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      The Effect of COVID-19 on Paediatric Emergencies and Admissions in Morocco: Cannot See the Forest for the Trees?

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          Abstract

          The first case of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) disease (COVID-19) was described in China, in December 2019 [1]. The continuous growth and global spread of COVID-19 cases forced the World Health Organization to declare a global pandemic on 11 March 2020 [2]. In Morocco, the first case was documented on 2 March 2020. Morocco officially declared the state of health emergency 18 days later, establishing a strict curfew from 6 pm to 8 am [3]. While COVID-19 confirmed cases have experienced a gradual increase, visits to the paediatric medical emergency departments at the Rabat Children’s Hospital decreased significantly. Where are the sick Moroccan children normally brought to the emergency department? Our emergency department usually receives a large number of serious cases, including acute complications of diabetes, asthma and epilepsy and other common emergencies, such as poisoning or burns. We compared the number of paediatric consultations (<16 years) in the emergency department from 16 March to 15 April 2020 with the number of consultations of the same period in the preceding year. The hospital uses a paper-based tracking system (in duplicate) to monitor all consultations to the emergency department. Consistently with the mild disease that SARS-COV-2 seems to typically cause in children [4, 5], very few consultations were due to COVID-19 affecting children (n = 10). However, the number of overall consultations decreased by 74% between the two periods (4232 vs. 1110; p < 0.005). Such decrease could easily reflect the many non-severe consultations that traditionally occur in any emergency department, and it is understandable to see numbers decreasing. However, the number of hospitalizations also declined (811 in 2019 vs. 471 in 2020, 41.9% reduction, p < 0.005; see Fig. 1) since containment measures were established on account of COVID-19. SARS-COV2 was only deemed responsible for 31 of those 471 admissions (6.6%), the diagnosis is based on either a positive PCR test or a high clinical suspicion in the context of a plausible epidemiological history. Of these, 10 cases were directly suspected on arrival, and further 21 cases were confirmed PCR-positive transferred cases from other hospitals throughout the country. Of the 10 COVID-19 cases, 9 suspected on arrival affected children with no pre-existing comorbidities (one was in an HIV+ patient), including a single case of Kawasaki-like disease, whose association with COVID-19 could not be firmly established. Fig. 1. Variability in outpatient visits and hospital admissions for the period from 16 March to 15 April in the years 2019 and 2020, at Hôpital d’Enfants de Rabat, Morocco. Factors worrying about parents attending hospital included the lack of public transportation and the fear of contamination by COVID-19. We are concerned about the significant decrease in the number of hospitalizations that represent children in a serious situation. Where did these severely ill patients go? Should we anticipate a new wave of serious non-COVID-19 paediatric admissions in Morocco? Let’s hope the trees allow us to see the rest of the forest.

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          The proximal origin of SARS-CoV-2

          To the Editor — Since the first reports of novel pneumonia (COVID-19) in Wuhan, Hubei province, China 1,2 , there has been considerable discussion on the origin of the causative virus, SARS-CoV-2 3 (also referred to as HCoV-19) 4 . Infections with SARS-CoV-2 are now widespread, and as of 11 March 2020, 121,564 cases have been confirmed in more than 110 countries, with 4,373 deaths 5 . SARS-CoV-2 is the seventh coronavirus known to infect humans; SARS-CoV, MERS-CoV and SARS-CoV-2 can cause severe disease, whereas HKU1, NL63, OC43 and 229E are associated with mild symptoms 6 . Here we review what can be deduced about the origin of SARS-CoV-2 from comparative analysis of genomic data. We offer a perspective on the notable features of the SARS-CoV-2 genome and discuss scenarios by which they could have arisen. Our analyses clearly show that SARS-CoV-2 is not a laboratory construct or a purposefully manipulated virus. Notable features of the SARS-CoV-2 genome Our comparison of alpha- and betacoronaviruses identifies two notable genomic features of SARS-CoV-2: (i) on the basis of structural studies 7–9 and biochemical experiments 1,9,10 , SARS-CoV-2 appears to be optimized for binding to the human receptor ACE2; and (ii) the spike protein of SARS-CoV-2 has a functional polybasic (furin) cleavage site at the S1–S2 boundary through the insertion of 12 nucleotides 8 , which additionally led to the predicted acquisition of three O-linked glycans around the site. 1. Mutations in the receptor-binding domain of SARS-CoV-2 The receptor-binding domain (RBD) in the spike protein is the most variable part of the coronavirus genome 1,2 . Six RBD amino acids have been shown to be critical for binding to ACE2 receptors and for determining the host range of SARS-CoV-like viruses 7 . With coordinates based on SARS-CoV, they are Y442, L472, N479, D480, T487 and Y4911, which correspond to L455, F486, Q493, S494, N501 and Y505 in SARS-CoV-2 7 . Five of these six residues differ between SARS-CoV-2 and SARS-CoV (Fig. 1a). On the basis of structural studies 7–9 and biochemical experiments 1,9,10 , SARS-CoV-2 seems to have an RBD that binds with high affinity to ACE2 from humans, ferrets, cats and other species with high receptor homology 7 . Fig. 1 Features of the spike protein in human SARS-CoV-2 and related coronaviruses. a, Mutations in contact residues of the SARS-CoV-2 spike protein. The spike protein of SARS-CoV-2 (red bar at top) was aligned against the most closely related SARS-CoV-like coronaviruses and SARS-CoV itself. Key residues in the spike protein that make contact to the ACE2 receptor are marked with blue boxes in both SARS-CoV-2 and related viruses, including SARS-CoV (Urbani strain). b, Acquisition of polybasic cleavage site and O-linked glycans. Both the polybasic cleavage site and the three adjacent predicted O-linked glycans are unique to SARS-CoV-2 and were not previously seen in lineage B betacoronaviruses. Sequences shown are from NCBI GenBank, accession codes MN908947, MN996532, AY278741, KY417146 and MK211376. The pangolin coronavirus sequences are a consensus generated from SRR10168377 and SRR10168378 (NCBI BioProject PRJNA573298) 29,30 . While the analyses above suggest that SARS-CoV-2 may bind human ACE2 with high affinity, computational analyses predict that the interaction is not ideal 7 and that the RBD sequence is different from those shown in SARS-CoV to be optimal for receptor binding 7,11 . Thus, the high-affinity binding of the SARS-CoV-2 spike protein to human ACE2 is most likely the result of natural selection on a human or human-like ACE2 that permits another optimal binding solution to arise. This is strong evidence that SARS-CoV-2 is not the product of purposeful manipulation. 2. Polybasic furin cleavage site and O-linked glycans The second notable feature of SARS-CoV-2 is a polybasic cleavage site (RRAR) at the junction of S1 and S2, the two subunits of the spike 8 (Fig. 1b). This allows effective cleavage by furin and other proteases and has a role in determining viral infectivity and host range 12 . In addition, a leading proline is also inserted at this site in SARS-CoV-2; thus, the inserted sequence is PRRA (Fig. 1b). The turn created by the proline is predicted to result in the addition of O-linked glycans to S673, T678 and S686, which flank the cleavage site and are unique to SARS-CoV-2 (Fig. 1b). Polybasic cleavage sites have not been observed in related ‘lineage B’ betacoronaviruses, although other human betacoronaviruses, including HKU1 (lineage A), have those sites and predicted O-linked glycans 13 . Given the level of genetic variation in the spike, it is likely that SARS-CoV-2-like viruses with partial or full polybasic cleavage sites will be discovered in other species. The functional consequence of the polybasic cleavage site in SARS-CoV-2 is unknown, and it will be important to determine its impact on transmissibility and pathogenesis in animal models. Experiments with SARS-CoV have shown that insertion of a furin cleavage site at the S1–S2 junction enhances cell–cell fusion without affecting viral entry 14 . In addition, efficient cleavage of the MERS-CoV spike enables MERS-like coronaviruses from bats to infect human cells 15 . In avian influenza viruses, rapid replication and transmission in highly dense chicken populations selects for the acquisition of polybasic cleavage sites in the hemagglutinin (HA) protein 16 , which serves a function similar to that of the coronavirus spike protein. Acquisition of polybasic cleavage sites in HA, by insertion or recombination, converts low-pathogenicity avian influenza viruses into highly pathogenic forms 16 . The acquisition of polybasic cleavage sites by HA has also been observed after repeated passage in cell culture or through animals 17 . The function of the predicted O-linked glycans is unclear, but they could create a ‘mucin-like domain’ that shields epitopes or key residues on the SARS-CoV-2 spike protein 18 . Several viruses utilize mucin-like domains as glycan shields involved immunoevasion 18 . Although prediction of O-linked glycosylation is robust, experimental studies are needed to determine if these sites are used in SARS-CoV-2. Theories of SARS-CoV-2 origins It is improbable that SARS-CoV-2 emerged through laboratory manipulation of a related SARS-CoV-like coronavirus. As noted above, the RBD of SARS-CoV-2 is optimized for binding to human ACE2 with an efficient solution different from those previously predicted 7,11 . Furthermore, if genetic manipulation had been performed, one of the several reverse-genetic systems available for betacoronaviruses would probably have been used 19 . However, the genetic data irrefutably show that SARS-CoV-2 is not derived from any previously used virus backbone 20 . Instead, we propose two scenarios that can plausibly explain the origin of SARS-CoV-2: (i) natural selection in an animal host before zoonotic transfer; and (ii) natural selection in humans following zoonotic transfer. We also discuss whether selection during passage could have given rise to SARS-CoV-2. 1. Natural selection in an animal host before zoonotic transfer As many early cases of COVID-19 were linked to the Huanan market in Wuhan 1,2 , it is possible that an animal source was present at this location. Given the similarity of SARS-CoV-2 to bat SARS-CoV-like coronaviruses 2 , it is likely that bats serve as reservoir hosts for its progenitor. Although RaTG13, sampled from a Rhinolophus affinis bat 1 , is ~96% identical overall to SARS-CoV-2, its spike diverges in the RBD, which suggests that it may not bind efficiently to human ACE2 7 (Fig. 1a). Malayan pangolins (Manis javanica) illegally imported into Guangdong province contain coronaviruses similar to SARS-CoV-2 21 . Although the RaTG13 bat virus remains the closest to SARS-CoV-2 across the genome 1 , some pangolin coronaviruses exhibit strong similarity to SARS-CoV-2 in the RBD, including all six key RBD residues 21 (Fig. 1). This clearly shows that the SARS-CoV-2 spike protein optimized for binding to human-like ACE2 is the result of natural selection. Neither the bat betacoronaviruses nor the pangolin betacoronaviruses sampled thus far have polybasic cleavage sites. Although no animal coronavirus has been identified that is sufficiently similar to have served as the direct progenitor of SARS-CoV-2, the diversity of coronaviruses in bats and other species is massively undersampled. Mutations, insertions and deletions can occur near the S1–S2 junction of coronaviruses 22 , which shows that the polybasic cleavage site can arise by a natural evolutionary process. For a precursor virus to acquire both the polybasic cleavage site and mutations in the spike protein suitable for binding to human ACE2, an animal host would probably have to have a high population density (to allow natural selection to proceed efficiently) and an ACE2-encoding gene that is similar to the human ortholog. 2. Natural selection in humans following zoonotic transfer It is possible that a progenitor of SARS-CoV-2 jumped into humans, acquiring the genomic features described above through adaptation during undetected human-to-human transmission. Once acquired, these adaptations would enable the pandemic to take off and produce a sufficiently large cluster of cases to trigger the surveillance system that detected it 1,2 . All SARS-CoV-2 genomes sequenced so far have the genomic features described above and are thus derived from a common ancestor that had them too. The presence in pangolins of an RBD very similar to that of SARS-CoV-2 means that we can infer this was also probably in the virus that jumped to humans. This leaves the insertion of polybasic cleavage site to occur during human-to-human transmission. Estimates of the timing of the most recent common ancestor of SARS-CoV-2 made with current sequence data point to emergence of the virus in late November 2019 to early December 2019 23 , compatible with the earliest retrospectively confirmed cases 24 . Hence, this scenario presumes a period of unrecognized transmission in humans between the initial zoonotic event and the acquisition of the polybasic cleavage site. Sufficient opportunity could have arisen if there had been many prior zoonotic events that produced short chains of human-to-human transmission over an extended period. This is essentially the situation for MERS-CoV, for which all human cases are the result of repeated jumps of the virus from dromedary camels, producing single infections or short transmission chains that eventually resolve, with no adaptation to sustained transmission 25 . Studies of banked human samples could provide information on whether such cryptic spread has occurred. Retrospective serological studies could also be informative, and a few such studies have been conducted showing low-level exposures to SARS-CoV-like coronaviruses in certain areas of China 26 . Critically, however, these studies could not have distinguished whether exposures were due to prior infections with SARS-CoV, SARS-CoV-2 or other SARS-CoV-like coronaviruses. Further serological studies should be conducted to determine the extent of prior human exposure to SARS-CoV-2. 3. Selection during passage Basic research involving passage of bat SARS-CoV-like coronaviruses in cell culture and/or animal models has been ongoing for many years in biosafety level 2 laboratories across the world 27 , and there are documented instances of laboratory escapes of SARS-CoV 28 . We must therefore examine the possibility of an inadvertent laboratory release of SARS-CoV-2. In theory, it is possible that SARS-CoV-2 acquired RBD mutations (Fig. 1a) during adaptation to passage in cell culture, as has been observed in studies of SARS-CoV 11 . The finding of SARS-CoV-like coronaviruses from pangolins with nearly identical RBDs, however, provides a much stronger and more parsimonious explanation of how SARS-CoV-2 acquired these via recombination or mutation 19 . The acquisition of both the polybasic cleavage site and predicted O-linked glycans also argues against culture-based scenarios. New polybasic cleavage sites have been observed only after prolonged passage of low-pathogenicity avian influenza virus in vitro or in vivo 17 . Furthermore, a hypothetical generation of SARS-CoV-2 by cell culture or animal passage would have required prior isolation of a progenitor virus with very high genetic similarity, which has not been described. Subsequent generation of a polybasic cleavage site would have then required repeated passage in cell culture or animals with ACE2 receptors similar to those of humans, but such work has also not previously been described. Finally, the generation of the predicted O-linked glycans is also unlikely to have occurred due to cell-culture passage, as such features suggest the involvement of an immune system 18 . Conclusions In the midst of the global COVID-19 public-health emergency, it is reasonable to wonder why the origins of the pandemic matter. Detailed understanding of how an animal virus jumped species boundaries to infect humans so productively will help in the prevention of future zoonotic events. For example, if SARS-CoV-2 pre-adapted in another animal species, then there is the risk of future re-emergence events. In contrast, if the adaptive process occurred in humans, then even if repeated zoonotic transfers occur, they are unlikely to take off without the same series of mutations. In addition, identifying the closest viral relatives of SARS-CoV-2 circulating in animals will greatly assist studies of viral function. Indeed, the availability of the RaTG13 bat sequence helped reveal key RBD mutations and the polybasic cleavage site. The genomic features described here may explain in part the infectiousness and transmissibility of SARS-CoV-2 in humans. Although the evidence shows that SARS-CoV-2 is not a purposefully manipulated virus, it is currently impossible to prove or disprove the other theories of its origin described here. However, since we observed all notable SARS-CoV-2 features, including the optimized RBD and polybasic cleavage site, in related coronaviruses in nature, we do not believe that any type of laboratory-based scenario is plausible. More scientific data could swing the balance of evidence to favor one hypothesis over another. Obtaining related viral sequences from animal sources would be the most definitive way of revealing viral origins. For example, a future observation of an intermediate or fully formed polybasic cleavage site in a SARS-CoV-2-like virus from animals would lend even further support to the natural-selection hypotheses. It would also be helpful to obtain more genetic and functional data about SARS-CoV-2, including animal studies. The identification of a potential intermediate host of SARS-CoV-2, as well as sequencing of the virus from very early cases, would similarly be highly informative. Irrespective of the exact mechanisms by which SARS-CoV-2 originated via natural selection, the ongoing surveillance of pneumonia in humans and other animals is clearly of utmost importance.
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            Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults

            Abstract Aim The coronavirus disease 2019 (COVID‐19) pandemic has affected hundreds of thousands of people. Data on symptoms and prognosis in children are rare. Methods A systematic literature review was carried out to identify papers on COVID‐19, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), using the MEDLINE and Embase databases between January 1 and March 18, 2020. Results The search identified 45 relevant scientific papers and letters. The review showed that children have so far accounted for 1%‐5% of diagnosed COVID‐19 cases, they often have milder disease than adults and deaths have been extremely rare. Diagnostic findings have been similar to adults, with fever and respiratory symptoms being prevalent, but fewer children seem to have developed severe pneumonia. Elevated inflammatory markers were less common in children, and lymphocytopenia seemed rare. Newborn infants have developed symptomatic COVID‐19, but evidence of vertical intrauterine transmission was scarce. Suggested treatment included providing oxygen, inhalations, nutritional support and maintaining fluids and electrolyte balances. Conclusions The coronavirus disease 2019 has occurred in children, but they seemed to have a milder disease course and better prognosis than adults. Deaths were extremely rare.
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              A safe flight for children through COVID-19 disaster: keeping our mind open!

              In 1972 the pilots of Eastern Air Lines Flight 401 to Miami International Airport noticed that the nose wheel of the landing gear was not locked properly in place. While the crew was troubleshooting the anomalous gear indicator and the autopilot was disconnected, they did not notice that the aircraft was gradually losing altitude until it finally crashed into the Florida Everglades. The improper division of duties on the flight deck, the exclusive focus on one aspect of the flight security, and the failure to think about all available resources for a safe landing was underlying this tragedy [2]. This event might be of help to face the current coronavirus induced disease-19 (Covid-19) crisis. Nowadays, most countries affected by Covid-19 are in lockdown. Standard measures put in place are travel bans, working from home, closure of schools, and, overall, limiting social contacts as much as possible. It is necessary to contrast the immediate consequences of Covid-19 pandemics such as a shortage of intensive care units and a high death toll. However, both health authorities and care providers should not forget the dormant and mostly unseen effects of these measurements, especially on vulnerable individuals. Through this editorial we would like to encourage its readers to comprehensively consider the possible negative and positive consequences of lockdown measures on children. School closures have led to 1.5 billion school-age children and adolescents being homebound, representing over 90% of the world’s student population, thereby reaching beyond borders and posing potential global issues for those affected [4]. Teachers, schools, and institutions have undertaken tremendous efforts to supply children with education at home. However, being homebound as a child should not be taken lightly. Besides the lack of knowledge-creating a possible educational backlog- also social and peer support provided by school, or sports clubs have vanished. Moreover, through social distancing, children are unable to visit their grandparents. On top of that, the new disease Covid-19 has brought about many unknowns and thereby causing social stigmatization towards groups of people, those infected and their family [5]. Yet, children are possibly not only affected in the social or educational domain. A lockdown could have serious health consequences, such as a risk of late presentation to the hospital, frequent dental problems [6], irregular sleeping patterns, an increase in sedentary behavior, as well as an increase in- or worsening of domestic violence [1]. The French Ministry of the Interior has reported a rise in child abuse warnings of 90%, substantiating the gravity of the situation [3]. On the other hand, every disaster has its learning opportunities, and so does the current Covid-19 crisis. We must not forget that the previously mentioned negative consequences might coincide with possible positive aspects. Children being homebound now have more time to spend with their caregivers, as well as with their siblings. Also, school closures might induce awareness in children that school and education is an opportunity, and school closures might lead to a decrease in negative social phenomena, such as bullying. Furthermore, the nature of the current crisis brought about national and international campaigns to raise awareness for personal hygiene. Parents are stimulated to educate children on health responsibilities and involve children in, e.g. washing hands. On top of that, in some cases, due to the lack of regular healthcare availability, parents are forced to rely on their skills to manage children with mild symptoms of any disease, and this might increase parents’ self-confidence in maintaining the health of their children. With this, we would like to encourage and inspire readers to take into account the possible negative consequences of the current Covid-19 crisis. But, simultaneously take into consideration the potential learning opportunities in the form of positive implications. Many of them have not been discussed, but they are reported in a comprehensively way, at least tentatively, in the figure. Some others might still be currently unknown. All in all, we hope that clinicians, researchers, caregivers, and any others involved will establish a broad focus towards this crisis, to facilitate a safe landing for our children.
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                Author and article information

                Journal
                J Trop Pediatr
                J. Trop. Pediatr
                tropej
                Journal of Tropical Pediatrics
                Oxford University Press
                0142-6338
                1465-3664
                03 August 2020
                : fmaa046
                Affiliations
                [f1 ]Paediatric Medical Emergency Department, Rabat Children's Hospital , Rabat, Morocco
                [f2 ] Laboratory Of Biostatistics, Clinical Research And Epidemiology, Faculty of Medecine and Pharmacy, Mohamed V University of Rabat , Rabat, Morocco
                [f3 ] Mohammed V University , Rabat, Morocco
                [f4 ] ISGlobal, Hospital Clínic—Universitat de Barcelona , Barcelona, Spain
                [f5 ] Centro de Investigação em Saúde de Manhiça (CISM) , Maputo, Mozambique
                [f6 ] ICREA , Pg. Lluís Companys 23, 08010 Barcelona, Spain
                [f7 ]Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona) , Barcelona, Spain
                [f8 ] Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP) , Madrid, Spain
                Author notes
                Correspondence: Quique Bassat, MD, PhD, Barcelona Institute for Global Health (ISGlobal), Rosselló 132, 08036 Barcelona, Spain. E-mail: quique.bassat@ 123456isglobal.org
                Article
                fmaa046
                10.1093/tropej/fmaa046
                7454865
                32744305
                5d692340-ea4a-4024-bfe5-00f4871c1f2a
                © The Author(s) [2020]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com

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