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©2020 American Academy of Pediatrics

Symptoms and Transmission of SARS-CoV-2 Among Children—Utah and Wisconsin, March–May 2020

Rebecca L. Laws, PhD, MPH*, Rebecca J. Chancey, MD*, Elizabeth M. Rabold, MD, MPH, Victoria T. Chu, MD, MPH, Nathaniel M. Lewis, PhD, Mark Fajans, MPH, Hannah E. Reses, MPH, Lindsey M.

Duca, PhD, Patrick Dawson, PhD, MPH, Erin E. Conners, PhD, MPH, Radhika Gharpure, DVM, MPH, Sherry Yin, MPH, Sean Buono, PhD, Mary Pomeroy, MSN, Anna R. Yousaf, MD, Daniel Owusu, PhD, Ashutosh Wadhwa, PhD, Eric Pevzner, PhD, MPH, Katherine A. Battey, BSN, MPH, Henry Njuguna,

MD, Victoria L. Fields, DVM, MPH, Phillip Salvatore, PhD, SM, Michelle O'Hegarty, PhD, Jeni Vuong, MS, Christopher J. Gregory, MD, MPH, Michelle Banks, MS, Jared Rispens, MD, Elizabeth Dietrich,

PhD, Perrine Marcenac, PhD, Almea Matanock, MD, MS, Ian Pray, PhD, MPH, Ryan Westergaard, MD, PhD, Trivikram Dasu, PhD, Sanjib Bhattacharyya, PhD, Ann Christiansen, MPH, Lindsey Page, MPH,

Angela Dunn, MD, Robyn Atkinson-Dunn, PhD, Kim Christensen, BS, Tair Kiphibane, BSN, Sarah Willardson, MPH, Garrett Fox, MPH, Dongni Ye, PhD, Scott A. Nabity, MD, Alison Binder, MS, Brandi

D. Freeman, PhD, Sandra Lester, PhD, Lisa Mills, PhD, Natalie Thornburg, PhD, Aron J. Hall, DVM, MSPH, Alicia M. Fry, MD, MPH, Jacqueline E. Tate, PhD,

Cuc H. Tran, PhD, MPH, Hannah L. Kirking, MD

DOI: 10.1542/peds.2020-027268

Journal: Pediatrics

Article Type: Regular Article

Citation: Laws RL, Chancey RJ, Rabold EM, et al. Symptoms and transmission of SARS-CoV-2 among children — Utah and Wisconsin, March–May 2020. Pediatrics. 2020; doi: 10.1542/peds.2020-027268

This is a prepublication version of an article that has undergone peer review and been accepted for publication but is not the final version of record. This paper may be cited using the DOI and date of access. This paper may contain information that has errors in facts, figures, and statements, and will be corrected in the final published version. The journal is providing an early version of this article to expedite access to this information. The American Academy of Pediatrics, the editors, and authors are not responsible for inaccurate information and data described in this version.

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Symptoms and Transmission of SARS-CoV-2 among Children— Utah and Wisconsin, March–May 2020

Rebecca L. Laws, PhD, MPH*1, Rebecca J. Chancey, MD*1, Elizabeth M. Rabold, MD, MPH1,2, Victoria T. Chu, MD, MPH1,2, Nathaniel M. Lewis, PhD1,2,3, Mark Fajans, MPH1, Hannah E.

Reses, MPH1, Lindsey M. Duca, PhD1,2, Patrick Dawson, PhD, MPH1,2, Erin E. Conners, PhD, MPH1, Radhika Gharpure, DVM, MPH1,2, Sherry Yin, MPH1, Sean Buono, PhD1,4, Mary

Pomeroy, MSN1,2, Anna R. Yousaf, MD1,2, Daniel Owusu, PhD1,2, Ashutosh Wadhwa, PhD1,4, Eric Pevzner, PhD, MPH1, Katherine A. Battey, BSN, MPH1, Henry Njuguna, MD1, Victoria L.

Fields, DVM, MPH1,2, Phillip Salvatore, PhD, SM1,2, Michelle O'Hegarty, PhD1, Jeni Vuong, MS1, Christopher J. Gregory, MD, MPH1, Michelle Banks, MS1, Jared Rispens, MD1,2, Elizabeth Dietrich, PhD1, Perrine Marcenac, PhD1,2, Almea Matanock, MD, MS1, Ian Pray, PhD, MPH1,2,5,

Ryan Westergaard, MD, PhD5, Trivikram Dasu, PhD6, Sanjib Bhattacharyya, PhD6, Ann Christiansen, MPH7, Lindsey Page, MPH6, Angela Dunn, MD3, Robyn Atkinson-Dunn, PhD3, Kim Christensen, BS3, Tair Kiphibane, BSN8, Sarah Willardson, MPH9, Garrett Fox, MPH1, Dongni Ye, PhD1, Scott A. Nabity, MD1, Alison Binder, MS1, Brandi D. Freeman, PhD1,4,

Sandra Lester, PhD1, Lisa Mills, PhD1, Natalie Thornburg, PhD1, Aron J. Hall, DVM, MSPH1, Alicia M. Fry, MD, MPH1, Jacqueline E. Tate, PhD1, Cuc H. Tran, PhD, MPH1, Hannah L.

Kirking, MD1

*Contributed equally as co-first authors. Author Affiliations 1. COVID-19 Response Team, U.S. Centers for Disease Control and Prevention (CDC) 2. Epidemic Intelligence Service, CDC 3. Utah Department of Health 4. Laboratory Leadership Service, CDC 5. Wisconsin Department of Health Services 6. City of Milwaukee Health Department, Wisconsin 7. North Shore Health Department, Wisconsin 8. Salt Lake County Health Department, Utah 9. Davis County Health Department, Utah Address correspondence to: Rebecca L. Laws Centers for Disease Control and Prevention 1600 Clifton Road NE Atlanta, GA 303029 Phone: 404-718-7093 Email: [email protected] Conflict of Interest Disclosures: The authors have no conflicts of interest to disclose. Funding/Support: This research was supported by the U.S. Centers for Disease Control and Prevention. Role of Funder: NA Clinical Trial Registration: NA


mailto:[email protected]



Abbreviations: SARS-CoV-2, Severe acute respiratory syndrome coronavirus 2; COVID-19, coronavirus disease 2019; WHO, World Health Organization; RT-PCR, real-time reverse transcription polymerase chain reaction; ELISA, enzyme-linked immunosorbent assay; CDC, Centers for Disease Control and Prevention; CSTE, Council of State and Territorial Epidemiologists; ARI, acute respiratory infection; CLI, COVID-19-like illness Article Summary This study describes a cohort of children exposed to SARS-CoV-2 in the household and their resulting infection rates, transmission patterns, and symptom profiles. What’s Known on This Subject The limited pediatric COVID-19 literature suggests that compared to adults, children may be infected less frequently, have less severe infections, and have a greater proportion of asymptomatic infections. However, more data are needed, particularly among pediatric outpatients with mild illness. What This Study Adds Among a cohort of household contacts of individuals with COVID-19, the rate of acquiring SARS-CoV-2 infection was similar between children and adults. Children who developed COVID-19 reported mild symptoms that were less frequent and severe than those experienced by adults. Contributors’ Statement Page Dr. Laws, Dr. Chancey, Dr. Rabold, and Dr. Tran conceptualized and designed the study, collected data, carried out the analyses, and wrote and revised the manuscript. Dr. Kirking conceptualized, designed, and coordinated the study, provided subject matter expertise, and critically reviewed the manuscript for important intellectual content. Dr. Hall, Dr. Fry, and Dr. Tate provided project leadership and subject matter expertise and reviewed the manuscript for important intellectual content. Dr. Ye and Dr. Nabity designed the study, carried out data management, and reviewed the manuscript. Dr. Chu, Mr. Fajans, Ms. Reses, Mr. Fox, and Ms. Binder carried out data management and reviewed the manuscript. Dr. Freeman, Dr. Lester, Dr. Mills, and Dr. Thornburg carried out laboratory specimen analysis and reviewed the manuscript. Dr. Lewis, Dr. Duca, Dr. Dawson, Dr. Conners, Dr. Gharpure, Ms. Yin, Dr. Buono, Ms. Pomeroy, Dr. Yousaf, Dr. Owusu, Dr. Wadhwa, Dr. Pevzner, Ms. Battey, Dr. Njuguna, Dr. Fields, Dr. Salvatore, Dr. O'Hegarty, Ms. Vuong, Dr. Gregory, Ms. Banks, Dr. Rispens, Dr. Dietrich, Dr. Marcenac, and Dr. Matanock collected data and specimens and reviewed the manuscript. Dr. Pray, Dr. Westergaard, Dr. Dasu, Dr. Bhattacharyya, Ms. Christiansen, Ms. Page, Dr. Dunn, Dr. Atkinson-Dunn, Ms. Christensen, Ms. Kiphibane, and Ms. Willardson assisted with household enrollment and reviewed the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.




Abstract Background and Objectives: Limited data exist on SARS-CoV-2 in children. We described infection rates and symptom profiles among pediatric household contacts of individuals with COVID-19. Methods: We enrolled individuals with COVID-19 and their household contacts, assessed daily symptoms prospectively for 14 days, and obtained specimens for SARS-CoV-2 RT-PCR and serology testing. Among pediatric contacts (<18 years), we described transmission, assessed risk factors for infection, and calculated symptom positive and negative predictive values (PPVs, NPVs). We compared secondary infection rates and symptoms between pediatric and adult contacts using generalized estimating equations. Results: Among 58 households, 188 contacts were enrolled (120 adults; 68 children). Secondary infection rates for adults (30%) and children (28%) were similar. Among households with potential for transmission from children, child-to-adult transmission may have occurred in 2/10 (20%), and child-to-child transmission may have occurred in 1/6 (17%). Pediatric case-patients most commonly reported headache (79%), sore throat (68%), and rhinorrhea (68%); symptoms had low PPVs except measured fever (100%; 95% CI: 44‒100%). Compared to symptomatic adults, children were less likely to report cough (OR: 0.15; 95% CI: 0.04‒0.57), loss of taste (OR: 0.21; 95% CI: 0.06‒0.74), and loss of smell (OR: 0.29; 95% CI: 0.09‒0.96), and more likely to report sore throat (OR: 3.4; 95% CI: 1.04‒11.18). Conclusions: Children and adults had similar secondary infection rates, but children generally had less frequent and severe symptoms. In two states early in the pandemic, we observed possible transmission from children in approximately one-fifth of households with potential to observe such transmission patterns. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.




Introduction

As of September 16, 2020, over 6.5 million cases of coronavirus disease 2019 (COVID-

19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), have been

reported in the United States.1 Although children under 18 years make up 22% of the U.S.

population,2 they comprise 8.3% of reported U.S. cases.3 This apparent underrepresentation of

children among cases is described in the limited pediatric COVID-19 literature, which suggests

that, compared to adults, children may be infected less frequently, have less severe infections,

and have a greater proportion of asymptomatic infections.4-10 Alternatively, these findings may

reflect decreased exposures due to mitigation efforts or less frequent testing.

Data are needed to characterize SARS-CoV-2 transmission from children and symptoms

of COVID-19, particularly among pediatric outpatients with mild illness. Here, we describe a

cohort of pediatric household contacts of individuals with COVID-19. We aimed to assess

pediatric rates of secondary infection, characterize transmission patterns, and describe symptoms

among children infected with SARS-CoV-2.

Methods

Study population

In collaboration with state and local health departments and in the setting of public health

emergency response, the U.S. Centers for Disease Control and Prevention (CDC) conducted a

household transmission investigation during March‒May 2020 in Milwaukee, Wisconsin, and

Salt Lake City, Utah, metropolitan areas. Methods from the full investigation are available at

Lewis et al.11; here, we describe a secondary analysis of the overall household transmission

investigation focusing on details related to children in the households. In brief, we approached

and enrolled a convenience sample of index case-patients with laboratory-confirmed SARS-




CoV-2 and their household contacts. Index case-patients were identified by local health

departments through routine surveillance and contact tracing activities. After completing their

own investigation of the reported case, local health department staff described the CDC

investigation protocol, asked if the index case-patient and household members were interested in

participating, and if so, referred them to the CDC team for study enrollment. Households were

eligible for enrollment if the index case-patient was within 10 days of his/her first positive test

for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction (RT-PCR) and

was at home during enrollment (i.e., not hospitalized) with at least one additional household

member who was willing to participate. All enrolled index case-patients and household contacts

were followed prospectively for 14 days.

Data collection and laboratory testing

Index case-patients and household contacts were interviewed using standard

questionnaires that captured demographics, medical history, prior SARS-CoV-2 testing, and

symptoms since the index case-patient’s illness onset (Supplemental material). At study

enrollment (Day 0), the CDC team visited the household to collect blood and respiratory

specimens (nasopharyngeal and self-collected anterior nasal swabs). If a household contact

developed new or worsening symptoms, the CDC team conducted an interim visit to collect

respiratory specimens from all household members. Five households were selected for intensive

swabbing requiring collection of respiratory specimens from all household members during four

interim visits regardless of symptom presence. At study close-out (Day 14), the CDC team

returned to collect blood and respiratory specimens. During the 14-day follow-up, participants




completed daily symptom logs which included temperature checks with study-provided digital

thermometers; a parent or guardian used discretion to determine if child(ren) needed assistance.

The City of Milwaukee Health Department Laboratory and the Utah Public Health

Laboratory tested respiratory specimens using the CDC 2019-nCoV real-time RT-PCR assay12

and processed and shipped blood specimens to CDC for serology testing using the CDC SARS-

CoV-2 spike protein enzyme-linked immunosorbent assay (ELISA).13

Statistical analyses

We classified household members as either “primary patient” or “household contact”; the

primary patient was the household member with earliest symptom onset (and positive SARS-

CoV-2 RT-PCR test). In most (89%) households, the primary patient was the same as the index

case-patient first identified by the health department. To assess transmission patterns, we

excluded households with co-primary patients (with symptom onset ≤2 days of each other), so

that each household had one source individual. We categorized household members <18 years as

children and classified adult and pediatric household contacts as “adult case-patients” and

“pediatric case-patients,” respectively, if they tested positive for SARS-CoV-2 by RT-PCR or

had total anti-SARS-CoV-2 antibody titers ≥100 by ELISA at any point during the study period.

Given the low community prevalence early in the pandemic and lag time between exposure and

study enrollment, seropositivity was used as a marker of recent acute infection.

We described demographics of household contacts, stratified by age. To account for

household clustering, we used generalized estimating equations (GEE) with an independent

correlation matrix and logit link to compare secondary infection rates between pediatric and

adult contacts. Among pediatric contacts, we calculated unadjusted odds ratios (ORs) and 95%




confidence intervals (CIs) using GEE to assess risk factors for infection. We calculated the serial

interval as the number of days between symptom onset of the primary patient and associated

secondary case-patient.

Among pediatric case-patients, we described timing of RT-PCR and serology results in

relation to primary patient and individual symptom onset. To assess the possibility of children

transmitting SARS-CoV-2 within households, we calculated the difference in symptom onset in

days between all case-patients in the same household. Based on expected minimum incubation

periods, we considered a child as a possible source of transmission if a subsequent case-patient

developed symptoms >2 days later.14-15 Community prevalence in these two metropolitan areas

was low during this time, and both were under stay-at-home orders which started soon after

study initiation and extended throughout study enrollment, reducing the likelihood of outside

exposures.

We categorized symptoms as constitutional (measured or subjective fever, chills,

myalgia, fatigue), upper respiratory (runny nose, nasal congestion, sore throat), lower respiratory

(cough, difficulty breathing, shortness of breath, wheezing, chest pain), neurologic (headache,

loss of taste, loss of smell), and gastrointestinal (nausea/vomiting, diarrhea, abdominal pain).

Among pediatric case-patients, we described the frequencies of reporting symptoms and meeting

COVID-19 and syndromic surveillance case definitions [COVID-19-like illness (CLI)15; Council

of State and Territorial Epidemiologists (CSTE) COVID-1916; influenza-like illness (ILI)17;

WHO acute respiratory infection (ARI)18] and calculated positive and negative predictive values

(PPVs, NPVs) and 95% CIs. We used GEE to compare symptom frequency and duration

between pediatric and adult case-patients; those who remained symptomatic at the end of the

study period were treated statistically as if their symptoms resolved on Day 14.




Ethical considerations

This protocol was reviewed by CDC and deemed non-human subjects research as part of

the COVID-19 public health response. All participants provided written consent (or child assent

with parental permission) prior to participation.

Results

Study population

Individuals from 62 households were enrolled; four households with co-primary patients

were excluded (Figure 1). Among the 58 households included (Utah, n=34; Wisconsin, n=24),

children resided in 33 (57%). One household had a pediatric primary patient. In total, 188

household contacts were enrolled and included; 68 (36%) were children (Table 1). Of 120 adult

contacts, 65 (54%) resided in households with children.

Among 68 pediatric contacts, 37 (54%) were female, 34 (50%) were between 5‒12 years,

and 43 (60%) were non-Hispanic white (Table 1). Nine (13%) children had an underlying

medical condition, with asthma the most commonly reported. Most (63%) pediatric contacts

were children of the primary patient, while 21% were siblings of the (adult) primary patient.

Among adult contacts, 74% were between 18‒49 years, and 49 (41%) had an underlying medical

condition. A full description of household characteristics and mitigation measures in the

household is available at Lewis et al.11




Secondary infections among pediatric and adult contacts

Among 68 pediatric contacts, 19 (28%) tested positive for SARS-CoV-2 by RT-PCR or

ELISA. Among 120 adult contacts, 36 (30%) tested positive, including 18/65 (28%) in

households with children and 18/55 (33%) in households without children (Figure 2). There were

no significant differences in secondary infection rates between adult and pediatric contacts

among all households (odds ratio (OR): 1.11; 95% confidence interval (CI): 0.56‒2.21) or among

households with children (OR: 0.99; 95% CI: 0.51‒1.90).

Risk factors for infection among pediatric contacts

Among the 19 pediatric case-patients, median age was 13 years (range: 3‒17;

interquartile range (IQR):10‒15 years), 12 (63%) were female, and 14 (74%) were non-Hispanic

white. Children of primary patients had increased odds of acquiring infection compared to

children in households where the primary patient was not their parent (OR: 17.28; 95% CI: 2.36‒

126.8). There were no significant differences in the odds of acquiring infection by age, sex, race-

ethnicity, underlying medical conditions, number of household members, household size, or ratio

of children to bedrooms/bathrooms. No children were hospitalized, and none died. The median

serial interval among pediatric case-patients was five days (IQR: 4‒9 days), and median

symptom duration was 10 days (IQR: 6‒14 days), although two children were still experiencing

symptoms at the end of the study period (Table 2).

Transmission patterns in households with children

Figure 3 displays serial intervals and transmission patterns in households with children.

There was potential for transmission from children in 12 households, i.e., there were susceptible




household contacts >2 days after illness onset of the first infected child in the house (Figure 3A;

Households A‒F and I‒N). Of 10 households with potential for child-to-adult transmission, two

(20%) (Households K, M) represent possible transmission from child to adult. Of 6 households

with potential for child-to-child transmission, one (17%) (Household L) represents possible

transmission between children. In Household L, the first infected child (female, 14 years) was a

caretaker for her infected mother and may have transmitted SARS-CoV-2 to her sibling (female,

10 years). In households with no pediatric case-patients (Figure 3B), 9/39 (23%) adult contacts

tested positive for SARS-CoV-2.

RT-PCR results in pediatric case-patients

The single pediatric primary patient had a positive RT-PCR respiratory specimen

collected prior to study enrollment and did not seroconvert during the study period (Figure 4;

Child A1).

Among the 19 pediatric case-patients, fifteen (79%) had positive RT-PCR respiratory

specimens collected before or during the study period (Figure 4). One child was asymptomatic at

the time of first RT-PCR positive test but developed symptoms two days later (Figure 4A; Child

H2); among the remaining 14 pediatric case-patients with positive RT-PCR respiratory

specimens, median time between symptom onset and RT-PCR positive test was 2 days (IQR: 1‒

6 days); specimens from three of these children were RT-PCR positive on the day of symptom

onset. At Day 14, three (16%) children had repeat RT-PCR positive specimens collected,

indicating that length of RT-PCR positivity was at least 14 days in those children.




Serology results in pediatric case-patients

Among the 19 pediatric case-patients, 17 had at least one available serum specimen; all

tested positive for SARS-CoV-2 antibodies by ELISA during the study period (Figure 4B).

These children had a median of 13 days between symptom onset and seropositivity (IQR: 7‒16

days), and a median of 17 days between primary patient symptom onset (i.e., exposure) and

seropositivity (IQR: 16‒24 days). Sixteen had paired sera; 9/16 (56%) showed evidence of

seroconversion during the study period.

Four pediatric case-patients tested positive by serology only (Figure 4; Children B1, C1,

M1, N1). All four displayed COVID-19 symptoms during or shortly before the study period but

after primary patient’s symptom onset. One (Child N1) seroconverted during the study period,

consistent with recent acute infection. Two children (B1, C1) had an initial RT-PCR positive test

16 days after primary patients’ symptom onset, and symptoms resolved on the day of or one day

prior to study enrollment. Child M1 had serum collected on Day 14 only, preceded by symptoms

consistent with acute infection.

Symptoms among pediatric household contacts

Among the 19 pediatric case-patients, all reported at least one symptom. Upper

respiratory and neurological symptoms (both 84%) were the most commonly reported symptom

categories (Figure 5). The most commonly reported individual symptoms were headache (79%),

sore throat (68%), rhinorrhea (68%), and nasal congestion (63%). Less than half of pediatric

case-patients reported any gastrointestinal symptoms (42%), cough (42%), loss of smell (32%),

loss of taste (21%), or measured fever (16%). In general, the majority of symptoms had low

PPVs; the highest PPV was for measured fever (PPV: 100%; 95% CI: 44‒100%), although it was




only reported by three pediatric case-patients (Table 3). The highest NPVs were in neurological

symptoms (NPV: 93%; 95% CI: 81‒97%), specifically headache (NPV: 91%; 95% CI: 78‒96%),

and upper respiratory symptoms (NPV: 90%; 95% CI: 75‒97%). COVID-19 and syndromic

surveillance case definitions had low PPVs and high NPVs (CSTE COVID-19, NPV: 93%, 95%

CI: 81‒98%; CLI, NPV: 89%, 95% CI: 77‒95%; WHO ARI, NPV: 90%, 95% CI: 74‒97%).

When comparing pediatric (n=19) and adult (n=36) case-patients, children had a lower

frequency of reporting most symptoms (Figure 6). Pediatric case-patients were significantly less

likely to report lower respiratory symptoms (OR: 0.17; 95% CI: 0.04‒0.82), cough (OR: 0.15;

95% CI: 0.04‒0.57), loss of taste (OR: 0.21; 95% CI: 0.06‒0.74), and loss of smell (OR: 0.29;

95% CI: 0.09‒0.96) than adult case-patients, and more likely to report sore throat (OR: 3.4; 95%

CI: 1.04‒11.18). Pediatric case-patients experienced a shorter duration of symptoms as compared

to adults (median of 10 vs. 16 days; β=-6.5; 95% CI: -10.1‒-2.9); this difference may be more

pronounced as two (11%) children compared to 14 (39%) adults remained symptomatic at the

end of the study period.

Discussion

This investigation followed a cohort of pediatric and adult household contacts of

individuals with COVID-19 over time to assess their symptoms, determine if they acquired

SARS-CoV-2 infection, and describe household transmission patterns. Our investigation is novel

in that we describe outpatient children with COVID-19, who otherwise may not have been

tested, and compare them with children who did not acquire infection and with adults who did.

We found that compared to adults, children acquired infection at similar rates but developed less

severe illness. We also found that among this pediatric population, being the child of a primary




patient increased the risk of acquiring infection in the household. Lastly, we observed that

children were a possible source of further transmission in approximately one-fifth of households

with the potential for such transmission patterns.

At the time of this investigation and until the availability of widespread testing,

symptoms consistent with SARS-CoV-2 infection had been the trigger for testing and diagnosis.

Our results are similar to other studies4, 7, 9 in that children with COVID-19 often had mild,

nonspecific symptoms (sore throat, rhinorrhea, nasal congestion, and headache) that may be

challenging to differentiate from other common childhood viral illnesses. In the absence of

features commonly associated with COVID-19 in adults (fever, cough, shortness of breath),

children with COVID-19 may not have sought care or did not meet diagnostic testing criteria

earlier in the pandemic, thus resulting in underrepresentation in surveillance data. In contrast to

the 8.3% of cases reported among children in the U.S.3, 35% of household cases in our study

population were in children, most of whom were identified because we tested all household

contacts regardless of symptoms.

As schools and daycares reopen, home and school-based symptom screening strategies

are being used to limit transmission.19-20 However, with most symptoms and case definitions

having low PPVs, symptom screening checklists may either be too broad, resulting in

unnecessarily restricting access, or too narrow, resulting in failed recognition of disease.

Additionally, recent studies suggest that asymptomatic children may transmit SARS-CoV-24, 7, 9,

21; although none of the children who tested positive for SARS-CoV-2 in our study were

asymptomatic, four were either presymptomatic or on the day of symptom onset at first positive

RT-PCR test, suggesting that they may have been shedding virus while not experiencing

symptoms. Clinicians and schools should maintain a lower threshold for laboratory testing in




children if there is an epidemiological link, especially to a parent with suspected or confirmed

COVID-19, including in asymptomatic or mildly symptomatic children. Although challenging,

use of syndromic case definitions and/or use of symptoms with high NPVs for COVID-19 or

other infectious diseases of concern may still have utility.

Improved understanding of children’s role in the transmission of SARS-CoV-2 is

important to better inform prevention recommendations. Studies conducted early in the pandemic

suggested that children were infrequently the primary source of household SARS-CoV-2

infections.22-23 However, a more recent study of 153 pediatric index patients found that older

children (10‒19 years) transmitted SARS-CoV-2 to 18.6% of household contacts24, and evidence

has emerged that children with COVID-19 have similar or higher viral loads than adults.25-27. We

were limited in our ability to observe transmission from children, but among households with the

potential for such patterns, we found possible child-to-adult transmission in 20% and possible

child-to-child transmission in 17%. Similarly, a case series of 15 households in Chicago, Illinois

suggested both child-to-child and child-to-adult transmission in 13%.28 We found that children

acquired infection at the same rate as adults, at approximately 30%. Compared to other

respiratory viral infections, this is higher than documented secondary transmission rates for

MERS-coronavirus (4%)29 and pandemic H1N1 (10.3%‒20.2%),30 the latter of which may have

had higher attack rates in children than adults. Seasonal influenza secondary attack rates range

widely by year, strain type, and age, making direct comparisons difficult.31-33 Our investigation

was subject to several limitations. We enrolled a small, convenience sample of households in two

states, which may not be representative of U.S. households; this may result in selection bias and

could affect the generalizability of our findings. Among all primary patients, only one was a

child, which limited our ability to observe transmission from children and which may not be




reflective of pediatric infection rates in high-transmission areas or when communities/schools are

open. Although we cannot be certain that the pediatric case-patients in our study acquired

infection in the household, these communities were under stay-at-home orders for the majority of

the study period, reducing the risk of acquiring infection in the community. Our small sample

size of children and the resulting wide confidence intervals may have limited our ability to

identify differences. The true infection rate among children may have been higher than reported

because we were unable to collect serum specimens on all pediatric contacts. Because our study

period was only 14 days, some household contacts may have developed additional symptoms or

acquired infection after the observation period ended. All symptoms were self-reported, or for

some children, reported by their parent(s), which may be subject to recall error, and some

symptoms were not systematically asked of all participants. Due to the high prevalence (28%) of

SARS-CoV-2 infection among pediatric contacts, the PPVs and NPVs reported here may not be

representative of all settings.

Our investigation provides additional information about symptoms of children with

COVID-19, timeline of exposure and symptom onset to laboratory-confirmed infection, and

household transmission patterns. Additional studies are warranted to examine pediatric

transmission patterns outside the home in other environments where children congregate such as

schools, and in areas with higher incidence than was observed during our study period. These

studies should include assessments of the effectiveness of mitigation efforts. Finally, additional

studies on previous exposures to other coronaviruses and duration of SARS-CoV-2 antibodies

may shed light on protective factors against future SARS-CoV-2 infections in children.




Conclusions

In this cohort of exposed household contacts, children acquired SARS-CoV-2 infection at

the same rate as adults, and among pediatric contacts, being the child of an individual with

COVID-19 increased the risk of acquiring infection. Children with COVID-19 commonly

reported mild symptoms, including headache, sore throat, rhinorrhea, and nasal congestion.

Compared to adults, children were less likely to report lower respiratory symptoms, particularly

cough, and had a shorter duration of illness. We observed that children were the potential source

of further transmission in approximately one-fifth of households with the opportunity to observe

such transmission patterns. These early pediatric data provide insight into the risk of COVID-19

infection and the resulting symptom profiles of children with mild illness. Further investigations

are warranted to better understand SARS-CoV-2 transmission from children both within and

outside the household.

Acknowledgments Davis County Health Department (UT): Heather Gibb, Sara Hall Summit County Health Department (UT): Carolyn Rose Salt Lake County Health Department (UT): Ilene Risk, Lee Cherie Booth, Jeff Sanchez, Madison Clawson, Tara Scribellito North Shore Health Department (WI): Kala Hardy, Christine Cordova, Kevin Rorabeck, Kathleen Platt City of Milwaukee Health Department (WI): Clinical, Epidemiology, and Laboratory Teams Wauwatosa Health Department (WI): Laura Conklin, Paige Bernau, Emily Tianen Wisconsin Department of Health Services: COVID-19 response team CDC COVID-19 Response: Mayer Antoine, Adebowale Ojo, Brandi Limbago, S. Michele Owens, Wendi Kuhnert-Tallman, Jeff Johnson, Collette Leaumont, Jenny Milucky, Amy Schumacher, Emily Weston, Jessica C. Smith, Michelle Johnson Jones, Jennifer Y. Huang, Erin Moritz, Aubrey Gilliland, Laura Calderwood, Jennifer Imaa, Kaytlin Renfro, Allison Miller, Katie Bantle, Lucia Pawloski, Margaret Williams, Stacy L. Thorne, Jana Manning, Micha Ghertner, Adriane Niare, Yoonjae Kang, Charlotte D. Kaboré




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2CDC. Bridged race population estimates. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://wonder.cdc.gov/bridged-race-v2018.html. 3CDC. CDC COVID Data Tracker: Demographic Trends of COVID-19 cases and deaths in the US reported to CDC. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. [cited September 16, 2020]. https://www.cdc.gov/covid-data-tracker/index.html#demographics. 4CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children – United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):422-426. Published 2020 Apr 10. doi:10.15585/mmwr.mm6914e4. 5Dattner I, Goldberg Y, Katriel G, et al. The role of children in the spread of COVID-19: Using household data from Bnei Brak, Israel, to estimate the relative susceptibility and infectivity of children. MedRxiv. https://doi.org/10.1101/2020.06.03.20121145.

6Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. [published online ahead of print, 2020 Feb 24]. JAMA. 2020;10.1001/jama.2020.2648. doi:10.1001/jama.2020.2648.

7Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics. 2020;145(6):e20200702. doi:10.1542/peds.2020-0702. 8World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Published February 28, 2020. 9Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis. 2020;20(6):689-696. doi:10.1016/S1473-3099(20)30198-5. 10Davies NG, Klepac P, Liu Y, et al. Age-dependent effects in the transmission and control of COVID-19 epidemics. Nat Med. 2020;26(8):1205-1211. doi:10.1038/s41591-020-0962-9. 11Lewis N, Chu V, et al. Household transmission of SARS-CoV-2 in the United States. Clin Infect Dis. ciaa1166, https://doi.org/10.1093/cid/ciaa1166. 12CDC. CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel https://www.fda.gov/media/134922/download. June 12, 2020.


https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

https://wonder.cdc.gov/bridged-race-v2018.html

https://www.cdc.gov/covid-data-tracker/index.html#demographics

https://doi.org/10.1093/cid/ciaa1166

https://www.fda.gov/media/134922/download



13Freeman B, Lester S, Mills L, Rasheed MAU, et al. Validation of a SARS-CoV-2 spike protein ELISA for use in contact investigations and sero-surveillance. bioRxiv 2020.04.24.057323; doi: https://doi.org/10.1101/2020.04.24.057323. 14Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020;172(9):577-582. doi:10.7326/M20-0504. 15CDC. Coronavirus disease 2019 (COVID-19): Symptoms of Coronavirus. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. [cited July 7, 2020]. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. 16Council of State and Territorial Epidemiologists. Infectious Disease Committee. Standardized surveillance case definition and national notification for 2019 novel coronavirus disease (COVID-19). Interim-20-ID-01. https://cdn.ymaws.com/www.cste.org/resource/resmgr/2020ps/Interim-20-ID-01_COVID-19.pdf. 17CDC. Influenza (Flu): Glossary of Influenza (Flu) Terms. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. [cited August 9, 2020]. https://www.cdc.gov/flu/about/glossary.htm. 18World Health Organization. Influenza: RSV surveillance case definitions. Geneva, Switzerland: WHO; 2020. [cited August 9, 2020]. https://www.who.int/influenza/rsv/rsv_case_definition/en/. 19CDC. Screening K-12 Students for Symptoms of COVID-19: Limitations and Considerations. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. [cited September 16, 2020]. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/symptom-screening.html. 20American Academy of Pediatrics. COVID-19 Planning Considerations: Guidance for School Re-entry. [cited September 16, 2020]. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/. 21Szablewski CM, et al. SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp – Georgia, June 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 7;69(31):1023-1025. doi:10.15585/mmwr.mm6931e1. 22Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARS-CoV-2 infections [published online March 30, 2020]. medRxiv. doi:2020.2003.2026.20044826. 23Posfay-Barbe KM, Wagner N, Gauthey M, et al. COVID-19 in children and the dynamics of infection in families. Pediatrics. 2020;146(2):e20201576. doi:10.1542/peds.2020-1576.


https://doi.org/10.1101/2020.04.24.057323

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

https://cdn.ymaws.com/www.cste.org/resource/resmgr/2020ps/Interim-20-ID-01_COVID-19.pdf

https://cdn.ymaws.com/www.cste.org/resource/resmgr/2020ps/Interim-20-ID-01_COVID-19.pdf

https://www.cdc.gov/flu/about/glossary.htm

https://www.who.int/influenza/rsv/rsv_case_definition/en/

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/





24Park YJ, Choe YJ, Park O, et al. Contact Tracing during Coronavirus Disease Outbreak, South Korea, 2020 [published online ahead of print, 2020 Jul 16]. Emerg Infect Dis. 2020;26(10):10.3201/eid2610.201315. doi:10.3201/eid2610.201315. 25Heald-Sargent T, et al. Age-Related Differences in Nasopharyngeal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Levels in Patients With Mild to Moderate Coronavirus Disease 2019 (COVID-19). [published online ahead of print, 2020 Jul 30]. JAMA Pediatr. 2020;174(9):902-903. doi:10.1001/jamapediatrics.2020.3651. 26Yonker LM, et al. Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses. [published online ahead of print, 2020 Aug 18]. J Pediatr. 2020;S0022-3476(20)31023-4. doi:10.1016/j.jpeds.2020.08.037. 27Baggio S, et al. SARS-CoV-2 viral load in the upper respiratory tract of children and adults with early acute COVID-19. [published online ahead of print, 2020 Aug 6]. Clin Infect Dis 2020;ciaa1157. doi: 10.1093/cid/ciaa1157. 28Mannheim J, Gretsch S, Layden JE, Fricchione MJ. Characteristics of Hospitalized Pediatric COVID-19 Cases - Chicago, Illinois, March - April 2020 [published online ahead of print, 2020 Jun 1]. J Pediatric Infect Dis Soc. 2020;piaa070. doi:10.1093/jpids/piaa070. 29Drosten C, et al. Transmission of MERS-coronavirus in household contacts. N Engl J Med. 2014;371(9):828-835. doi:10.1056/NEJMoa1405858. 30Savage R, et al. Assessing secondary attack rates among household contacts at the beginning of the influenza A (H1N1) pandemic in Ontario, Canada, April-June 2009: a prospective, observational study. BMC Public Health. 2011;11:234. Published 2011 Apr 14. doi:10.1186/1471-2458-11-234. 31Iyengar P, et al. Case-ascertained study of household transmission of seasonal influenza – South Africa, 2013. J Infect. 2015;71(5):578-586. doi:10.1016/j.jinf.215.09.001. 32Petrie JG, et al. Influenza transmission in a cohort of households with children: 2010-2011. PLoS One. 2013;8(9):e75339. Published 2013 Sept 25. doi:10.1371/journal.pone.0075339. 33Tsang TK, et al. Household Transmission of Influenza Virus. Trends Microbiol. 2016;24(2):123-133. doi:10.1016/j.tim.2015.10.012.


https://doi.org/10.1016/



Table 1. Demographic, Clinical, and Household Characteristics of Pediatric and Adult Household Contacts (N=188) of Primary Patients with COVID-19

Characteristic Pediatric contacts (n=68) n (%)

Adult contacts in all households

(n=120) n (%)

Adult contacts in households with children

(n=65) n (%)

Sex Male Female

31 (46) 37 (54)

61 (51) 59 (49)

28 (43) 37 (57)

Age (years) <1 1-4 5-12 13-17 18-49 50-64 ≥65

2 (3) 8 (12) 34 (50) 24 (35)

-- -- --

-- -- -- --

88 (73) 26 (22)

6 (5)

-- -- -- --

51 (78) 12 (18) 2 (3)

Race-ethnicity Non-Hispanic White Non-Hispanic Black Hispanic (any race) Non-Hispanic Asian Non-Hispanic AI/AN Non-Hispanic Multiracial

43 (63)

4 (6) 11 (16)

5 (7) 1 (1) 4 (6)

71 (59) 20 (17) 21 (18)

5 (4) 3 (3) 0 (0)

41 (63) 3 (5)

14 (22) 5 (8) 2 (3) 0 (0)

State Wisconsin Utah

21 (31) 47 (69)

41 (34) 79 (66)

17 (26) 48 (74)

Underlying medical conditions Any medical condition Chronic lung disease Asthma Diabetes Cardiovascular disease Kidney disease Liver disease Immunocompromising condition Neurodevelopmental disability Other chronic condition

9 (13) 7 (10) 7 (10) 1 (1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (1)

49 (41) 26 (22) 24 (21) 4 (3)

17 (14) 2 (2) 2 (2) 2 (2) 2 (2) 9 (8)

24 (37) 11 (17) 9 (15) 2 (3) 6 (9) 0 (0) 0 (0) 1 (2) 1 (2) 6 (9)

Relationship to primary patient Spouse/partner Child Sibling Parent Extended family Housemate

--

43 (63) 14 (21)

-- 9 (13) 2 (3)

33 (28) 17 (14) 16 (13) 24 (20) 11 (9)

19 (16)

25 (38) 8 (12)

11 (17) 13 (20) 5 (8) 3 (5)




Number of household members 2–4 5–6 ≥7

24 (35) 21 (31) 23 (34)

66 (55) 30 (25) 24 (20)

26 (40) 17 (26) 22 (34)

Square footage/household member <500 ≥500

30 (44) 38 (56)

59 (49) 61 (51)

26 (40) 39 (60)

Number of persons per bedroom ≤1 >1

27 (40) 41 (60)

61 (51) 59 (49)

34 (52) 31 (48)

Number of persons per bathroom ≤1 >1

6 (9)

62 (91)

15 (13)

105 (88)

7 (11)

58 (89)




Table 2. Risk Factors Associated with SARS-CoV-2 Infection among Pediatric Household Contacts (N=68)

Characteristics of Pediatric Household Contacts

SARS-CoV-2 Positive Children (n=19) n (%)

SARS-CoV-2 Negative Children

(n=49) n (%)

Odds Ratio€ (95% CI)

Age (years) <5 5-12 13-17

2 (11) 7 (37) 10 (53)

8 (16)

27 (55) 14 (29)

0.35 (0.06‒1.91) 0.36 (0.13‒1.05)

Ref Sex Male Female

7 (37) 12 (63)

24 (49) 25 (51)

0.61 (0.16‒2.37)

Ref Race-ethnicity Non-Hispanic White Other

14 (74) 5 (26)

29 (59) 20 (41)

Ref

0.52 (0.10‒2.64) Underlying medical conditions Any medical condition Asthma

4 (21) 2 (11)

5 (10) 5 (10)

2.35 (0.51‒10.89) 1.10 (0.12‒10.47)

Relationship to primary patient Child Sibling/Extended family/Housemate

18 (95)

1 (5)

25 (51) 24 (49)

17.28 (2.36‒126.8)

Ref Attended school in the two weeks before primary patient onset Yes No

7 (37) 12 (63)

15 (31) 34 (69)

1.32 (0.39‒4.46) Ref

Attended daycare in the two weeks before primary patient onset Yes No

1 (5) 18 (95)

2 (4) 47 (96)

1.31 (0.11‒15.50) Ref

Number of household members 2–4 5–6 ≥7

8 (42) 8 (42) 3 (16)

16 (33) 13 (26) 20 (41)

Ref

1.23 (0.27‒5.53) 0.29 (0.08‒1.13)

Square footage/household member <500 ≥500

5 (26) 14 (74)

25 (51) 24 (49)

0.34 (0.08‒1.50)

Ref Number of persons per bedroom ≤1 >1

8 (42) 11 (58)

19 (39) 30 (61)

Ref

0.87 (0.25‒3.10) Number of persons per bathroom ≤1 >1

3 (16) 16 (84)

3 (6)

46 (94)

Ref

0.35 (0.05‒2.50) Serial interval (days) (median, IQR)

5 (4–9) -- --

Duration of symptoms (days)*(median, IQR)

10 (6‒14) -- --

€Unadjusted odds ratios 95% CIs calculated using generalized estimating equations with an independent correlation matrix and logit link to account for clustering within households. *Symptom duration not available past study close out at Day 14; n=2 children were still experiencing symptoms at Day 14.




Table 3. Positive and Negative Predictive Values of Individual Symptoms among Pediatric Household Contacts (N=68) of Primary Patients with COVID-19

SARS-CoV-2 Positive Children (n=19)

SARS-CoV-2 Negative Children (n=49)

Symptom Positive Predictive Value

% (95% CI)

Symptom Negative Predictive Value

% (95% CI)

Symptoms Constitutional Fever Measured (≥38°C§) Subjectiveγ Chills Myalgia Fatigue* Lower respiratory Cough Discomfort while breathing* Shortness of breath Wheezing* Chest pain* Upper respiratory Sore throat Rhinorrhea Nasal congestion Neurological Headache Loss of taste or smell Loss of taste Loss of smell Gastrointestinal Nausea/vomiting Diarrhea Abdominal pain

14 10 3

10 6 7 8

11 8 3 3 1 2

16 13 13 12 16 15 7 4 6 8 5 4 3

10 5 0 5 4 2 6 5 5 0 1 0 0

21 6

16 10 11 10 2 2 2

16 5

12 6

58% (39‒76%) 67% (42‒85%)

100% (44‒100%) 67% (42‒85%) 60% (31‒83%) 78% (45‒94%)

-- 69% (44‒86%) 62% (36‒82%)

-- 75% (30‒95%)

-- --

43% (29‒59%) 68% (46‒85%) 45% (28‒62%) 55% (35‒73%) 59% (41‒75%) 60% (41‒77%) 78% (45‒94%) 67% (30‒90%) 75% (41‒93%) 33% (18‒53%) 50% (24‒76%) 25% (10‒50%) 33% (12‒65%)

89% (76‒95%) 83% (71‒91%) 75% (64‒84%) 83% (71‒91%) 78% (65‒86%) 80% (68‒88%)

-- 85% (72‒92%) 80% (68‒88%)

-- 75% (63‒84%)

-- --

90% (75‒97%) 88% (76‒94%) 85% (70‒93%) 85% (72‒92%) 93% (81‒97%) 91% (78‒96%) 80% (68‒88%) 75% (64‒85%) 78% (66‒87%) 75% (61‒85%) 76% (63‒85%) 71% (58‒82%) 73% (60‒83%)

Case Definitions COVID-19 case definitions COVID-19-like illness (CLI)a CSTE COVID-19b Syndromic surveillance case definitions Influenza-like illness (ILI)c WHO Acute Respiratory Infection (ARI) Definition for Community-Based RSV Surveillanced

14 16

8 16

9 10

2 22

61% (41‒78%) 62% (43‒78%)

80% (49‒94%) 42% (28‒58%)

89% (77‒95%) 93% (81‒98%)

81% (69‒89%) 90% (74‒97%)

§Equivalent to 100.4°F. γSubjective fever is defined as a fever that is felt (tactile) rather than measured. *Not included in list of symptoms asked of all participants; NPVs and PPVs not calculated. aFever, cough, or shortness of breath. bAt least one of the following: cough, shortness of breath, or discomfort breathing; OR at least two of the following: fever, chills, rigors, myalgia, headache, sore throat, loss of taste or smell. cFever and (cough and/or sore throat). dShortness of breath, cough, sore throat, congestion or runny nose


� � � � � � � � � � � � � � � � � � � � � � � � � � � � �� ! � " � � � � � � � � # $ " � !$ � � " � � � �� %� � � � � � � & " � � � � � " � � � � ' � " ( " ) � � � � � � � � � � � �� * +� � � � � � � � %& " � � � � � " � � � � %� � � � � � � � � � , " � � � � " � � � � � � � � �� , " � � � � � � � " � � � � � � � *- . / 0 / 1 . 2 3 4 5 6 2 3 4 . 7 8 4 9 : ; 8 : 69 < = > ?

@ A B C D D E F G C H I E G C D F8 4 9 : ; 8 : 69 < = J JK 7 5 . : 6 L 9 < = M NO 3 / . 7 P 2 9 L 9 < Q J

R 4 5 6 2 3 4 . 7 8 4 9 : ; 8 : 6 S 3 47 2 8 . / 9 2 7 T ; P : / 8 / T ; : / 4 99 < >K 7 5 . : 6 L 9 < UO 3 / . 7 P 2 9 L 9 < VR 4 5 6 2 3 4 . 7 8 4 9 : ; 8 : 6 2 W 8 . 5 7 2 7S 3 4 7 2 8 . / 9 2 7 6 T 2 8 / X 2 98 4 . . 2 8 : / 4 99 < MK 7 5 . : 6 L 9 < NO 3 / . 7 P 2 9 L 9 < M

YZ [\]_ a]^ b\

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Prepublication Release ©2020 American Academy of PediatricsFigure 1. Enrollment Flow Chart

*A convenience sample of index cases with laboratory-confirmed SARS-CoV-2 infection was identified by local health departments through routine surveillance and referred to the CDC team for study enrollment.


33%

28%

30%

28%

0% 10% 20% 30% 40% 50%

Adult contacts in householdswithout children (n=55)

Adult contacts in householdswith children (n=65)

Adult contacts in all households (n=120)

Pediatric household contacts (n=68)

Secondary Infection Rate

Figure 2. Secondary Infection Rates of SARS-CoV-2 among Pediatric and Adult Household Contacts (N=188)

Prepublication Release ©2020 American Academy of Pediatrics ©2020 American Academy of Pediatrics


Figure 3. Timeline§ of Symptom Onset of Pediatric and Adult Secondary Cases in Households With Children Figure 3 shows symptom onset of secondary case-patients in households with children relative to primary patient symptom onset. Each household member is represented by a single symbol (X, closed square, or open square). Panel A shows households with at least one child with laboratory-confirmed SARS-CoV-2 infection. Panel B shows households without no infections among children. §The study period extended beyond the timeline shown. For example, Households B, K, and M were followed for 30, 29, and 20 days, respectively.

Prepublication Release ©2020 American Academy of Pediatrics



Figure 4. Time from Symptom Onset in Primary Patient to SARS-CoV-2 RT-PCR and ELISA Test Results among Pediatric Case-patients Panel A and Panel B show the results from RT-PCR testing and SARS-CoV-2 ELISA testing, respectively, for each child with laboratory-confirmed SARS-CoV-2 infection, with the letter corresponding to the household (see Figure 3). Symptom onset, symptom resolution, and test results of the pediatric case-patient, relative to the primary patient symptom onset, are shown. Only one child (A1, in red) was a primary patient. Two children (A1, G2) continued to have symptoms beyond the study period. Not all children had serological test results at enrollment and study close-out visits.


74%

16%

53%

32%

37%

42%

58%

42%

16%

16%

5%

11%

84%

68%

68%

63%

84%

79%

21%

32%

42%

26%

16%

21%

0% 25% 50% 75% 100%

Any constitutional

Fever (≥38°C)§

Fever (subjective)†

Chills

Myalgia

Fatigue*

Any lower respiratory

Cough

Discomfort while breathing*

Shortness of breath

Wheezing*

Chest pain*

Any upper respiratory

Sore throat

Rhinorrhea

Nasal congestion

Any neurological

Headache

Loss of taste

Loss of smell

Any gastrointestinal

Nausea/vomiting

Abdominal pain

Diarrhea

Frequency

Any constitutional



Any neurological



Figure 5. Frequency of Symptoms among Children with Laboratory-confirmed SARS-CoV-2 Infection (n=19) *Symptom was not systematically asked of all participants.§Equivalent to 100.4°F.†Subjective fever is defined as a fever that is felt (tactile) rather than measured.


0.01 0.1 1 10

Any constitutional

Fever (≥38°C)§

Fever (subjective)†

Chills

Myalgia

Fatigue*


Cough

Discomfort while breathing*

Shortness of breath

Wheezing*

Chest pain*


Sore throat

Rhinorrhea

Nasal congestion

Any neurological

Headache

Loss of taste

Loss of smell


Nausea/vomiting

Abdominal pain

Diarrhea

Odds Ratios and 95% CIs

Symptom category

Individualsymptom

Any constitutional



Any neurological



Figure 6. Odds Ratios€ for the Presence of Symptoms Comparing Children (n=19) to Adults (n=36) with Laboratory-Confirmed SARS-CoV-2 Infection

€Unadjusted odds ratios 95% CIs calculated using generalized estimating equations with an independent correlation matrix and logit link to account for clustering within households. *Symptom was not systematically asked of all participants.§Equivalent to 100.4°F.†Subjective fever is defined as a fever that is felt (tactile) rather than measured.


Form Approved: OMB: 0920-1011 Exp. 4/23/2020

Human Infection with 2019 Novel Coronavirus (nCoV) Household Contact Questionnaire V1.7 rev 4/1/2020 (Household Transmission Investigation)

State: Household ID: __________ Study ID: _______________

Version 1.7 April 1, 2020 1 Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).

This questionnaire is to be administered to each household member (excluding the index patient). Interview Information 1. Date of Interview: / / (MM/DD/YYYY) 2. Name of Interviewer: _________________________________________ 3. Person completing the interview: Self Parent/guardian: ______________________________

Other: ___________________________________________________

Household Member Information 4. Household member’s name: First:_____________________________ Last:___________________________ 5. Date of birth: / / (MM/DD/YYYY) 6. Age: _______ years months days

7. Ethnicity: Hispanic/Latino Non-Hispanic/Latino Not Specified 8. Race: White Black Asian

Am Indian/Alaska Nat Nat Hawaiian/Other PI Other, specify:___________ Unknown

9. Sex: Male Female Unknown Other, specify:______________ 10. What is your relationship to [insert name of index patient]?

Spouse Child Parent Grandparent Sibling Employee Other _____________

11. What is the highest level of education you have completed? Less than high school High school diploma/GED Some college credit, no degree Technical degree/Associate’s degree Bachelor’s degree (i.e., B.A., B.S.) Master’s degree (i.e., MBA) Doctorate or professional degree

12. What is your occupation? ____________________________________________________

SARS-CoV-2 testing for household contacts 13. Have you been tested for coronavirus? Yes No If yes, please complete the following information:

a. Date of specimen collection_______________________________(MM/DD/YYYY) b. Result of test: Positive Negative Pending Don’t know/other ________________ c. Date of test result_______________________________(MM/DD/YYYY) d. Were you experiencing symptoms when you were tested? Yes No

i. Describe:_______________________________________________________________ e. Date of symptom onset: _____________________________(MM/DD/YYYY)

Notes:________________________________________________________________________________






Past Medical History 14. Please provide pre-existing medical conditions (complete regardless of age):

Asthma/reactive airway disease Yes No Unknown

Emphysema/COPD Yes No Unknown

Active tuberculosis Yes No Unknown If YES, on treatment: Yes No Unknown

Any other chronic lung diseases Yes No Unknown If YES, specify:

Diabetes Mellitus Yes No Unknown

Hypertension (high blood pressure) Yes No Unknown

Coronary artery disease/heart attack Yes No Unknown

Congestive heart failure Yes No Unknown

Stroke Yes No Unknown

Congenital heart disease Yes No Unknown

Any other heart diseases Yes No Unknown If YES, specify:

Any kidney disorders? If YES, answer the following:

Yes No Unknown

End-stage renal disease/dialysis Yes No Unknown

Renal insufficiency Yes No Unknown

Other kidney diseases Yes No Unknown If YES, specify:

Any liver disorders? If YES, answer the following:

Yes No Unknown

Alcoholic liver disease Yes No Unknown

Cirrhosis/End stage liver disease Yes No Unknown

Chronic hepatitis B Yes No Unknown

Chronic hepatitis C Yes No Unknown

Non-alcoholic fatty liver disease (NAFLD)/NASH

Yes No Unknown

Other chronic liver diseases Yes No Unknown If YES, specify:

HIV infection. If YES, answer the following:

Yes No Unknown

AIDS or CD4 count currently <200 Yes No Unknown

Ever receive a transplant? If YES, answer the following:

Yes No Unknown

Solid organ transplant If YES, date:

Stem cell transplant (e.g., bone marrow transplant)

Yes No Unknown If YES, date:

Cancer: current/in treatment or diagnosed in last 12 months

Yes No Unknown If YES, specify:___________________

Immunosuppressive therapy/medications Yes No Unknown If YES, specify:___________________ For what condition: _______________________

Other immunosuppressive conditions Yes No Unknown If YES, specify:___________________

Any other chronic diseases Yes No Unknown If YES, specify:






Developmental or neurologic disorder. If YES, answer the following:

Yes No Unknown If YES, specify:

Chromosomal or genetic abnormality Yes No Unknown If YES, specify:___________________________

Cerebral palsy Yes No Unknown

Epilepsy Yes No Unknown

Any other development or neurologic Disorder

If YES, specify:___________________________

Any other medical conditions as a child Yes No Unknown If YES, specify:

Were you born premature? Yes No Unknown If yes, gestation at birth:____________wks

15. [If female] Are you currently pregnant? Yes No Unknown N/A 16. [If female] Are you postpartum (≤6 weeks postpartum)? Yes No Unknown N/A 17. [If female] Are you breastfeeding? Yes No Unknown N/A 18. [If child <3 years] Is your child being breastfed? Yes No Unknown N/A Smoking/Vaping 19. Do you currently smoke tobacco on a daily basis, less than daily, or not at all? Daily Less than daily Not at all Unknown 20. [If not a daily smoker] In the past, have you smoked tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown 21. Do you currently vape or use electronic cigarettes on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

Symptoms Prior to Index Case’s Onset Note to interviewer: record symptom onset date of the index patient from household questionnaire cover sheet. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY) 22. Did you experience any symptoms of a respiratory illness in the 2 weeks prior to [insert name of index patient]

becoming ill? Yes No Unknown

Exposures Outside of the Household Note to interviewer: remind the interviewee to consult a calendar or diary for the following questions. Date of index patient symptom onset: ___/____/____(MM/DD/YYYY) 14 days prior to index patient’s symptom onset: ___/____/____ (MM/DD/YYYY)

23. Since [14 days PRIOR to the index patient’s symptom onset]…

Exposure Answer

…have you traveled (internationally or within the U.S., or on a cruise)?

Yes: with index patient Yes: w/o index patient No Unknown






…attend a mass gathering (e.g., religious event, wedding, party, dance, concert, banquet, festival, sports event, or other events)?


…have close contact (e.g. caring for, speaking with, touching, physically within 6 feet) with any suspected or known COVID-19 case outside of the household?


…work in a healthcare setting? Yes No Unknown If yes, what types of healthcare settings: Hospital Outpatient Clinic Emergency Dept Dental Clinic Dialysis Center ICU Long-term care facility Other, specify: __________ What type of job do you have at the healthcare setting? Admin staff Nurse/Nurse tech Doctor EMS Other, specify: ___________

…visit a healthcare setting (e.g. visit someone or have an appointment -- at a hospital, ED, outpatient clinic, dental clinic, long-term care facility)?

Yes No Unknown

…attend/work at a daycare? Yes No Unknown

…attend/work at a school? Yes No Unknown

Symptoms After the Index Case’s Onset Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)

24. Since ____/____/____, when [the index case] first became symptomatic, have you experienced any of the following symptoms?

Symptom Present?

Fever >100.4F (38C)c Yes No Unk

Subjective fever (felt feverish) Yes No Unk

Chills Yes No Unk

Muscle aches (myalgia) Yes No Unk






25. What date did you first become symptomatic? ___ / __ /_ __ (MM/DD/YYYY)

26. Are you currently experiencing any symptoms of a respiratory illness, such as fever, cough, or shortness of breath?

(Note: Flag any symptomatic household members for workflow planning and offer of self-nasal swab during visit) Yes No Unknown

Exposures to the Index Patient

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY) 27. Since [index case]’s symptoms started on [date of symptom onset of the index patient], did you …….?

Exposure Answer

…spend more than 10 minutes within 6 feet of the index patient?

Yes No Unknown

…have face to face contact with the index patient (i.e., within about 2 feet)?

Yes No Unknown

…spend any time within 6 feet of the index patient while he/she was coughing or sneezing?

Yes No Unknown

…shake hands with the index patient? Yes No Unknown

…hug the index patient? Yes No Unknown

…kiss the index patient? Yes No Unknown

Runny nose (rhinorrhea) Yes No Unk

Nasal congestion Yes No Unk

Sore throat Yes No Unk

Cough (new onset or worsening of chronic cough) Yes No Unk

Shortness of breath (dyspnea) Yes No Unk

Nausea/Vomiting Yes No Unk

Headache Yes No Unk

Abdominal pain Yes No Unk Loss of taste

Complete Partial Yes No Unk

Loss of smell Complete Partial

Yes No Unk

Diarrhea (≥3 loose/looser than normal stools/24hr period) Yes No Unk

Other, specify:






Exposure Answer

…take an object handed from or handled by the index patient? (e.g., pen, paper, food, utensil, etc.)

Yes No Unknown

…sleep in the same bedroom as the index patient? Yes No Unknown

…sleep in the same bed as the index patient? Yes No Unknown

…share a bathroom with the index patient? Yes No Unknown

…prepare food with the index patient? Yes No Unknown

…share meals with the index patient? Yes No Unknown

…eat from the same plate as the index patient? Yes No Unknown

…share a utensil with the index patient? Yes No Unknown

…share a drinking cup/glass with the index patient? Yes No Unknown

…travel in the same vehicle (car, bus, airplane), sitting within 6 feet of the index patient?

Yes No Unknown

28. Did you serve as primary caretaker for the index patient while he/she was ill? Yes No Unknown

29. When was your last exposure (include any exposures described above) to [name of the index patient]?

___ / __ /_ __ (MM/DD/YYYY) Ongoing exposure

30. How many days have you spent in the household since [date of symptom onset of index patient]? ____________

31. How many nights have you spent in the household since [date of symptom onset of index patient]? ___________



Human Infection with 2019 Novel Coronavirus (nCoV) Household Questionnaire V1.4 rev 3/23/2020 (Household Transmission Investigation) State: ____________ Household ID: ___________

Version 1.3 March 23, 2020 1 Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).

HOUSEHOLD QUESTIONNAIRE COVER SHEET - If there are multiple confirmed COVID-19 cases in the household at baseline, identify the case with the

earliest symptom onset as the index patient.

Index case information (fill out ahead of time from PUI/CRF and verify at time of questionnaire administration)

1. Index patient’s name: First: ________________________ Last: ______________________ 2. Phone number: __________________________________ 3. Address: ___________________________________________________________________

4. Index patient’s study ID: ___________ 5. Index patient’s date of birth: ____/_____/_______ (MM/DD/YYYY)

6. Date of symptom onset of the index patient: / / __(MM/DD/YYYY) 7. Date of specimen collection of index patient (first positive test): ____/____/________ (MM/DD/YYYY) 8. Date index patient received test result: __ /____/____ (MM/DD/YYYY)

Household member(s) (fill out ahead of time and verify/complete at time of questionnaire)

Name (first last)

Study ID Relationship to case

Age (yrs)

Sex DOB Phone number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.





HOUSEHOLD QUESTIONNAIRE Note: This questionnaire is to be administered to each household at enrollment. If possible, the head of household should provide information for questionnaire.

Interview information 1. Date of Interview: MM / DD / YYYY 2. Name of Interviewer: _________________________________________

3. Name of household member providing information for interview: _________ ________

Head of household? Yes No If no, relationship to head of household: ________________________

4. Location of the interview: At the household Over the phone Other, specify where: ____________________________________________

Describing the household 5. Location of the household:

County: __________________________ State: ___________________ ZIP Code: __________________

6. Confirm the number of household members from the cover sheet: __________persons Note to interviewer: Include resident family members, live-in staff, and long-term visitors.

7. What is the highest level of education completed by the head of the household? Less than high school High school diploma/GED Some college credit, no degree Technical degree/Associate’s degree Bachelor’s degree (i.e., B.A., B.S.) Master’s degree (i.e., MBA) Doctorate or professional degree

8. What is the occupation of the head of the household? _________________________________________

9. Do you live in a single-family home or multi-unit housing (like an apartment)? Single-family home Multi-unit housing Other (specify):_________________________

10. Do you own or rent your home? Own Rent

11. What is the approximate size of the residence: ___________ square feet 12. Number of floors in the residence: _________________ 13. Number of bedrooms in the residence: 14. Number of bathrooms in the residence:

15. What type of heating does this residence have?

Forced air Radiator Other, specify:_________ Don’t know





16. Since the index patient developed symptoms on [insert date of symptom onset]: a. Has air conditioning been used?

Yes No b. Has the household opened windows for ventilation?

Yes No c. Has any other form of ventilation (e.g. ceiling fans or portable fans) been used?

Yes No

Index patient information Note to interviewer: if the household member completing the interview is not the index patient, ask if the index patient is available for several questions. 17. Are you still experiencing symptoms related to your COVID-19 illness?

Yes No Never had symptoms If no, what date were you back to normal health? MM / DD / YYYY

18. Since you developed respiratory illness, have you done any of the following at home? (select all that apply)

Slept alone in a bed If yes, dates: ______________________________ Slept alone in separate bedroom If yes, dates: ______________________________ Used a private bathroom (not shared) If yes, dates: ______________________________ Wore personal protective equipment If yes, dates: ______________________________ Mask Gloves Other: ________________________________________________________ Other: _________________________________ If yes, dates: ______________________________

19. Which household member has been assisting you as your primary caretaker during your illness? Name: ______________________________________ None Unknown

20. What tasks has this primary caretaker assisted you with? Taking temperature Serving meals Cleaning bedroom Cleaning bathroom Help with toileting Other, specify _________________________________________________

Other: 21. Does the household have pets? Yes No

If yes, how many? _________ pets Note to the interviewer: only include mammalian pets (no livestock).

Species (dog, cat) Age (yrs) Indoor Pet? (y/n) Signs of illness? (y/n) If ill, date of illness onset

1.

2.

3.

4.

Notes:


originally published online October 8, 2020; Pediatrics and Hannah L. Kirking

Lisa Mills, Natalie Thornburg, Aron J. Hall, Alicia M. Fry, Jacqueline E. Tate, Cuc H. Tran Garrett Fox, Dongni Ye, Scott A. Nabity, Alison Binder, Brandi D. Freeman, Sandra Lester,Angela Dunn, Robyn Atkinson-Dunn, Kim Christensen, Tair Kiphibane, Sarah Willardson, Ryan Westergaard, Trivikram Dasu, Sanjib Bhattacharyya, Ann Christiansen, Lindsey Page,

Banks, Jared Rispens, Elizabeth Dietrich, Perrine Marcenac, Almea Matanock, Ian Pray, MichelleFields, Phillip Salvatore, Michelle O'Hegarty, Jeni Vuong, Christopher J. Gregory,

Owusu, Ashutosh Wadhwa, Eric Pevzner, Katherine A. Battey, Henry Njuguna, Victoria L.Radhika Gharpure, Sherry Yin, Sean Buono, Mary Pomeroy, Anna R. Yousaf, Daniel

Conners,Lewis, Mark Fajans, Hannah E. Reses, Lindsey M. Duca, Patrick Dawson, Erin E. Rebecca L. Laws, Rebecca J. Chancey, Elizabeth M. Rabold, Victoria T. Chu, Nathaniel M.

May 2020−March Utah and Wisconsin,−−Symptoms and Transmission of SARS-CoV-2 among Children

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originally published online October 8, 2020; Pediatrics and Hannah L. Kirking

Lisa Mills, Natalie Thornburg, Aron J. Hall, Alicia M. Fry, Jacqueline E. Tate, Cuc H. Tran Garrett Fox, Dongni Ye, Scott A. Nabity, Alison Binder, Brandi D. Freeman, Sandra Lester,Angela Dunn, Robyn Atkinson-Dunn, Kim Christensen, Tair Kiphibane, Sarah Willardson, Ryan Westergaard, Trivikram Dasu, Sanjib Bhattacharyya, Ann Christiansen, Lindsey Page,

Banks, Jared Rispens, Elizabeth Dietrich, Perrine Marcenac, Almea Matanock, Ian Pray, MichelleFields, Phillip Salvatore, Michelle O'Hegarty, Jeni Vuong, Christopher J. Gregory,

Owusu, Ashutosh Wadhwa, Eric Pevzner, Katherine A. Battey, Henry Njuguna, Victoria L.Radhika Gharpure, Sherry Yin, Sean Buono, Mary Pomeroy, Anna R. Yousaf, Daniel

Conners,Lewis, Mark Fajans, Hannah E. Reses, Lindsey M. Duca, Patrick Dawson, Erin E. Rebecca L. Laws, Rebecca J. Chancey, Elizabeth M. Rabold, Victoria T. Chu, Nathaniel M.

May 2020−March Utah and Wisconsin,−−Symptoms and Transmission of SARS-CoV-2 among Children

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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by thebeen published continuously since 1948. Pediatrics is owned, published, and trademarked by the Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has


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