resulting in psychosocial crises in schooling, examinations, and related childhood and paediatric routines.11 Many challenging decisions have been made to manage these crises while children are home-bound. Teaching has been partially resumed with online teaching, examinations have been postponed, modes of examinations have been modified, and formal schooling will only be resumed when there is evidence that the spread of COVID-19 is slowing or stopped. Although children fare better after infection, they may serve as vectors of viral transmission in the community. Specific interventions implemented to reduce such risks include quarantining and rigorous screening of asymptomatic or silent carriers. Isolation facilities have to be provided to contain and treat these relatively well infected patients, so that airborne infection isolation rooms can be reserved for more seriously affected patients. Although there is no robust evidence that lactating mothers spread the virus more easily than others, for those who are healthcare personnel working in high-risk areas, it may be prudent to switch them temporarily to lower-risk posts to reduce the risks of contracting the virus.

The next challenge for Hong Kong is to resume socio-economic activities whilst suppressing the outbreak of potential cases in the community. Children and young adults may be a big driver in the ‘second wave’ of the COVID-19 outbreak in Hong Kong, and appropriate measure should be taken to minimise this risk.

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have no conflicts of interest to disclose.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Centre for Health Protection, Hong Kong SAR Government. Latest situation of cases of COVID-19. Available from: https://www.chp.gov.hk/files/pdf/local_situation_covid19_en.pdf. Accessed 23 Apr 2020.

2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID- 19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42. Crossref

3. Ministry of Health Singapore. Official update of COVID- 19 situation in Singapore. 2020 Available from: https://covidsitrep.moh.gov.sg/. Accessed 29 Mar 2020.

4. Korean Centers for Disease Control and Prevention. The updates on COVID-19 in Korea as of 24 March. Available from: https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030&act=view&list_no=366633. Accessed 24 Mar 2020.

5. CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422-6. Crossref

6. Istituto Superiore di Sanita. Epidemia COVID-19 [in Italian]. Available from: https://www.epicentro.iss.it/coronavirus/bollettino/Bollettino sorveglianza integrata COVID-19_19-marzo 2020.pdf. Accessed 28 Mar 2020.

7. Shen K, Yang Y, Wang T, et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts’ consensus statement. World J Pediatr 2020 Feb 7. Epub ahead of print. Crossref

8. Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children. N Engl J Med 2020;382:1663-5. Crossref

9. Dong Y, Mo X, Hu Y, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics 2020 Mar 16. Epub ahead of print.

10. Hong Kong College of Paediatricians and Hong Kong Society for Paediatric Immunology Allergy and Infectious Diseases. Prevention of novel coronavirus infection, recommendations for parents. 5 February 2020. Available from: http://www.paediatrician.org.hk/index.php?option=com_docman&task=doc_view&gid=1768&Itemid=66. Accessed 22 Apr 2020.

11. Hong Kong SAR Government. SED opening remarks at press conference on measures against novel coronavirus infection. 25 January 2020. Available from: https://www.info.gov.hk/gia/general/202001/25/P2020012500583.htm. Accessed 10 May 2020.

To the Editor—In a general hospital, there are many clinical procedures involving aerosol-generating procedures (AGPs), such as bronchoscopy and other specific procedures involving airway care, that can induce the production of aerosols of various sizes, including droplet nuclei.1 According to the latest guidelines from the Centre for Health Protection of the Hong Kong SAR Government, the recommended personal protective equipment (PPE) for performing AGPs includes N95 respirator, eye protection, gown, gloves, and cap (optional).2 However, there was a severe and mounting disruption to the global supply of PPE amid the outbreak of coronavirus disease 2019 (COVID-19). In response, the Hospital Authority adjusted public hospital non-emergency services and non-essential services to focus manpower and resources.3 Reducing utilisation of PPE in various clinical services has become an issue of current concern at frontline and management levels.4 5

Physiotherapists often perform AGPs such as open suctioning of respiratory tract (including tracheostomy care). In the Physiotherapy Department of Tuen Mun Hospital, the workflow of chest physiotherapy service was reviewed and analysed to explore the possibility of AGPs being grouped and handled by a designated team of physiotherapists, and the service delivery process of chest physiotherapy was then re-designed. A designated AGP team was established in which a group of physiotherapists (8 in total, on rotation) solely delivering chest physiotherapy involving AGPs. The workload for the AGP team was centralised and managed with extended working hours to maximise the use of every N95 respirator. To facilitate the implementation of the new workflow and compliance of infection control measures, a patient care assistant was assigned to assist the physiotherapist in logistics and patient preparation prior to and after the treatment, to maximise work efficiency. Additional training was provided to the patient care assistant to enhance their competency in infection control measures. The patient care assistant also helped to ensure proper gowning procedures of the physiotherapist. The changes in workflow were well communicated and supported by all staff. The AGP team using the new workflow have been observed by the consultant microbiologist and the cluster infection control officer, and they have found that the new workflow fulfils the updated requirements of infection control.

Since implementing the new workflow in February 2020, consumption of PPE in the Physiotherapy Department has decreased substantially. The usage of N95 respirators decreased from approximately 60 pieces to eight pieces daily (>80% reduction), resulting in saving >1000 N95 respirators per month. Most importantly, such administrative change of workflow neither sacrificed the clinical service provision nor the occupational safety in performing high-risk AGPs. In addition to chest physiotherapy, the above measures may also be applicable to other clinical procedures involving AGP such as elective endotracheal intubation, bronchoscopy, and upper airway endoscopy.

All authors contributed to the concept of the study, acquisition and analysis of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. Available from: https://www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/. Accessed 19 Mar 2020.

2. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Recommended personal protective equipment (PPE) in hospitals/clinics under serious/emergency response level coronavirus disease (COVID-19). Available from: https://www.chp.gov.hk/files/pdf/recommended_ppe_for_nid_eng.pdf. Accessed 19 Mar 2020.

3. Hong Kong SAR Government. HA adjusts service provision to focus on combatting epidemic. Available from: https://www.info.gov.hk/gia/general/202002/10/P2020021000711.htm. Accessed 19 Mar 2020.

4. Hong Kong SAR Government. Protective gear supply ensured. Available from: https://www.news.gov.hk/eng/2020/03/20200313/20200313_180244_445.html. Accessed 19 Mar 2020.

5. Wong DH, Tang EW, Njo A, et al. Risk stratification protocol to reduce consumption of personal protective equipment for emergency surgeries during COVID-19 pandemic. Hong Kong Med J 2020 May 5. Epub ahead of print Crossref