Prolonged presence of SARS-CoV-2 in feces of pediatric patients during the convalescent phase

  1. Yuhan Xing
  2. Wei Ni
  3. Qin Wu
  4. Wenjie Li
  5. Guoju Li
  6. Jianning Tong
  7. Xiufeng Song
  8. Quansheng Xing

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Abstract

Background

Severe acute respiratory coronavirus 2 (SARS-CoV-2) is a newly identified virus which mainly spreads from person-to-person. Presence of SARS-CoV-2 has been constantly reported in stools of patients with coronavirus disease 2019 (COVID-19). However, there is a paucity of data concerning fecal shedding of the virus in pediatric patients.

Objective

To investigate dynamic changes of SARS-CoV-2 in respiratory and fecal specimens in children with COVID-19.

Methods

From January 17, 2020 to February 23, 2020, three pediatric cases of COVID-19 were reported in Qingdao, Shandong Province, China. Epidemiological, clinical, laboratory, and radiological characteristics and treatment data of these children were collected. Real-time fluorescence reverse-transcriptase-polymerase-chain reaction (RT-PCR) was performed to detect SARS-CoV-2 RNA in throat swabs and fecal specimens. Patients were followed up to March 10, 2020, the final date of follow-up, and dynamic profiles of RT-PCR results were closely monitored.

Results

All the three pediatric cases were household contacts of adults whose symptoms developed earlier. Severity of disease was mild to moderate and fever was the most consistent and predominant symptom at onset of illness of these children (two cases had body temperature higher than 38.5°C). All children showed increased lymphocytes (>4.4×10 9 /L) with normal white blood cell counts on admission. Radiological changes were not typical for COVID-19. All children showed good response to supportive treatment. Clearance of SARS-CoV-2 in respiratory tract occurred within two weeks after abatement of fever, whereas viral RNA remained positive in stools of pediatric patients for longer than 4 weeks. Two children had fecal SARS-CoV-2 turned negative 20 days after throat swabs showing negative, while that of another child lagged behind for 8 days.

Interpretation

SARS-CoV-2 may exist in gastrointestinal tract for a longer time than respiratory system. Persistent shedding of SARS-CoV-2 in stools of infected children indicates the potential for the virus to be transmitted through fecal excretion. Massive efforts should be made at all levels to prevent spreading of the infection among children after reopening of kindergartens and schools.

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    SciScore for 10.1101/2020.03.11.20033159: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: This study was approved by the Ethics Commission of Qingdao Women and Children’s Hospital (QFFLL-KY-2020-11) and written informed consent was obtained from patients’ legal guardians prior to enrolment.
    Consent: This study was approved by the Ethics Commission of Qingdao Women and Children’s Hospital (QFFLL-KY-2020-11) and written informed consent was obtained from patients’ legal guardians prior to enrolment.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableFecal specimens were first collected in two patients (case 1, 1.5-year-old male; and case 2, 5-year-old male) on day 4 after onset of the disease.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    The limitations of this study should also be noted. In response to the emerging disease, only respiratory specimens were required for the detection of SARS-CoV-2 according to clinical guidelines in the early stage of COVID-19 outbreak. We therefore failed to obtain stool samples from the patients during their first few days of hospitalization and could not determine whether throat swabs and fecal samples showed positive on RT-PCR analysis simultaneously. Moreover, we did not culture the virus isolated from the feces to test the viability nor measure viral loads in the samples due to limited conditions. Taken together, there is an urgent need to re-evaluate the current version of Diagnosis and Treatment Plan of Corona Virus Disease 2019 (tentative seventh edition).13 Nucleic acid testing on fecal specimens should be added to the current criteria for hospital discharge and release of isolation. We call for multi-center studies with larger sample size to clarify the time lag between fecal and respiratory specimens negative for RNA RT-PCR analysis in infected children. Postscript: We reported to the local health authority immediately once we noticed the persistent shedding of SARS-CoV-2 in feces of our pediatric patients about three weeks ago. When this paper was finalized, the seventh edition of Diagnosis and Treatment Plan of Corona Virus Disease 2019 had just been issued and indicated the possibility of fecal-oral transmission of SARS-CoV-2. Currently, capable hospitals in som...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2020.03.11.20033159v1 on medRxiv