Changing Face of Medicine
Authors: P. Wade
Journal: BMJ (1955)

<h3>Summary</h3> <h3>Background</h3> Beginning in early February 2020, COVID-19 spread across the state of Georgia, leading to 258,354 cumulative cases as of August 25, 2020. The time scale of spreading (i.e., serial interval) and magnitude of spreading (i.e., <i>R</i><sub><i>t</i></sub> or reproduction number) for COVID-19, were observed to be heterogenous by demographic characteristics, region and time period. In this study, we examined the COVID-19 transmission in the state of Georgia, United States. <h3>Methods</h3> During February 1 to July 13, 2020, we identified 4080 transmission pairs using contact information from reports of COVID-19 cases from the Georgia Department of Public Health. We examined how various transmission characteristics were affected by disease symptoms, demographics (age, gender, and race), and time period (during shelter-in-place and after reopening). In addition, we estimated the time course of reproduction numbers during early February–mid-June for all 159 counties in the state of Georgia, using a total of 118,491 reported COVID-19 cases. <h3>Findings</h3> Over this period, the serial interval appeared to decrease from 5.97 days in February–April to 4.40 days in June–July. With regard to age, transmission was assortative and patterns of transmission changed over time. COVID-19 mainly spread from adults to all age groups; transmission among and between children and the elderly was found less frequently. Younger adults (20– 50 years old) were involved in the majority of transmissions occurring during or after reopening subsequent to the shelter-in-place period. By mid-July, two waves of COVID-19 transmission were apparent, separated by the shelter-in-place period in the state of Georgia. Counties around major cities and along interstate highways had more intense transmission. <h3>Interpretation</h3> The transmission of COVID-19 in the state of Georgia had been heterogeneous by area and changed over time. The shelter-in-place was not long enough to sufficiently suppress COVID-19 transmission in densely populated urban areas connected by major transportation links. Studying local transmission patterns may help in predicting and guiding states in prevention and control of COVID-19 according to population and region. <h3>Funding</h3> Emory COVID-19 Response Collaborative. <h3>Research in context</h3> <h3>Evidence before this study</h3> The ongoing COVID-19 pandemic has caused 37,109,581 cases and 1,070,355 deaths worldwide as of October 11, 2020. We searched PubMed for articles published on and before October 11, 2020 using keywords “novel coronavirus”, “SARS–nCoV–2”, “COVID-19”, “transmission”, “serial interval”, “reproduction number”, and “shelter-in-place”. Few published studies have estimated the serial interval but no study was found that examined the time-varying serial interval. Few studies have examined the transmission patterns between groups with different characteristics. And no study has examined the timevarying reproduction number for COVID-19 and impact of shelter-in-place order at the county level in the United States. <h3>Added value of this study</h3> To our knowledge, this is the first study showing the multiple aspects of COVID-19 transmission, including serial interval, transmission patterns between age, gender, or race groups, and spatiotemporal patterns, based on data from 118,491 confirmed COVID-19 cases and 4080 tracked pairs of infector and infectee. We found that during February–July the serial interval for symptom onset shortened, and the major contribution to the spread of COVID-19 shifted to younger ages (from 40–70 years old in February–April to 20–50 years old in June–July). We also found three to four weeks of the shelter-in-place slowed transmission but was insufficient to prevent transmission into urban and peri-urban counties connected with major transportation. <h3>Implications of all the available evidence</h3> The contracting serial intervals and increasing spread by younger generation show the COVID-19 transmission at county level changes over time. The spatiotemporal patterns of transmission in county level further provide important evidence to guide effective COVID-19 prevention and control measures (e.g., shelter-in-place) in different areas.