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Meta-Analysis
. 2021 Apr 9;12(4):e00343.
doi: 10.14309/ctg.0000000000000343.

Prevalence and Persistent Shedding of Fecal SARS-CoV-2 RNA in Patients With COVID-19 Infection: A Systematic Review and Meta-analysis

Yawen Zhang  1 , Mengsha Cen  1 , Mengjia Hu  2 , Lijun Du  1 , Weiling Hu  1 , John J Kim  3 , Ning Dai  1   4
Affiliations
Meta-Analysis

Prevalence and Persistent Shedding of Fecal SARS-CoV-2 RNA in Patients With COVID-19 Infection: A Systematic Review and Meta-analysis

Yawen Zhang et al. Clin Transl Gastroenterol. .

Abstract

Introduction: The prevalence and shedding of fecal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA indicate coronavirus disease 2019 (COVID-19) infection in the gastrointestinal (GI) tract and likely infectivity. We performed a systemic review and meta-analysis to evaluate the prevalence and the duration of shedding of fecal RNA in patients with COVID-19 infection.

Methods: PubMed, Embase, Web of Science, and Chinese databases Chinese National Knowledge Infrastructure and Wanfang Data up to June 2020 were searched for studies evaluating fecal SARS-CoV-2 RNA, including anal and rectal samples, in patients with confirmed COVID-19 infection. The pooled prevalence of fecal RNA in patients with detectable respiratory RNA was estimated. The days of shedding and days to loss of fecal and respiratory RNA from presentation were compared.

Results: Thirty-five studies (N = 1,636) met criteria. The pooled prevalence of fecal RNA in COVID-19 patients was 43% (95% confidence interval [CI] 34%-52%). Higher proportion of patients with GI symptoms (52.4% vs 25.9%, odds ratio = 2.4, 95% CI 1.2-4.7) compared with no GI symptoms, specifically diarrhea (51.6% vs 24.0%, odds ratio = 3.0, 95% CI 1.9-4.8), had detectable fecal RNA. After loss of respiratory RNA, 27% (95% CI 15%-44%) of the patients had persistent shedding of fecal RNA. Days of RNA shedding in the feces were longer than respiratory samples (21.8 vs 14.7 days, mean difference = 7.1 days, 95% CI 1.2-13.0). Furthermore, days to loss of fecal RNA lagged respiratory RNA by a mean of 4.8 days (95% CI 2.2-7.5).

Discussion: Fecal SARS-CoV-2 RNA is commonly detected in COVID-19 patients with a 3-fold increased risk with diarrhea. Shedding of fecal RNA lasted more than 3 weeks after presentation and a week after last detectable respiratory RNA.

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Conflict of interest statement

Guarantor of the article: Ning Dai, MD, PhD, and John J. Kim, MD, MS.

Specific author contributions: Y.W.Z.: collected and interpreted data, drafted the manuscript, and approved the final version of the manuscript. M.S.C.: and M.J.H.: collected data and approved the final version of the manuscript. L.J.D.: drafted the manuscript and approved the final version of the manuscript. W.L.H., J.J.K., and N.D.: planned and conducted the study, interpreted data, and approved the final version of the manuscript.

Financial support: This work was supported by the Medical Health Project of Zhejiang Province (2020RC064).

Potential competing interests: None to report.

Figures

Figure 1.
Figure 1.
Flow diagram of study selection. CNKI, China National Knowledge Infrastructure.
Figure 2.
Figure 2.
Pooled prevalence of detectable SARS-CoV-2 RNA in fecal samples of patients with confirmed COVID-19 infection. (a) Forest plots of included studies. (b) Funnel plots of included studies. CI, confidence interval; COVID-19, coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Figure 3.
Figure 3.
Comparison of pooled prevalence of SARS-CoV-2 RNA in fecal samples of patients with COVID-19 infection with or without GI symptoms. (a) Comparison among patients with or without GI symptoms. (b) Comparison among patients with or without diarrhea. CI, confidence interval; COVID-19, coronavirus disease 2019; GI, gastrointestinal; OR, odds ratio; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Figure 4.
Figure 4.
Pooled prevalence of SARS-CoV-2 RNA in fecal samples of patients with COVID-19 patients after loss of RNA in respiratory samples. (a) Forest plots of included studies. (b) Funnel plots of included studies. CI, confidence interval; COVID-19, coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Figure 5.
Figure 5.
Comparison of pooled durations for persistent shedding and loss of SARS-CoV-2 RNA in fecal and respiratory samples of patients with COVID-19 infection. (a) Persistent shedding of SARS-CoV-2 RNA in fecal/anal/rectal and respiratory samples of COVID-19 patients. (b) Loss of SARS-CoV-2 RNA in fecal/anal/rectal and respiratory samples of COVID-19 patients. Results of respiratory samples were used as control during comparison. CI, confidence interval; COVID-19, coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; WMD, weighted mean difference.
See this image and copyright information in PMC

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