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The Epidemiology of SARS-CoV-2 in a Pediatric Healthcare Network in the United States

Our take —

In a large US pediatric care network, the overall prevalence of SARS-CoV-2 was relatively low, but differed by testing site and indication for testing. Results reveal some concerning racial and ethnic disparities with Black patients and those with public insurance having higher rates of infection. The majority of patients showed mild but typical symptoms, and few progressed to severe illness. All analyses were descriptive with no adjustment for confounding, and many of the findings warrant additional research. Testing was conducted in clinical settings, and thus should not be interpreted as community prevalence among children which would likely be much lower.

Study design

Case Series; Retrospective Cohort

Study population and setting

This retrospective study characterizes SARS-CoV-2 prevalence and clinical course among 7256 patients tested for SARS-CoV-2 in the Children’s Hospital of Philadelphia (CHOP) Care Network between March 9 and June 1, 2020. The CHOP Network includes an acute care hospital, 31 primary care centers, 4 urgent care centers, 10 specialty care centers, and 3 ambulatory surgical facilities across southeastern Pennsylvania and southern New Jersey. Patients with invalid or inconclusive test results, older than 21 years, or obstetrics patients were excluded.

Summary of Main Findings

Among 7256 patients (median age 5.9 years) tested for SARS-CoV-2, 424 (5.8%) tested positive. Patients aged 18-21 years had the highest test positive rate (11.2%), whereas those aged 1-5 years had the lowest (3.9%). Black patients had a higher test positive rate than white patients (10.6% vs. 3.3%), and patients with self-pay or government/public insurance had higher test positive rates than those with private insurance (11.4%, 9.3% vs. 3.4%). The majority of patients who tested positive had a prior exposure or were symptomatic (371/424, 87.5%). Most patients who tested positive had fever, cough, or shortness of breath (318/424, 75%), and only 54/424 (12.7%) were asymptomatic. Less than 20% (77/424) of patients were hospitalized, though COVID-19 was not considered the reason for hospitalization in 26/77 (33.8%). Twelve patients developed critical illness requiring mechanical ventilation, and 2 patients died during the study, both of whom had severe comorbidities.

Study Strengths

This was a large multi-site cohort of well-characterized pediatric patients with complete follow-up.

Limitations

Test positive rates likely do not represent population-level estimates, as the sample was composed of a combination of symptomatic cases or patients with known exposure as well as patients tested per hospital protocols. Tests were performed at a variety of different sites – drive through testing sites (39.2%), emergency department (31.8%), outpatient clinics (15.3%), inpatient hospitals (10.5%), and urgent care centers (3.2%) – and via different assays and sample collection processes, which could limit generalizability, and may impact sensitivity of the tests. A large number of repeat tests (n=1659) were excluded, but it is unclear why repeated testing was performed and whether positive tests were preferentially selected among patients who were repeat tested; this could result in an over-estimation of test positive rate. No adjusted analyses were performed and all comparisons are descriptive, so they should be interpreted with caution.

Value added

This was a large study of SARS-CoV-2 prevalence and COVID-19 clinical presentation in a well-characterized US pediatric care network.

This review was posted on: 18 July 2020