Transmission of SARS-CoV-2 in standardised first few X cases and household transmission investigations: A systematic review and meta-analysis

Abstract

We aimed to estimate the household secondary infection attack rate (hSAR) of SARS-CoV-2 in investigations aligned with the WHO Unity Studies Household Transmission Investigations (HHTI) protocol. We conducted a systematic review and meta-analysis according to PRISMA 2020 guidelines. We searched Medline, Embase, Web of Science, Scopus and medRxiv/bioRxiv for "Unity-aligned" First Few X cases (FFX) and HHTIs published 1 December 2019 to 26 July 2021. Standardised early results were shared by WHO Unity Studies collaborators (to 1 October 2021). We used a bespoke tool to assess investigation methodological quality. Values for hSAR and 95% confidence intervals (CIs) were extracted or calculated from crude data. Heterogeneity was assessed by visually inspecting overlap of CIs on forest plots and quantified in meta-analyses. Of 9988 records retrieved, 80 articles (64 from databases; 16 provided by Unity Studies collaborators) were retained in the systematic review; 62 were included in the primary meta-analysis. hSAR point estimates ranged from 2% to 90% (95% prediction interval: 3%-71%; I ² = 99.7%); I ² values remained >99% in subgroup analyses, indicating high, unexplained heterogeneity and leading to a decision not to report pooled hSAR estimates. FFX and HHTI remain critical epidemiological tools for early and ongoing characterisation of novel infectious pathogens. The large, unexplained variance in hSAR estimates emphasises the need to further support standardisation in planning, conduct and analysis, and for clear and comprehensive reporting of FFX and HHTIs in time and place, to guide evidence-based pandemic preparedness and response efforts for SARS-CoV-2, influenza and future novel respiratory viruses.

Keywords: SARS‐CoV‐2; epidemiologic studies; family characteristics (household); pandemic; systematic review and meta‐analysis; transmission.

FIGURE 1

PRISMA flow chart. Other reasons for exclusion during full‐text screening were: The full‐text was not accessible; duplicate investigations with different indexing; commentaries; corrections; non‐COVID related investigations, and conference abstracts, preprints and short reports with subsequent publications. Abbreviations: FFX, first few X cases investigations; HHTI, household transmission investigation; WHO, World Health Organization

FIGURE 2

Forest plot of the household secondary infection attack rates (hSAR) in included investigations (n = 62), ordered from highest estimated hSAR (top) to lowest estimated hSAR (bottom). The hSAR and 95% confidence intervals (CI) are shown on the right margin