Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study

Potential sources, modes of transmission and effectiveness of prevention measures against SARS-CoV-2

During the current SARS-CoV-2 pandemic new studies are emerging daily providing novel information about sources, transmission risks and possible prevention measures. In this review, we aimed to comprehensively summarize the current evidence on possible sources for SARS-CoV-2, including evaluation of transmission risks and effectiveness of applied prevention measures. Next to symptomatic patients, asymptomatic or pre-symptomatic carriers are a possible source with respiratory secretions as the most likely cause for viral transmission. Air and inanimate surfaces may be sources; however, viral RNA has been inconsistently detected. Similarly, even though SARS-CoV-2 RNA has been detected on or in personal protective equipment (PPE), blood, urine, eyes, the gastrointestinal tract and pets, these sources are currently thought to play a negligible role for transmission. Finally, various prevention measures such as handwashing, hand disinfection, face masks, gloves, surface disinfection or physical distancing for the healthcare setting and in public are analysed for their expected protective effect.

COVID-19 in 17 Italian Pediatric Emergency Departments

BACKGROUND

Variability in presentation of children with coronavirus disease 2019 (COVID-19) is a challenge in emergency departments (EDs) in terms of early recognition, which has an effect on disease control and prevention. We describe a cohort of 170 children with COVID-19 and differences with the published cohorts.

METHODS

Retrospective chart reviews on children (0-18 years) evaluated in 17 Italian pediatric EDs.

RESULTS

In our cohort (median age of 45 months; interquartile range of 4 months-10.7 years), we found a high number of patients <1 year with COVID-19 disease. The exposure happened mainly (59%) outside family clusters; 22% had comorbidities. Children were more frequently asymptomatic (17%) or with mild diseases (63%). Common symptoms were cough (43%) and difficulty feeding (35%). Chest computed tomography, chest radiograph, and point-of-care lung ultrasound were used in 2%, 36%, and 8% of cases, respectively. Forty-three percent of patients were admitted because of their clinical conditions. The minimal use of computed tomography and chest radiograph may have led to a reduced identification of moderate cases, which may have been clinically classified as mild cases.

CONCLUSIONS

Italian children evaluated in the ED infrequently have notable disease symptoms. For pediatrics, COVID-19 may have rare but serious and life-threatening presentations but, in the majority of cases, represents an organizational burden for the ED. These data should not lower the attention to and preparedness for COVID-19 disease because children may represent a source of viral transmission. A clinically driven classification, instead of a radiologic, could be more valuable in predicting patient needs and better allocating resources.

COVID-19: lessons to date from China

The pandemic due to a novel coronavirus has been sweeping across different regions of the globe since January 2020. Early reports of this infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) consisted of mostly adult patients. As the outbreak spreads rapidly beyond the epicentre of Wuhan, it becomes clear that infants and children of all ages are susceptible to this infection. In China, there have been more than 1200 paediatric cases. Most paediatric patients acquire the infection through household contact with infected adults. The disease in children is usually self-limiting and most infected children will recover uneventfully within 7-10 days. Other than symptoms of the respiratory tract, many children may present with gastrointestinal symptoms. Older children are more likely to have asymptomatic infection. Although deaths related to SARS-CoV-2 are rarely reported in the paediatric age group, young children and those with underlying medical conditions are more likely to develop severe illness. Only a small fraction of neonates born to infected mother would acquire the virus by vertical transmission. Because a large proportion of children and adolescents may have asymptomatic or mildly symptomatic infection, children are likely to play an important role in community transmission of this infection. Screening of children who have a definitive contact history will facilitate early diagnosis and isolation of all infected children. This review summarises the lessons learned in China with regard to the current understanding of SARS-CoV-2 infection in the paediatric population.

Variety of radiological findings in a family with COVID-19: a case report

Introduction

In December 2019, a case series of pneumonia associated with seafood and wet animal market was reported as coronavirus disease 2019 (COVID-19) in Wuhan, Hubei, China. The COVID-19 less frequently affects the pediatric group, and asymptomatic children are commonly reported. This feature is important due to the potential transmissibility of COVID-19 through these cases. There is a variety of atypical clinical symptoms and imaging manifestations among children infected with COVID-19.

Case presentation

We report two sisters with COVID-19 pneumonia who had close contact with their 77-year-old grandmother. Their grandmother expired with a confirmed diagnosis of COVID-19. The older sister (15 years old) firstly presented with severe cough, fever, dyspnea, diarrhea, and lymphopenia. A chest computed tomography (CT) scan showed atypical lobar pneumonic infiltration only in the left lower lobe. The younger sister (6 years old) was affected the following day with milder symptoms (i.e., fever and cough). Her chest CT scan demonstrated typical mild generalized patchy ground-glass opacity with interlobular septal thickening scattered in both lungs. The CT presentation of their grandmother showed typical bilateral white lungs with crazy paving appearance. The standard regimen for both sisters was administrated, and the patients’ respiratory conditions improved after 5 days of treatment. Both cases were discharged with good general conditions.

Conclusion

Children are considered potentially important causes of COVID-19 transmission. The symptoms in children are milder, and clinicians should be aware of taking a definite history of infected family members. Atypical clinical symptoms and imaging features are more common in children than adults; therefore, it is necessary to identify the typical and atypical imaging patterns of COVID-19 pneumonia in the pediatric population.

Coronaviruses: Innate Immunity, Inflammasome Activation, Inflammatory Cell Death, and Cytokines

The innate immune system acts as the first line of defense against pathogens, including coronaviruses (CoVs). Severe acute respiratory syndrome (SARS)-CoV and Middle East respiratory syndrome (MERS)-CoV are epidemic zoonotic CoVs that emerged at the beginning of the 21st century. The recently emerged virus SARS-CoV-2 is a novel strain of CoV that has caused the coronavirus 2019 (COVID-19) pandemic. Scientific advancements made by studying the SARS-CoV and MERS-CoV outbreaks have provided a foundation for understanding pathogenesis and innate immunity against SARS-CoV-2. In this review, we focus on our present understanding of innate immune responses, inflammasome activation, inflammatory cell death pathways, and cytokine secretion during SARS-CoV, MERS-CoV, and SARS-CoV-2 infection. We also discuss how the pathogenesis of these viruses influences these biological processes.

Comparison of Clinical and Laboratory Features and Treatment Options of 237 Symptomatic and Asymptomatic Children Infected with SARS-CoV-2 in the Early Phase of the COVID-19 Pandemic in Turkey

Little is known about the therapeutic use of hydroxychloroquine in pediatric patients with coronavirus disease 2019 (COVID-19). Here, we retrospectively retrieved data of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR-positive pediatric patients from 20 hospitals in 8 Turkish cities. We obtained epidemiological, clinical, and laboratory features of the patients, as well as the drugs used for treating COVID-19. A total of 237 nasopharyngeal swab SARS-CoV-2 PCR-positive children were included in the study from March 26, 2020 to June 20, 2020. The mean age of asymptomatic children (118 ± 62 months) was higher than that of symptomatic children (89 ± 69 months). Symptomatic children had significantly lower mean lymphocyte counts and higher mean CRP, D-dimer, procalcitonin, and LDH levels than asymptomatic children in the univariate analysis. Among 156 children, 78 (50%), 15, 44, and 21 were treated with a hydroxychloroquine-containing regimen, hydroxychloroquine + azithromycin + oseltamivir, hydroxychloroquine + azithromycin, and hydroxychloroquine alone, respectively. Among 156 patients who received medical treatment, 90 (58%) underwent pre- and/or post-treatment electrocardiogram (ECG). However, none of them had ECG abnormalities or required hydroxychloroquine discontinuation due to adverse drug reactions.

Drug repurposing approach to fight COVID-19

Currently, there are no treatment options available for the deadly contagious disease, coronavirus disease 2019 (COVID-19). Drug repurposing is a process of identifying new uses for approved or investigational drugs and it is considered as a very effective strategy for drug discovery as it involves less time and cost to find a therapeutic agent in comparison to the de novo drug discovery process. The present review will focus on the repurposing efficacy of the currently used drugs against COVID-19 and their mechanisms of action, pharmacokinetics, dosing, safety, and their future perspective. Relevant articles with experimental studies conducted in-silico, in-vitro, in-vivo, clinical trials in humans, case reports, and news archives were selected for the review. Number of drugs such as remdesivir, favipiravir, ribavirin, lopinavir, ritonavir, darunavir, arbidol, chloroquine, hydroxychloroquine, tocilizumab and interferons have shown inhibitory effects against the SARS-CoV2 in-vitro as well as in clinical conditions. These drugs either act through virus-related targets such as RNA genome, polypeptide packing and uptake pathways or target host-related pathways involving angiotensin-converting enzyme-2 (ACE2) receptors and inflammatory pathways. Using the basic knowledge of viral pathogenesis and pharmacodynamics of drugs as well as using computational tools, many drugs are currently in pipeline to be repurposed. In the current scenario, repositioning of the drugs could be considered the new avenue for the treatment of COVID-19.

COVID-19 in children: what did we learn from the first wave?

A pandemic caused by the novel coronavirus, severe acute respiratory syndrome - coronavirus 2 (SARS-CoV-2), has caused high rates of mortality, predominantly in adults. Children are significantly less affected by SARS-CoV-2 with far lower rates of recorded infections in children compared to adults, milder symptoms in the majority of children and very low mortality rates. A suspected late manifestation of the disease, paediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 (PIMS-TS), has been seen in small numbers of children and has a more severe disease course than acute SARS-CoV-2. The pandemic has meant that children around the world have been kept off school, isolated from their extended family and friends and asked to stay inside. The UK has been declared as being in an economic recession and unemployment rates are increasing. These indirect effects of SARS-CoV-2 are likely to have a significant impact on many children for years to come. Consolidating the knowledge that has accumulated during the first wave of this pandemic is essential for recognising the clinical signs, symptoms and effective treatment strategies for children; identifying children who may be at increased risk of severe SARS-CoV-2 infection; planning the safe delivery of healthcare and non-health related services that are important for childrens' wellbeing; and engaging in, and developing, research to address the things that are not yet known. This article summarises the evidence that has emerged from the early phase of the pandemic and offers an overview for those looking after children or planning services.

Pharmacotherapy of Acute COVID-19 Infection and Multisystem Inflammatory Syndrome in Children: Current State of Knowledge

Background: The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic is a health care emergency across the world. Although mitigation measures, such as social distancing and face masks, have attempted to slow the spread of the infection, cases continue to rise. Children who are otherwise healthy tend to develop a milder acute Coronavirus disease 2019 (COVID-19) infection and have lower mortality rates compared with adults. Methods: Guidelines and current primary and secondary literature on the treatment of COVID-19 and the multisystem inflammatory syndrome in children were searched and reviewed. There are 6 published pediatric series that included 252 children with acute COVID-19 infection and describe various treatments and outcomes. Results: Guidelines recommend treating pediatric patients similarly to adult patients. Currently, no prophylactic drug therapy has been shown to reduce the spread of infection. Treatment options for acute COVID-19 are limited to remdesivir and glucocorticoids for patients who require oxygen and/or mechanical ventilation. The efficacy of hydroxychloroquine, chloroquine, and azithromycin has not been proven and their safety has been a concern. Other therapies that are being explored include interleukin (IL)-1 and IL-6 inhibitors. In children, an atypical Kawasaki-like disease emerged after recent exposure to SARS-CoV-2 and has been named Multisystem Inflammatory Syndrome in Children (MIS-C). Nine case series, including 418 pediatric patients, described pharmacotherapies used and patient outcomes. These pharmacotherapies included intravenous immune globulin and glucocorticoids and in some patients, IL-1 and IL-6 inhibitors. Conclusion: Given the paucity of data in children, this article presents currently recommended pharmacotherapies for the treatment of acute COVID-19 infection in adult patients and whenever available, in pediatric patients. Pharmacotherapies used in the treatment of MIS-C in children are also reviewed.

Hematological manifestations of SARS-CoV-2 in children

Infection from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), though mainly a respiratory disease, can impair many systems, including causing hematological complications. Lymphopenia and hypercoagulability have been reported in adults with coronavirus disease 2019 (COVID-19) and are considered markers of poor prognosis. This review summarizes the hematological findings in children with SARS-CoV-2 infection. The majority of infected children had a normal leukocyte count, while the most common white blood cell abnormality was leukopenia. Lymphopenia, which may be a marker of severe disease, was rarer in children than in adults, possibly due to their immature immune system or due to the less severe manifestation of COVID-19 in this age group. Age may have an impact, and in neonates and infants the most common abnormality was lymphocytosis. Abnormalities of red blood cells and platelets were uncommon. Anemia and hypercoagulability were reported mainly in children presenting the novel multisystem inflammatory syndrome (MIS) associated with SARS-CoV-2.

Ramping up of SARS CoV-2 testing for the diagnosis of COVID-19 to better manage the next phase of pandemic and reduce the mortality in India

The coronavirus disease 2019 (COVID-19) pandemic is caused by the severe acute respiratory syndrome coronavirus-2, a new member of the Coronavirus family. The virus was first identified in Wuhan, China, where the epidemic originated. The viral genome was sequenced and a real time reverse transcription polymerase chain reaction assay was developed and used for the detection of virus. Different countries took different approaches for the diagnosis of COVID-19. Some countries prioritized extensive testing for COVID-19 at a very early phase of the pandemic whereas other countries took a long time to build the testing capacity and to implement the testing extensively. The assay design formats were available in the public domain and thereby allowing researchers to replicate them to make diagnostic kits. Consequently, several antigen or antibody-based diagnostic tests were also developed for the diagnosis of COVID-19. However, there were some validation and regulatory challenges while bringing these assays into the market. During the course of the pandemic, it became clear that the countries which implemented testing at an early stage of the pandemic were capable of controlling the spread more effectively than those that implemented them at later stages. As several countries implemented a lockdown for controlling the spread of the virus, it is critical to build the testing capability to meet the extensive need of testing while exiting the lockdown. Testing and isolation of positive cases are the most effective ways of preventing the spread of virus and gradually returning life back to normality.

Coronavirus global pandemic: An overview of current findings among pediatric patients

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic has been emerged as a cardinal public health problem. Children have their own specific clinical features; notably, they seem to be escaping the severe respiratory adverse effects. The international scientific community is rapidly carrying out studies, driving to the need to reassess knowledge of the disease and therapeutic strategies.

AIM

To assess the characteristics of COVID-19 infected children worldwide of all ages, from neonates to children and adolescents, and how they differ from their adult counterparts.

SEARCH STRATEGY

An electronic search in PubMed was conducted, using combinations of the following keywords: coronavirus, SARS-CoV-2, COVID-19, children. The search included all types of articles written in English between January 1, 2019 until August 15, 2020.

RESULTS

The search identified 266 relevant articles. Children were mainly within family clusters of cases and have relatively milder clinical presentation compared with adults; children were reported to have better outcomes with a significantly lower mortality rate. Cough and fever were the most common symptoms while pneumonia was the cardinal respiratory manifestation of infected children. Laboratory results and thoracic imaging give varying results.

CONCLUSIONS

Children were mainly family cluster cases and usually presented with a mild infection, although cases presented with the multisystem inflammatory syndrome are becoming more apparent. Studies determining why the manifestations of SARS-CoV-2 infection are so variable may help to gain a better understanding of the disease and accelerate the development of vaccines and therapies.

Point-of-care lung ultrasound imaging in pediatric COVID-19

BACKGROUND

There has been limited data regarding the usefulness of lung ultrasound (US) in children with COVID-19.

OBJECTIVE

To describe lung US imaging findings and aeration score of 34 children with COVID-19.

METHODS

This study included 0-16-year-old patients with confirmed COVID-19, who were admitted between April 19 and June 18, 2020 in two hospitals in the city of Sao Paulo, Brazil. Lung US was performed as part of the routine evaluation by a skilled Pediatric Emergency physician. Clinical and laboratory data were collected and severity classifications were done according to an available clinical definition. The lung US findings were described for each lung field and a validated ultrasound lung aeration score was calculated. Data obtained was correlated with clinical information and other imaging modalities available for each case.

RESULTS

Thirty-four confirmed COVID-19 patients had a lung US performed during this period. Eighteen (18/34) had abnormalities on the lung US, but eight of them (8/18) had a normal chest radiograph. Ultrasound lung aeration score medians for severe/critical, moderate, and mild disease were 17.5 (2-30), 4 (range 0-14), 0 (range 0-15), respectively (p = 0.001). Twelve patients (12/34) also had a chest computed tomography (CT) performed; both the findings and topography of lung compromise on the CT were consistent with the information obtained by lung US.

CONCLUSION

Point-of-care lung US may have a key role in assessing lung injury in children with COVID-19.

Duration of Viral Clearance in Children With SARS-CoV-2 Infection in Rajasthan, India

Objective

Methods

Results

Conclusions

COVID-19 in Pediatric Patients: A Focus on CHD Patients

Coronavirus disease 2019 (COVID-19) is a global pandemic caused by SARS-CoV-2 virus. As of the 30th of September 2020, around 34,000,000 cases have been reported globally. Pediatrics with underlying congenital heart disease represent a small yet a critical proportion of these patients. In general, the majority of infected children experience mild to moderate disease with significant interindividual variability in laboratory and radiographic findings. Nevertheless, in healthy children with COVID-19, cardiac involvement has been documented and is attributed to various causes. Myocarditis, arrhythmias, cardiogenic shock, and serious multisystem inflammatory syndrome in children are all encountered. Since COVID-19 is a recent novel disease and based on previous experience with respiratory infections, children with underlying congenital heart disease should be given special attention. To date, little data is available about COVID-19 presentation, complications, and appropriate treatment in this population. However, variable and inconsistent disease presentation and severity have been observed. This paper discusses COVID-19 course of illness in pediatric population with a special emphasis on the cardiac manifestations of the disease in healthy population and also on the disease course in congenital heart disease patients in particular.

SARS-CoV-2 Pandemic Impact on Pediatric Emergency Rooms: A Multicenter Study

From 9 March to 3 May 2020, lockdown was declared in Italy due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Our aim was to evaluate how the SARS-CoV-2 pandemic and related preventive strategies affected pediatric emergency rooms (ERs) during this period. We performed a retrospective cohort multicenter study, comparing the lockdown period to the corresponding period in 2019. We examined 15 Italian pediatric ERs in terms of visit rates, specific diagnoses (grouped as air communicable diseases and non-air communicable diseases), and triage categories. During the lockdown period, ER admissions decreased by 81% compared to 2019 (52,364 vs. 10,112). All ER specific diagnoses decreased in 2020 and this reduction was significantly higher for air communicable diseases (25,462 vs. 2934, p < 0.001). Considering the triage category, red codes remained similar (1% vs. 1%), yellow codes increased (11.2% vs. 22.3%), and green codes decreased (80.3% vs. 69.5%). We can speculate that social distancing and simple hygiene measures drastically reduced the spread of air communicable diseases. The increase in yellow codes may have been related to a delay in primary care and, consequently, in ER admissions.

Clinical Features of COVID-19 in Uzbekistan

BACKGROUND

As of April 30, 2020, a total of 2,039 cases of the novel coronavirus disease 2019 (COVID-19) were confirmed in the Republic of Uzbekistan after the first detection on March 15. Reports on symptoms of COVID-19 are non-specific and known to vary from asymptomatic, mild to severe, or fatal. This study aimed to analyze the symptomatic and clinical characteristics of study participants based on the medical records of participants hospitalized with COVID-19 in Uzbekistan.

METHODS

We collected all data from medical records of COVID-19 confirmed patients in 19 hospitals from 13 regions of Uzbekistan between March 15 and April 30. We selected 1,030 patients discharged from the hospitals after COVID-19 treatment as study participants, excluding those with missing data. Further, we collected demographics, symptoms, clinical outcomes, and treatment data through medical records.

RESULTS

More than half (57.6%) of confirmed cases of COVID-19 were males, and the median age was 36.0 years. The most frequent symptoms at the first inspection on hospital admission of all patients were fatigue (59.7%), dry cough (54.1%), pharyngalgia (31.6%), headache (20.6%), and anorexia (12.5%). Compared to the oldest group, the youngest group showed a lower frequency of symptoms. About half of the group aged 18-49 years reported that they came from abroad. One-fifth of patients in group 50-84 received oxygen support, while no patients in group aged 0-17 years received oxygen support. About two-thirds of the participants from intensive care unit (ICU) came from abroad, whereas 42.1% of the non-ICU group returned from other countries. Regarding symptoms, 16.9% of the patients in the ICU group were asymptomatic, while 5.8% in the non-ICU group were asymptomatic.

CONCLUSION

This study suggests that the medical delivery system and resource distribution need to be implemented based on clinical characteristics by age and severity to delay and effectively respond to the spread of infections in the future. This study analyzed symptoms of COVID-19 patients across Uzbekistan, which is useful as primary data for policies on COVID-19 in Uzbekistan.

COVID-19 in Children and Neonates: A Comprehensive Review Article

Context: Novel coronavirus (COVID-19) has become a new public health crisis, posing a great threat to the people all around the world. We aimed to review the articles on COVID-19 in pediatric population to help physicians and other healthcare workers understand the importance of detecting silent disease carriers in this age group and stop further transmission to other healthy individuals and manage symptomatic patients based on the latest recommendations. Methods: We searched databases including PubMed, Scopus, Google Scholar, and Medline and reviewed 70 articles from December 2019 to mid-July 2020. Relevant articles about COVID-19 in children were included. Results: According to the latest reports, 1% - 5% of infected patients were under 19 years old. Death in this age group was rare but it can occur in children with severe disease. The overall course of disease -mainly pulmonary involvement- of the infected children tend to be milder than adults. This may be related to both host factors and exposure. The lab tests and computed tomography (CT) scan findings are nonspecific and milder compared to those in older ages. The cornerstone of COVID-19 management in pediatric group is supportive care. Of note, there is not any approved specific drug for treatment of children affected by COVID-19. Conclusions: COVID-19 disease characteristics in children are not yet fully established, which poses a significant problem for pediatric medical specialists. It should be considered that most children are asymptomatic or have mild symptoms. Critical cases, although uncommon, can occur especially in children with underlying diseases.

Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: A multicentre study

BACKGROUND

The use of face masks by children for the prevention of COVID 19 is still controversial, especially with regards to who should wear the face mask and at what age.

OBJECTIVES

The study aimed to ascertain the perception of mothers on masking in children as a preventive strategy for COVID-19.

METHODOLOGY

This was a cross-sectional study carried out in two health institutions among 387 mothers who presented with their children for the first time in the hospital during the COVID 19 pandemic. A pretested, semi-structured, interviewer-administered questionnaire which was designed by the researchers was used for data collection.

RESULTS

Minority (44.7%) of the mothers perceived masking in children as an appropriate measure for the prevention of COVID-19. The frequent reasons given by majority (55.3%) of the mothers for the inappropriateness of face mask in children included perceived difficulty in breathing (38.5%) and the child's readiness to pull it off (29.3%). A significantly higher proportion of the children whose mothers were 35 years and above, 64.2% would wear face masks when compared with 31.7% of those whose mothers were < 30 years of age (χ2 = 28.632, p<0.001). Similarly, a significantly higher proportion (51.0%) of the children who were more than one year of age would wear a face mask when compared with 20.5% of those aged eight days to one year (χ2 = 19.441, p<0.001). The children whose mothers were <30 years were about four times less likely to wear a face mask when compared with those whose mothers were aged 35 years and above. (AOR = 0.273; 95%CI: 0.155-0.478). The children whose fathers have attained tertiary education were about twice less likely to wear face masks when compared with those whose fathers have attained secondary education and less. (AOR = 0.554; 95%CI: 0.334-0.919). Mothers' perception of COVID-19 had no significant influence on children's use of face mask (χ2 = 2.337, p = 0.127).

CONCLUSION

Maternal perception of masking in children as an appropriate strategy for preventing COVID-19 is adjudged low in this study. Right perception is significantly enhanced by maternal educational status, employment and marital status.

CLINICAL AND LABORATORY CHARACTERISTICS OF SARS-COV-2 INFECTION IN CHILDREN AND ADOLESCENTS

OBJECTIVE

To present the current evidence on clinical and laboratory characteristics of infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during childhood and adolescence.

DATA SOURCE

This is a narrative review conducted in the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Latin American and Caribbean Health Sciences Literature in the Virtual Health Library (LILACS/VHL), Scopus, Web of Science, Cochrane Library, portal of the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES), Scientific Electronic Library Online (SciELO), ScienceDirect, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The terms used were SARS-CoV-2, COVID-19, novel coronavirus, child, newborn, and adolescent.

DATA SYNTHESIS

Unlike adults, most children infected by SARS-CoV-2 have mild or asymptomatic clinical presentations. Symptomatic children mainly have low fever and cough, with some associated gastrointestinal symptoms. Severe cases are rare and occur especially in infants under one year of age. Detection of viral particles in feces seems to be more persistent in children and can be used as a tool for diagnosis and control of the quarantine period. Different from adults, children can present distinct inflammatory responses, as has happened in new cases of Kawasaki-like syndrome associated with SARS-CoV-2 infection.

CONCLUSIONS

Most children have asymptomatic or mild presentations, with a prevalence of fever, cough, and gastrointestinal symptoms. New cases with different systemic inflammatory reactions in children have been reported, with clinical manifestations distinct from those typically found in adults.

Development of research on COVID-19 by the World Scientific Community in the first half of 2020

The World Scientific Community has carried out several studies on the novel coronavirus, responsible for the current COVID-19 pandemic. This study aimed to verify the development level and research evolution on COVID-19, summarizing experts' main trends in the first half of 2020. The most cited articles focused on understanding the disease, addressing aspects of its transmission, viral activity period, symptoms, health complications, risk factors, and the estimate of new cases. These papers also focused on the treatment/prevention and management of COVID-19. Several drugs and alternative treatments have been investigated, such as the convalescent plasma transfusion and stem cell transplantation, while an efficient vaccine is developed. Prevention and control measures, such as social isolation and immediate case identification, were also investigated. Therefore, the main COVID-19 trends were identified and classified in disease, treatment/prevention, and pandemic management, contributing to scientific understanding and future studies.

Clinical presentations, laboratory and radiological findings, and treatments for 11,028 COVID-19 patients: a systematic review and meta-analysis

This systematic review and meta-analysis investigated the comorbidities, symptoms, clinical characteristics and treatment of COVID-19 patients. Epidemiological studies published in 2020 (from January-March) on the clinical presentation, laboratory findings and treatments of COVID-19 patients were identified from PubMed/MEDLINE and Embase databases. Studies published in English by 27th March, 2020 with original data were included. Primary outcomes included comorbidities of COVID-19 patients, their symptoms presented on hospital admission, laboratory results, radiological outcomes, and pharmacological and in-patient treatments. 76 studies were included in this meta-analysis, accounting for a total of 11,028 COVID-19 patients in multiple countries. A random-effects model was used to aggregate estimates across eligible studies and produce meta-analytic estimates. The most common comorbidities were hypertension (18.1%, 95% CI 15.4-20.8%). The most frequently identified symptoms were fever (72.4%, 95% CI 67.2-77.7%) and cough (55.5%, 95% CI 50.7-60.3%). For pharmacological treatment, 63.9% (95% CI 52.5-75.3%), 62.4% (95% CI 47.9-76.8%) and 29.7% (95% CI 21.8-37.6%) of patients were given antibiotics, antiviral, and corticosteroid, respectively. Notably, 62.6% (95% CI 39.9-85.4%) and 20.2% (95% CI 14.6-25.9%) of in-patients received oxygen therapy and non-invasive mechanical ventilation, respectively. This meta-analysis informed healthcare providers about the timely status of characteristics and treatments of COVID-19 patients across different countries.PROSPERO Registration Number: CRD42020176589.

Management of Pediatric Kidney Transplant Patients During the COVID-19 Pandemic: Guidance From the Canadian Society of Transplantation Pediatric Group

PURPOSE OF THE PROGRAM

To provide guidance on the management of pediatric kidney transplant patients during the COVID-19 pandemic.

SOURCES OF INFORMATION

Program-specific documents, preexisting, and related to COVID-19; documents from provincial, national, and international kidney transplant societies/agencies and organ procurement agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature.

METHODS

Challenges in the care of pediatric kidney transplant patients during the COVID-19 pandemic were highlighted within the Canadian Society of Transplantation (CST) Pediatric Group. It identified pediatric kidney transplant nephrologists (including a pediatric nephrologist ethicist) across the country and formed a workgroup. The initial guidance document was drafted and members of the workgroup reviewed and discussed all suggestions in detail via e-mail and virtual meetings. Disagreements were resolved by consensus. The document was reviewed by the CST Kidney Transplant Working Group, by the Canadian Society of Nephrology (CSN) COVID-19 Rapid Response Team (RRT), and an infectious disease expert. The suggestions were presented at an interactive webinar sponsored by CSN in collaboration with the CST and Canadian Association of Pediatric Nephrologists (CAPN), and attended by pediatric kidney health care professionals for further peer input. Final revisions were made based on feedback received. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity.

KEY FINDINGS

We identified 8 key areas of pediatric kidney transplant care that may be affected by the COVID-19 pandemic: (1) transplant activity, (2) outpatient clinic activity, (3) monitoring, (4) multidisciplinary care, (5) medications (immunosuppression and others), (6) patient/family education/support, (7) school and employment, and (8) management of pediatric kidney transplant patients who are COVID-19 positive. We make specific suggestions for each of these areas.

LIMITATIONS

A full systematic review of available literature was not undertaken for the sake of expediency in development of this guideline. There is a paucity of literature to support evidence-based recommendations at this time. Instead, these guidelines were formulated based on expert opinion derived from available knowledge/experience and are subject to the biases associated with this level of evidence. The parallel review process that was created to expedite the publication of this work may not be as robust as standard arms' length peer review processes.

IMPLICATIONS

These recommendations are meant to serve as a guide to pediatric kidney transplant directors, clinicians, and administrators for providing the best patient care in the context of limited resources while protecting patients and health care providers wherever possible by limiting exposure to COVID-19. We recognize that recommendations may not be applicable to all provincial/local health authority practices and that they may not be delivered to all patients given the time and resource constraints affecting the individual provincial/local health jurisdiction.

The Challenges of a Children's Hospital during the COVID-19 Pandemic: The Pediatric Surgeon's Point of View

During the coronavirus disease of 2019 (COVID-19) emergency, in the pediatric surgical setting, it has been essential to avoid and contain infections as well as to protect both the patients and the surgical team. During this emergency, procedures and workflow were adapted to provide the safest possible environment for both the surgical team and the patients. Pediatric surgical activities were reorganized during the COVID-19 pandemic at the "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), Italy. Resources were optimized in order to maintain high levels of care and quality of assistance. During the COVID-19 emergency, the pediatric surgical department at the "Vittore Buzzi" Children's Hospital became an acute care surgical service. For the reorganization of surgical activities, institutional protocols were adapted in order to preserve the pediatric-specific characteristics of our service; five crucial points were specifically addressed. The pediatric surgical procedures carried out during the initial two months of the Italian lockdown are also reported. Continuity of care was maintained for children affected by severe diseases, such as tumors and neurosurgical conditions, whose treatment could not be deferred. Telemedicine and telecommunication were adopted as quick-support modalities for pre- and post-operative care. This reorganization allowed us to preserve the "pediatric specificity" and all care-related procedures offered at this high-quality/high-volume surgical care referral center.

Global prevalence and pathogenesis of headache in COVID-19: A systematic review and meta-analysis

Background: This study was conducted to determine the prevalence of headache in coronavirus disease 2019 (COVID-19) and to assess its association as a predictor for COVID-19. This study also aimed to discuss the possible pathogenesis of headache in COVID-19. Methods: Available articles from PubMed, Scopus, and Web of Science were searched as of September 2 nd, 2020. Data on characteristics of the study, headache and COVID-19 were extracted following the PRISMA guidelines. Biases were assessed using the Newcastle-Ottawa scale. The cumulative prevalence of headache was calculated for the general population (i.e. adults and children). The pooled odd ratio (OR) with 95% confidence intervals (95%CI) was calculated using the Z test to assess the association between headache and the presence of COVID-19 cases. Results: We included 104,751 COVID-19 cases from 78 eligible studies to calculate the global prevalence of headache in COVID-19 and 17 studies were included to calculate the association of headache and COVID-19. The cumulative prevalence of headache in COVID-19 was 25.2% (26,464 out of 104,751 cases). Headache was found to be more prevalent, approximately by two-fold, in COVID-19 patients than in non-COVID-19 patients (other respiratory viral infections), OR: 1.73; 95% CI: 1.94, 2.5 with p=0.04. Conclusion: Headache is common among COVID-19 patients and seems to be more common in COVID-19 patients compared to those with the non-COVID-19 viral infection. No definitive mechanisms on how headache  emerges in COVID-19 patients but several possible hypotheses have been proposed. However, extensive studies are warranted to elucidate the mechanisms. PROSPERO registration: CRD42020210332 (28/09/2020).

Global prevalence and pathogenesis of headache in COVID-19: A systematic review and meta-analysis

Background: This study was conducted to determine the prevalence of headache in coronavirus disease 2019 (COVID-19) and to assess its association as a predictor for COVID-19. This study also aimed to discuss the possible pathogenesis of headache in COVID-19. Methods: Available articles from PubMed, Scopus, and Web of Science were searched as of September 2 nd, 2020. Data on characteristics of the study, headache and COVID-19 were extracted following the PRISMA guidelines. Biases were assessed using the Newcastle-Ottawa scale. The cumulative prevalence of headache was calculated for the general population (i.e. adults and children). The pooled odd ratio (OR) with 95% confidence intervals (95%CI) was calculated using the Z test to assess the association between headache and the presence of COVID-19 cases. Results: We included 104,751 COVID-19 cases from 78 eligible studies to calculate the global prevalence of headache in COVID-19 and 17 studies were included to calculate the association of headache and COVID-19. The cumulative prevalence of headache in COVID-19 was 25.2% (26,464 out of 104,751 cases). Headache was found to be more prevalent, approximately by two-fold, in COVID-19 patients than in non-COVID-19 patients (other respiratory viral infections), OR: 1.73; 95% CI: 1.94, 2.5 with p=0.04. Conclusion: Headache is common among COVID-19 patients and seems to be more common in COVID-19 patients compared to those with the non-COVID-19 viral infection. No definitive mechanisms on how headache  emerges in COVID-19 patients but several possible hypotheses have been proposed. However, extensive studies are warranted to elucidate the mechanisms. PROSPERO registration: CRD42020210332 (28/09/2020).

Age separation dramatically reduces COVID-19 mortality rate in a computational model of a large population

COVID-19 pandemic has caused a global lockdown in many countries throughout the world. Faced with a new reality, and until a vaccine or efficient treatment is found, humanity must figure out ways to keep the economy going, on one hand, while keeping the population safe, on the other hand, especially those that are susceptible to this virus. Here, we use a Watts–Strogatz network simulation, with parameters that were drawn from what is already known about the virus, to explore five different scenarios of partial lockdown release in two geographical locations with different age distributions. We find that separating age groups by reducing interactions between them protects the general population and reduces mortality rates. Furthermore, the addition of new connections within the same age group to compensate for the lost connections outside the age group still has a strong beneficial influence and reduces the total death toll by about 62%. While complete isolation from society may be the most protective scenario for the elderly population, it would have an emotional and possibly cognitive impact that might outweigh its benefit. Therefore, we propose creating age-related social recommendations or even restrictions, thereby allowing social connections while still offering strong protection for the older population.

Immune responses to SARS-CoV-2 in three children of parents with symptomatic COVID-19

Compared to adults, children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have predominantly mild or asymptomatic infections, but the underlying immunological differences remain unclear. Here, we describe clinical features, virology, longitudinal cellular, and cytokine immune profile, SARS-CoV-2-specific serology and salivary antibody responses in a family of two parents with PCR-confirmed symptomatic SARS-CoV-2 infection and their three children, who tested repeatedly SARS-CoV-2 PCR negative. Cellular immune profiles and cytokine responses of all children are similar to their parents at all timepoints. All family members have salivary anti-SARS-CoV-2 antibodies detected, predominantly IgA, that coincide with symptom resolution in 3 of 4 symptomatic members. Plasma from both parents and one child have IgG antibody against the S1 protein and virus-neutralizing activity detected. Using a systems serology approach, we demonstrate higher levels of SARS-CoV-2-specific antibody features of these family members compared to healthy controls. These data indicate that children can mount an immune response to SARS-CoV-2 without virological confirmation of infection, raising the possibility that immunity in children can prevent the establishment of SARS-CoV-2 infection. Relying on routine virological and serological testing may not identify exposed children, with implications for epidemiological and clinical studies across the life-span.

A Pediatric Infectious Diseases Perspective of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Novel Coronavirus Disease 2019 (COVID-19) in Children

Understanding the role that children play in the clinical burden and propagation of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19) infections, is emerging. While the severe manifestations and acute clinical burden of COVID-19 have largely spared children compared with adults, understanding the epidemiology, clinical presentation, diagnostics, management, and prevention opportunities and the social and behavioral impacts on child health is vital. Foremost is clarifying the contribution of asymptomatic and mild infections to transmission within the household and community and the clinical and epidemiologic significance of uncommon severe post-infectious complications. Here, we summarize the current knowledge, identify resources, and outline research opportunities. Pediatric infectious diseases clinicians have a unique opportunity to advocate for the inclusion of children in epidemiological, clinical, treatment, and prevention studies to optimize their care as well as to represent children in the development of guidance and policy during pandemic response.

Clinical characteristics of 10 children with a pediatric inflammatory multisystem syndrome associated with COVID-19 in Iran

BACKGROUND

Although symptoms and signs of COVID-19 (Coronavirus disease 2019) in children are milder than adults, there are reports of more severe cases which were defined as pediatric inflammatory multisystem syndrome (PIMS). The purpose of this report was to describe the possible association between COVID-19 and PIMS in children.

METHODS

From 28 March to 24 June 2020, 10 febrile children were admitted with COVID-19 infection showing characteristics of PIMS in Buali tertiary hospital of Sari, in Mazandaran province, northern Iran. Demographic and clinical characteristics, laboratory and imaging findings, and therapeutic modalities were recorded and analyzed.

RESULTS

The mean age of the patients was 5.37 ± 3.9 years (13 months to 12 years). Six of them were boys. Kawasaki disease, myocarditis, toxic shock syndrome, appendicitis, sepsis, urosepsis, prolonged febrile seizure, acute hemorrhagic edema of infancy, and COVID-19-related pneumonia were their first presentation. All of them had increased C-reactive protein levels, and most of them had elevated erythrocyte sedimentation rate, lymphopenia, anemia, and hypoalbuminemia. Three of them had thrombocytopenia(PLT < 106). Six of them were serologically or polymerase chain reaction positive for COVID-19, and 4 of them were diagnosed as COVID-19 just by chest computed tomography scan. Most of the patients improved without a residual sequel, except one who died with multiorgan failure and another case was discharged with a giant coronary aneurysm.

CONCLUSIONS

Children with COVID-19 may present symptoms similar to Kawasaki disease and inflammatory syndromes. PIMS should be considered in children with fever, rash, seizure, cough, tachypnea, and gastrointestinal symptoms such as vomiting, diarrhea, and abdominal pain.

A Meta-Analysis of 67 Studies with Presenting Symptoms and Laboratory Tests of COVID-19 Patients

OBJECTIVES/HYPOTHESIS

The objective of this meta-analysis was to look at the pooled prevalence of symptoms, laboratory tests, and imaging of all COVID-19 infected patients. This will allow better identification of potential COVID-19 patients and take appropriate precautions.

STUDY DESIGN

Meta analysis.

METHODS

We searched three databases, PubMed, EMBASE, and Ovid to identify studies published between Dec-2019 and May-2020. All studies reporting upper-aerodigestive symptoms of COVID-19 infection were included. The meta-analysis was conducted following meta-analyses of observational studies in epidemiology (MOOSE) guidelines, which have evaluated the pooled prevalence of 14 symptoms and nine laboratory investigations.

RESULTS

Based on inclusion criteria, 67 publications consisting of 8302 patients were included. Among adults, the pooled proportion of hypertensive and diabetic patients was 18% and 7%. Cough (53% [0.46-0.61]), anosmia (38% [0.19-0.58]), loss/distortion of taste (31% [0.17-0.45]), and nasal obstruction (26% [0.12-0.39]) were the most common ear, nose & throat (ENT) symptoms. Fever (69% [0.62-0.76]) and fatigue (31% [0.26-0.37]) were the commonest generalized symptoms. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were raised in 56% (0.41-0.71) and 49% (0.21-0.77), respectively. Interestingly, lymphopenia (41% [0.30-0.53]) and leucopenia (22% [0.16-0.29]) were more common than lymphocytosis (33% [0.02-0.64]) and leucocytosis (12% [0.09-0.16]). Fever (69% vs. 44%), cough (53% vs. 33%), and dyspnea (20% vs. 4%) were more common in adults as compared to the pediatric population. Diarrhea was more common among the pediatric cases (12%) versus (9%). The pooled estimate of fatality was 4%.

CONCLUSIONS

The most commonly experienced ENT symptom was cough followed by anosmia and dysguesia. Raised ESR and CRP with leukopenia and lymphopenia are common laboratory findings. Majority of the infected patients had abnormal computed tomography findings. COVID infection is less severe in pediatric patients. Laryngoscope, 131:1254-1265, 2021.

Features Discriminating COVID-19 From Community-Acquired Pneumonia in Pediatric Patients

Purpose: To discuss the different characteristics of clinical, laboratory and chest computed tomography (CT) between coronavirus disease 2019 (COVID-19) and community-acquired pneumonia (CAP) in pediatric patients. Methods: We retrospectively retrieved data of inpatients with COVID-19 from January 21st to March 14th, 2020, and CAP from November 1st, 2019 to December 31st, 2019 in Wuhan Children's Hospital. We divided CAP into mycoplasma pneumonia and other viral pneumonia. We analyzed clinical and radiological features from those patients, and compared the differences among COVID-19, mycoplasma pneumonia and other viral pneumonia. Results: Eighty COVID-19 inpatients from January 21st to March 14th, 2020, as well as 95 inpatients with mycoplasma pneumonia and 50 inpatients with other viral pneumonia from November 1st, 2019 to December 31st, 2019 were included in our study. All patients were confirmed with RT-PCR. The clinical symptoms were similar in the three groups. Except fever and cough, diarrhea (6/80, 7.5%), tachypnea (2/80, 2.5%), and fatigue (6/80, 7.5%) were less common in COVID-19 patients. Compared to mycoplasma pneumonia and other viral pneumonia inpatients, COVID-19 patients present remarkably increased alanine aminotransferase (69/80, 86.3%). The typical CT feature of COVID-19 is ground-glass opacity, and it was more common in COVID-19 patients (32/80, 40%). Conclusion: The COVID-19 shared similar onsets with CAP. Even though the ground-glass opacity and elevated level of ALT were frequent in COVID-19, the better way for treatment and management of this disease is quickly and accurately identifying the pathogen.

Longitudinal Changes on Clinical Features in 28 Children With COVID-19 in Shenzhen, China

Objective: To investigate the clinical characteristics of children with coronavirus disease 2019 (COVID-19) and identify the occurrence of viral shedding of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) during follow-up.

Methods: We retrospectively retrieved data from pediatric patients with COVID-19 from the Shenzhen Third People's Hospital in China. The dynamics of SARS-CoV-2 and antibodies against SARS-CoV-2 were analyzed during hospitalization and after discharge.

Results: From January 23 to March 15, 2020, a total of 28 pediatric patients were diagnosed with COVID-19 and were followed for at least 1 month. The median age was 7 years (IQR 3.5–10) and none of the children progressed to severe COVID-19 during hospitalization. Ten patients tested positive for SARS-CoV-2 1 month after discharge while four patients tested positive during the 2nd month after discharge. Only three of 12 children showed detectable immunoglobulin-M (IgM) on day 5, 18, and 21 after illness onset, respectively.

Conclusions: COVID-19 disease was relatively mild among children while a number did test positive after discharge from the hospital. Public health initiatives should thus adapt control measures targeted toward children.

Ocular Manifestations and Clinical Characteristics of Children With Laboratory-Confirmed COVID-19 in Wuhan, China

Importance

Ocular manifestations and outcomes in children with confirmed coronavirus disease 2019 (COVID-19), relevant affecting factors, and differences in ocular disease between children and adults have yet to be fully understood.

Objective

To investigate ocular manifestations and clinical characteristics of children with laboratory-confirmed COVID-19.

Design, Setting, and Participants

This cross-sectional study was conducted at Wuhan Children's Hospital in Wuhan, China. Children with COVID-19 confirmed by severe acute respiratory syndrome coronavirus disease 2 nucleic acid tests of upper respiratory tract specimens between January 26 and March 18, 2020, were included.

Main Outcomes and Measures

Onset clinical symptoms and duration, ocular symptoms, and needs for medication.

Results

A total of 216 pediatric patients were included, among whom 134 (62%) were boys, with a median (interquartile range) age of 7.25 (2.6-11.6) years. Based on the exposure history, 193 children (89.4%) had a confirmed (173 [80.1%]) or suspected (20 [9.3%]) family member with COVID-19 infection. The most common symptoms among symptomatic children were fever (81 [37.5%]) and cough (79 [36.6%]). Of 216 children, 93 (43.1%) had no systemic or respiratory symptoms. All children with mild (101 [46.8%]) or moderate (115 [53.2%]) symptoms recovered without reported death. Forty-nine children (22.7%) showed various ocular manifestations, of which 9 had ocular complaints being the initial manifestations of COVID-19. The common ocular manifestations were conjunctival discharge (27 [55.1%]), eye rubbing (19 [38.8%]), and conjunctival congestion (5 [10.2%]). Children with systemic symptoms (29.3% vs 14.0%; difference, 15.3%; 95% CI, 9.8%-20.7%; P = .008) or with cough (31.6% vs 17.5%; difference, 14.1%; 95% CI, 8.0%-20.3%; P = .02) were more likely to develop ocular symptoms. Ocular symptoms were typically mild, and children recovered or improved.

Conclusions and Relevance

In this cross-sectional study, children hospitalized with COVID-19 in Wuhan, China, presented with a series of onset symptoms including fever, cough, and ocular manifestations, such as conjunctival discharge, eye rubbing, and conjunctival congestion. Patients' systemic clinical symptoms or cough were associated with ocular symptoms. Ocular symptoms recovered or improved eventually.

What could explain the late emergence of COVID-19 in Africa?

At the end of November 2019, a novel coronavirus responsible for respiratory tract infections emerged in China. Despite drastic containment measures, this virus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spread in Asia and Europe. The pandemic is ongoing with a particular hotspot in southern Europe and America in spring 2020. Many studies predicted an epidemic in Africa similar to that currently seen in Europe and the USA. However, reported data do not confirm these predictions. Several hypotheses that could explain the later emergence and spread of the coronavirus disease 2019 (COVID-19) pandemic in African countries are being discussed, including the lack of health-care infrastructure capable of clinically detecting and confirming COVID-19 cases, the implementation of social distancing and hygiene, international air traffic flows, the climate, the relatively young and rural population, the genetic polymorphism of the angiotensin-converting enzyme 2 receptor, cross-immunity and the use of antimalarial drugs.

Harnessing immunotherapy to combat COVID-19: A modern snake oil or silver bullet?

Coronavirus disease 2019 (COVID-19), an infectious disease caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2), has emerged into a global health and economic menace. Amidst the COVID-19 turmoil, recent failures/uncertain outcomes in clinical trials involving the anti-malarial (hydroxychloroquine), anti-viral (remdesivir) or the combination of anti-malarial/antibiotic (hydroxychloroquine/azithromycin) regimens have predisposed the physicians to distrust these “highly-touted” drugs for COVID-19. In this milieu, immunotherapy might be a credible modality to target or modify specific/non-specific immune responses that interfere with the survival of intracellular pathogens. This scientific review throws light on the epidemiology of COVID-19, its pathogenesis and the current clinical scenario of immunotherapeutics including convalescent plasma (CP), type-1 interferons (IFN–I) and human monoclonal antibodies (mAbs) to combat COVID-19. The treatment outcomes underscore that immunotherapy might be a reliable tool to assuage COVID-19-associated immunopathology. However, specific patient pool studies are warranted to ascertain the precise (re)purposing of immunotherapeutics for COVID-19.

[Covid-19: clinical aspects and management]

Asymptomatic infections are not rare and most patients complain with fever and respiratory signs. Clinical signs are polymorphic and aspecific. Chest CT scan is commonly used as a diagnostic and triage tool in patients admitted to hospitalization. The 2 main complications are respiratory distress related to worsening pneumonia with an associated cytokine storm occurring mostly 7 to 10 days after disease onset, and thromboembolic disease. The fatality rate is around 2%. In-hospital management includes oxygen supply when needed and prevention of thromboembolic disease. Associated bacterial infections seem to be rare. Remdesivir might reduce the time to recovery in hospitalized patients needing an oxygen supply. Dexamethasone might reduce the fatality rate in patients requiring mechanical ventilation. The development of many candidate vaccines gives hope to fight the pandemic.

Imaging Findings of SARS-CoV-2 Infection in Pediatrics: A Systematic Review of Coronavirus Disease 2019 (COVID-19) in 850 Patients

RATIONALE AND OBJECTIVES

Children with COVID-19 seem to have a relatively milder disease and better prognosis; however, severe disease or death could still occur in this age group. Although the knowledge on the clinical and epidemiology of COVID-19 in pediatric patients is being accumulated rapidly, relevant comprehensive review on its radiological manifestations is still lacking. The present article reviews the radiological characteristics of COVID-19 in pediatrics, based on the previous studies.

MATERIALS AND METHODS

We conducted a systematic literature search for published articles by using Medline, Scopus, Google Scholar and Embase online databases. All studies describing CT findings of COVID-19 in pediatrics (<18years) were included.

RESULTS

A total of 39 studies with 850 pediatric patients were reviewed. 225 (26.5%) of patients had normal CT findings. Ground-glass opacities and consolidations were the most common CT abnormalities (384/625, 61.5%). Other findings were halo sign, interstitial opacities, bronchial wall thickening, and crazy-paving sign. Approximately 55% of patients had unilateral pulmonary findings. Most studies found peripheral and lower-lobe distribution to be a prominent imaging finding.

CONCLUSION

Our study showed that imaging findings in children were often milder and more focal than adults, typically as ground-glass opacities and consolidations with unilateral lower-lobe predominance, which have been regressed during the recovery time. A balance must be struck between the risk of radiation and the need for chest CT. If still necessary, low-dose CT is more appropriate in this age group. Albeit, due to the limited number of reported pediatrics with COVID-19, and the lack of consistency in CT descriptors, further work is still needed in this regard.

Determining the optimal strategy for reopening schools, the impact of test and trace interventions, and the risk of occurrence of a second COVID-19 epidemic wave in the UK: a modelling study

BACKGROUND

As lockdown measures to slow the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection begin to ease in the UK, it is important to assess the impact of any changes in policy, including school reopening and broader relaxation of physical distancing measures. We aimed to use an individual-based model to predict the impact of two possible strategies for reopening schools to all students in the UK from September, 2020, in combination with different assumptions about relaxation of physical distancing measures and the scale-up of testing.

METHODS

In this modelling study, we used Covasim, a stochastic individual-based model for transmission of SARS-CoV-2, calibrated to the UK epidemic. The model describes individuals' contact networks stratified into household, school, workplace, and community layers, and uses demographic and epidemiological data from the UK. We simulated six different scenarios, representing the combination of two school reopening strategies (full time and a part-time rota system with 50% of students attending school on alternate weeks) and three testing scenarios (68% contact tracing with no scale-up in testing, 68% contact tracing with sufficient testing to avoid a second COVID-19 wave, and 40% contact tracing with sufficient testing to avoid a second COVID-19 wave). We estimated the number of new infections, cases, and deaths, as well as the effective reproduction number (R) under different strategies. In a sensitivity analysis to account for uncertainties within the stochastic simulation, we also simulated infectiousness of children and young adults aged younger than 20 years at 50% relative to older ages (20 years and older).

FINDINGS

With increased levels of testing (between 59% and 87% of symptomatic people tested at some point during an active SARS-CoV-2 infection, depending on the scenario), and effective contact tracing and isolation, an epidemic rebound might be prevented. Assuming 68% of contacts could be traced, we estimate that 75% of individuals with symptomatic infection would need to be tested and positive cases isolated if schools return full-time in September, or 65% if a part-time rota system were used. If only 40% of contacts could be traced, these figures would increase to 87% and 75%, respectively. However, without these levels of testing and contact tracing, reopening of schools together with gradual relaxing of the lockdown measures are likely to induce a second wave that would peak in December, 2020, if schools open full-time in September, and in February, 2021, if a part-time rota system were adopted. In either case, the second wave would result in R rising above 1 and a resulting second wave of infections 2·0-2·3 times the size of the original COVID-19 wave. When infectiousness of children and young adults was varied from 100% to 50% of that of older ages, we still found that a comprehensive and effective test-trace-isolate strategy would be required to avoid a second COVID-19 wave.

INTERPRETATION

To prevent a second COVID-19 wave, relaxation of physical distancing, including reopening of schools, in the UK must be accompanied by large-scale, population-wide testing of symptomatic individuals and effective tracing of their contacts, followed by isolation of diagnosed individuals.

FUNDING

None.

Transmission of SARS-CoV-2 in Australian educational settings: a prospective cohort study

BACKGROUND

School closures have occurred globally during the COVID-19 pandemic. However, empiric data on transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children and in educational settings are scarce. In Australia, most schools have remained open during the first epidemic wave, albeit with reduced student physical attendance at the epidemic peak. We examined SARS-CoV-2 transmission among children and staff in schools and early childhood education and care (ECEC) settings in the Australian state of New South Wales (NSW).

METHODS

Laboratory-confirmed paediatric (aged ≤18 years) and adult COVID-19 cases who attended a school or ECEC setting while considered infectious (defined as 24 h before symptom onset based on national guidelines during the study period) in NSW from Jan 25 to April 10, 2020, were investigated for onward transmission. All identified school and ECEC settings close contacts were required to home quarantine for 14 days, and were monitored and offered SARS-CoV-2 nucleic acid testing if symptomatic. Enhanced investigations in selected educational settings included nucleic acid testing and SARS-CoV-2 antibody testing in symptomatic and asymptomatic contacts. Secondary attack rates were calculated and compared with state-wide COVID-19 rates.

FINDINGS

15 schools and ten ECEC settings had children (n=12) or adults (n=15) attend while infectious, with 1448 contacts monitored. Of these, 633 (43·7%) of 1448 had nucleic acid testing, or antibody testing, or both, with 18 secondary cases identified (attack rate 1·2%). Five secondary cases (three children; two adults) were identified (attack rate 0·5%; 5/914) in three schools. No secondary transmission occurred in nine of ten ECEC settings among 497 contacts. However, one outbreak in an ECEC setting involved transmission to six adults and seven children (attack rate 35·1%; 13/37). Across all settings, five (28·0%) of 18 secondary infections were asymptomatic (three infants [all aged 1 year], one adolescent [age 15 years], and one adult).

INTERPRETATION

SARS-CoV-2 transmission rates were low in NSW educational settings during the first COVID-19 epidemic wave, consistent with mild infrequent disease in the 1·8 million child population. With effective case-contact testing and epidemic management strategies and associated small numbers of attendances while infected, children and teachers did not contribute significantly to COVID-19 transmission via attendance in educational settings. These findings could be used to inform modelling and public health policy regarding school closures during the COVID-19 pandemic.

FUNDING

NSW Government Department of Health.

Major cluster of paediatric 'true' primary chilblains during the COVID-19 pandemic: a consequence of lifestyle changes due to lockdown

BACKGROUND

Over the last months, during the COVID-19 pandemic, a growing number of chilblain-like lesions were reported mainly in children and rarely in young adults. The relationship with SARS-CoV-2 infection was postulated, often without any laboratory, instrumental or clinical confirmation. The disclosure of information about chilblain-like lesions as a COVID-19 manifestation in social media has created concern in children's families and paediatricians.

OBJECTIVES

To verify whether the chilblain-like lesions were caused by SARS-CoV-2 infection.

METHODS

Prospective study on a case series including children who presented with acral lesions at the Pediatric Dermatology Outpatient and Pediatric Emergency Unit of the University of Bologna, from 1 April to 30 April 2020. We reported demographical, laboratory and clinical features, history of close contact with COVID-19 patients, presence of similar skin lesions in other family members, precipitating and risk factors for chilblain onset.

RESULTS

We evaluated eight patients (five females, three males) aged between 11 and 15 years. We excluded acute or previous SARS-CoV-2 infection with RT-PCR nasopharyngeal swab, serum antibody levels using chemiluminescent immunoassays. Other acute infections causing purpuric lesions at the extremities were negative in all patients. Skin lesion biopsy for histological and immunohistochemical evaluation was made in two cases and was consistent with chilblain. PCR assay on skin lesion biopsy for parvovirus B19, Mycoplasma pneumoniae and SARS-CoV-2 was performed in a patient and resulted negative. We identified common precipitating and risk factors: physical (cold and wet extremities, low BMI), cold and wet indoor and outdoor environment, behaviours, habits and lifestyle. We therefore reached a diagnosis of primary chilblains.

CONCLUSIONS

During the COVID-19 pandemic, a 'cluster' of primary chilblains developed in predisposed subjects, mainly teenagers, due to cold exposure in the lockdown period. Laboratory findings support our hypothesis, although it is also possible that an unknown infectious trigger may have contributed to the pathogenesis.

Clinical Manifestations and Outcomes of Critically Ill Children and Adolescents with Coronavirus Disease 2019 in New York City

OBJECTIVES

To describe the clinical manifestations and outcomes of critically ill children with coronavirus disease-19 (COVID-19) in New York City.

STUDY DESIGN

Retrospective observational study of children 1 month to 21 years admitted March 14 to May 2, 2020, to 9 New York City pediatric intensive care units (PICUs) with severe acute respiratory syndrome coronavirus 2 infection.

RESULTS

Of 70 children admitted to PICUs, median age was 15 (IQR 9, 19) years; 61.4% male; 38.6% Hispanic; 32.9% black; and 74.3% with comorbidities. Fever (72.9%) and cough (71.4%) were the common presenting symptoms. Twelve patients (17%) met severe sepsis criteria; 14 (20%) required vasopressor support; 21 (30%) developed acute respiratory distress syndrome (ARDS); 9 (12.9%) met acute kidney injury criteria; 1 (1.4%) required renal-replacement therapy, and 2 (2.8%) had cardiac arrest. For treatment, 27 (38.6%) patients received hydroxychloroquine; 13 (18.6%) remdesivir; 23 (32.9%) corticosteroids; 3 (4.3%) tocilizumab; and 1 (1.4%) anakinra; no patient was given immunoglobulin or convalescent plasma. Forty-nine (70%) patients required respiratory support: 14 (20.0%) noninvasive mechanical ventilation, 20 (28.6%) invasive mechanical ventilation (IMV), 7 (10%) prone position, 2 (2.8%) inhaled nitric oxide, and 1 (1.4%) extracorporeal membrane oxygenation. Nine (45%) of the 20 patients requiring IMV were extubated by day 14 with median IMV duration of 218 (IQR 79, 310.4) hours. Presence of ARDS was significantly associated with duration of PICU and hospital stay, and lower probability of PICU and hospital discharge at hospital day 14 (P < .05 for all).

CONCLUSIONS

Critically ill children with COVID-19 predominantly are adolescents, have comorbidities, and require some form of respiratory support. The presence of ARDS is significantly associated with prolonged PICU and hospital stay.