EClinicalMedicine 32 (2021) 100717

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EClinicalMedicine
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Research Paper

Descriptive epidemiology of SARS-CoV-2 infection in Karnataka state,

South India: Transmission dynamics of symptomatic vs. asymptomatic
infections
Narendra Kumara,1, Shafeeq K. Shahul Hameeda,1, Giridhara R. Babub,
Manjunatha M. Venkataswamya, Prameela Dineshc, Prakash Kumar B.G.c, Daisy A. Johnb,
Anita Desaia, Vasanthapuram Ravia,*
a
Department of Neurovirology, National Institute of Mental Health And Neuro Sciences (NIMHANS), Hosur Road, Bengaluru 560029, India
b
Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, India
c
State Surveillance Unit, Directorate of Health and Family Welfare, Government of Karnataka, India

A R T I C L E I N F O A B S T R A C T

Article History: Background: The huge surge in COVID-19 cases in Karnataka state, India, during early phase of the pandemic
Received 30 September 2020 especially following return of residents from other states and countries required investigation with respect
Revised 23 December 2020 to transmission dynamics, clinical status, demographics, comorbidities and mortality. Knowledge on the role
Accepted 23 December 2020
of symptomatic and asymptomatic cases in transmission of SARS-CoV-2 was not available.
Available online 6 January 2021
Methods: The study included all the cases reported from March 8 - May 31, 2020. Individuals with a history of
international or domestic travel from high burden states, Influenza-like Illness or Severe Acute Respiratory
Keywords:
Illness and high-risk contacts of COVID-19 cases were included. Detailed analysis based on contact tracing
SARS-CoV-2 virus
COVID-19
data available from the line-list of state surveillance unit was performed using cluster network analysis
Epidemiology software.
Karnataka Findings: Amongst the 3404 COVID-19 positive cases, 3096 (91%) were asymptomatic while 308 (9%) were
Symptomatic vs asymptomatic symptomatic. Majority of asymptomatic cases were in the age range of 16 and 45 years while symptomatic
cases were between 31 and 65 years. Mortality rate was especially higher among middle-aged and elderly
cases with co-morbidities, 34/38 (89¢4%). Cluster network analysis of 822 cases indicated that the secondary
attack rate, size of the cluster and superspreading events were higher when the source case was symptomatic
as compared to an asymptomatic.
Interpretation: Our findings indicate that both asymptomatic and symptomatic SARS-CoV-2 cases transmit
the infection, although symptomatic cases were the main driving force within the state during the beginning
of the pandemic. Considering the large proportion of asymptomatic cases, their ability to spread infection
cannot be overlooked. Notwithstanding the limitations and bias in identifying asymptomatic cases, the find-
ings have major implications for testing policies. Active search, early testing and treatment of symptomatic
elderly patients with comorbidities should be prioritized for containing the spread of COVID-19 and reducing
mortality.
Funding: Intermediate Fellowship, Wellcome Trust-DBT India Alliance to Giridhara R Babu, Grant number: IA/
CPHI/14/1/501499.
© 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

1. Introduction associated with international travel among returnees from COVID-19

India reported the first case of coronavirus disease 2019 (COVID-
19) on January 30, 2020, in a medical student who travelled from
Wuhan, China [1]. In the beginning, COVID-19 cases in India were
* Corresponding author.
E-mail address: virusravi@gmail.com (V. Ravi).
1
Both these authors contributed equally to the manuscript.
affected countries. Since then, Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2) infection has spread across all states. As
of September 16, 2020, a total of 5020,359 SARS-CoV-2 infections
have been reported from India [2]. Karnataka, a state in the southern
part of India, has a population of 64¢41 million spread across 30
administrative units called districts. Karnataka state reported the first
case of COVID-19 in an international traveler on March 8, 2020 [3]. In
the subsequent three months (March 8 to May 31, 2020) the number

https://doi.org/10.1016/j.eclinm.2020.100717
2589-5370/© 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
2 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717
Research in context
Evidence before this study
Understanding transmission dynamics in the spread of SARS-
CoV-2 is important for controlling the COVID-19 pandemic. We
retrieved all English-language articles reporting the transmis-
sion dynamics of SARS-CoV-2 from symptomatic and asymp-
tomatic cases through systematic searches of major databases
that included PubMed, medRxiv, bioRxiv, arXiv, SSRN, Research
Square and Wellcome Open Research for peer reviewed articles,
preprints and research reports. Our search identified publica-
tions that included terms related to ‘symptomatic’, ‘asymptom-
atic’, ‘transmission dynamics’, ‘covid-190 and ‘SARS-CoV-20
between January 1 - June 1, 2020. Data pertaining to the role of
symptomatic and asymptomatic cases in transmission of SARS-
CoV-2 during early phase of the pandemic was not available
from India or any LMIC with a similar setting.
Added value of this study
The study provides evidence that: (i) Transmission of SARS-
CoV-2 occurs both from asymptomatic and symptomatic cases.
(ii) Symptomatic index case results in higher secondary attack
rate, bigger size of the cluster and higher occurrence of overt
clinical illness. (iii) SSE’s are more commonly associated with
symptomatic index cases. (iv) COVID-19 mortality is higher in
elderly with comorbidities.
Implications of all the available evidence
The findings of this study have major implications for policies
related to surveillance and testing. Active search and early
detection of symptomatic elderly patients with comorbidities
should be prioritized to reduce mortality. Further, testing of all
individuals in high risk settings to capture silent transmission
by asymptomatic individuals should be an integral component
of the policy to prevent spread of SARS-CoV-2.
of COVID-19 cases steadily increased to 3404 in the state. The health
authorities of the state initiated laboratory-based surveillance, tradi-
tional infection control and public health strategies to contain the
spread [4,5]. These included tracing, testing and tracking of contacts
and isolating COVID-19 positive subjects [6]. The state implemented
several public health measures, including retrospective contact trac-
ing, survey for influenza-like illness and strengthening the laboratory
network under the Integrated Disease Surveillance Programme
(IDSP). Also, the state had more than 17 task forces set up under the
Karnataka State Disaster Management [7]. Several innovative meas-
ures were taken to tackle COVID-19 in the initial months. For exam-
ple, invoking powers under Epidemic Diseases Control Act, the state
started using information from available apps to notify people about
their possible interaction with a COVID-19 positive person.
From March 25, 2020, the country was under complete lockdown
until May 31, 2020, in four phases [8]. The first phase of the lockdown
was from March 25, 2020, to April 14, 2020. The second phase of
lockdown was from April 15, 2020, to May 03, 2020, the third phase
of lockdown from May 04
17, and the fourth phase from May
18
31, 2020. From the beginning of the third phase, the Government
of India issued guidelines permitting inter-district and inter-state
travel for stranded persons. Consequently, there was a huge surge of
COVID-19 positive cases from May 4
31, by which time most of the
residents of Karnataka (n = 93,073) from other states, especially from
those with a high burden of COVID-19 cases, returned home [9]. As of
September 16, 2020, a total of 8,932,699 samples have been tested in
the state, of which 851,212 tested positive (9¢5%) [10].
From the beginning of the pandemic, there has been considerable
debate on the role of asymptomatic and symptomatic persons in
spreading the SARS-CoV-2 infection. Initially, the World Health Orga-
nization (WHO) inferred that the role of asymptomatic persons in
transmission was minimal [11,12]. However, the WHO acknowledged
later that there is a growing body of evidence that even asymptom-
atic persons can spread the disease [13]. Previous reports suggest
that nearly 4
32% of the infections are spread through asymptomatic
persons [14,15]. Determining the role of asymptomatic persons in
viral transmission in low and middle-income countries (LMICs) is
very important. The urban areas in these countries have high popula-
tion density, poor personal hygiene, with ubiquitous crowding. In
this report, we describe the epidemiology of SARS-CoV-2 infection in
the southern state of Karnataka, India, during the lockdown phase
with special emphasis on transmission dynamics of symptomatic and
asymptomatic cases.
2. Materials and methods
2.1. Study population
The study included all cases diagnosed with COVID-19 in the Kar-
nataka state, reported from March 8 - May 31, 2020. Case identifica-
tion was carried out by the staff of each district, which included the
district surveillance officer and their teams, the Integrated Disease
Surveillance Programme (IDSP) team, and the urban health authori-
ties of the major cities. Reporting of Influenza-Like Illness (ILI) and
Severe Acute Respiratory Illness (SARI) cases was mandatory for even
private health care providers. The contacts of COVID-19 positive peo-
ple who were in quarantine were monitored. With respect to domes-
tic and international travellers, the state had a policy of quarantining
and subsequent testing of all passengers exposed to a COVID-19 posi-
tive case. Most of the travellers were from COVID-19 affected coun-
tries or states within India. Upon arrival in to the state, they were
immediately subjected to testing. If tested positive they were hospi-
talized and if negative, were quarantined for 14 days with a repeat
test being carried out between 7th and 10th day of quarantine [16].
2.2. Case definitions
A suspect case of COVID-19 was essentially based on the crite-
ria defined by the Ministry of Health and Family Welfare, Govern-
ment of India described elsewhere [17]. Briefly, any person with a
recent history of international travel (14 days), domestic travel
from high burden states of Maharashtra, Gujarat, Delhi, and Tamil
Nadu and anyone within the state with symptoms of ILI and SARI
as well as known high-risk contacts of a confirmed COVID-19
patients were also included. Asymptomatic SARS
CoV
2 cases
were defined as those with positive SARS
CoV
2 RT-PCR in the
absence of symptoms [18].
2.3. Laboratory testing
Testing for SARS-CoV-2 was done initially at five laboratories
in the state. This was quickly ramped up to 63 laboratories across
the state by May 31, 2020, resulting in an enhanced capacity for
testing and identification of COVID-19 cases across Karnataka.
Nasopharyngeal and oropharyngeal swabs collected into virus
transport medium from suspected cases were subjected to an RT-
PCR for detection of SARS-CoV-2 RNA using the Indian Council of
Medical Research (ICMR) guidelines for testing [19]. Three RT-PCR
kits approved by ICMR were used in the study and the details are
provided in Table S1. All positive and negative results were
entered immediately upon their availability into the ICMR portal
and shared with the district/state surveillance teams to facilitate
immediate tracing of contacts.
 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717
Fig. 1. Distribution of case categories, number of cases and interventions undertaken. X axis depicts the timeline while Y axis depicts the number of COVID-19 positive cases. The
date wise interventions undertaken by the state of Karnataka is described. The category of patients and the progression in numbers is depicted in various colors in a wave pattern.
2.4. Data collection
All the sociodemographic, clinical, and risk factor details
(travel history, symptoms, comorbidities, etc.) of patients for
every suspected case was collected on the day of sampling and
entered into a standardized line list by the surveillance teams in
the respective districts/cities. The line list also included informa-
tion about the type of sample, date of sample collection, date of
testing, type of RT PCR kit used, and the test results, as well as
the details of contacts. All contacts were traced based on the
information provided by the individual and subjected to testing
as per the national guidelines [20]. All the data was maintained
in a centralized database by the State Surveillance Officer. Every
effort was made to ensure that missing data, if any, was collected
from the subjects by the surveillance team. All the data were de-
identified before extraction and analysis. A subject who was
detected SARS-CoV-2 positive was given a P number. The lesser
the P number, the earlier the patient was detected either as a
source or as a contact of a known source. The study has been
reported in accordance with the RECORD guidelines.
2.5. Data analysis
The data analysis from the line list was based on the date of
collection of a sample from March 8 to May 31, 2020. The trends
in the positivity rate over time were described by calculating the
seven-day moving average. The number tested per million was
computed by using a State-specific population denominator. The
number of individual tests and contacts tested per confirmed case
was calculated. Laboratory accessibility was examined by sub-
tracting the date of specimen collection from the specimen
receipt date. An indicator for contacts tested per case was esti-
mated by dividing the number of tests among contacts of cases
with the number of positive cases. Contact tracing information
available in the line list was analyzed to determine the source of
infection. Based on the contact tracing information, cluster net-
work analysis was performed and presented using Microsoft Excel
and Gephi network analysis software [21]. Secondary attack rates
were calculated using standard methods, and the dispersion
3
parameter was calculated for asymptomatic and symptomatic
subjects and expressed as the k value [22,23]. As suggested
recently [24] smaller values of k indicate greater heterogeneity,
and in general, k value<1 is associated with a high number of
‘superspreaders’.
2.6. Descriptive epidemiology of cases by time, place and person
The frequencies of characteristics of cases were described by age,
gender, residence, type of exposure (contact or travel), and symp-
toms. The presence of any symptoms at the time of specimen collec-
tion was also recorded. The date of specimen collection was used to
draw the epidemic curve. The time trends were annotated with that
of the implementation of various public health measures or key
events related to the epidemic (Fig. 1).
2.7. Statistical analysis
All the data were entered into the excel sheet and analyzed using
the Statistical Package for Social Sciences (SPSS, version 26) to deter-
mine the significance of various parameters. The cluster network
analysis was performed using Gephi (version 0¢9¢2) for analyzing the
transmission dynamics. Statistical significance was expressed as a p-
value, calculated using the chi-square test, t-test for 95% confidence
interval (CI).
2.8. Funding
Giridhara R Babu is funded by an Intermediate Fellowship by the
Wellcome Trust DBT India Alliance (Clinical and Public Health
research fellowship); grant number: IA/CPHI/14/1/501499.
2.9. Role of the funding agency
The funding agency of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of the article.
All the authors had full access to all the data in the study and corre-
sponding author had final responsibility for submitting for publica-
tion.
4 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717

Table 1
Age group and gender of COVID-19 cases (Mean age 31¢26) (n = 3404).
Age group Asymptomatic (%; 95% CI) Symptomatica (%; 95% CI)
<15 542 (17¢5; 16¢2 - 18¢8) 17 (5¢5; 3¢0 - 8¢0)
16
30 1149 (37¢1; 35¢4 - 38¢8) 61 (19¢8; 15¢3 - 24¢3)
31
45 916 (29¢6; 28¢0 - 31¢2) 96 (31¢2; 26¢0 - 36¢4)
46
60 374 (12¢1; 11¢0 - 13¢2) 72 (23¢4; 18¢7 - 28¢1)
>60 115 (3¢7; 3¢0 - 4¢4)) 62 (20¢1; 15¢6 - 24¢6)
Total 3096 308
Gender ratio (M:F) 1884 (69; 67¢3
70¢6): 211 (61; 55¢5
66¢4):
1212 (31; 29¢3
32¢6) 97 (39; 33¢5
44¢4)
a
Clinical manifestations of symptomatic cases are provided in supplementary
Table S2.
3. Results
3.1. Testing
Figure S1 presents the district-wise distribution of cases. The
highest number of COVID-19 cases were identified in the capital city
of Bengaluru, followed by Kalburgi, Mandya, Yadgir, Udupi, and Rai-
chur. During the study period, the Karnataka state was testing
approximately 4377 per million, with a positivity rate of 1¢1%. The
total cases per million were 2708 in the state. Karnataka followed
contact tracing diligently with the highest number of contacts (47¢4)
traced for each positive case detected [4,18].
Description of cases by time, place, and person: The age, gender dis-
tribution, and clinical details of all the COVID-19 cases in Karnataka
are presented in Table 1. To understand the dynamics of SARS-CoV-2
transmission within the state, we undertook a detailed analysis of
the data available in the line list. Amongst the 3404 COVID-19 posi-
tive cases, 3096 (91%) were asymptomatic, while 308 (9%) were
symptomatic. The age distribution revealed that 54¢6% (1691/3096,
95% CI; 52¢8
56¢3) of the asymptomatic cases were less than 30 years
of age compared to 25¢3% (78/308, 95% CI; 20¢4
30¢1); of symptom-
atic in this age group. On the other hand, 43¢5% (134/308, 95% CI;
38
49) of the symptomatic were over 46 years of age compared to
15¢8% (489/3404, 95% CI; 14¢5
17) of the asymptomatics in this age
group. The percentage of symptomatic and asymptomatic in the age
range 31
45 were more or less similar (31¢2% and 29¢6% respec-
tively) as shown in Table 1. The gender distribution revealed a male
preponderance in both asymptomatic and symptomatic cases.
Table 2 presents the clinical status and outcome of the COVID-19
cases in Karnataka. Overall, amongst the 3404 cases, the final out-
come was available for 1394 (41%) at the end of the study period
(May 31, 2020) while the remaining 2010 (59%) were active cases.
Amongst those, where the outcome was available 7¢6% (106/1394,
95% CI; 6¢2
9) had a variety of comorbidities (Table S3). Further, the
occurrence of comorbidities was ten-fold higher in symptomatic
cases, 29¢1% (73/251, 95% CI; 23¢3
34¢6), as compared to asymptom-
atic cases, 2¢9% (33/1143, 95% CI; 1¢8
3¢7). The instant case fatality
rate recorded in Karnataka was 3¢8% (54/1394, 95% CI; 2¢8
4¢8).
Amongst those who died, 87% (47/54, 95% CI; 78
96) were
symptomatic cases, while 13% (7/54, 95% CI; 4
22) were asymptom-
atic cases. Among the 38 symptomatic cases with comorbidities who
died, 89¢4% (34/38, 95% CI; 79¢6
99¢2) were among the middle-aged
and elderly. The cause of death among the seven asymptomatic cases
is presented in Table S4. Overall, 39% (1340/3404) of cases recovered
and were discharged from the hospital, while 59% (2010/3404) were
active cases as of May 31, 2020. (not presented in the table).
Fig. 2 shows the distribution of overall percent test positivity rate
and the source in 3137/3404 cases. The acquisition of SARS-CoV-2
infection could mostly be attributed to travel (2264, 72¢1%); domestic
travel (2136, 68%) and international (128, 4%) or as a known contact
with a COVID-19 positive case (873, 27¢8%). In the remaining 267
cases (7¢8%), the precise reason behind the acquisition of infection
could not be ascertained. Amongst these 267 cases, 111 (41¢6%) pre-
sented with ILI / SARI with no information of contact with a COVID-
19 positive case. In the remaining 156 (58¢4%) cases, the source of
infection was not traceable. However, the initial adjusted test positiv-
ity rate was 1% on March 8, 2020 which gradually declined to less
than 1% until mid-April 2020, following which there was a steady
increased to 10% until the end of the study (Figure S2).
As evident from Fig. 3, COVID-19 positive cases were initially
detected in the city of Bengaluru and subsequently spread to people
in the other districts, either by contact in Bengaluru or by travelling
to other districts. The other hotspot districts were Gulbarga, Mysore
and Dakshina Kannada, which had an independent source of infec-
tion and local spread. The majority of the COVID-19 cases (68¢5%;
2264/3304) had a history of either international (5¢7%; 128/2264) or
domestic travel (94¢3% 2136/2264), which implies that this was the
main mode of introduction of SARS-CoV-2 into the state. Amongst
those with a history of international travel 41/128 arrived at the city
of Bengaluru. Similarly 44/128 arrived into the other international
airport situated at Mangalore city of Dakshin Kannada district and
travelled to their hometowns. Domestic travel from other states of
India to the districts of Yadgir, Mandya, Udupi, Raichur and Kalaburgi
accounted for more than 200 COVID-19 positive cases. Additionally
inter-district travel within the state from the city of Bengaluru to
Davanagere district contributed to the spread of 124 COVID-19 posi-
tive cases. Overall, our analysis revealed that the city of Bengaluru
had the highest number of COVID-19 positive cases (378), followed
by Kalaburgi (307), Mandya (284), and Yadgir(284), respectively.
Amongst the 873 cases with a history of contact with a COVID-19
positive case, 822 could be epidemiologically linked to 144 source
cases. The remaining 51/873 had a history of contact but could not be
precisely linked to a known source. Using the information available
in the line-list, cluster network analysis was performed to derive
dynamics of transmission (Fig. 4 and Table 3) from symptomatic and
asymptomatic index cases. Amongst the 144 index cases, 32% (46)
contributed to large clusters (>5 cases). As evident from Table 3, 69%
(32/46) index cases were symptomatic while 31% (14/46) were
asymptomatic. The size of each cluster ranged from 5 to 58 cases per
cluster for symptomatic index cases (Mean 17¢03; 95% CI 15¢7
18¢4).
On the other hand, the clusters resulting from asymptomatic cases
range from 5 to 23 per cluster (Mean 8¢1; 95% CI 7¢2
9¢1). Amongst

Table 2
Comorbidities in COVID19 cases.

Outcome Asymptomatic (n = 1143) Symptomatic (n = 251) Total (%)

With comorbidity (%) Without comorbidity (%; 95% CI) With comorbidity (%; 95% CI) Without comorbidity (%; 95% CI)

Recovered 33 (100; NA) 1103 (99¢4; 98¢4 - 99¢5) 35 (48; 36¢5 - 59¢4) 169 (95; 91¢8 - 98¢2) 1340 (96¢1)
Died 0 7a (0¢6; 0¢2 - 1¢0) 38b (52; 40¢5 - 63¢4) 9 (5; 1¢8 - 8¢2) 54 (3¢9)
Total 33 1110 73 178 1394
NA-Not Applicable.
a
The causes of death in these 7 patients were unrelated to COVID-19; Myocardial infarction (3), Traumatic Brain Injury (2), Suicide (1), and Septic shock (1).
b
Among these 38 cases, 34 (89.4%) were above the age of 45 years.
 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717
Fig. 2. Distribution of case categories and overall test positivity. X axis depicts the timeline, Y axis depicts the overall test positivity rate while the Z axis depicts the number of
COVID-19 positive cases. Note there was a huge surge in the number of COVID-19 positive cases in the second half of May 2020.
the 545 cases originating from 32 symptomatic index cases, 41 were
symptomatic, and 504 were asymptomatic. On the contrary, only 2/
114 cases originating from 14 asymptomatic index cases manifested
symptoms (Table 3). The dispersion parameter (k value) of asymp-
tomatic cases was thrice that of symptomatic cases. Detailed cluster
wise distribution of cases are mentioned in Table S6. Graphic repre-
sentation of transmission dynamics in the large clusters (>5 cases) is
presented in Fig. 4. Overall, among the 545 cases resulting from
symptomatic source cases, 67.5% (368) cases were contributed by 12
superspreading events (SSEs) originating from symptomatic cases.
Whereas, two SSEs originating from asymptomatic cases contributed
to 16¢7% (19/114) cases (Fig. 4). Among the total 705 (46 source and
659 secondary) cases which fall into clusters of 5 or more cases, 291
accounted for within household transmission. The mean number of
cases per household was 3.06 (95%CI; 2.8
3.2) ranging between 2
and 8 cases per household. Further, there was no significant differ-
ence observed with respect to the number of transmission cycles
between clusters resulting from symptomatic (Mean 1¢47; 95% CI
1¢15
1¢79) and asymptomatic (Mean 1¢18; 95% CI 0¢93
1¢42) index
cases (data not presented).
4. Discussion
This study describes the epidemiology of SARS-CoV-2 infections in
the state of Karnataka, South India. Before March 8, 2020, there were
no COVID-19 cases in Karnataka. SARS-CoV-2 infection was intro-
duced into the state by people travelling from foreign countries until
the country went into lockdown in the fourth week of March 2020
when international flights were not allowed into the country (Fig. 1).
What initially started as an infection in the capital city of Bengaluru
at the beginning of March 2020, quickly spread to the other parts of
the state (Fig. 3). The majority of cases were mainly (68¢5%; 2264/
3304) attributable to domestic (94¢3%, 2136/2264) and international
5
travel (5¢7%; 128/2264), thereby suggesting that this was the main
mode of introduction of SARS-CoV-2 into the state. It is presumed
that these subjects had acquired the infection at the place where
they initiated their travel. Alternatively, it is possible that they
acquired it during their travel from fellow passengers, especially the
domestic travellers.
From the detailed epidemiological analysis of data in this study, it
emerges that both symptomatic and asymptomatic cases contributed
to the transmission and spread of SARS-CoV-2 infection within the
state. An overwhelming majority of the COVID-19 cases in Karnataka
were asymptomatic at the time of specimen collection, and this is
similar to the results reported in India as well as other Asian coun-
tries [25] and in stark contrast to what is reported in several western
countries [26]. Most of the asymptomatic cases in this study were
young adults or middle-aged (Table 1: <46 years of age).
Our analysis suggests that the symptomatic cases were the prime
drivers of the SARS-CoV-2 transmission within the state during the
early phase of the pandemic. The evidence for this is manifold: (i)
The mean secondary attack rate was 7¢1 for symptomatic cases (90
symptomatic source cases transmitted infection to 645) as compared
to 3¢1 for asymptomatic cases (54 asymptomatic source cases trans-
mitted infection to 177), and this difference was statistically signifi-
cant (Table S5). (ii) Cluster network analysis revealed that
symptomatic source patients contributed to 32 large clusters (>5
cases) with the mean size of each cluster being 17¢03 (range 5
58).
In contrast, the asymptomatic source cases contributed to 14 large
clusters (Table 3 and Fig. 4) with the mean size of each cluster being
8¢1 (range 5
23). (iii) The proportion of secondary cases in the clus-
ters manifesting overt clinical illness was higher when the index case
was symptomatic compared to asymptomatic (Table 3 and Table S6).
(iv) The dispersion parameter for symptomatic source cases was
three-fold lower (k = 1¢2) as compared to asymptomatic source cases
(k = 3¢6), thereby, indicating the higher propensity of transmission
6 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717

Fig. 3. Distribution and direction of transmission of COVID-19 cases in Karnataka State. Each dot represents a person with COVID-19. Primary cases are in red and secondary cases in
blue. Blue colored dots connected to primary cases using lines. The dots not connected by lines represent independent introduction from elsewhere. Bengaluru city was the epicen-
ter, had the highest density of COVID-19 cases, from where spread occurred to several districts in the state.
 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717 7

Fig. 4. Cluster diagram depicting symptomatic and asymptomatic COVID-19 cases in the Karnataka state, March
May 2020. Each case is represented as a dot: red dot indicates a
symptomatic case while yellow dots represent an asymptomatic case. The index case in each cluster is depicted as a larger dot and also indicated with the P number. The lesser the
P number, the earlier the patient was detected either as a source or as a contact of a known source. Note there were 46 clusters with five or more cases. The index case of majority
(32/46) of clusters was a symptomatic patient (red). Large open circles (depicted using interrupted lines) represent superspreading events (>6 cases originating from a
source). Overall, among the 545 cases resulting from symptomatic source cases, 67.5% (368) cases were contributed by 12 SSEs originating from symptomatic cases. Whereas, two
SSEs originating from asymptomatic cases contributed to 16.7% (19/114) cases.

Table 3
Cluster network analysisa depicting the clinical status of index cases and dispersion parameter of COVID19 cases.

Index case status Distribution of index cases Total number of cases Clinical status of cases Average number of cases per Dispersion parameter
(n = 46) associated with the index associated with the index cluster (95% CI) (k value)
case (n = 659) case (n = 659)

Symptomatic 32 (69%) 545 (82¢7%) Symptomatic (n = 41) 17¢03 (15¢7
18¢4) 1¢2

Asymptomatic(n = 504)
Asymptomatic 14 (31%) 114 (17¢3%) Symptomatic (n = 2) 8¢1 (7¢2
9¢1) 3¢6
Asymptomatic (n = 112)
a
Restricted to large clusters (>5 cases).
8 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717
from symptomatic cases especially associated with SSEs (>6 cases
originating from an index case) [27].
Studies from western countries have observed that the true pro-
portion of asymptomatic cases is as low as 20% [28]. On the contrary,
several other studies have observed higher proportion of asymptom-
atic cases especially in India [19,29-33]. Karnataka state had better
contact tracing in the country during the early stage of the pandemic
by detecting 47¢4 contacts per confirmed COVID-19 case [19]. Hence,
we believe that there was no bias in selection of cases which could
have skewed the observation that more than 90% of cases were
asymptomatic. Indeed, it is merely a reflection of the COVID-19 sce-
nario during the early stage of pandemic in the state of Karnataka.
Although, it may be argued that some of the asymptomatic cases may
have developed symptoms after 7
13 days, all the cases during the
lockdown period were hospitalized and were under medical observa-
tion for 14 days. Therefore the chances of misclassification was
unlikely [28,34]. Moreover, the selection of contacts or cases in the
testing system was according to the national guidelines that man-
dated active search and testing for SARS-CoV-2 infection in each state
[20].
There was no risk factor ascribed for acquisition of SARS-CoV-2 in
267/3404 cases (7¢8%) in the present study. There are two likely
explanations for this. Firstly, it may be argued that it is indicative of
“community transmission”. Recent reports of SARS-CoV-2 seropreva-
lence studies carried out across India have indicated that substantial
transmission has occurred in rural areas although it was higher in
urban settings. Further, it was noted that a mere 3% of seropositive
individuals reported COVID-19 symptoms [35,36]. Secondly, owing
to limitations in routine surveillance data collection, especially dur-
ing the early phase of the epidemic in India as reported by an earlier
study, it is likely that the 267 cases are indicative of community
transmission [37].
There were two limitations to this study. Firstly, the study was
restricted to the early period of the pandemic when large number of
infections occurred due to travel. As a result, complete contact tracing
data was available only in 966/3404 (28¢4%) COVID-19 cases until
May 31, 2020. Although contact tracing for all cases would be ideal,
given the reality of the rapid and extensive spread of SARS-CoV-2
virus, there were numerous constraints and challenges in achieving
this. Secondly, a key factor in the transmission of COVID-19 is the
high level of shedding of SARS-CoV-2 virus from the upper respira-
tory tract. Viral RNA shedding is higher at the time of symptom onset
and declines after days or weeks [38]. The difficulty of distinguishing
asymptomatic cases from those who are pre-symptomatic is a major
stumbling block. Since longitudinal data on the occurrence of symp-
toms after the date of collection of specimens was available for the
quarantine period (14 days) of this study, it is plausible that a few
cases with extreme incubation periods may have become symptom-
atic [34]. Consequently, we relied upon available credible data to
understand the dynamics of transmission of SARS-CoV-2 and firmly
believe the results of this study covering nearly 3500 positive cases
(by RT PCR), from an Indian state with a population size of more than
65 million offers significant lessons for most countries of the Global
South.
In conclusion, the findings of this study demonstrate that, during
the early phase of the pandemic, spread of SARS-CoV-2 infection in
the state of Karnataka occurred from both asymptomatic and symp-
tomatic individuals. While preventive measures such as use of face
masks, social distancing, isolation, quarantine and hand washing are
essential to curtail the spread of SARS-CoV-2 from both asymptom-
atic and symptomatic individuals, public health policy should empha-
size on the higher potential of symptomatic cases to transmit the
infection to a larger number of contacts during the early phase of
pandemic. Active search and early detection of symptomatic elderly
patients with comorbidities should be prioritized to reduce mortality.
Further, surveillance and testing of all individuals in high-risk
settings to capture ‘silent’ transmission by asymptomatic individuals
should be an integral component of the policy to prevent spread of
SARS-CoV-2.
Data sharing statement
Study data (in spreadsheet form, with included data definitions) is
available with the Office of the State Surveillance Officer, Govern-
ment of Karnataka. Data sharing requests are subject to approval by
the Commissioner of Health and Family Welfare, Government of Kar-
nataka. Data and other information can be requested by sending an e-
mail to the corresponding author at: virusravi@gmail.com.
Author contributions
NK and SKSH contributed equally to data collection, analysis and
preparation of manuscript, GRB contributed to analysis and review of
manuscript, MMV contributed to laboratory testing, data analysis
and review of the manuscript, PD and PKBG contributed to collection,
collation of data and preparation of line-list, DAJ contributed to data
analysis and figures, AD contributed to data analysis, preparation and
review of the manuscript and VR conceptualized the study and con-
tributed to data analysis, preparation and review of the manuscript.
Declaration of Competing Interest
The authors declare no conflict of interest.
Acknowledgements
The authors acknowledge the COVID laboratory and data manage-
ment team of Deptartmet of Neurovirology, NIMHANS (in alphabeti-
cal order): John Bannerjee, Tina Damodar, Priti Das, Anson George,
Kiran Hosallimath, Ruthu Nagaraju, Tanmoy Nandi, Amrita Pattanaik,
Chitra Pattabiraman, Harsha PK, Risha Rasheed, Vijaykiran Reddy,
Vijayalaksmi Reddy, Ashwini M A, Sourabh Suran as well as all the
staff of the ICMR approved SARS-CoV-2 testing laboratories in the
state of Karnataka. The contributions of the state and district surveil-
lance officers and their teams are also gratefully acknowledged.
Supplementary materials
Supplementary material associated with this article can be found
in the online version at doi:10.1016/j.eclinm.2020.100717.
References
[1] Bhosale S, Kulkarni AP. Is a problem shared, a problem halved? Not always! The
novel coronavirus COVID-19 outbreak. Indian J Crit Care Med 2020;24(2):88–9.
[2] WHO. World Health Organisation (WHO) COVID-19 Dashboard. https://covid19.
who.int/region/searo/country/in 2020 [https://covid19.who.int/region/searo/
country/in. (Accessed on 17 Sep 2020; 10:00 IST).
[3] BBMP COVID-19 WAR ROOM BULLETIN-22; 14-04-2020 https://bbmp.gov.in/
PDF/coronavirus/aprilwarroom/Covid_Bengaluru_14April_2020%20Bulletin%
2022%20English.pdf. 2020. (Accessed on 11 Nov 2020; 14:00 IST).
[4] COVID19 information Portal GoK, Department of Health and Family Welfare, Ben-
galuru, Government circulars. COVID19 information Portal, Govt. of Karnataka,
Department of Health and Family Welfare, Bengaluru, Government circulars.
https://covid19.karnataka.gov.in/govt_bulletin/en. (Accessed on 17 Sep 2020;
14:00 IST).
[5] LPaDS David M. COVID-19 (CORONAVIRUS): a global emergency outbreak and its
implications in India. Int J Zool Appl Biosci 2020.
[6] KGoK DOHFW. Containment plan for novel coronavirus disease 2019 (COVID-19).
Services DOHFW; 2020 https://covid19.karnataka.gov.in/new-page/GENERAL-
%20INFORMATION/en (Accessed on 17 Sep 2020; 14:00 IST) 2020.
[7] DOHFW. COVID-19 Information Portal Government Orders: Government of Kar-
nataka; 2020 [cited 2020]. https://covid19.karnataka.gov.in/newpage/Govern-
ment%20Orders/en. (Accessed on 14 Sep 2020, 14:00 IST).
[8] Kumar MS, Bhatnagar T, Manickam P, Kumar VS, Rade K, Shah N, et al. National
sero-surveillance to monitor the trend of SARS-CoV-2 infection transmission in
 N. Kumar et al. / EClinicalMedicine 32 (2021) 100717
India: protocol for community-based surveillance. Indian J Med Res 2020;151
(5):419–23.
[9] Karnataka Go. S. Sindhu, https://sevasindhu.karnataka.gov.in/cscadmin/OverallU-
sageServiceReport.aspx (Accessed on 11 Nov 2020; 12:00 IST).
[10] Karnataka Go. DOHFW, GoK,10-11-2020, Media Bulletin. https://covid19.karna-
taka.gov.in/storage/pdf-files/Media-Bulletin/10-11-2020%20HMB%20English.pdf
(Accessed on 11 Nov 2020; 11:20 IST).
[11] A J. We don’t actually have that answer yet’: WHO clarifies comments on asymp-
tomatic spread of Covid-19 https://www.statnews.com/2020/06/09/who-com-
ments-asymptomatic-spread-covid-19/ (Accessed on 16 Sep 2020: 10:30 IST).
2020
[12] J D. Unpacking the New WHO Controversy Over Asymptomatic COVID-19 Trans-
mission. 2020.
[13] Organization W.H. Transmission of COVID-19 by asymptomatic cases: http://
www.emro.who.int/health-topics/corona-virus/transmission-of-covid-19-by-
asymptomatic-cases.html. http://www.emro.who.int/health-topics/corona-virus/
transmission-of-covid-19-by-asymptomatic-cases.html. (Accessed on 16 Sep
2020; 10:30 IST).
[14] Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology,
transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19):
a review. JAMA 2020;324(8):782–93.
[15] Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic pro-
portion of coronavirus disease 2019 (COVID-19) cases on board the Diamond
Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill 2020;25(10).
[16] Karnataka Government Circular 2020 https://covid19.karnataka.gov.in/storage/
pdf-files/Home%20quarantine%20for%20primary%20contacts.pdf. (Accessed on
13 Nov 2020; 14:00 IST).
[17] Control. NCfD. The updated case definitions and contact-categorization. New
Delhi: NCDC, Directorate General of Health Services, Ministry of Health and Fam-
ily Welfare, Government of India; 2020.
[18] Organization W.H. Clinical Management of COVID-19: Interim Guidance May 27.
2020. 2020.
[19] (In alphabetical order: Priya Abrahamy NAl, Giridhara R. Babu 7, Suganya Barani 8,
Balram Bhargava 4, Tarun Bhatnagar 8, Ajay Singh Dhama 3, Raman R. Ganga-
khedkar 2, Sidhartha Giri 2, Nivedita Gupta 2, Karishma K. Kurup 5, Ponnaiah
Manickam 9, Manoj Murhekar yy, Varsha Potdar 1, Ira Praharaj 2, Kiran Rade 6, D.
C.S. Reddy 11, V. Saravanakumar 10, Naman Shah 12, Harpreet Singh 3, Jeromie
Wesley Vivian Thangaraj 8, Naveen Yadav 8), C.VID Epidemiology & Data Man-
agement Team @, C. O.VID Laboratory Team*, V. R. D.LN Team$, @COVID Epidemi-
ology & Data Management Team (in alphabetical order): Tanu Anand HKB,
Pranab Chatterjee, Himanshu Chauhan, R Deepa, Amirthammal Gunasekaran,
Daisy A John, Shashi Kant, Sanket Kulkarni, Vinit Kumar, J. P. Muliyil, Ravindra
Mohan Pandey, Swarup Sarkar, Sujeet Singh, S.njay Zodpey, *COVID Laboratory
Team (in alphabetical order): Srima Adhikari JA, Naveen KumarAgarwal, Saurabh
G Agarwal, Prerna Aggarwal, Anurag Agrawal, Arti Agrawal, Safaa Muneer
Ahmed, G Ambernath, Nitin Ambhore, VP Amudha, Sohini Arora, Ashok, Anita,
Awanti, Veer Badriyah TA, Amrita Kumari B, Maneesh Bagai, Dipa Baido, Baijayan-
timala, Rupinder Bakshi, Bhaswati Bandyopaghyay, Avi Kumar Bansal, Abhik
Baneerjee, Sonal Bangadi, Anurag Bansal, Shakeera Banu, Mahesh Baragundi, Pra-
deep Barde, Purabi Barman, Purnima Barua, Sharad Bhalla, Bharat, V Kusuma
Bharathi, Anudita Bhargava, M Bhaskar, Sandeep Bhatia, Sima Bhatt, Binita, Ritu
Bist, Debasis Biswas, Samrat Biswas, SK Biswas, Biswa Borkakoty, Siddhesh KC,
Harish Chander, Jagdish Chander, R Sree Charan, Krishna Chandran R, Chandrase-
kar, Leena Chatterjee, Mitali Chatterjee, Bhaskar Narayan Chaudhuri, Sandeep P
Chaudhari, Aparna Chaudhary, Nirupauma Chayani, VV Chincholkar, Deepinder
Kaur Chhina, Elantamilan D, Ashwin Dalal, Mandeep Dalal, Lalit Dar, Aseem Das,
Pradeep Das, Poonam Das, Suryasnata Dass, P K Dash, Somnadh Dash, K S Daya-
nidhi, Mandeep Dalal, Deepa, R Deepa, Vijayshri Deotale, Kairavi J Desai, Archana
Deshpande, Smita Deshpande, Yogita Desai, Krupi Desai, M Neelaveni Devi, Sar-
ada Devi, Sulochana Devi, Dhanapa,l Kanwardeep Dhingra, Rahul Dhodapkar, V
DilliRani, Anupa Dixit, Nandini Dugal, Shanta Dutta, Sarjana Dutt, Anjum Farhana,
Bashir Fomda, Shantala G, Rajni Gaind, Shelly Sharma Ganguly, Neeta Gangurde,
Amit Garg, T Geethanjali, Paramjeet S Gill, CP Girish Kumar, Varun Goel, Shiv
Gopal, Parijat Goswami, Puneeth Gonnabatuhulla, Kiran Gosavi, Navin Grover,
Baldev Raj Gulati, Pooja Gumaste, Anjali Gupta, Minakshi Gupta, Piyali Gupta,
Ekta Gupta, Srinita Gupta, Rattan Gurnani, Bijayesh Haldar, Haritha, Krishnan H
Harshan, Beena Philomina J, Amita Jain, Manoj Jais, Pratik Jariwala, SC Jaryal,
Tanuja Javadekar, Jayalakshmi, Jayshree, Daisy A John, T Jeyamurugan, Neerja Jin-
dal, Ameeta Joshi, Pankaj Joshi, Jyothi, Lakshmi Jyothi, Lancy Justus, Nayana
Ingole, Jyoti Iravane, Anil K, Anju Kagal, Iravathy Goud kalal, Usha Kalawat, Deep-
jyoti Kalita, P Kamala, N Kamath, Rajesh Kannangai, Santosh Karade, Jatinder
Kaur, K. Kaveri, Kavitha, S Kavitha, Maithili Kavathekar, K Kesavarao, Rashmi Kha-
dapkar, ID Khan, Shoeb Akhtar Khan, Neeta Khandelwal, PK Khatri, Nilofar
Khayyam, D Kishore, Sandeep V Kokate, Prasanthi Koli, Vinita Kothari, Meka Kou-
mudi, Mohan Kumar, R Senthil Kumar, Sharath Kumar, P Sravan Kumar, Suresh
Kumar EK, D Pradeep Kumar, Ranjeet Kumar, AV Seshu Kumar, S Kumar, P Ratna
Kumari, Kumari, Yogendra Kumar, Pradip Kundu, Jyothi Kunduru, Shoba Kurian,
Jyothi Lakshmi, G. Jyothi Lakshmi, S. Lalitha, V Madhavi Latha, Madhavi Latha,
Shailesh Lichade, S Madhavi, Udaya Kumar Madhurachari, Tapan Majumdar,
Paras Mandalecha Paras Mandalecha, Dhruti Manek, Sasidhar Majeti, Malathi,
Bharti Malhotra, Paras Mandalecha, Manoj, Devajyothi Majumdar, Supriya Malvi,
D Therese Mary, Haris Mazoor, Guruprasad Medigeshi, M Lucy Nirmal Medona,
Jeya Meenak, Deepak Kumar Mishra, Meena Mishra, Vaibhav Mishra, Kavitha MP,
Prakash Modi, Mohanasundaram, Dharitri Mohapatra, Monica, Sandeepan
9
Mukherjee, AK Munirajan, Varsha Munj, DS Murthy, Anitha Mutha, Vijaya
Lakshmi Nag, Mythily Nagasundaram, M Ramamurthy Naik, Nair, Reena Nakra,
Gopal Nath, Rajender P, N Shekhar Pal, Samiran Panda, Ajay Parida, Banojini Par-
ida, Arunima Patel, Jaimin Patel, Parthiben, Shilpa Paranjape, Dipankar Pattanik,
Manish Patel, Parimal H Patel, Sachin Patel, Vainav Patel, Binod Kumar Pati, Asha
B Patil, Niranjan Patil, Nikhil Patkar, Beena Paul, Nikhil Phadke, AC Phukan,
Prabha, Monika Prabhakar, Jaya Prakash, RS Prasad, Ranjit Prasad, Sujay Prasad,
Amresh Puri, Manju Purohit, Vijay David Raj, Raghu, Rajan, Rajesh, S Rajesh, Y
Rajini, Rishabh Rajput, Raju, Giri Raju, B Jabardhan Raju, Sunil Raju, C Ramachan-
dra, SV Ramamurty, Vandana Rana, Vidhya R Rani, VV Ramanchndra Rao, Elmy
Samsun Rasul, V Ravi, RK Ratho, Sharmila Raut, Vinita Rawat, Raja Ray, Ujjwayini
Ray, S Subba Reddy, Mahesh Reddy, A Sugunakar Reddy, Raveendra HR Reddy,
Sowjanya Reddy, PR Rekha, Savi Rodrigues, Anusha Rohit, Shabnam Roohi,
krishna S, Lavanya S, Pushkala. S, Mahesh Sabeetha, Deepak Sadwani, Arvind
Sahu, Sunitha Sahu, Apurva Sarin, Sahu, VP Sarasu, Saranya, S Saravanan, Raman
Sardana, Arunabhao Sarkar, Dibyendu Sarkar, Smita sarma, Satish, Partha Sarathi
Satpathi, Savitri, Shailaja Saxena, Sonal Saxena, Saubhik Sengupta, Rajeev Seth,
Purvi Shah, Sweta Shah, Sandip C shah, SK Shahi, Nazira Shaikh, P Shankar, Ajanta
Sharma, Anshu Sharma, Pooja Sharma, Shashi Sudan Sharma, Jayanthi Shastri,
Nikita Sherwani, Shivaleela, Jayasree Shivadasan, Shreekumar, Ajith Singh, Binay
Kumar Singh, Dig Vijay Singh, RK Manojkumar Singh, Satyendra Narayan Singh,
Shashi P Singh, Simrita Singh, Sudagar Singh, Varsha A Singh, VB Singh, Sivaku-
mar, Rakesh Srivastava, Sudha, C Sugumari, Sukanta Sinha, Ghanshyam Sone, KN
Sridhar, CN Srinivas, S Srinivasan, Sandeep Kumar Srivastava, Sunija, K Sunitha, A
Surekha, Sreekar, Namita Srivastava, M Mary Sujatha, B Usha Sundari, Swarnala-
tha, VP Sugnan, Sunita, Rupali Suryawanshi, Swarna, Venkatesha DT, Ajay Tahlan,
Anil Tarigopula, Thilakavathi, Utpal Tatu, MS Tevatia, Narendra Vijay Tirpude,
Tiwari, Srikanth Tripathy, Jyotirmaryee Turuk, Robin Tuli, Milind Ubale, Ujjala,
Nawaz Umar, Banappa Unger, Sireesha Vaidya, Niraml A Vaniawala, V.Vasuki, N.
P. B. Veenakumari, M Veeraswamy, MM Vegad, Rosy Vennila, Ranjan Verma,
Santwana Verma, Vijaya, A Vijayalakshmi, RD Vishwakarma, Veena Volvoikar,
Chand Wattal, Madhu Yadav, Sarita Yadav, Vijay Yenagi, K.mraan Zaman, G. B.
Zore, 1 Virus Research & Diagnostic Laboratory Network (VRDLN) Team (in alpha-
betical order)SG ICMR COVID Study Group, Bhushan A, Kaur H, Narayan J, Rana S,
Vijay N. Laboratory surveillance for SARS-CoV-2 in India: performance of testing
& descriptive epidemiology of detected COVID-19, January 22 - April 30, 2020.
Indian J Med Res 2020;151(5):424–37.
[20] ICMR N.D. Advisory Strategy of COVID 19 testing in India (Version 2,3 and 4).
[21] HS Bastian M, Jacomy M. Gephi: an open source software for exploring and
manipulating networks. International AAAI conference on weblogs and social
media; 2009.
[22] Zhang Y, Li Y, Wang L, Li M, Zhou X. Evaluating transmission heterogeneity and
super-spreading event of COVID-19 in a metropolis of China. Int J Environ Res
Public Health 2020;17(10).
[23] Endo A, Abbott S, Kucharski AJ, Funk S, Group CftMMoIDC-W. Estimating the
overdispersion in COVID-19 transmission using outbreak sizes outside China.
Welcome Open Res 2020;5:67.
[24] Bar-On YM, Sender R, Flamholz AI, Phillips R, Milo R. Quantitative clarification of
key questions about COVID-19 epidemiology. arXiv: Other Quant Biol 2020.
[25] Day M. Covid-19: four fifths of cases are asymptomatic, China figures indicate.
BMJ 2020;369:m1375.
[26] Oran DP, Topol EJ. Prevalence of asymptomatic SARS-CoV-2 infection: a narrative
review. Ann Intern Med 2020;173(5):362–7.
[27] Wong F, Collins JJ. Evidence that coronavirus superspreading is fat-tailed. Proc.
Natl. Acad. Sci. USA 2020.
[28] Nogrady B. What the data say about asymptomatic COVID infections (Accessed on
11th December 2020). Nature 2020.
[29] Jain P, Prakash O, Nyayanit DA, Verma AK, Yadav PD, Khan DN, et al. Identification
of SARS-CoV-2 clusters from symptomatic cases in India. Indian J Med Res
2020;152(1 & 2):111–5.
[30] Laxminarayan R, Wahl B, Dudala SR, Gopal K, Mohan BC, Neelima S, et al. Epide-
miology and transmission dynamics of COVID-19 in two Indian states. Science
2020;370(6517):691–7.
[31] Ing AJ, Cocks C, Green JP. COVID-19: in the footsteps of Ernest Shackleton. Thorax
2020;75(8):693–4.
[32] Petersen I, Phillips A. Three quarters of people with SARS-CoV-2 infection are
asymptomatic: analysis of English household survey data. Clin Epidemiol
2020;12:1039–43.
[33] He J, Guo Y, Mao R, Zhang J. Proportion of asymptomatic coronavirus disease
2019: a systematic review and meta-analysis. J Med Virol 2020.
[34] Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation
period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed
cases: estimation and application. Ann Intern Med 2020;172(9):577–82.
[35] BT Murhekar M, Selvaraju S, et al. Findings from the second nationwide house-
hold serosurvey SSRN-Preprints with Lancet 2020.
[36] Murhekar MV, Bhatnagar T, Selvaraju S, Rade K, Saravanakumar V, Vivian Than-
garaj JW, et al. Prevalence of SARS-CoV-2 infection in India: findings from the
national serosurvey, May-June 2020. Indian J Med Res 2020;152(1 & 2):48–60.
[37] Gupta N, Praharaj I, Bhatnagar T, Vivian Thangaraj JW, Giri S, Chauhan H, et al.
Severe acute respiratory illness surveillance for coronavirus disease 2019, India,
2020. Indian J Med Res 2020;151(2 & 3):236–40.
[38] Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymp-
tomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N
Engl J Med 2020;382(22):2081–90.