Although pediatric patients appear to be at low risk for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), emerging data suggest that cases may be under-reported in children, and prolonged fecal viral shedding in pediatric patients may position them as potential infection carriers. This is according to a recent paper published in Digestive and Liver Disease.
Children infected by the virus tend to have less severe disease. In Italy, many testing facilities were initially reserved for severe cases, which may have resulted in under-reporting of the infection rate in children. Regions with more prominent testing and greater quarantining efforts have reported higher rates of infection in pediatric patients compared with Italy. Despite the potentially higher-than-reported infection, children tend to be mostly asymptomatic or have mild symptoms.
SARS-CoV-2 may actively replicate in the gastrointestinal (GI) tract, with diarrhea representing an initial symptom in up to half of COVID-19 cases. Clinical observations have indicated that a higher proportion of pediatric cases of COVID-19 present with diarrhea, fever, and vomiting compared with adult cases. In children, GI localization may be an alternative site of viral shedding and transmission.
Currently, the medical literature lacks sufficient evidence to describe the comprehensive scope of GI involvement in SARS-CoV-2. One theory suggests that transmission of SARS-CoV-2 can occur through fecal-oral dissemination, as this is true for SARS-CoV-1, a virus that shares the same receptor as SARS-CoV-2.
According to the article authors, the long fecal viral shedding may explain “the link in the transmission chain between school, community, and home.” School-aged children may have transmitted the virus to other members of their family prior to the onset of school closures. A common avenue of transmission may have included shared household bathrooms.
The decision to reopen schools, the authors argue, should take into consideration the period of time involved in viral fecal shedding and the risks of transmission among children. Once data have confirmed the role of viral transmission and amplification among children, “social and public health policies (eg, avoiding interaction with elderly people) could be established to slow down transmission and protect vulnerable populations.”
Oliva S, Cucchiara S, Locatelli F. Children and fecal SARS-CoV-2 shedding: Just the tip of the iceberg of Italian COVID-19 outbreak? [published online July 7, 2020]. Dig Liver Dis. doi: 10.1016/j.dld.2020.06.039