Prolonged viral shedding in feces of children with COVID-19: a systematic review and synthesis of data

Abstract

During the coronavirus disease 2019 (COVID-19) epidemic, many reports have indicated that children shed the virus longer than adults in stool, and that most of the children had mild or even asymptomatic infections, which increased the potential risk for feces to be a source of contamination and may play an important role in the spread of the virus. In this review, we collected relevant literature to summarize the duration of fecal viral shedding in children with COVID-19. We found that in about 60% of the cases, the fecal shedding time was between 28 and 42 days, which was much longer than that of adults. We further explored the possible reason for prolonged shedding and its the potential impact. The poor hand hygiene practices of children, their tendency to swallow sputum and/or saliva, the significant difference in expression of angiotensin-converting enzyme 2 (ACE2) in intestine between children and adults, and the variance in immune status and intestinal microbiome could be considered as potential casual agents of longer fecal viral shedding duration of children. Conclusion : Children with COVID-19 show prolonged fecal shedding compared to adults. Several mechanisms may be involved in the longer fecal viral shedding. Viral shedding in the stool could be contributing to a possible route of transmission. Therefore, we think that further preventive measures in children should be taken to reduce the spread of the disease. What is Known: • Children with COVID-19 are more likely to have asymptomatic infections and to experience mild symptoms. • Some patients continue to shed the virus in feces, despite respiratory samples testing negative. What is New: • Children with COVID-19 carried a longer-term fecal viral shedding than adults. • The poor hand hygiene practices of children, their tendency to swallow sputum and/or saliva, the difference in expression of ACE2 in intestine between children and adults, and the variance in immune status and intestinal microbiome could be considered as potential casual agents of longer fecal viral shedding duration of children.

Promises and challenges of mucosal COVID-19 vaccines

“…Gut infection by SARS-CoV-2 is characterized by the detection of viral antigen in epithelial cells of the intestine and glands, which is consistent with the expression of ACE2 by these cells [ [38] , [40] ]. Viral RNA is shed in the fecal matter for prolonged periods with longer shedding periods reported for children than adults [ 41 ], although it remains to be proven whether shed virus is replication competent and infectious, with literature suggesting contradictory results [ [42] , [43] , [44] ]. This, nevertheless, supports that the gut mucosa is a site of SARS-CoV-2 antigen exposure.…”

Infection, Dysbiosis and Inflammation Interplay in the COVID Era in Children

“…Other studies have shown that after acute infection with SARS-CoV-2, children continue to have the virus in their feces for a long time compared to adults, despite negative breath tests [ 123 , 124 ].…”

Achalasia Following SARS-CoV-2 Infection: A Case Report and Review of Literature

“…However, as our comprehension of the virus and its pathophysiology has deepened, it has become evident that the impact of SARS-CoV-2 extends beyond the respiratory system, with the gastrointestinal (GI) tract being a notable site of involvement [4,5]. A significant subset of COVID-19 patients exhibits gastrointestinal symptoms, including diarrhea, nausea, and vomiting, and viral shedding in feces has been documented [5,6,7,8]. The propensity of SARS-CoV-2 to infect the GI tract is attributed to its utilization of the angiotensin-converting enzyme 2 (ACE2) receptor for cellular entry, a receptor abundantly expressed in various tissues, including the epithelial cells of the GI tract [9].…”