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Coronavirus (COVID-19)

Clinical Characteristics and Viral RNA Detection in Children With Coronavirus Disease 2019 in the Republic of Korea

Educational Objective To analyze the full clinical course and the duration of severe acute respiratory syndrome coronavirus 2 RNA detectability in children confirmed with coronavirus disease 2019 (COVID-19) in the Republic of Korea, where rigorous public health interventions have been implemented.
1 Credit CME
JAMA Pediatrics
Published Online: August 28, 2020
Original Investigation
Mi Seon Han, MD, PhD1;
Eun Hwa Choi, MD, PhD2;
Sung Hee Chang, MD3;
Byoung-Lo Jin, MD4;
Eun Joo Lee, MD5;
Baek Nam Kim, MD6;
Min Kyoung Kim, MD7;
Kihyun Doo, MD8;
Ju-Hee Seo, MD, PhD9;
Yae-Jean Kim, MD, PhD10;
Yeo Jin Kim, MD11;
Ji Young Park, MD, PhD12;
Sun Bok Suh, MD, PhD13;
Hyunju Lee, MD, PhD14;
Eun Young Cho, MD15;
Dong Hyun Kim, MD16;
Jong Min Kim, MD17;
Hye Young Kim, MD, PhD18;
Su Eun Park, MD, PhD19;
Joon Kee Lee, MD, PhD20;
Dae Sun Jo, MD, PhD21;
Seung-Man Cho, MD22;
Jae Hong Choi, MD23;
Kyo Jin Jo, MD19;
Young June Choe, MD, PhD24;
Ki Hwan Kim, MD25;
Jong-Hyun Kim, MD, PhD26
Author Affiliations
  • 1Department of Pediatrics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
  • 2Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
  • 3Department of Pediatrics, Seoul Medical Center, Seoul, Korea
  • 4Department of Pediatrics, Hongseong Medical Center, Hongseong, Korea
  • 5Department of Pediatrics, Seongnam Citizens Medical Center, Seongnam, Korea
  • 6Department of Pediatrics, Gyeonggi Provincial Medical Center Ansung Hospital, Ansung, Korea
  • 7Department of Pediatrics, Seonam Hospital, Seoul, Korea
  • 8Department of Pediatrics, Gyeonggi Provincial Medical Center Icheon Hospital, Icheon, Korea
  • 9Department of Pediatrics, Dankook University Hospital, Cheonan, Korea
  • 10Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 11Department of Pediatrics, Masan Medical Center, Changwon, Korea
  • 12Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
  • 13Department of Pediatrics, Busan Medical Center, Busan, Korea
  • 14Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
  • 15Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
  • 16Department of Pediatrics, Inha University Hospital, Incheon, Korea
  • 17Department of Pediatrics, Myongji Hospital, Goyang, Korea
  • 18Department of Pediatrics, Pusan National University Hospital, Busan, Korea
  • 19Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
  • 20Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Korea
  • 21Department of Pediatrics, Jeonbuk National University Medical School, Jeonju, Korea
  • 22Department of Pediatrics, Dongguk University College of Medicine, Gyeongju, Korea
  • 23Department of Pediatrics, Jeju National University Hospital, Jeju, Korea
  • 24Department of Social and Preventive Medicine, Hallym University College of Medicine, Chuncheon, Korea
  • 25Department of Pediatrics, Incheon St Mary's Hospital, The Catholic University of Korea, Incheon, Korea
  • 26Department of Pediatrics, St Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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Key Points

Question  How long is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA detected in children, and are children with coronavirus disease 2019 (COVID-19) identifiable by symptoms?

Findings  In this case series of 91 children with COVID-19 in Korea, 22.0% were asymptomatic. Only 8.5% of symptomatic cases were diagnosed at the time of symptom onset, while 66.2% had unrecognized symptoms before diagnosis and 25.4% developed symptoms after diagnosis; SARS-CoV-2 RNA was detected for a mean of 17.6 days overall and 14.1 days in asymptomatic cases.

Meaning  Symptom screening fails to identify most COVID-19 cases in children, and SARS-CoV-2 RNA in children is detected for an unexpectedly long time.

Abstract

Importance  There is limited information describing the full spectrum of coronavirus disease 2019 (COVID-19) and the duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA detection in children.

Objective  To analyze the full clinical course and the duration of SARS-CoV-2 RNA detectability in children confirmed with COVID-19 in the Republic of Korea, where rigorous public health interventions have been implemented.

Design, Setting, and Participants  This case series of children with COVID-19 was conducted in 20 hospitals and 2 nonhospital isolation facilities across the country from February 18, 2020, to March 31, 2020. Children younger than 19 years who had COVID-19 were included.

Exposures  Confirmed COVID-19, detected via SARS-CoV-2 RNA in a combined nasopharyngeal and oropharyngeal swab or sputum by real-time reverse transcription–polymerase chain reaction.

Main Outcomes and Measures  Clinical manifestations during the observation period, including the time and duration of symptom occurrence. The duration of SARS-CoV-2 RNA detection was also analyzed.

Results  A total of 91 children with COVID-19 were included (median [range] age, 11 [0-18] years; 53 boys [58%]). Twenty children (22%) were asymptomatic during the entire observation period. Among 71 symptomatic cases, 47 children (66%) had unrecognized symptoms before diagnosis, 18 (25%) developed symptoms after diagnosis, and only 6 (9%) were diagnosed at the time of symptom onset. Twenty-two children (24%) had lower respiratory tract infections. The mean (SD) duration of the presence of SARS-CoV-2 RNA in upper respiratory samples was 17.6 (6.7) days. Virus RNA was detected for a mean (SD) of 14.1 (7.7) days in asymptomatic individuals. There was no difference in the duration of virus RNA detection between children with upper respiratory tract infections and lower respiratory tract infections (mean [SD], 18.7 [5.8] days vs 19.9 [5.6] days; P = .54). Fourteen children (15%) were treated with lopinavir-ritonavir and/or hydroxychloroquine. All recovered, without any fatal cases.

Conclusions and Relevance  In this case series study, inapparent infections in children may have been associated with silent COVID-19 transmission in the community. Heightened surveillance using laboratory screening will allow detection in children with unrecognized SARS-CoV-2 infection.

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Global Health Infectious Diseases Pediatrics Coronavirus (COVID-19)
Article Information

Accepted for Publication: June 17, 2020.

Corresponding Authors: Jong-Hyun Kim, MD, PhD, Department of Pediatrics, St Vincent's Hospital, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, Korea, 16247 (jh00mn@catholic.ac.kr); Eun Hwa Choi, MD, PhD, Department of Pediatrics, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Korea, 03080 (eunchoi@snu.ac.kr).

Published Online: August 28, 2020. doi:10.1001/jamapediatrics.2020.3988

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Han MS et al. JAMA Pediatrics.

Author Contributions: Drs Han and Choi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Han, E. Choi, Jong-Hyun Kim.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Han, E. Choi, S. Park, Choe.

Critical revision of the manuscript for important intellectual content: Han, E. Choi, Chang, Jin, E. Lee, B. Kim, M. Kim, Doo, Seo, Yae-Jean Kim, Yeo Jin Kim, J. Park, Suh, H. Lee, E. Cho, D. Kim, Jong Min Kim, H. Kim, J. Lee, D. Jo, S. Cho, J. Choi, K. Jo, Choe, K. Kim, Jong-Hyun Kim.

Statistical analysis: Han, Choe.

Administrative, technical, or material support: Han, E. Choi, Chang, Jin, E. Lee, B. Kim, M. Kim, Doo, Seo, Yae-Jean Kim, Yeo Jin Kim, J. Park, Suh, H. Lee, E. Cho, D. Kim, Jong Min Kim, H. Kim, S. Park, J. Lee, D. Jo, S. Cho, J. Choi, K. Jo, K. Kim, Jong-Hyun Kim.

Supervision: E. Choi, Jong-Hyun Kim.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank all the medical staff at hospitals, city and provincial medical centers, and community facilities for their dedication to provide care for COVID-19; staff at the local health departments for their dedication; members of the Korean Society of Pediatric Infectious Diseases for their valuable advice on the management of COVID-19 cases; and staff at the Korea Centers for Disease Control and Prevention for their tireless efforts to combat this public health emergency.

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