key: cord-0975288-mz06mkqf
authors: Xing, Yuhan; Ni, Wei; Wu, Qin; Li, Wenjie; Li, Guoju; Tong, Jianning; Song, Xiufeng; Xing, Quansheng
title: Prolonged presence of SARS-CoV-2 in feces of pediatric patients during the convalescent phase
date: 2020-03-13
journal: nan
DOI: 10.1101/2020.03.11.20033159
sha: f332a4421ce9d32958a22c95fd90b325dbc96ee4
doc_id: 975288
cord_uid: mz06mkqf

Background: Severe acute respiratory coronavirus 2 (SARS-CoV-2) is a newly identified virus which mainly spreads from person-to-person. Fecal shedding of SARS-CoV-2 has been constantly reported in patients with coronavirus disease 2019 (COVID-19). Most published studies focus on adult populations, whereas data concerning pediatric patients is relatively scarce. Methods: From January 17, 2020 to March 6, 2020, three pediatric cases of COVID-19 were reported in Qingdao, Shandong Province, China. Epidemiological, clinical, laboratory, and radiological characteristics and treatment data of these children were collected. Real-time fluorescence reverse-transcriptase-polymerase-chain reaction (RT-PCR) was performed to detect SARS-CoV-2 RNA in throat swabs and fecal specimens. Results: All the three pediatric cases were household contacts of adults whose symptoms developed earlier. There has been no evidence showing the virus was transmitted from the children to others. Severity of disease of these children was mild to moderate and fever was the most consistent and predominant symptom at onset of illness (two cases had body temperature higher than 38.5 Celsius). All children showed increased lymphocytes (>4.4*109/L) with normal white blood cell counts on admission. One child had elevated serum levels of procalcitonin and C-reaction protein. Radiological changes were not typical for COVID-19. All children showed good response to supportive treatment. Clearance of SARS-CoV-2 in respiratory tract occurred within two weeks after abatement of fever, whereas persistent presence of viral RNA was found in stools of all children. One case had fecal SARS-CoV-2 turned negative 8 days after throat swabs showing negative, while that of another child lagged behind for 20 days. At the time of writing, one child still had positive results for RT-PCR analysis in stools after negative conversion of viral RNA in respiratory samples (over 19 days behind). Conclusions: Pediatric patients with COVID-19 are very different from adult patients in regards to epidemiological, clinical, laboratory, and radiological characteristics. Prolonged shedding of SARS-CoV-2 in stools of infected children indicates the potential for the virus to be transmitted through fecal excretion. Massive efforts should be made at all levels to prevent spreading of the infection among children after reopening of kindergartens and schools.

On December 12, 2019, 27 pneumonia cases of unknown cause emerged in Wuhan, Hubei Province, China. 1 The etiological agent was identified as a novel coronavirus and was later renamed as severe acute respiratory coronavirus 2 (SARS-CoV-2) by the world health organization (WHO). 2, 3 The pandemic of coronavirus disease 2019 (COVID- 19) has wreaked havoc in China and spread rapidly to about ninety countries, constituting a global threat with the highest risk impact. 4 Epidemiological evidence gained in China suggested that most individuals lack relevant immunity and are generally susceptible to the virus. The majority of published studies of COVID-19 focused on adult populations. [5] [6] [7] [8] While knowledge on SARS-CoV-2 infection in children are still yet to be fully developed and only a limited number of case reports of pediatric patients are currently available. [9] [10] [11] [12] As of February 23, 2020, a cumulative total of 60 confirmed COVID-19 cases were reported in Qingdao, Shandong Province, China, of which three cases (5%) were children temperature for more than 3 days", "with obvious features of absorption of inflammation shown in lung imaging" and "negative results of the nucleic acid tests of respiratory pathogens for consecutive two times [sampling interval at least 1 day]"). 13

From January 17, 2020 to February 23, 2020, a total of 60 patients were diagnosed with COVID-19 in Qingdao, Shandong Province, China. We recruited all three pediatric patients with laboratory confirmed SARS-CoV-2 infection who were reported by the local health authority. Diagnosis of COVID-19 was based on the WHO interim guidance. 14 Patients were followed up on a regular basis after hospital discharge till March 10, 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 March 13, 2020. . https://doi.org/10.1101/2020.03. 11.20033159 doi: medRxiv preprint This study was approved by the Ethics Commission of Qingdao Women and Children's Hospital (QFFLL-KY-2020-11) and written informed consent was obtained from patients' legal guardians prior to enrolment.

Personal, clinical, laboratory, and radiological characteristics and treatment and outcomes information were obtained with standardized data collection forms from electronic medical records. Additionally, we directly contacted patients' families to ascertain epidemiological and symptom information. Data were entered into a computerized database and doublechecked by two researchers independently.

Throat swabs were obtained from patients on admission. Fecal specimens were first collected in two patients (case 1, 1.5-year-old male; and case 2, 5-year-old male) on day 4 after onset of the disease. While the stool sample from another patient (case 3, 6-year-old female) was obtained 9 days after hospital discharge. To monitor the dynamic changes of viral shedding, we obtained throat swabs from patients every day during hospitalization and every other day during follow-up after discharge. Fecal specimens were collected applying a similar rationale since the first day of sample collection (samples from case 3 were only collected during follow-up period). Presence of SARS-CoV-2 RNA was detected by real-time fluorescence reverse-transcriptase-polymerase-chain reaction (RT-PCR) using a commercial kit approved by the China Food and Drug Administration. Detailed procedures were described elsewhere. 15 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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 doi: medRxiv preprint Laboratory findings of these children on admission to hospital are shown in Table 1 . On admission, all the children had increased lymphocyte count (>4.4×10 9 /L). Only case 1 showed decreased neutrophil count (<1.7×10 9 /L), whereas those of the other two children were within normal range. Elevation of platelets was observed in case 1 and case 2. Case 3 had increased levels of procalcitonin (0.73 ng/mL) and C-reaction protein ( (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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 doi: medRxiv preprint from case 3 and the child's family members 9 days after hospital discharge. This child showed positive results for RT-PCR analysis in feces. During quarantine and follow-up period, clearance of SARS-CoV-2 in stool samples occurred 20 days after viral RNA in respiratory specimens turning negative. Detailed information was not available as no fecal sample was examined during hospitalization.

The newly issued report of the WHO-China Joint Mission on COVID-19 summarized the evidence so far on SARS-CoV-2 and pointed out 2.4% of those infected were individuals below 18 years of age. 18 According to data released by the China Centers for Disease Control and Prevention, only 0.9% of COVID-19 patients were children under the age of 10 years. 19 Among the 60 patients infected with SARS-CoV-2 in Qingdao, 3 (5%) cases were children younger than 10 years of age.

Most of the pediatric COVID-19 patients had mild disease with good treatment response and a relatively short time to resolution, with exception of one critically ill case reported in Wuhan. 12 Consistent with previous findings, the three infected children in our study only presented with fever and mild cough or with no obvious symptom but CT abnormalities.

From available data, children appeared to be slightly affected by SARS-CoV-2, a feature resembling that of SARS-CoV emerged 17 years ago. 20 However, the relatively low attack rate of COVID-19 in children could be explained by the stringent implementation of home confinement and prolonged school closure during the outbreak as required by the Chinese governments. Whether it is also the case during school year is hard to tell. One distinct feature of pediatric cases is that almost all of them are infected through household contact with adult patients. [9] [10] [11] [12] 21 As with all new diseases, many characteristics of COVID-19 still remain largely unknown. There is limited data to support the notion that children are less susceptible to SARS-CoV-2 infection or virus transmission is less effective among them. Viral RNA has been constantly detected in stool samples and anal swabs collected from confirmed cases of COVID-19. 5, [22] [23] [24] [25] In one study, fecal specimens from 9 (53%) of 17 patients were positive for nucleic acid testing, although viral loads of the stool were less than those of respiratory samples. 24 Presence of SARS-CoV-2 was even detected in environmental samples taken from the surface of toilet bowl and sink in infection isolation rooms. 26 Moreover, SARS-CoV-2 remained viable in the stool of infected patients as reported by some case reports. 18 Evidence so far indicates the potential for SARS-CoV-2 to be transmitted through fecal excretion. 18 Although the role of fecal shedding in viral 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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 doi: medRxiv preprint transmission has not been systematically determined, a cautious approach is warranted when handling stool samples.

While we were closely monitoring the dynamic changes of fecal SARS-CoV-2 in our patients, a 6-year-old boy in Guangzhou, Guangdong Province, China, was reported to be under more than 34 days of hospitalization due to prolonged presence of viral RNA in stools after showing negative in respiratory samples. Actually, this phenomenon is not rare among pediatric patients. 27 Xiao and colleagues demonstrated that about a quarter of COVID-19 patients had SARS-CoV-2 RNA detectable in feces after viral clearance in respiratory tract. 25 However, the researchers did not discuss whether persistent shedding of SARS-CoV-2 was more common in certain age group than the others (patient's ages ranged from 10 months to 78 years in this study). Therefore, discharged patients might be a potential source of transmission and follow-up after hospital discharge or discontinuation of quarantine is advisable.

In The limitations of this study should also be noted. In response to the emerging disease, only respiratory specimens were required for the detection of SARS-CoV-2 according to clinical guidelines in the early stage of COVID-19 outbreak. We therefore failed to obtain stool samples from the patients during their first few days of hospitalization and could not determine whether throat swabs and fecal samples showed positive on RT-PCR analysis simultaneously. Moreover, we did not culture the virus isolated from the feces to test the viability nor measure viral loads in the samples due to limited conditions. 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. testing on fecal specimens should be added to the current criteria for hospital discharge and release of isolation. We call for multi-center studies with larger sample size to clarify the time lag between fecal and respiratory specimens negative for RNA RT-PCR analysis in infected children.

We reported to the local health authority immediately once we noticed the persistent 

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None reported. 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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 doi: medRxiv preprint

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

We thank Municipal Centre of Disease Control and Prevention of Qingdao for coordinating data collection for COVID-19 patients in Qingdao. We thank all patients and their families involved in the study. We thank all health-care workers involved in the diagnosis and treatment of patients. And we thank Prof Gary WK Wong for guidance in study design and interpretation of results.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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 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 March 13, 2020. . https://doi.org/10.1101/2020.03.11.20033159 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. ↓ denotes levels below the 1st percentile lower reference limit; NA= not available.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.