Abstract
Transmission of SARS-CoV-2 has significant implications for hospital infection prevention and control, discharge management, and public health. We reviewed available literature to reach an evidenced-based consensus on the expected duration of viral shedding. We queried 4 scholarly repositories and search engines for studies reporting SARS-CoV-2 viral shedding dynamics by PCR and/or culture available through September 8, 2020. We calculated the pooled median duration of viral RNA shedding from respiratory and fecal sources. The review included 77 studies on SARS-CoV-2. All studies reported PCR-based testing and 12 also included viral culture data. Among 28 studies, the overall pooled median duration of RNA shedding from respiratory sources was 18.4 days (95% CI, 15.5-21.3; I2 = 98.87%; P < .01). When stratified by disease severity, the pooled median duration of viral RNA shedding from respiratory sources was 19.8 days (95% CI, 16.2-23.5; I2 = 96.42%; P < .01) among severely ill patients and 17.2 days (95% CI, 14.0-20.5; I2 = 95.64%; P < .01) in mild-to-moderate illness. Viral RNA was detected up to 92 days after symptom onset. Viable virus was isolated by culture from -6 to 20 days relative to symptom onset. SARS-COV-2 RNA shedding can be prolonged, yet high heterogeneity exists. Detection of viral RNA may not correlate with infectivity since available viral culture data suggests shorter durations of shedding of viable virus. Additional data are needed to determine the duration of shedding of viable virus and the implications for risk of transmission.
Highlights
77 studies and reports were eligible for inclusion: prospective case series (N = 35), retrospective case series (N = 28), case reports (N = 11), point prevalence survey (N = 2), and position statements (N = 1) (Table 1)
The pooled median duration of viral RNA shedding from respiratory sources among patients with mild-to-moderate illness, based upon 10 studies that reported sufficient data (Appendix Table 1 online), was 17.2 days
We summarized available data on duration of SARS-CoV-2 viral RNA shedding, isolation of viable virus, and the impact of infection severity on shedding duration
Summary
We queried PubMed, LitCoVID, the World Health Organization COVID-19 literature repository, and Google Scholar for studies and reports available through September 8, 2020. Articles reporting duration of SARS-CoV-2 shedding based upon PCR testing or culture directly from human specimens were included. We reviewed the design, objective, population, healthcare system setting, diagnostic testing method, timing of tests, sample source, patient symptoms, and severity of illness. We constructed random-effects models using the restricted maximum likelihood estimator for τ 2 to calculate pooled median durations of viral RNA shedding.[1] All studies providing sample size and sufficient data on measures of central tendency and spread were included in our analysis. We grouped nasopharyngeal (NP), oropharyngeal (OP), saliva, and sputum samples together as “respiratory” samples Fecal samples included both stool and rectal swabs. We calculated pooled medians among PCR respiratory samples for all available, mild-to-moderate illness, severe-to-critical illness, and for all fecal samples. Analysis was performed using R version 4.0.0 software[2] using the metamedian package.[3]
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