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Hijano DR, Ferrolino JA, Gu Z, Brazelton JN, Zhu H, Suganda S, Glasgow HL, Dallas RH, Allison KJ, Maron G, Darji H, Tang L, Fabrizio TP, Webby RJ, Hayden RT. Digital PCR to Measure SARS-CoV-2 RNA, Variants, and Outcomes in Youth. J Pediatric Infect Dis Soc 2023; 12:618-626. [PMID: 37956414 PMCID: PMC10725239 DOI: 10.1093/jpids/piad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/10/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The role of SARS-CoV-2 viral load in predicting contagiousness, disease severity, transmissibility, and clinical decision-making continues to be an area of great interest. However, most studies have been in adults and have evaluated SARS-CoV-2 loads using cycle thresholds (Ct) values, which are not standardized preventing consistent interpretation critical to understanding clinical impact and utility. Here, a quantitative SARS-CoV-2 reverse-transcription digital PCR (RT-dPCR) assay normalized to WHO International Units was applied to children at risk of severe disease diagnosed with COVID-19 at St. Jude Children's Research Hospital between March 28, 2020, and January 31, 2022. METHODS Demographic and clinical information from children, adolescents, and young adults treated at St. Jude Children's Research Hospital were abstracted from medical records. Respiratory samples underwent SARS-CoV-2 RNA quantitation by RT-dPCR targeting N1 and N2 genes, with sequencing to determine the genetic lineage of infecting virus. RESULTS Four hundred and sixty-two patients aged 0-24 years (median 11 years old) were included during the study period. Most patients were infected by the omicron variant (43.72%), followed by ancestral strain (22.29%), delta (13.20%), and alpha (2.16%). Viral load at presentation ranged from 2.49 to 9.14 log10 IU/mL, and higher viral RNA loads were associated with symptoms (OR 1.32; CI 95% 1.16-1.49) and respiratory disease (OR 1.23; CI 95% 1.07-1.41). Viral load did not differ by SARS-CoV-2 variant, vaccination status, age, or baseline diagnosis. CONCLUSIONS SARS-CoV-2 RNA loads predict the presence of symptomatic and respiratory diseases. The use of standardized, quantitative methods is feasible, allows for replication, and comparisons across institutions, and has the potential to facilitate consensus quantitative thresholds for risk stratification and treatment.
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Affiliation(s)
- Diego R Hijano
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jose A Ferrolino
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Zhengming Gu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jessica N Brazelton
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Haiqing Zhu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Sri Suganda
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Heather L Glasgow
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ronald H Dallas
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Kim J Allison
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Gabriela Maron
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Himani Darji
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Li Tang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Thomas P Fabrizio
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Richard J Webby
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Randall T Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Osborn LJ, Chen PY, Flores-Vazquez J, Mestas J, Salas E, Glucoft M, Smit MA, Costales C, Dien Bard J. Clinical utility of SARS-CoV-2 subgenomic RT-PCR in a pediatric quaternary care setting. J Clin Virol 2023; 164:105494. [PMID: 37210881 DOI: 10.1016/j.jcv.2023.105494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND During active transcription, SARS-CoV-2 generates subgenomic regions of viral RNA. While standard SARS-CoV-2 RT-PCR amplifies region(s) of genomic RNA, it cannot distinguish active infection from remnant viral genomic material. However, screening for subgenomic RNA (sgRNA) by RT-PCR may aid in the determination of actively transcribing virus. OBJECTIVES To evaluate the clinical utility of SARS-CoV-2 sgRNA RT-PCR testing in a pediatric population. STUDY DESIGN Retrospective analysis was performed on inpatients from February-September 2022 positive for SARS-CoV-2 by RT-PCR with a concomitant order for sgRNA RT-PCR. Chart abstractions were conducted to determine clinical outcomes, management, and infection prevention and control (IPC) practices. RESULTS Of 95 SARS-CoV-2 positive samples from 75 unique patients, 27 (28.4%) were positive by sgRNA RT-PCR. A negative sgRNA RT-PCR test allowed for de-isolation in 68 (71.6%) patient episodes. Regardless of age or sex, a positive sgRNA RT-PCR result significantly correlated with disease severity (P = 0.007), generalized COVID-19 symptoms (P = 0.012), hospitalization for COVID-19 (P = 0.019), and immune status (P = 0.024). Moreover, sgRNA RT-PCR results prompted changes in management in 28 patients (37.3%); specifically, therapeutic escalation in 13/27 (48.1%) positives and de-escalation in 15/68 (22.1%) negatives. CONCLUSIONS Taken together, these findings underscore the clinical utility of sgRNA RT-PCR testing in a pediatric population as we report significant associations between sgRNA RT-PCR results and clinical parameters related to COVID-19. These findings align with the proposed use of sgRNA RT-PCR testing to guide patient management and IPC practices in the hospital setting.
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Affiliation(s)
- Lucas J Osborn
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Pei Ying Chen
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jessica Flores-Vazquez
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Javier Mestas
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Edahrline Salas
- Department of Infection Prevention and Control, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Marisa Glucoft
- Department of Infection Prevention and Control, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Michael A Smit
- Department of Infection Prevention and Control, Children's Hospital Los Angeles, Los Angeles, CA, United States; Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Cristina Costales
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.
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Rodrigues GM, Volpato FCZ, Wink PL, Paiva RM, Barth AL, de-Paris F. SARS-CoV-2 Variants of Concern: Presumptive Identification via Sanger Sequencing Analysis of the Receptor Binding Domain (RBD) Region of the S Gene. Diagnostics (Basel) 2023; 13:diagnostics13071256. [PMID: 37046474 PMCID: PMC10093469 DOI: 10.3390/diagnostics13071256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/29/2023] Open
Abstract
Variants of concern (VOCs) of SARS-CoV-2 are viral strains that have mutations associated with increased transmissibility and/or increased virulence, and their main mutations are in the receptor binding domain (RBD) region of the viral spike. This study aimed to characterize SARS-CoV-2 VOCs via Sanger sequencing of the RBD region and compare the results with data obtained via whole genome sequencing (WGS). Clinical samples (oro/nasopharyngeal) with positive RT-qPCR results for SARS-CoV-2 were used in this study. The viral RNA from SARS-CoV-2 was extracted and a PCR fragment of 1006 base pairs was submitted for Sanger sequencing. The results of the Sanger sequencing were compared to the lineage assigned by WGS using next-generation sequencing (NGS) techniques. A total of 37 specimens were sequenced via WGS, and classified as: VOC gamma (8); delta (7); omicron (10), with 3 omicron specimens classified as the BQ.1 subvariant and 12 specimens classified as non-VOC variants. The results of the partial Sanger sequencing presented as 100% in agreement with the WGS. The Sanger protocol made it possible to characterize the main SARS-CoV-2 VOCs currently circulating in Brazil through partial Sanger sequencing of the RBD region of the viral spike. Therefore, the sequencing of the RBD region is a fast and cost-effective laboratory tool for clinical and epidemiological use in the genomic surveillance of SARS-CoV-2.
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Affiliation(s)
- Grazielle Motta Rodrigues
- Residência Multiprofissional em Saúde e em Área Profissional da Saúde do Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Serviço de Diagnóstico Laboratorial, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
| | - Fabiana Caroline Zempulski Volpato
- LABRESIS–Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre 90160-093, Rio Grande do Sul, Brazil
| | - Priscila Lamb Wink
- LABRESIS–Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre 90160-093, Rio Grande do Sul, Brazil
| | - Rodrigo Minuto Paiva
- Serviço de Diagnóstico Laboratorial, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
| | - Afonso Luís Barth
- LABRESIS–Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre 90160-093, Rio Grande do Sul, Brazil
| | - Fernanda de-Paris
- Residência Multiprofissional em Saúde e em Área Profissional da Saúde do Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Serviço de Diagnóstico Laboratorial, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- LABRESIS–Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Rio Grande do Sul, Brazil
- Correspondence:
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Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is usually mild and self-limited in children. However, a few Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infections in children may progress to severe disease with respiratory distress or can result in a multisystem inflammatory syndrome (MIS-C) associated with COVID-19. The immune mechanisms for these differential clinical outcomes are largely unknown. METHODS A prospective cohort study was performed to analyze the laboratory parameters, antibody response, immune phenotypes and cytokine profiles of 51 children with different clinical presentations of COVID-19. RESULTS We found that the absolute lymphocyte counts gradually decreased with disease severity. Furthermore, SARS-CoV-2 IgG levels in the acute phase and convalescence were not significantly different in patients with different disease severity. A decrease in CD3 + , CD4 + and CD8 + T cells was observed as disease severity increased. Both CD4 + and CD8 + T cells were activated in children with COVID-19, but no difference in the percentage of HLADR + -expressing cells was detected across the severity groups. In contrast, MIS-C patients exhibited augmented exhausted effector memory CD8 + T cells. Interestingly, the cytokine profile in sera of moderate/severe and MIS-C patients revealed an increase in anti-inflammatory IL-1RA and a suppression of tumor necrosis factor-α, RANTES, eotaxin and PDGF-BB. MIS-C patients also exhibited augmented IL-1β. CONCLUSIONS We report distinct immune profiles dependent on severity in pediatric COVID-19 patients. Further investigation in a larger population will help unravel the immune mechanisms underlying pediatric COVID-19.
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Martin MA, Keith M, Pace RM, Williams JE, Ley SH, Barbosa-Leiker C, Caffé B, Smith CB, Kunkle A, Lackey KA, Navarrete AD, Pace CDW, Gogel AC, Eisenberg DT, Fehrenkamp BD, McGuire MA, McGuire MK, Meehan CL, Brindle E. SARS-CoV-2 specific antibody trajectories in mothers and infants over two months following maternal infection. Front Immunol 2022; 13:1015002. [PMID: 36304449 PMCID: PMC9596287 DOI: 10.3389/fimmu.2022.1015002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/22/2022] [Indexed: 12/15/2022] Open
Abstract
Infants exposed to caregivers infected with SARS-CoV-2 may have heightened infection risks relative to older children due to their more intensive care and feeding needs. However, there has been limited research on COVID-19 outcomes in exposed infants beyond the neonatal period. Between June 2020 - March 2021, we conducted interviews and collected capillary dried blood spots from 46 SARS-CoV-2 infected mothers and their infants (aged 1-36 months) for up to two months following maternal infection onset (COVID+ group, 87% breastfeeding). Comparative data were also collected from 26 breastfeeding mothers with no known SARS-CoV-2 infection or exposures (breastfeeding control group), and 11 mothers who tested SARS-CoV-2 negative after experiencing symptoms or close contact exposure (COVID- group, 73% breastfeeding). Dried blood spots were assayed for anti-SARS-CoV-2 S-RBD IgG and IgA positivity and anti-SARS-CoV-2 S1 + S2 IgG concentrations. Within the COVID+ group, the mean probability of seropositivity among infant samples was lower than that of corresponding maternal samples (0.54 and 0.87, respectively, for IgG; 0.33 and 0.85, respectively, for IgA), with likelihood of infant infection positively associated with the number of maternal symptoms and other household infections reported. COVID+ mothers reported a lower incidence of COVID-19 symptoms among their infants as compared to themselves and other household adults, and infants had similar PCR positivity rates as other household children. No samples returned by COVID- mothers or their infants tested antibody positive. Among the breastfeeding control group, 44% of mothers but none of their infants tested antibody positive in at least one sample. Results support previous research demonstrating minimal risks to infants following maternal COVID-19 infection, including for breastfeeding infants.
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Affiliation(s)
- Melanie A. Martin
- Department of Anthropology, University of Washington, Seattle, WA, United States,Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States,*Correspondence: Melanie A. Martin,
| | - Monica Keith
- Department of Anthropology, University of Washington, Seattle, WA, United States,Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States
| | - Ryan M. Pace
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States
| | - Janet E. Williams
- Department of Animal, Veterinary and Food Sciences, University of Idaho, Moscow, ID, United States
| | - Sylvia H. Ley
- Department of Epidemiology, Tulane University School of Public Health, New Orleans, LA, United States
| | - Celestina Barbosa-Leiker
- College of Nursing, Washington State University Health Sciences Spokane, Spokane, WA, United States
| | - Beatrice Caffé
- Department of Anthropology, Washington State University, Pullman, WA, United States
| | - Caroline B. Smith
- Department of Anthropology, Washington State University, Pullman, WA, United States
| | - Amanda Kunkle
- Department of Anthropology, University of Washington, Seattle, WA, United States
| | - Kimberly A. Lackey
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States
| | - Alexandra D. Navarrete
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
| | - Christina D. W. Pace
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States
| | - Alexandra C. Gogel
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States
| | - Dan T.A. Eisenberg
- Department of Anthropology, University of Washington, Seattle, WA, United States,Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States
| | - Bethaney D. Fehrenkamp
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States,Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Medical Education, University of Idaho, Moscow, ID, United States
| | - Mark A. McGuire
- Department of Animal, Veterinary and Food Sciences, University of Idaho, Moscow, ID, United States
| | - Michelle K. McGuire
- Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, ID, United States
| | - Courtney L. Meehan
- Department of Anthropology, Washington State University, Pullman, WA, United States
| | - Eleanor Brindle
- Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States,Maternal, Newborn and Child Health & Nutrition, PATH, Seattle, WA, United States
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Cohen R, Aupiais C, Filleron A, Cahn-Sellem F, Romain O, Béchet S, Auvrignon A, Batard C, Virey B, Jung C, Rybak A, Levy C. Diagnostic accuracy of SARS-CoV-2 rapid antigen test from self-collected anterior nasal swabs in children compared to rapid antigen test and RT-PCR from nasopharyngeal swabs collected by healthcare workers: A multicentric prospective study. Front Pediatr 2022; 10:980549. [PMID: 36210936 PMCID: PMC9532740 DOI: 10.3389/fped.2022.980549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Testing for SARS-CoV-2 is central to COVID-19 management. Rapid antigen test from self-collected anterior nasal swabs (SCANS-RAT) are often used in children but their performance have not been assessed in real-life. We aimed to compare this testing method to the two methods usually used: reverse transcription polymerase chain reaction from nasopharyngeal swabs collected by healthcare workers (HCW-PCR) and rapid antigen test from nasopharyngeal swabs collected by healthcare workers (HCW-RAT), estimating the accuracy and acceptance, in a pediatric real-life study. From September 2021 to January 2022, we performed a manufacturer-independent cross-sectional, prospective, multicenter study involving 74 pediatric ambulatory centers and 5 emergency units throughout France. Children ≥6 months to 15 years old with suggestive symptoms of COVID-19 or children in contact with a COVID-19-positive patient were prospectively enrolled. We included 836 children (median 4 years), 774 (92.6%) were symptomatic. The comparators were HCW-PCR for 267 children, and HCW-RAT for 593 children. The sensitivity of the SCANS-RAT test compared to HCW-RAT was 91.3% (95%CI 82.8; 96.4). Sensitivity was 70.4% (95%CI 59.2; 80.0) compared to all HCW-PCR and 84.6% (95%CI 71.9; 93.1) when considering cycle threshold <33. The specificity was always >97%. Among children aged ≥6 years, 90.9% of SCANS-RAT were self-collected without adult intervention. On appreciation rating (from 1, very pleasant, to 10, very unpleasant), 77.9% of children chose a score ≤3. SCANS-RAT have good sensitivity and specificity and are well accepted by children. A repeated screening strategy using these tests can play a major role in controlling the pandemic.
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Affiliation(s)
- Robert Cohen
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Créteil, France
- Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
- Groupe de Pathologie Infectieuse Pédiatrique (GPIP), Créteil, France
| | - Camille Aupiais
- Assistance Publique–Hôpitaux de Paris, Clinical Epidemiology Unit, Robert Debré University Hospital, ECEVE INSERM UMR 1123, Université de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris, Pediatric Department, Jean Verdier University Hospital, Université Sorbonne Paris Nord, Bondy, France
| | - Anne Filleron
- Department of Pediatrics, CHU Nîmes, University of Montpellier, Nîmes, France
| | | | - Olivier Romain
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
- Assistance Publique–Hôpitaux de Paris, Neonatalogy Department, Antoine Béclère University Hospital, Université Paris Saclay, Clamart, France
| | - Stéphane Béchet
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Créteil, France
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
| | - Anne Auvrignon
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
| | - Christophe Batard
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
| | - Brigitte Virey
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
| | - Camille Jung
- Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
| | - Alexis Rybak
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Créteil, France
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
- Assistance Publique–Hôpitaux de Paris, Clinical Epidemiology Unit, Robert Debré University Hospital, ECEVE INSERM UMR 1123, Université de Paris, Paris, France
- Assistance Publique–Hôpitaux de Paris, Pediatric Emergency Department, Robert Debré University Hospital, Université de Paris, Paris, France
| | - Corinne Levy
- Association Clinique et Thérapeutique Infantile du Val-de-Marne (ACTIV), Créteil, France
- Clinical Research Center, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Association Française de Pédiatrie Ambulatoire (AFPA), Orléans, France
- Groupe de Pathologie Infectieuse Pédiatrique (GPIP), Créteil, France
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