First known person-to-person

transmission of severe acute

respiratory syndrome coronavirus 2
(SARS-CoV-2) in the USA Isaac Ghinai
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 Articles

First known person-to-person transmission of severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA
Isaac Ghinai*, Tristan D McPherson*, Jennifer C Hunter, Hannah L Kirking, Demian Christiansen, Kiran Joshi, Rachel Rubin, Shirley Morales-Estrada,
Stephanie R Black, Massimo Pacilli, Marielle J Fricchione, Rashmi K Chugh, Kelly A Walblay, N Seema Ahmed, William C Stoecker, Nausheen F Hasan,
Deborah P Burdsall, Heather E Reese, Megan Wallace, Chen Wang, Darcie Moeller, Jacqueline Korpics, Shannon A Novosad, Isaac Benowitz,
Max W Jacobs, Vishal S Dasari, Megan T Patel, Judy Kauerauf, E Matt Charles, Ngozi O Ezike, Victoria Chu, Claire M Midgley, Melissa A Rolfes,
Susan I Gerber, Xiaoyan Lu, Stephen Lindstrom, Jennifer R Verani, Jennifer E Layden, for the Illinois COVID-19 Investigation Team†

Summary
Background Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome Lancet 2020; 395: 1137–44
coronavirus 2 (SARS-CoV-2), first detected in China in December, 2019. In January, 2020, state, local, and federal Published Online
public health agencies investigated the first case of COVID-19 in Illinois, USA. March 12, 2020
https://doi.org/10.1016/
S0140-6736(20)30607-3
Methods Patients with confirmed COVID-19 were defined as those with a positive SARS-CoV-2 test. Contacts were
See Comment page 1093
people with exposure to a patient with COVID-19 on or after the patient’s symptom onset date. Contacts underwent
*These authors contributed
active symptom monitoring for 14 days following their last exposure. Contacts who developed fever, cough, or equally
shortness of breath became persons under investigation and were tested for SARS-CoV-2. A convenience sample of †Memberrs of the Illinois
32 asymptomatic health-care personnel contacts were also tested. COVID-19 Investigation Team are
listed in the appendix (pp 1–2)
Findings Patient 1—a woman in her 60s—returned from China in mid-January, 2020. 1 week later, she was Epidemic Intelligence Service
hospitalised with pneumonia and tested positive for SARS-CoV-2. Her husband (Patient 2) did not travel but had (I Ghinai MBBS,
T D McPherson MD,
frequent close contact with his wife. He was admitted 8 days later and tested positive for SARS-CoV-2. Overall,
H E Reese PhD, M Wallace DrPH,
372 contacts of both cases were identified; 347 underwent active symptom monitoring, including 152 community V Chu MD), Division of
contacts and 195 health-care personnel. Of monitored contacts, 43 became persons under investigation, in addition Healthcare Quality Promotion,
to Patient 2. These 43 persons under investigation and all 32 asymptomatic health-care personnel tested negative for National Center for Emerging
and Zoonotic Infectious
SARS-CoV-2. Diseases (J C Hunter DrPH,
S A Novosad MD,
Interpretation Person-to-person transmission of SARS-CoV-2 occurred between two people with prolonged, I Benowitz MD), Division of Viral
unprotected exposure while Patient 1 was symptomatic. Despite active symptom monitoring and testing of Diseases, National Center for
Immunization and Respiratory
symptomatic and some asymptomatic contacts, no further transmission was detected. Diseases (H L Kirking MD,
M Wallace, V Chu,
Funding None. C M Midgley PhD, S I Gerber MD,
X Lu MS, S Lindstrom PhD),
Division of Bacterial Diseases,
Copyright © 2020 Elsevier Ltd. All rights reserved. National Center for
Immunization and Respiratory
Introduction in the USA was reported on Jan 30, when the husband Diseases (H E Reese,
In January, 2020, a novel virus, severe acute respiratory of the index patient, who had not travelled outside J R Verani MD), Influenza
Division, National Center for
syndrome coronavirus 2 (SARS-CoV-2), was iden­tified as the USA, tested positive for SARS-CoV-2. Public health Immunization and Respiratory
the causative agent for a cluster of pneumonia cases authorities did an intensive epidemiological investigation Diseases (M W Jacobs BA,
initially detected in Wuhan City, Hubei province, China.1 of the two confirmed cases. M A Rolfes PhD), One Health
SARS-CoV-2, which causes the disease now named This Article describes the first person-to-person Office, National Center for
Emerging and Zoonotic
coronavirus disease 2019 (COVID-19), had spread transmission of COVID-19 in the USA, including the Infectious Diseases
throughout China and to 26 additional countries as of clinical and laboratory features of both patients and the (V S Dasari MPH), Centers for
Feb 18, 2020.2 Phylogenetic data implicate a zoonotic assessment and monitoring of several hundred indivi­ Disease Control and Prevention,
Atlanta, GA, USA; Illinois
origin,3 and the rapid spread suggests ongoing person- duals with potential exposure to SARS-CoV-2.
Department of Public Health,
to-person transmission. Several studies offer additional Springfield, IL, USA (I Ghinai,
insight into person-to-person transmission.4–9 However, Methods D P Burdsdall PhD,
substantial knowledge gaps remain regarding the Epidemiological investigation M T Patel MPH, J Kauerauf MPH,
E M Charles BA, N O Ezike MD);
transmissibility between humans, including the level of The Illinois Department of Public Health, Chicago
Chicago Department of Public
exposure to a confirmed case at which transmission is Department of Public Health, Cook County Department Health, Chicago, IL, USA
more likely to occur. of Public Health, and DuPage County Health Department (T D McPherson, S R Black MD,
On Jan 23, 2020, Illinois, USA, reported the state’s first consulted with the US Centers for Disease Control and M Pacilli MPH, M J Fricchione MD,
K A Walblay MPH, J E Layden MD);
laboratory-confirmed case (index case) of COVID-19 in a Prevention (CDC) for technical assistance and invited a
Cook County Department of
traveller who returned from Wuhan in mid-January, 2020. CDC field team to assist with onsite investigations after Public Health, Oak Forest, IL,
Subsequently, the first evidence of secondary transmission laboratory confirmation of the first case of COVID-19. USA (D Christiansen DrPH,

www.thelancet.com Vol 395 April 4, 2020 1137

 Articles
K Joshi MD, R Rubin MD,
S Morales-Estrada MPH);
DuPage County Health
Department, Wheaton, IL, USA
(R K Chugh MD); Metro
Infectious Disease Consultants,
Burr Ridge, IL, USA
(N S Ahmed MD,
W C Stoecker MD); Premier
Primary Care Physicians,
Carol Stream, IL, USA
(N F Hasan MD); Cook County
Health, Chicago, IL, USA
(C Wang MD, D Moeller MD,
J Korpics MD); Feinberg School
of Medicine, Northwestern
University, Chicago, IL, USA
(C Wang, D Moeller, J Korpics);
Lake Erie College of
Osteopathic Medicine, Erie, PA,
USA (M W Jacobs); and
Boonshoft School of Medicine,
Wright State University,
Dayton, OH, USA (V S Dasari)
Correspondence to:
Dr Tristan D McPherson, Chicago
Department of Public Health,
Chicago, IL 60612, USA
oko9@cdc.gov
or
Dr Jennifer E Layden, Chicago
Department of Public Health,
Chicago, IL 60604, USA
jennifer.layden@cityofchicago.
org
See Online for appendix
1138
Research in context
Evidence before this study
We searched PubMed for articles published between database
inception and Feb 18, 2020, describing transmission of severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using
the search terms “severe acute respiratory syndrome
coronavirus 2”, “SARS-CoV-2”, “novel coronavirus”,
“2019-nCoV”, or “COVID-19”; and “transmission”, “person-to-
person”, or “human-to-human”. We found 34 articles, of which
13 were primary reports of person-to-person transmission.
None provided full details of the contact investigation and
none were from North America.
Added value of this study
We detail prolonged, unprotected contact between a travel-
related index case who was symptomatic and her husband,
who subsequently acquired infection. This represents the first
known person-to-person transmission of SARS-CoV-2 in
the USA. We also detail a thorough contact investigation
Patients with COVID-19 were defined as individuals
with laboratory-confirmed SARS-CoV-2 infection. Con­
tacts were defined as people who reported or were
identified to have potential exposure to a case on or after
the day of symptom onset of the case (table 1). The earliest
reported day with new symptoms was used as date of
symptom onset. The date of symptom onset for the index
case is considered day 0 for the purposes of this
investigation, and all subsequent dates will be described
by day of investigation (DOI), starting with DOI 0. In this
Article, the numbers of contacts exposed to either case
on or after the day of their first positive laboratory result
are also presented.
Patients with COVID-19 were interviewed using a
standardised questionnaire to identify symptom history,
locations visited while symptomatic, and individuals
with whom they had contact while symptomatic. The
Illinois COVID-19 Investigation Team, comprised of
local and state public health staff and the CDC field team,
worked with locations visited (eg, workplaces, retail
establishments, or health-care facilities) by patients with
COVID-19 to identify additional individuals who might
have had exposures to SARS-CoV-2. To identify possible
exposures in health-care personnel, patient logs and
staffing records were obtained and reviewed for all
health-care settings visited by patients with COVID-19.
Security footage was reviewed to identify additional
health-care personnel and patients who had contact
with patients with COVID-19 during transport through
the admitting hospital. Health-care personnel were
defined as all people working in health-care settings
who had the potential for exposure to infectious
materials,12 including members of the Illinois COVID-19
Investigation Team. All other contacts were classified as
community members, including patients in the same
related to these cases. We identified, risk-stratified, and actively
monitored almost 350 contacts of both cases. 43 contacts
developed symptoms of fever, cough, or shortness of breath in
the 14 days following their last exposure to either case and
were tested for SARS-CoV-2, and 32 asymptomatic health-care
professional contacts who had exposures across a range of risk
levels were also tested for SARS-CoV-2. All 75 tested negative.
Implications of all the available evidence
Person-to-person transmission of SARS-CoV-2 occurred
between two people with prolonged, unprotected exposure.
No further transmission was detected, despite monitoring
contacts for symptoms and testing all who developed fever,
cough, or shortness of breath and testing a convenience sample
of asymptomatic health-care professional contacts. Further
detailed reports of contact investigations associated with cases
of SARS-CoV-2 could improve understanding of the
transmissibility of this novel virus.
indoor environment in a health-care setting (eg, a
hospital waiting room).
Exposure risk classification
Health-care personnel and community members with
potential exposure to SARS-CoV-2 were interviewed using
standardised contact questionnaires to assess exposure
and whether the individual had true contact with a patient
with COVID-19. Exposure risk was classified according
to frameworks designed by members of the Illinois
COVID-19 Investigation Team in consultation with CDC
subject-matter experts (table 1). These frameworks were
based on published guidance for Middle East respiratory
syndrome coronavirus and designed and implemented
before interim risk assessment guidance for COVID-19
released by CDC.10,11
Active monitoring of contacts
All health-care personnel and community contacts
assessed to have had low-risk, medium-risk, medium-
high-risk, or high-risk exposures were enrolled in active
symptom monitoring, which continued for 14 days after
last exposure to a patient with COVID-19. Active symp­
tom monitoring was done using Research Electronic
Data Capture software (Vanderbilt University, Nashville,
TN). Contacts received automated, twice-daily emails
inquiring about symptoms, including cough and
shortness of breath, and a request for a self-measured
temperature. If symptoms or fever (temperature of >38°C)
were reported, or if contacts did not respond or declined
email monitoring, public health officials telephoned
contacts daily. For hospital-based health-care personnel
not excluded from work, pre-shift symptom assessment
for fever, cough, or shortness of breath was implemented
by hospital occupational health services. To identify any
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Community contacts Health-care personnel contacts

Type of exposure Example Public health measure Type of exposure Example Public health measure
High-risk Living in the same household Domestic partner Home quarantine for Performing or being present in the Health-care personnel Home quarantine*;
contacts as, being an intimate partner 14 days after last room for a procedure likely to not wearing all exclude from work;
of, or providing care in a exposure*; active generate higher concentrations of recommended PPE active symptom
non-health-care setting symptom monitoring respiratory secretions or aerosols who collected or were monitoring for 14 days
(such as a home) for a person for 14 days after last while not using all recommended present for the after last exposure
with symptomatic laboratory- exposure PPE†, or close contact while not collection of
confirmed COVID-19 wearing respiratory protection with nasopharyngeal or
a patient with laboratory-confirmed oropharyngeal
COVID-19 infection who was not specimens‡
wearing a facemask
Medium- Prolonged or frequent contact Family members Home quarantine for Prolonged (15 min or more) contact Performing a check of Exclude from work;
high-risk with a person with visited for prolonged 14 days after last with a patient with laboratory- the vital signs and active symptom
contacts symptomatic laboratory- periods or close work exposure*; active confirmed COVID-19 infection or phlebotomy on a monitoring for 14 days
confirmed COVID-19§ associates symptom monitoring their secretions or excretions while masked patient while after last exposure
for 14 days after last not using all recommended PPE† wearing gloves and a
exposure surgical mask
Medium-risk Close contact with a person Colleagues who work Active symptom More than brief contact (>1–2 min) Examined patient for Exclude from work;
contacts with symptomatic laboratory- less closely together monitoring for 14 days with a patient with laboratory- 5 min while wearing active symptom
confirmed COVID-19 and not but still have regular after last exposure confirmed COVID-19 infection or mask, gown, gloves, monitoring for 14 days
having any exposures that face-to-face contact their secretions or excretions while and faceshield (but no after last exposure
meet a high-risk or medium- not using all recommended PPE† respirator)
high-risk definition that does not meet a high-risk or
medium-high-risk definition
Low-risk Being in the same indoor Shared a hospital or Active symptom Any duration of contact with a Examined patient while Active symptom
contacts environment with (or within outpatient waiting monitoring for 14 days patient with laboratory-confirmed wearing gloves, gown, monitoring for 14 days
2 h of) a person with room or entered space after last exposure COVID-19 while using all faceshield, or goggles after last exposure
symptomatic laboratory- within 2 h of a case recommended PPE†, brief and appropriate,
confirmed COVID-19 interaction with the patient fit-tested respiratory
(1–2 min) not involving direct protection; entered
contact while not using all patient’s room briefly
recommended PPE†, or working at to bring the patient a
the same time and location as a drink but did not have
confirmed case but unsure whether direct contact with the
they were in the same room patient or their
secretions or excretions
Non-contacts Interactions with a person with Walking by a patient None Did not meet any of the high-risk, Walking by a patient in None
symptomatic laboratory- in a corridor medium-high-risk, medium-risk, a corridor
confirmed COVID-19 that do or low-risk conditions
not meet high-risk, medium-
high-risk, medium-risk,
or low-risk conditions
COVID-19=coronavirus disease 2019. PPE=personal protective equipment. CDC=US Centers for Disease Control and Prevention. MERS-CoV=Middle East respiratory syndrome coronavirus. *Implemented after
identification of the second case of laboratory-confirmed COVID-19 in Illinois on Jan 30, 2020. †Recommended PPE includes respiratory protection (ie, respirator), goggles or faceshield that covers the front and
sides of face, gloves, and a gown. ‡Risk categorisation was developed on Jan 26, 2020, before published guidance from CDC for COVID-19.10 Criteria were based on published MERS-CoV guidance and additional
input from CDC subject matter experts. Close contact was defined as being within approximately 6 feet or within the room or care area of a confirmed COVID-19 case (including sharing a health-care waiting area or
room), or being in a shared air space vacated by a confirmed case within the previous 2 h. Transient interactions, such as walking by confirmed case, were not considered close contact. Of note, nasopharyngeal and
oropharyngeal specimen collection were not listed as aerosol-generating procedures in the CDC guidance, but were included as high-risk exposures in this investigation. §Risk categorisation was developed on
Jan 31, 2020, before published guidance from CDC for COVID-19.11 Criteria were based on published MERS-CoV guidance and additional input from CDC and state and local health officials. The medium-high-risk
classification was included owing to the identification of some community contacts who did not meet the highest category of exposure risk but were nevertheless concerning.

Table 1: Illinois risk classification of health-care personnel and community contacts with potential exposure to COVID-19

contacts (including those that could not be reached for
active symptom monitoring) seeking care for fever, cough,
or shortness of breath at an emergency department,
the Illinois Department of Public Health used locally
available, near real-time surveillance data received from
regional acute care hospitals, which included symptom
and diagnoses data and personally identifiable infor­
mation for matching.
If a contact developed fever, cough, or shortness of
breath during active symptom monitoring, they were
classified as a person under investigation (PUI; a standard
case designation used by CDC during an outbreak)13 and
were isolated and tested for SARS-CoV-2.
Specimen collection and laboratory testing
For PUIs, specimens were collected and sent to CDC for
testing. Specimens included upper (nasopharyngeal and
oropharyngeal swabs) and lower respiratory specimens
(sputum) if spontaneously produced. For patients with
COVID-19, nasopharyngeal, oropharyngeal, serum,
sputum, urine, and stool specimens were collected and
sent to CDC for testing at initial presentation, and then

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Day of Investigation 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 28 30 31

Patient 1 Wuhan Community Hospital Home*

Subjective fever 38·2°C

Fatigue
Symptoms

Cough
Nausea
Abdominal discomfort
Dizziness
Nasopharyngeal swab
SARS-CoV-2 rtPCR results

Oropharyngeal swab
Sputum
Serum
Urine
Stool inc

Patient 2 Community Hospital Home*

Subjective fever
Fatigue
Symptoms

Cough Worsened from baseline

Nausea
Shortness of breath Worsened from baseline

Headache
Haemoptysis

Enrolled in active symptom monitoring

Nasopharyngeal swab
SARS-CoV-2 rtPCR results

inc

Oropharyngeal swab
Sputum inc inc

Serum
Urine
Stool

Figure: Symptoms and results of rtPCR testing for SARS-CoV-2 by day of investigation
Gradient shading indicates unclear period of symptom onset from patient report. inc=inconclusive result. rtPCR=real-time RT-PCR. SARS-CoV-2=severe acute
respiratory syndrome coronavirus 2. *Patient 1 and Patient 2 in home isolation.

every 2–3 days. Additionally, a convenience sample of Role of the funding source
32 asymptomatic health-care personnel contacts had There was no funding source for this study.
one-time nasopharyngeal and oropharyngeal specimens
obtained at least 7 days from their highest-risk expo­ Results
sure. All health-care personnel contacts were offered Patient 1 is a female in her 60s who travelled to Wuhan
testing, but laboratory capacity and availability of health- on Dec 25, 2019, and returned to Illinois on Jan 13, 2020,
care personnel to undergo testing were limited in the and who was not symptomatic while travelling. In
setting of this urgent investigation. Before Patient 2 Wuhan, she visited a hospitalised relative regularly and
reported symptoms to public health investigators, visited other family members who had undiagnosed
nasopharyngeal and oropharyngeal swabs were also respiratory illnesses, one of whom was later hospitalised
collected from Patient 2 owing to his high-risk exposures with viral pneumonia. No contacts had laboratory-
to Patient 1. confirmed COVID-19, but it is unknown whether any
Specimens were collected per CDC guidance.14 All were tested for SARS-CoV-2.
specimens were refrigerated at 2–8°C before shipping on On DOI 6, she sought care at an outpatient clinic for
icepacks to CDC. CDC did real-time RT-PCR (rtPCR) to fever, fatigue, and cough and was hospitalised that day for
detect three separate genetic markers of SARS-CoV-2, pneumonia. She was reported to public health authorities
as previously described.15 The cycle threshold value as a PUI on DOI 7. Retrospectively, she reported that her
ranges for the three markers were interpreted as a semi- symptoms, which also included nausea, abdominal
quanti­tative measure of the RNA concentration in the discomfort, and dizziness, started as early as 6 days before
specimen. admission (figure).

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Since first reported date of symptom onset On or after date of first positive specimen
Total contacts Did not Met PUI PUIs positive for Total contacts Did not Met PUI PUIs positive
become a PUI criteria* COVID-19† become a PUI criteria* for COVID-19†
Community contacts
High risk 1 0 1 1/1 1 0 1 1/1
Medium high 7 5 2 0/2 1 1 0 ··
Medium 28 24 4 0/4 0 0 0 ··
Low 116 111 5 0/5 65 61 4 0/4
Total 152 140 12 1/12 67 62 5 1/5
Health-care personnel contacts
High risk 32 28 4 0/4 22 20 2 0/2
Medium high 39 30 9 0/9 29 24 5 0/5
Medium 12 6 6 0/6 9 5 4 0/4
Low 112 99 13 0/13 95 84 11 0/11
Total 195 163 32 0/32 155 133 22 0/22
Total contacts 347 303 44 1‡ 222 195 27 1‡
Data are n or n/N. PUI=person under investigation. COVID-19=coronavirus disease 2019. *US Centers for Disease Control and Prevention PUI criteria for contacts of a
confirmed case: fever (subjective or objective) or signs or symptoms of lower respiratory illness (eg, cough or shortness of breath). †PUIs were tested for COVID-19 using
real-time RT-PCR for severe acute respiratory syndrome coronavirus 2. Only results from PUIs tested for COVID-19 in this investigation are presented here. ‡The index
patient, Patient 1, is excluded from this total

Table 2: Actively monitored contacts and PUIs owing to contact with a patient with COVID-19, Illinois, USA, 2020

Before hospitalisation, she had frequent, close con­
tact with her husband on DOI 0–6 when she had an
active cough. Her husband had not travelled to Wuhan.
She and her husband live together, eat together, share
a bed, and have frequent face-to-face interactions.
Facemasks or other personal protective equipment
(PPE) were not used at the home. Her husband was
classified as having high-risk exposures and began
active symptom monitoring on DOI 7 with specimen
collection on DOI 11, before his report of any new
symptoms.
Patient 2 has chronic obstructive pulmonary disease,
with a chronic, productive cough and baseline dyspnoea;
therefore, the timing of symptom onset related to
COVID-19 was difficult to determine (figure). When first
interviewed as a contact on DOI 7, he reported no fever
or change in chronic respiratory symptoms. Later, he
reported increased dyspnoea and sputum production
starting on DOI 11, which was also the first day of
specimen collection as a contact in Patient 1’s investi­
gation. Upon further interview of Patient 2’s contacts, it
was suggested that some non-specific symptoms might
have started as early as DOI 3, with fatigue and worsening
cough. On DOI 14, he reported new haemoptysis and
worsening dyspnoea through active monitoring. He was
promptly admitted to the hospital and placed in an
airborne infection isolation room (AIIR). Nasopharyngeal
and oropharyngeal specimens from DOI 11 tested positive
for SARS-CoV-2 on DOI 15.
On hospital admission, vital signs, and physical
examination for Patient 1 were within normal limits. Her
chest radiograph demonstrated no abnormalities, but a
CT scan of her chest revealed bilateral multifocal
infiltrates and mediastinal and hilar lymphadenopathy.
On admission, Patient 2 had mild tachypnoea and coarse
breath sounds with mild wheezes bilaterally, although
whether these signs represented a change from his
baseline status is unclear. Patient 2’s chest radiograph
showed emphysematous changes and right lower lobe
infiltrates consistent with pneumonia. For both patients,
testing for other viral and bacterial respiratory infec­­
tions was negative. Both experienced mild leukopenia
(Patient 1 white blood count nadir 3·0 × 10³ cells per μL,
Patient 2 nadir 3·4 × 10³ cells per μL), lympho­ penia
(Patient 1 absolute lymphocyte count nadir 0·7 × 10³ cells
per μL, Patient 2 nadir 0·8 × 10³ cells per μL), and
mild elevations in aspartate aminotransferase and
alanine aminotransferase (Patient 1 peak 46 units per L
and 66 units per L, Patient 2 peak 47 units per L and
75 units per L). No other remarkable laboratory results
were noted.
Both patients recovered and were discharged to home
isolation on DOI 23. Hospital admission was extended
while arrangements were made for home isolation.
Home isolation for both patients was lifted on DOI 33,
following two sets of negative respiratory specimens
collected 24 h apart.
Patient 1 wore a facemask in the emergency department
waiting room and was placed on droplet precautions in
the emergency department and for the first 10 h after
admission. She was subsequently transferred to an AIIR,
where health-care personnel entering the patient’s
room were required to adhere to Standard, Contact, and
Airborne Precautions, including hand hygiene, gloves,
gown, respirator, and eye protection.16 Health-care per­
sonnel were enrolled in active monitoring, and potential

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breaches were recorded and investigated to determine
risk classification. Patient 2 was immediately evaluated
and admitted to an AIIR and placed on Transmission-
Based Precautions as described for Patient 1.
For Patient 1, initial nasopharyngeal, oropharyngeal, and
sputum specimens collected on DOI 7 were positive,
whereas serum and urine were negative. Her initial
sputum rtPCR cycle threshold values ranged between
24–25, indicating high viral burden before isolation.
Sputum specimens remained positive longer than all other
specimens for both cases (figure, appendix pp 3–4). Stool
specimens collected for Patient 1 also remained positive
longer than nasopharyngeal and oropharyngeal speci­
mens; however, Patient 2 had no positive stool specimens.
Neither Patient 1 or 2 had serum or urine specimens that
tested positive for SARS-CoV-2.
372 contacts of either Patient 1 or Patient 2 were
identified. Public health investigators were able to
assess exposure risk and actively monitor symptoms
for 347 (93%) of the 372 contacts, including 222 (94%) of
236 contacts with exposure on or after the date of first
positive specimen collection. There were 25 people that
had insufficient contact information to complete active
monitoring. None of these individuals were found to
have emergency department visits with fever, cough, or
shortness of breath using near real-time surveillance
data received from regional acute care hospitals for
14 days after their last exposure. Data presented are
for those actively monitored. Of these 347 contacts,
195 (56%) were health-care personnel and 152 (44%)
were community members. Although the majority of
monitored contacts (228 [66%] of 347) had low-risk
exposures, 119 (34%) had exposures of medium risk or
greater (table 2).
Although Patient 1 and 2 live together and were
hospitalised in the same facility, and therefore shared
several common contacts (65 shared community contacts
from emergency department or outpatient waiting rooms
and 28 health-care personnel who interacted with both
patients), they also had many unique contacts. Patient 1
had 92 unique health-care personnel contacts and
16 unique community contacts, including one household
contact (Patient 2). Patient 2 had 75 unique health-care
personnel contacts and 71 unique community contacts,
including 51 from outpatient waiting rooms.
The majority of contacts (303 [87%] of 347 total moni­
tored contacts and 195 [88%] of 222 monitored contacts
on or after the date of first positive specimen collection)
did not develop symptoms consistent with PUI criteria.
Additionally, surveillance data from Illinois acute care
hospitals indicated that no asymptomatic monitored
contacts or other contacts who could not be reached for
active symptom monitoring presented to an emergency
department with fever, cough, or shortness of breath
during DOI 6–30.
During active symptom monitoring, 44 (13%) of
347 total contacts became PUIs, including 27 (12%) of
1142
222 monitored contacts who had exposures on or after the
date of first positive specimen collection.
As a household contact, Patient 2 was the only commu­
nity member who had a high-risk exposure. He became
a PUI and subsequently the only other patient with
COVID-19 in this investigation. Of the remaining 43 PUIs,
all tested negative for SARS-CoV-2 while symptomatic;
32 of these PUIs were health-care personnel and 11 were
community contacts. Although 18 (41%) of 44 PUIs had
low-risk exposures, 26 (59%) had exposures of medium
risk or greater.
32 health-care personnel contacts who were not
PUIs had one-time nasopharyngeal and oropharyngeal
specimens collected 7–14 days after their highest-risk
exposure. All of these exposures occurred on or after the
date of first positive specimen collection of a patient with
COVID-19. 21 (66%) of these asymptomatic health-care
personnel had exposures of medium risk or greater. All
were negative for SARS-CoV-2 at the time of testing.
Discussion
This Article documents the first known person-to-person
transmission of SARS-CoV-2 in the USA. Transmission
occurred between close household contacts, from an index
travel-associated case who subsequently transmitted the
infection to her husband. Their prolonged, unprotected
close contact occurred across multiple days early in her
illness, before Patient 1 sought clinical care. No add­
itional cases of COVID-19 were identified through active
symptom monitoring of several hundred community and
health-care personnel contacts, testing of symptomatic
PUIs, or screening of a subset of asymptomatic health-
care personnel contacts. These data suggest that person-
to-person transmission of COVID-19 might be most likely
to occur through unprotected, prolonged exposure to a
patient with symptomatic COVID-19. Our experience of
limited transmission of SARS-CoV-2 differs from that
documented in Wuhan, where transmission has been
reported to occur across the wider community and in
health-care personnel,6 and from experiences of other
similar coronaviruses.17–19 The severity of illness, the extent
of viral shedding, and timing of exposures to a symp­
tomatic patient might all have contributed to the limited
transmission described here. Infection control measures
within the hospital setting and an aggressive public health
response might also have prevented further exposures.
Much like the first US case of COVID-19 in Washington,20
both Illinois patients had mild-to-moderate illnesses that
started with non-specific symptoms, making early iden­
tification difficult for patients, clinicians, and public
health investigators. Furthermore, Patient 2’s baseline
cough and dyspnoea made iden­ tifying new symptoms
challenging. These factors have implications for detection
of future cases. Clinicians and public health officials
should maintain a low threshold for testing in patients
with comorbidities that might obscure obvious signs and
symptoms of COVID-19.
www.thelancet.com Vol 395 April 4, 2020

The timing and duration of viral shedding after
SARS-CoV-2 infection is unknown. In the two Illinois
patients, sputum specimens remained rtPCR-positive
longer than other specimen types. Recognising that rtPCR
testing detects any SARS-CoV-2 RNA, not necessarily
infectious virus, further studies are needed to understand
how viral shedding and detection are associated with
transmission. Such studies have implications for public
health recommendations regarding the type and duration
of isolation required for patients with COVID-19 and will
allow for more focused and targeted contact tracing and
testing of appropriate specimens based on duration of
illness.
These data are preliminary and subject to several
limitations. First, this Article describes only one known
transmission event and the associated contact investi­
gation. Findings might not be generalisable or repre­
sentative of broader transmission patterns. Second, this
investigation might not have identified all individuals
with potential exposure to SARS-CoV-2, because epi­
demio­logical investigations are dependent on individuals’
recall of places visited, people seen, and symptom onset.
The date of symptom onset for Patient 2 was especially
difficult to ascertain. Given this uncertainty, we applied a
conservative approach for identifying contacts of Patient 2
by using the earliest reported date of possible symptom
onset, DOI 3. This could have artificially increased the
number of contacts and provided false reassurance of
infrequent transmission. Therefore, we also present data
separately for exposures that occurred on or after the first
known date of viral positivity.
Third, this investigation took place before published
CDC guidance for classifying exposure risk among
contacts of patients with COVID-19.10,12 The risk classi­
fication used here differed from the now published
guidance in some key areas. For example, we considered
nasopharyngeal and oropharyngeal specimen collection
aerosol-generating procedures, and therefore classified
health-care personnel performing these without all
recommended PPE as high risk, whereas they are
classified as medium risk according to the guidance.
Additionally, we included community members as
contacts if they entered the same indoor environment
(eg, hospital waiting room) within 2 h of a patient with
COVID-19, an approach based on other viruses with
airborne transmission patterns, such as measles. Current
interim guidance requires contacts to have been in the
room at the same time as a patient with COVID-19.
Therefore, the risk stratifications used here might not be
comparable to future investigations using this guidance.
Fourth, nasopharyngeal and oropharyngeal specimens
collected on both PUIs and asymptomatic health-care
personnel contacts were collected at a single timepoint;
a single negative SARS-CoV-2 rtPCR might not be
sufficient to definitively rule out infection over a 14-day
incubation period, and only a convenience sample of a
minority of health-care personnel contacts were tested in
www.thelancet.com Vol 395 April 4, 2020
Articles
this study, albeit weighted to capture those with higher-
risk exposures. Additionally, the active symptom moni­
toring employed here would not detect asymptomatic
transmission. Future serological studies of exposed
contacts will allow a better understanding of asymp­
tomatic infection rates. Furthermore, updated CDC
guidance recommends including sore throat as a
possible symptom of COVID-19 when evaluating health-
care personnel,10 whereas in this investigation, only
those with fever, cough, or shortness of breath were
tested for SARS-CoV-2.
Nevertheless, our ongoing investigation has only
detected transmission of SARS-CoV-2 in a single house­
hold contact with frequent, prolonged interactions with
the index patient. The absence of COVID-19 among health-
care personnel supports recommendations regarding
appropriate infection control. These findings also support
CDC’s assessment that, without using appropriate PPE,
people living in the same household as, or providing care
in a non-health-care setting for, a person with symptomatic
laboratory-confirmed COVID-19 have high-risk exposure.21
In these contexts, CDC’s recommendation for people with
high-risk exposures to remain quarantined with no public
activities might be effective in reducing onward person-to-
person transmission of SARS-CoV-2.11 Given the difficulty
in detecting new symptoms in patients with underlying
lung disease, CDC recommends that clinicians consi­
dering a diagnosis of COVID-19 should discuss testing
with public health departments on a case-by-case basis.22
Patients with potential exposure to SARS-CoV-2 with a
fever, cough, or shortness of breath should call their
health-care provider before seeking care so that appro­
priate preventive actions can be implemented.21 Health-
care facilities should rapidly triage and isolate suspected
PUIs and notify infection prevention services and local
health departments for support in testing, management,
and containment efforts.22
Contributors
IG, TDM, JCH, and HLK each led aspects of the contact investigation and
JRV and JEL provided overall leadership and guidance to the investigation.
IG, TDM, JCH, HLK, DC, KJ, RR, SM-E, SRB, MP, MJF, RKC, KAW,
DPB, HER, MW, CW, DM, JaK, SAN, IB, MWJ, VSD, MTP, JuK, EMC,
NOE, JRV, and JEL completed the investigation of cases and collected
epidemiological data. NSA, WCS, and NFH provided clinical care to the
patients and assisted with clinical descriptions. XL and SL described and
did laboratory specimen processes and testing for all patients. JCH, HLK,
SAN, IB, VC, CMM, MAR, SIG, and JRV provided technical assistance
and input in content areas, including infection control, epidemiological
methods, medical countermeasures, and subject matter expertise.
IG, TDM, and JEL drafted and revised this manuscript. All authors
reviewed, revised, and approved the final manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank the patients, staff at local and state health departments of
Illinois, staff at the US Centers for Disease Control and Prevention
(CDC) Division of Viral Disease Laboratory, CDC staff at the Emergency
Operations Center, and members of the COVID-19 response teams at
the local, state, and national levels for their input and collaboration on
this investigation. For their partnership and dedication, we thank the
1143
 Articles
clinical team and associates of AMITA Health St Alexius Medical
Center, including Charmaine Arosen, Roxann Barber, Candi Boros,
Jeffrey Butler, Joan Cappelletti, Carla Casia, James Collier,
Paula Crossen, Polly Davenport, Steven Dlugo Mindy Doumani,
Suzanne Dwyer, Allison Folkerts, Darlene Gallagher, Karen Gorman,
Melissa Granato, Michael Handler, Michelle Hereford, Lauren Johnson,
Michelle Johnston, Lynwood Jones, Mary Kerber, Kihe Kim, Craig Kuhl,
Monica Kziazcyk, Adam Leung, Cindie Lietzke, Ann Lucey,
Stuart Marcus, Tim Mathews, Rosemarie Mayer-Semar,
Connie Noltemeyer, Shawn O’Connor, Mary Ann Palermo, Ana Payne,
Carol Pfeifer, Chris Quinlan, Monica Rodriguez-Simzky, Deborah Rudd,
Johanna Senyk, Vrusha Shastri, Natalie Sowizral, Lisa Sturm,
Jeremy Swaw, Thor Thordarson, Jennylee Vazquez, Kim Vogt,
Jaime Zalewski, and Eric Zemaitaitis.
The opinions expressed by authors contributing to this Article do not
necessarily reflect the opinions of the CDC or the institutions with
which the authors are affiliated.
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Feb 19, 2020).
www.thelancet.com Vol 395 April 4, 2020
Another random document with
no related content on Scribd:
 [“God’s blessing on his heart that made this:” sayd one, “specially
for reuiuing our auncient liberties. And I pray God it may take such
place with the magistrates, that they may ratifie our olde freedome.”
“Amen,” sayd another: “for that shall bee a meane both to stay and
vpholde themselues from falling, and also to preserue many kinde,
true, zealous, and well meaning mindes from slaughter and infamy. If
king Richarde and his counsailours had allowed, or at the least but
winked at some such wits, what great commodities might they haue
taken thereby? First, they should haue knowen what the people
misliked and grudged at, (which no one of their flatterers either
woulde or durst haue tolde them) and so mought haue found meane,
eyther by amendment (which is best) or by some other pollicy to
haue stayed the people’s grudge: the forerunner commonly of ruler’s
destruction.[1750] Vox populi, vox Dei, in this case is not so famous a
prouerbe, as true: the experience of all times doe[1751] approue it.
They should also haue bene warned of their owne sinnes, which call
continually for God’s vengeaunce, which neuer faileth to fall on their
neckes sodainly and horribly, vnles it bee stayed with hearty
repentaunce. These weighty commodities mought they haue taken
by Collingbourn’s vaine rime. But, as all thinges worke to the best in
them that bee good, so best thinges heape vp mischiefe in the
wicked, and all to hasten their vtter destruction. For after this poore
wretche’s lamentable persecution (the common rewarde of best
endeuours) strait followed the fatall[1752] destruction both of this
tyrant, and of his tormentours. Which I wishe might bee so set forth,
that they might bee a warning for euer, to all in authority, to beware
howe they vsurpe or abuse theyr offices.” “I haue here,” quoth[1753] I,
“king Richard’s tragedy.” “Reade it, wee pray you:” quoth[1754] they.
“With a good will,” quoth[1755] I. “For the better vnderstanding
whereof, imagine that you see him tormented with Diues in the
deepe pit of hell, and thence howling this which followeth.”]
 [How Richarde Plantagenet Duke of
Glocester murdered his brother’s
children, vsurping the crowne, and in
the third yeare of his raigne was most
worthely depriued of life and
kingdome, in Bosworth plaine, by
Henry Earle of Richmond after called
King Henry the vij. the 22 of August
1485.[1756]
1.

What heart so hard, but doth abhorre to heare

The rufull raigne of me the third Richard?
King vnkindly calde, though I the crown did weare,
Who entred by rigour, but right did not regard,
By tyranny proceding in killing king Edward,
Fift of that name, right heyr vnto the crowne,
With Richard his brother, princes of renowne.

2.

Of trust they were committed vnto my gouernaunce,

But trust turned to treason, too truly it was tryed,
Both agaynst nature, duty, and alleigaunce,
For through my procurement most shamefully they dyed:
Desire of a kingdom forgetteth all kinred,
 As after by discourse it shalbe shewed here,
How cruely these innocents in prison murdered[1757]
were.

3.

The lords and commons all with one assent,

Protectour made me both of land and king,
But I therewith, alas, was not content:
For minding mischife I ment another thing,
Which to confusion in short time did mee bring:
For I, desirous to rule and raigne alone,
Sought crowne and kingdom, yet title had I none.

4.

To all peeres and princes a president I may bee,

The like to beware how they do enterprise,
And learne theyr wretched falles by my fact to foresee,
Which rufull stand bewayling my chaunce before theyr
eyes,
As one cleane bereft of all felicityes:
For right through might I cruelly defaced,
But might helped right and mee agayne displaced.

5.

Alas, that euer prince should thus his honour stayne

With the bloud of innocents, most shamefull to be tolde:
For these two noble impes I caused to be slaine,
Of yeares not full ripe as yet to rule and raigne:
For which I was abhorred both of yong and olde,
But as the deede was odious in sight of God and man,
So shame and destruction in the end I wan.

6.

Both God, nature, duty, alleigaunce all forgot,

This vile and haynous act vnnaturally conspyred:[1758]
Which horrible deede done, alas, alas, God wot,
Such terrours mee tormented, and my sprites[1759] fired
As vnto such a murder and shamefull deede required,
Such broyle dayly felt I breeding in my brest,
Whereby, more and more, increased mine vnrest.

7.

My brother’s children were right heyres vnto the crowne,

Whom nature rather bound to defend then destroy,
But I not regarding theyr right nor my renowne,
My whole care and study to this end did employe,
The crowne to obtayne, and them both to put downe:
Wherein I God offended, prouoking iust his ire,
For this my attempt and most wicked desire.

8.

To cursed[1760] Cayn compare my carefull case,

Which did vniustly slay his brother iust Abel:
And did not I in rage make run that rufull race
My brother duke of Clarence? whose deth I shame to tel,
For that it was so straunge as it was horrible:
For sure he drenched was, and yet no water neare,
Which straunge is to bee tolde, to all that shall it heare.

9.

The but hee was not whereat I did shoote,

But yet he stoode betweene the marke and mee,
For had he liu’d,[1761] for mee it was no boote
To tempt[1762] the thing that by no meanes could bee,
For I third was then of my brethren three:
But yet I thought the elder being gone,
Then needes must I beare the stroke alone.
 10.

Desire of rule made mee, alas, to rewe,

My fatall fall I could it not foresee,
Puft vp in pride, so hawty then I grewe,
That none my peere I thought now could bee,
Disdayning such as were of high degree:
Thus dayly rising, and pulling other downe,
At last I shot how to win the crowne.

11.

And dayly deuising which was the best way

And meane, how I might my nephues both deuour:
I secretly then sent, without furder delay,
To Brackinbury, then lieutenaunt of the tower,
Requesting him by letters to helpe vnto his power,
For to accomplish this my desire and will,
And that hee would secretly my brother’s children kill.

12.

He aunswered playnly with a flat nay,

Saying that to dye hee would not doe that deede:
But finding then a profer to my[1763] pray,
“Well worth a friend (quoth[1764] I) yet in time of neede:”
Iames Tyrrill hight his name, whom with all speede,
I sent agayne to Brackinbury, as you heard before,
Commaunding him deliuer the keyes of euery dore.

13.

The keyes hee rendred,[1765] but partaker would not be

Of that flagitious fact. O, happy man, I say:
As you haue heard before, he rather chose to dye,
Then on those sely lambes his violent hands to lay:
His conscience him pricked his prince to betraye,
 O constant minde, that wouldst not condiscend,
Thee may I prayse, and my selfe discommend.

14.

What though hee refused, yet bee sure you may,

That other were as ready to take in hand that[1766] thing,
Which watched and wayted as duely for their pray,
As euer did the cat for the mouse taking,
And how they might their purpose best to passe bring:
Where Tyrrill hee thought good to haue no bloud shed,
Becast them to kill by smothering in their bed.

15.

The wolues at hand were redy to deuoure

The seely lambes in bed, wheras they laye,
Abiding death, and looking for the howre,
For well they wist, they could not scape away:
Ah, woe is mee, that did them thus betray,
In assigning this vile deede to bee done,
By Miles Forrest and wicked Ihon Dighton.

16.

Who priuely into their chamber stale,

In secret wise somwhat before midnight,
And gan the bed together tug and hale,
Bewrapping them, alas, in wofull[1767] plight,
Keping them downe, by force, by power, and might,
With haling, tugging, turmoyling, turnde[1768] and tost,
Tyll they of force were forced yeeld the ghost.

17.

Which when I heard, my hart I felt was eased

Of grudge, of griefe, and inward deadly payne,
But with this deede the nobles were displeased,
And sayde: “O God, shall such a tyrant raygne,
That hath so cruelly his brother’s children slayne?”
Which bruit once blowen in the people’s ears,
Their doloure was such, that they brast out in tears.

18.

But what thing may suffise vnto the gredy[1769] man,

The more hee baths in bloud, the bloudier hee is alway:
By proofe I do this speake, which best declare it can,
Which onely was the cause of this prince’s decay:
The wolfe was neuer gredier then I was of my pray:
But who so vseth murder, full well affirme I dare,
With murder shall bee quit, ere hee thereof beware.

19.

And marke the sequel of this begone mischiefe:

Which shortly after was cause of my decay,
For high and low conceiued such a griefe
And hate agaynst mee, which sought, day by day,
All wayes and meanes that possible they may,
On mee to bee reuenged for this sinne,
For cruelly murdering vnnaturally my kyn.

20.

Not only kyn, but king, the truth to say,

Whom vnkindely of kingdome I bereft,
His lyfe from him, I also raught[1770] away,
With his brother’s, which to my charge was[1771] left:
Of ambition beholde the worke and weft,
Prouoking mee to do this haynous treason,
And murder them, agaynst all right and reason.

21.

After whose death thus wrought by violence,

The lords not lyking this vnnaturall deede,
Began on mee to haue greate diffidence,
Such brinning hate gan in their harts to breede,
Which made mee doubt, and sore my daunger dreede:
Which doubt and dreede proued not in vayne,
By that ensude, alas, vnto my payne.

22.

For I supposing all things were as I wished,

When I had brought these sely[1772] babes to bane,
But yet in that my purpose far I missed:
For as the moone doth chaunge after the wane,
So chaunged the hearts of such as I had tane
To bee most true, to troubles did mee tourne:
Such rage and rancoure in boyling brests doth[1773]
burne.

23.

And sodainly a bruit abroade was blowne,

That Buckingham the duke, both sterne and stout,
In field was ready, with diuers to mee knowne,
To giue mee battayle if I durst come out:
Which daunted mee and put mee in greate doubt,
For that I had no army then prepared:
But after that, I litle for it cared.

24.

But yet remembring, that oft a litle sparke

Suffred doth growe vnto a greate flame,
I thought it wisdome wisly for to warke,
Mustred then men in euery place I came:
And marched forward dayly with the same,
Directly towards the towne of Salisbury,
Where I gat knowledge of the duke’s army.
 25.

And as I passed ouer Salisburie downe,

The rumour ran the duke was fled and gone,
His hoast dispersed besides Shrewesbury towne,
And hee dismaied was left there post alone,
Bewailing his chaunce and making great mone:
Towards whome I hasted with all expedition,
Making due search and diligent inquisition.

26.

But at the fyrst I could not of him heare,

For hee was scaped by secrete bywayes,
Unto the house of Humfrey Banastaire,
Whome hee had much preferred in his dayes,
And was good lorde to him, in all assaies:
Which hee full ill[1774] requited in the end,
When hee was driuen to seeke a trusty frend.

27.

For so it happened to his mishap, alas,

When I no knowledge of the duke could heare:
A proclamation, by my commaundement, was
Published and cryed throughout euery shyre,
That whoso could tell where the duke were,
A thousand marke shoulde haue for his payne:
What thing so hard but mony can obtayne?

28.

But were it for mony, meede, or dreede,

That Banastaire thus betrayed his ghest,
Diuers haue diuersly deuined of this deede,
Some deeme the worst, and some iudge the best,
The doubt not dissolued, nor playnly exprest:
But of the duke’s death hee doubtless was cause,
 Which dyed without iudgement, or order of lawes.

29.

Loe, this noble duke I brought thus vnto bane,

Whose doings I doubted and had in greate dread,
At Banastaire’s house I made him to bee tane,
And without iudgement be shortned by the head,
By the shriue of Shropshyre to Salisburie led,
In the market place vpon the scaffolde newe,
Where all the beholders did much his death rewe.

30.

And after this done I brake vp my hoaste,

Greatly applauded with this heauy hap,[1775]
And forthwith I sent to euery sea cost,
To foresee all mischieues and stop euery gap,
Before they shoud chaunce or[1776] light in my lap,
Geuing them in charge to haue good regarde
The sea cost to keepe, with good watch and warde.

31.

Dyrecting my letters vnto euery shriue,

With strait commaundement vnder our name,
To suffer no man in their partes to aryue,
Nor to passe forth out of the same,
As they tendred our fauour, and voyde would our blame,
Doing therein theyr payne and industry,
With diligent care and vigilant eye.

32.

And thus setting things in order as you heare,

To preuent mischieues that might then betyde,
I thought my selfe sure, and out of all feare,
And for other things began to prouide:
To Nottingham castle straight did I ryde,
Where I was not very long space,
Straunge tydings came, which did mee sore amaze.

33.

Reported it was, and that for certainty,

The earle[1777] of Richmond landed was in Wales
At Milford hauen, with an huge army,
Dismissing his nauy which were many sayles:
Which, at the fyrst, I thought flying tales,
But in the end did otherwise proue,
Which not a little did mee vexe and moue.

34.

Thus fauning fortune gan on mee to frowne,

And cast on mee her scornfull lowring looke:
Then gan I feare the fall of my renowne,
My heart it faynted, my sinowes sore they shooke,
This heauy hap a scourge for sinne I tooke:
Yet did I not then vtterly dispayre,
Hoping storms past the weather shoulde bee fayre.

35.

And then with all speede possible I might,

I caused them muster throughout euery shyre,
Determining with the earle spedely to fyght,
Before that his power much encreased were,
By such as to him great fauour did beare:
Which were no small number, by true report made,
Dayly repayring him for to ayde.

36.

Dyrecting my letters to diuers noble men,

With earnest request their power to prepare
To Notingham castle, where, as I lay then,
To ayde and assist mee in this waighty affayre:
Where straite to my presence did then repayre,
Ihon duke of Northfolke, his eldest sonne also,
With th’earle of Northumberland and many other mo.

37.

And thus being furnisht with men and munition,

Forwarde wee marched in order of battayle ray,
Making by scouts euery way inquisition,
In what place the earle with his campe lay:
Towards whom dyrectly wee tooke then our way,
Euermore mynding to seeke our most auayle,
In place conuenient to gieue to him battayle.

38.

So long wee laboured, at last our armies met

On Bosworth playne, besides Lecester towne,
Where sure I thought the garland for to get,
And purchase peace, or els to lose my crowne:
But fickle fortune, alas, on mee did frowne,
For when I was enchamped in the fielde,
Where most I trusted I soonest was begylde.

39.

The brand of malice thus kindling in my brest

Of deadly hate which I to him did beare,
Pricked mee forward, and bad mee not desist,
But boldly fight, and take at all no feare,
To wyn the field, and the earle to conquere:
Thus hoping glory greate to gayne and get,
Myne army then in order did I set.

40.
Betyde mee lyfe or death I desperatly ran,
And ioyned mee in battayle with this earle so stoute,
But fortune so him fauoured that hee the battayle wan,
With force and great power I was beset about:
Which when I did beholde, in midst of the whole route,
With dint of sword I cast mee on him to be reuenged,
Where in the midst of them my wretched life I ended.

41.

My body was hurried and tugged like a dog,

On horsebacke all naked and bare as I was borne:
My heade, hands, and feete, downe hanging lyke a hog,
With dirte and bloud besprent, my corpes all to torne,
Cursing the day that euer I was borne:
With greuous woundes bemangled, moste horrible to
see,
So sore they did abhorre this my vile cruelty.

42.

Loe, heare you may behold the due and iust rewarde
Of tyranny and treason, which God doth most detest:
For if vnto my duety I had taken regarde,
I might haue liued still in honour with the best,
And had I not attempt the thing that I ought leste:
But desyre to rule, alas, did mee so blinde,
Which caused mee to doe agaynst nature and kynde.

43.

Ah, cursed caytife, why did I climbe so hye,

Which was the cause of this my balefull thrall:
For still I thirsted for the regall dignitye,
But hasty rising threatneth sodayne fall:
Content your selues with your estates all,
And seeke not right by wrong to suppresse,
For God hath promist ech wrong to redresse.
 44.

See here the fine and fatall fall of mee,

And guerdon due for this my wretched deede,
Which to all princes a miroir now may bee,
That shall this tragicall story after reede,
Wishing them all by mee to take heede,
And suffer right to rule as it is reason:
For tyme tryeth out both truth and also treason.

F. Seg.[1778]]
 [When I had read this, we had much talke about it. For it was
thought not vehement enough for so violent a man as king Richard
had bene. The matter was well enough liked of some, but the meetre
was misliked almost of all. And when diuers therefore would not
allowe it, “What,” quoth[1779] one, “you know not wherevpon you
sticke: els you would not so much mislike this because of the
vncertaine meeter. The cumlines called by the rhetoricians decorum,
is specially to bee obserued in all thinges. Seing than that king
Richard neuer kept measure in any of his doings, seeing also hee
speaketh in hell, whereas is no order: it were against that[1780]
decorum of his personage, to vse either good meetre or order. And
therefore if his oration were farre worse, in my opinion it were more
fit for him. Mars and the muses did neuer agree. Neither is to be
suffered, that their milde sacred arte should seeme to proceede from
so cruell and prophane a mouth as his: seeing they themselues doe
vtterly abhorre it. And although wee read of Nero, that hee was
excellent both in musicke and in versifying, yet doe not I remember
that euer I sawe any song or verse of his making: Minerua iustly
prouiding, that no monument should remayne of any such vniust
vsurpation. And therefore let this passe euen as it is, which the writer
I know both could and would amend in many places, saue for
keeping the decorum, which he purposely hath obserued herein.” “In
deede,” quoth[1781] I, “as you say: it is not meete that so disorderly
and vnnaturall a man as king Richard was, should obserue any
metricall order in his talke: which notwithstanding in many places of
his oration is very well kepte: it shall passe therefore euen as it is,
though too good for so euill[1782] a person.”[1783] Then they willed
mee to reade the blacke Smith. “With a good will,” quoth I: “but first
you must imagin that you see him standing on a ladder ouer shrined
with the Tyburne, a meete stage for all such rebelles and traytours:
and there stoutly saying as followeth.”]
The wilfvll fall of the blacke Smith,
and the foolishe ende of the Lorde
Awdeley, in Iune, Anno 1496.[1784]
1.

Who is more bolde then is the blinde beard?[1785]

Where is more craft than in the clouted shone?
Who catch more harme than such as nothing feard?[1786]
Where is more guile then where mistrust in[1787] none?
No plaisters helpe before the griefe be knowen,
So seemes by mee who could no wisdome lere,
Untill such time I bought my wit too deare.

2.

Who, being boystrous, stout, and braynlesse bolde,

Puft vp with pride, with fire and furyes fret,
Incenst with tales so rude and playnly tolde,
Wherein deceit with double knot was knit,
I trapped was as seely fishe in net,
Who swift in swimming, not doubtfull of[1788] deceit,
Is caught in gin wherein is layde no bayt.

3.

Such force and vertue hath this dolefull playnt,

Set forth with sighes and teares of crocodile,
Who seemes in sight as simple as a saynt,
Hath layde a bayte the wareles to begyle,
And as they wepe they worke deceit the while,
 Whose rufull cheare the rulers so relent,
To worke in haste that they at last repent.

4.

Take heede therefore ye rulers of the land,

Be blinde in sight, and stop your other eare:
In sentence slow, till skill the truth hath scand,
In all your doomes both loue and hate forbeare,
So shall your iudgement iust and right appeare:
It was a southfast sentence long agoe,
That hasty men shall neuer lacke much woe.

5.

Is it not truth? Baldwine, what sayest thou?

Say on thy minde: I pray thee muse no more:
Me thinke thou star’st and look’st[1789] I wot not howe,
As though thou neuer saw’st[1790] a man before:
Belike thou musest why I teach this lore,
Els what I am, that here so bouldly[1791] dare,
Among the prease of princes to compare.

6.

Though I bee bolde I pray the blame not mee,

Like as men sowe, such corne nedes must they reape,
And nature hath so planted in[1792] eche degree,
That crabs like crabs will kindly crall and crepe:
The suttle foxe vnlike the sely shepe:
It is according to my education,
Forward to prease in rout and congregation.

7.

Behold my coate burnt with the sparkes of fire,

My lether apron fylde with the[1793] horse shoe nayles,
Beholde my hammer and my pinsers here,
Beholde my lookes, a marke that seldom fayles,
My cheekes declare I was not fed with quayles,
My face, my cloathes, my tooles, with all my fashion,
Declare full well a prince of rude creation.

8.

A prince I sayde, a prince, I say agayne,

Though not by byrth, by crafty vsurpation:
Who doubts but some men princehood do obtayne,
By open force, and wrongfull domination?
Yet while they rule are had in reputation:
Euen so by mee, the while I wrought my feate
I was a prince, at least in my conceyte.

9.

I dare the bolder take on mee the name,

Because of him whom here I leade in hand,
Tychet lord Awdley, a lorde of byrth[1794] and fame,
Which with his strength and powre serude in my band,
I was a prince while that I was so mande:
His butterfly still vnderneath my shielde
Displayed was, from Welles to Blackeheath fielde.

10.

But now beholde hee doth bewayle the same:

Thus after wits theyr rashnes do depraue:
Beholde dismayde hee dare not speake for shame,
He lookes like one that late came from the graue,
Or one that came forth of Trophonius caue,
For that in wit hee had so litle pith,
As he a lord to serue a traytour smith.

11.
Such is the courage of the noble hart,
Which doth despise the vile and baser sort,
Hee may not touch that sauers of the cart,
Him listeth not with ech jacke lout to sport,
Hee lets him passe for payring of his porte:
The iolly egles catch not litle flees,
The courtly silkes match seelde with homely frees.

12.

But surely, Baldwine, if I were allowde

To say the troth, I could somewhat declare:
But clarkes will say: “This smith doth waxe to prowde,
Thus in precepts of wisedome to compare:”
But smiths must speake that clarkes for feare ne dare:
It is a thing that all men may lament,
When clarkes keepe close the truth lest they be shent.

13.

The hostler, barber, miller, and the smith,

Heare of the sawes of such as wisdom ken,
And learne some wit, although they want the pith
That clarkes pretend: and yet, both now and then,
The greatest clarkes proue not the wisest men:
It is not right that men forbid should bee
To speake the truth, all were hee bond or free.

14.

And for because I [haue] vsed to fret and fome,

Not passing greatly whom I should displease,
I dare be bolde a while to play the mome,
Out of my sacke some other’s faults to lease,
And let mine[1795] owne behinde my backe to peyse:
For hee that hath his owne before his eye,
Shall not so quicke another’s fault espye.
 15.

I say was neuer no such wofull case,

As is when honour doth it selfe abuse:
The noble man that vertue doth embrace,
Represseth pride, and humblenes doth vse,
By wisdome workes, and rashnes doth refuse:
His wanton will and lust that bridle can
In deede, is gentill, both to God and man.

16.

But where the nobles want both wit and grace,

Regarde no rede, care not but for theyr lust,
Oppresse the poore, set will in reason’s place,
And in theyr wordes and doomes bee found vniust,
Wealth goeth to wracke till all lye in the dust:
There fortune frownes, and spite begins[1796] to growe,
Till high, and lowe, and all be ouerthrowe.

17.

Then sith that vertue hath so good rewarde,

And after vice so duly wayteth shame,
How hapth that princes haue no more regarde,
Theyr tender youth with vertue to enflame?
For lacke whereof theyr wit and will is lame,
Infect with folly, prone to lust and pryde,
Not knowing how themselues or theyrs to guyde.

18.

Whereby it hapneth to the wanton wight,

As to a ship vpon the stormy seas,
Which lacking sterne to guide it selfe aright,
From shore to shore the winde and tyde to[1797] teese,
Fynding no place to rest or take his ease,
Till at the last it sinke vpon the sande: