Diagnostic value of symptoms for pediatric SARS-CoV-2 infection in a primary care setting
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Abstract
To evaluate the diagnostic value of symptoms used by daycares and schools to screen children and adolescents for SARS-CoV-2 infection, we analyzed data from a primary care setting.
Methods
This cohort study included all patients ≤17 years old who were evaluated at Providence Community Health Centers (PCHC; Providence, U.S.), for COVID-19 symptoms and/or exposure, and received SARS-CoV-2 polymerase chain reaction (PCR) testing between March-June 2020. Participants were identified from PCHC electronic medical records. For three age groups– 0–4, 5–11, and 12–17 years–we estimated the sensitivity, specificity, and area under the receiver operating curve (AUC) of individual symptoms and three symptom combinations: a case definition published by the Rhode Island Department of Health (RIDOH), and two novel combinations generated by different statistical approaches to maximize sensitivity, specificity, and AUC. We evaluated symptom combinations both with and without consideration of COVID-19 exposure. Myalgia, headache, sore throat, abdominal pain, nausea, anosmia, and ageusia were not assessed in 0–4 year-olds due to the lower reliability of these symptoms in this group.
Results
Of 555 participants, 217 (39.1%) were SARS-CoV-2-infected. Fever was more common among 0–4 years-olds (p = 0.002); older children more frequently reported fatigue (p = 0.02). In children ≥5 years old, anosmia or ageusia had 94–98% specificity. In all ages, exposure history most accurately predicted infection. With respect to individual symptoms, cough most accurately predicted infection in <5 year-olds (AUC 0.69) and 12–17 year-olds (AUC 0.62), while headache was most accurate in 5–11 year-olds (AUC 0.62). In combination with exposure history, the novel symptom combinations generated statistically to maximize test characteristics had sensitivity >95% but specificity <30%. No symptom or symptom combination had AUC ≥0.70.
Conclusions
Anosmia or ageusia in children ≥5 years old should raise providers’ index of suspicion for COVID-19. However, our overall findings underscore the limited diagnostic value of symptoms.
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SciScore for 10.1101/2021.03.29.21254600: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: Sensitivity, specificity, and AUC estimates were calculated with the reportROC package for R.(13) Ethics: The PCHC Human Subjects Review Committee approved this study and waived informed consent.
Consent: Sensitivity, specificity, and AUC estimates were calculated with the reportROC package for R.(13) Ethics: The PCHC Human Subjects Review Committee approved this study and waived informed consent.Randomization Ten-fold cross-validation was performed, in which the whole data set was randomly split into learning and test data sets. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
… SciScore for 10.1101/2021.03.29.21254600: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Institutional Review Board Statement IRB: Sensitivity, specificity, and AUC estimates were calculated with the reportROC package for R.(13) Ethics: The PCHC Human Subjects Review Committee approved this study and waived informed consent.
Consent: Sensitivity, specificity, and AUC estimates were calculated with the reportROC package for R.(13) Ethics: The PCHC Human Subjects Review Committee approved this study and waived informed consent.Randomization Ten-fold cross-validation was performed, in which the whole data set was randomly split into learning and test data sets. Blinding not detected. Power Analysis not detected. Sex as a biological variable not detected. Table 2: Resources
Experimental Models: Organisms/Strains Sentences Resources Race/ethnicity was grouped into Hispanic, non-Hispanic (NH) Black, NH White, and NH other (Asians, other Pacific Islanders, more than one race, and unknown). NH Whitesuggested: NoneResults 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:This study had limitations. Data were collected early in the pandemic; however, symptoms are not expected to change over the course of the pandemic, and the clinical and public health implications of this study remain relevant and practical. As previously discussed, the AUCs of exposure and symptoms that we observed may represent a “best case scenario,” but this possibility only strengthens the overarching message that symptoms are poorly predictive of COVID-19. Despite these limitations, our assessment of the diagnostic value of symptoms fills an important gap in the pediatric COVID-19 literature. The poor AUCs we observed mean that symptoms should not be used alone to identify pediatric SARS-CoV-2 infection, and underscore the importance of widely available and efficient testing.
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).
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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