SARS-CoV-2 and the Role of Orofecal Transmission: Evidence Brief
Jefferson T, Spencer EA, Brassey J, Heneghan C.
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.
Published Online July 17, 2020.
http://www.cebm.net/evidence-synthesis/transmission-dynamics-of-covid-19/

Table of 35 Included Studies.
Main findings of 35 studies on orofecal transmission of SARS-CoV-2

Study (link tosummary)Using samples collected between February and April 2020 from sewage
treatment plants in Queensland, Australia, SARS-CoV-2 was detected by
RT-qPCR assay, confirmed by sequencing.

Ahmed 2020

A descriptive review of 14 studies looking at fecal excretion of COVID-19
to 15th March 2020 found that COVID-19 may be transmitted oro-fecally,
but the number of studies with findings of viable virions in the faeces issmall, making this mode of transmission uncertain.

Amirian 2020

A short review of available evidence of the orofecal transmission and its
possible relation to wastewater management indicated that recreational
water could have concentration of SARS-CoV-2 agent via faulty
wastewater management.

Cahill 2020

Testing of 24-h composite raw sewage samples from two large wastewater
treatment plants in Spain showed that SARS-CoV-2 was detected insewage 41 days (15th January 2020) before the declaration of the first
COVID-19 case (25th February 2020) in Spain, and in frozen samples
dating back to 12th March 2019. If these results are confirmed, theysuggest SARS CoV-2 has been around longer than first thought.

Chavarria-Miro2020

This retrospective study of 133 hospitalised COVID-19 patients identified
22 whose sputum or fecal samples tested positive, after their pharyngeal
swabs became negative.

Chen 2020

This study analysed stool samples from a cohort of 59 patients with
COVID-19 in Hong Kong during February 2020 and additionally did aCheung 2020

Transmission of SARS-CoV-2: implications for Orofecal transmission potential of COVID-19

meta-analysis of data from 11 studies on the prevalence of gastrointestinal
symptoms and stool excretion of viruses. Fecal discharge continues longafter respiratory shedding of COVID-19 has ceased.
This study reviewed literature on the potential of SARS-CoV-2 to infect thehuman gastrointestinal tract, and shed via the fecal route to generate
orofecal transmission. Various observational and mechanistic evidence
supports that SARS-CoV-2 can infect and be shed from the humangastrointestinal tract.

Ding S 2020

This study randomly sampled in rooms and areas in the COVID-19
designated infectious diseases hospital Nanjing, China. 4/107 surface
samples tested positive: two ward door door-handles, one bathroom toilet
toilet-seat cover and one bathroom door door-handle. Three were weakly
positive from a bathroom toilet seat, one bathroom washbasin tap leverand one bathroom ceiling exhaust louvre. 1/46 corridor air samples tested
weakly positive.

Ding Z 2020

This short review reported that in children, the orofecal route is analternative route of transmission, regardless of presenting COVID 19
symptomatology. Exclusion of SARS-CoV-2 infection by single time point
nasopharyngeal swabs should not be used in children.

Dona 2020

This review of 26 studies reported that there is a high rate of PCR positive
persistence of SARS-CoV-2 in faecal samples of patients with COVID-19.

Gupta 2020

Among a group of hospitalised patients with low severity COVID-19,
digestive symptoms were present in 57%. Patients with digestive
symptoms were more likely to be fecal virus-positive than those withrespiratory symptoms.

Han C 2020

SARS-CoV-2 RNA was detected in serum, urine or stool samples in 20%
of patients hospitalised with COVID-19. However, the virus could not be
isolated from these samples and therefore the risk of transmission via
these media is not established.

Kim J-M 2020

This systematic review concluded that extensive uncertainty on theecology of SARS-CoV-2 makes it hard to make specific recommendations
on handling and prevention of transmission. CoV are susceptible to heat,surfactants and low pH.

Kingsbury 2020

This systematic review showed that Coroviridae have been isolated indifferent types of liquids from waste to surface water, but in general, they
appear to be unstable. Chlorination and higher temperatures lead to their

La Rosa 20201

Transmission of SARS-CoV-2: implications for Orofecal transmission potential of COVID-19

inactivation.
An environmental surveillance study based on twelve influent sewagesamples, collected between February and April 2020 from wastewater
treatment plants in Milan and Rome, Italy showed SARS-CoV-2 RNA
fragments have been identified in sewage in Italy, and suggest a novel
RT-PCR test for screening of waters.

La Rosa 2020aSARS-CoV-2 was detected in the sewage of five sites a week after the first
COVID-19 case in the Netherlands. Even at low COVID-19 prevalence
sewage surveillance could be a sensitive tool to monitor the viralcirculation.

Medema 2020

This review reports that the gastrointestinal tract supports the growth ofSARS-CoV-2 to an extent similar to previous SARS infections and that
gastric symptoms are frequently experienced in COVID-19.

Parasa 2020

A systematic review of 4 case series including 36 children with mild
COVID-19 found that fecal shedding in children with COVID-19 occurs on
average nine days longer than by the respiratory route.

Santos 2020

This pilot study in India found SARS-CoV-2 RNA in fecal samples from 12
symptomatic and asymptomatic COVID-19 patients.

Senapati 2020

Combining in vitro data, pollution analysis and a virus survivability model,based on data from 39 countries, SARS-CoV-2 can remain stable withinwater for up to 25 days. Country-specific risk of infection posed by faecal
contaminated water is environment-dependent, with water flow andtemperature as important variables.

Shutler 2020

Reviewed GI features of, and faecal test results in, COVID-19 from casereports and retrospective clinical studies: Gastrointestinal symptoms arecommon in COVID-19 patients and were observed with increased
prevalence as the epidemic progressed in China. SARS-CoV-2 enters GI
epithelial cells, and the faeces of COVID-19 patients are potentially
infectious.

Tian 2020

In this case series from China, 2 stool specimens out of 44 positives
contained live virus, suggesting that orofecal transmission is possible.
Transmission of the virus by respiratory and extra respiratory routes mayhelp explain the rapid spread of disease.

Wang W 20202

Transmission of SARS-CoV-2: implications for Orofecal transmission potential of COVID-19

No live SARS-CoV was found in any sewage samples from two hospitals
receiving COVID-19 patients. SARS-CoV RNA was detected in sewage
concentrates of two hospitals receiving SARS patients prior to disinfection,and occasionally after disinfection.

Wang XW 2020

In 98 hospitalized COVID-19 cases, patients’ faecal samples remained
positive for SARS-CoV-2 for a mean of 11 days (maximum 5 weeks) after
respiratory tract samples became negative.

Wu Y 2020

An increase of SARS-CoV-2 genome units in raw wastewaters in andaround Paris, France accurately followed the increase of human
COVID-19 cases observed at the regional level.

Wurtzer 2020

Assessing viral RNA in feces from 71 patients with SARS-CoV-2 infection
during their hospitalizations, and examining the viral RNA and viralnucleocapsid protein in gastrointestinal tissues from one of the patients,suggests SARS-CoV-2 may both infect the gastrointestinal system andtransmit via an orofecal route.
Detection of some viral nucleocapsid protein in rectal epithelial cells of
COVID-19 patients suggests that some infectious viral particles may
survive the harsh gastrointestinal environment.

Xiao 2020

This case series of 28 hospitalised patients for whom faeces samples were Xiao 2020b
available indicated that infectious virus was present in faeces from twocases who also tested positive for viral RNA by RT-PCR.
This study of 10 children with COVID-19 found that symptoms amongchildren were nonspecific and relatively mild; rectal swabs tested positive
among 8/10 cases even once nasopharyngeal tests became negative.

Xu Y 2020

Live virus has been isolated from the stools of one severe pneumonia
case, pointing to a possible oro-fecal spread.

Yong Z 2020

A retrospective case note survey of 2,138 paediatric patients withsuspected SARS-CoV-2 infection in Wuhan Children’s Hospital fromJanuary to March 2020 suggested that in some children, fecal shedding
may be a sign of prolonged mildly asymptomatic infection and represent
the final phase of the disease.

Yuan 2020

This laboratory study showed that human enterocytes expressing highACE2 receptor levels could support infection with SARS-CoV-2. However,the virus is rapidly inactivated in the GI tract, and no infectious virus wasobtained from stool samples from COVID-19 patients.

Zang 20203

Transmission of SARS-CoV-2: implications for Orofecal transmission potential of COVID-19A small pilot sample of 14 cases indicated agreement for the presence of
COVID-19 between oropharyngeal samples and fecal samples.

Zhang J 2020Three children with mild symptoms who were SARS-CoV-2 throat swab
specimen negative on discharge from hospital were stool positive 10 days
post-discharge.

Zhang T 2020

A small study of hospitalised COVID-19 patients indicated that RNA ofSARS-CoV-2 may be shed via multiple bodily routes, and highlights thatCOVID-19 is found in anal swabs sometimes when oral swabs show noviral RNA.

Zhang W 2020

This laboratory study showed that SARS-CoV-2 can infect bat intestinal
cells, and demonstrated SARS-CoV-2 replication in human intestinalorganoids, suggesting that the human intestinal tract might be atransmission route of SARS-CoV-2.

Zhou J 20204