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Assessment of Pediatric Admissions for Kawasaki Disease or Infectious Disease During the COVID-19 State of Emergency in Japan

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
April 6, 2021
Original Investigation
Takuya Hara, MD1;
Kenji Furuno, MD, PhD1;
Kenichiro Yamamura, MD, PhD2;
Junji Kishimoto, PhD3;
Yumi Mizuno, MD, PhD1;
Kenji Murata, MD, PhD1;
Sagano Onoyama, MD, PhD4;
Ken Hatae, MD, PhD4;
Megumi Takemoto, MD, PhD5;
Yoshito Ishizaki, MD, PhD6;
Shunsuke Kanno, MD, PhD7;
Kazuo Sato, MD, PhD7;
Yoshitomo Motomura, MD, PhD8;
Yasunari Sakai, MD, PhD8;
Shouichi Ohga, MD, PhD8;
Mayumi Yashiro, BA9;
Yoshikazu Nakamura, MD, PhD9;
Toshiro Hara, MD, PhD1
Author Affiliations
  • 1Kawasaki Disease Center, Fukuoka Children’s Hospital, Kashiiteriha, Higashi-ku, Fukuoka, Japan
  • 2Department of Perinatal and Pediatric Medicine, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
  • 3Department of Research and Development of Next Generation Medicine, Faculty of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
  • 4Division of Pediatrics, Japanese Red Cross Fukuoka Hospital, Ookusu, Minami-Ku, Fukuoka, Japan
  • 5Division of Pediatrics, Hamanomachi Hospital, Nagahama, Chuo-ku, Fukuoka, Japan
  • 6Division of Pediatrics, National Hospital Organization Fukuokahigashi Medical Center, Chidori, Koga, Fukuoka, Japan
  • 7Division of Pediatrics, National Hospital Organization Kyushu Medical Center, Jigyohama, Chuo-ku, Fukuoka, Japan
  • 8Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
  • 9Department of Public Health, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
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Key Points

Question  Is Kawasaki disease (KD) associated with droplet- or contact-transmitted infection?

Findings  In this cross-sectional study of 17 235 pediatric patients, the number of admissions for KD showed no significant change (27.4% decrease) during quarantine owing to the COVID-19 pandemic, whereas there were significant decreases in numbers of hospital admissions for droplet-transmitted or contact-transmitted respiratory tract infections (75.3% decrease) and gastrointestinal infections (86.3% decrease). Thus, the ratio of KD admissions to admissions for these infections increased.

Meaning  These findings suggest that contact or droplet transmission is not a major route for KD development and that KD may be associated with airborne disease.

Abstract

Importance  The development of Kawasaki disease (KD) has been suggested to be associated with droplet- or contact-transmitted infection; however, its triggers and transmission modes remain to be determined. Under an epidemic of SARS-CoV-2, the COVID-19 state of emergency in Japan served as a nationwide social experiment to investigate the impact of quarantine or isolation on the incidence of KD.

Objective  To assess the role of droplet or contact transmission in the etiopathogenesis of KD.

Design, Setting, and Participants  This multicenter, longitudinal, cross-sectional study was conducted from 2015 to 2020 at Fukuoka Children’s Hospital and 5 adjacent general hospitals. The number of admissions for KD and infectious diseases were analyzed. Participants were pediatric patients admitted to the participating hospitals for KD or infectious diseases.

Exposures  Quarantine and isolation owing to the COVID-19 state of emergency.

Main Outcomes and Measures  The primary end points were the ratios of patients with KD to patients with respiratory tract or gastrointestinal infections admitted from April to May in 2015 to 2019 and 2020. A Poisson regression model was used to analyze them.

Results  The study participants included 1649 patients with KD (median [interquartile range] age, 25 [13-43] months; 901 boys [54.6%]) and 15 586 patients with infectious disease (data on age and sex were not available for these patients). The number of admissions for KD showed no significant change between April and May in 2015 to 2019 vs the same months in 2020 (mean [SD], 24.8 [5.6] vs 18.0 [4.0] admissions per month; 27.4% decrease; adjusted incidence rate ratio [aIRR], 0.73; 95% CI, 0.48-1.10; P = .12). However, the number of admissions for droplet-transmitted or contact-transmitted respiratory tract infections (mean [SD], 157.6 [14.4] vs 39.0 [15.0] admissions per month; 75.3% decrease; aIRR, 0.25; 95% CI, 0.17-0.35; P < .001) and gastrointestinal infections (mean [SD], 43.8 [12.9] vs 6.0 [2.0] admissions per month; 86.3% decrease; aIRR, 0.14; 95% CI, 0.04-0.43; P < .001) showed significant decreases between April and May in 2015 to 2019 vs the same months in 2020 (total, 12 254 infections). Thus, the ratio of KD to droplet- or contact-transmitted respiratory tract and gastrointestinal infections incidence in April and May 2020 was significantly increased (ratio, 0.40 vs 0.12; χ21 = 22.76; P < .001).

Conclusions and Relevance  In this study, the significantly increased incidence of KD compared with respiratory tract and gastrointestinal infections during the COVID-19 state of emergency suggests that contact or droplet transmission is not a major route for KD development and that KD may be associated with airborne infections in most cases.

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Cardiology Infectious Diseases Pediatrics Rheumatology Coronavirus (COVID-19)
Article Information

Accepted for Publication: February 10, 2021.

Published: April 6, 2021. doi:10.1001/jamanetworkopen.2021.4475

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

Correction: This article was corrected on May 26, 2021, to fix an error in the Discussion.

Corresponding Author: Toshiro Hara, MD, PhD, Kawasaki Disease Center, Fukuoka Children’s Hospital, 5-1-1, Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan (hara.t@fcho.jp).

Author Contributions: Drs Takuya Hara and Toshiro Hara 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: Furuno, Yamamura, Toshiro Hara.

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

Drafting of the manuscript: Takuya Hara, Furuno, Yamamura, Mizuno, Onoyama, Yashiro, Nakamura, Toshiro Hara.

Critical revision of the manuscript for important intellectual content: Takuya Hara, Furuno, Yamamura, Kishimoto, Murata, Hatae, Takemoto, Ishizaki, Kanno, Sato, Motomura, Sakai, Ohga, Toshiro Hara.

Statistical analysis: Takuya Hara, Furuno, Yamamura, Kishimoto.

Obtained funding: Mizuno, Toshiro Hara.

Administrative, technical, or material support: Furuno, Sato, Toshiro Hara.

Supervision: Furuno, Sakai, Ohga, Toshiro Hara.

Conflict of Interest Disclosures: Dr Sakai reported receiving grants from JSPS Kakenhi and grants from AMED during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by a Fukuoka Children’s Hospital Research Grant.

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 Contributions: We thank all the staff in Fukuoka Children’s Hospital Kawasaki Disease Center and 5 hospitals for the patient care. Ami Saitou, BSW (Fukuoka Children’s Hospital), helped collect the data and was not compensated beyond their normal salary. Katie Oakley, PhD, and Alison Sherwin, PhD (both from Edanz Group) edited a draft of this manuscript and were paid a fee.

References
1.
Kawasaki  T .  Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children [in Japanese].   Arerugi. 1967;16(3):178-222.PubMedGoogle Scholar
2.
McCrindle  BW , Rowley  AH , Newburger  JW ,  et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention.  Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association.   Circulation. 2017;135(17):e927-e999. doi:10.1161/CIR.0000000000000484PubMedGoogle ScholarCrossref
3.
Hara  T , Nakashima  Y , Sakai  Y , Nishio  H , Motomura  Y , Yamasaki  S .  Kawasaki disease: a matter of innate immunity.   Clin Exp Immunol. 2016;186(2):134-143. doi:10.1111/cei.12832PubMedGoogle ScholarCrossref
4.
Kim  KY , Kim  DS .  Recent advances in Kawasaki disease.   Yonsei Med J. 2016;57(1):15-21. doi:10.3349/ymj.2016.57.1.15PubMedGoogle ScholarCrossref
5.
Fujita  Y , Nakamura  Y , Sakata  K ,  et al.  Kawasaki disease in families.   Pediatrics. 1989;84(4):666-669.PubMedGoogle Scholar
6.
Kottek  A , Shimizu  C , Burns  JC .  Kawasaki disease in monozygotic twins.   Pediatr Infect Dis J. 2011;30(12):1114-1116. doi:10.1097/INF.0b013e31822ac4ffPubMedGoogle ScholarCrossref
7.
Uehara  R , Belay  ED .  Epidemiology of Kawasaki disease in Asia, Europe, and the United States.   J Epidemiol. 2012;22(2):79-85. doi:10.2188/jea.JE20110131PubMedGoogle ScholarCrossref
8.
Holman  RC , Christensen  KY , Belay  ED ,  et al.  Racial/ethnic differences in the incidence of Kawasaki syndrome among children in Hawaii.   Hawaii Med J. 2010;69(8):194-197.PubMedGoogle Scholar
9.
Lee  KY , Han  JW , Lee  JS .  Kawasaki disease may be a hyperimmune reaction of genetically susceptible children to variants of normal environmental flora.   Med Hypotheses. 2007;69(3):642-651. doi:10.1016/j.mehy.2006.12.051PubMedGoogle ScholarCrossref
10.
Onouchi  Y .  The genetics of Kawasaki disease.   Int J Rheum Dis. 2018;21(1):26-30. doi:10.1111/1756-185X.13218PubMedGoogle ScholarCrossref
11.
Xie  X , Shi  X , Liu  M .  The roles of genetic factors in Kawasaki disease: a systematic review and meta-analysis of genetic association studies.   Pediatr Cardiol. 2018;39(2):207-225. doi:10.1007/s00246-017-1760-0PubMedGoogle ScholarCrossref
12.
Nakamura  A , Ikeda  K , Hamaoka  K .  Aetiological significance of infectious stimuli in Kawasaki disease.   Front Pediatr. 2019;7:244. doi:10.3389/fped.2019.00244PubMedGoogle ScholarCrossref
13.
Okano  M , Thiele  GM , Sakiyama  Y , Matsumoto  S , Purtilo  DT .  Adenovirus infection in patients with Kawasaki disease.   J Med Virol. 1990;32(1):53-57. doi:10.1002/jmv.1890320109PubMedGoogle ScholarCrossref
14.
Esper  F , Shapiro  ED , Weibel  C , Ferguson  D , Landry  ML , Kahn  JS .  Association between a novel human coronavirus and Kawasaki disease.   J Infect Dis. 2005;191(4):499-502. doi:10.1086/428291PubMedGoogle ScholarCrossref
15.
Furuse  Y , Ko  YK , Saito  M ,  et al; National Task Force for COVID-19 Outbreak in Japan.  Epidemiology of COVID-19 outbreak in Japan, from January-March 2020.   Jpn J Infect Dis. 2020;73(5):391-393. doi:10.7883/yoken.JJID.2020.271PubMedGoogle ScholarCrossref
16.
Jordan-Villegas  A , Chang  ML , Ramilo  O , Mejías  A .  Concomitant respiratory viral infections in children with Kawasaki disease.   Pediatr Infect Dis J. 2010;29(8):770-772. doi:10.1097/INF.0b013e3181dba70bPubMedGoogle ScholarCrossref
17.
Shike  H , Shimizu  C , Kanegaye  JT ,  et al.  Adenovirus, adeno-associated virus and Kawasaki disease.   Pediatr Infect Dis J. 2005;24(11):1011-1014. doi:10.1097/01.inf.0000183769.31951.1ePubMedGoogle ScholarCrossref
18.
Lloyd  AJ , Walker  C , Wilkinso  M .  Kawasaki disease: is it caused by an infectious agent?   Br J Biomed Sci. 2001;58(2):122-128.PubMedGoogle Scholar
19.
Chang  LY , Lu  CY , Shao  PL ,  et al.  Viral infections associated with Kawasaki disease.   J Formos Med Assoc. 2014;113(3):148-154. doi:10.1016/j.jfma.2013.12.008PubMedGoogle ScholarCrossref
20.
Sato  K , Ouchi  K , Taki  M .  Yersinia pseudotuberculosis infection in children, resembling Izumi fever and Kawasaki syndrome.   Pediatr Infect Dis. 1983;2(2):123-126. doi:10.1097/00006454-198303000-00011PubMedGoogle ScholarCrossref
21.
Baba  K , Takeda  N , Tanaka  M .  Cases of Yersinia pseudotuberculosis infection having diagnostic criteria of Kawasaki disease.   Contrib Microbiol Immunol. 1991;12:292-296.PubMedGoogle Scholar
22.
Vincent  P , Salo  E , Skurnik  M , Fukushima  H , Simonet  M .  Similarities of Kawasaki disease and Yersinia pseudotuberculosis infection epidemiology.   Pediatr Infect Dis J. 2007;26(7):629-631. doi:10.1097/INF.0b013e3180616d3cPubMedGoogle ScholarCrossref
23.
Tahara  M , Baba  K , Waki  K , Arakaki  Y .  Analysis of Kawasaki disease showing elevated antibody titres of Yersinia pseudotuberculosis.   Acta Paediatr. 2006;95(12):1661-1664. doi:10.1080/08035250600750080PubMedGoogle ScholarCrossref
24.
Horinouchi  T , Nozu  K , Hamahira  K ,  et al.  Yersinia pseudotuberculosis infection in Kawasaki disease and its clinical characteristics.   BMC Pediatr. 2015;15:177. doi:10.1186/s12887-015-0497-2PubMedGoogle ScholarCrossref
25.
Nakashima  Y , Sakai  Y , Mizuno  Y ,  et al.  Lipidomics links oxidized phosphatidylcholines and coronary arteritis in Kawasaki disease.   Cardiovasc Res. 2021;117(1):96-108. doi:10.1093/cvr/cvz305PubMedGoogle ScholarCrossref
26.
Kusuda  T , Nakashima  Y , Murata  K ,  et al.  Kawasaki disease-specific molecules in the sera are linked to microbe-associated molecular patterns in the biofilms.   PLoS One. 2014;9(11):e113054. doi:10.1371/journal.pone.0113054PubMedGoogle Scholar
27.
Whittaker  E , Bamford  A , Kenny  J ,  et al; PIMS-TS Study Group and EUCLIDS and PERFORM Consortia.  Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2.   JAMA. 2020;324(3):259-269. doi:10.1001/jama.2020.10369PubMedGoogle ScholarCrossref
28.
Verdoni  L , Mazza  A , Gervasoni  A ,  et al.  An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study.   Lancet. 2020;395(10239):1771-1778. doi:10.1016/S0140-6736(20)31103-XPubMedGoogle ScholarCrossref
29.
Toubiana  J , Poirault  C , Corsia  A ,  et al.  Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study.   BMJ. 2020;369:m2094. doi:10.1136/bmj.m2094PubMedGoogle ScholarCrossref
30.
Feldstein  LR , Rose  EB , Horwitz  SM ,  et al; Overcoming COVID-19 Investigators; CDC COVID-19 Response Team.  Multisystem inflammatory syndrome in U.S. children and adolescents.   N Engl J Med. 2020;383(4):334-346. doi:10.1056/NEJMoa2021680PubMedGoogle ScholarCrossref
31.
Dufort  EM , Koumans  EH , Chow  EJ ,  et al; New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team.  Multisystem inflammatory syndrome in children in New York State.   N Engl J Med. 2020;383(4):347-358. doi:10.1056/NEJMoa2021756PubMedGoogle ScholarCrossref
32.
Cheung  EW , Zachariah  P , Gorelik  M ,  et al.  Multisystem inflammatory syndrome related to COVID-19 in previously healthy children and adolescents in New York City.   JAMA. 2020;324(3):294-296. doi:10.1001/jama.2020.10374PubMedGoogle ScholarCrossref
33.
Morand  A , Urbina  D , Fabre  A .  COVID-19 and Kawasaki like disease: the known-known, the unknown-known and the unknown-unknown.   Preprints. Published online May 9, 2020. doi:10.20944/preprints202005.0160.v1Google Scholar
34.
Tay  MZ , Poh  CM , Rénia  L , MacAry  PA , Ng  LFP .  The trinity of COVID-19: immunity, inflammation and intervention.   Nat Rev Immunol. 2020;20(6):363-374. doi:10.1038/s41577-020-0311-8PubMedGoogle ScholarCrossref
35.
Liu  PP , Blet  A , Smyth  D , Li  H .  The science underlying COVID-19: implications for the cardiovascular system.   Circulation. 2020;142(1):68-78. doi:10.1161/CIRCULATIONAHA.120.047549PubMedGoogle ScholarCrossref
36.
Varga  Z , Flammer  AJ , Steiger  P ,  et al.  Endothelial cell infection and endotheliitis in COVID-19.   Lancet. 2020;395(10234):1417-1418. doi:10.1016/S0140-6736(20)30937-5PubMedGoogle ScholarCrossref
37.
Licciardi  F , Pruccoli  G , Denina  M ,  et al.  SARS-CoV-2-induced Kawasaki-like hyperinflammatory syndrome: a novel COVID phenotype in children.   Pediatrics. 2020;146(2):e20201711. doi:10.1542/peds.2020-1711PubMedGoogle Scholar
38.
Pouletty  M , Borocco  C , Ouldali  N ,  et al.  Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort.   Ann Rheum Dis. 2020;79(8):999-1006. doi:10.1136/annrheumdis-2020-217960PubMedGoogle ScholarCrossref
39.
Ouldali  N , Pouletty  M , Mariani  P ,  et al.  Emergence of Kawasaki disease related to SARS-CoV-2 infection in an epicentre of the French COVID-19 epidemic: a time-series analysis.   Lancet Child Adolesc Health. 2020;4(9):662-668. doi:10.1016/S2352-4642(20)30175-9PubMedGoogle ScholarCrossref
40.
Rodó  X , Curcoll  R , Robinson  M ,  et al.  Tropospheric winds from northeastern China carry the etiologic agent of Kawasaki disease from its source to Japan.   Proc Natl Acad Sci U S A. 2014;111(22):7952-7957. doi:10.1073/pnas.1400380111PubMedGoogle ScholarCrossref
41.
Rodó  X , Ballester  J , Cayan  D ,  et al.  Association of Kawasaki disease with tropospheric wind patterns.   Sci Rep. 2011;1:152. doi:10.1038/srep00152PubMedGoogle ScholarCrossref
42.
Manlhiot  C , Mueller  B , O’Shea  S ,  et al.  Environmental epidemiology of Kawasaki disease: linking disease etiology, pathogenesis and global distribution.   PLoS One. 2018;13(2):e0191087. doi:10.1371/journal.pone.0191087PubMedGoogle Scholar
43.
Jorquera  H , Borzutzky  A , Hoyos-Bachiloglu  R , García  A .  Association of Kawasaki disease with tropospheric winds in Central Chile: is wind-borne desert dust a risk factor?   Environ Int. 2015;78:32-38. doi:10.1016/j.envint.2015.02.007PubMedGoogle ScholarCrossref
44.
Corinaldesi  E , Pavan  V , Andreozzi  L ,  et al.  Environmental factors and Kawasaki disease onset in Emilia-Romagna, Italy.   Int J Environ Res Public Health. 2020;17(5):1529. doi:10.3390/ijerph17051529PubMedGoogle ScholarCrossref
45.
Ballester  J , Burns  JC , Cayan  D , Nakamura  Y , Uehara  R , Rodó  X .  Kawasaki disease and ENSO-driven wind circulation.   Geophys Res Lett. 2013;40(10):2284-2289. doi:10.1002/grl.50388Google ScholarCrossref
46.
Sonobe  T .  A summary of the epidemiologic surveys on Kawasaki disease conducted over 30 years.   JMAJ. 2005;48(1):30–33. Accessed March 9, 2021. https://www.med.or.jp/english/pdf/2005_01/030_033.pdfGoogle Scholar
47.
Akhtar  J , Garcia  AL , Saenz  L , Kuravi  S , Shu  F , Kota  K .  Can face masks offer protection from airborne sneeze and cough droplets in close-up, face-to-face human interactions? a quantitative study.   Phys Fluids (1994). 2020;32(12):127112. doi:10.1063/5.0035072PubMedGoogle Scholar
48.
Venter  ZS , Aunan  K , Chowdhury  S , Lelieveld  J .  COVID-19 lockdowns cause global air pollution declines.   Proc Natl Acad Sci U S A. 2020;117(32):18984-18990. doi:10.1073/pnas.2006853117PubMedGoogle ScholarCrossref
49.
Moelling  K , Broecker  F .  Air microbiome and pollution: composition and potential effects on human health, including SARS coronavirus infection.   J Environ Public Health. 2020;2020:1646943. doi:10.1155/2020/1646943PubMedGoogle Scholar
50.
Zeft  AS , Burns  JC , Yeung  RS ,  et al.  Kawasaki disease and exposure to fine particulate air pollution.   J Pediatr. 2016;177:179-183.e1. doi:10.1016/j.jpeds.2016.06.061PubMedGoogle ScholarCrossref
51.
Wyatt  LS , Frenkel  N .  Human herpesvirus 7 is a constitutive inhabitant of adult human saliva.   J Virol. 1992;66(5):3206-3209. doi:10.1128/JVI.66.5.3206-3209.1992PubMedGoogle ScholarCrossref
52.
Levy  JA , Ferro  F , Greenspan  D , Lennette  ET .  Frequent isolation of HHV-6 from saliva and high seroprevalence of the virus in the population.   Lancet. 1990;335(8697):1047-1050. doi:10.1016/0140-6736(90)92628-UPubMedGoogle ScholarCrossref
53.
Kozajda  A , Jeżak  K , Kapsa  A .  Airborne Staphylococcus aureus in different environments: a review.   Environ Sci Pollut Res Int. 2019;26(34):34741-34753. doi:10.1007/s11356-019-06557-1PubMedGoogle ScholarCrossref
54.
Netea  MG , Domínguez-Andrés  J , Barreiro  LB ,  et al.  Defining trained immunity and its role in health and disease.   Nat Rev Immunol. 2020;20(6):375-388. doi:10.1038/s41577-020-0285-6PubMedGoogle ScholarCrossref
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