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Outbreak of COVID-19 in Germany Resulting from a Single Travel-Associated Primary Case

22 Pages Posted: 31 Mar 2020

See all articles by Merle M. Böhmer

Merle M. Böhmer

Bavarian Health And Food Safety Authority (LGL)

Udo Buchholz

Robert Koch Institute - Department for Infectious Disease Epidemiology

Victor M. Corman

Charité - Universitätsmedizin Berlin

Martin Hoch

Bavarian Health And Food Safety Authority (LGL)

Katharina Katz

Bavarian Health And Food Safety Authority (LGL)

Durdica V. Marosevic

Bavarian Health And Food Safety Authority (LGL)

Stefanie Böhm

Bavarian Health And Food Safety Authority (LGL)

Tom Woudenberg

Bavarian Health And Food Safety Authority (LGL)

Nikolaus Ackermann

Bavarian Health And Food Safety Authority (LGL)

Regina Konrad

Bavarian Health And Food Safety Authority (LGL)

Ute Eberle

Bavarian Health And Food Safety Authority (LGL)

Bianca Treis

Bavarian Health And Food Safety Authority (LGL)

Alexandra Dangel

Bavarian Health And Food Safety Authority (LGL)

Katja Bengs

Bavarian Health And Food Safety Authority (LGL)

Volker Fingerle

Bavarian Health And Food Safety Authority (LGL)

Anja Berger

Bavarian Health And Food Safety Authority (LGL)

Stefan Hörmansdorfer

Bavarian Health And Food Safety Authority (LGL)

Siegfried Ippisch

Bavarian Health And Food Safety Authority (LGL)

Bernd Wicklein

Bavarian Health And Food Safety Authority (LGL)

Andreas Grahl

Bavarian Health And Food Safety Authority (LGL)

Kirsten Pörtner

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE)

Nadine Muller

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE)

Nadine Zeitlmann

Robert Koch Institute

T. Sonia Boender

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE)

Wei Cai

Robert Koch Institute

Andreas Reich

Robert Koch Institute

Maria an der Heiden

Robert Koch Institute

Ute Rexroth

Robert Koch Institute

Osamah Hamouda

Robert Koch Institute

Julia Schneider

Charité - Universitätsmedizin Berlin - Institute of Virology

Talitha Veith

Charité - Universitätsmedizin Berlin - Institute of Virology

Barbara Mühlemann

Charité - Universitätsmedizin Berlin - Institute of Virology

Roman Wölfel

Bundeswehr Institute of Microbiology

Markus Antwerpen

Bundeswehr Institute of Microbiology

Mathias Walter

Bundeswehr Institute of Microbiology

Ulrike Protzer

Technische Universität München (TUM) - Institute of Virology

Bernhard Liebl

Ludwig Maximilian University of Munich (LMU)

Walter Haas

Robert Koch Institute

Andreas Sing

Bavarian Health And Food Safety Authority (LGL)

Christian Drosten

Charité - Universitätsmedizin Berlin - Institute of Virology

Andreas Zapf

Bavarian Health And Food Safety Authority (LGL)

More...

Abstract

Background: In December 2019, a newly identified coronavirus (SARS-CoV-2) emerged in Wuhan, China, causing respiratory disease (COVID-19) presenting with fever, cough and frequently pneumonia. WHO has set the strategic objective to interrupt virus spread of SARS-CoV-2 worldwide. An outbreak in Bavaria, Germany, starting end of January 2020, gave the opportunity to study transmission events, incubation period, and attack rates.

Methods: A case was defined as a person with SARS-CoV-2-infection confirmed by PCR. Case interviews were conducted to i) describe timing of onset and nature of symptoms, ii) identify and classify contacts. High-risk contacts were actively followed and monitored for symptoms, low-risk contacts were tested upon self-reporting of symptoms. Whole genome sequencing was used to confirm epidemiological links and clarify transmission events where contact histories were ambiguous; integration with epidemiological data enabled precise reconstruction of exposure events and incubation periods.

Results: Case #0 was a Chinese person who visited Germany for professional reasons. Sixteen subsequent cases emerged in four transmission generations. Signature mutations occurred upon foundation of generation 2, as well as in one patient pertaining to generation 4. Median incubation period and serial interval were 4.0 days, respectively. Transmissions occurred frequently pre-symptomatic, at day of symptom onset and during prodromal phase (symptoms other than fever and cough for ≥1 day at beginning of illness phase). Attack rates were 75% among members of a household cluster in common isolation, 10% among household contacts only together until isolation of case, and 5% among non-household high-risk contacts.

Conclusions: While our cases present with predominately mild, non-specific symptoms, infectiousness before or on the day of symptom onset or during prodromal phase is substantial. Additionally, the incubation period is often very short, false-negative tests may occur. Although the outbreak was apparently controlled, successful long-term and global containment of COVID-19 may be difficult to achieve.

Funding Statement: Contributions by C. D. and V. M. C. were funded by the German Ministry of Health (Konsiliarlabor für Coronaviren), as well as the German Center for Infection Research. S.B., T.W., K.P., N.M, and T.S.B. are fellows of the ECDC Fellowship Programme, supported financially by the European Centre for Disease Prevention and Control (ECDC).

Declaration of Interests: The authors declared no competing interest.

Ethics Approval Statement: The outbreak investigation was conducted as part of the authoritative, official tasks of the county health departments as well as the state health department of the Bavarian Health and Food Safety Authority, supported by the Robert Koch Institute. As conducted in response to a public health emergency, this study was exempt from institutional review board approval.

Keywords: COVID-19; SARS-CoV-2; Outbreak; Germany; Attack rate; Transmission

Suggested Citation

Böhmer, Merle M. and Buchholz, Udo and Corman, Victor M. and Hoch, Martin and Katz, Katharina and Marosevic, Durdica V. and Böhm, Stefanie and Woudenberg, Tom and Ackermann, Nikolaus and Konrad, Regina and Eberle, Ute and Treis, Bianca and Dangel, Alexandra and Bengs, Katja and Fingerle, Volker and Berger, Anja and Hörmansdorfer, Stefan and Ippisch, Siegfried and Wicklein, Bernd and Grahl, Andreas and Pörtner, Kirsten and Muller, Nadine and Zeitlmann, Nadine and Boender, T. Sonia and Cai, Wei and Reich, Andreas and an der Heiden, Maria and Rexroth, Ute and Hamouda, Osamah and Schneider, Julia and Veith, Talitha and Mühlemann, Barbara and Wölfel, Roman and Antwerpen, Markus and Walter, Mathias and Protzer, Ulrike and Liebl, Bernhard and Haas, Walter and Sing, Andreas and Drosten, Christian and Zapf, Andreas, Outbreak of COVID-19 in Germany Resulting from a Single Travel-Associated Primary Case (3/5/2020). Available at SSRN: https://ssrn.com/abstract=3551335 or http://dx.doi.org/10.2139/ssrn.3551335

Merle M. Böhmer

Bavarian Health And Food Safety Authority (LGL)

Veterinärstraße 2
85764 Oberschleißheim
Germany

Udo Buchholz

Robert Koch Institute - Department for Infectious Disease Epidemiology ( email )

Berlin
Germany

Victor M. Corman

Charité - Universitätsmedizin Berlin ( email )

Charitéplatz 1
Berlin, 10117
Germany

Martin Hoch

Bavarian Health And Food Safety Authority (LGL)

Veterinärstraße 2
85764 Oberschleißheim
Germany

Katharina Katz

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Durdica V. Marosevic

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Stefanie Böhm

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Tom Woudenberg

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Nikolaus Ackermann

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Regina Konrad

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Ute Eberle

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Bianca Treis

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Alexandra Dangel

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Katja Bengs

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Volker Fingerle

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Anja Berger

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Stefan Hörmansdorfer

Bavarian Health And Food Safety Authority (LGL)

Veterinärstraße 2
85764 Oberschleißheim
Germany

Siegfried Ippisch

Bavarian Health And Food Safety Authority (LGL)

Veterinärstraße 2
85764 Oberschleißheim
Germany

Bernd Wicklein

Bavarian Health And Food Safety Authority (LGL)

Veterinärstraße 2
85764 Oberschleißheim
Germany

Andreas Grahl (Contact Author)

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Kirsten Pörtner

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE)

Berlin
Germany

Nadine Muller

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE) ( email )

Berlin
Germany

Nadine Zeitlmann

Robert Koch Institute ( email )

Berlin
Germany

T. Sonia Boender

Robert Koch Institute - Postgraduate Training for Applied Epidemiology (PAE)

Berlin
Germany

Wei Cai

Robert Koch Institute ( email )

Berlin
Germany

Andreas Reich

Robert Koch Institute ( email )

Berlin
Germany

Maria An der Heiden

Robert Koch Institute ( email )

Berlin
Germany

Ute Rexroth

Robert Koch Institute ( email )

Berlin
Germany

Osamah Hamouda

Robert Koch Institute

Berlin
Germany

Julia Schneider

Charité - Universitätsmedizin Berlin - Institute of Virology ( email )

Berlin
Germany

Talitha Veith

Charité - Universitätsmedizin Berlin - Institute of Virology ( email )

Berlin
Germany

Barbara Mühlemann

Charité - Universitätsmedizin Berlin - Institute of Virology ( email )

Berlin
Germany

Roman Wölfel

Bundeswehr Institute of Microbiology ( email )

Munich
Germany

Markus Antwerpen

Bundeswehr Institute of Microbiology ( email )

Munich
Germany

Mathias Walter

Bundeswehr Institute of Microbiology ( email )

Munich
Germany

Ulrike Protzer

Technische Universität München (TUM) - Institute of Virology ( email )

Munich
Germany

Bernhard Liebl

Ludwig Maximilian University of Munich (LMU) ( email )

Geschwister-Scholl-Platz 1
Munich, DE Bavaria 80539
Germany

Walter Haas

Robert Koch Institute ( email )

Berlin
Germany

Andreas Sing

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

Christian Drosten

Charité - Universitätsmedizin Berlin - Institute of Virology ( email )

Berlin
Germany

Andreas Zapf

Bavarian Health And Food Safety Authority (LGL) ( email )

Veterinärstraße 2
85764 Oberschleißheim
Germany

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