Detection of Covid-19 in Children in Early January 2020 in Wuhan, China

Multisystem inflammatory syndrome associated with COVID-19 from the pediatric emergency physician's point of view

OBJECTIVE

Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) is a rare and challenging diagnosis requiring early treatment. The diagnostic criteria involve clinical, laboratory, and complementary tests. This review aims to draw pediatrician attention to this diagnosis, suggesting early treatment strategies, and proposing a pediatric emergency care flowchart.

SOURCES

The PubMed/MEDLINE/WHO COVID-19 databases were reviewed for original and review articles, systematic reviews, meta-analyses, case series, and recommendations from medical societies and health organizations published through July 3, 2020. The reference lists of the selected articles were manually searched to identify any additional articles.

SUMMARY OF THE FINDINGS

COVID-19 infection is less severe in children than in adults, but can present as MIS-C, even in patients without comorbidities. There is evidence of an exacerbated inflammatory response with potential systemic injury, and it may present with aspects similar to those of Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C can develop weeks after COVID-19 infection, suggesting an immunomediated cause. The most frequent clinical manifestations include fever, gastrointestinal symptoms, rash, mucous membrane changes, and cardiac dysfunction. Elevated inflammatory markers, lymphopenia, and coagulopathy are common laboratory findings. Supportive treatment and early immunomodulation can control the intense inflammatory response and reduce complications and mortality.

CONCLUSIONS

MIS-C associated with COVID-19 is serious, rare, and potentially fatal. The emergency department pediatrician must recognize and treat it early using immunomodulatory strategies to reduce systemic injury. Further studies are needed to identify the disease pathogenesis and establish the most appropriate treatment.

Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak

OBJECTIVE

The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge.

BACKGROUND

Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children.

STUDY DESIGN

We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation.

RESULTS

Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29-3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ± 39 vs 47 ± 27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2.

CONCLUSIONS

Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

Comprehensive analysis of genomic diversity of SARS-CoV-2 in different geographic regions of India: an endeavour to classify Indian SARS-CoV-2 strains on the basis of co-existing mutations

Accumulation of mutations within the genome is the primary driving force in viral evolution within an endemic setting. This inherent feature often leads to altered virulence, infectivity and transmissibility, and antigenic shifts to escape host immunity, which might compromise the efficacy of vaccines and antiviral drugs. Therefore, we carried out a genome-wide analysis of circulating SARS-CoV-2 strains to detect the emergence of novel co-existing mutations and trace their geographical distribution within India. Comprehensive analysis of whole genome sequences of 837 Indian SARS-CoV-2 strains revealed the occurrence of 33 different mutations, 18 of which were unique to India. Novel mutations were observed in the S glycoprotein (6/33), NSP3 (5/33), RdRp/NSP12 (4/33), NSP2 (2/33), and N (1/33). Non-synonymous mutations were found to be 3.07 times more prevalent than synonymous mutations. We classified the Indian isolates into 22 groups based on their co-existing mutations. Phylogenetic analysis revealed that the representative strains of each group were divided into various sub-clades within their respective clades, based on the presence of unique co-existing mutations. The A2a clade was found to be dominant in India (71.34%), followed by A3 (23.29%) and B (5.36%), but a heterogeneous distribution was observed among various geographical regions. The A2a clade was highly predominant in East India, Western India, and Central India, whereas the A2a and A3 clades were nearly equal in prevalence in South and North India. This study highlights the divergent evolution of SARS-CoV-2 strains and co-circulation of multiple clades in India. Monitoring of the emerging mutations will pave the way for vaccine formulation and the design of antiviral drugs.

Children and youth with diabetes are not at increased risk for hospitalization due to COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), responsible for the coronavirus disease COVID-19, was first identified in Wuhan, China in December 2019. Diabetes, as well as other cardiovascular comorbidities, has been recognized as a major risk factor for outcomes and mortality in adults with COVID-19, particularly in the elderly with type 2 diabetes. Based on these conclusions, COVID-19 data on adults have been generalized to youth with diabetes. Nevertheless, experience from pediatric diabetes practices in China (Wuhan), Italy, Spain (Catalonia), and the United States (San Francisco Bay Area) consistently report only a single severe case of COVID-19 in a 20-year-old female youth with type 1 diabetes (T1D) that was hospitalized for bilateral pneumonia and was subsequently discharged without complications. In Italy, information on COVID-19 in all children with diabetes is collected on a weekly basis and those with positive swab test or infection-related symptoms reported to a dedicated national registry. Of a total of 15 500 children tested, 11 subjects with T1D (age 8-17y) tested positive for COVID-19; 6/11 were asymptomatic and the rest presented with mild symptoms. In the rest of locations, youths with T1D diagnosed with COVID-19 were based on clinical suspicion and a confirmatory PCR test (Wuhan:0; Catalonia-HSJD:3; California-Stanford:2). All of them were asymptomatic or had a mild course. We suggest that COVID-19 data from adults should not be generalized to children, adolescents, and youth with diabetes as their outcomes and prognosis seem to be similar to their non-diabetic-peers and consistently milder than adults with diabetes.

COVID-19, nausea, and vomiting

Exclusion of nausea (N) and vomiting (V) from detailed consideration as symptoms of COVID-19 is surprising as N can be an early presenting symptom. We examined the incidence of NV during infection before defining potential mechanisms. We estimate that the overall incidence of nausea (median 10.5%), although variable, is comparable with diarrhea. Poor definition of N, confusion with appetite loss, and reporting of N and/or V as a single entity may contribute to reporting variability and likely underestimation. We propose that emetic mechanisms are activated by mediators released from the intestinal epithelium by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) modulate vagal afferents projecting to the brainstem and after entry into the blood, activate the area postrema (AP) also implicated in anorexia. The receptor for spike protein of SARS-CoV-2, angiotensin 2 converting enzyme (ACE2), and transmembrane protease serine (for viral entry) is expressed in upper gastrointestinal (GI) enterocytes, ACE2 is expressed on enteroendocrine cells (EECs), and SARS-CoV-2 infects enterocytes but not EECs (studies needed with native EECs). The resultant virus-induced release of epithelial mediators due to exocytosis, inflammation, and apoptosis provides the peripheral and central emetic drives. Additionally, data from SARS-CoV-2 show an increase in plasma angiotensin II (consequent on SARS-CoV-2/ACE2 interaction), a centrally (AP) acting emetic, providing a further potential mechanism in COVID-19. Viral invasion of the dorsal brainstem is also a possibility but more likely in delayed onset symptoms. Overall, greater attention must be given to nausea as an early symptom of COVID-19 and for the insights provided into the GI effects of SARS-CoV-2.

Cardiovascular implications and complications of the coronavirus disease-2019 pandemic: a world upside down

PURPOSE OF REVIEW

The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic analyzing the most recent data clustered over the last several months.

RECENT FINDINGS

COVID-19 afflicts the cardiovascular system producing acute cardiac injury in 10-20% of cases with mild disease but in greater than 50-60% in severe cases, contributing to patients' demise. Other cardiovascular complications include arrhythmias, heart failure, pulmonary embolism and shock. Off-label therapies are being trialed with their own inherent cardiovascular risks, while supportive therapies currently dominate, until more specific and effective antiviral therapies and vaccinations become available. A controversial issue relates to the safety of drugs blocking the renin--angiotensin system as an angiotensin-converting enzyme (ACE) homologue, ACE2, serves as the receptor for viral entry into host cells. However, to-date, no harm has been proven for these drugs.

SUMMARY

In the cardiovascular system, COVID-19 can induce acute cardiac injury, arrhythmias, heart failure, pulmonary embolism, shock and death, whereas anti-COVID therapies also confer serious cardiovascular side-effects. Ongoing extensive efforts focus on specific vaccines and antivirals. Meanwhile, cardiovascular risk factors and diseases should be jointly controlled according to current evidence-based guidelines.

Immunopathological similarities between COVID-19 and influenza: Investigating the consequences of Co-infection

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a global public health emergency since December 2019, and so far, more than 980,000 people (until September 24, 2020) around the world have died. SARS-CoV-2 mimics the influenza virus regarding methods and modes of transmission, clinical features, related immune responses, and seasonal coincidence. Accordingly, co-infection by these viruses is imaginable because some studies have reported several cases with SARS-CoV-2 and influenza virus co-infection. Given the importance of the mentioned co-infection and the coming influenza season, it is essential to recognize the similarities and differences between the symptoms, immunopathogenesis and treatment of SARS-CoV-2 and influenza virus. Therefore, we reviewed the virology, clinical features, and immunopathogenesis of both influenza virus and SARS-CoV-2 and evaluated outcomes in cases with SARS-CoV-2 and influenza virus co-infection.

Impact of the COVID-19 pandemic on the lifestyle, mental health, and quality of life of adults in South Korea

OBJECTIVE

The COVID-19 pandemic continues to pose significant challenges to nations. The Korean government aimed to mitigate the spread of COVID-19 through stay-at-home strategies and maintaining social distance, which are likely to result in major changes in the lifestyle, mental health, and quality of life of citizens. This study aimed to investigate the impact of the COVID-19 pandemic on these factors in Koreans over 20 years old.

METHODS

The study sample consisted of 104 adults in South Korea aged over 20 years. An online survey was conducted between August and October 2020, in which participants were asked to complete the Yonsei Lifestyle Profile to assess lifestyle changes, the Center for Epidemiological Studies-Depression Scale, and the World Health Organization Quality of Life Scale abbreviated version. To investigate the changes in people's lifestyles, depression, and quality of life post COVID-19, descriptive statistics were calculated for these indicators before and after the onset of the pandemic. The p-value was two-sided, and values <0.05, were regarded as statistically significant.

RESULTS

There was a significant decline in physical and other meaningful activities, including activities of daily living, leisure, social activity, and education. However, there were no significant changes in nutrition, except in the consumption of carbohydrates and minerals. Participants reported that their quality of life and mental health had decreased after the pandemic struck.

CONCLUSIONS

We obtained novel data on the changes in the lifestyle, mental health, and quality of life of South Korean adults before and after the onset of the pandemic. The results of our study may assist health policymakers and practitioners in the development of health education or relevant interventions to deal with the pandemic situation as well as future crises.

Paediatric surgery and COVID-19: urgent lessons to be learned

Background

The dissemination of scientific data on coronavirus disease 2019 (COVID-19) continually builds but, in April 2020, could not keep up with the spread of the disease. Through technology, surgeons in Italy and the UK, representing both peak and pre-peak infective time zones, were able to communicate so that the urgent lessons on the huge expected demands of care learned in Italy could be brought to the UK in advance. This paper specifically discusses the issues related to paediatric surgery, currently under-reported in the literature.

Methods

The aim of this paper is to conjoin experience from the field to provide a framework for a safe assessment and treatment of paediatric patients by adopting a systemic approach aimed at reducing the risk of contamination. We reviewed the processes and good practices that were undertaken in contexts of emergency such as in Italy and the UK and then adapted them within the Systems Engineering Initiative for Patient Safety (SEIPS) framework to provide an assessment of how to reorganize the services in order to cope with an unexpected situation. The SEIPS model is the adopted theoretical framework, which allows to analyse the system in its main components with a human factors and ergonomics (HFE) perspective.

Results

The results introduce some of the good practices and recommendations developed during the emergency in the surgical scenario with a focus on the paediatric patients. They represent the lessons learned from the combination of the little existing evidence of literature and the experience from surgical teams who responded in an impromptu and unrehearsed way.

Conclusions

Lessons learned from the frontline ‘on the fly’ during COVID-19 emergency should be consolidated and taken into the future. In order to prepare proactively for the next phases and get ahead of the curve of these hospital accesses, there is a need for a risk assessment of the new clinical pathways with a multidisciplinary approach centred on HFE with the adoption of the SEIPS model and an involvement of all the surgical teams.

Knowledge, risk perception and adherence to COVID-19 prevention advisory among police officers in Makurdi Metropolis Benue State, 2020

Introduction

the current pandemic of coronavirus disease (COVID-19) caused by a novel strain (SARS-CoV-2) is enormous and continues to pose a threat to the lives of people. In Nigeria, as of 21^st April 2020, 668 confirmed cases, 22 deaths and 188 recoveries have been reported. Police officers are at the forefront of enforcing advisories to ensure public compliance. However, there is a paucity of data on knowledge, risk perception, and adherence to COVID-19 advisories issued by the Health authorities particularly among the police officers. We, therefore, assessed the knowledge, risk perceptions and adherence to NCDC recommended advisory on COVID-19.

Methods

we conducted a two-stage sampling cross-sectional study among different cadres of police officers in Benue State, Nigeria using a pretested, semi-structured, interviewer-administered questionnaire. The results of the study were presented in frequencies and proportions. Chi-square test was used for an association between variables at p-value < 0.05.

Results

the mean age of the 305 participants was 39.1 ± 8.4 years and most, 124 (40.7%) of the participants were within age-group 30-39 years, 19 (64.3%.8) were male, 250 (82.0%) were married and 160 (52.5%) had secondary education as the highest qualification. Majority of the participants, 301 (98.7%) have heard about COVID-19 and the commonest source of information was via television/radio, 230 (76.4%). Most participants demonstrate a good knowledge of COVID-19 infection, 302 (99.0%) and positive risk perception of COVID-19, 303 (99.3%) but few demonstrated good adherences on COVID-19 prevention practices, 133 (43.6%). Participants’ academic qualification (X² = 10.98, p = 0.001) and cadre (X² = 112.5, p = 0.001) were found to be associated with good adherence.

Conclusion

while most participants had a good knowledge of COVID-19 transmission dynamics, and positive risk perception about COVID-19, good adherence to public health advisories were low. We recommended periodic training, provision of adequate PPE and personal hand-sanitizers as a strategy to improve adherence.

Performance analysis of lightweight CNN models to segment infectious lung tissues of COVID-19 cases from tomographic images

The pandemic of Coronavirus Disease-19 (COVID-19) has spread around the world, causing an existential health crisis. Automated detection of COVID-19 infections in the lungs from Computed Tomography (CT) images offers huge potential in tackling the problem of slow detection and augments the conventional diagnostic procedures. However, segmenting COVID-19 from CT Scans is problematic, due to high variations in the types of infections and low contrast between healthy and infected tissues. While segmenting Lung CT Scans for COVID-19, fast and accurate results are required and furthermore, due to the pandemic, most of the research community has opted for various cloud based servers such as Google Colab, etc. to develop their algorithms. High accuracy can be achieved using Deep Networks but the prediction time would vary as the resources are shared amongst many thus requiring the need to compare different lightweight segmentation model. To address this issue, we aim to analyze the segmentation of COVID-19 using four Convolutional Neural Networks (CNN). The images in our dataset are preprocessed where the motion artifacts are removed. The four networks are UNet, Segmentation Network (Seg Net), High-Resolution Network (HR Net) and VGG UNet. Trained on our dataset of more than 3,000 images, HR Net was found to be the best performing network achieving an accuracy of 96.24% and a Dice score of 0.9127. The analysis shows that lightweight CNN models perform better than other neural net models when to segment infectious tissue due to COVID-19 from CT slices.

Social Work Responses and Household-level Determinants of Coronavirus Preparedness in Rural Ethiopia

The novel coronavirus caused the death of many people globally, and in Ethiopia. The death of people due to COVID surpasses 1,466,289with more than 63,135,973 cases in the world. This study aimed to identify the barriers toward the understanding of COVID-19, the rural (agrarians) public commitment to respond coronavirus, and the factors that affect their preparedness in rural Ethiopia. Probit regression and descriptive statistics were used to analyze data from a sample of 190 respondents. The result revealed that the public infrastructural problems (roads, health centers, telecommunication and broadcasting service) were the main barriers identified in this study. In response, the agricultural and health extension providers, college and university students, local administrators and government official, religious leaders, and community elders were contributing to enhance the public understanding and preparedness. The model result confirmed that gender, age group, family education level, membership to communal association, family mobile usage, health extension service, non-farm income, and economic situation were significant factors for preparedness. Intervention aimed at easing identified key limit factors to rural and agrarian community preparedness as well as the way to enhance public understanding through reasonable support to local stakeholders against COVID-19.

Diagnostic, Prognostic, and Therapeutic Use of Radiopharmaceuticals in the Context of SARS-CoV-2

The coronavirus disease 2019 (COVID-19) outbreak has devastated the healthcare systems and economies of over 200 countries in just a few months. The etiological agent of COVID-19, SARS-CoV-2, is a highly contagious virus that can be transmitted by asymptomatic and symptomatic carriers alike. While in vitro testing techniques have allowed for population-wide screening, prognostic tools are required to assess the disease severity and therapeutic response, contributing to improve the patient clinical outcomes. Moreover, no specific antiviral against COVID-19 exists at the time of publication, severely limiting treatment against the infection. Hence, there is an urgent clinical need for innovative therapeutic strategies that may contribute to manage the COVID-19 outbreak and prevent future pandemics. Herein, we critically examine recent diagnostic, prognostic, and therapeutic advancements for COVID-19 in the field of radiopharmaceuticals. First, we summarize the gold standard techniques used to diagnose COVID-19, including in vitro assays and imaging techniques, and then discuss how radionuclide-based nuclear imaging provides complementary information for prognosis and treatment management of infected patients. Second, we introduce new emerging types of radiotherapies that employ radioimmunoconjugates, which have shown selective cytotoxic response in oncological studies, and critically analyze how these compounds could be used as therapeutic agents against SARS-CoV-2. Finally, this Perspective further discusses the emerging applications of radionuclides to study the behavior of pulmonary SARS-CoV-2 aerosol particles.

Dysentery as the only presentation of COVID-19 in a child: a case report

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused irreparable damage to society, and the damage continues. Pediatricians are confronted with COVID-19 in a variety of presentations, which may lead to delayed diagnosis and treatment. Early diagnosis of the disease plays an important role in preventing transmission of the virus in the community.

Case presentation

Here we report a 27-month-old previously healthy Iranian female child who presented with fever and bloody diarrhea, diagnosed with COVID-19 based on contact history, exclusion of enteric bacterial pathogens and parasites, and positive stool and nasopharyngeal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase polymerase chain reaction (RT-PCR) tests. The patient had viral shedding for more than a month.

Conclusions

The pediatric population usually does not present with typical clinical features of COVID-19, which are respiratory involvement. Dysentery may be the only presentation of this disease, and long-term isolation should be considered, as the viral shedding may last for more than a month.

The Importance of Advancing Severe Acute Respiratory Syndrome Coronavirus 2 Vaccines in Children

While the role of children in the chain of transmission of SARS-CoV-2 remains to be fully defined, they likely play an important role based on our knowledge of other respiratory viruses. Children are more likely to be asymptomatic or have milder symptoms and less likely to present for healthcare and be tested for SARS-CoV-2; thus, our current estimates are likely under-representative of the true burden of SARS-CoV-2 in children. Given the potential direct benefit of a SARS-CoV-2 vaccine in children and the substantial indirect benefit through community protection or ‘herd immunity’, we argue that planning and implementation of SARS-CoV-2 vaccines should include children. Furthermore, community protection occurred after widespread implementation of prior childhood vaccines against Streptococcus pneumoniae, rubella and rotavirus. We detail considerations for vaccine clinical trials, potential barriers to the implementation of widespread vaccination and argue why children would be an ideal target population for vaccination.

Spatiotemporal patterns and trends of community transmission of the pandemic COVID-19 in South Asia: Bangladesh as a case study

South Asian (SA) countries have been fighting with the pandemic novel coronavirus disease 2019 (COVID-19) since January 2020. Earlier, the country-specific descriptive study has been done. Nevertheless, as transboundary infection, the border sharing, shared cultural and behavioral practice, effects on the temporal and spatial distribution of COVID-19 in SA is still unveiled. Therefore, this study has been revealed the spatial hotspot along with descriptive output on different parameters of COVID-19 infection. We extracted data from the WHO and the worldometer database from the onset of the outbreak up to 15 May, 2020. Europe has the highest case fatality rate (CFR, 9.22%), whereas Oceania has the highest (91.15%) recovery rate from COVID-19. Among SA countries, India has the highest number of cases (85,790), followed by Pakistan (38,799) and Bangladesh (20,065). However, the number of tests conducted was minimum in this region in comparison with other areas. The highest CFR was recorded in India (3.21%) among SA countries, whereas Nepal and Bhutan had no death record due to COVID-19 so far. The recovery rate varies from 4.75% in the Maldives to 51.02% in Sri Lanka. In Bangladesh, community transmission has been recorded, and the highest number of cases were detected in Dhaka, followed by Narayanganj and Chattogram. We detected Dhaka and its surrounding six districts, namely Gazipur, Narsingdi, Narayanganj, Munshiganj, Manikganj, and Shariatpur, as the 99% confidence-based hotspot where Faridpur and Madaripur district as the 95% confidence-based spatial hotspots of COVID-19 in Bangladesh. However, we did not find any cold spots in Bangladesh. We identified three hotspots and three cold spots at different confidence levels in India. Findings from this study suggested the "Test, Trace, and Isolation" approach for earlier detection of infection to prevent further community transmission of COVID-19.

Risk Factors for Severity in Children with Coronavirus Disease 2019: A Comprehensive Literature Review

The coronavirus disease 2019 (COVID-19) pandemic has affected hundreds of thousands of people. The authors performed a comprehensive literature review to identify the underlying mechanisms and risk factors for severe COVID-19 in children. Children have accounted for 1.7% to 2% of the diagnosed cases of COVID-19. They often have milder disease than adults, and child deaths have been rare. The documented risk factors for severe disease in children are young age and underlying comorbidities. It is unclear whether male gender and certain laboratory and imaging findings are also risk factors. Reports on other potential factors have not been published.

[Prevention and treatment of COVID-19 in the pediatric population from the family and community perspective]

Based on the report on the situation of COVID-19 in Spain, dated April 3, 2020, the confirmed cases amount to 117,710, of which 343 are under 14 years of age (< 1%). It is essential to know the specificity of this process in the child population, as well the specific recommendations for proper prevention and care of children during the COVID-19 pandemic. The paper aim is to analyze the scientific evidence on the specific recommendations for pediatric care in cases of COVID-19 from the family and community settings.The main recommendations and preventive measures in primary health care settings and at home have been selected and analyzed from an integrative approach that includes the biopsychosocial aspects of the child during confinement.The importance of caring for children in the face of the disease lies above all in ensuring the correct measures for the prevention of contagion due to the condition of acting as possible carriers during an incubation period of up to 21 days. The recommendation is that children actively participate in routine preventive actions to contain the spread of the disease. At the household level, isolation is an important challenge for families where there are manifestations of uncertainty, fear and helplessness in the face of changes and among the recommendations are establishing routines and order through schedules of activities and leisure together with hygiene measures.Given the rapidity with which the COVID-19 pandemic has occurred, there is little evidence at the moment. Research on prevention and treatment in the pediatric age needs to be developed to improve the available recommendations.

Human and novel coronavirus infections in children: a review

Coronaviruses, seven of which are known to infect humans, can cause a spectrum of clinical presentations ranging from asymptomatic infection to severe illness and death. Four human coronaviruses (hCoVs)-229E, HKU1, NL63 and OC43-circulate globally, commonly infect children and typically cause mild upper respiratory tract infections. Three novel coronaviruses of zoonotic origin have emerged during the past two decades: severe acute respiratory syndrome coronavirus (SARS-CoV-1), Middle East respiratory syndrome coronavirus (MERS-CoV) and the recently discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is the cause of the ongoing coronavirus disease 2019 (COVID-19) pandemic. These novel coronaviruses are known to cause severe illness and death predominantly in older adults and those with underlying comorbidities. Consistent with what has been observed during the outbreaks of SARS and MERS, children with COVID-19 are more likely to be asymptomatic or to have mild-to-moderate illness, with few deaths reported in children globally thus far. Clinical symptoms and laboratory and radiological abnormalities in children have been similar to those reported in adults but are generally less severe. A rare multisystem inflammatory syndrome in children (MIS-C) which has resulted in critical illness and some deaths has recently been described. Clinical trials for therapeutics and vaccine development should include paediatric considerations. Children may play an important role in the transmission of infection and outbreak dynamics and could be a key target population for effective measures to control outbreaks. The unintended consequences of the unprecedented scale and duration of pandemic control measures for children and families around the world should be carefully examined.Abbreviations: 2019-nCoV, 2019 novel coronavirus; ADEM, acute demyelinating encephalomyelitis; AAP, American Academy of Pediatrics; ACE-2, angiotensin-converting enzyme 2; ARDS, acute respiratory distress syndrome; BCG, bacillus Calmette-Guérin; BNP, brain natriuretic peptide; CDC, Centers for Disease Control and Prevention; CRP, C-reactive protein; CSF, cerebrospinal fluid; COVID-19, coronavirus disease 2019; CT, computed tomography; CXR, chest X-ray; DOL, day of life; hCoV, human coronavirus; ICU, intensive care unit; IL, interleukin; IVIG, intravenous immunoglobulin; KD, Kawasaki disease; LDH, lactate dehydrogenase; MERS, Middle East respiratory syndrome; MERS-CoV, Middle East respiratory syndrome coronavirus; MEURI, monitored emergency use of unregistered and experimental interventions; MIS-C, multi-system inflammatory syndrome in children; PCR, polymerase chain reaction; PICU, paediatric intensive care unit; RNA, ribonucleic acid; RCT, randomised-controlled trial; RSV, respiratory syncytial virus; SARS, severe acute respiratory syndrome; SARS-CoV-1, severe acute respiratory syndrome coronavirus 1; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TNF-alpha, tumour necrosis factor alpha; UK United Kingdom; UNICEF, United Nations Children's Fund; USA, United States of America; WHO, World Health Organization.

Vaccines and routine immunization strategies during the COVID-19 pandemic

Severe acute respiratory syndrome coronavirus 2 related disease (COVID-19) is now responsible for one of the most challenging and concerning pandemics. By August 2020, there were almost 20 million confirmed cases worldwide and well over half-million deaths. Since there is still no effective treatment or vaccine, non-pharmaceutical interventions have been implemented in an attempt to contain the spread of the virus. During times of quarantine, immunization practices in all age groups, especially routine childhood vaccines, have also been interrupted, delayed, re-organized, or completely suspended. Numerous high-income as well as low- and middle-income countries are now experiencing a rapid decline in childhood immunization coverage rates. We will, inevitably, see serious consequences related to suboptimal control of vaccine-preventable diseases (VPDs) in children concurrent with or following the pandemic. Routine pediatric immunizations of individual children at clinics, mass vaccination campaigns, and surveillance for VPDs must continue as much as possible during pandemic.

A systematic review and meta-analysis of children with coronavirus disease 2019 (COVID-19)

To provide a comprehensive and systematic analysis of demographic characteristics, clinical symptoms, laboratory findings, and imaging features of coronavirus disease 2019 (COVID-19) in pediatric patients. A meta-analysis was carried out to identify studies on COVID-19 from 25 December 2019 to 30 April 2020. A total of 48 studies with 5829 pediatric patients were included. Children of all ages were at risk for COVID-19. The main illness classification ranged as: 20% (95% confidence interval [CI]: 14%-26%; I2  = 91.4%) asymptomatic, 33% (95% CI: 23%-43%; I2  = 95.6%) mild and 51% (95% CI: 42%-61%; I2  = 93.4%) moderate. The typical clinical manifestations were fever 51% (95% CI: 45%-57%; I2  = 78.9%) and cough 41% (95% CI: 35%-47%, I2  = 81.0%). The common laboratory findings were normal white blood cell 69% (95% CI: 64%-75%; I2  = 58.5%), lymphopenia 16% (95% CI: 11%-21%; I2  = 76.9%) and elevated creatine-kinase MB 37% (95% CI: 25%-48%; I2  = 59.0%). The frequent imaging features were normal images 41% (95% CI: 30%-52%; I2  = 93.4%) and ground-glass opacity 36% (95% CI: 25%-47%; I2  = 92.9%). Among children under 1 year old, critical cases account for 14% (95% CI: 13%-34%; I2  = 37.3%) that should be of concern. In addition, vomiting occurred in 33% (95% CI: 18%-67%; I2  = 0.0%) cases that may also need attention. Pediatric patients with COVID-19 may experience milder illness with atypical clinical manifestations and rare lymphopenia. High incidence of critical illness and vomiting symptoms reward attention in children under 1 year old.

A mini-review on the effects of COVID-19 on younger individuals

Coronavirus disease 2019 (COVID-19) pandemic has uprooted our lives like never before since its onset in the late December 2019. The world has seen mounting infections and deaths over the past few months despite the unprecedented measures countries are implementing, such as lockdowns, social distancing, mask-wearing, and banning gatherings in large groups. Interestingly, young individuals seem less likely to be impacted by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19. While the rate of transmission, symptom presentation, and fatality is lower in children than people from other age groups, they have been disproportionately affected by strict lockdown measures needed to curb viral spread. In this review, we describe the association between patient age and COVID-19, epidemiology of SARS-CoV-2 infection in children, psychological effects associated with lockdowns and school closures, and possible mechanisms underlying lower transmission rate of COVID-19 in children.

ECIEN-2020 study: the effect of COVID-19 on admissions for non-COVID-19 diseases

BACKGROUND

The pandemic caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) has had great effects on health systems worldwide, not only in relation to coronavirus disease 2019 (COVID-19) cases but also affecting patients with other pathologies.

METHODS

ECIEN-2020 is an observational study conducted in a tertiary referral hospital in Navarra, Spain. It describes the effects of COVID-19 pandemic and the preventive measures adopted, in pediatric admissions for non-COVID-19 diseases. Admissions during March-June 2020 (first wave of the COVID-19 pandemic in Spain) are described and compared with the same quarter in 2019. A sub-analysis was performed delving into epidemiology. Patient characteristics (age, sex, past medical history), disease characteristics (symptoms, duration of symptoms, previous consultation in Primary Care Health Center), and admission characteristics (place and average stay) were analyzed.

RESULTS

A 33% reduction in the number of pediatric hospital admissions was observed, decreasing from 529 hospitalizations in 2019 to 353 in 2020 (P < 0.001). This highlights a 48% reduction in patients admitted for pulmonary diseases. There were no significant changes in average hospital-stay, percentage of intensive care unit admissions, or in admissions for other reasons. Percentage of patients admitted among those seen in the emergency department rose from 5.1% in 2019 to 10.9% in 2020, whereas the total number of consultations in the emergency department decreased by 68%.

CONCLUSION

The pandemic and the measures adopted due to SARS-CoV-2 have significantly decreased pediatric admissions for non-COVID-19 diseases, especially due to a reduction in the hospitalization for respiratory diseases.

Epidemiology of COVID-19 infection in young children under five years: A systematic review and meta-analysis

INTRODUCTION

Emerging evidence suggests young children are at greater risk of COVID-19 infection than initially predicted. However, a comprehensive understanding of epidemiology of COVID-19 infection in young children under five years, the most at-risk age-group for respiratory infections, remain unclear. We conducted a systematic review and meta-analysis of epidemiological and clinical characteristics of COVID-19 infection in children under five years.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses , we searched several electronic databases (Pubmed, EMBASE, Web of Science, and Scopus) with no language restriction for published epidemiological studies and case-reports reporting laboratory-confirmed COVID-19 infection in children under five years until June 4, 2020. We assessed pooled prevalence for key demographics and clinical characteristics using Freeman-Tukey double arcsine random-effects model for studies except case-reports. We evaluated risk of bias separately for case-reports and other studies.

RESULTS

We identified 1,964 articles, of which, 65 articles were eligible for systematic review that represented 1,214 children younger than five years with laboratory-confirmed COVID-19 infection. The pooled estimates showed that 50% young COVID-19 cases were infants (95% CI: 36% - 63%, 27 studies); 53% were male (95% CI: 41% - 65%, 24 studies); 43% were asymptomatic (95% CI: 15% - 73%, 9 studies) and 7% (95% CI: 0% - 30%, 5 studies) had severe disease that required intensive-care-unit admission. Of 139 newborns from COVID-19 infected mothers, five (3.6%) were COVID-19 positive. There was only one death recorded.

DISCUSSION

This systematic review reports the largest number of children younger than five years with COVID-19 infection till date. Our meta-analysis shows nearly half of young COVID-19 cases were asymptomatic and half were infants, highlighting the need for ongoing surveillance to better understand the epidemiology, clinical pattern, and transmission of COVID-19 to develop effective preventive strategies against COVID-19 disease in young paediatric population.

Coronavirus (COVID-19): A Systematic Review and Meta-analysis to Evaluate the Significance of Demographics and Comorbidities

Background

The unprecedented outbreak of a contagious respiratory disease caused by a novel coronavirus has led to a pandemic since December 2019, claiming millions of lives. The study systematically reviews and summarizes COVID-19's impact based on symptoms, demographics, comorbidities, and demonstrates the association of demographics in cases and mortality in the United States.

Methods

PubMed and Google Scholar were searched from December 2019- August 2020, and articles restricted to the English language were collected following PRISMA guidelines. US CDC data was used for establishing statistical significance of age, sex, and race.

Results

Among 3745 patients in China, mean age is 50.63 (95% CI: 36.84, 64.42) years, and 55.7 % (95% CI: 52.2, 59.2) were males. Symptoms included fever 86.5% (82.7, 90.0), fatigue 41.9% (32.7, 51.4), dyspnea 29.0% (21.2, 37.5), cough 66.0% (61.3, 70.6), mucus 66% (61.3, 70.6), lymphopenia 18.9% (5.2, 38.0). Prevalent comorbidities were hypertension 16.4% (12.5, 20.8), diabetes 8.9% (7.0, 11.1), CVD 10.9% (6.1, 16.7), ARDS 14.6% (4.9, 27.8), malignancy 1.5 (0.05, 2.8), 1.3% (0.08, 1.9), COPD 1.3 (0.08, 1.9). 63.5 % (33.5, 88.7) received oxygen therapy, 20.8% (8.9, 35.7) were in ventilation, 23.5% (5.9, 47.8) were at the ICU. 86.5% (76.8, 94) had antiviral, 73.9% (55.3, 89.0) had antibiotics, 30% (20.6, 40.2) corticosteroids treatment.In the US, the odds ratio of infection in males to females is 0.873 (CI: 0.052,14.791), while the odds of dying from infection is 1.378 (CI: 0.081, 23.528) for males. The prevalence of infection is higher in females; case and death rates are higher in whites and Hispanics than other races; the death rate is higher in males irrespective of race and age; death rate per 100,000 population increases monotonically with age.

Conclusion

Results showed that metabolic diseases comprising CVD, diabetes, hypertension, and respiratory diseases, including COPD, ARDS, are the most common comorbidities to severe condition and poor prognosis in covid-19 patients. Following the recent FDA's guidance for designing Covid-19 vaccine trials, stratification factors of age, race, sex, and comorbidities need consideration in allocation. This study aimed to provide clinical researchers, health policy planners a detailed insight into the coronavirus disease.

The effect of the COVID-19 pandemic on paediatric cancer care: lessons learnt from a major paediatric oncology department in Turkey

The COVID-19 pandemic has disrupted cancer care. An audit at a major Paediatric Oncology Department in Turkey was performed to determine its impact on paediatric cancer care. A comparison was made among the number of daily paediatric cancer patients, diagnostic and treatment procedures. The data for the ‘COVID-19 period’ (10 March to 31 October 2020) were compared with the corresponding ‘prior year control period’ (10 March to 31 October 2019). Moreover, presentation delay (duration between first symptoms to healthcare visit) was calculated for new cases. The findings indicate that the mean 34.7 outpatients per day during ‘COVID-19 period’ was significantly lower than the ‘prior year control period’ (52.2). There were 17.7 inpatients per day during the ‘COVID-19 period’ which was significantly lower than 23.8 inpatients per day during the ‘prior year control period’. Significant reduction in the daily mean number of patients undergoing chemotherapy, radiotherapy, surgery and imaging studies during the ‘COVID-19 period’ was also evident. A negative trend in the diagnosis of new paediatric cancers was evident with 128 new cancer cases during the ‘COVID-19 period’, whereas the corresponding number was 212 for the ‘prior year control period’. The presentation delay (median 31 days) remain unchanged during the ‘COVID-19 period’. The findings suggest significant damage to paediatric cancer care during the COVID-19 pandemic. Appropriate obligatory actions by oncology societies and policymakers can minimise longer term negative impacts.

Curriculum response to the crisis

Education is going through a period of crisis related to the SARS-CoV-2 pandemic that most probably will follow a continuum organized into distinct phases: emergency, recovery, reconstruction, development, and institutionalization. This article analyzes the response of curriculum to an unpredictable, chaotic, and recursive crisis situation. The article also highlights the role of important, but often forgotten, actors in a formal education system-parents-and examines the stresses the pandemic has placed on them. Finally, in the light of the continuum of the educational crisis and the impacts of Covid-19 on certain curricular dimensions, the article concludes with reflections on the need to rethink curricula, even in education systems that considered themselves robust in their institutionalization.

Proximity ligation assay: an ultrasensitive method for protein quantification and its applications in pathogen detection

It is of great significance to establish sensitive and accurate pathogen detection methods, considering the continuous emergence or re-emergence of infectious diseases seriously influences the safety of human and animals. Proximity ligation assay (PLA) is developed for the sensitive protein detection and also can be used for the detection of pathogens. PLA employs aptamer or monoclonal/polyclonal antibody-nucleic acid complexes as proximity probes. When the paired proximity probes bind to the same target protein or protein complex, they will be adjacent to each other and form an amplifiable DNA sequence through ligation. Combining the specificity of enzyme-linked immunosorbent assay (ELISA) and sensitivity of polymerase chain reaction (PCR), PLA transforms the detection of protein into the detection of DNA nucleic acid sequence. Therefore, as an ultrasensitive protein assay, PLA has great potential for quantification, localization of protein, and clinical diagnostics. In this review, we summarize the basic principles of PLA and its applications in pathogen detection. KEY POINTS: • Different forms of proximity ligation assay are introduced. • Applications of proximity ligation assay in pathogen detection are summarized. • Proximity ligation assay is an ultrasensitive method to quantify protein and pathogen.

COVID-19 infection in children: A systematic review and meta-analysis of clinical features and laboratory findings

OBJECTIVE

We aimed to provide a meta-analysis of previously published papers on the COVID-19-related clinical features and laboratory findings in children.

METHOD

This meta-analysis was conducted by using Medline/PubMed, Scopus, Web of Sciences and Google Scholar. Finally, 32 articles were selected for full-text assessment.

RESULTS

The most frequent symptoms were fever, cough, vomiting, diarrhea, sore throat, and dyspnea. Regarding the combined results of the meta-analysis, fever (46%, 95% CI 40-53%), cough (37%, 95% CI 29-46%), diarrhea (19%, 95% CI 9-28%), and pharyngalgia (13%, 95% CI 5-20%) were the most widely reported symptom. Besides, positive RT-PCR test results (43%, 95% CI 33-53%), low oxygen saturation (38%, 95% CI 25-51%), and elevated D-dimer levels (36%, 95% CI 16-56%) were the most common laboratory findings.

CONCLUSION

This review found that clinical presentations were milder, the prognosis was better, and the mortality rate was lower in children with COVID-19 compared with adult patients; however, children are potential carriers, like adults, and can transmit the infection among the population. Therefore, early identification and intervention in pediatric patients with COVID-19 are essential in order to control the pandemic. Moreover, gastrointestinal symptoms were more common symptoms among children.

Recent Developments on Therapeutic and Diagnostic Approaches for COVID-19

The ongoing pandemic of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has made a serious public health threat worldwide with millions of people at risk in a growing number of countries. Though there are no clinically approved antiviral drugs and vaccines for COVID-19, attempts are ongoing for clinical trials of several known antiviral drugs, their combination, as well as development of vaccines in patients with confirmed COVID-19. This review focuses on the latest approaches to diagnostics and therapy of COVID-19. We have summarized recent progress on the conventional therapeutics such as antiviral drugs, vaccines, anti-SARS-CoV-2 antibody treatments, and convalescent plasma therapy which are currently under extensive research and clinical trials for the treatment of COVID-19. The developments of nanoparticle-based therapeutic and diagnostic approaches have been also discussed for COVID-19. We have assessed recent literature data on this topic and made a summary of current development and future perspectives.

Validation of self-collected buccal swab and saliva as a diagnostic tool for COVID-19

BACKGROUND

Effective management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires large-scale testing to identify and isolate infectious carriers. Self-administered buccal swab and saliva collection are convenient, painless, and safe alternatives to the current healthcare worker (HCW)-collected nasopharyngeal swab (NPS).

METHODS

A cross-sectional single-centre study was conducted on 42 participants who had tested positive for SARS-CoV-2 via an NPS within the past 7 days. Real-time polymerase chain reaction (RT-PCR) was performed and cycle threshold (Ct) values were obtained for each test. The positive percent agreement (PPA), negative percent agreement (NPA), and overall agreement (OA) were calculated for the saliva samples and buccal swabs, and compared with NPS.

RESULTS

Among the 42 participants, 73.8% (31/42) tested positive by any one of the three tests. With reference to NPS, the saliva test had PPA 66.7%, NPA 91.7%, and OA 69.0%; the buccal swab had PPA 56.7%, NPA 100%, and OA 73.8%.

CONCLUSION

Self-collected saliva tests and buccal swabs showed only moderate agreement with HCW-collected NPS. Primary screening for SARS-CoV-2 may be performed with a saliva test or buccal swab, with a negative test warranting a confirmatory NPS to avoid false-negatives, minimize discomfort, and reduce the risk of spread to the community and HCWs.

Severe COVID-19, multisystem inflammatory syndrome in children, and Kawasaki disease: immunological mechanisms, clinical manifestations and management

Multisystem inflammatory syndrome (MIS-C) is a pediatric hyperinflammation disorder caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It has now been reported from several countries the world over. Some of the clinical manifestations of MIS-C mimic Kawasaki disease (KD) shock syndrome. MIS-C develops 4-6 weeks following SARS-CoV-2 infection, and is presumably initiated by adaptive immune response. Though it has multisystem involvement, it is the cardiovascular manifestations that are most prominent. High titres of anti-SARS-CoV-2 antibodies are seen in these patients. As this is a new disease entity, its immunopathogenesis is not fully elucidated. Whether it has some overlap with KD is still unclear. Current treatment guidelines recommend use of intravenous immunoglobulin and high-dose corticosteroids as first-line treatment. Mortality rates of MIS-C are lower compared to adult forms of severe COVID-19 disease.

Pediatric lung imaging features of COVID-19: A systematic review and meta-analysis

RATIONALE

Pediatric COVID-19 studies have been mostly restricted to case reports and small case series, which have prevented the identification of specific pediatric lung disease patterns in COVID-19. The overarching goal of this systematic review and meta-analysis is to provide the first comprehensive summary of the findings of published studies thus far describing COVID-19 lung imaging data in the pediatric population.

METHODS

A systematic literature search of PubMed was performed to identify studies assessing lung-imaging features of COVID-19 pediatric patients (0-18 years). A single-arm meta-analysis was conducted to obtain the pooled prevalence and 95% confidence interval (95% CI).

RESULTS

A total of 29 articles (n = 1026 children) based on chest computerized tomography (CT) images were included. The main results of this comprehensive analysis are as follows: (1) Over a third of pediatric patients with COVID-19 (35.7%, 95% CI: 27.5%-44%) had normal chest CT scans and only 27.7% (95% CI: 19.9%-35.6%) had bilateral lesions. (2) The most typical pediatric chest CT findings of COVID-19 were ground-glass opacities (GGO) (37.2%, 95% CI: 29.3%-45%) and the presence of consolidations or pneumonic infiltrates (22.3%, 95% CI: 17.8%-26.9%). (3) The lung imaging findings in children with COVID-19 were overall less frequent and less severe than in adult patients. (4) Typical lung imaging features of viral respiratory infections in the pediatric population such as increased perihilar markings and hyperinflation were not reported in children with COVID-19.

CONCLUSION

Chest CT manifestations in children with COVID-19 could potentially be used for early identification and prompt intervention in the pediatric population.

The kidney, COVID-19, and the chemokine network: an intriguing trio

On December 30th 2019, some patients with pneumonia of unknown etiology were reported in the Program for Monitoring Emerging Diseases (ProMED), a program run by the International Society for Infectious Diseases (ISID), hypothesized to be related to subjects who had had contact with the seafood market in Wuhan, China. Chinese authorities instituted an emergency agency aimed at identifying the source of infection and potential biological pathogens. It was subsequently named by the World Committee on Virus Classification as 2019-nCoV (2019-novel coronavirus) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A number of studies have demonstrated that 2019-nCoV and the SARS-CoV shared the same cell entry receptor named angiotensin-converting enzyme 2 (ACE2). This is expressed in human tissues, not only in the respiratory epithelia, but also in the small intestines, heart, liver, and kidneys. Here, we examine the most recent findings on the effects of SARS-CoV-2 infection on kidney diseases, mainly acute kidney injury, and the potential role of the chemokine network.

Transmission of SARS-CoV-2 through breast milk and breastfeeding: a living systematic review

The pandemic of coronavirus disease 2019 (COVID-19) is caused by infection with a novel coronavirus strain, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At present, there is limited information on potential transmission of the infection from mother to child, particularly through breast milk and breastfeeding. Here, we provide a living systematic review to capture information that might necessitate changes in the guidance on breast milk and breastfeeding given the uncertainty in this area. Our search retrieved 19,414 total records; 605 were considered for full-text eligibility and no ongoing trials were identified. Our review includes 340 records, 37 with breast milk samples and 303 without. The 37 articles with analyzed breast milk samples reported on 77 mothers who were breastfeeding their children; among them, 19 of 77 children were confirmed COVID-19 cases based on RT-PCR assays, including 14 neonates and five older infants. Nine of the 68 analyzed breast milk samples from mothers with COVID-19 were positive for SARS-CoV-2 RNA; of the exposed infants, four were positive and two were negative for COVID-19. Currently, there is no evidence of SARS-CoV-2 transmission through breast milk. Studies are needed with longer follow-up periods that collect data on infant feeding practices and on viral presence in breast milk.

Risk profiles of severe illness in children with COVID-19: a meta-analysis of individual patients

BACKGROUND

We prepared a meta-analysis on case reports in children with COVID-19, aiming to identify potential risk factors for severe illness and to develop a prediction model for risk assessment.

METHODS

Literature retrieval, case report selection, and data extraction were independently completed by two authors. STATA software (version 14.1) and R programming environment (v4.0.2) were used for data handling.

RESULTS

This meta-analysis was conducted based on 52 case reports, including 203 children (96 boys) with COVID-19. By severity, 26 (12.94%), 160 (79.60%), and 15 (7.46%) children were diagnosed as asymptomatic, mild/moderate, and severe cases, respectively. After adjusting for age and sex, 11 factors were found to be significantly associated with the risk of severe illness relative to asymptomatic or mild/moderate illness, especially for dyspnea/tachypnea (odds ratio, 95% confidence interval, P: 6.61, 4.12-9.09, <0.001) and abnormal chest X-ray (3.33, 1.84-4.82, <0.001). A nomogram modeling age, comorbidity, cough, dyspnea or tachypnea, CRP, and LDH was developed, and prediction performance was good as reflected by the C-index.

CONCLUSIONS

Our findings provide systematic evidence for the contribution of comorbidity, cough, dyspnea or tachypnea, CRP, and LDH, both individually and jointly, to develop severe symptoms in children with asymptomatic or mild/moderate COVID-19.

IMPACT

We have identified potential risk factors for severe illness in children with COVID-19. We have developed a prediction model to facilitate risk assessment in children with COVID-19. We found the contribution of five risk factors to develop severe symptoms in children with asymptomatic or mild/moderate COVID-19.

Respiratory Therapeutic Strategies in Children and Adolescents with COVID-19: A Critical Review

Evidence on the treatment strategies for the child population with critical conditions due to COVID-19 is scarce and lacks consensus. Thus, this study aimed to critically review non-pharmacological respiratory strategies for this population. Original studies were searched in six databases considering predefined inclusion criteria. Other studies and recommendations were also included after a manual search. Oxygen therapy, invasive (IMV) and non-invasive (NIV) ventilation were the most frequently addressed interventions. In general, the original studies have cited these strategies, but detailed information on the parameters used was not provided. The recommendations provided more detailed data, mainly based on experiences with other acute respiratory syndromes in childhood. In the context of oxygen therapy, the nasal catheter was the most recommended strategy for hypoxemia, followed by the high-flow nasal cannula (HFNC). However, the risks of contamination due to the dispersion of aerosols in the case of the HFNC were pointed out. Lung protective IMV with the use of bacteriological or viral filters was recommended in most documents, and there was great variation in PEEP titration. Alveolar recruitment maneuvers were mentioned in a few recommendations. NIV was not consensual among studies, and when selected, several precautions must be taken to avoid contamination. Airway suctioning with a closed-circuit was recommended to reduce aerosol spread. Information on prone positioning and physiotherapy was even more scarce. In conclusion, oxygen therapy seems to be essential in the treatment of hypoxemia. If necessary, IMV should not be delayed, and protective strategies are encouraged for adequate pulmonary ventilation. Information about techniques that are adjuvant to ventilatory support is superficial and requires further investigation.

Proinflammatory IgG Fc structures in patients with severe COVID-19

Severe acute respiratory syndrome coronavirus 2 infections can cause coronavirus disease 2019 (COVID-19), which manifests with a range of severities from mild illness to life-threatening pneumonia and multi-organ failure. Severe COVID-19 is characterized by an inflammatory signature, including high levels of inflammatory cytokines, alveolar inflammatory infiltrates and vascular microthrombi. Here we show that patients with severe COVID-19 produced a unique serologic signature, including an increased likelihood of IgG1 with afucosylated Fc glycans. This Fc modification on severe acute respiratory syndrome coronavirus 2 IgGs enhanced interactions with the activating Fcγ receptor FcγRIIIa; when incorporated into immune complexes, Fc afucosylation enhanced production of inflammatory cytokines by monocytes, including interleukin-6 and tumor necrosis factor. These results show that disease severity in COVID-19 correlates with the presence of proinflammatory IgG Fc structures, including afucosylated IgG1.

Clinical Manifestations of Gastrointestinal Symptoms in COVID-19 Patients: An Integrative Review

After the outbreak of novel coronavirus disease 2019 (COVID-19) in Wuhan, China, its spread to other countries is rapidly increasing. In this integrative review, we report the prevalence of gastrointestinal symptoms in patients with COVID-19. For this purpose, available articles on gastrointestinal manifestations in patients with COVID-19, which were reported from China, were reviewed. All reviewed articles were searched from December 11, 2019, to June 20, 2020, based on specific key words. Related findings in these articles show that the main target of COVID-19 is lung tissue, as after the virus enters the body, it mainly causes respiratory symptoms in affected patients. But in addition to respiratory symptoms, it is possible that, over time, these patients present with other symptoms, the most obvious of which are gastrointestinal symptoms. It is well documented that diarrhea and vomiting are the most common gastrointestinal symptoms in COVID-19 patients. As part of this report, we also look at the incidence and frequency of gastrointestinal symptoms in COVID-19 patients in Iran. The results can be used by providers as a guideline for better management of gastrointestinal symptoms in these patients.

Epidemiological, Clinical, and Laboratory Features of Children With COVID-19 in Turkey

Objectives: The aim of this study is to identify the epidemiological, clinical, and laboratory features of coronavirus disease 2019 (COVID-19) in children. Methods: A retrospective study was conducted by pediatric infectious disease specialists from 32 different hospitals from all over Turkey by case record forms. Pediatric cases who were diagnosed as COVID-19 between March 16, 2020, and June 15, 2020 were included. Case characteristics including age, sex, dates of disease onset and diagnosis, family, and contact information were recorded. Clinical data, including the duration and severity of symptoms, were also collected. Laboratory parameters like biochemical tests and complete blood count, chest X-ray, and chest computed tomography (CT) were determined. Results: There were 1,156 confirmed pediatric COVID-19 cases. In total, male cases constituted 50.3% (n = 582) and females constituted 49.7% (n = 574). The median age of the confirmed cases was 10.75 years (4.5-14.6). Of the total cases, 90 were younger than 1 year of age (7.8%), 108 were 1-3 years of age (9.3%), 148 were 3-6 years of age (12.8%), 298 were 6-12 years of age (25.8%), 233 were 12-15 years of age (20.2%), and 268 cases were older than 15 years of age (23.2%). The most common symptom of the patients at the first visit was fever (50.4%) (n = 583) for a median of 2 days (IQR: 1-3 days). Fever was median at 38.4°C (38.0-38.7°C). The second most common symptom was cough (n = 543, 46.9%). The other common symptoms were sore throat (n = 143, 12.4%), myalgia (n = 141, 12.2%), dyspnea (n = 118, 10.2%), diarrhea (n = 112, 9.7%), stomachache (n = 71, 6.1%), and nasal discharge (n = 63, 5.4%). When patients were classified according to disease severity, 263 (22.7%) patients were asymptomatic, 668 (57.7%) patients had mild disease, 209 (18.1%) had moderate disease, and 16 (1.5%) cases had severe disease. One hundred and forty-nine (12.9%) cases had underlying diseases among the total cases; 56% of the patients who had severe disease had an underlying condition (p < 0.01). The need for hospitalization did not differ between patients who had an underlying condition and those who do not have (p = 0.38), but the need for intensive care was higher in patients who had an underlying condition (p < 0.01). Forty-seven (31.5%) of the cases having underlying conditions had asthma or lung disease (38 of them had asthma). Conclusions: To the best of our knowledge, this is one of the largest pediatric data about confirmed COVID-19 cases. Children from all ages appear to be susceptible to COVID-19, and there is a significant difference in symptomatology and laboratory findings by means of age distribution.

Multicenter Initial Guidance on Use of Antivirals for Children With Coronavirus Disease 2019/Severe Acute Respiratory Syndrome Coronavirus 2

BACKGROUND

Although coronavirus disease 2019 (COVID-19) is mild in nearly all children, a small proportion of pediatric patients develop severe or critical illness. Guidance is therefore needed regarding use of agents with potential activity against severe acute respiratory syndrome coronavirus 2 in pediatrics.

METHODS

A panel of pediatric infectious diseases physicians and pharmacists from 18 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of best available evidence and expert opinion.

RESULTS

Given the typically mild course of pediatric COVID-19, supportive care alone is suggested for the overwhelming majority of cases. The panel suggests a decision-making framework for antiviral therapy that weighs risks and benefits based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression. If an antiviral is used, the panel suggests remdesivir as the preferred agent. Hydroxychloroquine could be considered for patients who are not candidates for remdesivir or when remdesivir is not available. Antivirals should preferably be used as part of a clinical trial if available.

CONCLUSIONS

Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For those rare cases of severe or critical disease, this guidance offers an approach for decision-making regarding antivirals, informed by available data. As evidence continues to evolve rapidly, the need for updates to the guidance is anticipated.

Multidisciplinary Guidance Regarding the Use of Immunomodulatory Therapies for Acute Coronavirus Disease 2019 in Pediatric Patients

BACKGROUND

Immune-mediated lung injury and systemic hyperinflammation are characteristic of severe and critical coronavirus disease 2019 (COVID-19) in adults. Although the majority of severe acute respiratory syndrome coronavirus 2 infections in pediatric populations result in minimal or mild COVID-19 in the acute phase of infection, a small subset of children develop severe and even critical disease in this phase with concomitant inflammation that may benefit from immunomodulation. Therefore, guidance is needed regarding immunomodulatory therapies in the setting of acute pediatric COVID-19. This document does not provide guidance regarding the recently emergent multisystem inflammatory syndrome in children (MIS-C).

METHODS

A multidisciplinary panel of pediatric subspecialty physicians and pharmacists with expertise in infectious diseases, rheumatology, hematology/oncology, and critical care medicine was convened. Guidance statements were developed based on best available evidence and expert opinion.

RESULTS

The panel devised a framework for considering the use of immunomodulatory therapy based on an assessment of clinical disease severity and degree of multiorgan involvement combined with evidence of hyperinflammation. Additionally, the known rationale for consideration of each immunomodulatory approach and the associated risks and benefits was summarized.

CONCLUSIONS

Immunomodulatory therapy is not recommended for the majority of pediatric patients, who typically develop mild or moderate COVID-19. For children with severe or critical illness, the use of immunomodulatory agents may be beneficial. The risks and benefits of such therapies are variable and should be evaluated on a case-by-case basis with input from appropriate specialty services. When available, the panel strongly favors immunomodulatory agent use within the context of clinical trials. The framework presented herein offers an approach to decision-making regarding immunomodulatory therapy for severe or critical pediatric COVID-19 and is informed by currently available data, while awaiting results of placebo-controlled randomized clinical trials.

SARS-CoV-2 Infections and COVID-19 Fatality: Estimation of Infection Fatality Ratio and Current Prevalence

COVID-19 is one of the most important problems for public health, according to the number of deaths associated to this pathology reported so far. However, from the epidemiological point of view, the dimension of the problem is still unknown, since the number of actual cases of SARS-CoV-2 infected people is underestimated, due to limited testing. This paper aims at estimating the actual Infection Fatality Ratio (number of deaths with respect to the number of infected people) and the actual current prevalence (number of infected people with respect to the entire population), both in a specific population and all over the world. With this aim, this paper proposes a method to estimate Infection Fatality Ratio of a still ongoing infection, based on a daily estimation, and on the relationship between this estimation and the number of tests performed per death. The method has been applied using data about COVID-19 from Italy. Results show a fatality ratio of about 0.9%, which is lower than previous findings. The number of actual infected people in Italy is also estimated, and results show that (i) infection started at the end of January 2020; (ii) a maximum number of about 100,000 new cases in one day was reached at the beginning of March 2020; (iii) the estimated cumulative number of infections at the beginning of October 2020 is about 4.2 million cases in Italy (more than 120 million worldwide, if a generalization is conjectured as reasonable). Therefore, the prevalence at the beginning of October 2020 is estimated at about 6.9% in Italy (1.6% worldwide, if a generalization is conjectured).

COVID-19 infection in pediatric subjects: study of 36 cases in Conakry

The aim of this study was to evaluate the main clinical and evolutionary features of SARS-CoV-2 infection in children aged 0-18 years who were suspected and diagnosed for COVID-19 during routine consultations in the pediatric ward of the Ignace Deen National Hospital in Conakry. This retrospective study targeted all children admitted to the Pediatrics Department during the study period and focused on children whose clinical examination and/or history indicated a suspicion of SARS-CoV-2 infection. Only children with a positive reverse transcriptase-polymerase chain reaction (RT-PCR) test were included. Clinical and paraclinical data were rigorously analyzed. Anonymity and respect for ethical rules were the norm. Medical records were used as the data source and a questionnaire was developed for collection. The analysis was done using STATA/SE version 11.2 software. The mean age of the patients observed was 9.66±1.32 years, with a sex ratio of 1.25. The history of the patients found that 36.11 had already been in contact with a COVID-19 positive subject, of which 8 or 22 had close relatives treated for COVID-19 and 5 had been with classmates treated for COVID-19. Fever and physical asthenia, runny nose and throat pain were respectively found in 58.33%, 50% and 30.55% of patients with irritability in 25%. Asymptomatic children were 30.55%. The diagnosis was confirmed after a positive RT-PCR test. Thoracic computed tomography (CT) scan was normal in 80.55% of the children. They were given mostly azithromycin 15mg/kg, zinc and chloroquine sulfate 5mg/kg. The mean age of the patients observed was 9.66 years, with a sex ratio of 1.25. The history of the patients found that 36.11 had already been in contact with a COVID-19 positive subject, of which 8 or 22 had close relatives treated for COVID-19 and 5 had been with classmates treated for COVID-19. Fever and physical asthenia, runny nose and throat pain were respectively found in 58.33%, 50% and 30.55% of patients with irritability in 25%. Asymptomatic children were 30.55%. The diagnosis was confirmed after a positive RT-PCR test. Thoracic computed tomography (CT) scan was normal in 80.55% of the children. They were given mostly azithromycin 15mg/kg, zinc and chloroquine sulfate 5mg/kg.