Seroprevalence of SARS-Cov-2 Antibodies in Children - a Prospective Multicentre Cohort Study
Conditions: COVID, Corona Virus Infection, Multisystem Inflammatory Syndrome in Children
Sponsor: Queen's University, Belfast

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Title: 
Seroprevalence of SARS-Cov-2 Antibodies in Children 
 
Short title: 
Seroprevalence of SARS-Cov-2 Antibodies in Children 
 
 
 
 
Protocol 
Version: 10.0 
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2022 
 
Chief Investigator: 
Dr Thomas Waterfield 
1) 
Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast 
2) 
Royal Belfast Hospital for Sick Children, Belfast HSC Trust. 
 
Study Sponsor:  
Queen’s University Belfast University Road 
Belfast BT7 1NN 
 
 
Study Funding: 
Royal Belfast Hospital for Sick Children – Charitable funds and 
Queen’s University Belfast – Soft funds 

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Contact Details: Individuals 
 
Chief Investigator 
Co-Investigator 
Dr Thomas Waterfield  
Wellcome-Wolfson Institute for Experimental 
Medicine, Queen’s University Belfast, 
97 Lisburn Road, Belfast 
BT9 7AE 
Tel:07872990521 
Email: t.waterfield@qub.ac.uk 
Professor Michael D Shields Centre for  
Wellcome-Wolfson Institute for Experimental 
Medicine, Queen’s University Belfast, 
97 Lisburn Road, Belfast,  
BT9 7AE  
Tel:07920132237 
Email: m.shields@qub.ac.uk 
Co-Investigator 
Co-Investigator 
Dr Sharon Christie 
Royal Belfast Hospital for Sick Children 
Grosvenor Road 
Belfast  
BT126BA 
Tel:07899 913551 
Email: Sharon.christie@belfasttrust.hscni.net 
Dr Shamez Ladhani 
St George’s Hospital London 
Blackshaw Road 
Tooting 
London 
SW17 0QT 
Tel:02083277155 
Email: shamez.ladhani@phe.gov.uk 
Co-Investigator 
Co-Investigator 
Dr Julie-Ann Maney 
Royal Belfast Hospital for Sick Children 
Grosvenor Road 
Belfast  
BT126BA 
Tel: 07917245264 
Email:julieann.maney@belfasttrust.hscni.net 
Dr Chris Watson 
Wellcome-Wolfson Institute for Experimental 
Medicine, Queen’s University Belfast, 
97 Lisburn Road, Belfast,  
BT9 7AE  
Tel:07575292297 
Email: chris.watson@qub.ac.uk 
Co-Investigator 
Co-Investigator 
Dr Mark Lyttle 
Faculty of Health and Applied Sciences, 
University of the West of England 
Bristol 
Tel:07788185454 
Email:mdlyttle77@gmail.com 
Dr Derek Fairley 
Regional Virus Reference Laboratory  
Royal Victoria Hospital 
Grosvenor Road 
Belfast 
BT12 6BA 
Tel:07772926576 
Email:derek.fairley@belfasttrust.hscni.net 
Statistician 
Statistician 
Dr Hannah Mitchell 
Mathematical Sciences Research Centre, 
Queen’s University Belfast 
Belfast 
BT97AE 
Tel: 02890971922 
Email: h.mitchell@qub.ac.uk 
Dr Lisa McFetridge 
Mathematical Sciences Research Centre, 
Queen’s University Belfast 
Belfast 
BT97AE 
Tel:02890971922 
Email: l.mcfetridge@qub.ac.uk 
Co-Investigator 
Co-Investigator 

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Dr James Mckenna 
Regional Virus Reference Laboratory  
Royal Victoria Hospital 
Grosvenor Road 
Belfast 
BT12 6BA 
Tel: 07791433363 
Email:james.mckenna@belfasttrust.hscni.net 
Dr Julie Richardson 
Royal Belfast Hospital for Sick Children 
Grosvenor Road 
Belfast  
BT126BA 
Email: julieaquigley@gmail.com 
Research Governance Manager (Queen’s 
University Belfast) 
Dr Paula Tighe 
Research Governance, Ethics and Integrity 
Queen’s University Belfast 
63 University Road, Belfast  
BT126BA  
Tel: 02890973861 
Email: p.tighe@qub.ac.uk 

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TABLE OF CONTENTS 
Contents 
GLOSSARY .......................................................................................................................... 5 
PROTOCOL SUMMARY ........................................................................................................ 6 
BACKGROUND INFORMATION ............................................................................................ 9 
Introduction ............................................................................................................................... 9 
Point-of-care (POC) testing ............................................................................................................... 9 
Disease process ............................................................................................................................... 10 
Rationale for the study ................................................................................................................... 10 
Objectives/Outcome ................................................................................................................ 11 
STUDY DESIGN .................................................................................................................. 11 
Population ............................................................................................................................... 11 
Recruitment of healthy children ..................................................................................................... 12 
Recruitment of unwell children with Covid-19 ............................................................................... 12 
Withdrawal of consent .................................................................................................................... 13 
ASSESSMENTS AND PROCEDURES ..................................................................................... 14 
Phlebotomy, swabs and finger pricks ........................................................................................ 14 
Adverse events ......................................................................................................................... 14 
Additional testing ..................................................................................................................... 14 
Background sero-prevalence .................................................................................................... 15 
Potential risks/benefits .................................................................................................... 15 
STATISTICAL CONSIDERATIONS ......................................................................................... 15 
ETHICAL CONSIDERATIONS & RISK ASSESSMENT ............................................................... 15 
Consenting Issues ............................................................................................................................ 15 
Additional procedures..................................................................................................................... 16 
Risks to researchers ........................................................................................................................ 16 
Case report forms (CRF) .................................................................................................................. 16 
Ethical approval ................................................................................................................ 16 
FINANCIAL ARRANGEMENTS ............................................................................................. 16 
PUBLICATION ................................................................................................................... 17 
REFERENCES ..................................................................................................................... 17 
 

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GLOSSARY 
 
 
 
 
 
CE-IVD 
Conformite Europeene In Vitro Diagnostics 
COVID-19 
COrona Virus Disease 2019 
CRF 
Case Report Form 
LAMP 
Loop mediated isotherm AMPlification 
NHS 
National Health Service 
PCR 
Polymerase Chain Reaction 
POC 
Point-of-care 
PICU 
Paediatric Intensive Care Unit 
PCR 
Polymerase Chain Reaction 
PPE 
Personal Protective Equipment  
RBHSC 
Royal Belfast Hospital for Sick Children 
SARS-CoV-2 
Severe Acute Respiratory Syndrome CoronaVirus 2 

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PROTOCOL SUMMARY 
 
 
Full title: 
 Short title: 
  Rationale: 
RAPid diagnostics, antibody testing and host response in 
children with CovID-19 (RAPID-19) 
RAPID-19 
Very little is known regarding the symptoms and signs of 
Covid-19 disease in children. In particular we do not know 
how many children are asymptomatic carriers of the SARS-
CoV-2 virus and what the symptoms and signs of mild Covid-
19 disease are. We need to understand the pattern of 
immunological (e.g. cytokine) response is in children who 
experience mild versus severer disease. We also need to 
develop a rapid accurate point of care (POC) test for SARS-
CoV-2 virus. We have an opportunity to complete this 
research rapidly in Northern Ireland and because we are 2-3 
weeks behind mainland UK in the development of the 
COVID-19 epidemic we are ideally suited to this.  
In the midst of this rapidly evolving pandemic we have 
designed this pragmatic study to start addressing the above 
issues. 
  Study type: 
Prospective cohort study 
Population: 
1) Healthy children (between 2 and 15 years of age) of 
healthcare professionals (n=1000+/- 10%). 
2) Children up to 15 years of age admitted to the Royal 
Belfast Hospital for Sick Children with confirmed Covid-19 
disease (n=10 to 30) and children admitted with confirmed 
other serious infections (n=10 to 30) 
  Study sites: 
Royal Belfast Hospital for Sick Children (RBHSC, a large 
tertiary children’s hospital in Northern Ireland) and 
additional UK sites.  
The Ulster Independent Clinic (a private hospital that has 
offered free support to the study) 
Study duration per participant: 12 months (maximum) 
 

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Description of 
intervention: 
Healthy cohort: 
Daily symptom diary if/when unwell: 
Week 0:  
 
Blood test (5ml) to measure antibodies indicating 
previous infection, cytokine baseline and proteomic, 
and transcriptomic baseline. 
When/if develop symptoms:  
 
Nasal and throat swabs to assess for current 
infections with SARS-CoV2. 
 
Blood test (5ml) to measure antibodies indicating 
previous infection, cytokine response and 
proteomic, and transcriptomic response (where 
possible). 
Week 8:   
 
Blood test (5ml) to measure antibodies indicating 
previous infection, cytokine response and 
proteomic, and transcriptomic response.  
 
Crevicular fluid swab to measure antibodies  
4 to 6 months: 
 
Blood test (5ml) to measure antibodies indicating 
previous infection, cytokine response and 
proteomic, and transcriptomic response.  
 
Crevicular fluid swab to measure antibodies and/or 
to perform viral testing 
10 to 12 months – Only for individuals with antibodies 
detected at one of the three previous clinic appointments, 
Testing timed at 10 to 12 months.  
 
Blood test (5ml) to measure antibodies indicating 
previous infection, cytokine response and 
proteomic, and transcriptomic response.  
 
Survey data to record any interim Covid-19 
infections/exposure and any Covid-19 vaccinations 
received.  
 

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Admitted cohort: 
 
Review of medical notes to record symptoms. 
 
Residual blood samples to measure antibodies, 
assess the host cytokine response, proteomic, and 
transcriptomic response to infection. If no residual 
specimen then consent sought for a single blood 
test (5ml) to measure antibodies indicating previous 
infection, cytokine response and proteomic, and 
transcriptomic response. 
 
Daily blood spot (2 drops of blood). Taken via a 
finger prick. To monitor the cytokine response. 
Timed, where possible, with any routine blood tests.  
 
At 4 weeks and 8 weeks a single blood test (5ml) to 
measure antibodies indicating previous infection, 
cytokine response and proteomic, and 
transcriptomic response.  
Primary Outcome measures: 
 
 
 
 
 
 
 
 
 
Secondary Outcome measures: 
 
 
Diagnostic test accuracy of a rapid diagnostic test for  
SARS-CoV2 
 
SARS-CoV2 nasal swab PCR-positivity in healthy 
children of healthcare professionals. 
 
IgM and IgG positivity in healthy children of 
healthcare professionals at recruitment, at 8 weeks 
and at 4 to 6 months 
 
To correlate clinical symptoms with infection and 
seroconversion to SARS-CoV2 in healthy children of 
healthcare professionals 
 
IgM and IgG positivity to SARS-CoV2 at recruitment, 
at 4 weeks and at 8 weeks in children hospitalised 
with COVID-19 
 
To correlate clinical symptoms with swab PCR 
positivity in children  
 
Host cytokine response, proteomic and 
transcriptomic response in severe disease 
 
 

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BACKGROUND INFORMATION 
 
Introduction 
Coronaviruses are non-segmented positive-stranded RNA viruses with a roughly 30 kb 
genome (1).  The majority of coronaviruses cause disease in a specific host species but some 
have infected humans by cross-species transmission. This process has led to a number of 
severe outbreaks of human disease including severe acute respiratory syndrome (SARS) in 
2003 and Middle East respiratory syndrome (MERS) in 2012 (1).  
 
From December 2019 a novel infection “severe acute respiratory syndrome coronavirus 2” 
(SARS-CoV-2) was identified in the Wuhan region of China. The infection was identified as the 
causal factor in a growing number of severe cases of pneumonia (1). This disease was 
subsequently named coronavirus disease 2019 (COVID-19) by WHO. SARS-CoV-2 has been 
shown to cause severe disease similar to the previous SARS coronavirus from 2003. Severe 
disease is associated with pneumonia and damage to vital organs including lung, heart, liver, 
and kidney (1). Pneumonia is the leading cause of mortality in children worldwide but very little 
is known regarding the disease process in children.  
 
 
We do not know - why so many children exhibit mild disease, or why some 
children suffer severe disease and die. 
 
 
We need an accurate rapid point of care diagnostic test to diagnose SARS-CoV-2 
infection (the cause of COVID-19). 
 
 
Point-of-care (POC) testing  
A rapid POC test for SARS-CoV-2 is essential. With such a potentially fatal disease confirming 
the diagnosis early will allow for prompt and appropriate therapy.  A rapid test would also allow 
for early cohorting of children thereby improving flow through the emergency department. 
Finally rapid testing could support the wider fight against Covid-19 through quicker contact 
tracing and isolation. 
 
The research team in Belfast have a lot of experience of using Loop-mediated isothermal 
AMPlification (LAMP) for the rapid diagnosis of serious infections in children and have been 
involved with the development of LAMP testing for Meningococcal Disease, invasive E.coli 
infection Group B Streptococcal disease (2,-4). There now exists a CE marked commercially 
available LAMP rapid test for SARS-CoV-2 that can be performed with minimal equipment 
within 30 minutes (Figure1). The test can be performed using a single throat or nasal swab. 

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  Figure 1: Schematic of    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease process 
Very little is known regarding the symptoms and signs of Covid-19 disease in children (1). In 
particular we do not know how many children are asymptomatic carriers of the SARS-CoV-2 
virus and what the symptoms and signs of mild Covid-19 disease are. We also do not know 
why some, previously well, children develop severe disease. Research is required to 
understand the symptoms and signs of infection, the spectrum of disease and the host immune 
response in those with severe disease. We intend to compare the host immune response in 
children with mild.moderate and severe Covid-19 disease and compare that to the immune 
response in children with other serious infections.  
 
Rationale for the study 
This RAPID-19study aims to improve our understanding of how Covid-19 affects healthy 
children. By following children of healthcare workers we have an opportunity to follow children 
as they acquire Covid-19 and develop immunity. During this time we will be able assess the 
performance of antibody tests and rapid diagnostics. These tests are vital in the fight against 
Covid-19. We have chosen to study children of healthcare workers as we feel this group is a 
highest risk of contracting the infection during the current social distancing measures. We 
intend to study the seroprevalence of SARS-Cov2 in populations in Northern Ireland and 
mainland UK. The purpose for this is that Northern Ireland is currently seeing very low 
transmission rates whereas mainland UK is seeing much higher rates. By recruiting children 
from both Northern Ireland and mainland UK we can better understand how the timing of 
different social distancing measures affects transmission.  
 
In addition to the main cohort (children of healthcare workers) we intend to recruit children with 
known Covid-19 admitted to the RBBHSC. We expect that severe disease and admission to 
hospital will be an uncommon event for most children and we expect only 1 or 2 children of the 
(100-120) healthcare workers to be admitted for treatment. By following admitted children we 
have an opportunity to research the full spectrum of disease from minor illness through to 
moderate and severe disease. By following a range of severities we can gain an insight into 

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the different cytokine proteomic, and transcriptomic responses. This will provide insight into 
prognostication and potential therapeutics.  We need to begin this research immediately as 
part of a national pandemic response. We believe Northern Ireland is approximately 2-3 weeks 
behind mainland UK in the development of the COVID-19 epidemic and we have a short 
window of opportunity to begin this study.  If we delay the start of this project by more than a 
few days we will potentially lose that opportunity. 
 
Objectives/Outcome 
 
 
STUDY DESIGN 
 
Population 
 
1) Healthy children (between 2 and 15 years of age) of healthcare professionals. (n=1000+/- 
10%) Healthy children defined as children not currently receiving antibiotics, not admitted 
to hospital within the last seven days, not receiving immunosuppressive drugs and never 
diagnosed with a malignancy or chronic disease affecting the immune system, kidneys, 
heart or lungs.  
2) Children aged 15 years and under admitted to the Royal Belfast Hospital for Sick 
Children with confirmed Covid-19 disease (n=10 to 30) and children admitted with other 
serious infections (n=10 to 30) 
Primary Objectives: 
 
 
 
 
 
 
 
 
 
 
 
 
Secondary Objectives: 
 
 
 
Diagnostic test accuracy of a rapid diagnostic test 
for     SARS-CoV2 
 
SARS-CoV2 nasal swab PCR-positivity in healthy 
children of healthcare professionals. 
 
IgM and IgG positivity in healthy children of 
healthcare professionals at recruitment, at 8 weeks 
and at 4 to  6 months 
 
To correlate clinical symptoms with infection and 
seroconversion to SARS-CoV2 in healthy children of 
healthcare professionals 
 
IgM and IgG positivity to SARS-CoV2 at recruitment, 
at 4 weeks and at 8 weeks in children hospitalized 
with COVID-19 
 
To correlate clinical symptoms with nasal swab PCR 
positivity in children  
 
Host cytokine response, proteomic and 
transcriptomic response in severe disease 
 

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Recruitment of healthy children 
Healthy children of healthcare workers will be identified by the use of internal websites and 
email. In all instances informed consent will be obtained prior to including children in the study. 
We intend to recruit approximately 1000+/- 10% healthy children. Potential participants will be 
provided with a participant information sheet and consent form. This will be followed up with a 
telephone conversation to answer any questions. Completed consent forms will be stored 
securely within the University or at the participating NHS site.  
 
Consent/assent form completion 
Wherever possible the child will be included in the consent/assent process. We will ask parents 
to involve their children with consent discussions at home using the age-appropriate 
information sheets provided.  
 
If a child turns 16 during the follow up period they will be invited to provide consent using the 
appropriate consent form. If they decline consent they will be withdrawn from the study. 
 
Withdrawal of Consent 
The parent is free to withdraw consent at any time without providing a reason and without 
being subject to any resulting detriment. The rights and welfare of the patients will be protected 
and the quality of medical care will not be adversely affected if they decline to participate in the 
study the principle investigator (or their deputy) will maintain a record of all those that withdraw 
consent to participate in the study. 
 
Recruitment of unwell children with Covid-19 
Children with Covid-19 admitted to the RBHSC for emergency treatment will be identified by 
clinical staff in the ED and a member of the research team will screen them for inclusion. We 
intend to recruit between 10 and 30 patients with Covid-19 and a matched population of 
between 10 and 30 patients with other serious infections. Data regarding the clinical status of 
the child will be recorded by the research team and residual blood samples, that would 
otherwise be discarded, will be stored. At the earliest appropriate opportunity consent will be 
sought to use the data and stored samples. This process is known as research without prior 
consent (RWPC) and the research team have experience of utilising this approach for previous 
emergency research (5-7). Research without prior consent in children has been shown to be 
appropriate and well accepted by parents when conducted in emergency situations and when 
information and opportunities for consent are offered at an appropriate time (5-7). Unwell 
children WILL NOT UNDERGO ANY ADDITIONAL PHLEBOTOMY EVENTS OR 
SWABBING beyond usual care without prior consent. 
 
Based on the best practice guidance for performing research without prior consent a member 
of the research team will check with the relevant ward staff that the participant is stable and 
that timing is appropriate before approaching the parent (8). If the participant’s condition has 
not stabilised additional time will be allowed before approaching parent. A member of the ward 
team would explain the nature of the study and invite the parent to talk with a researcher. A 
member of the research team will explain to parents the reasons why informed consent cannot 
be sought in emergency care research. These discussions will occur at a convenient time for 
the family and via telephone to prevent spread of Covid-19. 
 
A member of the research team will also discuss with the parent the: 
 
Objectives 
 
Risks and inconveniences of the study 
 
Conditions under which it is to be conducted 
 
Emphasise that participation in the study is voluntary and that the participant may 
withdraw from the study at any time and for any reason. 
 
The parent will be sent a link for the patient information and consent forms. Upon reviewing the 
documents, all participants will be given opportunity to ask any questions that may arise, have 

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the opportunity to discuss the study with their surrogates and have time to consider the 
information prior to agreeing to participate. These steps will occur via telephone where 
possible. 
 
Consent/assent form completion 
Wherever possible the child will be included in the consent/assent process. We will ask parents 
to involve their children with consent discussions in hospital. When a consent form is 
completed it will be stored, securely and electronically, on University servers. Paper copies of 
the consent forms will be available as a backup option.   
 
When a child turns 16 during the study they will be invited to provide consent again at the enxt 
clinic visit. They will only remain in the study if consent is provided.  
 
Death prior to consent being sought 
This is likely to be a rare occurrence. If a participant dies before consent has been sought, the 
site principle investigator (or nominated deputy) will obtain information from clinical colleagues 
and establish the most appropriate practitioner to notify parents of the research involvement. 
Consent can be sought from parents following the death of their child at the most appropriate 
time point. However, it is at the discretion of the clinical staff to determine if this is appropriate 
for each individual family. It maybe that it is not appropriate for consent to be obtained. If the 
clinical team deem an approach inappropriate then the child will be excluded from the study. If 
an approach is deemed appropriate then a researcher will call the family, provide study 
information and provide a link to the participant information sheet and consent forms. 
 
Discharge/transfer prior to consent being sought 
If a child is discharged prior to consent being obtained then the child will be excluded from the 
study. 
 
Consent declined 
If research without prior consent is declined the child’s data will not be included. The site 
principle investigator (or nominated deputy) will maintain a record of all instances of declined 
consent. 
 
 
Withdrawal of consent 
The parent is free to withdraw consent at any time without providing a reason and without 
being subject to any resulting detriment. The rights and welfare of the patients will be protected 
and the quality of medical care will not be adversely affected if they decline to participate in the 
study. The site principle investigator (or their deputy) will maintain a record of all those that 
withdraw consent to participate in the study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ASSESSMENTS AND PROCEDURES 
Table 1: Study assessments/procedures 
 
Assessment/pro
cedure 
Well children 
Unwell children 
Consent 
discussion 
In advance via telephone for well children. 
. 
At the earliest appropriate opportunity 
Assessment of 
eligibility criteria 
In advance to attending initial clinic appointment (via 
telephone).  
Screening performed by clinical staff with eligibility 
confirmed by the research team 
Swabs 
When unwell  
Crevicular Fluid Swabs if/when available and if 
practical at that site.Can be performed at routine clinic 
appointment. 
All admitted children 
Phlebotomy  
 
Weeks 0 and 8 and again at between 4 and 
6 months and 12 months 
 
If/when unwell if possible 
Residual blood stored pending consent. Consent 
also sought for additional phlebotomy as inpatient 
and again at 4 to 6 months.  
Finger prick 
blood tests 
Only if phlebotomy fails 
Daily during admission. 
Data collection 
Symptom diaries when unwell. Notes review if 
admitted. 
By research team using a notes review and 
additional history taken during consent discussion. 
 
 
 
Phlebotomy, swabs and finger pricks 
All procedures will be performed by trained paediatric healthcare professionals, with at 
least three years paediatric experience, wearing appropriate protective personal 
equipment. To minimise any distress we intend to make use of and topical anaesthetic 
creams. For both swabs and blood tests the parent can choose not to have the test 
performed at any point. 
 
Crevicular Fluid 
Crevicular fluid swabs involve collecting saliva on a small mouth swab that is placed next 
to the gums. This is far less uncomfortable than throat or nasal swabs. Where available 
we want to utilize this method instead of throat/nasal swabbing. We wish to offer routine 
swabs at week 8 and at 6 months for viral PCR and/or antibody testing. The importance of 
this is that if crevicular fluid proves reliable for antibody testing then this could be used as 
an alternative to painful blood tests in young children.  
 
Adverse events 
Any adverse events will be recorded. The most likely adverse events relate to additional 
phlebotomy. All phlebotomy will be performed by experienced healthcare professionals and 
any complications (such as slight bruising) will be managed with appropriate first aid and 
analgesia In the exceptionally unlikely event of a more significant adverse event the child will 
be assessed by non-research team members at the  Royal Belfast Hospital for Sick Children 
Emergency Department. 
 
Additional testing 
All residual specimens will be made available for, appropriate, further analysis relating to 
Covid-19 including validation of other rapid diagnostic tests, antibody and immunity testing 
and further development of biomarkers of infection/prognosis. 
 
 

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Background sero-prevalence/Cross-reactivity with other seasonal 
coronaviruses 
The background sero-prevalence of IgM and IgG positivity to SARS-CoV2 will be determined 
from residual samples of children with blood taken for non-infective reasons (n=150 to 300). 
These will be collected in a fully anonymised from the Royal Victoria Hospital laboratory 
and/or participating NHS sites in mainland UK. Consent to perform this testing will not be 
sought.  
 
Serum/plasma collected during the study will undergo testing for other seasonal 
coronaviruses as part of the antibody response assessment.  
 
Potential risks/benefits 
The RAPID-19 study involves performing additional phlebotomy events on well and healthy 
children. This has the potential to cause distress. This will be minimised by the use of topical 
anaesthetic creams. Rarely the phlebotomy may cause harm through local bruising. To 
minimise this all phlebotomy will be performed by experienced healthcare professionals with at 
least three years paediatric experience. Any complications arising from phlebotomy will be 
recorded. The RAPID-19 study also involves additional swabbing of healthy children. This is a 
low risk intervention with no expected harms but can cause some minor distress. For both 
swabs and blood tests the parent can choose not to have the test performed at any point.  
 
There are no benefits for the participants in this study. 
 
STATISTICAL CONSIDERATIONS 
 
The study population will be described in terms of demographic characteristics, clinical 
symptoms and signs, parenteral antibiotic use, admission to hospital, admission to intensive 
care and survival using descriptive statistics. The performance of the rapid test (index) will be 
compared to laboratory PCR (reference standard) with sensitivity, specificity, negative 
predictive value (NPV) and positive predictive value (PPV) (with 95% confidence intervals) 
reported.  
 
The clinical features, cytokine response, proteome and transcriptome will be described for 
unwell, admitted children. The cytokine, proteomic and transcriptomic response will be 
compared between healthy children and those with severe disease.  
 
The sample size for this study is a pragmatic one that allows for the study to be completed in a 
timely way whilst also being likely to provide insights into the disease process and accuracy of 
clinical tests.  
 
ETHICAL CONSIDERATIONS & RISK ASSESSMENT 
 
Consenting Issues 
During the Covid-19 pandemic there is a need for social distancing and this poses a number 
of challenges with obtaining consent. It is essential that social distancing is maintained and as 
such we will perform consent discussion via the telephone and seek written consent 
electronically where possible. This will minimise face-face contact and spread of infection 
through the use of paper documents. For those healthy children recruited to the study there 
will be time to obtain prior informed consent.  
 

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For those admitted with severe Covid-19 disease the process will be more complicated. We 
wish to evaluate a rapid test for the diagnosis of Covid-19 and also to monitor the host 
response during the infection. It is vital that we collect clinical data from the onset of the 
infection and that we store vital residual specimens before they are discarded. Due to the 
urgency of treating severe Covid-19 it would not be appropriate for researchers to delay 
urgent care and we will instead seek consent at the earliest appropriate opportunity. This is 
in-line with best practice guidance and our experience of other previously successful trials (5-
8). If consent is declined the collected clinical data will be permanently deleted and any stored 
residual samples destroyed as planned by the NHS site they are stored at. No additional 
procedures, such as phlebotomy/nasal swabs/finger pricks will take place without prior 
consent.  
 
Additional procedures 
The phlebotomy, finger scratches and swabs will involve some distress for children. This will 
be minimised by having these procedures performed by experienced paediatric doctors and 
nurses (a least three years paediatric training). A topical anesthetic cream will be offered for 
blood tests.).  
 
Risks to researchers 
The risk to researchers will be minimised by minimising face-face discussions with family 
members and by avoiding handling of potentially hazardous materials where possible. All 
procedures and specimen handling will be performed wearing appropriate personal protective 
equipment (PPE).  
 
Case report forms (CRF) 
Data will be recorded on an electronic CRF using a numerical reference number that can be 
linked back to the original patient if required. The CRF will only include clinical data pertinent to 
the study. Examples include basic demographic data such as age, gender and clinical data 
such as current symptoms of infection. The symptom CRFs will be completed online by 
parents. 
 
Individual participant medical information obtained as a result of this study is considered 
confidential and disclosure to third parties is prohibited with the exception that medical 
information may be given to the participant’s medical team and all appropriate medical 
personnel responsible for the participant’s welfare. 
 
Providing information regarding antibody testing 
Results of antibody testing will be disseminated at future clinical meetings. A guide to 
interpreting results will be produced to guide families as to how to interpret test results. 
Following the final 6 month appointment those children with newly identified antibodies will 
have their results sent to them via post.  
 
Ethical approval 
The study protocol, including the participant information sheets and consent/assent forms and 
all other relevant study documentation will be submitted for review by the Research Ethics 
Committee (REC). 
 
FINANCIAL ARRANGEMENTS 
This study has been supported by the Royal Belfast Hospital for Sick Children charitable 
funds and Queen’s University with donations of £23,000 
 
 

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PUBLICATION 
The results will be analysed and published as soon as possible. High impact journals will be     
targeted as will academic meetings with the aim disseminating the key-learning around Covid- 
19 affecting children. 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
REFERENCES 
 
1) Qiu, H. Wu, J. Hong, L. et al. Clinical and epidemiological features of 36 children with 
coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort 
study. The Lancet ID. Published online - March 25, 2020. 
https://doi.org/10.1016/S1473-3099(20)30198-5 
 
2) Waterfield, T., Lyttle, M.D., Fairley, D. et al. The “Petechiae in children” (PiC) study: 
evaluating potential clinical decision rules for the management of feverish children with 
non-blanching rashes, including the role of point of care testing for Procalcitonin & 
Neisseria meningitidis DNA – a study protocol. BMC Pediatr 18, 246 (2018). 
https://doi.org/10.1186/s12887-018-1220-x 
 
 
3) Bourke, TW. McKenna, JP. Coyle, Peter. et al. Diagnostic accuracy of loop-mediated 
isothermal amplification as a near-patient test for meningococcal disease in children: an 
observational cohort study. The Lancet ID. Published:February 26, 2015. 
https://doi.org/10.1016/S1473-3099(15)70038-1 
 

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4) McKenna, JP. Cox, C. Fairley, DJ. Loop-mediated Isothermal Amplification Assay for 
Rapid Detection of Streptococcus Agalactiae (Group B Streptococcus) in Vaginal 
Swabs - A Proof of Concept Study. J Med Microbiol, 66 (3), 294-300 Mar 2017. 
https://doi.org/10.1099/jmm.0.000437 
 
5) Waterfield T, Lyttle MD, Shields M, et al. Parents’ and clinicians’ views on conducting 
paediatric diagnostic test accuracy studies without prior informed consent: qualitative 
insight from the Petechiae in Children study (PiC)Archives of Disease in Childhood 
Published Online First: 07 June 2019. https://doi.org/10.1099/jmm.0.000437  
 
6) Inwald D, Canter RR, Woolfall K, et al. Restricted fluid bolus versus current practice in 
children with septic shock: the FiSh feasibility study and pilot RCT. Health Technol 
Assess. 2018;22(51):1–106. https://doi.org/10.3310/hta22510 
 
7) Woolfall, K., Roper, L., Humphreys, A. et al. Enhancing practitioners’ confidence in 
recruitment and consent in the EcLiPSE trial: a mixed-method evaluation of site training 
– a Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) 
study. Trials 20, 181 (2019). https://doi.org/10.1186/s13063-019-3273-z 
 
8) CONseNt methods in paediatric Emergency and urgent Care Trials. Guidance available 
at. https://www.liverpool.ac.uk/population-health-sciences/research/connect/.