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Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses

Massachusetts General Hospital


Asymptomatic carriers, including children, can spread infection and carry virus into their household


Potential role children play in the coronavirus infectious disease 2019 (COVID-19) pandemic

Factors that drive severe illness in children

Study design

0-22 years

With suspected infection

Presenting to urgent care clinics or being hospitalized

For confirmed/suspected SARS-CoV-2 infection

Or multisystem inflammatory syndrome in children (MIS-C)

Enrolled provided

Nasopharyngeal, oropharyngeal, and/or blood specimens

SARS-CoV-2 viral load


ACE2 RNA levels


192 children

Forty-nine children (26%) were diagnosed with acute SARS-CoV-2 infection

An additional 18 children (9%) met criteria for MIS-C

Nasopharyngeal viral load was highest in children in the first 2 days of symptoms

Some children carry very high viral loads even before symptoms develop

Viral load in respiratory secretions of children was high, despite mild or absent symptoms

Significantly higher than hospitalized adults with severe disease (P = .002)

Age of child / young person did not impact viral load

Younger children had lower ACE2 expression (P=0.004)

Source of children’s infection

Nine (18%) did not have a known infected household contact

26 (53%) attended grade school.


SARS-CoV-2 infection and non-COVID-19-related illnesses presented similarly

In the positive group

25 (51%) presented with fever

Cough 23, (47%)

Congestion 17 (35%)

Rhinorrhea 14, 29%)

Headache 13, 27%)

None of which were significantly different between the two groups

Significant difference

Anosmia 10, 20%

Sore throat 17, 35%

COVID – 19 symptom tracker app

Rash in up to 20% of cases


Children may be a potential source of contagion in the SARS-CoV-2 pandemic

Contradict previous reports, children to be less likely to be the index case within a household

Children with high viral loads and non-specific symptoms including rhinorrhea and cough can likely transmit SARS-CoV-2 as easily as other viral infections spread by respiratory particles

If schools were to re-open fully without necessary precautions, it is likely that children will play a larger role in this pandemic

Potential transmission between children and families should be considered when designing strategies to mitigate the pandemic

In spite of milder disease or lack of symptoms

Immune dysregulation is implicated in severe post-infectious MIS-C


ACE2 expression in the nasopharynx increases with age

Multisystem inflammatory syndrome (MIS-C)

IgM and IgG to the receptor binding domain spike protein were increased in severe MIS-C (P less than 0.001)

In severe MIS-C, more often a broadly elevated IgG response

To a multitude of respiratory viruses, including;

Other coronaviruses, 229E, NL63, HKU1, and OC43

Respiratory Syncytial Virus


Several weeks after possible SARS-CoV-2 infection or exposure

MIS-C presented more often with

Viral load the same as other infected children




Less often with symptoms of an upper respiratory tract infection

Criteria for COVID – 19 MIS-C
Fever more than 38oC for more than 24 hours

Laboratory evidence of inflammation

At least two organs involved

No alternative plausible diagnoses and a

Positive serology or antigen test

Exposure to an individual with COVID-19 within 4 weeks prior to the onset of symptoms
Severe cardiac complications, including hypotension, shock, and acute heart failure

Understanding post-infectious immune responses in pediatric is critical for designing treatment and prevention strategies



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