Symptomatic and Asymptomatic Viral Shedding in Pediatric Patients Infected With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)

Abstract

Since the global emergence and spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), initial attention appropriately focused on severely affected adults, who represent the highest proportion of symptomatic infections. 1 However, as the pandemic has evolved, a significant effect on children has also become evident. 2 Data from multiple affected countries have corroborated that children are clearly susceptible to infection and may develop severe primary and unique secondary inflammatory complications of infection, including multisystem inflammatory syndrome of children. 3-5 However, the vast majority of infected children have mild or unrecognized disease, and this population may play important epidemiologic roles by potentiating spread of infection through communities 6 and/or boosting herd immunity. Only small numbers of children have been included in prior studies focused on kinetics of viral shedding in the setting of symptomatic or asymptomatic SARS-CoV-2 infection. 7-12 To our knowledge, no prior studies have systematically focused on the frequency of asymptomatic infection in children or the duration of symptoms and viral shedding in both asymptomatic and symptomatic children. Han and colleagues 13 provide data accumulated from 22 centers throughout South Korea that address this important knowledge gap. The unique structure of the South Korean public health system facilitated large-scale testing, aggressive contact tracing and testing, and isolation/direct observation of asymptomatic or mildly symptomatic children in designated health care facilities (rather than home quarantine). This structure allowed for the sequential observation, testing (median testing interval of every 3 days), and comparison of 91 asymptomatic, presymptomatic, and symptomatic children with mild to moderate upper and lower respiratory tract infection, identified primarily by contact tracing from laboratory-proven cases. The first important take-home point from this study is that not all infected children have symptoms, and even those with symptoms are not necessarily recognized in a timely fashion. A major strength of this study is the inclusion of asymptomatic children (20 of 91 [22%]), presymptomatic children (18 of 91 [20%]), and symptomatic children (53 of 91 [58%]). 13 Most symptomatic infected children had experienced symptoms a median (range) of 3 (1-28) days prior to being diagnosed by test

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