Paediatrica Indonesiana p-ISSN 0030-9311; e-ISSN 2338-476X; Vol.61, No.1(2021). p.53-60; DOI: 10.14238/pi61.1.2021.53-60 Case Report Case report of a COVID-19 family cluster originating from a boarding school Citra Cesilia1, Silvia Sudarmaji2, Djatnika Setiabudi3, Heda Melinda Nataprawira3 ince it was first identified in Wuhan City, Hubei The Case Province, China in December 2019, SARS-CoV-2 has spread to 195 countries and infected more than 8 million people globally. Indonesia, an archipelago On April 16, 2020 the Malaysia Ministry of Health Sconsisting of thousands of islands and 34 provinces, has announced a new cluster of COVID-19 from students the largest number of confirmed cases and mortality in Southeast Asia. A total of 464 districts/cities in Indonesia returning from a boarding school in Temboro, have been affected by COVID-19, of which 189 districts/ Magetan Regency, East Java, Indonesia, with 43 cities are considered to be local transmission areas. Riau Malaysian students confirmed to have COVID-19 Province, located in Sumatra Island, consists of 12 districts/ cities with a population of more than 6.8 million. This upon their return to Malaysia. Since that time, the province has the 1st largest number of COVID-19 cases on Indonesian government has coordinated with COVID Sumatra Island. Currently, more than 3000 childrens have task forces in various provinces to trace students been infected with case fatality rate <0.3% and recovery rate >90%. In May 2020, the public health office of Riau who returned to their respective homes. Several reported that just 34 children were confirmed to have provinces reported confirmed COVID-19 cases from COVID-19, with symptoms varying from asymptomatic to the Magetan cluster, including Aceh, West Sumatra, moderate with only a few family clusters identified. Dur- Riau, East Kalimantan, and East Nusa Tenggara. ing the pandemic, contact tracing is the main approach to detect and isolate sources of infection in order to reduce The case from the Magetan cluster in Riau Province viral transmission. This method has also been used to was first discovered in the Indragiri Hilir District. A control transmission of other respiratory diseases such as 19-year-old boy was successfully traced. His rapid tuberculosis (TB), MERS, and SARS. We report here on a familial cluster of COVID-19 in the Meranti Island Re- gency, which is located 145 km from the city of Pekanbaru (Riau Province). The island can only be reached in four hours by speed boat. [Paediatr Indones. 2021;61:53-60; DOI: 10.14238/pi61.1.2021.53-60 ]. From the Department of Child Health, Universitas Riau Medical School/ Arifin Achmad General Hospital1 and Meranti General Hospital2, Riau, Keywords: case report; contact investigation; and Department of Child Health, Universitas Padjadjaran Medical School/ 3 COVID-19; Indonesia; SARS-CoV-2 Dr. Hasan Sadikin General Hospital, Bandung, West Java , Indonesia. Corresponding author: Citra Cesilia. Department Of Child Health, Universitas Riau Medical School/Arifin Achmad General Hospital. Email: [email protected]. Submitted September 27, 2020. Accepted January 20, 2021. Paediatr Indones, Vol. 61, No. 1, January 2021 • 53 Citra Cesilia et al.: Case report of a COVID-19 family cluster originating from a boarding school diagnostic test (RDT) for antibodies and reverse including his father, mother, 3 children and also 1 transcription-polymerase chain reaction (RT-PCR) close friend (Table 2). The mother (A2), brother swab for SARS-CoV-2 showed positive results. He (A3), sister (A4), and close friend (A5) also had RDT returned to Riau from Magetan on April 12, 2020. and RT-PCR positive results, even though none had Information about the number of other students from symptoms (Figures 1 and 2). Despite living on the Magetan was obtained from him. Other students went same roof as A1-A4, A6 showed negative RT-PCR to various regencies/cities in Riau, namely Indragiri results. Hilir, Bengkalis, Pelalawan, Siak Regency, Meranti The five family members and one friend were Island, and Dumai City, using private vehicles and did interviewed. Previously, A2-A4 came to pick A1 up at not report to their local health departments. the airport, then travel overland using private car from In the Meranti Islands Regency, the District Sultan Syarif Qasyim Pekanbaru Airport to Meranti Health Office traced students originating from Island. It took approximately 1 hour drive from airport Magetan and conducted RDT, RT-PCR swabs, to Sungai Duku Harbor, 5-6 hours from Sungai Duku laboratory examinations, and chest computerized Harbor to Meranti Island using fast ferry, and another tomography (CT scans). As of May 10, 2020 there 3-4 hour drive from harbor to the patient’s home. were 10 children aged 0-18 years who lived in Meranti During the trip, A1-A4 often open their mask. A5 Islands Regency suspected to have COVID-19, of did not live in the same house as A1, however, had whom 4 of them were boarding school students close contacts with A1 almost every day within 14 from Magetan and confirmed later of being infected days. From the 5 members of this family cluster, only with SARS-CoV-2. The exact data on the number A1 had a complaint of hoarseness, while others had of students from Magetan who returned to Meranti no complaints. was unknown because they returned back to Meranti A1-A5 were diagnosed positive with SARS- Islands independently without reporting to the local CoV-2, according to the Guidelines of COVID-19 health office, so the data for 4 people were obtained Control and Prevention version 4 by Directorate from information from fellow students who knew General of COVID-19 Control and Prevention.1 each other. Epidemiological, demographic, clinical, and laboratory On May 14, 2020, a 17-year-old male student testing data were obtained from patients’ medical (A1) tested positive by PCR swab after having been records. nasopharyngeal swab specimens were traced by the Meranti District Health Office. He maintained in viral-transport medium. The SARS- complained only of pain when swallowing; he had no CoV-2 was confirmed by RT-PCR by using the protocol fever, cough, shortness of breath, or chest tightness. described previously.1 A rapid antibody test was positive, so the patient was According to Riau’s Task Force Protocol that isolated and contact tracing was performed. From current time, all COVID-19 confirmed patients must contact tracing 6 people were found to have close be isolated in the hospital regardless of the results. contact with A1. His family, consisting 5 persons, Thus, case A1-A5 were all hospitalized in a district Table 1. Demographic characteristics of a family cluster Case Age, years Gender Relation to Symptoms Date of positive Number of Date of negative Positive index case RT-PCR days since RT-PCR PCR potential duration exposure A1 17 M Index case Sore throat May 14, 2020 Unknown May 18, 2020 3 days A2 40 F Mother None May 15, 2020 unknown May 20, 2020 5 days A3 18 M Brother None May 15, 2020 unknown May 20, 2020 5 days A4 11 F Sister None May, 15,2020 unknown May 31, 2020 17 days A5 17 F Friend None May, 25, 2020 unknown June 1, 2020 8 days A6 39 M Father None Negative - - - 54 • Paediatr Indones, Vol. 61, No. 1, January 2021 Citra Cesilia et al.: Case report of a COVID-19 family cluster originating from a boarding school Figure 1. Clinical timeline Figure 2. Patients’ RT-PCR results general hospital, however, case A2 and A3 were the hospital and was treated for 10 days (from May treated in pulmonary ward while A1, A4 were treated 14, 2020 to May 24, 2020). A4 was treated in the in the pediatric ward. Due to difficult bureaucracies, hospital for 15 days (from May 14, 2020 to June 3, treatment histories of A2 and A3 were not possible. 2020), meanwhile A5 for 20 days (from May 24, 2020 The other 3 Magetan boarding school students were to June 10, 2020). also hospitalized and showed mild symptoms, further The laboratory test results were within normal information was unknown. limits. All patients underwent chest CT-scan; a After the RT-PCR results of A1 showed positive ground glass appearance was identified in only A4 (May 14, 2020), A1 was immediately admitted to and A5 (Figure 3 and Figure 4). None of the patients Paediatr Indones, Vol. 61, No.1, January 2021 • 55 Citra Cesilia et al.: Case report of a COVID-19 family cluster originating from a boarding school Figure 3. CT scan image of case A4 Figure 4. CT scan image of case A5 56 • Paediatr Indones, Vol. 61, No. 1, January 2021 Citra Cesilia et al.: Case report of a COVID-19 family cluster originating from a boarding school had leukopenia, thrombocytopenia, monocytosis, higher in adults compared to infants and toddlers increased neutrophil-to-lymphocyte (NLR) ratio or (<5 years old).10 Despite children’s tendency to have decreased absolute-lymphocyte-count (ALC) . milder COVID-19 symptoms, it is important to make Follow up RT PCR was performed to the three elderly caregivers aware of the risk of transmission subjects. A1 had negative results in swab-2 (May 18 , from young children.2 2020) and swab-3 (May 20, 2020). A4 had positive Real-time RT-PCR is the standard diagnostic result in swab-2 (May 16, 2020), negative in swab-3 method for COVID-19. Although it is very specific, (May 24, 2020), went back positive on swab 4-5 (25 this method has lower sensitivity in mild symptoms and May 27, 2020) and finally negative on swab-6 patients (62.5% compared to 78.2%)11 and a long and -7 (May 31, 2020 and June 1, 2020, respectively).