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Of the 49 confirmed pediatric cases, 11 (22.4%) were domestic cases including Shanghai residents (8) children and Wuhan residents (3), and 38 (77.6%) were imported cases from European countries (28), the US (8), Canada (1) and Philippines (1). The ratio of male-to female was 1.3 (28/21); the mean age was 11.5 ± 5.12 years with 9 (18.4%) aged 7 months-6 years, 16 (32.7%) aged 7-12 years and 24 (48.9%) aged 13-17 years. Domestic cases were significantly younger than imported cases (5.8 ± 4.1 years vs. 13.2 ± 4.1 years, P < 0.05).
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Twenty-one (42.9%) children had contact with confirmed or suspect symptomatic cases of COVID-19. Exposure settings included household in 15 cases (71.4%), school dormitory in 5 cases (23.8%), and travel bus in 1 (4.8%) case. Of the 11 domestic cases, 9 (81.8%) had a clear epidemiological linkage with 8 confirmed family cluster cases and 1 traveler cases. Of the 38 imported cases, 12 (31.6%) had a clear contact with 7 confirmed or suspect family cluster cases and 5 school-dormitory cases.
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On initial screening, 28 (57.1%) cases were symptomatic and 21 (42.9%) cases were asymptomatic. Chest CT and X-ray were performed for 40 cases and 9 cases, respectively. Lung lesions were revealed in 20 (40.8%) cases including 15 symptomatic cases and 5 asymptomatic cases. The prominent radiographic findings included ground-glass opacity and patchy infiltrates. Neither the 13 mild cases nor the 16 asymptomatic carriers developed radiographic evidence of pneumonia during follow-up investigation. None of the cases progressed to severe disease.
Twenty-one (42.9%) had cough, 16 (32.7%) had fever, 8 (16.3%) had sore throat, 8 (16.3%) had stuffy nose, 7 (14.2%) had rhinorrhea (Table 1). Six (12.2%) children aged 15-17 years including 1 asymptomatic carrier and 5 symptomatic cases self-reported transient loss of taste and smell during hospitalization. Of the 16 febrile patients, 12 (24.5%) had a body temperature of 37.5 ℃-38.4 ℃ and 4 (8.2%) had a body temperature of 38.5 ℃-40.0 ℃; the duration of fever ranged from 1 to 8 days (mean: 2.1 ± 1.9 days, median: 1 day). Antiviral drugs were not recommended for treatment. Hydroxychloroquine was administered to 5 cases > 14 years for 1-2 days and then discontinued considering that the patients' conditions were mild and stable. A 17-year-old patient received hydroxychloroquine on day 7 after disease onset because he had persistent 7-day fever and increased lung lesions revealed by chest CT, and fever subsided 1 day after hydroxychloroquine treatment. One patient with pneumonia received 3-day oral azithromycin therapy because he was confirmed with mycoplasma pneumoniae infection.
Total
n = 49Local cases
n = 11Imported cases
n = 38Demographic Age range (year, mean ± SD) 0.6-17 (11.5 ± 5.12) 0.6-11 (5.8 ± 4.1) 2-17 (13.2 ± 4.1) Male patients (n. %) 28 (57.1%) 6 (54.5%) 22 (57.9%) Symptom (n. %) Cough 21 (42.9%) 9 (81.8%) 12 (31.6%) Fever 16 (32.7%) 8 (72.7%) 8 (21.1%) Sore throat 8 (16.3%) 3 (27.3%) 5 (13.2%) Stuffy nose 8 (16.3%) 4 (36.4%) 4 (10.5%) Rhinorrhea 7 (14.3%) 3 (27.3%) 4 (10.5%) Tachypnea/respiratory distress 0 0 0 Vomit 0 0 0 Diarrhea 0 0 0 Pneumoniaa 20 (40.8%) 6 (54.5%) 14 (36.8%) Loss of taste and smell 6 (12.2%) 0 6 (12.2%) aPneumonia was confirmed by chest X-ray or CT, including 5 asymptomatic cases. Table 1. Demographic and clinical features in local cases and imported cases.
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The laboratory findings in symptomatic cases and asymptomatic cases were shown in Table 2. All cases showed a normal range of serum biochemistry markers on admission and during follow-up testing except one patient who developed mild liver injury (alanine aminotransferase/aspartate aminotransferase: 110/59 IU/L) after 6-day hydroxychloroquine therapy. The elevated liver enzyme returned to the normal range after discontinuation of hydroxychloroquine. Leukopenia (the counts of white blood cell < 4.0 × 109/L) was seen in 5 cases, neutropenia (the counts of neutrophil < 0.5 × 109/L) was seen 2 asymptomatic cases with radiographic evidence of pneumonia. One mild case showed an elevated level of C-reactive protein (CRP) (35 mg/L). There were no statistically significant differences in the serum biochemistry markers, CRP, procalcitonin and other laboratory tests between the symptomatic group and asymptomatic group.
Total
n = 49Symptomatic cases
n = 28Asymptomatic cases
n = 21Demographic Age range (year, mean ± SD) 0.7-17 (11.5 ± 5.12) 0.7-17 (11.3 ± 5.74) 2.3-17 (11.8 ± 4.3) Male patients (n. %) 28 (57.1%) 15 (53.6%) 13 (61.9%) Laboratory findings (median, IQR) White blood cell count (× 109/L) 6.1 (4.8-6.1) 6.2 (4.6-8.1) 6.0 (4.8-7.5) Neutrophil count (× 109/L) 2.7 (2.0-4.1) 3.0 (2.2-4.2) 2.8 (2.2-3.6) Lymphocyte count (× 109/L) 2.2 (1.7-2.8) 2.0 (1.7-2.8) 2.4 (2-3) Platelet count (× 109/L) 265 (215.5-331) 244 (205.8-319.8) 282 (226.5-343.5) C-reactive protein (mg/L) 0.5 (0.5-8) 4.1 (0.5-8) 0.5 (0.5-8.0) Procalcitonin (ng/dL) 0.03 (0.02-0.05) 0.04 (0.02-0.07) 0.02 (0.02-0.03) Alanine aminotransferase (U/L) 16.0 (12-20) 14.9 (10-21.5) 16.5 (13-19.5) Aspartate aminotransferase (U/L) 23.0 (18.8-29.8) 21.7 (18-33.7) 24.3 (19-29) Creatinine (µmol/L) 50.7 (39.4-64.2) 52.0 (34.5-68.8) 50.7 (41-59.6) Urea (mmol/L) 4.2 (3.5-4.7) 4.1 (3.5-5.3) 4.2 (3.4-4.5) Creatine kinase (U/L) 80 (65.5-101) 75.5 (54-94.3) 84 (69.5-105) Creatine kinase-MB (U/L) 15.0 (12.8-21.1) 15 (12.4-19.6) 15.3 (13.4-22.6) Lactate dehydrogenase (U/L) 212.5 (188.3-234) 211 (186-242) 214 (193-229.5) Cardiac troponin I 0.01 (0.01-0.03) 0.02 (0.01-0.04) 0.01 (0.01-0.02) SD standard deviation, IQR interquartile range. Table 2. Demographic and laboratory findings in symptomatic cases and asymptomatic cases.
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None of the 49 cases had SARS-CoV-2 RNA detected in serum and urine. Forty-five (91.8%) cases had SARS-CoV-2 RNA detected in stool. The patterns of viral shedding were shown in Fig. 1. Overall, the duration of viral RNA shedding is longer in gastrointestinal tract than in upper respiratory tract (P < 0.05). There was no significant difference in the mean duration of viral shedding between asymptomatic and symptomatic cases in upper respiratory tract (14.1 ± 6.4 days vs. 14.8 ± 8.4 days, P > 0.05) and in gastrointestinal tract (28.1 ± 13.3 days vs. 30.8 ± 18.6 days, P > 0.05). Young children < 7 years of age shed viral RNA in stool for a significantly longer duration than school-aged children ≥ 7 years of age (P < 0.05, Table 3).
Figure 1. The duration of virus RNA shedding by age and symptom. A, B The duration of virus RNA shedding in stool samples. Younger children shed viral RNA in stool for a longer duration than older children (P = 0.001). C, D The duration of virus RNA shedding in nasopharyngeal swabs.
No of cases Mean ± SD Range P value Virus RNA shedding in gastrointestinal tract (days) in 37 casesa consecutively monitored < 7 years 5 52.8 ± 12.0 41–70 7–12 years 12 33.3 ± 11.0 12–48 0.001 > 12 years 20 21.2 ± 12.5 2–41 Symptomatic cases 18 30.8 ± 18.6 4–70 0.616 Asymptomatic cases 19 28.1 ± 13.3 2–45 Virus RNA shedding in upper respiratory tract (days) in 49 cases consecutively monitored < 7 years 9 11.1 ± 8.5 2–27 7–12 years 16 16.9 ± 7.7 4–30 0.182 > 12 years 24 14.2 ± 6.8 4–30 Symptomatic cases 28 14.8 ± 8.4 2–30 0.772 Asymptomatic cases 21 14.1 ± 6.4 4–27 aAmong the 45 cases tested positive for SARS-CoV-2 RNA, thirty-seven were followed up until the nucleic acids of SARS-CoV-2 were undetectable and 8 children could not return to hospital for follow-up because they lived outside Shanghai City. Table 3. The duration of virus RNA shedding by age and symptom.
Forty-three (87.8%) of the 49 cases including 25 symptomatic cases and 18 asymptomatic cases had seropositivity for IgG and IgM combined antibodies against SARS-CoV-2 within 1-3 weeks after confirmation with asymptomatic infection or disease onset. As shown in Fig. 2, 19 (44.2%) cases developed seropositivity for antibodies within 1 week, 14 (32.6%) cases developed seropositivity for antibodies within 1-2 weeks, and 10 (23.3%) cases developed seropositivity for antibodies within 2-3 weeks. We noted that 66.7% of asymptomatic cases developed seropositivity within 1 week while only 28% of symptomatic cases developed seropositivity within 1 week. Among 6 cases who had seronegative, the last serum sample tested for antibodies was collected on day 8-22 after disease onset or confirmation with infection before hospital discharge.
Figure 2. The patterns of antibody response to SARS-CoV-2 by clinical symptomatology (A) and age (B). The figure shows the percentage of the antibody production time in different stage including 66.7% of asymptomatic cases developed seropositivity within 1 week, only 28% of symptomatic cases developed seropositivity within 1 week.