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Susceptibility to SARS-CoV-2 Infection Among Children and Adolescents Compared With AdultsA Systematic Review and Meta-analysis

Educational Objective To systematically review the susceptibility to and transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children and adolescents compared with adults.
1 Credit CME
Key Points

Question  What is the evidence on the susceptibility to and transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among children and adolescents compared with adults?

Findings  In this systematic review and meta-analysis including 32 studies, children and adolescents younger than 20 years had 44% lower odds of secondary infection with SARS-CoV-2 compared with adults 20 years and older; this finding was most marked in those younger than 10 to 14 years. Data were insufficient to conclude whether transmission of SARS-CoV-2 by children is lower than by adults.

Meaning  Preliminary evidence suggests that children have a lower susceptibility to SARS-CoV-2 infection compared with adults, but the role that children and adolescents play in transmission of this virus remains unclear.


Importance  The degree to which children and adolescents are infected by and transmit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. The role of children and adolescents in transmission of SARS-CoV-2 is dependent on susceptibility, symptoms, viral load, social contact patterns, and behavior.

Objective  To systematically review the susceptibility to and transmission of SARS-CoV-2 among children and adolescents compared with adults.

Data Sources  PubMed and medRxiv were searched from database inception to July 28, 2020, and a total of 13 926 studies were identified, with additional studies identified through hand searching of cited references and professional contacts.

Study Selection  Studies that provided data on the prevalence of SARS-CoV-2 in children and adolescents (younger than 20 years) compared with adults (20 years and older) derived from contact tracing or population screening were included. Single-household studies were excluded.

Data Extraction and Synthesis  PRISMA guidelines for abstracting data were followed, which was performed independently by 2 reviewers. Quality was assessed using a critical appraisal checklist for prevalence studies. Random-effects meta-analysis was undertaken.

Main Outcomes and Measures  Secondary infection rate (contact-tracing studies) or prevalence or seroprevalence (population screening studies) among children and adolescents compared with adults.

Results  A total of 32 studies comprising 41 640 children and adolescents and 268 945 adults met inclusion criteria, including 18 contact-tracing studies and 14 population screening studies. The pooled odds ratio of being an infected contact in children compared with adults was 0.56 (95% CI, 0.37-0.85), with substantial heterogeneity (I2 = 94.6%). Three school-based contact-tracing studies found minimal transmission from child or teacher index cases. Findings from population screening studies were heterogenous and were not suitable for meta-analysis. Most studies were consistent with lower seroprevalence in children compared with adults, although seroprevalence in adolescents appeared similar to adults.

Conclusions and Relevance  In this meta-analysis, there is preliminary evidence that children and adolescents have lower susceptibility to SARS-CoV-2, with an odds ratio of 0.56 for being an infected contact compared with adults. There is weak evidence that children and adolescents play a lesser role than adults in transmission of SARS-CoV-2 at a population level. This study provides no information on the infectivity of children.

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Article Information

Accepted for Publication: August 23, 2020.

Published Online: September 25, 2020. doi:10.1001/jamapediatrics.2020.4573

Correction: This article was corrected on November 2, 2020, to add the Funding/Support and Role of the Funder/Sponsor sections and fix the degree for Jasmina Panovska-Griffiths.

Corresponding Author: Russell M. Viner, PhD, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London WC1N 1EH, United Kingdom (r.viner@ucl.ac.uk).

Author Contributions: Dr Viner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Viner, Bonell, Hudson, Eggo.

Acquisition, analysis, or interpretation of data: Viner, Mytton, Bonell, Melendez-Torres, Ward, Waddington, Thomas, Russell, van der Klis, Koirala, Ladhani, Panovska-Griffiths, Davies, Booy, Eggo.

Drafting of the manuscript: Viner, Mytton, Bonell, Melendez-Torres, Waddington, Thomas, Eggo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Viner, Melendez-Torres, Waddington, Thomas, Russell, Booy, Eggo.

Administrative, technical, or material support: Viner, Mytton, Waddington, Koirala.

Study supervision: Viner, Bonell, Eggo.

Conflict of Interest Disclosures: Dr Mytton has received grants from the National Institute of Health Research and personal fees from Public Health England. No other disclosures were reported.

Funding/Support: Dr Eggo was supported by grant MR/S003975/1 from Health Data Research UK and grant MC_PC 19065 from the Medical Research Council.

Role of the Funder/Sponsor: 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.

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