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Prevalence of SARS-CoV-2 Infection in Children and Their Parents in Southwest Germany

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Key Points

Question  What is the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the seroprevalence of SARS-CoV-2 antibodies in children aged 1 to 10 years and a corresponding parent in a population-based sample in southwest Germany?

Findings  This large-scale, multicenter, cross-sectional investigation of 4964 participants accurately determined anti–SARS-CoV-2 seropositivity by combining the results of enzyme-linked immunosorbent assay and immunofluorescence tests. The estimated SARS-CoV-2 seroprevalence was low in parents (1.8%) and 3-fold lower in children (0.6%).

Meaning  The low seroprevalence of SARS-CoV-2 antibodies in young children in this study may indicate that they do not play a key role in SARS-CoV-2 spreading during the current pandemic.

Abstract

Importance  School and daycare closures were enforced as measures to confine the novel coronavirus disease 2019 (COVID-19) pandemic, based on the assumption that young children may play a key role in severe acute respiratory coronavirus 2 (SARS-CoV-2) spread. Given the grave consequences of contact restrictions for children, a better understanding of their contribution to the COVID-19 pandemic is of great importance.

Objective  To describe the rate of SARS-CoV-2 infections and the seroprevalence of SARS-CoV-2 antibodies in children aged 1 to 10 years, compared with a corresponding parent of each child, in a population-based sample.

Design, Setting, and Participants  This large-scale, multicenter, cross-sectional investigation (the COVID-19 BaWü study) enrolled children aged 1 to 10 years and a corresponding parent between April 22 and May 15, 2020, in southwest Germany.

Exposures  Potential exposure to SARS-CoV-2.

Main Outcomes and Measures  The main outcomes were infection and seroprevalence of SARS-CoV-2. Participants were tested for SARS-CoV-2 RNA from nasopharyngeal swabs by reverse transcription–polymerase chain reaction and SARS-CoV-2 specific IgG antibodies in serum by enzyme-linked immunosorbent assays and immunofluorescence tests. Discordant results were clarified by electrochemiluminescence immunoassays, a second enzyme-linked immunosorbent assay, or an in-house Luminex-based assay.

Results  This study included 4964 participants: 2482 children (median age, 6 [range, 1-10] years; 1265 boys [51.0%]) and 2482 parents (median age, 40 [range, 23-66] years; 615 men [24.8%]). Two participants (0.04%) tested positive for SARS-CoV-2 RNA. The estimated SARS-CoV-2 seroprevalence was low in parents (1.8% [95% CI, 1.2–2.4%]) and 3-fold lower in children (0.6% [95% CI, 0.3-1.0%]). Among 56 families with at least 1 child or parent with seropositivity, the combination of a parent with seropositivity and a corresponding child with seronegativity was 4.3 (95% CI, 1.19-15.52) times higher than the combination of a parent who was seronegative and a corresponding child with seropositivity. We observed virus-neutralizing activity for 66 of 70 IgG-positive serum samples (94.3%).

Conclusions and Relevance  In this cross-sectional study, the spread of SARS-CoV-2 infection during a period of lockdown in southwest Germany was particularly low in children aged 1 to 10 years. Accordingly, it is unlikely that children have boosted the pandemic. This SARS-CoV-2 prevalence study, which appears to be the largest focusing on children, is instructive for how ad hoc mass testing provides the basis for rational political decision-making in a pandemic.

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Article Information

Accepted for Publication: December 2, 2020.

Published Online: January 22, 2021. doi:10.1001/jamapediatrics.2021.0001

Corresponding Author: Burkhard Tönshoff, MD, Department of Pediatrics I, University Children’s Hospital, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany (burkhard.toenshoff@med.uni-heidelberg.de) and Klaus-Michael Debatin, MD, Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Eythstraße 24, D-89075 Ulm, Germany (klaus-michael.debatin@uniklinik-ulm.de).

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Tönshoff B et al. JAMA Pediatrics.

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

Concept and design: Tönshoff, Renk, Meissner, Jeltsch, Euler, Zernickel, Wölfle, Handgretinger, Engel, Kern, Hoffmann, Franz, Henneke, Debatin, Kräusslich.

Acquisition, analysis, or interpretation of data: Tönshoff, Mueller, Elling, Renk, Meissner, Hengel, Garbade, Kieser, Jeltsch, Grulich-Henn, Euler, Stich, Chobanyan-Jürgens, Janda, Wölfle, Stamminger, Iftner, Ganzenmueller, Schmitt, Görne, Laketa, Olberg, Plaszczyca, Cortese, Pape, Remme, Huzly, Panning, Weigang, Giese, Ciminski, Ankerhold, Kochs, Schwemmle, Niemeyer, Engel, Kern, Hoffmann, Franz, Henneke, Debatin, Kräusslich, Bartenschlager.

Drafting of the manuscript: Tönshoff, Elling, Renk, Hengel, Garbade, Kieser, Iftner, Ganzenmueller, Laketa, Plaszczyca, Cortese, Huzly, Panning, Schwemmle, Henneke, Debatin, Kräusslich.

Critical revision of the manuscript for important intellectual content: Tönshoff, Mueller, Elling, Renk, Meissner, Hengel, Garbade, Kieser, Jeltsch, Grulich-Henn, Euler, Stich, Chobanyan-Jürgens, Zernickel, Janda, Wölfle, Stamminger, Iftner, Ganzenmueller, Schmitt, Görne, Olberg, Plaszczyca, Pape, Remme, Huzly, Panning, Weigang, Giese, Ciminski, Ankerhold, Kochs, Schwemmle, Handgretinger, Niemeyer, Engel, Kern, Hoffmann, Franz, Henneke, Debatin, Bartenschlager.

Statistical analysis: Elling, Garbade, Kieser, Schmitt, Olberg, Pape, Remme.

Obtained funding: Hengel, Chobanyan-Jürgens, Iftner, Schwemmle, Niemeyer, Hoffmann, Henneke, Debatin, Kräusslich.

Administrative, technical, or material support: Tönshoff, Mueller, Elling, Renk, Meissner, Hengel, Garbade, Jeltsch, Grulich-Henn, Euler, Stich, Chobanyan-Jürgens, Zernickel, Janda, Wölfle, Stamminger, Iftner, Ganzenmueller, Schmitt, Laketa, Plaszczyca, Cortese, Huzly, Panning, Kochs, Schwemmle, Niemeyer, Hoffmann, Franz, Henneke, Kräusslich, Bartenschlager.

Supervision: Tönshoff, Mueller, Renk, Meissner, Hengel, Garbade, Jeltsch, Wölfle, Iftner, Ganzenmueller, Huzly, Panning, Kochs, Schwemmle, Handgretinger, Niemeyer, Engel, Kern, Hoffmann, Franz, Henneke, Debatin, Kräusslich.

Conflict of Interest Disclosures: Dr Tönshoff, Elling, Renk, Stich, Janda, Stamminger, Ganzenmueller, Engel, Hoffmann, Franz, Debatin, and Kräusslich reported grants from Ministry of Science, Research, and Art Baden-Württemberg during the conduct of the study. Dr Wölfle reported grants from the Ministry of Science, Research and Art Baden-Württemberg to her institution during the conduct of the study. Dr Mueller reported grants from the Ministry of Science, Research and Art Baden-Württemberg Department of Infectious Diseases, Virology, and University Hospital Heidelberg during the conduct of the study. Dr Plaszczyca reported grants from Deutsche Forschungsgemeinschaft (German Research Foundation; project 240245660–SFB 1129) and German Center for Infection Research (project 8029801806) during the conduct of the study. Dr Cortese reported grants from Deutsche Forschungsgemeinschaft (project 240245660–SFB 1129) and German Center for Infection Research (project 8029801806) during the conduct of the study. Dr Kern reported grants from Gilead, ViiV, Pfizer, Merck Sharp & Dohme, and Cellectis outside the submitted work. Dr Henneke reported grants from the State of Baden Württemberg during the conduct of the study and grants from German Research Council, the German Ministry of Education and Sciences, and the Else-Kröner Research Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: The COVID-19 BaWü study was funded by the Ministry of Science, Research and Art Baden-Württemberg within the framework of the special funding line for coronavirus disease 2019 research.

Role of the Funder/Sponsor: The funder 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.

Additional Information: Drs Hoffmann, Franz, Hennecke, Debatin, and Kräusslich were equal principal investigators and Drs Tönshoff, Müller, Elling, Renk, and Meissner were equal acting investigators in this multicenter study.

Additional Contributions: We are especially indebted to all families who participated in this study. The engagement and great motivation of the staff of the participating University Children’s Hospitals, working 7 days per week to execute the study timely and quickly, and similarly of the staff in the 2 testing laboratories in Freiburg and Heidelberg, have been extraordinary and require special recognition. Fred Hamprecht, PhD, Heidelberg Collaboratory for Image Processing, Interdisciplinary Centre for Scientific Computing, Heidelberg University, Anna Kreshuk, PhD, European Molecular Biology Laboratory, Heidelberg, and Tim Waterboer, PhD, Deutsches Krebsforschungszentrum, and their groups very generously provided resources and advice. We thank Maria Anders Össwein, MSc, Stephanie Ullrich, PhD, Stefanie Wolf, PhD, Ira Pistorius Knopf, PhD, Paul Schnitzler, PhD, Kathleen Börner, PhD, Anke-Mareil Heuser, PhD, Department of Infectious Diseases, Virology, Heidelberg University, and Markus Zorn, PhD, Central Laboratory, University Hospital Heidelberg, for support in serological and polymerase chain reaction analyses. We thank Myriam Scherer, PhD, Anna Reichel, PhD, and Eva-Maria Schilling, PhD, Institute of Virology, Ulm University, and Angelika Iftner, Institute for Medical Virology, University Hospital of Tübingen, for their help with polymerase chain reaction analysis. We thank Annette Ulbrich, Iris Schelleter, and Heike Matzkuhn, University Children's Hospital Heidelberg, Bernadette Bächle, Bianca Rippberger, and Simone Hock, Center for Pediatrics and Adolescent Medicine, University Medical Center and Faculty of Medicine Freiburg, Jonathan Remppis, MD, Sarah Johler, MD, University Children’s Hospital Tübingen, and Monika Weiß, Centre for Paediatric Clinical Studies at the University Children’s Hospital Tübingen, and all the participating recruiting physicians and nurses for their excellent support. We are grateful to the HILDA-Biobank, in particular Ali-Riza Kaya, Marco Teller and Dirk Lebrecht, PhD. We very much acknowledge the important organizational work of Anneke Haddad, PhD, Susanne Grüninger, Sylvia Rathmann, PhD, Centre for Clinical Studies Freiburg, Sandra Schickinger, Aileen Heselich, and Tara Marianna Ziegelbauer, Center for Pediatrics and Adolescent Medicine, University Medical Center and Faculty of Medicine Freiburg. We are grateful for the statistical advice of Harald Binder, PhD, Department for Biometry, Epidemiology and Medical Bioinformatics, University of Freiburg. Many thanks to Valeria Falcone, PhD, Institute of Virology, University Medical Centre and Faculty of Medicine, University of Freiburg, for coordinating and reading of the serological tests in Freiburg. None of them received compensation.

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