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Volume 27, Number 1—January 2021
Research Letter

Absence of SARS-CoV-2 Transmission from Children in Isolation to Guardians, South Korea

Eun Joo Lee, Dong Hyun Kim, Sung Hee Chang, Sun Bok Suh, Jina Lee, Hyunju Lee, and Mi Seon HanComments to Author 
Author affiliations: Seongnam Citizens Medical Center, Seongnam, South Korea (E.J. Lee); Inha University Hospital, Incheon, South Korea (D.H. Kim); Seoul Medical Center, Seoul, South Korea (S.H. Chang); Busan Medical Center, Busan, South Korea (S.B. Suh); Asan Medical Center, University of Ulsan College of Medicine, Seoul (J. Lee); Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam (H. Lee); Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul (M.S. Han)

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Abstract

We explored transmission of severe acute respiratory syndrome coronavirus 2 among 12 children and their uninfected guardians in hospital isolation rooms in South Korea. We found that, even with close frequent contact, guardians who used appropriate personal protective equipment were not infected by children with diagnosed coronavirus disease.

Coronavirus disease (COVID-19) in children is known to occur mainly from family clusters (1). However, children can be the only infected members in a household, especially when COVID-19 is contracted from relatives or teachers. Such situations raise concerns about isolation because little information is available on transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, during colocation of young children with their uninfected guardians. Although children generally are asymptomatic or have mild symptoms, they could be infective (1,2). We explored whether SARS-CoV-2 was transmitted from children to their uninfected guardians in a hospital isolation setting.

During February 18–June 7, 2020, we analyzed all children <19 years of age with COVID-19 and their uninfected guardians who were isolated together in 7 hospitals in South Korea. The infected children were encouraged to wear face masks. The guardians were advised to wear personal protective equipment (PPE), but the degree of PPE varied among hospitals. Adherence to PPE was monitored by the medical staff; compliance was judged as good when PPE was worn most of the time, fair for frequent adherence, and poor when PPE was worn for less than half of the observed time. Children’s isolation was lifted when 2 consecutive negative respiratory samples were obtained >24 hours apart. To ascertain secondary transmission, guardians’ respiratory samples were tested for SARS-CoV-2 if symptoms developed, before their child’s isolation was lifted, and 2 weeks after the end of isolation. This study was approved by the institutional review board of each hospital and written informed consent was waived.

Among 94 children with COVID-19 isolated in 7 hospitals, 12 children were isolated with a single uninfected guardian (Table). The median age of the patients was 6 years (range 2 months–11 years), and children were isolated for a median of 17 days (range 7–37 days). Most (7/12) children were asymptomatic, 4 had fever or respiratory symptoms, and 1 had pneumonia. Only 4 children cooperated well with wearing face masks.

The guardians included 10 mothers, 1 father, and 1 uncle; all complied with wearing PPE (Table). Most (10/12) guardians wore gloves and masks, either KF94 masks, which filter »94% of particles of 0.4 μm in size, or N95 masks which filter »95% of particles of 0.3 μm in size; 7 also wore gowns or coveralls. One guardian used a surgical mask and 1 guardian wore a KF80 mask, which filters »80% of particles of 0.6 μm, and gloves. Most (10/12) guardians had frequent close contact, but 2 children kept a distance of >1 m from their guardians during isolation. None of the guardians were SARS-CoV-2–positive during the study.

For comparison, we also analyzed 2 cases in which adults with COVID-19 were isolated with their uninfected children because no other caregivers were available (Appendix). The adult patients always wore face masks, but the 2 children never wore PPE and always had physical contact with their parents. However, the children did not become infected. The infected parents’ adherence to the use of masks likely aided in curbing SARS-CoV-2 transmission to their uninfected children by reducing virus particles in respiratory droplets (3).

Appropriate use of PPE, especially face masks, might have protected uninfected guardians in our study. Previous reports have emphasized the use of face masks to prevent SARS-CoV-2 transmission in healthcare and community settings (4). Considering the decreased risk for virus transmission noted with PPE, guardians should be counseled on the proper use of PPE when in isolation with infected children.

We did not observe SARS-CoV-2 transmission from children to guardians in isolation settings in which close proximity would seem to increase transmission risk. Recent studies have suggested that children are not the main drivers of the COVID-19 pandemic, although the reasons remain unclear (5). A large study on contacts of COVID-19 case-patients in South Korea observed that household transmission was lowest when the index case-patient was 0–9 years of age (6). Among pediatric cases, the secondary attack rate from children to household members was estimated to be only 0.5% (7). Reduced transmission from children in households was also reported in Switzerland and China and in educational settings in Australia (810).

This study is limited by its small sample size, which limits the ability to generalize its results. Moreover, we did not assess the patients’ viral load, which could indirectly reflect the infectivity of the children, nor did we assess patient serology, which could further ascertain their infection status. Despite these limitations, our study provides information on SARS-CoV-2 transmission from children to guardians in isolation rooms. Additional assessments of the transmissibility of SARS-CoV-2 by children and the role of PPE in preventing infection could provide guidance during the ongoing pandemic. Nonetheless, our study adds to growing evidence that young children are less likely to contribute to the spread of COVID-19 among their adult guardians.

Dr. E.J. Lee is a pediatrician at the Seongnam Citizens Medical Center, Seongnam, Korea. Her clinical expertise is in the field of pediatric gastroenterology, and her primary research focuses on gut microbiome in children.

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References

  1. Han  MS, Choi  EH, Chang  SH, Jin  B-L, Lee  EJ, Kim  BN, et al. Clinical characteristics and viral RNA detection in children with COVID-19 in the Republic of Korea. JAMA Pediatr. 2020 Aug 28 [Epub ahead of print].
  2. Furukawa  NW, Brooks  JT, Sobel  J. Evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. Emerg Infect Dis. 2020 May 4 [Epub ahead of print].
  3. Leung  NHL, Chu  DKW, Shiu  EYC, Chan  KH, McDevitt  JJ, Hau  BJP, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med. 2020;26:67680. DOIPubMed
  4. Chu  DK, Akl  EA, Duda  S, Solo  K, Yaacoub  S, Schünemann  HJ; COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395:197387. DOIPubMed
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  6. Park  YJ, Choe  YJ, Park  O, Park  SY, Kim  YM, Kim  J, et al.; COVID-19 National Emergency Response Center, Epidemiology and Case Management Team. Contact tracing during coronavirus disease outbreak, South Korea, 2020. Emerg Infect Dis. 2020;26:24658. DOIPubMed
  7. Kim  J, Choe  YJ, Lee  J, Park  YJ, Park  O, Han  MS, et al. Role of children in household transmission of COVID-19. Arch Dis Child. 2020 [Epub ahead of print].
  8. Posfay-Barbe  KM, Wagner  N, Gauthey  M, Moussaoui  D, Loevy  N, Diana  A, et al. COVID-19 in children and the dynamics of infection in families. Pediatrics. 2020;146:e20201576. DOIPubMed
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  10. Macartney  K, Quinn  HE, Pillsbury  AJ, Koirala  A, Deng  L, Winkler  N, et al.; NSW COVID-19 Schools Study Team. Transmission of SARS-CoV-2 in Australian educational settings: a prospective cohort study. Lancet Child Adolesc Health. 2020;4:80716. DOIPubMed

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Cite This Article

DOI: 10.3201/eid2701.203450

Original Publication Date: November 30, 2020

Table of Contents – Volume 27, Number 1—January 2021

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Mi Seon Han, Department of Pediatrics, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, South Korea

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Page created: October 19, 2020
Page updated: December 21, 2020
Page reviewed: December 21, 2020
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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