Moroccan Journal Of Public Health Vol. 1, N° 1 (2020), 20-28 ISSN: 2658-8099 Review How is the SARS-cov-2 virus transmitted ?

Zouhair ELKARHAT1, Hicham CHAROUTE1, Lahcen WAKRIM 2, Abdelhamid BARAKAT 1, Hassan ROUBA 1 *

1 Laboratory of Genomics and Human Genetics, Institut Pasteur du Maroc , Casablanca , Morocco 2 Virology Unit, Immunovirology Laboratory, Institut Pasteur du Maroc, Casablanca, Morocco. *Corresponding Author E-mail: [email protected]

Article info SUMMARY

Received : November 2020 Since December 2019, the recent outbreak of disease (COVID-19) Accepted : November 2020 Online : December 2020 has continued to spread drastically around the world. To date, no approved drug or vaccine is available to treat or prevent this new coronavirus (SARS-CoV-2) keywords SARS-CoV-2 infection. Unprecedented global effort has been made by researchers to Covid-19 understand the various routes of SARS-CoV-2 virus transmission in order to Transmission Infection effectively prevent the contamination. In this review, we discuss the updated Contamination literature regarding the different modes of SARS-CoV-2 transmission.

Introduction (WHO 2020). It is an enveloped linear single-stranded

On March 11, 2020, the World Health Organization RNA virus of the beta-coronavirus family with a genome (WHO) classifies the outbreak due to Severe Acute of 29,903 nucleotides (NCBI Reference Sequence: Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) as a NC_045512.2). SARS-CoV-2 uses the same portal of entry public health emergency. This epidemic has just taken the into cells as SARS-COV, the ACE2 receptor on epithelial proportions of a pandemic (Gorbalenya et al. 2020). The cells (Z. Liu et al. 2020). The Spike protein on the virus viral pathology, linked to this Corona Virus, is described in envelope has sufficient affinity with ACE2 to allow entry China for the first time in December 2019 and is named of the virus into the cell (Z. Liu et al. 2020). Inside it, the COVID-19 (Coronavirus Disease 2019) (WHO 2020). The viral RNA is replicated by a viral polymerase (RNA transmission of this virus reported worldwide, is found on dependent RNA polymerase). The transcription and all continents. Until today, November 4,2020, over 43 translation steps necessary for the formation of proteins are million cases have tested positive for SARS-cov-2 which carried out by the cellular machinery. has caused the death of over 1 million of these cases

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The virus assembles in the endoplasmic reticulum, then samples, 63% of nasal swabs, 32% of pharyngeal swabs, migrates to the plasma membrane in vesicles to bud and 29% of fecal samples, 1% of blood samples and 0% of infect other cells (Sicari et al. 2020). urine samples (W. Wang et al. 2020). In addition, several The main symptoms of COVID-19 are: fever or a feeling studies have evaluated the SARS-CoV-2 persistence in of fever (chills, hot-cold), cough, headache, body aches, several different surfaces (Table 1). Transmission of the unusual fatigue, sudden loss of smell (without nasal virus through the respiratory and extrarespiratory routes obstruction), total disappearance of the taste, or diarrhea may help explain the rapid spread of the disease. In this and in more serious forms: breathing difficulties that may review, we discuss the latest literature regarding the require hospitalization in intensive care or even lead to potential of various routes of SARS-CoV-2 transmission. death (Y.-C. Wu, Chen, et Chan 2020). Respiratory Transmission There are two main types of diagnostic tests for SARS- CoV-2 infection. Tests for the direct detection of the virus The principal mode of SARS viruses transmission is by the polymerase chain reaction technique (PCR) and through respiratory transmission. Indeed, the virus is serological tests (Caruana et al. 2020). The first type is transmitted with virions suspended in large droplets of relatively rapid and well mastered by laboratories. It is saliva from an infected person (> 5 μm) (Fennelly 2020). carried out on a biological sample, most often These droplets are usually formed by coughing, sneezing, nasopharyngeal with a small swab introduced deep into the singing, breathing and speaking (Anderson et al. 2020). nose. This sample can also be associated with a sample Inhalation of these respiratory droplets can lead to infection from the lower respiratory tract (sputum, etc.). The sample when the healthy person is in direct contact with a patient is then analyzed in the laboratory in order to directly look having symptoms or at a distance of less than 1 m for the presence of the genetic material (RNA) of the virus (Organization 2020). and thus confirm the diagnosis of the infection (Cheng et Aerosol transmission also appears to be possible via fine al. 2020). On the other hand, the second type of diagnostic aerosols expelled from the patient's airways, which would tests, serological tests, are used to look for the presence in remain longer than the droplets. These fine particles can the blood of antibodies directed against SARS-CoV-2 (IgM enter the bronchial and alveolar regions after inhalation, / IgG). These tests can determine if the person has been which can lead to infection (Vella et al. 2020). infected with the virus in the previous weeks (Cheng et al. 2020). These tests do not allow an early diagnosis of the helps decrease infection rate. In fact, a infection since the production of specific antibodies by the study on the contamination rate of train passengers, which immune system takes a certain time, which can vary from a included 2,334 index cases and 72,093 close contacts few days to a few weeks. showed that the infection rate decreased with increasing Several studies have shown the possibility to detect viral distance and increased with increasing co-travel time (Hu RNA in various body fluid samples. Wang et al detected et al. s. d.). In the other hand, good ventilation can decrease viral SARS-cov-2 RNA in samples from multiple sites of the rate of infection, whereas poor ventilation has been 205 patients with COVID-19 (W. Wang et al. 2020). implicated in many transmission groups (James 2020; Indeed, they detected viral RNA in 93% of Furuse et al. 2020). Several studies have shown that bronchoalveolar lavage fluid samples, 72% of sputum wearing a mask can decrease the rate of SARS-COV-2

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transmission, which supports the dominant role of patient with COVID-19 (Ong et al. 2020). Samples of the respiratory spread of this new virus (Chu et al. 2020; Lee et surface of the toilet bowl, the interior of the bowl and the Jeong, s. d.; Chou et al. 2020). door handle were taken from the room of a patient whose feces tested positive for SARS-CoV-2 before routine Fecal–Oral Transmission cleaning. Interestingly, all these samples were positive Until today, several studies have analyzed the possibility of (Ong et al. 2020). After the routine cleaning, other samples fecal-oral transmission of the SARS-COV-2 virus (Table were taken in the same way and all of them were negative 2). In Wuhan's early data, gastrointestinal symptoms like this time, implying that current contamination measures diarrhea, abdominal pain, and vomiting were present in 2- such as the use of antiseptics containing ethanol and 10% of patients with COVID-19 (N. Chen et al. 2020; D. disinfectants containing chlorine or bleach are effective.

Wang et al. 2020). The mechanisms of SARS-cov-2 Vertical Transmission interaction with the gastrointestinal tract remain to this day Although several studies have evaluated the possibility of unclear and we believe that this new virus uses ACE2 as a vertical transmission of SARS-CoV-2 (Yang et Liu 2020). viral receptor. There is still a need for further conclusive evidence. Some Xiao et al. have shown that SARS-CoV-2 can be found in studies have suggested that vertical transmission is possible stool samples even though it is not detectable in the based on the fact that newborns born to mothers with respiratory tract (Xiao et al. 2020). In Zhang et al. study, COVID-19 had elevated IgM antibodies after birth all subjects had positive RT-PCR results in the stool after (Kimberlin et Stagno 2020; Zeng et al. 2020). Zeng et al. 10 days, with no positive throat swabs, clinical symptoms examined 6 cases of newborns born to mothers with or imaging results (T. Zhang et al. 2020). Holshue et al. COVID-19 and determined that two of them had elevated detected SARS-CoV-2 RNA in the stool of a patient in the IgM levels (Zeng et al. 2020). Also, Dong et al, presented a United States (Holshue et al. 2020). case of a newborn born to a mother with COVID-19 which tested negative for COVID1-9 on nasopharyngeal samples, Prolonged viral detection in fecal samples has also been but was found to have elevated IgM antibodies 2 hours detected in children after recovery from COVID-19 after his birth (Dong et al. 2020). (T. Zhang et al. 2020). This result is supplemented by the Wu et al, study which showed that the Zamaniyan et al. reported the case of a pregnant woman viral RNA of SARS-COV-2 can be present in stool with COVID-19 who gave birth to a premature baby at 32 samples for nearly 5 weeks after the patient's respiratory weeks gestation. The newborn baby showed no signs of samples have been tested negative (Y. Wu et al. 2020). infection with SARS-CoV-2. However, the COVID-19 test Also, Liu J et al, showed that patients had positive RT-PCR on the amniotic sample was positive. After 24 hours of her results in anal swabs after recovery (J. Liu et al. 2020). cesarean birth, the nasal and throat test for COVID19 were Thus, the virus could remain viable in the environment for positive while the tests for COVID19 on vaginal secretion days, which could lead to fecal-oral transmission. Indeed, and on the blood of the umbilical cord were negative. Since Ong et al. supported the possibility of this transmission by the amniotic fluid and the newborn have tested positive, demonstrating extensive environmental contamination of a this may suggest that the newborn was affected intrauterine

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by SARS-CoV-2 (Zamaniyan et al. 2020). A retrospective In order to demonstrate that ocular swabs samples study of nine COVID-19 pregnant mothers who underwent contained infectious virus, Colavita et al successfully cesarean delivery, six of them tested negative for confirmed the viral replication of SARS-cov-2 after COVID19 on amniotic fluid, cord blood, neonatal throat inoculating an RNA-positive ocular sample into Vero E6 swab, and breast milk (H. Chen et al. 2020). Thus, further cells. This implies that the eye fluid of patients with studies are needed to further elucidate this vertical COVID19 may contain an infectious virus and serve as a transmission mode of SARS-cov-2. possible source of infection (Colavita et al. 2020) .

Ocular transmission Sexual Transmission

Transmission of the SARS-cov-2 virus through the ocular Sexual transmission of SARS-covid-2 remains uncertain surface is now considered a possible route of transmission. and much discussed. Although ACE2 receptors are Indeed, Lu et al reported the case of a healthcare worker expressed in the vagina and testes, no active virus was who was infected with the SARS-cov-2 virus after visiting detected in semen or vaginal secretions (Z. Wang et Xu a patient while wearing an N95 respirator, but no protective 2020; Jing et al. 2020). However, during sexual glasses. These health workers developed redness in their intercourse, transmission of the virus can occur through eyes, followed by pneumonia (Lu, Liu, et Jia 2020). direct contact and through respiratory droplets and saliva. Although Li et al. reported that viral RNA was detected in Some studies have noted the detection of viral RNA in the semen of 15.8% of COVID-19 patients (Li et al. 2020), conjunctival samples, while others have shown limited several other studies have failed to confirm the presence of evidence for its presence. In a study of 17 cases confirmed SARS-cov-2 RNA by PCR in semen and vaginal secretions to have COVID-19, tears were collected and all samples of patients with COVID-19 (Pan et al. 2020; Qiu et al. tested negative for the presence of SARS-CoV-2, while 2020; Song et al. 2020). nasopharyngeal samples were positive. In a study of 33 patients with COVID-19 and without ocular manifestation, Conclusion analysis of ocular secretion samples from two patients This study provides a literature review of the current (6.1%) revealed the presence of viral RNA (Xie et al. scientific knowledge about the main mechanisms of SARS- 2020). Colavita et al. analyzed samples from the surface of CoV-2 transmission. According to the information the eye of a patient with COVID19 almost every day available to date, SARS-CoV-2 is spread mainly by during his hospitalization. Viral RNA was detected until respiratory droplets generated when an infected patient day 21 (and day 27) of his hospitalization (Colavita et al. coughs or sneezes, and through prolonged close personal 2020). Deng et al. reported that of 114 patients with contact with an infected patient. Thus, hand hygiene and COVID-19 of varying severity, none of the conjunctival personal protective equipment can reduce contamination secretion samples taken was positive for SARS-CoV-2 and spread of this disease. RNA (Deng et al. 2020).

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Table 1: Persistence of SARS-CoV-2 virus on different environmental surfaces

Study Environemental surfaces Persistence Relative Temp. (°C) humidity (%) (van Doremalen et al. 2020, 1) Aerosol 3 ha 65 21–23 (Chin et al. 2020) Banknote paper 2 d 65 22 (van Doremalen et al. 2020, 1) Cardboard 1 d 65 21–23 (Chin et al. 2020) Cloth 1 d 65 22 (van Doremalen et al. 2020, 1) Copper 4 h 65 21–23 (Kasloff et al. 2020) Cotton 1h4h 35–40 20 (Kasloff et al. 2020) Gloves (chemical) 4 d 35–40 20 (Kasloff et al. 2020) Gloves (nitrile) 7 d 35–40 20 (Kasloff et al. 2020) N95 mask 14 d 35–40 20 (Kasloff et al. 2020) N100 mask 14 d 35–40 20 (Chin et al. 2020) Paper 30 min 65 22 (van Doremalen et al. 2020, 1) Plastic (polypropylene) 3 d 65 21–23 (Chin et al. 2020) Plastic 4 d 65 22 (Kasloff et al. 2020) Plastics from face shield 21 d 35–40 20 (van Doremalen et al. 2020, 1) Stainless steel 3 d 65 21–23 (Chin et al. 2020) Stainless steel 4 d 65 22 (Kasloff et al. 2020) Stainless steel 14 d 35–40 20 (Chin et al. 2020) Surgical mask outer layer 7 d 65 22 (Chin et al. 2020) Surgical mask inner layer 4 d 65 22 (Chin et al. 2020) Tissue paper 30 min 65 22 (Kasloff et al. 2020) Tyvek 14 d 35–40 20 (Chin et al. 2020) Wood 1 d 65 22

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Table 2: Fecal-oral transmission of SARS-COV-2 virus Study Geographic location Relevant specimen type Number of positive patients/total number tested (%) (X.-W. Wang et al. 2005) Hubei, Shandong, and Fecal samples 44/153 (29) Beijing, China (J. Zhang, Wang, et Xue Jinhua, China Fecal samples 5/14 (36) 2020) (W. Zhang et al. 2020) Wuhan, China Anal swabs First day of sampling: 4/16 (25) Fifth day of sampling: 6/16 (38) (Jiehao et al. 2020) Shanghai and Fecal samples Day 3–13 after onset of illness: 5/6 Qingdao, China (83) Day 18–30 after onset of illness: 5/5 (100) (Xiao et al. 2020) Zhuhai, China Fecal samples Biopsy tissue 39/73 (53) from esophagus, stomach, duodenum, and rectum available for one patient (Tang et al. 2020) Zhoushan, China Fecal samples 1/3 (33) (Young et al. 2020) Singapore Fecal samples 4/8 (50) (Kujawski et al. 2020) AZ, CA, IL, MA, WA, and Fecal samples 7/10 (70) WI, United States (Ling et al. 2020) Shanghai, China Fecal samples 54/66 (82) (W. Chen et al. 2020) Guangzhou, China Anal swabs 11/28 (39) (Chan et al. 2020) Guangdong, China Fecal samples 0/7 (0) (Kam et al. 2020) Kallang, Singapore Fecal samples 1/1

Conflicts of Interest

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