Pediatric COVID-19 and Community Spread: A Conversation with MGH researchers

Note: This video transcript has been edited for length and clarity.

KG: My name is Katharine Grant and I'm a communications coordinator at Mass General for Children. I'm here with Dr. Alessio Fasano, chief of the Division of Pediatric Gastroenterology and Nutrition at MGfC, and Dr. Lael Yonker, director of the Cystic Fibrosis Center at MGfC. The two pediatricians are lead authors with 28 other contributors on groundbreaking research into COVID-19 and children. Their study, "Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses" has just been published in the Journal of Pediatrics. So Dr. Fasano, can you start out by telling us, are children immune from or protected against the virus that causes COVID-19 and what do your findings tell us about children and community spread of COVID-19?

AF: Our findings, in a nutshell, suggest that kids like adults are susceptible to the infection. They can have the virus infecting the upper airways and therefore they are capable of eventually  spreading the virus around. This is possible even if they typically develop symptoms that seem to be milder than adults or no symptoms at all.

KG: And Dr. Yonker, how does COVID-19 present differently in pediatric versus adult cases and why does this make COVID-19 more difficult to diagnose in children?

LY: Kids generally develop significantly milder symptoms following SARS-CoV-2 infection and it has a lot of overlap with common colds or mild asthma exacerbation. Kids generally present with congestion, maybe a mild cough, maybe a fever, but some kids are asymptomatic. Only fifty percent of kids we found actually develop fever from SARS-CoV-2 infection, and so there's no real diagnostic criteria for an acute infection. It's really very mild symptoms. We found kids are more likely to have a lack of sense of smell, but kids aren't really good at articulating this. Younger kids especially wouldn't necessarily be good at articulating a lack of sense of smell. Also, we found that it may be that kids with COVID-19 are more likely to have a sore throat, but the numbers are really high in kids who don't have COVID-19 as well. So there's a lot of overlap with kids. This means it’s hard to identify as opposed to adults, who really develop much more significant respiratory symptoms and the classic fever, congestion, fatigue, shortness of breath, etc. The presentation is much more dramatic in the adults, while milder and harder to characterize in kids.

KG: Thank you. And Dr. Yonker, your work found high viral loads in children of all ages. Can you please explain what this means in terms of transmissibility and why this surprised you?

LY: Sure. The higher the viral load, especially in respiratory secretions, generally with all other viruses correlates with increased transmissibility. So if you have a lot of virus in your airways and secretions, you're more likely to spread those to others. What surprised us is when you think of a hospital and all of the COVID-19 patients that were in the hospital, you would see caregivers and providers with masks on, N-95 face shields, real full-body coverings and we found that kids have significantly higher viral loads than these hospitalized patients. And these kids are walking around feeling pretty well, maybe some mild symptoms, but it definitely raises concern for the potential for transmissibility from these kids into the community.

KG: Right. So turning to Dr. Fasano, how do these findings contribute to the current discussion on reopening schools safely? And if you could have a conversation with national and local policy makers about the safe reopening of schools and daycares what would you tell them?

AF: School reopening is a subject of discussion that is very pertinent nowadays because there are different opinions, of course, on what to do when the time comes for schools to be reopened.

And then again, legislators and policymakers are engaged in this kind of discussion based on assumptions that are not entirely scientifically proven (i.e. the idea that kids will not be involved in SARS-CoV-2 infections and therefore they are safe to go to schools with no problems.) This paper suggests otherwise. It suggests that we need to really be careful when it comes to creating policies for local schools. Infection in kids can be stealthy. They can have the infection and not be symptomatic or they have no specific symptoms, like Dr. Yonker just told us. Therefore, you can't really know beforehand who carries the virus and who does not. And carrying the virus means that they can potentially spread the virus to other kids or operators in the school (the teachers, administrators, etc.) who can in turn bring this back home. The major price will always be paid by the low socioeconomic part of the society, because these are often multi-generation family households in which all the people at home, grandparents and so on, can eventually be susceptible to be infected when these kids get back home. So the question is, should we reopen the schools? And if we do, under which kind of circumstances?

Again, working on the premise that kids are not a problem will be a major mistake. If we need to open the school, we need to really be aware of what kind of environment we are talking about. Is this an environment in which the attack rate is resurging and therefore we need to be extremely careful? If that's the case, there are policies that need to be considered to try to minimize the risk of spreading the virus: decreasing the density in the classroom, maintaining physical distance, wearing a mask when possible (particularly the older kids), hand hygiene, keeping the kids in the same classroom and having the teachers rotate, having lunch break in the classroom and not the cafeterias with larger congregations, and utilizing a mixed model of in-person and remote teaching. If these factors are not considered, there is the possibility of creating the situation of a second wave that would be disastrous for everybody. It would be disastrous for the economy, the well-being of people, and most importantly because of the morbidity and mortality shown by this virus that we previously believed to only affect the elderly. Now the age has gotten younger and younger. And the reason why is because younger people may be less prone to implement these policies to decrease the spread of the virus. And now with the school reopening, we'll put kids into the mix which may create a situation that will prolong this pandemic.

KG: Thank you, Dr. Fasano. So Dr. Yonker, as pediatricians at MGfC, you and Dr. Fasano have been fielding a lot of questions about COVID-19 and children. What are your recommendations to parents who ask you about sending their kids back to school and daycare?

LY: We have been getting this question a lot. Every single parent has this question and it's a good question. I don't think that there is a straightforward answer for every school and every family, but I think that it really depends on the safety precautions of the school or the daycare facility. What we've shown is that there's no age restriction. There's no age that is less likely to carry high viral loads, so all of these considerations that are generally recommended (masks, social distancing, remote learning, frequent nasal swabs or screening) have to take place for all the age ranges. These sorts of things will have to be implemented in a way that makes sense for the school and for the children. I definitely think it depends on what safety precautions are in place so that the family can feel as though they can send their child safely back to school. And also not just for the safety of the child, but for the safety of the family. Whatever the child is exposed to they're going to bring it back into their house and the pandemic is going to continue. So we need to find ways to mitigate the spread through the children.

KG: Thank you, Dr. Yonker. And finally to Dr. Fasano, what are the next steps for this collaborative research team into the immune response in pediatric COVID-19?

AF: To answer a specific biological question you need the big numbers. Dr. Yonker has been capable of building this biobank (one of the largest that we have in the nation) of kids that have been exposed to SARS-CoV-2. And that will allow us to answer specific questions. For example, why do kids develop milder symptoms than adults? Why do kids not have the lower airway involvement like adults? We know that many of the casualties so far have been related to the fact that the virus can infect the lower airways and you can develop a very severe pneumonia, require ventilation, and so on. Why does this not happen in kids? There is a false sense of safety for kids-- the mortality rate in kids is a fraction of the rate in adults, but we need to be aware that there can be severe consequences in kids, like the multi-system inflammatory syndrome in children (MIS-C). We have seen cases of these kids that can really have severe consequences. And speaking of severe consequences, infection can cause other long-term consequences that can affect other organs like the heart and the kidney, even in infections with milder symptoms. These are all questions that we can answer once we will have the critical mass of data. We will continue to recruit patients to tackle this matter and seek answers. Regarding the vaccine, there has been a lot of discussion about efficacy, other remedies that need to be in the pipeline, and so on. These are questions that we intend to answer with our team in attempts to really mitigate this pandemic, while at the same time trying to develop strategies to ameliorate the possibility of long-term consequences in pediatrics.

KG: Thank you Dr. Fasano and Dr. Yonker. This study is available here: https://doi.org/10.1016/j.jpeds.2020.08.037