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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 …
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