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hand, children who were suspected to be COVID-19 patients but negative on SARS-CoV-2 PCR had more fever or cough symptoms compared to those with COVID-19. COVID-19 positive children had significantly more contact with COVID-19 patients whereas children with negative SARS-CoV-2 results had almost no contact with COVID-19 patients. Sensitivity and specificity of symptoms as fever and cough were low and are not useful to distinguish children with and without COVID-19. It is well-known that children have lower suscep-tibility to SARS-CoV-23, 7), but most of the studies are comparisons between children and adults. However, in our daily pediatric practice, we need to know if the patient had COVID-19 or not in the child population, and Japanese Society for Infection Prevention and Control guidelines recommend to ask patients with COVID-19 symptoms to take distance from other patients when waiting at an outpatient clinic. However, in our study, we could not distinguish children with COVID-19 and without COVID-19 by clinical symptoms such as fever and cough which means that dividing patients in waiting rooms into COVID-19 suspected and non-suspected groups, clinical symptoms will not be effective, and separating children by presenting symptoms will result in mixing of both COVID-19 and non-COVID-19 patients in the same waiting areas. What we can do so far is to require personal protective methods in all children and medical staff even in general outpatient clinics throughout this pandemic.The lack of symptoms in COVID-19 children in this study also raises significant concerns about the usefulness of passive or active case-finding to control the pandemic in children. While contact tracing is a known effective mechanism for controlling the pandemic and recommended by the WHO8), in the absence of a mass testing program and with widespread community transmission, our study shows that COVID-19 children are unlikely to be identified based on symptoms alone, and will spread the disease widely until an adult is infected and presents with symptoms. While schools and nurseries remain open the pandemic cannot be controlled without mass testing, and the govern-ment needs to reconsider approaches to pandemic control based on symptomatic case finding alone. Years after the beginning of this pandemic the disease remains largely uncontrolled in Japan, and it is time to recognize that the Japanese govern-ment’s control efforts have been insufficient. A shift to widespread mass testing would overcome the challenges in identifying coronavirus in chil-dren, and enable the government to more rapidly control the disease, especially if it is to continue to keep schools open.Our study suggests that among several contact pathways, contact with family members plays an important role in transmission, consistent with other studies9). Among other contact situations, we found transmission in school, nursery and karate lessons. Although there were a small number of patients with these transmission routes, we must remain aware of them, as they are indicators of uncontrolled community spread. School children are educated to use masks, maintain social distance, and wash their hands but the effectiveness of these strategies outside the household has not been established10), younger children are unable to wear masks11) and activities that require physical contact like karate make these practices impossible to follow. Moreover, there are studies that report the presence of SARS-CoV-2 positive results in stool samples after recovery from COVID-1912), so that such personal protective measures may be impos-sible in preschool children.There are some limitations in our study. This study is the study done at the very first time of the pandemic and some results cannot be applied to the present situation. Our hospital only has a six- bed intensive care unit, and so severe cases are admitted to other hospitals. However, to the best of our knowledge, there was no severe pediatric case in Tokyo during the study period. Another limita-tion is that many positive cases are diagnosed at public health centers and children who were suspected to have COVID-19 and tested SARS- CoV-2 came to our hospital directly. Finally, we concluded that clinical symptoms do not distin-guish children with and without COVID-19 based on sensitivity and specificity of clinical symptoms, however, we should consider that the prior priority differs between the groups. However, as we are currently in a pandemic situation, our study may be helpful for daily pediatric practice. 625