research

HIGHLIGHTS
INFECTION

COVID-19: faecal–oral transmission? y

15 years, initially tested positive (mean age 54.9 years) who

after being screened by presented to three hospitals in
eight patients had persis nasopharyngeal swab real-time China, 99 (48.5%) patients
reverse transcrip tion PCR presented with digestive
tently positive rectal
(RT–PCR). Next, the symptoms as their chief
swabs even after researchers conducted a series complaint. 60% of patients
their naso of nasopharyngeal and rectal without digestive symptoms
pharyngeal tests were swabs to investigate the pattern were cured and discharged,
of viral excretion. Eight patients compared with 34.3% of
negative had real-time RT–PCR-positive patients with digestive
Severe acute respiratory
rectal swabs. In addition, these symptoms. In a short Research
syndrome coronavirus 2
eight patients had persistently Letter published in the Journal
(SARS-CoV-2) infection, which
positive rectal swabs even after of the American Medical
causes coronavirus disease
their nasopharyngeal tests Association, different tissues of
2019 (COVID-19), first
were negative. Four patients patients with COVID-19
emerged in China in December
were discharged after two (n=1,070 specimens from 205
2019 and has now spread
consecutive negative rectal patients of mean age 44 years)
worldwide, with a reported
swabs, but the rectal swabs of were tested by RT–PCR. 32%
351,731 confirmed cases and
two of these patients later of pharyngeal swabs (126 of
15,374 deaths as of 23 March
became positive again, despite 398) and 29% of faecal
2020 according to John
nasopharyngeal tests samples (44 of 153) tested
Hopkins University. The
remaining negative. Finally, the positive. Electron microscopy
infection is typically
researchers used the viral RNA of four SARS-CoV-2-positive
characterized by respiratory
measurements to determine faecal specimens detected live
symptoms, which indicates
that viral shedding from the virus in stool samples from two
droplet transmission. However,
digestive system might be patients who did not have
several case studies have
longer-lasting than that from diarrhoea.
reported gastrointestinal
the respiratory tract. The
symptoms and/or evidence that
findings suggest that we also
some patients with
need to use rectal swabs to
SARS-CoV-2 infection have
confirm diagnosis of
viral RNA or live infectious
COVID-19, says Kang Zhang,
virus present in faeces, which
a corresponding author of the
suggests that another possible
study.
route might be faecal–oral
There had been earlier reports,
transmission.
particularly in adults, of gastro
In a clinical characterization of
intestinal symptoms and of the
ten paediatric patients with
possibility of a faecal–oral route
SARS-CoV-2 infection in China,
of transmission. In a cohort of
none of whom required
1,099 patients with COVID-19
respiratory support or intensive
from 552 hospitals in China,
care and all of whom lacked
published in the New England
signs of pneumonia, eight
Journal of Medicine, 5.0% of
tested positive on rectal swabs,
patients presented with nausea The precise mechanisms by
even after nasopharyngeal
or vomiting and 3.8% which SARS-CoV-2 interacts
testing was negative. The
presented with diarrhoea. Also, with the gastrointestinal tract
details were published as a
preliminary findings published in remain unknown. SARS-CoV-2
Brief Communication in Nature
the American Journal of is thought to use ACE2 as a
Medicine. The patients, whose
Gastroenterology found that of viral receptor, and ACE2
ages ranged from 2 months to
204 patients with COVID-19 mRNA is highly expressed in
the gastrointestinal system. specimens from 73 children and adults may be and will test more patients to
e

G
hospitalized patients with shedding infectious virus and confirm faecal–oral
/

s
SARS-CoV-2 infection. 39 they could transmit it. This is transmission,” says Zhang.
e

g
patients tested positive for another reason to emphasize Jordan Hindson
a
SARS-CoV-2 RNA in stool good personal hygiene,” says
samples. In addition, 17 Mary Estes at Baylor College Original article Xu, Y. et al. Characteristics of
m
I

e
pediatric SARS-CoV-2 infection and potential
l
patients remained positive for of Medicine, Texas, who was evidence for persistent fecal viral shedding.
p

o SARS-CoV-2 in stool after not involved in these studies. Nat. Med. https://doi.org/10.1038/s41591-020-
e 0817-4 (2020)
P becoming negative in “Physicians and caretakers of Related articles Guan, W. et al. N. Engl. J. Med.
:

t
respiratory samples. Viral host potentially-infected children https://doi.org/10.1056/NEJMoa2002032 (2020)
receptor ACE2 stained positive need to be aware that stools | Wang, W. et al.
i

d
JAMAhttps://doi.org/10.1001/jama.
e

r mostly in gastrointestinal might be infectious,” adds 2020.3786 (2020) | Xiao, F. et al.

C
epithelial cells. Estes. The results are Gastroenterology

Together, these findings have preliminary and further research https://doi.org/10.1053/j.gastro.2020.02.055

In preliminary findings (2020) | Pan, L. Am. J. Gastroenterol.
published in Gastroenterology, implications for our is needed. “We are now https://doi.org/

researchers examined clinical understanding of SARS-CoV-2 assembling a much larger

10.14309/ajg.0000000000000620 (2020)

transmission. “Asymptomatic cohort to confirm our results

NAture Reviews | GastrOenterOlOgy & HepatOlOgy

volume 17 | MAY 2020 | 259