PMC:7269710 / 3778-9246 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7269710","sourcedb":"PMC","sourceid":"7269710","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7269710","text":"Methods\n\nStudy design\nSince Jan 2, 2020, the Ministry of Health in Singapore has been refining local case-definitions for people suspected of having COVID-19 (appendix p 4). Doctors are required by law to notify the Ministry of Health of cases of COVID-19.7 Further, Singapore implemented enhanced surveillance on Jan 31, 2020, to test for COVID-19 among patients in intensive care units and people who died of unknown cause, all people with pneumonia in hospitals, and individuals with influenza-like illness in sentinel primary-care clinics. Hospital-based doctors also have permission to test patients who they view with suspicion for clinical or epidemiological reasons. A confirmed case of COVID-19 is defined as an individual with a respiratory sample positive for SARS-CoV-2, using a laboratory-based PCR test (appendix p 1). Phylogenetic analysis is done of available viral genomic sequences to ascertain genetic clustering.\nResearch in context\nEvidence before this study\nWe searched PubMed up to Feb 15, 2020 for reports published in English with no date limitations using the keywords “COVID-19” and “cluster”. A family cluster of coronavirus disease 2019 (COVID-19) was reported in Shenzhen, Guangdong. Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has also been reported among co-workers in Germany.\nAdded value of this study\nWe analysed three clusters of COVID-19 in Singapore to assess interactions and possible modes of transmission. Our findings show that SARS-CoV-2 is transmissible in community settings beyond household clusters. Importation and limited local transmission of SARS-CoV-2 could have occurred before the lockdown of Wuhan and China's institution of travel restrictions.\nImplications of all the available evidence\nCountries should focus on enhancing detection and containment of local clusters of COVID-19, through surveillance of individuals with general pneumonia or influenza-like illnesses, and of people who have been in contact with unwell travellers from China. It is also important for countries to do active case-finding among close contacts of affected individuals, including contacts with mild symptoms, to contain clusters and stop them from spreading.\nThe Ministry of Health in Singapore identified the first three clusters of COVID-19 cases on Feb 3, 2020, Feb 5, 2020, and Feb 8, 2020. All epidemiological investigations and outbreak containment measures were implemented under the Infectious Diseases Act,7 which provides for use of data for analysis to control outbreaks.\n\nEpidemiological investigation\nWe interviewed people with confirmed COVID-19 to obtain data for demographic characteristics, clinical symptoms, and activity patterns, from 14 days preceding symptom onset until isolation in hospital. We initiated contact tracing to identify close contacts (ie, people who spend a prolonged time within 2 m of a confirmed case) and other contacts who had some interactions with the case. We asked people with confirmed COVID-19 about possible contact with confirmed cases reported overseas in the 14 days before symptom onset. We used open source information from other countries (including government websites), news aggregators (eg, ProMed), and media reports to identify secondary transmissions in the respective clusters. For each cluster, we investigated the implicated setting to ascertain potential interactions. We reviewed activity maps of other confirmed cases in Singapore to identify potential epidemiological links to each cluster.\nWe placed close contacts under quarantine for 14 days from last exposure to the individual with confirmed COVID-19, either at home or at designated government quarantine facilities. We monitored their health status daily; people who developed symptoms were conveyed in dedicated ambulances to hospital for isolation and testing as part of active case-finding. We video-called individuals who were quarantined at home three times a day to verify their location; quarantine violators were tagged with a continuous tracking device. We placed other contacts (depending on risk stratification) on phone surveillance or advised them to self-monitor and visit a primary-care clinic if they became unwell.\n\nClinical management\nWe isolated people with confirmed COVID-19 in individual negative-pressure rooms with anterooms. We did blood investigations including a complete blood count, renal and liver function tests, and amounts of C-reactive protein and lactate dehydrogenase. Treatment was mainly supportive; we started some patients on oral lopinavir (400 mg) with ritonavir (100 mg) twice daily. We obtained clinical data for chronic medical illnesses, physical examinations, laboratory and radiological results, and clinical progression and outcome from inpatient medical records.\n\nAnalysis of disease transmission data\nWe reported the median (IQR) incubation period, defined as the duration between estimated dates of infection and reported symptom onset, using R. We reported the serial interval range between transmission pairs in the household cluster. We also calculated the probable number of transmissions arising from each confirmed case of COVID-19 by assuming that there was one unknown primary case for each of the three clusters.\n\nRole of the funding source\nThis study received no funding. The corresponding authors had full access to all data in the study and had final responsibility for the decision to submit for 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