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/

References: Included Studies
Ahmed W, Angel N, Edson J et al. First confirmed detection of SARS-CoV-2 in untreatedwastewater in Australia: A proof of concept for the wastewater surveillance of COVID-19 in thecommunity. Science of The Total Environment. 2020;728:138764.
https://doi.org/10.1016/j.scitotenv.2020.138764
Amirian ES. Potential fecal transmission of SARS-CoV-2: Current evidence and implications for
public health. Int J Infect Dis. 2020;95(1878-3511):363-70.
https://doi.org/10.1016/j.ijid.2020.04.057
Cahill N, Morris D. Recreational waters - A potential transmission route for SARS-CoV-2 tohumans? [published online ahead of print, 2020 Jun 11]. Sci Total Environ. 2020;740:140122.
https://doi.org/10.1016/j.scitotenv.2020.140122
Chavarria-Miró G, Anfruns-Estrada E, Guix S et al. Sentinel surveillance of SARS-CoV-2 inwastewater anticipates the occurrence of COVID-19 cases. ​medRxiv.
2020:2020.06.13.20129627
Chen Y, Wang AH, Yi B, et al. Zhonghua Liu Xing Bing Xue Za Zhi. 2020;41(5):667-671.
doi:10.3760/cma.j.cn112338-20200304-00251
Chen Y, Chen L, Deng Q, et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19
patients. J Med Virol. 2020;92(7):833-840. ​doi:10.1002/jmv.25825
Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal manifestations of SARS-CoV-2
infection and virus load in fecal samples from a Hong Kong cohort: systematic review andmeta-analysis [published online ahead of print, 2020 Apr 3]. Gastroenterology.
2020;S0016-5085(20)30448-0. ​doi:10.1053/j.gastro.2020.03.065

SARS-CoV-2 and the Role of Orofecal Transmission
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.

Ding S, Liang TJ. Is SARS-CoV-2 also an enteric pathogen with potential fecal-oraltransmission? A COVID-19 virological and clinical review [published online ahead of print, 2020
Apr 27]. Gastroenterology. 2020;S0016-5085(20)30571-0. ​doi:10.1053/j.gastro.2020.04.052
Ding Z, Qian H, Xu B et al. Toilets dominate environmental detection of SARS-CoV-2 virus in ahospital.2020. medRxiv 2020.04.03.20052175; doi:
https://doi.org/10.1101/2020.04.03.20052175
Donà D, Minotti C, Costenaro P, Da Dalt L, Giaquinto C. Fecal-Oral Transmission ofSARS-CoV-2 In Children: is it Time to Change Our Approach?. Pediatr Infect Dis J.
2020;39(7):e133-e134. ​doi:10.1097/INF.0000000000002704
Gupta S, Parker J, Smits S, Underwood J, Dolwani S. Persistent viral shedding of SARS-CoV-2
in faeces - a rapid review. Colorectal Dis. 2020;22(6):611-620. ​doi:10.1111/codi.15138
Han C, Duan C, Zhang S, et al. Digestive symptoms in COVID-19 patients with mild disease
severity: clinical presentation, stool viral RNA testing, and outcomes. Am J Gastroenterol. 2020.
doi:10.14309/ajg.0000000000000664
Kim J-M, Kim HM, Lee EJ et al. Osong Public Health Res Perspect. 2020 Jun; 11(3): 112–117.
doi: 10.24171/j.phrp.2020.11.3.02
Kingsbury J, Lake R. Potential for foodborne transmission of COVID-19: literature review
update. New Zealand Food Safety & Science Research Centre. 2020.
https://www.unitedfresh.co.nz/assets/COVID-19/United-Fresh---Potential-for-Foodborne-Transm
ission-of-Covid-19---Literature-Review-Update-19-May-20.pdf
La Rosa G, Bonadonna L, Lucentini L, Kenmoe S, Suffredini E. Coronavirus in water
environments: Occurrence, persistence and concentration methods - A scoping review. Water
Res. 2020;179:115899. ​doi:10.1016/j.watres.2020.115899
La Rosa G, Iaconelli M, Mancini P, Bonanno Ferraro G, Veneri C, Bonadonna L, et al. First
detection of SARS-COV-2 in untreated wastewaters in Italy. ​medRxiv.
2020:2020.04.25.20079830.
Medema G, Heijnen L, Elsinga G, Italiaander R, Brouwer A. Presence of SARS-Coronavirus-2in sewage. ​medRxiv. 2020:2020.03.29.20045880​.
Parasa S, Desai M, Thoguluva Chandrasekar V, et al. Prevalence of gastrointestinal symptoms
and fecal viral shedding in patients with coronavirus disease 2019: a systematic review andwww.cebm.net/evidence-synthesis​ ​1

SARS-CoV-2 and the Role of Orofecal Transmission
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.

meta-analysis. JAMA Netw Open. 2020;3(6):e2011335. Published 2020 Jun 1.
doi:10.1001/jamanetworkopen.2020.11335
Santos VS, Gurgel RQ, Cuevas LE, Martins-Filho PR. Prolonged fecal shedding ofSARS-CoV-2 in pediatric patients. A quantitative evidence synthesis [published online ahead ofprint, 2020 May 22]. J Pediatr Gastroenterol Nutr. 2020;10.1097/MPG.0000000000002798.
doi:10.1097/MPG.0000000000002798
Shim E, Tariq A, Choi W, Lee Y, Chowell G. Transmission potential and severity of COVID-19 inSouth Korea. Int J Infect Dis. 2020;93:339-344. ​doi:10.1016/j.ijid.2020.03.031
Tian Y, Rong L, Nian W, He Y. Review article: gastrointestinal features in COVID-19 and thepossibility of faecal transmission. Aliment Pharmacol Ther. 2020;51(9):843-851.
doi:10.1111/apt.15731
Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical specimens.
JAMA. 2020;323(18):1843–1844. ​doi:10.1001/jama.2020.3786
Wang XW, Li J, Guo T, et al. Concentration and detection of SARS coronavirus in sewage from
Xiao Tang Shan Hospital and the 309th Hospital of the Chinese People's Liberation Army.
Water Sci Technol. 2005;52(8):213-221​.
Wu Y, Guo C, Tang L, et al. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples.
Lancet Gastroenterol Hepatol. 2020. ​10.1016/S2468-1253(20)30083-2
Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infection ofSARS-CoV-2. Gastroenterology. 2020. ​10.1053/j.gastro.2020.02.055
Xiao F, Sun J, Xu Y, et al. Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19[published online ahead of print, 2020 May 18]. Emerg Infect Dis.
2020;26(8):10.3201/eid2608.200681. ​doi:10.3201/eid2608.200681
Xu Y, Li X, Zhu B, et al. Characteristics of pediatric SARS-CoV-2 infection and potential
evidence for persistent fecal viral shedding. Nat Med. 2020;26(4):502-505.
doi:10.1038/s41591-020-0817-4
Yong Z, Cao C, Shuangli Z et al. Isolation of 2019-nCoV from a Stool Specimen of aLaboratory-Confirmed Case of the Coronavirus Disease 2019 (COVID-19)[J]. China CDC
Weekly, 2020, 2(8): 123-124. ​doi: 10.46234/ccdcw2020.033

www.cebm.net/evidence-synthesis​ ​2

SARS-CoV-2 and the Role of Orofecal Transmission
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.

Yuan C, Zhu H, Yang Y, et al. Viral loads in throat and anal swabs in children infected withSARS-CoV-2. Emerg Microbes Infect. 2020;9(1):1233-1237.
doi:10.1080/22221751.2020.1771219
Zang R, Castro MFG, McCune BT et al. The SARS-CoV-2 virus infects cultured
ACE2-expressing human enterocytes aided by the TMPRSS2 and TMPRSS4 serine proteases.
Science Immunology 13 May 2020: Vol. 5, Issue 47, eabc3582 ​DOI:
10.1126/sciimmunol.abc3582
Zhang J, Wang S, Xue Y. Fecal specimen diagnosis 2019 novel coronavirus-infectedpneumonia. J Med Virol. 2020. ​10.1002/jmv.25742
Zhang T, Cui X, Zhao X, et al. Detectable SARS-CoV-2 viral RNA in feces of three children
during recovery period of COVID-19 pneumonia. J Med Virol. 2020;92(7):909-914.
doi:10.1002/jmv.25795
Zhang W, Du RH, Li B, et al. Molecular and serological investigation of 2019-nCoV infectedpatients: implication of multiple shedding routes. Emerg Microbes Infect. 2020;9(1):386-389.
https://doi.org/10.1080/22221751.2020.1729071
Zhou J, Li C, Liu X, et al. Infection of bat and human intestinal organoids by SARS-CoV-2[published online ahead of print, 2020 May 13]. Nat Med. 2020;10.1038/s41591-020-0912-6.
doi:10.1038/s41591-020-0912-6

www.cebm.net/evidence-synthesis​ ​3

SARS-CoV-2 and the Role of Orofecal Transmission
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.

References: Other
1. ​ Transmission of SARS-CoV-2: implications for infection prevention precautions

https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infectionprevention-precautions
2. Patient-derived mutations impact pathogenicity of SARS-CoV-2 Hangping Yao et al.​https://www.medrxiv.org/content/10.1101/2020.04.14.20060160v2.full.pdf
3. ​Holmes K.V. Enteric infections with coronaviruses and toroviruses. Novartis Found Symp.
2001;238:258–269. discussion 26​9–275.
4. ​ ​ ​ Ye G, Lin H, Chen S, et al. Environmental contamination of SARS-CoV-2 in healthcare

5. ​Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment
Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a
Symptomatic Patient. ​JAMA.​ 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227
6. Guo ZD, Wang ZY, Zhang SF, et al. Aerosol and Surface Distribution of Severe Acute
7. Wang J, Feng H, Zhang S, et al. SARS-CoV-2 RNA detection of hospital isolation wards
8. ​ Zhou J et al. Human intestinal tract serves as an alternative infection route for Middle East respiratory
syndrome coronavirus. Sci Adv. 2017;3:eaao4966.
https://advances.sciencemag.org/content/3/11/eaao4966
9. Lee SS, Wong NS. Probable transmission chains of Middle East respiratory syndrome coronavirus andthe multiple generations of secondary infection in South Korea. Int J Infect Dis. 2015 Sep; 38():65-7.
10. ​Further studies on human enteric coronaviruses.​ ​Caul EO, Egglestone SI.
11. ​Booth CM et al. Clinical features and short-term outcomes of 144 patients with SARS in the greater
Toronto area. JAMA. 2003;289:2801–2809.
12. ​Leung WK, To K-F, Chan PKS, Chan HLY, Wu AKL, Lee N, Yuen KY, Sung JJY. Enteric involvementof severe acute respiratory syndrome-associated coronavirus infection. Gastroenterology 125, 1011–1017(2003).
13. ​Hung IFN et al. Viral loads in clinical specimens and SARS manifestations. Emerg. Infect. Dis. 10,1550–1557 (2004).
14. ​Peiris JSM et al. Clinical progression and viral load in a community outbreak ofcoronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003;361:1767–1772.
15. ​WHO environmental health team reports on Amoy gardens. Available at:
http://www.info.gov.hk/gia/general/200305/16/0516114.htm​.
16. ​Ding Y, He L, Zhang Q, et al. Organ distribution of severe acute respiratory syndrome (SARS)
associated coronavirus (SARS-CoV) in SARS patients: implications for pathogenesis and virustransmission pathways. ​J Pathol​. 2004;203(2):622-630. doi:10.1002/path.1560

www.cebm.net/evidence-synthesis​ ​4

SARS-CoV-2 and the Role of Orofecal Transmission
In: Analysis of the Transmission Dynamics of COVID-19: An Open Evidence Review.

17. ​Wang XW, Li JS, Guo TK, et al. Concentration and detection of SARS coronavirus in sewage fromXiao Tang Shan Hospital and the 309th Hospital [published correction appears in J Virol Methods. 2005
Dec;130(1-2):210]. ​J Virol Methods​. 2005;128(1-2):156-161. doi:10.1016/j.jviromet.2005.03.022
18. Analysis of SARS-CoV-2 transmission clusters and superspreading events Gwen Knight, Quentin
Leclerc and Adam Kucharski, on behalf of CMMID working group Report for SPI-M, 3rd June 2020.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/897562/S0473_SPI-M_Superspreading_and_clusters.pdf
19. ​Hartmann, Katrin (2005).​ "​ Feline infectious peritonitis"​. ​Veterinary Clinics of North America: Small
Animal Practice.​ ​35​ (1): 39–79. ​doi​:​10.1016/j.cvsm.2004.10.011
20. I​mmune evasion of porcine enteric coronaviruses and viral modulation of antiviral innate signaling.
21. ​ ​Fan Y, Zhao K, Shi ZL, Zhou P. Bat Coronaviruses in China. ​Viruses.​ 2019;11(3):210. Published2019 Mar 2. doi:10.3390/v11030210
22. ​Killerby ME, Biggs HM, Midgley CM, Gerber SI, Watson JT. Middle East Respiratory SyndromeCoronavirus Transmission. Emerg Infect Dis. 2020;26(2):191-198.
https://dx.doi.org/10.3201/eid2602.190697

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