Scientific Ambiguity in the Time of Coronavirus Disease 2019—Reply

In Reply We welcome the opportunity that our colleagues from La Paz University Hospital provide to explain our findings further.¹ First, we appreciate the clarification about the first case of severe acute respiratory illness coronavirus 2 (SARS-CoV2) infection in Madrid, Spain. At this point, few people still argue against testing. World Health Organization Director General Tedros Ghebreyesus stated in a press conference on March 16, 2020: “We have a simple message for all countries: test, test, test. Test every suspected case.”

However, we were very aware of laboratories’ overload, financial constraints, and need for a coordinated response. The criteria for testing patients followed the Ministry of Health recommendations, in coordination with each Hospital’s protocols, the Preventive Departments, and the Public Health Regional Department.² At the contention phase of the epidemic, the recommendation of the Spanish Ministry of Health was to test “patients with symptoms of viral infection or respiratory symptoms and recent trips to risk areas or contact with cases of COVID-19.”³ From March 9, 2020, onwards, the epidemiologic criterion disappeared as Madrid was considered an area of community transmission. If the patient met the criteria of “case under investigation,” the case was communicated to the Hospital Management Team and to the Regional Public Health Department. This Department confirmed whether the case was to be investigated using molecular tests. Tests not compliant with official recommendations were simply not possible.

As stated, cases under investigation included patients at risk of admission with respiratory symptoms and patients with risk of complications owing to baseline disease and signs compatible with coronavirus disease 2019 (COVID-19) with epidemiologic contact or living in areas with community transmission. In cases under investigation, having the result was mandatory before discharge or admitting a patient to the ward. At that point, the turnaround time of the polymerase chain reaction was from 12 to 36 hours. Meanwhile, the patients remained in observation areas and received treatment. Eventually, 40% of patients with COVID-19 and 32% of patients without COVID-19 were discharged without definitive admission. This rate falls within usual ones.⁴

All patients showed symptoms of viral infection or respiratory symptoms that the attending pediatricians considered consistent with COVID-19 on presentation.⁵ Diagnoses of the 41 patients admitted with COVID-19 are stated in the first paragraph of the second page. There were no asymptomatic carriers. Only 2 coinfections were found.¹ There is no overestimation in describing that 25 of 41 children (60%) with confirmed infection were admitted.

Relating to the patients admitted in the pediatric intensive care units (PICUs), the syndromic diagnoses were asthma flare, bronchiolitis, and 2 pneumonia cases. Three of them required ventilatory support beyond nasal prongs, which is a common criterion for PICU admission. An additional child received high-flow therapy out of the PICU. All were admitted following pediatric intensivists’ criteria. Opposite to the authors’ remark, the PICU admission rate was lower than the 12.6% reported by the Spanish Authorities on April 23, 2020.⁶ Reasons for the high rate of hospital and PICU admissions were discussed in the last paragraph of the discussion, where we also stated that these results must be interpreted with caution.

Corresponding Author: Alfredo Tagarro, MD, PhD, Pediatrics Department. Hospital Universitario Infanta Sofía. Paseo de Europa, 34. 28703 San Sebastian de los Reyes, Madrid, Spain (alfredotagarro@gmail.com).

Published Online: October 19, 2020. doi:10.1001/jamapediatrics.2020.2937

Conflict of Interest Disclosures: Dr Tagarro reported other from GSK outside the submitted work. Dr Moraleda reported Fundación para la Investigación Biomédica Hospital 12 de Octubre receives payments from different sources not related with this submitted work. No other disclosures were reported.