Respiratory Medicine

The effect of the COVID-19 pandemic on non-COVID respiratory ED visits in Israel

a b s t r a c t

Background: The COVID 19 pandemic has had a crucial effect on the patterns of disease and treatment in the healthcare system. This study examines the effect of the COVID-19 pandemic on respiratory ED visits and admis- sions broken down by age group and respiratory diagnostic category.

Methods: Data on non-COVID related ED visits and hospitalizations from the ED were obtained in a retrospective analysis for 29 acute care hospitals, covering 98% of ED beds in Israel, and analyzed by 5 age groups: under one- year-old, 1-17, 18-44, 45-74 and 75 and over. Diagnoses were classified into three categories: upper respiratory tract infections (URTI), pneumonia, and COPD or asthma. Data were collected for the whole of 2020, and com- pared for each month to the average number of cases in the three pre-COVID years (2017-2019).

Results: In 2020 compared to 2017-2019, there was a decrease of 34% in non-COVID ED visits due to URTI, 40% for pneumonia and a 35% decrease for COPD and asthma. Reductions occurred in most age groups, but were most marked among infants under a year, during and following lockdowns, with an 80% reduction. Patients over 75 years old displayed a marked drop in URTI visits. Pediatric asthma visits fell during lockdowns, but spiked when restrictions were lifted, accompanied by a higher proportion admitted. The percent of admissions from the ED visits remained mostly stable for pneumonia; the percent of young adults admitted with URTI decreased significantly from March to October.

Conclusions: Changing patterns of ED use were probably due to a combination of a reduced rate of viral diseases,

availability of additional virtual services, and avoidance of exposure to the ED environment. Improved hygiene measures during peaks of Respiratory infections could be implemented in future to reduce respiratory morbidity; and continued provision of remote health services may reduce overuse of ED services for mild cases.

(C) 2022

  1. Introduction

During the first year of the COVID-19 pandemic, reductions in sea- sonal flu and other respiratory viruses have been noted in different parts of the world, potentially due to social distancing, use of masks and improved hygiene, as well as school closures and restricted travel. [1-4] A systematic review including multiple countries concluded that the introduction of non-Pharmaceutical interventions, aimed to reduce COVID transmission, also resulted in reduced flu burden. [5] Reductions in overall ED visits have also been reported following the pandemic and the Public health measures in place, in Japan [6] and in the US. [7] Such reduction was also documented in pediatric ED visits. [8]

* Corresponding author.

E-mail address: [email protected] (V. Myers).

Respiratory infections are transmitted in a similar way to COVID, so visits and admissions related to non-COVID respiratory infections are likely to be affected by public health measures.

Since different age groups were differentially affected by COVID bur- den, and by public health measures (e.g. workplace or school closures), it is prudent to investigate whether there was also a differential effect on acute respiratory illnesses requiring urgent care.

In Israel, the first COVID-19 case was confirmed at the end of Febru- ary 2020. The first wave of disease was observed in mid-March and April 2020, with up to 550 new confirmed COVID-19 cases per day. With rising numbers of new cases, a national lockdown was imposed in April. In May and June, the number of new cases decreased dramati- cally, and restrictions were gradually removed. In July 2020, the number of new infections started to rise, creating a second disease wave and reaching a peak of 9000 new cases per day in late September to early

https://doi.org/10.1016/j.ajem.2022.01.005

0735-6757/(C) 2022

October, when a second national lockdown was implemented. Based on the overall population of 9.135 million citizens on 31/12/2019, [9] the figures of the first and second waves represent a rate of 6.0 and 76.6 daily cases per 100,000 population in the first and second waves, re- spectively.

Public health measures, including the enforcement of mask wearing, social distancing, and closing schools differentially by grade were the main strategy to tackle the spread of infection throughout these months, until the national vaccination effort began in late December 2020. Pa- tients were encouraged to forgo physical appointments and choose tele- medicine (telephone or video appointments) where possible.

Study question: The aim of this study was to compare the effect of the COVID-19 pandemic on non-COVID respiratory visits to the ED and the percent of ED patients admitted in different age groups and by types of respiratory diagnostic category.

  1. Methods

We extracted data on ED visits and hospitalizations from the ED from the National Emergency Department Visits Database (NEDVD) maintained in the Health Information Division in the Ministry of Health (MOH), and conducted a retrospective analysis. The NEDVD includes all visits to ED in 29 acute care hospitals in Israel (covering 98% of ED beds). The database includes demographic characteristics, time of admission and discharge, destination following discharge and diagnosis according to ICD-9-CM.

Data on ED visits and admissions were analyzed in 5 age groups: under one year old, 1-17, 18-44, 45-74 and 75 and over. Data were col- lected for 2020 by month, and compared for each month to the number of cases in the corresponding month averaged from 2017 to 2019, in order to overcome potential confounders arising from fluctuations in cases from one year to the next. All patients with diagnosis of COVID- 19 were excluded from the study. We chose three categories of acute re- spiratory diagnoses: Upper respiratory tract infections (URTI) (460-466, 786.01, 786.02 ICD-9-CM codes), pneumonia (480-486

ICD-9-CM codes), and COPD or asthma (491-496, 786.07 ICD-9-CM codes). The number of influenza visits was extremely small and there- fore was not included in the analysis. Other respiratory diseases not in- cluded in this study were other chronic diseases of the lung and pleura and external harm to the respiratory tract such as pneumothorax and aspirations.

Hospital admissions from ED are reported as the percent of admis- sions of ED visits for each of the three respiratory diagnostic types. The percent of admissions was compared to that of the percent from av- erage 2017-2019.

We analyzed the data with SAS version 9.4. P values were calculated according to the method recommended by Silcocks. [10]

  1. Results
    1. ED visits

During 2020 there were 108,012 ED visits with respiratory related diagnoses compared to 152,526, which was the average number of visits per year in 2017-2019 (Table 1). Of these, there was a decrease

of 32% in the total amount of visits to the ED due to URTI, a decrease of 33% of visits for pneumonia and a 32% decrease for COPD and Asthma. These three groups comprised 85% of all non-Covid19 respiratory re- lated visits.

Reductions were seen in most age groups (Figs. 1 & 2). Fig. 1 presents the ratio of ED visits between 2020 vs the average of 2017-2019 per month; Fig. 2 presents raw number of visits per month. Among infants under a year, this reduction was most marked during and shortly after both lockdowns (April-May and October-December 2020) with an 80% reduction in visits compared to corresponding months in 2017-2019. This reduction was around 40% in July-September when re- strictions were relaxed. For infants a reduction occurred in all types of respiratory complaints throughout the year. During the first wave, the reduction was more prominent for asthma and wheezing compared with URTI, and pneumonia (89%, 76% and 72%, respectively).

Among children aged 1-17, the pattern was slightly different. While ED visits were reduced compared to the previous years for all respira- tory diseases, asthma behaved differently. Asthma visits dropped during April and May, but peaked in June to a rate almost twice as high as the previous years, subsequently dropping again to the same level as in pre- vious years.

In young adults, aged 18-44, from April till the end of 2020 respiratory ED visits were lower than in previous years for all causes. The 45-74 age group showed a reduction in all causes with a greater reduction in URTI. From mid to end of 2020, pneumonia showed less reduction in the num- ber of ED visits, compared with the other Diagnostic categories.

Reductions for persons aged 75 and over were less marked than in younger age groups. The greatest decrease was seen for URTI, reaching a 75% drop in October and December. Visits for pneumonia decreased overall by only 25%.

In most months and in most age groups in all three disease catego- ries, the decrease in number of ED visits in 2020 was statistically signif- icant compared to the average of 2017-2019 (p < 0.05) (Table 2).

    1. Hospital admissions

The percent of admissions from ED to hospital wards was signifi- cantly higher for pneumonia (p < 0.05) for the total study population from April till the end of 2020 compared to previous years. The decrease in percent of admission for URTI was significant from February till De- cember. The decrease of percent of admission for Asthma or COPD was statistically significant only in March-April and June-August (Fig. 3, Table 3).

Overall, the percentage of admissions from the ED remained more stable in children than in adults (Table 3). The percentage of pneumonia cases admitted among aged 0-44 was similar to the previous year, while for 45 and over there were some fluctuations over the year. The percent- age for URTI cases was significantly lower among those aged 18-44 from March till October and December (p < 0.05), for other ages there were some fluctuations over the year. Infants under a year old showed a higher admission rate for asthma and wheezing during March, June and December (p < 0.05) only, and children aged 1-17 showed a de- crease only in April and increase only in November (p < 0.05). Among adults percent admitted for asthma or COPD was reduced in some months compared to previous years.

Table 1

ED visits and admission rates by disease category, year and relative change, 2020/average 2017-2019

ED visits (N, % change)

% of ED visits admitted

2020

Average 2017-2019

% change 2020/average 2017-2019

2020

Average 2017-2019

URTI

47,220

69,323

-32%

18%

21%

Pneumonia

26,662

39,749

-33%

67%

63%

COPD & asthma

17,510

25,428

-32%

51%

52%

All respiratory

108,012

152,526

-29%

45%

44%

Image of Fig. 1

Fig. 1. Ratio of ED visits by disease category and month, 2020/average 2017-2019.

Image of Fig. 2

Fig. 2. Number of ED visits by disease category in 2020 and average of 2017-2019.

Table 2

Number of ED visits by disease category in 2020 vs average of 2017-2019.

Age Month N-average 2017-2019 N-2020 p value

Pneumonia 2017-2019

URTI 2017-2019

Asthma/COPD 2017-2019

Pneumonia 2020

URTI 2020

Asthma/COPD 2020

Pneumonia

URTI

Asthma/COPD

1

404

2547

251

320

1968

156

0.002

0.000

0.000

2

258

1460

167

204

1128

131

0.013

0.000

0.041

3

241

1014

172

218

688

115

0.297

0.000

0.001

4

154

622

137

40

129

16

0.000

0.000

0.000

5

140

512

114

16

132

12

0.000

0.000

0.000

<1 year 6

109

466

86

71

407

75

0.005

0.048

0.431

7

103

490

84

54

293

54

0.000

0.000

0.014

8

74

409

63

43

244

39

0.006

0.000

0.021

9

120

714

114

57

412

77

0.000

0.000

0.010

10

156

897

123

29

183

29

0.000

0.000

0.000

11

254

1264

180

52

455

51

0.000

0.000

0.000

12

421

2512

251

78

489

53

0.000

0.000

0.000

1

1271

2314

589

1075

2411

424

0.000

0.163

0.000

2

931

1785

423

805

1877

450

0.003

0.133

0.379

3

893

1618

461

699

1206

326

0.000

0.000

0.000

4

693

1334

396

148

449

95

0.000

0.000

0.000

5

649

1387

472

99

549

194

0.000

0.000

0.000

1-17 years 6

562

1384

385

259

1158

690

0.000

0.000

0.000

7

571

1504

344

185

873

351

0.000

0.000

0.810

8

459

1283

304

129

776

258

0.000

0.000

0.056

9

533

1613

672

180

1159

479

0.000

0.000

0.000

10

613

1664

577

89

617

158

0.000

0.000

0.000

11

780

1735

639

202

1116

512

0.000

0.000

0.000

12

1324

2437

728

235

1223

360

0.000

0.000

0.000

1

468

2229

333

575

2759

320

0.001

0.000

0.648

2

394

1880

300

402

2360

361

0.804

0.000

0.020

3

442

1852

320

465

2582

323

0.472

0.000

0.948

4

449

1622

321

281

1139

191

0.000

0.000

0.000

5

441

1486

299

229

809

157

0.000

0.000

0.000

18-44 years 6

355

1306

244

259

1323

235

0.000

0.000

0.704

7

301

1315

260

187

1160

178

0.000

0.002

0.000

8

275

1306

233

160

895

167

0.000

0.000

0.001

9

309

1302

284

166

940

181

0.000

0.000

0.000

10

314

1455

316

133

677

162

0.000

0.000

0.000

11

304

1411

297

131

774

236

0.000

0.000

0.009

12

444

1980

338

151

857

216

0.000

0.000

0.000

1

1221

1735

1140

1427

1633

1016

0.000

0.083

0.008

2

1036

1417

943

942

1123

837

0.036

0.000

0.013

3

1061

1292

933

975

1415

755

0.061

0.019

0.000

4

905

1055

826

612

725

408

0.000

0.000

0.000

5

815

824

735

549

408

430

0.000

0.000

0.000

45-74 years 6

656

684

650

646

612

581

0.803

0.049

0.053

7

659

660

695

577

477

467

0.021

0.000

0.000

8

650

667

631

565

396

447

0.016

0.000

0.000

9

674

770

715

512

408

405

0.000

0.000

0.000

10

738

872

790

511

349

405

0.000

0.000

0.000

11

727

807

755

513

353

438

0.000

0.000

0.000

12

1057

1289

988

544

437

510

0.000

0.000

0.000

1

1735

884

645

1462

656

486

0.000

0.000

0.000

2

1403

620

495

1107

423

408

0.000

0.000

0.004

3

1338

565

464

1019

362

280

0.000

0.000

0.000

4

1129

461

412

652

174

164

0.000

0.000

0.000

5

991

319

352

700

135

192

0.000

0.000

0.000

75+ years 6

866

250

302

709

212

218

0.000

0.085

0.000

7

867

245

318

760

143

222

0.008

0.000

0.000

8

889

271

292

716

111

215

0.000

0.000

0.001

9

853

304

299

666

100

178

0.000

0.000

0.000

10

1000

370

342

640

91

170

0.000

0.000

0.000

11

976

307

361

673

126

219

0.000

0.000

0.000

12

1284

551

488

759

133

227

0.000

0.000

0.000

  1. Discussion

Our analysis, extracted from the national ED Visits Database and covering data from all 29 general hospitals in Israel, demonstrated the effect of the waves of pandemic activity on non-COVID ED visits and hospitalizations during the first year of the pandemic,

compared with parallel months in the previous, pre-pandemic years.

The study demonstrates a dramatic reduction in respiratory ED visits in parallel to lockdowns and Stay at Home orders during both pandemic waves in all age groups and diagnoses. The decrease was more prominent in infants and children (under 1 year and 1-17 olds) compared with adults.

Image of Fig. 3

Fig. 3. Percent of ED visits admitted, by disease category and month, 2020 and average 2017-2019.

    1. What could explain this drop in ED visits?

During the first year of the pandemic, public health measures were the main defence strategy to reduce transmission, in Israel as in other countries. Campaigns urged people to use telemedicine where possible.

[11] Paediatrician visits became more available via telephone or video chat through the HMO, which may have relieved burden on urgent care services. Use of telemedicine visits jumped from 15% in 2019 to 29% in 2020 [12], with a marked increase in older patients, and minority groups which had previously low use of digital services. [13] Further- more, schools were closed for 8 weeks during the first wave and while preschool and younger schoolchildren subsequently returned to the classroom, the majority of older schoolchildren did not return to full in-person classes until after the second wave. Mandatory face masks from April 12, 2020, for children aged 6+ and adults, in public spaces, including schools, probably contributed to the decrease of viral trans- mission, since masks were associated with a 47% decrease in transmis- sion of respiratory viruses in the general (non-Healthcare workers) population. [14] A retrospective analysis of daily viral positive tests, Daily ED visits and hospitalizations during a 10-year follow-up in Canada revealed that community respiratory viruses were a major driver of ED visits and hospitalizations due to respiratory tract infections and COPD but hardly contributed to asthma. [15]

Lower incidence of influenza has been reported in Israel [16] as well as in other countries compared to previous years [1-4]. The current find- ings show variations across age groups for pneumonia, and other acute Respiratory disorders. Data from one US medical centre reported a sig- nificant drop in pediatric ED visits for acute respiratory illnesses over 3 months (March-May 2020) compared to previous years. [17] This pattern is supported here with national data across a whole year from Israel, and excluding patients ultimately found to be COVID-19 positive, allowing a comprehensive analysis of changing ED use in relation to the timing of the pandemic peaks of increased infection incidence.

Infants had dramatically reduced ED visits for all respiratory causes during the two pandemic waves. This points both to less morbidity due to lockdowns, but also to possible overuse in this population during routine times, in addition to parents’ fear of their infants contracting COVID-19 infection while waiting in the ED, or upon admission to the wards. Analysis of hospital admissions can indicate severity of cases, and whether changes in use of ED for respiratory conditions represent underuse or usual overuse. [18] The admission rate for infants and chil- dren varied but in general did not increase dramatically in most months. The admission rate remained largely unchanged in older adults,

indicating that cases coming to the ED during 2020 were not more se- vere than usual. This supports the assumption that the major contribu- tor to decreased ED visits is a true decrease in need – less respiratory infections that cause UTRI and pneumonia.

Changes in urgent asthma visits can shed light on changes in overall respiratory morbidity since exacerbation of asthma in infants is related to respiratory viruses in more than 80% of cases. Other reasons are expo- sure to both indoor and outdoor allergens and pollutants and poor med- ical control. [19] Asthma visits and proportion of children admitted dropped during the first two COVID waves which involved lockdowns, and then spiked in June 2020, corresponding with relaxation of restric- tions and opening of schools. Other cases are seasonal and allergy- related, potentially explaining the peaks in June and October among children. Lockdowns, face-mask wearing and less exposure to other children during remote learning might explain a considerable reduction in asthma related ED visits.

Studies of asthma in the United States during the COVID-19 pan- demic have shown reduced hospitalizations, fewer ED visits, and im- proved Asthma control during the pandemic, and have linked these favourable outcomes to lockdowns and school closures [17-21].

In contrast, older groups suffer more from COPD and less from sea- sonal/allergic asthma. Reductions in COPD were demonstrated through- out the pandemic year, likely influenced by fewer viruses circulating and less air pollution during lockdowns. COPD is correlated with in- creased risk of severe pneumonia and poor outcomes when patients de- velop COVID-19. This might divert patients to avoid utilization of healthcare services which require physical contact like ED visits. [20] older age groups showed smaller reductions in ED visits for pneumonia, which are less affected by outdoor influences in frail older populations. Different patterns in children and adults may indicate different be- haviours, with older adults staying home more, Wearing masks and maintaining physical distance from others, while young children were less likely to wear masks (correctly) and to social distance. The greatest change in children’s exposure was likely related to school closures. In the summer months when restrictions were relaxed, children were back at school/summer camps and congregating with others, likely to a greater degree than adults. This might explain a 72% increase during June 2020, compared with June 2019, of asthma related ED visits. This contrasts with the US which had consistently lower pediatric asthma- related ED visits throughout the year, but also did not re-open schools

during this period. [21]

Strengths of the study include comprehensive data from all ED de- partments, and exclusion of COVID 19 positive patients in order to

Table 3

Percent of ED patients admitted by disease category in 2020 vs average of 2017-2019.

Age Month

Pneumonia 2017-2019

Pneumonia 2020

P value

URTI 2017-2019

URTI 2020

P value

Asthma/COPD 2017-2019

Asthma/COPD 2020

P value

1

42%

45%

0.375

39%

39%

0.641

33%

30%

0.512

2

43%

41%

0.633

38%

39%

0.655

32%

39%

0.145

3

41%

44%

0.434

31%

33%

0.525

33%

44%

0.030

4

38%

43%

0.612

24%

26%

0.595

34%

19%

0.283

5

36%

50%

0.296

20%

25%

0.141

33%

25%

0.758

<1 year 6

36%

37%

0.892

17%

23%

0.017

33%

48%

0.029

7

38%

30%

0.286

20%

14%

0.033

35%

44%

0.212

8

39%

30%

0.307

21%

17%

0.255

40%

38%

1.000

9

33%

25%

0.223

21%

19%

0.392

33%

44%

0.085

10

34%

38%

0.687

26%

21%

0.163

35%

45%

0.320

11

41%

42%

0.885

34%

26%

0.001

37%

47%

0.173

12

41%

35%

0.288

38%

23%

0.000

32%

53%

0.004

1

32%

31%

0.482

14%

15%

0.329

31%

38%

0.009

2

34%

35%

0.768

13%

14%

0.458

33%

35%

0.561

3

35%

33%

0.371

14%

13%

0.369

31%

35%

0.262

4

34%

29%

0.280

13%

11%

0.450

33%

21%

0.022

5

35%

33%

0.914

14%

16%

0.267

34%

35%

0.872

6

33%

34%

0.777

13%

13%

0.961

34%

38%

0.088

7

32%

37%

0.160

13%

11%

0.135

31%

33%

0.351

8

33%

35%

0.625

14%

13%

0.494

34%

34%

0.766

9

32%

26%

0.149

13%

11%

0.070

36%

40%

0.102

10

34%

36%

0.731

13%

15%

0.383

33%

25%

0.062

11

34%

37%

0.489

13%

16%

0.005

34%

41%

0.007

1-17 years 12

33%

36%

0.354

14%

13%

0.399

32%

36%

0.202

1

47%

45%

0.298

14%

14%

0.360

33%

36%

0.417

2

42%

39%

0.319

14%

14%

0.525

30%

29%

0.540

3

43%

40%

0.230

15%

8%

0.000

27%

20%

0.015

4

43%

39%

0.259

15%

9%

0.000

28%

24%

0.184

5

40%

35%

0.164

17%

11%

0.000

30%

24%

0.182

18-44 years 6

41%

44%

0.362

18%

9%

0.000

30%

29%

1.000

7

43%

36%

0.087

18%

12%

0.000

29%

26%

0.521

8

44%

46%

0.602

16%

11%

0.000

30%

19%

0.003

9

44%

44%

1.000

16%

9%

0.000

28%

28%

0.928

10

44%

50%

0.162

16%

12%

0.007

27%

28%

0.924

11

46%

42%

0.453

16%

14%

0.150

30%

27%

0.337

12

44%

48%

0.438

16%

12%

0.002

31%

28%

0.567

1

72%

73%

0.444

22%

25%

0.011

66%

65%

0.881

2

72%

75%

0.080

22%

22%

0.871

64%

64%

0.806

3

70%

68%

0.264

22%

15%

0.000

63%

60%

0.204

4

70%

74%

0.031

22%

19%

0.050

63%

56%

0.010

5

70%

71%

0.718

23%

20%

0.203

63%

57%

0.039

45-74 years 6

71%

71%

0.803

25%

21%

0.040

63%

61%

0.406

7

72%

70%

0.208

25%

21%

0.085

63%

56%

0.006

8

75%

70%

0.044

26%

24%

0.450

63%

59%

0.116

9

71%

71%

0.827

23%

18%

0.045

62%

60%

0.372

10

72%

70%

0.385

24%

21%

0.285

63%

65%

0.540

11

75%

75%

0.821

25%

26%

0.646

63%

61%

0.388

12

74%

75%

0.634

24%

21%

0.109

66%

64%

0.338

1

87%

88%

0.559

40%

46%

0.007

74%

75%

0.954

2

86%

88%

0.183

41%

47%

0.014

74%

74%

1.000

3

87%

88%

0.526

39%

45%

0.024

74%

70%

0.119

4

87%

90%

0.026

41%

48%

0.103

72%

68%

0.268

5

88%

90%

0.212

38%

37%

0.850

75%

65%

0.005

75+ 6

89%

91%

0.048

41%

36%

0.205

73%

72%

0.800

7

89%

91%

0.078

41%

51%

0.042

76%

71%

0.143

8

90%

89%

0.782

42%

47%

0.358

76%

70%

0.095

9

88%

88%

1.000

43%

46%

0.524

76%

71%

0.127

10

88%

85%

0.017

39%

32%

0.217

75%

76%

0.775

11

89%

88%

0.500

40%

40%

0.923

76%

72%

0.232

12

89%

88%

0.224

41%

38%

0.464

75%

76%

0.623

eliminate COVID morbidity and examine the effect of the pandemic on other respiratory morbidity. All the data are aggregative preventing analysis based on individual factors.

  1. Conclusion and implications

National data from the whole of 2020 demonstrated fewer ED visits for non-COVID respiratory causes occurring throughout the pandemic year compared to the previous year, with the sharpest decrease during the two lockdowns, especially among young children The marked

reduction in URTIs suggests that improved hygiene measures, such as mask wearing and social distancing during peaks of respiratory infec- tions could be implemented in the future to reduce morbidity in influ- enza, RSV and other viral outbreaks and not only during the COVID-19 era.

Improved access to community services during out-of-hours or more accessible remote communication with the paediatrician to sup- port parents in the management of children’s illnesses could be consid- ered to reduce burden on ED in this age group. Indeed, additional services provided by HMOs during the pandemic, including telephone

and other virtual visits, may have had an impact on ED visits, with GPs and paediatricians being more available, in Israel [22] as elsewhere [23]. In this sense, the accelerated utilization of remote health created by the pandemic, if continued in the future, might reduce ED overuse in times of normalcy too. Indeed Bestsenny et al. estimated – based on US Medicare and Medicaid data – that in the future 20% of ED visits could be avoided or diverted using telemedicine and remote urgent care [24].

Changing patterns of ED use for URTI this year were probably due to a combination of both a reduced rate of viral diseases such as RSV and influenza, and also parents refraining from over exposure to the ED en- vironment for fear of COVID-19 contamination. We can hope that this experience might prove to be an incentive in future years to reduce the use of ED services for mild URTI cases, some of which could be treated in the community.

As pandemic waves continue to come and go, and we attempt to adapt to the new normal and live with COVID, lessons can be learned from the past year. Parents should be reminded to keep home sick chil- dren to reduce the spread of respiratory and other diseases, and contin- ued provision of virtual services may help reduce the burden on urgent care teams.

Funding

None.

CRediT authorship contribution statement

Ziona Haklai: Writing – review & editing, Formal analysis, Data curation. Yael Applbaum: Writing – review & editing, Formal analysis, Data curation. Vicki Myers: Writing – review & editing, Formal analysis, Data curation. Mor Saban: Writing – review & editing, Formal analysis, Data curation. Ethel-Sherry Gordon: Writing – review & editing, Formal analysis, Data curation. Rachel Wilf-Miron: Writing – review & editing, Formal analysis, Data curation. Osnat Luxenburg: Writing – review & editing, Formal analysis, Data curation.

Declaration of Competing Interest

None.

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