Saliva: an important alternative for screening and monitoring of COVID-19 in children

Santos, Catielma Nascimento; Rezende, Karla Mayra; Oliveira Neto, Nilson Ferreira de; Okay, Thelma Suely; Braz-Silva, Paulo Henrique; Bönecker, Marcelo

doi:10.1590/1807-3107bor-2020.vol34.0125

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Critical Review, Pediatric Dentistry • Braz. oral. res. 34 • 2020 • https://doi.org/10.1590/1807-3107bor-2020.vol34.0125 copy

Saliva: an important alternative for screening and monitoring of COVID-19 in children

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

The increasing number of cases of COVID-19 worldwide poses challenges to healthcare systems not only in effectively identifying individuals positive for SARS-CoV-2, but also in isolating cases to minimise contagion in early diagnosing more severe cases that will need hospitalization. Less-invasive collection methods are indispensable in a pandemic scenario as large-scale tests are necessary to understand the actual evolution of contagion in different populations, thus enabling decision-making based on scientific evidence. Saliva has been shown to be an alternative for diagnosing viral infections as this biological fluid can be easily and quickly collected without using specific devices and causing less discomfort during collection, which is an important factor for use in children. Despite the smaller percentage of severe cases of COVID-19 among children, they seem to play an important role in the contagion as they have the same potential of transmission as that of adults. Knowing the evolution of COVID-19 pandemic in children is extremely important, mainly regarding the changing in rules of social distancing, such as re-opening schools and recreational activities spaces. In addition, countless cases of a severe multi-systemic inflammatory syndrome that shares clinical and laboratory features with Kawasaki's disease have been recently related to SARS-CoV-2 infections in children, adolescents and young adults. In view of this scenario, the aim of this study was to present saliva as an alternative for seeking diagnostic and prognostic markers of COVID-19 in children, including adequate sample collection techniques for different age groups.

Keywords:
Coronavirus; COVID-19; Diagnosis; Pediatrics; Saliva

Clinical classifications	Characteristics
Asymptomatic infection	Children tested positive for 2019-nCoV, but without clinical manifestations or abnormal chest imaging findings.
Acute upper respiratory tract infection	Children presenting with fever, cough, pharyngeal pain, nasal congestion, fatigue, headache, myalgia among other signs and symptoms, but without signs of pneumonia according to the chest imaging or sepsis.
Mild pneumonia	Children with or without fever, respiratory symptoms such as cough; and chest imaging indicating pneumonia, but not reaching the criteria of severe pneumonia.
Severe pneumonia	1. Increased respiratory rate: ≥ 70 times/min (<1 year), ≥50 times/min (≥1year) (after ruling out the effects of fever and crying);
	2. Oxygen saturation;
	3. Hypoxia: assisted breathing (moans, nasal flaring, and three concave signs), cyanosis, intermittent apnea;
	4. Disturbance of consciousness: somnolence, coma or seizures;
	5. Food refusal or feeding difficulty, with signs of dehydration.
Critical cases	Those who meet any of the following criteria and require ICU admission: (1) Respiratory failure requiring mechanical ventilation; (2) Shock; (3) Combined with other organs failure.

Orientations	Detailing
Physical distancing	Maintain a distance of at least 1 metre for both students (all age-groups) and staff, where feasible.
	Limit mixing of classes and of age groups for school and after-school activities.
	The high-school timetable can be modified, with some students and teachers attending in the morning, others in the afternoon, others in the evening. Schools can also minimize shared break times by alternating when and where classes take meals.
	Consider increasing the number of teachers or having recourse to volunteer support, if possible, to allow for fewer students per classroom (if space is available).
	Ensure crowd control during school or day-care drop off and pick up periods; clearly identify entry and exits, with marking direction for walking; consider restrictions for parents and care-givers entering school campus and premises.
	Create awareness that ensures students do not gather in large groups or in close proximity when in lines, when leaving the school and in their free time.
Wearing of masks	Children aged 5 years and under should not be required to wear masks.
	For children between six and 11 years of age, a risk-based approach should be applied to the decision to use a mask.
	Children and adolescents 12 years or older should follow the national mask guidelines for adults.
	All efforts should be made to ensure the use of a mask does not interfere with learning.
Ventilation	Consider using natural ventilation.
	Ensure adequate ventilation, mainly to occupied spaces.
	If heating, ventilation and air conditioning (HVAC) systems are used, they should be regularly inspected, maintained and cleaned.
	For mechanical systems increase the total airflow supply and the percentage of outdoor air, such as by using economizer modes of HVAC operations (potentially as high as 100%).C17
	Disable demand-control ventilation (DCV) controls that reduce air supply based on temperature or occupancy.
	Consider running the HVAC system at maximum outside airflow for 2 hours before and after times when the building is occupied.
Hygiene and daily practices	Create a schedule for frequent hand hygiene.
	Provide sufficient soap and clean water or alcohol-based rub at school entrances and throughout the school and in classrooms.
	Schedule regular cleaning of the school environment as well as daily increase frequency of cleaning in the canteen, gym and sports facilities and changing rooms.
	Put in place respiratory and hand hygiene and physical distancing measures in transportation such as school buses.
Screening and management of sick students, teachers and other school staff	Enforce the policy of “staying at home if unwell” for students, teachers or school staff with potential COVID-19 infection and connect them with local healthcare providers for assessment, testing and care. If possible, connect with local organizations to provide home care support and ensure communication between home and school.
	Consider daily screening for history of fever or feeling feverish in the previous 24 hours upon entry into the building for all staff, students and visitors to identify persons who are sick.
	Ensure students who have been in contact with a COVID-19 case stay home for 14 days. School officials should notify public health authorities in the event of a positive COVID-19 case among students or staff.

Techniques	Age
Techniques	0-6 months old	Early childhood (up to 3 yrs)	Pre-school age (3– 6 yrs)	School age (> 6 yrs)
Aspiration of saliva with syringe and test tube	X	X
Open suction		X	X	X
Close suction			X	X
Expectoration or spit				X
Drainage				X
Swab		X	X	X

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[1] Corresponding Author: Paulo Henrique Braz-Silva, E-mail: pbraz@usp.br