Editors’ Note: This article was accepted on April 6, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.

What is the incidence of co-infection in children who are positive for COVID-19?

As of writing this column, the data are currently very limited regarding this topic as, overall, children appear to demonstrate milder signs of infection. A study by Xia et al retrospectively evaluated 20 hospitalized children in Wuhan Children’s Hospital in China over a 17-day period.¹ Patient ages ranged from 1 day to 14 years, with a median age of 2 years. According to the authors, the total number of confirmed COVID-19 cases at this time in China was 37,251. The exact reasons for hospitalization of these children were not mentioned. There was a confirmed COVID-19 close contact in 13 of 20 (65 percent) of these pediatric hospitalized cases. Co-infection with another pathogen—either viral or bacterial—occurred in 8 of 20 (40 percent) of patients. The pathogens included cytomegalovirus (n=1), influenza A (n=1), influenza B (n=2), mycoplasma (n=4), and respiratory syncytial virus (n=1); one patient was, therefore, positive for COVID-19 and two additional pathogens. Importantly, most of the children did not demonstrate pulmonary physical exam findings (approximately 75 percent), suggesting that children are potential underrecognized carriers of this pathogen.

Regarding co-infection with coronavirus—while not specific to COVID-19—a study in Nepal by Uddin et al found a co-infection rate of 46 percent (137 of 296 patients). This was a prospective surveillance study over three years in children from birth to 6 months of age. In that population, the most common pathogens of co-infection were rhinovirus, bocavirus, and respiratory syncytial virus.

While it is reassuring that children appear to be less symptomatic than adults in COVID-19 infections, it is important to recognize that co-infections currently appear to be common.

Conclusion

While the data are very limited—especially in COVID-19-positive patients—it is important to recognize that co-infection does not appear to be uncommon and children may be minimally symptomatic with the disease. The best current co-infection estimate in hospitalized children is 40 percent.

References

1. Xia W, Shao J, Guo Y et al. Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults [published online ahead of print March 5, 2020]. Pediatr Pulmonol.
2. Uddin SMI, Englund JA, Kuypers JY, et al. Burden and risk factors for coronavirus infections in infants in rural Nepal. Clin Infect Dis. 2018;67(10):1507-1514.