Household secondary attack rate of COVID-19 and associated determinants in Guangzhou, China: a retrospective cohort study

Abstract

Background: As of June 8, 2020, the global reported number of COVID-19 cases had reached more than 7 million with over 400 000 deaths. The household transmissibility of the causative pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), remains unclear. We aimed to estimate the secondary attack rate of SARS-CoV-2 among household and non-household close contacts in Guangzhou, China, using a statistical transmission model.

Methods: In this retrospective cohort study, we used a comprehensive contact tracing dataset from the Guangzhou Center for Disease Control and Prevention to estimate the secondary attack rate of COVID-19 (defined as the probability that an infected individual will transmit the disease to a susceptible individual) among household and non-household contacts, using a statistical transmission model. We considered two alternative definitions of household contacts in the analysis: individuals who were either family members or close relatives, such as parents and parents-in-law, regardless of residential address, and individuals living at the same address regardless of relationship. We assessed the demographic determinants of transmissibility and the infectivity of COVID-19 cases during their incubation period.

Findings: Between Jan 7, 2020, and Feb 18, 2020, we traced 195 unrelated close contact groups (215 primary cases, 134 secondary or tertiary cases, and 1964 uninfected close contacts). By identifying households from these groups, assuming a mean incubation period of 5 days, a maximum infectious period of 13 days, and no case isolation, the estimated secondary attack rate among household contacts was 12·4% (95% CI 9·8-15·4) when household contacts were defined on the basis of close relatives and 17·1% (13·3-21·8) when household contacts were defined on the basis of residential address. Compared with the oldest age group (≥60 years), the risk of household infection was lower in the youngest age group (<20 years; odds ratio [OR] 0·23 [95% CI 0·11-0·46]) and among adults aged 20-59 years (OR 0·64 [95% CI 0·43-0·97]). Our results suggest greater infectivity during the incubation period than during the symptomatic period, although differences were not statistically significant (OR 0·61 [95% CI 0·27-1·38]). The estimated local reproductive number (R) based on observed contact frequencies of primary cases was 0·5 (95% CI 0·41-0·62) in Guangzhou. The projected local R, had there been no isolation of cases or quarantine of their contacts, was 0·6 (95% CI 0·49-0·74) when household was defined on the basis of close relatives.

Interpretation: SARS-CoV-2 is more transmissible in households than SARS-CoV and Middle East respiratory syndrome coronavirus. Older individuals (aged ≥60 years) are the most susceptible to household transmission of SARS-CoV-2. In addition to case finding and isolation, timely tracing and quarantine of close contacts should be implemented to prevent onward transmission during the viral incubation period.

Funding: US National Institutes of Health, Science and Technology Plan Project of Guangzhou, Project for Key Medicine Discipline Construction of Guangzhou Municipality, Key Research and Development Program of China.

Figure 1

Spatial distribution of COVID-19 case clusters on the basis of contact tracing data from Guangzhou, China, from Jan 7, 2020, to Feb 18, 2020 Overall distribution of COVID-19 case clusters in Guangzhou (A), and distribution in the subregions defined in panel A (B–G). Individuals were considered as primary cases if their symptom onset dates were the earliest or 1 day (≤3 days for an imported case) after the earliest in the cluster and as secondary cases otherwise. Non-infected contacts are not shown. The displayed location of each case is randomly perturbed away from the actual residential address.

Figure 2

Epidemic curve based on symptom onset dates of COVID-19 cases in Guangzhou from Jan 6, 2020, to Feb 18, 2020 Estimated R_t for three scenarios: scenario 1, all imported cases (who travelled to or resided in Hubei province 14 days before symptom onset) considered as primary cases, and all secondary cases were infected by primary cases in the same case cluster; scenario 2, which is identical to scenario 1, with the additional assumption that local primary cases might have been infected by earlier cases in other clusters; and scenario 3, which is identical to scenario 2, with the additional assumption that imported secondary cases were considered as infected by primary cases in the same cluster. R_t=effective reproductive number.