Prevalence and characteristics of fever in adult and paediatric patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis of 17515 patients

Abstract

Background: Coronavirus disease 2019 (COVID-19), a pandemic disease caused by the severe acute respiratory syndrome coronavirus 2 started to spread globally since December 2019 from Wuhan, China. Fever has been observed as one of the most common clinical manifestations, although the prevalence and characteristics of fever in adult and paediatric COVID-19 patients is inconclusive. We aimed to conduct a systematic review and meta-analysis to estimate the overall pooled prevalence of fever and chills in addition to fever characteristics (low, medium, and high temperature) in both adult and paediatric COVID-19 patients.

Methods: The protocol of this systematic review and meta-analysis was registered with PROSPERO (CRD42020176327). PubMed, Scopus, ScienceDirect and Google Scholar databases were searched between 1st December 2019 and 3rd April 2020 without language restrictions. Both adult (≥18 years) and paediatric (<18 years) COVID-19 patients were considered eligible. We used random-effects model for the meta-analysis to obtain the pooled prevalence and risk ratio (RR) with 95% confidence intervals (CIs). Quality assessment of included studies was performed using the Joanna Briggs Institute critical appraisal tools. Heterogeneity was assessed using the I² statistic and Cochran's Q test. Robustness of the pooled estimates was checked by different subgroups and sensitivity analyses.

Results: We identified 2055 studies, of which 197 studies (n = 24266) were included in the systematic review and 167 studies with 17142 adults and 373 paediatrics were included in the meta-analysis. Overall, the pooled prevalence of fever in adult and paediatric COVID-19 patients were 79.43% [95% CI: 77.05-81.80, I2 = 95%] and 45.86% [95% CI: 35.24-56.48, I2 = 78%], respectively. Besides, 14.45% [95% CI: 10.59-18.32, I2 = 88%] of the adult COVID-19 patients were accompanied with chills. In adult COVID-19 patients, the prevalence of medium-grade fever (44.33%) was higher compared to low- (38.16%) and high-grade fever (14.71%). In addition, the risk of both low (RR: 2.34, 95% CI: 1.69-3.22, p<0.00001, I2 = 84%) and medium grade fever (RR: 2.79, 95% CI: 2.21-3.51, p<0.00001, I2 = 75%) were significantly higher compared to high-grade fever, however, there was no significant difference between low- and medium-grade fever (RR: 1.17, 95% CI: 0.94-1.44, p = 0.16, I2 = 87%). 88.8% of the included studies were of high-quality. The sensitivity analyses indicated that our findings of fever prevalence for both adult and paediatric patients are reliable and robust.

Conclusions: The prevalence of fever in adult COVID-19 patients was high, however, 54.14% of paediatric COVID-19 patients did not exhibit fever as an initial clinical feature. Prevalence and risk of low and medium-grade fevers were higher compared to high-grade fever.

Fig 1. PRISMA flow diagram of study selection.

Fig 2. Prevalence of chills in adult COVID-19 patients.

Fig 3. Risks of fever prevalence in (A) severe or critical vs non-severe, (B) non-survived vs survived (recovered or discharged) and (C) ICU vs non-ICU adult COVID-19 patients.

Fig 4. Prevalence of (A) low (37.3–38.0°C), (B) medium (38.0–39.0°C) and (C) high-grade (>39.0°C) fever in adult COVID-19 patients.

Fig 5. Risks of (A) low-grade fever (37·3–38·0°C) vs medium-grade fever (38·1–39·0°C), (B) high-grade fever (>39·0°C) vs low-grade fever (37·3–38·0°C), and (C) high-grade fever (>39·0°C) vs medium-grade fever (38·1–39·0°C) in adult COVID-19 patients.

Fig 6. Funnel plots on (A) adult and (B) paediatric COVID-19 studies.

Fig 7. Galbraith plot identified eight outlier studies as potential sources of heterogeneity.