key: cord-333532-vrfduv5a
authors: Patel, Kishan Pravin; Patel, Puja A.; Vunnam, Srinivas R.; Jain, Rohit; Vunnam, Rama R.
title: COVID-19 Patients: Are Current Isolation Guidelines Effective Enough?
date: 2020-05-11
journal: Public Health
DOI: 10.1016/j.puhe.2020.04.048
sha: 
doc_id: 333532
cord_uid: vrfduv5a

nan

As the coronavirus disease 2019 (COVID-19) pandemic continues to evolve, the number of cases and the death toll continue to rise, posing a substantial threat to global public health. As of April 23, 2020, the United States has the highest number of COVID-19 cases (31.5%) and deaths (22.8%) in the world 1 . Both clinicians and hospitalized patients are facing complications including limited resources, workforce and information, thus, making infection control an even higher priority. The median basic reproduction number (R0) of Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is estimated to be 5.7 (95% CI, 3.8 to 8.9) 2 ; this value holds great significance as, theoretically, an infection will continue to spread as long as R0 >1.

With growing concern, the focus needs to shift towards strategies to mitigate the spread of infection in both hospital and community settings alike. We believe the current isolation guidelines need to be revisited and clinicians should counsel COVID-19 patients to practice contact precautions for longer durations given new evidence suggesting the possibility of a fecaloral route of transmission.

According to current Center for Disease Control (CDC) recommendations, discontinuation of transmission-based precautions per the test-based strategy in COVID-19 patients is warranted after all of the following: (1) resolution of fever without the use of fever-reducing medications;

(2) improvement in respiratory symptoms; and (3) two consecutive negative reverse transcriptase polymerase chain reaction (rRT-PCR) results obtained at least 24 hours apart by nasopharyngeal swabs 3 . For asymptomatic individuals, contact precautions can be discontinued seven days following diagnosis, should they remain asymptomatic -three days following the 2 discontinuation, individuals should still practice social distancing and nasal/oral barrier protection 3 .

To date, COVID-19 has been thought to be transmitted via respiratory droplets with most patients commonly presenting with fever, cough, or dyspnea. However, studies have also versus 16.7 ± 6.7) 6 . In a case series conducted examining the first 12 COVID-19 patients in the US, SARS-CoV-2 RNA was detected in the stool of 7/10 patients 7 . Furthermore, a recent case reported an asymptomatic COVID-19 patient who retested positive for SARS-CoV-2 despite being discharged after two negative consecutive respiratory nucleic acid tests at least 24 hours apart, raising concern for inadequate discharge protocol. Notably, he was found to have a weakly positive stool sample test during his observation. Should these patients remain contagious and prematurely discontinue self-isolation, they may disrupt current infection control 8 . Moreover, one study to date has successfully cultured live SARS-CoV-2 from a fecal specimen, with implications that stool samples may contaminate hands, food, water, etc 9 .

The resilience of SARS-CoV-2 plays a role in its virulence and pathogenesis. Due to its hard outer shell, the virus can remain active for extended periods of time and may be more resistant to antimicrobial and digestive enzymes in body fluids 10 . Additionally, per nucleocapsid and membrane protein analysis, SARS-CoV-2 has been classified as Category B, which means it has intermediate grades of both respiratory and fecal-oral transmission potentials 10 . A study suggested that the half-life of the aerosolized form of SARS-CoV-2 is approximated to be 1.1-1.2 hours. However, it was found to remain viable on wooden and metal surfaces for up to 72 hours, supporting a concern for indirect transmission beyond respiratory particles 11 .

Given the possibility of fecal-oral transmission, evidence noting the occurrence of viral RNA shedding in feces for up to a month, and the current state of the pandemic, we believe it is reasonable to extend the duration of contact isolation precautions as currently outlined by the practicing respiratory hygiene, and maintaining social distance 12 .

Currently, time and resources are limited but our efforts should not be. The COVID-19 pandemic is a public health emergency, and clinicians need to act accordingly. With consideration of its high virulence, high infectivity, and the concern for a fecal-oral route of transmission, we suggest modifying guidelines to extend isolation and/or contact precautions in the best interest of patients, healthcare workers, and the global community as a whole.

Key words: COVID 19; SARS CoV-2; Gastrointestinal; Isolation; Fecal-oral; transmission; precautions

World Health Organization

High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. Emerging Infectious Diseases

Disposition of Non-Hospitalized Patients with COVID-19

COVID-19: Gastrointestinal Manifestations and Potential Fecal-Oral Transmission

The Presence of SARS-CoV-2 RNA in Feces of COVID-19 Patients

Prolonged presence of SARS-CoV-2 viral RNA in faecal samples

First 12 patients with coronavirus disease 2019 (COVID-19) in the United States

SARS-CoV-2 turned positive in a discharged patient with COVID-19 arouses concern regarding the present standard for discharge

Chinese)

Shell disorder analysis predicts greater resilience of the SARS-CoV-2 (COVID-19) outside the body and in body fluids

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Rational use of personal protective equipment for coronavirus disease ( COVID-19) and considerations during severe shortages: interim guidance