In a study published in the Journal of Pediatrics, Mass General and MassGeneral Hospital for Children researchers provide critical data showing that children play a larger role in the community spread of COVID-19 than previously thought.

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My name is Katharine Grant and I'm a communications coordinator at MassGeneral Hospital for Children. I'm here with Dr. Alessio Fasano, chief of the Division of Pediatric Gastroenterology and Nutrition at MGHfC and Dr. Lael Yonker, director of the Cystic Fibrosis Center at MGHfC. The two pediatricians are lead authors with 28 other contributors on groundbreaking research into COVID-19 and children. Their study, "Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses" has just been published in the Journal of Pediatrics. So Dr. Fasano, can you start out by telling us, are children immune from or protected against the virus that causes COVID-19 and what do your findings tell us about children and community spread of COVID-19? You know, our findings in a nutshell suggest that kids like adults are susceptible to the infection. They can have the virus infecting the upper airways and therefore they are capable eventually to spread the virus around even if they typically develop symptoms that seem to be milder than adults or no symptoms at all. And Dr. Yonker, how does COVID-19 present differently in pediatric versus adult cases and why does this make COVID-19 more difficult to diagnose in children? Kids generally develop significantly milder symptoms following SARS-CoV- infection and it has a lot of overlap with common colds or mild asthma exacerbation so kids generally present with congestion, maybe a mild cough, maybe a fever, but some kids are asymptomatic. Only fifty percent of kids we found actually develop fever from SARS-CoV-2 infection and so there's no real diagnostic criteria for an acute infection. It's really very mild symptoms. We found kids are more likely to have a lack of sense of smell but kids aren't really good at articulating this. Younger kids especially wouldn't necessarily be good at articulating a lack of sense of smell. Also, we found that maybe kids with COVID-19 are more likely to have a sore throat, but the numbers are really high in kids who don't have COVID- as well so there's a lot of overlap with kids. So it's hard to identify as opposed to adults, who really develop much more significant respiratory symptoms and it's a very classic fever, congestion, fatigue, shortness of breath, and so the presentation is much more dramatic in the adults and much more mild and harder to characterize in kids. Thank you. And Dr. Yonker, your work found high viral loads in children of all ages. Can you please explain what this means in terms of transmissibility and why this surprised you? Sure. So with viral load, the higher the viral load especially in respiratory secretions generally with all other viruses correlates with increased transmissibility so if you have a lot of virus in your airways and secretions you're more likely to spread those to others. What surprised us is when you think of a hospital and all of the COVID-19 patients that were in the hospital you would see caregivers and providers with masks on, N-95 face shields, real full body coverings and we found that kids have significantly higher viral loads than these hospitalized patients. And these kids are walking around feeling pretty well, maybe some mild symptoms, but it just definitely raises concern for the potential for transmissibility from these kids into the community. Right. So turning to Dr. Fasano, how do these findings contribute to the current discussion on reopening schools safely and if you could have a conversation with national and local policy makers about the safe reopening of schools and daycares what would you tell them? School reopening is an object of discussion that is very pertinent nowadays because there are different opinions, of course, on what to do when time comes that school needs to be reopened. And then again, legislators and policymakers are engaged in this kind of discussion based on assumptions that are not entirely scientifically proven (i.e. the idea that kids will not be involved in SARS-CoV-2 infections and therefore they are safe to go to schools with no problems.) Of course this paper suggests otherwise, suggests that we need to really be careful when it comes to policy to local schools because kids can be stealthy. They can have the infection and not be symptomatic or they have no specific symptoms, like Dr. Yonker just told us. And therefore you can't really know beforehand know who carries the virus and who does not. And carrying the virus means that potentially they can spread the virus and they can spread the virus to other kids or operators in the school (the teachers, administrators, and so on and so forth) that in turn bring this back home. And of course the major price will be paid always by the low socioeconomic part of the society because these are the ones in which they have multi-generation family households where all the people at home, grandparents and so on, that can eventually be susceptible to be infected when these kids get back home. So the question is should we reopen the school? And if we do under which kind of circumstances? Again, working on the premise that kids are not a problem will be a major mistake. So if we need to open the school, we need to really be aware of what kind of environment we are talking about. Is this an environment which the attack rate is resurging and therefore we need to be very very careful? If that's the case, decreasing the density in the classroom, maintaining physical distance, wearing a mask where possible (particularly the older kids), hand hygiene, keeping the kids in the same classroom and having the teachers rotating rather the other way around, and having lunch break in the classroom and not the cafeterias with larger congregations and eventually have a mixed model of in-person and remote teaching are all policies that need to be considered to try to minimize the risk of spreading the virus, creating the situation of a second wave that would be disastrous for everybody. For the economy, the well-being of people, and most importantly because of the morbidity and mortality shown by this virus that we previously believed to only affect the elderly and now the age has gotten younger and younger. And the reason why is because younger people they are less prone to implement these policies to decrease the spread of the virus. And now with the school reopening, we'll put in the mix also kids which will create a situation that will prolong for much longer time this pandemic. Thank you, Dr. Fasano. Dr. Yonker, as pediatricians at MGHfC, you and Dr. Fasano have been fielding a lot of questions about COVID-19 and children. What are your recommendations to parents who ask you about sending their kids back to school and daycare? We have been getting this question a lot. Every single parent has this question and it's a good question. I don't think that there is a straightforward answer for every school and every family, but I think that it really depends on the safety precautions of the school or the daycare facility. What we've shown is that there's no age restriction. There's no age that is less likely to carry high viral loads, so all of these considerations have to take place for all the age ranges. Things that are generally recommended like masks, social distancing, remote learning, frequent nasal swabs or screening. These sort of things will have to be implemented in a way that makes sense for the school and for the children, but definitely I would think it depends on what safety precautions are in place so that the family can feel as though they can send their child safely back to school. And also, not just for the safety of the child, but for the safety of the family because whatever the child is exposed to they're going to bring it back into their house and the pandemic is going to continue. So we need to find ways to mitigate the spread through the children. Thank you, Dr. Yonker. And finally, Dr. Fasano, what are the next steps for this collaborative research team into the immune response in pediatric COVID-19? To answer some specific biologic question you need the big numbers. Dr. Yonker has been capable to build this biobank that is one of the largest that we have in the nation of kids that have been eventually exposed to SARS-CoV-2. And that will allow us to answer specific questions. For example, why kids develop milder symptoms than adults and why kids do not have the lower airway involvement like adults. So we know that many of the casualties so far have been related to the fact that you know the virus can infect the the lower airways and you develop a very severe pneumonia, require ventilation, and so on and so forth. Why in kids does this not happen? There is the false sense of safety for kids, in that the mortality rate in kids is a fraction of in adults but we need to be aware that there is also severe consequences in the kids like the multi-system inflammatory syndrome in children, so-called MIS-C, and we have seen cases of these kids that can really have severe consequences. And speaking of severe consequences, if you're infected, even if you don't have severe symptoms, there are other long-term consequences that can affect other organs like the heart and the kidney that can be eventually hit by this infection. These are all questions that we can answer once we will have the critical mass of data and we will continue to recruit patients to answer how to tackle this matter. If we talk about the vaccine, and I know that now there's a lot of discussion about vaccines (with Russia being the first country to register a vaccine, if the vaccine will be effective, if there are going to be other remedies that need to be in the pipeline) and so on and so forth. So these are pretty much a lot of questions that we intend to answer with our team trying to really mitigate this pandemic but at the same time to try to develop strategies to ameliorate the possibility of long-term consequences in pediatrics. Thank you Dr. Fasano and Dr. Yonker. To learn more about this important study please visit www.massgeneral.org. Thank you!