PMC:7269710 / 9248-21150 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":"Results\n\nConfirmed cases of COVID-19\n36 individuals were confirmed to have COVID-19, and these people were related to three local clusters, referred to as A (containing 11 people), B (consisting of 20 individuals), and C (comprising five people; figure 1 ). Of these affected individuals, 17 tested positive for SARS-CoV-2 in Singapore, of whom only two (both from cluster C) had recent travel history to China 14 days before onset of symptoms (table ). Two people from cluster A and 17 from cluster B were reported by the health authorities of countries where they resided or travelled to.\nFigure 1 Timing of events and cases in three clusters of COVID-19 in Singapore\nAge and sex are shown for each case (left panels), with other pertinent information (eg, relationship or nationality). Timeline of events (right panels); onset dates of symptomatic cases are shown, when available. COVID-19=coronavirus disease 2019.\nTable Demographic, clinical, and radiological characteristics of individuals who tested positive for SARS-CoV-2 in Singapore\nIndividuals (n=17)\nAge (years) 40 (36–51)\nGender\nMale 7 (41%)\nFemale 10 (59%)\nEthnic origin\nChinese 16 (94%)\nOther 1 (6%)\nNationality\nSingaporean 13 (76%)\nChinese 3 (18%)\nIndonesian 1 (6%)\nCluster\nA (tourist group from China and shopworkers) 9 (53%)\nB (company conference) 3 (18%)\nC (church) 5 (29%)\nChronic illness\nYes* 3 (18%)\nNo 14 (82%)\nTravel to China in past 14 days\nYes 2 (12%)\nNo 15 (88%)\nSymptoms\nFever 15 (88%)\nCough 14 (82%)\nSore throat 8 (47%)\nShortness of breath 6 (35%)\nMyalgia 5 (29%)\nDiarrhoea 4 (24%)\nChest pain 3 (18%)\nRunny nose 1 (6%)\nNausea or vomiting 1 (6%)\nChest radiography findings on admission†\nPresent 8 (53%)\nAbsent 7 (47%)\nInterval between symptom onset and hospitalisation (days) 4 (3–9)\nData are median (IQR) or n (%). SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.\n* Allergic rhinitis (n=1), hypertension (n=1), and cervical spondylosis (n=1).\n† Data available for 15 individuals.\n\nCluster A\nThe Ministry of Health in Singapore was alerted to two individuals with locally acquired COVID-19 on Feb 3, 2020 (AC1 and AC2; figure 1 upper panels). They did not fit the case-definition for suspected COVID-19 but were tested because they reported frequent occupational contact with Chinese tourists. These two people were later identified to be linked epidemiologically to two other affected individuals (AGX1 and AGX2), a father and daughter reported by official and media websites in Guangxi, China,8, 9, 10 to be Chinese tourists who travelled to Singapore on Jan 22, 2020, and who visited several tourist sites on Jan 22–23, 2020, as part of a tour group. AGX1 and AGX2 subsequently departed for Malaysia before re-entry into Singapore for their flight to Guangxi on Jan 27, 2020, and they developed symptoms on Jan 28, 2020, after arrival in Guangxi. Details of the tour participants and the itinerary, obtained through the Singapore-based tour guide for the Singapore tour segment (AT1, who also tested positive for SARS-CoV-2) corroborated with details for AGX1 and AGX2 reported by Guangxi websites.\nOf 20 tourists in the tour group from Guangxi, five or six were reported by AT1 to be coughing during the tour. To the best of our knowledge, only AGX1 and AGX2 had laboratory-confirmed COVID-19 (positive PCR for SARS-CoV-2).8 However, in view of the reported respiratory symptoms among tour group participants, it is possible that other tour group members were the primary cases.\nAmong the places visited by the tour group in Singapore were a complementary health products shop and a jewellery shop; both shops are patronised frequently by Chinese tour groups. The visits to the complementary health products shop lasted approximately 30 min, and the visit to the jewellery shop lasted roughly 1 h. Four assistants in the complementary health products shop (AC1, AC2, AC3, and AC4) and one assistant in the jewellery shop (AJ1) were identified to have COVID-19. All five shop assistants were at work on the day the tour group from Guangxi visited. AC1, AC2, AC3, and AC4 reported that they would assist customers to apply samples of medicinal oil on their bodies, and handwashing was not usually done between customers. Three secondary transmission cases were identified in the household of AC1 (AH1, AH2, and AH3), none of whom were contacts of other cases.\nFor the cases who were confirmed on or before Feb 5, 2020, 179 close contacts who were in Singapore and contactable were placed under quarantine, of whom two close contacts (AC3 and AC4) subsequently reported to be unwell and tested positive for SARS-CoV-2. An additional six close contacts were quarantined. For active surveillance, 16 shop assistants at the complementary health products shop and the sole remaining uninfected household member of AC1, who were all asymptomatic, were tested and none were positive for SARS-CoV-2.\nViral genomic sequences were available for four cases (AH1, AH2, AH3, and AT1) and phylogenetic analysis confirmed their linkage, as suggested by the epidemiological data (appendix pp 2–3).\n\nCluster B\nOn Feb 4, 2020, Malaysia confirmed a case of COVID-19 in an individual (B1) who had recent travel history to Singapore on Jan 16–23, 2020, for a company conference (a closed business meeting for employees from company branches globally), which was attended by at least 111 participants from 19 different countries on Jan 20–22, 2020. 17 attendees at the conference were from mainland China and at least one was from Wuhan. Subsequently, six participants at the conference who had no recent travel history to China (B2, B3, B4, B5, B6, and B7) tested positive for SARS-CoV-2 (figure 1 middle panels). Two affected individuals from Singapore were identified through contact tracing of participants after notification from the Malaysian International Health Regulation (IHR) focal point.\nThe conference programme included business presentations, workshops, breakout discussions, a welcome reception and meals, team-building games, and a Singapore city bus tour. Seating arrangements (where available) for the conference, and interviews with affected individuals, indicated close interactions between cases. Two groups (B1 and B3, and B4 and B7) were seated at the same tables for a 3-h Chinese banquet-style dinner on Jan 20, 2020, with three and two attendees from China, respectively. Four cases (B1, B3, B4, and B5) were in a 4-h breakout session on Jan 21, 2020, with 41 other participants, including ten from China, of whom three had dined with B1 and B3 or B4 and B7 at the Chinese banquet. Furthermore, the team-building games entailed close physical contact.\nWith initial news of B1, 15 conference participants remaining in Singapore were contacted to find out about their health status. Four people reported being unwell with fever, respiratory symptoms, or both and were tested for SARS-CoV-2; two individuals (B4 and B5) tested positive for the virus. The third local case (B6) was identified via activity mapping to have attended the conference and had subsequent interactions with company staff. 153 close contacts were placed under quarantine. Hotel staff were told to monitor their health status, and none reported being unwell during the conference or subsequently. 13 secondary cases of COVID-19 were reported among family members of B1 in Malaysia and contacts of B7 in France.\n\nCluster C\nThe Ministry of Health in Singapore identified two people from Singapore (C3 and C4), with no recent travel history to China, who tested positive for SARS-CoV-2 from enhanced pneumonia surveillance. Activity mapping showed that both individuals had visited the same church on Jan 19, 2020. C5 was identified through active case-finding. Two other people with COVID-19 were subsequently linked to this cluster (C1 and C2, who are husband and wife). These individuals were Chinese nationals from Wuhan who arrived in Singapore on Jan 19, 2020. Re-interviews with C1 and C2 found they had also visited the church on the same day. All five people were asymptomatic during the church visit (figure 1 lower panels).\nThe church is an independent church that occasionally receives a few visitors from China at the Mandarin service conducted every Sunday.11 Although C1 and C2 were not church members, they attended the 2-h morning service when they travelled to Singapore. They left immediately after the service and did not report having lunch at the church. Based on closed-circuit camera findings, C5 occupied the same seat as did cases C1 and C2 at the prayer meeting after the morning service, but they did not recall meeting each other.\nAmong the 227 regular church members, 191 members were contacted, of whom 142 attended the church on Jan 19, 2020. Of these people, only two had travel history to Guangdong, China, 14 days before Jan 19, 2020; both reported being well. Six were unwell and referred for further management and none tested positive for SARS-CoV-2. 93 close contacts were placed under quarantine.\nNo additional cases linked to any of the three clusters were identified as of Feb 14, 2020.\n\nAnalysis of disease transmission data\nAlthough we were unable to identify the primary case or cases in each cluster with certainty, in cluster A, the cases in the two shops and the tour guide had inter-related interactions with the Guangxi tour group in which two cases were found. Exposures of the shop assistants were assumed to occur on Jan 23, 2020, and the tour guide on Jan 22, 2020, or Jan 23, 2020. In cluster C, the only overlap in activities was on Jan 19, 2020, when all five cases visited the church and exposures most likely occurred. For cluster B, we used information on reported activities to infer most likely infection times within the meeting. Excluding the household cluster, we had information on both estimated infection time and reported date of symptom onset for 19 people. The incubation periods are plotted in figure 2 . The median incubation period was 4 days (IQR 3–6). Without accounting for potential tertiary transmission within the household (infected by a case who was not the primary case), the serial interval for the three transmission pairs in the household cluster ranged between 3 days and 8 days.\nFigure 2 Incubation periods for cases with known probable exposure times\nMedian (IQR) time to onset was 4 days (IQR 3–6).\nAssuming one unknown primary case seeded the outbreaks in each cluster, we noted that 31% of transmission pairs were associated with one individual (B7), and 32 observed cases had no onward transmission (figure 3 ).\nFigure 3 Probable secondary cases arising from each COVID-19 case\nCOVID-19=coronavirus disease 2019.\n\nClinical findings\nOf 17 locally confirmed cases, fever and cough were the two most common symptoms, reported in 15 (88%) and 14 (82%) individuals, respectively (table). One case, a 6-month old male infant, was asymptomatic until one spike of fever 2 days into hospital admission. Pulmonary opacities were reported on chest radiography at admission in eight (53%) individuals, and developed over the course of admission in four additional people. Lymphopenia (\u003c1·1 × 109 cells per L) was seen in six people and thrombocytopenia (\u003c150 × 109 cells per L) in four individuals over the course of admission. Median time from symptom onset to hospital admission was 4 days (IQR 3–9).\nThe clinical course was uncomplicated for most individuals, with resolution of symptoms over the first few days. Hospital admission was prolonged because of persistently positive SARS-CoV-2 PCR from nasopharyngeal swab testing (median 6 days, range 3–9). One individual needed supplemental oxygen via nasal prongs and another two developed acute respiratory distress requiring intubation and intensive care. Four individuals received experimental treatment of lopinavir with ritonavir. No deaths were recorded in these three clusters as of March 7, 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