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Since the first reports of SARS-CoV-2 infections in China, doctors, parents and policy-makers have been aware that COVID-19 is ‘not just another respiratory virus’ in children. There is a large discrepancy in case rate and prognosis between young children and older adults that has caught everyone by surprise, and for which the mechanisms remain unknown. As community testing has demonstrated a significant number of children with no or subclinical symptoms,1 key questions needs answering: are there low rates of confirmed infection in children because children are not becoming infected and/or infectious, or is COVID-19 in children usually such a benign upper respiratory illness that does not even cause infants or immune suppressed children to need hospital admission? If children are infected, are they infectious to each other and/or to adults? If so, how long for?
The implications of asymptomatic but potentially infectious children in the community are important. If, as for influenza,2 children are the primary drivers of household SARS-CoV-2 transmission, then silent spread from children who did not alert anyone to their infection could be a serious driver of community transmission. On this presumption but without evidence, school closures were implemented almost ubiquitously around the world to try and halt the potential spread of disease despite early modelling that suggested this would have less impact than most other non-pharmacological interventions.3
Early contact tracing data from Shenzhen, China, appeared to confirm a role for children in transmission. Although apparently presenting with more benign disease or even without symptoms, similar attack rates were found in children and adults in individual households.4 However, the story has subsequently evolved.
Some regions have implemented widespread community testing, such as South Korea and Iceland. Both countries found children were significantly underrepresented. In Iceland, this is true both in …
Correction notice This paper has been amended since it was published Online First. The digital object identifiers were missing from some of the references. Also, we have removed the ‘accessed date’ for reference 11 because this was added by the publisher and was not the date accessed by the authors. The article states ‘In New South Wales, Australia none of 735 students and 128 staff contracted COVID-19 from nine child and nine adult initial school cases despite close contact.’ This paragraph has been rewritten to provide more clarity. The publisher has also updated references which cite preprints to make it clearer that these are preprints. In paragraph four, starting ‘In some regions…’ it should have been clearer that the data from Japan was also reported in a preprint.
Contributors APSM and SNF both conceived the paper. APSM wrote the first draft of the manuscript, and SNF and APSM both edited and agreed on the final manuscript.
Funding The salaries of APSM and SNF are funded in part by the NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.