Chest computed tomography in children with COVID-19 respiratory infection
Identifieur interne : 000315 ( Pmc/Corpus ); précédent : 000314; suivant : 000316Chest computed tomography in children with COVID-19 respiratory infection
Auteurs : Wei Li ; Huaqian Cui ; Kunwei Li ; Yijie Fang ; Shaolin LiSource :
- Pediatric Radiology [ 0301-0449 ] ; 2020.
Abstract
Infection with COVID-19 is currently rare in children.
To describe chest CT findings in children with COVID-19.
We studied children at a large tertiary-care hospital in China, during the period from 28 January 2019 to 8 February 2020, who had positive reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19. We recorded findings at any chest CT performed in the included children, along with core clinical observations.
We included five children from 10 months to 6 years of age (mean 3.4 years). All had had at least one CT scan after admission. Three of these five had CT abnormality on the first CT scan (at 2 days, 4 days and 9 days, respectively, after onset of symptoms) in the form of patchy ground-glass opacities; all normalised during treatment.
Compared to reports in adults, we found similar but more modest lung abnormalities at CT in our small paediatric cohort.
Url:
DOI: 10.1007/s00247-020-04656-7
PubMed: 31901986
PubMed Central: 7080075
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PMC:7080075Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Chest computed tomography in children with COVID-19 respiratory infection</title><author><name sortKey="Li, Wei" sort="Li, Wei" uniqKey="Li W" first="Wei" last="Li">Wei Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Cui, Huaqian" sort="Cui, Huaqian" uniqKey="Cui H" first="Huaqian" last="Cui">Huaqian Cui</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Department of Medical Affairs, The Fifth Affiliated Hospital,</institution><institution>Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Li, Kunwei" sort="Li, Kunwei" uniqKey="Li K" first="Kunwei" last="Li">Kunwei Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Fang, Yijie" sort="Fang, Yijie" uniqKey="Fang Y" first="Yijie" last="Fang">Yijie Fang</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Li, Shaolin" sort="Li, Shaolin" uniqKey="Li S" first="Shaolin" last="Li">Shaolin Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">31901986</idno><idno type="pmc">7080075</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080075</idno><idno type="RBID">PMC:7080075</idno><idno type="doi">10.1007/s00247-020-04656-7</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000315</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000315</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Chest computed tomography in children with COVID-19 respiratory infection</title><author><name sortKey="Li, Wei" sort="Li, Wei" uniqKey="Li W" first="Wei" last="Li">Wei Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Cui, Huaqian" sort="Cui, Huaqian" uniqKey="Cui H" first="Huaqian" last="Cui">Huaqian Cui</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Department of Medical Affairs, The Fifth Affiliated Hospital,</institution><institution>Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Li, Kunwei" sort="Li, Kunwei" uniqKey="Li K" first="Kunwei" last="Li">Kunwei Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Fang, Yijie" sort="Fang, Yijie" uniqKey="Fang Y" first="Yijie" last="Fang">Yijie Fang</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author><author><name sortKey="Li, Shaolin" sort="Li, Shaolin" uniqKey="Li S" first="Shaolin" last="Li">Shaolin Li</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</nlm:aff></affiliation></author></analytic><series><title level="j">Pediatric Radiology</title><idno type="ISSN">0301-0449</idno><idno type="eISSN">1432-1998</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p id="Par1">Infection with COVID-19 is currently rare in children.</p></sec><sec><title>Objective</title><p id="Par2">To describe chest CT findings in children with COVID-19.</p></sec><sec><title>Materials and methods</title><p id="Par3">We studied children at a large tertiary-care hospital in China, during the period from 28 January 2019 to 8 February 2020, who had positive reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19. We recorded findings at any chest CT performed in the included children, along with core clinical observations.</p></sec><sec><title>Results</title><p id="Par4">We included five children from 10 months to 6 years of age (mean 3.4 years). All had had at least one CT scan after admission. Three of these five had CT abnormality on the first CT scan (at 2 days, 4 days and 9 days, respectively, after onset of symptoms) in the form of patchy ground-glass opacities; all normalised during treatment.</p></sec><sec><title>Conclusion</title><p id="Par5">Compared to reports in adults, we found similar but more modest lung abnormalities at CT in our small paediatric cohort.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Pediatr Radiol</journal-id><journal-id journal-id-type="iso-abbrev">Pediatr Radiol</journal-id><journal-title-group><journal-title>Pediatric Radiology</journal-title></journal-title-group><issn pub-type="ppub">0301-0449</issn><issn pub-type="epub">1432-1998</issn><publisher><publisher-name>Springer Berlin Heidelberg</publisher-name><publisher-loc>Berlin/Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">31901986</article-id><article-id pub-id-type="pmc">7080075</article-id><article-id pub-id-type="publisher-id">4656</article-id><article-id pub-id-type="doi">10.1007/s00247-020-04656-7</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Chest computed tomography in children with COVID-19 respiratory infection</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Li</surname><given-names>Wei</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Cui</surname><given-names>Huaqian</given-names></name><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Li</surname><given-names>Kunwei</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Fang</surname><given-names>Yijie</given-names></name><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Li</surname><given-names>Shaolin</given-names></name><address><email>lishlin5@mail.sysu.edu.cn</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Radiology, The Fifth Affiliated Hospital, Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.12981.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2360 039X</institution-id><institution>Department of Medical Affairs, The Fifth Affiliated Hospital,</institution><institution>Sun Yat-sen University,</institution></institution-wrap>52 East Meihua Road, New Xiangzhou, Zhuhai, Guangdong Province China</aff></contrib-group><pub-date pub-type="epub"><day>11</day><month>3</month><year>2020</year></pub-date><fpage>1</fpage><lpage>4</lpage><history><date date-type="received"><day>18</day><month>2</month><year>2020</year></date><date date-type="rev-recd"><day>18</day><month>2</month><year>2020</year></date><date date-type="accepted"><day>2</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© Springer-Verlag GmbH Germany, part of Springer Nature 2020</copyright-statement><license><license-p>This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p id="Par1">Infection with COVID-19 is currently rare in children.</p></sec><sec><title>Objective</title><p id="Par2">To describe chest CT findings in children with COVID-19.</p></sec><sec><title>Materials and methods</title><p id="Par3">We studied children at a large tertiary-care hospital in China, during the period from 28 January 2019 to 8 February 2020, who had positive reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19. We recorded findings at any chest CT performed in the included children, along with core clinical observations.</p></sec><sec><title>Results</title><p id="Par4">We included five children from 10 months to 6 years of age (mean 3.4 years). All had had at least one CT scan after admission. Three of these five had CT abnormality on the first CT scan (at 2 days, 4 days and 9 days, respectively, after onset of symptoms) in the form of patchy ground-glass opacities; all normalised during treatment.</p></sec><sec><title>Conclusion</title><p id="Par5">Compared to reports in adults, we found similar but more modest lung abnormalities at CT in our small paediatric cohort.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Child</kwd><kwd>Computed tomography</kwd><kwd>Coronavirus</kwd><kwd>COVID-19</kwd><kwd>Pneumonia</kwd><kwd>Viral</kwd></kwd-group></article-meta></front><body><sec id="Sec1"><title>Introduction</title><p id="Par6">On 31 December 2019, an “unknown viral pneumonia” was first reported in Wuhan, China; it was initially named the 2019 novel coronavirus (2019-nCoV) [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>]. On 11 February 2020, the International Committee on Taxonomy of Viruses referred to a new coronavirus capable of infecting humans as SARS-CoV-2 [<xref ref-type="bibr" rid="CR3">3</xref>]. On the same day, the World Health Organization announced that the official name of the disease caused by this virus is COVID-19 [<xref ref-type="bibr" rid="CR4">4</xref>]. As of 4 March 2020, there were 93,094 confirmed cases of COVID-19 in 77 countries, with 80,422 in China [<xref ref-type="bibr" rid="CR5">5</xref>]. According to recently published literature, similar to previously reported coronavirus infections, the typical radiographic image of pulmonary involvement in COVID-19 is parenchymal destruction expressed as ground-glass opacities and consolidation [<xref ref-type="bibr" rid="CR6">6</xref>]. It has been reported that the susceptible population to the virus is mainly older adults with low immunity, and there have been few reports of paediatric patients [<xref ref-type="bibr" rid="CR7">7</xref>]. Our objective was to present preliminary findings of abnormalities at chest CT in children with proven COVID-19.</p></sec><sec id="Sec2"><title>Materials and methods</title><p id="Par7">The Fifth Affiliated Hospital of Sun Yat-sen University is a large-scale third-level comprehensive hospital integrating medical treatment, teaching and scientific research. It is also the only directly affiliated hospital of Sun Yat-sen University on the west bank of the Pearl River estuary. The hospital has 2,680 faculty members. It is the only treatment unit for COVID-19 in Zhuhai City, Guangdong Province. The hospital has 50 paediatric beds. About 1 million people are served by the institution, and in 2019 it had 4,203 paediatric admissions and 88,808 paediatric outpatient appointments.</p><p id="Par8">We identified children who presented to the institution and were initially suspected to have COVID-19 infection during the period 28 January 2020 to 8 February 2020. Children who tested positive on a reverse transcriptase polymerase chain reaction test for COVID-19 were included in this study. We recorded the available clinical history, laboratory findings and any CT imaging in these children. We obtained informed consent from patients and our ethics committee approved this study.</p></sec><sec id="Sec3"><title>Results</title><p id="Par9">Five children were evaluated. Four tested positive on the first RT-PCR, and one tested positive on the sixth test. None of the children had a chest radiograph. All had a non-enhanced chest CT after admission. Among the five, three initially had abnormal lung CT with fairly modest patchy ground-glass opacities, all three with normal chest CT at follow-up (Figs. <xref rid="Fig1" ref-type="fig">1</xref>, <xref rid="Fig2" ref-type="fig">2</xref> and <xref rid="Fig3" ref-type="fig">3</xref>). A summary of presentation, clinical course and imaging finding is given in Table <xref rid="Tab1" ref-type="table">1</xref>.<fig id="Fig1"><label>Fig. 1</label><caption><p>Axial non-enhanced chest CT in a boy age 1 year 5 months (Patient 1 in Table <xref rid="Tab1" ref-type="table">1</xref>). <bold>a</bold> Four days after admission there is patchy ground-glass opacification (<italic>arrowheads</italic>) of the right upper lobe. <bold>b</bold> Five days subsequently, during antiviral treatment, the appearances have normalised</p></caption><graphic xlink:href="247_2020_4656_Fig1_HTML" id="MO1"></graphic></fig><fig id="Fig2"><label>Fig. 2</label><caption><p>Axial non-enhanced chest CT in a 4-year-old boy (Patient 4 in Table <xref rid="Tab1" ref-type="table">1</xref>). <bold>a</bold> Two days after admission there is patchy ground-glass opacification (<italic>arrowheads</italic>) of the left lower lobe. <bold>b</bold> Five days subsequently, during symptomatic and supportive treatment, the appearances have normalised</p></caption><graphic xlink:href="247_2020_4656_Fig2_HTML" id="MO2"></graphic></fig><fig id="Fig3"><label>Fig. 3</label><caption><p>Axial non-enhanced chest CT in a 3-year-old boy (Patient 3 in Table <xref rid="Tab1" ref-type="table">1</xref>). <bold>a</bold> Nine days after onset of symptoms, there is patchy ground-glass opacification (<italic>arrowheads</italic>) in the left lower lobe. <bold>b</bold> Seven days subsequently, during antiviral treatment, the appearances have normalised</p></caption><graphic xlink:href="247_2020_4656_Fig3_HTML" id="MO3"></graphic></fig><table-wrap id="Tab1"><label>Table 1</label><caption><p>Patient demographics, treatment and outcomes</p></caption><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Patient</th><th rowspan="2">Age/gender</th><th rowspan="2">Presenting history</th><th rowspan="2">RT-PCR positive</th><th rowspan="2">CRP at presentation, mg/L<break></break>(normal reference values 0–3)</th><th rowspan="2">White blood cells, ×10<sup>9</sup>/L<break></break>(normal reference values 4.5–11)</th><th colspan="2">Initial chest CT</th><th rowspan="2">Treatment</th><th colspan="2">Follow-up chest CT</th><th rowspan="2">Length of hospital stay</th><th rowspan="2">Outcome<sup>a</sup></th></tr><tr><th>Days from admission or onset of symptoms to scan</th><th>Findings</th><th>Days after initial CT</th><th>Findings</th></tr></thead><tbody><tr><td>1</td><td>1 y 5 m/M</td><td>Asymptomatic, grandmother positive RT-PCR</td><td>6th test</td><td>9.4</td><td>9.2</td><td>4</td><td>Patchy ground-glass opacities</td><td>Antiviral, anti-infective therapy, immunoglobulin therapy, interferon, Lianhua qingwen granules</td><td>5</td><td>Normal</td><td colspan="2">Remains in hospital for observation; 24 days at time of writing</td></tr><tr><td>2</td><td>10 m/F</td><td>Asymptomatic, parents and grandparents positive RT-PCR</td><td>1st test</td><td>0.9</td><td>14.8</td><td>2</td><td>Normal</td><td>Montelukast sodium chewable tablets, immunoglobulin therapy</td><td colspan="2">Not performed</td><td>14 days</td><td>Discharged home</td></tr><tr><td>3</td><td>3 y/M</td><td>Runny nose, cough, sputum, sore throat, fever after 3 days; father positive RT-PCR</td><td>1st test</td><td>0.7</td><td>15.0</td><td>9</td><td>Patchy ground- glass opacities</td><td>Antiviral, anti-infective therapy, immunoglobulin therapy</td><td>7</td><td>Normal</td><td>12 days</td><td>Discharged home</td></tr><tr><td>4</td><td>4 y/M</td><td>Asymptomatic, father positive RT-PCR</td><td>1st test</td><td>0.2</td><td>6.6</td><td>2</td><td>Patchy ground- glass opacities</td><td>Montelukast sodium chewable tablets, immunoglobulin therapy</td><td>5</td><td>Normal</td><td>13 days</td><td>Discharged home</td></tr><tr><td>5</td><td>6 y/M</td><td>Asymptomatic, travelled from high-endemic area (Wuhan)</td><td>1st test</td><td>0.6</td><td>5.3</td><td>3</td><td>Normal</td><td>Interferon, Montelukast sodium chewable tablets, immunoglobulin therapy</td><td colspan="2">Not performed</td><td colspan="2">Remains in hospital for observation; 13 days at time of writing</td></tr></tbody></table><table-wrap-foot><p><italic>CRP</italic> C-reactive protein, <italic>CT</italic> computed tomography, <italic>F</italic> female, <italic>M</italic> male, <italic>m</italic> months, <italic>RT-PCR</italic> reverse transcriptase polymerase chain reaction test for COVID-19, <italic>y</italic> years</p><p><sup>a</sup>Recovery defined as afebrile, improved respiratory symptoms, normalised chest CT, and two consecutive (24-h interval) RT-PCR tests negative</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec4"><title>Discussion</title><p id="Par10">Two children with confirmed COVID-19 infection had no sign of abnormality at chest CT. The remaining three showed characteristic but very modest radiologic abnormality before treatment in the form of patchy ground-glass opacification. The imaging changes disappeared during treatment.</p><p id="Par11">Based on current diagnostic criteria, laboratory tests (such as swab tests) have become the standard and formative assessment for the diagnosis of COVID-19 infection. However, CT can be diagnostically helpful because current laboratory tests are time-consuming, sometimes return false-negative results, and do not always keep up with the needs of a growing number of infected people. Previous radiologic studies have shown that adults with COVID-19 infection have CT features of ground-glass opacities and consolidation, typically with peripheral distribution, and bilateral multifocal lower-lobe predominance [<xref ref-type="bibr" rid="CR8">8</xref>]. Our observations were similar, but in our small cohort the CT findings were very modest.</p></sec><sec id="Sec5"><title>Conclusion</title><p id="Par12">Our preliminary observations in a small cohort of children with COVID-19 infection demonstrated rather moderate lung abnormality at CT with peripheral ground-glass lesions, similar to those seen in adults with COVID-19.</p></sec></body><back><fn-group><fn><p><bold>Publisher’s note</bold></p><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></fn><fn><p>Wei Li and Huaqian Cui contributed equally to this work.</p></fn></fn-group><notes notes-type="ethics"><title>Compliance with ethical standards</title><notes notes-type="COI-statement"><title>Conflicts of interest</title><p id="Par13">None</p></notes></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">World Health Organization (2020) Coronavirus disease (COVID-19) outbreak. <ext-link ext-link-type="uri" xlink:href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019">https://www.who.int/emergencies/diseases/novel-coronavirus-2019</ext-link>. 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