Since newborn babies, as well as their mothers and the hospital staff looking after them, are very vulnerable to COVID-19, we need policies and systems that can help to protect them, write Profs Angela Dramowski and Adrie Bekker from the Department of Paediatrics and Child Health in an opinion piece for Daily Maverick (28 July).

• Read the article below or click here for the piece as published.

Protecting newborns and their mothers during the COVID-19 pandemic

Angela Dramowski and Adrie Bekker*

Multiple challenges exist in preventing infection of one of our most vulnerable population groups, but Tygerberg Hospital is rising to the challenge with the implementation of policies and systems that not only mitigate the spread of coronavirus, but also address broader infection control.

While caring for patients during COVID-19 has focused mainly on adults, this is also a worrying time for a very vulnerable section of our population – our newborn babies, as well as their mothers and the hospital staff looking after them in neonatal and obstetric wards across South Africa.

Neonates (babies who are under 28 days old) and especially preterm babies (less than 37 weeks gestational age) and those who weigh below 2.5 kilograms, are particularly vulnerable as their underdeveloped immune systems struggle to fight infections. Hospitalised newborns are at even higher risk of infections, including COVID-19, as they often have to spend considerable time in hospital for feeding and growing, where they are exposed to multiple caregivers. Most of our public sector hospitals don't have isolation facilities. This increases the risk of spreading the virus among babies, mothers and hospital staff.  

One of the difficulties in shielding hospitalised babies from COVID-19 is that many adults have asymptomatic infections or may transmit the virus before their first symptoms develop. Young mothers could also unknowingly be spreading the virus, as up to 45% of all adult COVID-19 infections are asymptomatic. In one USA study, one in seven pregnant mothers tested positive for COVID-19 – 88% of them asymptomatic – during the height of the New York pandemic.

We are still learning a lot about transmission and disease patterns of COVID-19 from small case series and reports. With the currently available information, the coronavirus can be transmitted to neonates in three ways. Mothers can transmit the virus to babies after birth. This is likely to be the main way of spreading the virus to newborns, via droplets from the mother's mouth and nose and by direct and indirect contact with contaminated surfaces and objects. The second path of transmission is by other adults that come in contact with the baby after birth. This could occur in the community or in hospital when babies get exposed to COVID-infected people or contaminated surfaces and objects. The third route is when the virus is spread across the placenta to the foetus. This is very rare and difficult to prove, with very few reported cases globally so far.   

While reported cases of babies testing positive for COVID-19 have been low worldwide, COVID-19 is still a risk for neonates, and we cannot afford to drop our guard in any way.

At Tygerberg Hospital in Cape Town, we are doing all we can to protect our babies, mothers and staff.  In theory, if medical staff wear appropriate Personal Protective Equipment (PPE) no high-risk exposures to COVID-19 should occur. But despite our best Infection Prevention and Control (IPC) measures, medical staff still become ill, as they can contract the virus anywhere, from home and in the hospital to public transport.  Staff then have to go home and isolate until their test results are reported, and take further time to recover if their test results are positive.

Absenteeism is also hitting hard, as staff are under immense physical and mental pressure during the pandemic, with many fearing for their own as well as their family's safety. This makes it extremely difficult to perform normal newborn care in very busy units that are routinely overcrowded and understaffed. It can also be very upsetting for mothers who become ill and test positive for the coronavirus. If their babies are premature or very ill, mothers cannot enter the neonatal ward and have to self-isolate at home or in quarantine or isolation facilities until they are no longer infectious.

But there are important steps we have been able to take to mitigate the spread of COVID-19 in our neonatal wards and among our healthcare workers. One of these strategies is to screen all visiting mothers for symptoms daily and to insist they wear face masks.  If testing is widely available, hospitals should consider testing pregnant women when they are admitted to hospital, while symptomatic mothers and staff should have urgent access to quick COVID-19 testing. We also need to ensure that we don't unnecessarily admit babies to hospital and don't keep babies in hospital for longer than needed, so that we decrease their risk of exposure to COVID-19.

The COVID-19 pandemic has been an intense learning curve for medical staff in our neonatal  wards at Tygerberg Hospital. We have used a combination of face-to-face teaching of all cadres of staff, as well as short videos, written guidance and posters in the clinical areas. We've stepped up our communication with staff through guidelines and training on how to reduce stigma, use PPE correctly and how to clean surfaces and equipment. We have made use of web-based applications to store updated guidelines for easy access, especially as guidance is frequently updated as new evidence becomes available.

We've also introduced a system in each ward, where nurses report IPC issues and concerns to the IPC practitioners and we have increased the frequency of audits to check that controls are in place.

In neonatal wards, expressed breast milk is extremely important in the care of preterm and term babies. We have put policies in place about how to clean glass jars with expressed breast milk, and how to sanitise bottles to prevent any possible transmission of the Coronavirus.  

Clearly this is a team effort. You can have all the appropriate policies but implementation is what counts. Hospital management has a key role to play through clear communication with staff, managing fear and false information and securing more staff and PPE.

We expect lessons learnt from COVID-19 will also stand us in good stead in our work with the National Neonatal Sepsis Task Force, which was set up last September.  The task force is made up of experts from hospitals across South Africa. It provides technical advice and guidance on surveillance on neonatal sepsis, which is caused by bacterial infections and is a major cause of death among newborn babies. The task force is also working on ways to better prevent infections, such as hospital-acquired pneumonia, urinary tract and bloodstream infections as well as hospital outbreaks in neonatal units.

The pipeline of new agents to treat Anti-Microbial Resistant (AMR) infections is very limited, so by doing good IPC, we can limit the spread of AMR pathogens and reduce the need for very broad-spectrum antibiotic therapy.

COVID-19 has posed challenges that we could never have imagined this time last year. It's been a tough journey, but we are learning and growing through the experience. The importance of basic concepts such as surface cleaning and washing hands in the time of the coronavirus has improved practices in our wards and has also cascaded into the community.

We are optimistic that the good habits people have learnt during COVID-19 may help reduce bacterial infections, as well as other respiratory virus and diarrhoeal disease transmissions in the long run.

We are hopeful that through the gloom of the pandemic, we will emerge more capable to protect babies and their mothers, and promote better health and hygiene in our hospitals, homes and communities.

*Professor Adrie Bekker is a neonatologist at Tygerberg Children's Hospital in Cape Town and Associate Professor in the Department of Paediatrics and Child Health at Stellenbosch University. Professor Angela Dramowski is a paediatric infectious diseases specialist and clinician researcher in the Department of Paediatrics and Child Health at Stellenbosch University  Both authors are part of the National Neonatal Sepsis Task Force.