key: cord-0911335-cokrk77y authors: Howard, L. M.; Garguilo, K.; Gillon, J.; Seegmiller, A. C.; Schmitz, J. E.; Webber, S. A.; Banerjee, R. title: Characteristics and clinical features of SARS-CoV-2 infections among ambulatory and hospitalized children and adolescents in an integrated health care system in Tennessee date: 2020-10-13 journal: medRxiv : the preprint server for health sciences DOI: 10.1101/2020.10.08.20208751 sha: 4887a406fbbaed0ce8c1e68d76751dcdade068ae doc_id: 911335 cord_uid: cokrk77y Background Little is known regarding the full spectrum of illness among children with SARS-CoV-2 infection across ambulatory and inpatient settings. Methods Active surveillance was performed for SARS-CoV-2 by polymerase chain reaction among asymptomatic and symptomatic individuals in a quaternary care academic hospital laboratory in Tennessee from March 12-July 17, 2020. For symptomatic patients [≤]18 years of age, we performed phone follow-up and medical record review to obtain sociodemographic and clinical data on days 2, 7, and 30 after diagnosis and on day 30 for asymptomatic patients [≤]18 years. Daily and 7-day average test positivity frequencies were calculated for children and adults beginning April 26, 2020. Results SARS-CoV-2 was detected in 531/10327 (5.1%) specimens from patients [≤]18 years, including 46/5752 (0.8%) asymptomatic and 485/4575 (10.6%) specimens from 459 unique symptomatic children. Cough (51%), fever (42%), and headache (41%) were the most common symptoms associated with SARS-CoV-2 infection. SARS-CoV-2-related hospitalization was uncommon (18/459 children; 4%); no children with SARS-CoV-2 infection during the study period required intensive care unit admission. Symptom resolution occurred by follow-up day 2 in 192/459 (42%), by day 7 in 332/459 (72%), and by day 30 in 373/396 (94%). The number of cases and percent positivity rose in late June and July in all ages. Conclusions In an integrated healthcare network, most pediatric SARS-CoV-2 infections were mild, brief, and rarely required hospital admission, despite increasing cases as community response measures were relaxed. The CDC assay employed the N1 and N2 primer/probe sets for SARS-CoV-2 with amplification/detection on an Applied Biosystems QuantStudio 7 Flex. Specimens were nasopharyngeal or nasal swabs in viral transport media, with the exception of the IDNOW, for which dry swabs were used. Testing on the IDNOW platform was limited to asymptomatic pateints only, while the other platforms included both symptomatic and asymptomatic individuals. SARS-CoV-2 PCR testing became available in our institution on March 12, 2020. At that time, given limited testing capacity, testing criteria in children were restricted to symptomatic individuals (new onset respiratory symptoms and fever or known contact with a SARS-CoV-2 infected individual); these indications were communicated electronically to ordering providers by hospital leadership. Routine screening of all pregnant women admitted to the Labor and Delivery unit began on April 22, 2020. Routine screening of asymptomatic individuals prior to other hospital admissions, initiation of chemotherapy, stem cell or solid organ transplant, or certain surgical or medical procedures was initiated on May 4, 2020. While indications for testing expanded over time to include asymptomatic individuals admitted to hospital or undergoing outpatient procedures, testing guidance was standardized across testing sites. Daily numbers of tests performed and number of positive tests among symptomatic and asymptomatic subjects were collected from April 26, 2020 through July 17, 2020 for this assessment. For symptomatic patients and neonates born in our hospital to SARS-CoV-2-positive women detected upon routine hospital admission, our team performed phone follow-up at days 2, 7, and 30 after the laboratory diagnosis to obtain baseline sociodemographic characteristics and All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint ascertain data on exposures, comorbidities, clinical symptoms, and illness status. We also reviewed medical records, when available, to collect clinical and demographic information. For asymptomatic patients with a positive screening test, our team performed phone follow-up at 30 days after the positive test result. Descriptive analyses were conducted using STATA/SE 14.2 (StataCorp LP, College Station, TX). Daily and 7-day moving average percent positivity frequencies were calculated and stratified by asymptomatic and symptomatic status. While the majority of the analyses were done in the pediatric age group, test positivity rates were compared between children and adults during the same study period. From March 12 to July 17, 2020, SARS-CoV-2 tests were positive in 5261/70071 (7.5%) specimens obtained at VUMC testing sites and hospitals across all age groups, including 531/10327 (5.1%) specimens in patients ≤18 years, compared to 4730/59744 (7.9%) specimens in patients >18 years. Forty-six/5752 (0.8%) specimens from asymptomatic children and adolescents screened after close contact with a SARS-CoV-2 infected individual or prior to hospitalization or medical procedures were positive for SARS-CoV-2. Among 5752 specimens tested in asymptomatic patients ≤18 years, 3766 (65.5%) specimens were tested prior to medical procedures, 1265 (22.0%) prior to hospital admission, 190 (3.3%) prior to chemotherapy, 98 for known exposure All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint emergency department; it is unclear if the cause of death was related to SARS-CoV-2 infection. We observed 1 case of MIS-C during the study period. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint In this cohort of children tested for SARS-CoV-2 at a single academic institution in the southeastern U.S. from March 12-July 17, 2020, the frequency of SARS-CoV-2 infection was substantially higher among symptomatic (10.6%) than asymptomatic (0.8%) children. Symptomatic children and adolescents in our cohort most commonly exhibited febrile respiratory syndromes without GI symptoms, which were generally brief and mild, with only a small minority [17] Similarly, we observed that Hispanic children comprised roughly one-third of symptomatic patients and nearly 40% of hospitalized patients in our cohort. In another recent report from a large, integrated pediatric healthcare network in Pennsylvania, despite a relatively All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint low frequency of critical illness, a higher proportion of patients required hospitalization for children might have a relatively minor impact, particularly if SARS-CoV-2 transmissibility is low in the setting of only mild or subclinical infection. In our community, a "Safer at Home" order went into effect on March 23, 2020, directing all residents of the county to stay home unless engaged in certain essential activities, with restrictions in place pertaining to operation and capacity of certain local businesses, including retail shops, non-essential service establishments, bars, and restaurants. A phased reopening process was initiated on May 11, 2020, involving clear guidelines for liberalizing restrictions, Our study has a number of important strengths. By identifying all children with SARS-CoV-2 detections in the context of an integrated health network as the outbreak emerged, our study enabled a comprehensive assessment of the full spectrum of pediatric infection in the community, from asymptomatic infection to more severe illness. By prospectively following these subjects, we were able to assess not only the symptoms present at diagnosis, but also to follow the duration of symptoms, and to follow asymptomatic subjects for the development of symptoms after the initial detection. Our study is also subject to some limitations. Our cohort is limited to patients who visited one of our network's testing sites for assessment. Due to limited testing capacity, especially earlier in the study period, testing was recommended only for individuals with new-onset respiratory symptoms, fever, or a known SARS-CoV-2-positive contact; thus, providers were discouraged from sending SARS-CoV-2 testing on patients with other symptoms, such as gastrointestinal or general symptoms alone, which introduced sampling bias. Real-time All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint monitoring of testing indications was impractical and testing practices may have varied by provider. In summary, symptomatic SARS-CoV-2 infections among individuals ≤18 years were generally associated with respiratory symptoms, mild illness that usually resolved within a week, and rarely required hospitalization. Cases increased in our community in both children and adults as local businesses reopened, highlighting the importance of community mitigation strategies in reducing SARS-CoV-2 transmission. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. Nashville COVID-19 Response: Safer at Home Order. Available at: https://www.asafenashville.org. Accessed July 7, 2020. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. . https://doi.org/10.1101/2020.10.08.20208751 doi: medRxiv preprint Figure 2 . Number of samples tested for SARS-CoV-2 from April 26, 2020 to July 17, 2020 among symptomatic and asymptomatic pediatric (≤18 years) and adult (>18 years) patients (left y-axis); 7-day average percent of samples tested positive for SARS-CoV-2 (right y-axis). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 13, 2020. Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California Clinical Characteristics of Coronavirus Disease