lancet-header
Preprints with The Lancet is part of SSRN´s First Look, a place where journals and other research experts identify content of interest prior to publication. These preprint papers are not peer-reviewed. Authors have either opted in at submission to The Lancet family of journals to post their preprints on Preprints with The Lancet, or submitted directly via SSRN. The usual SSRN checks and a Lancet-specific check for appropriateness and transparency have been applied. Preprints available here are not Lancet publications or necessarily under review with a Lancet journal. These papers should not be used for clinical decision making or reporting of research to a lay audience without indicating that this is preliminary research that has not been peer-reviewed. For more information see the Comment published in The Lancet, or visit The Lancet´s FAQ page, and for any feedback please contact preprints@lancet.com

Coronavirus Disease 2019 Outbreak Likely Caused by Sewage Exposure in a Low-Income Community: Guangzhou, China, April 2020

25 Pages Posted: 16 Jul 2020

See all articles by Jun Yuan

Jun Yuan

Guangzhou Center for Disease Control and Prevention

Zongqiu Chen

Guangzhou Center for Disease Control and Prevention

Chenghua Gong

Guangzhou Center for Disease Control and Prevention

Hui Liu

Guangzhou Center for Disease Control and Prevention

Baisheng Li

Guangdong Center for Disease Control and Prevention

Kuibiao Li

Guangzhou Center for Disease Control and Prevention

Xi Chen

Guangzhou Center for Disease Control and Prevention

Conghui Xu

Guangzhou Center for Disease Control and Prevention

Qinlong Jing

Guangzhou Center for Disease Control and Prevention

Guocong Liu

Guangzhou Center for Disease Control and Prevention

Pengzhe Qin

Guangzhou Center for Disease Control and Prevention

Yufei Liu

Guangzhou Center for Disease Control and Prevention

Yi Zhong

Guangzhou Center for Disease Control and Prevention

Lijuan Huang

Guangzhou Center for Disease Control and Prevention

Bao-Ping Zhu

National Association of Chronic Disease Directors

Zhicong Yang

Guangzhou Center for Disease Control and Prevention

More...

Abstract

Background: SARS-CoV-2 has been identified in the feces of COVID-19 patients. However, fecal transmission has never been shown epidemiologically. In April 2020, a COVID-19 outbreak occurred in a low-income community in Guangzhou, China. We investigated this outbreak to identify the mode of transmission.  

Methods: A home quarantined order was issued in the community. We collected throat swab samples from the residents and environmental samples from the surfaces inside and around the houses, and conducted RT-PCR testing and genome sequencing. We defined a case as a resident in this community with a positive RT-PCR test. We conducted a retrospective cohort study among the residents living in the same building as the cases to identify transmission risk factors.  

Findings: We found eight cases (four couples) in this community of 2888 residents (attack rate=2.8/1000), with onset from April 5 to 21, 2020. During their incubation periods, Cases 1 and 2 frequented a Market T, where an outbreak was ongoing. Cases 3-8 never visited Market T during incubation periods, lived in separate buildings from, and never interacted with, Cases 1 and 2. Retrospective cohort study showed that working as cleaners or street scavengers (RR=13, 95% CI: 1.8-99), not changing to clean shoes after returning home (RR=7.4, 95% CI: 1.7-33), collating and cleaning dirty shoes after returning home (RR=6.3, 95% CI: 1.4-28) were significant exposure risk factors. Of 63 samples collected from street sewage puddles and sewage pipes, 19% tested positive for SARS-CoV-2. Of 50 samples taken from the cases’ apartments, 24% tested positive. RNA sequencing showed that the viruses identified from the squat toilet and the shoe-bottom dirt from the apartments of Cases 1 and 2 are homologous with those from Cases 3-8 and those identified from the sewage samples. The sewage pipe leading from the apartment of Cases 1 and 2 down to the drainage had a large crack above the ground. Rainfalls after the onset of Cases 1 and 2 flooded the streets.  

Interpretation: Our investigation has for the first time provided epidemiologic evidence that SARS-CoV-2 can be spread by sewage. This finding highlighted the importance of sewage management, especially in densely-populated places with poor hygiene and sanitation measures, such as urban slums and other low-income communities in developing countries.  

Funding: No.

Declaration of Interests: The authors declare no competing interests.

Ethics Approval Statement: This study was approved by the ethics committees of GZCDC (approval number GZCDC-ECHR-2020A0004).

Keywords: COVID-19; SARS-CoV-2; disease outbreak; infectious disease transmission; epidemiology; risk factor; sewage management

Suggested Citation

Yuan, Jun and Chen, Zongqiu and Gong, Chenghua and Liu, Hui and Li, Baisheng and Li, Kuibiao and Chen, Xi and Xu, Conghui and Jing, Qinlong and Liu, Guocong and Qin, Pengzhe and Liu, Yufei and Zhong, Yi and Huang, Lijuan and Zhu, Bao-Ping and Yang, Zhicong, Coronavirus Disease 2019 Outbreak Likely Caused by Sewage Exposure in a Low-Income Community: Guangzhou, China, April 2020 (5/30/2020). Available at SSRN: https://ssrn.com/abstract=3618204 or http://dx.doi.org/10.2139/ssrn.3618204

Jun Yuan

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Zongqiu Chen

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Chenghua Gong

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Hui Liu

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Baisheng Li

Guangdong Center for Disease Control and Prevention ( email )

Guangdong
China

Kuibiao Li

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Xi Chen

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Conghui Xu

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Qinlong Jing

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Guocong Liu

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Pengzhe Qin

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Yufei Liu

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Yi Zhong

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Lijuan Huang

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Bao-Ping Zhu

National Association of Chronic Disease Directors ( email )

GA
United States

Zhicong Yang (Contact Author)

Guangzhou Center for Disease Control and Prevention ( email )

Dexing 1st Cross Street
Guangzhou, Guangdong 510440
China

Click here to go to TheLancet.com

Paper statistics

Abstract Views
473
Downloads
50
PlumX Metrics