Investigation of a COVID-19 outbreak in Germany resulting from a single travel-associated primary case: a case series

In December, 2019, the newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, causing COVID-19, a respiratory disease presenting with fever, cough, and often pneumonia. WHO has set the strategic objective to interrupt spread of SARS-CoV-2 worldwide. An...

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Published in:The Lancet Infectious Diseases 2020-08, Vol.20 (8), p.920-928
Main Authors: Böhmer, Merle M, Buchholz, Udo, Corman, Victor M, Hoch, Martin, Katz, Katharina, Marosevic, Durdica V, Böhm, Stefanie, Woudenberg, Tom, Ackermann, Nikolaus, Konrad, Regina, Eberle, Ute, Treis, Bianca, Dangel, Alexandra, Bengs, Katja, Fingerle, Volker, Berger, Anja, Hörmansdorfer, Stefan, Ippisch, Siegfried, Wicklein, Bernd, Grahl, Andreas, Pörtner, Kirsten, Muller, Nadine, Zeitlmann, Nadine, Boender, T Sonia, Cai, Wei, Reich, Andreas, an der Heiden, Maria, Rexroth, Ute, Hamouda, Osamah, Schneider, Julia, Veith, Talitha, Mühlemann, Barbara, Wölfel, Roman, Antwerpen, Markus, Walter, Mathias, Protzer, Ulrike, Liebl, Bernhard, Haas, Walter, Sing, Andreas, Drosten, Christian, Zapf, Andreas
Format: Article
Language:English
Subjects:
Adolescent
Adult
Betacoronavirus - classification
Betacoronavirus - genetics
Betacoronavirus - isolation & purification
Body fluids
Child
Child, Preschool
China
Communicable Diseases, Imported - epidemiology
Communicable Diseases, Imported - pathology
Communicable Diseases, Imported - transmission
Communicable Diseases, Imported - virology
Containment
Coronavirus Infections - epidemiology
Coronavirus Infections - transmission
Coronaviruses
Cough
COVID-19
Disease Outbreaks
Disease transmission
Disease Transmission, Infectious
Epidemics
Epidemiology
Fever
Food safety
Gene sequencing
Genomes
Germany - epidemiology
Households
Humans
Infections
Infectious diseases
Interviews as Topic
Middle Aged
Mutation
Outbreaks
Pandemics
Patients
Pneumonia, Viral - epidemiology
Pneumonia, Viral - transmission
Polymerase chain reaction
Protective equipment
Public health
Quarantine
Respiratory diseases
Reverse Transcriptase Polymerase Chain Reaction
Risk
Risk Assessment
RNA, Viral - genetics
SARS-CoV-2
Secretions
Severe acute respiratory syndrome
Severe acute respiratory syndrome coronavirus 2
Signs and symptoms
Testing laboratories
Travel
Travel-Related Illness
Ultrasonic testing
Viral diseases
Whole genome sequencing
Young Adult
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Summary:In December, 2019, the newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, causing COVID-19, a respiratory disease presenting with fever, cough, and often pneumonia. WHO has set the strategic objective to interrupt spread of SARS-CoV-2 worldwide. An outbreak in Bavaria, Germany, starting at the end of January, 2020, provided the opportunity to study transmission events, incubation period, and secondary attack rates. A case was defined as a person with SARS-CoV-2 infection confirmed by RT-PCR. Case interviews were done to describe timing of onset and nature of symptoms and to identify and classify contacts as high risk (had cumulative face-to-face contact with a confirmed case for ≥15 min, direct contact with secretions or body fluids of a patient with confirmed COVID-19, or, in the case of health-care workers, had worked within 2 m of a patient with confirmed COVID-19 without personal protective equipment) or low risk (all other contacts). High-risk contacts were ordered to stay at home in quarantine for 14 days and were actively followed up and monitored for symptoms, and low-risk contacts were tested upon self-reporting of symptoms. We defined fever and cough as specific symptoms, and defined a prodromal phase as the presence of non-specific symptoms for at least 1 day before the onset of specific 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. Secondary attack rates were calculated as the number of cases divided by the number of contacts, using Fisher's exact test for the 95% CIs. Patient 0 was a Chinese resident who visited Germany for professional reasons. 16 subsequent cases, often with mild and non-specific symptoms, emerged in four transmission generations. Signature mutations in the viral genome occurred upon foundation of generation 2, as well as in one case pertaining to generation 4. The median incubation period was 4·0 days (IQR 2·3–4·3) and the median serial interval was 4·0 days (3·0–5·0). Transmission events were likely to have occurred presymptomatically for one case (possibly five more), at the day of symptom onset for four cases (possibly five more), and the remainder after the day of symptom onset or unknown. One or two cases resulted from contact with a case during the prodroma
ISSN:1473-3099
1474-4457
1474-4457
DOI:10.1016/S1473-3099(20)30314-5