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

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

www.thelancet.com Vol 395 April 4, 2020 1139

 Articles

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).

1140 www.thelancet.com Vol 395 April 4, 2020

 Articles

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

www.thelancet.com Vol 395 April 4, 2020 1141

 Articles
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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www.thelancet.com Vol 395 April 4, 2020
Another random document with
no related content on Scribd:
women clerks. In England women clerks number over 100,000. And
the British Government is steadily advertising: Wanted, 30,000
women a week to replace men for the armies.
“Who works, fights,” Lloyd George has said, in the English
Parliament. English women enlisting for agriculture have been given
a government certificate attesting: “Every woman who helps in
agriculture during the war is as truly serving her country as is the
man who is fighting in trenches or on the sea.”
“But,” protests the bewildered woman from only the other day,
“they told us that women didn’t know enough to do man’s work, that
she wasn’t strong enough for much of anything beyond light
domestic duty like washing and scrubbing and cooking and raising a
family of six or eight or ten children.”
“Nothing that anybody ever said about women before August,
1914,” I answer, “goes to-day. All the discoveries the scientists
thought they had made about her, all the reports the sociologists
solemnly filed over her, all the limitations the educators laid on her
and all the jokes the punsters wrote about her—everything has gone
to the scrap-heap as repudiated as the one-time theory that the earth
was square instead of round. Everything they said she wasn’t and
she couldn’t and she didn’t, she now is and she can and she does.”

IT IS UNIVERSAL SERVICE
Even women who do not need to work for pay are working without
it and adding to the demonstration of what women can do. See the
colonel’s lady taking the place of Julie O’Grady at the lathe for week-
end work in the munition factories to release the regular worker for
one day’s rest in seven. Lady Lawrence in a white tunic and wearing
a diamond wrist watch is in charge of the canteen at the Woolwich
Arsenal, supervising the serving of kippers and toast at the tea hour
for the 2,000 women employés. Lady Sybil Grant, Lord Rosebery’s
daughter, is the official photographer to the Royal Naval Air Service
at Roehampton. The Countess of Limerick, assisted by fifty women
of title, among them Lady Randolph Churchill, is running the
Soldiers’ Free Refreshment Buffet at the London Bridge Station. The
Marchioness of Londonderry, directing the Military Cookery Section
of the Women’s Legion, has given to her nation the woman army
cook who has recently replaced 5,000 men. Women of world-wide
fame have cheerfully turned to the task that called. Beatrice
Harraden, celebrated author of “Ships That Pass in the Night,” is in
the uniform of an orderly at the Endell Street War Hospital, where
she has done a unique service in organising the first hospital library
for the patients. May Sinclair, whose recent book, “The Three
Sisters,” is one of the great contributions to feminist literature, is
enrolled as a worker at the Kensington War Hospital Supply
Department. She has invented the machine used there to turn out
“swabs” seven times faster than formerly they were made by hand.
There is the greatest diversity in war service. One of the first calls
answered by the suffragists was for an emergency gang of 300
women from the metropolis to supervise the baling of hay for the
army. Lloyd George has been supplied with a woman secretary and
a woman chauffeur, the latter a girl who was a celebrated hunger
striker before the war. In the royal dockyards and naval
establishments there are 7,000 women employed. Through the
Woman’s National Land Service Corps 5,000 university and other
women of education have been recruited to serve as forewomen of
detachments of women farm labourers. The army last spring was
asking for 6,000 women at the War Office to assist in connection with
the work of the Royal Flying Corps. Oh, the list of what women are
doing to-day is as indefinitely long as everything that there is to be
done.
And the woman movement sweeps on directly toward the gates of
government. See the woman war councillor who recently arrived in
1916. She came into view first in Germany, where Frau
Kommerzienrat Hedwig Heyl of Berlin is a figure almost as important
as is the Imperial Chancellor. The daughter of the founder of the
North German Lloyd Line, herself the president of the Berlin Lyceum
Club and the manager of the Heyl Chemical Works, in which she
succeeded her late husband as president, Frau Heyl knows
something of organisation. And she it is who has been responsible
more than any other of the Kaiser’s advisers for the conservation of
the food supply which keeps the German armies strong against a
world of its opponents. The second day after war was declared, in
conference with the Minister of the Interior, she had formulated the
plan that by night the Government had telegraphed to every part of
Germany: there was formed the Nationaler Frauendien to control all
of the activities of women during the war. She was placed at the
head of the Central Commission. It was the Nationaler Frauendien
that made the suggestions which the Government adopted for the
conservation of the food supply. And it was they who were entrusted
with organising the food supplies of the nation and educating the
women in their use to the point of highest efficiency. As a personal
contribution to this end, Frau Heyl has published a War Cook Book,
arranged an exhibit of substitute foods for war use, and has turned
one section of her chemical works into a food factory from which she
supplies the government with 6,000 pounds of tinned meat a day for
the army.
After all, who are the real food controllers of a nation? Could a
minister of finance, for instance, bring up a family on, say, 20
shillings a week? Yet there were women in every nation doing that
before they achieved fame on the firing line and in the making of
munitions. Last spring, as the food question became a gravely
determining factor in the war, it began to be more and more apparent
that the feminine mind trained to think in terms of domestic economy,
might have something of value to contribute to questions of state.
Why let Germany monopolise this particular form of efficiency? And
England in 1917 called to its Ministry of Food two women, Mrs.
Pember Reeves, one of its radical suffragists, and Mrs. C. S. Peel,
the editor of a woman’s magazine and a cook book.
About the same time each of the warring nations decided that the
mobilised women forces everywhere could be most efficiently
directed by women. Germany appointed as an attaché for each of
the six army commands throughout the empire a woman who is to
serve as “Directress of the Division for Women’s Service.” From Dr.
Alice Salomon in the Berlin-Potsdam district to Fraulein Dr. Gertrude
Wolf in the Bavarian War Bureau, each of these new appointees is a
feminist leader from that woman movement of yesterday. In France
the enrolment of French women is under the direction of Mme. Emile
Boutroux and Mme. Emile Borel. In England the highest appointment
for a woman since the war is the calling of Mrs. H. J. Tennant, the
prominent suffragist, to be Director of the Woman’s Department of
National Service. America, preparing to enter the great conflict in the
spring of 1917, at the very outset organised a Woman’s Division of
the National Defence Council and called to its command Dr. Anna
Howard Shaw, the great suffrage leader.
It’s a long way back to the Doll’s House, isn’t it, with woman’s
place to-day in the workshop and the factory, the war hospital, the
war zone and the war office? And now they are calling women to the
electorate. Russia has spoken, England has spoken. America is
making ready. Doesn’t Mr. Kipling want to revise his verses: “When
man gathers with his fellow braves for council, he does not have a
place for her”?
It really has ceased to be necessary for woman any longer to
plead her cause. Every government’s doing it for her. The woman
movement now is both called and chosen. And the British
Government is the most active feminist advocate of all. The greatest
brief for the woman’s cause that ever was arranged is a handsome
volume on “Women’s War Work,” issued by the British War Office, as
a guide to employers of labour throughout the United Kingdom. This
famous publication lists exactly ninety-six trades and 1,701 jobs
which the Government says women can do just as well as men,
some of them even better. A second publication issued in London
with the approval of the War Office, sets forth in more literary form
“Women’s Work in Wartime,” and is dedicated to “The Women of the
Empire, God save them every one.”
It was in 1916 that I talked with a German gentleman who is near
enough to the Kaiser to voice the point of view from that part of the
world. “Women from now on are going to have a more important
place in civilisation than they ever have held before,” affirmed Count
von Bernstorff as we sat in his official suite at the Ritz Hotel in New
York. “In the ultimate analysis,” he spoke slowly and impressively, “in
the ultimate analysis,” he repeated, “it is the nation with the best
women that’s going to win this war.”
 “Do you know what I think?” says the Soul of a Suffragette as we
stand before the Great Push. “I think that whoever else wins this war,
woman wins.”
Her country’s call? Listen: there is a higher overtone—her man’s
call. Is it not the woman behind the man behind the gun who has
achieved her apotheosis?
 CHAPTER IV
Women Who Wear War Jewelry
There is a new kind of jewelry that will be coming out soon. We
shall see it probably this season or at least within the next few
months. It will take precedence of all college fraternity pins and
suffrage buttons and society insignia and even of the costliest
jewels. For it will be unique. Since no American woman has ever
before worn it.
As a Mayflower descendant or a Colonial Dame or a Daughter of
the Revolution, you may have proudly pinned on the front of your
dress the badge that establishes your title perhaps to heroic
ancestry. In the gilt cabinet in the front parlour you may even cherish
among curios of the wide, wide world a medal of honour as your
choicest family heirloom. Who was it who won it, grandfather or
great-grandfather or great-great-grandfather? Anyway, it was that
soldier lad of brave uniformed figure whose photograph you will find
in the old album that disappeared from the centre-table something
like a generation ago. We are getting them out from the attics now,
the dusty, musty albums, and turning their pages reverently to look
into the pictured eyes of the long ago. Some one who still recalls it
must tell us again this soldier-boy’s story. Somewhere he did a deed
of daring. Somehow he risked his life for his country. And a grateful
government gave him this, his badge of courage. It’s fine to have in
the family, there in the parlour cabinet. You are proud, are you not, to
be of a brave man’s race? But blood, they say, will always tell.
Heroism and daring may be pulsing in your veins to-day as once in
his.
Have you ever thought how it might be to have your own badge of
courage? Ah, yes, even though you are a woman. No, it is true, there
are no such decorations that have been handed down from
grandmother or great-grandmother or great-great-grandmother. It is
not that they did not deserve them. But their deeds were done too far
behind the front for that recognition. To-day, as it happens, the new
woman movement has advanced right up to the firing line, and it’s
different. Every nation fighting over in Europe is bestowing honours
of war on women. There is no reason to doubt that special acts of
gallantry and service on the part of American women now in action
with the hospitals and relief agencies that have accompanied our
troops abroad, shall be similarly recognised by the War Department.
To earn a decoration, you see—not merely to inherit one—that can
be done to-day.
She was the first war heroine I had ever seen, Eleanor Warrender.
Over in London I gazed at her with bated breath—and to my surprise
and astonishment found her just like other women.
Among those called to the colours in England in 1914, she is one
of the specially distinguished who have followed the battle flags to
within sight of the trenches, within sound of the guns. And,
somehow, one will inadvertently think of these as some sort of super-
woman. Before this there have been those who did what they could
for their men under arms. There was one woman who risked her life
heroically for British soldiers. And Florence Nightingale’s statue has
been set along with those of great men in a London public square. In
this war many women are risking their lives. They are receiving all
the crosses of iron and silver and gold. And to the lady of the
decoration who wears this war jewelry, it is a souvenir of sights such
as women’s eyes have seldom or never looked on before since the
world began.
I have said that Eleanor Warrender seemed to me just like other
women. And she is at first; other war heroines are. Until you catch
the expression in their eyes, which affords you suddenly, swiftly, the
fleeting glimpse of the soul of a woman who knows. There is that
about all real experience that does not fail to leave its mark. You may
get it in the quality of the voice, in a chance gesture that is merely
the sweep of the hand, or in the subtle emanation of the personality
that we call atmosphere. But wherever else it may register, there are
unveiled moments when you may read it in the eyes of these women
who know—that they have seen such agony and suffering and horror
as have only been approximated before in imaginative writing. The
ancient pagans mentioned in their books that have come down to us,
a place they called Hades, where everything conceivable that was
frightful and awful should happen. The Christians called it Hell.
But nobody had been there. And there were those in very modern
days who said in their superior wisdom that it could not be, that it did
not exist. Now how are we all confounded! For it is here and now.
The Lady with the Decoration has seen it. Look, I say, in her eyes.
For that is where you will find out. She does not talk of what she
has been through.
“My friend Eleanor Warrender,” Lady Randolph Churchill told me,
“has been under shell-fire for three years, nursing at hospitals all
along the front from Furnes to the Vosges Mountains. Sometimes
she has spent days with her wounded in dark cellars where they had
to take refuge from the bombs that came like hail—and the cellars
were infested with rats.”
Eleanor Warrender, when I saw her, came into the Ladies’ Empire
Club at 67 Grosvenor Street, London.
High-bred, tall, and slender, she wore the severe tailor-made suit
in which you expect an Englishwoman to be attired. In the buttonhole
of her left coat lapel there was a dark silk ribbon striped in a
contrasting colour from which hung a small bronze Maltese cross. It
is the Croix de Guerre bestowed on her by the French Government
for “conspicuous bravery and gallant service at the front.” She
dropped easily on a chintz-covered lounge before the grate fire in the
smoking-room. A club-member caught sight of the ribbon in the coat
lapel. “I say, Eleanor,” she said eagerly, coming over to examine it.
Miss Warrender was home on leave. In a few days she would be
returning again to her unit in France. She has been living where one
does not get a bath every day and there are not always clean
sheets. One sleeps on the floor if necessary, and what water there is
available sometimes must be carefully saved for dying men to drink.
The Red Cross flag that floats over the hospital is of no protection
whatever. Sometimes it seems only a menace, as if it were a sign to
indicate to the enemy where they may drop bombs on the most
helpless.
There is a slight soft patter at the window-pane and it isn’t rain. It’s
shrapnel. The warning whistle has just sounded. There is the cry in
the streets—“Gardez vous!” The taubes are here. A Zeppelin bomb
explodes on contact, so you seek safety in the cellar, which it may
not reach. But a taube bomb, small and pointed, pierces a floor and
explodes at the lowest level reached. So you may not flee from a
taube bomb to anywhere. You just stay with your wounded and wait.
Ah, there is the explosion which makes the cots here in the ward
rock and the men shake as with palsy and turn pale. But, thank God,
this time the explosion is outside and in the garden. Beyond the
window there, what was a flower-bed three minutes ago is an
upturned heap of earth and stone. They are bringing in now four
more patients for whom room must be made besides these from the
battlefield that have been operated on, twenty of them, since nine
o’clock this morning. These four who are now being laid tenderly on
the white cots have two of them had their legs blown off, and two
others are already dying from wounds more mortal.
Eleanor Warrender a little later closes their eyes in the last sleep.
She has watched beside hundreds of men like that as they have
gone out into the Great Beyond. And just now she walks into the
Ladies’ Empire Club as calmly as if she had but come from a
shopping tour in Oxford Street. Ah, well, but one can suffer just so
much, as on a musical instrument you may strike the highest key
and you may strike it again and again until it flats a little on the ear
because you have become so accustomed to it. But it is the limit. It is
the highest key. There is nothing more beyond, at least. And that is
what you feel ultimately about these women who have come through
the experience that leads to the decoration. It is one in the most
constant danger who arrives at length at the most constant calm.
 THE VISCOUNTESS ELIZABETH BENOIT D’AZY
Of the old French aristocracy, one of the most conspicuous
examples that the war affords of noblesse oblige in the Red
Cross Service.
“I don’t know really why it should be called bravery,” says Eleanor
Warrender’s quiet voice. “You see, a bomb has never dropped on
me, so I have no actual personal experience of what it would be like.
Now in that old convent in Flanders turned into a hospital, Sister
Gertrude at the third cot from where I stood had a leg blown off, and
Sister Felice had lost an arm, and I think it was very brave of them to
go right on nursing in the danger zone afterward. But I—as I have
said—no bomb has ever hit me. And having no experience of what
the sensation would be like, it isn’t particularly brave of me to go
about my business without special attention to a danger of which I
have no experience of pain to remember. As for death,” and Eleanor
Warrender looked out in Grosvenor Street into the yellow grey
London fog, “as for death, it is, after all, only an episode. And what
does it matter whether one is here or there?”
Eleanor Warrender and others have gone out into the great
experience on the borderland with death from quiet and uneventful
lives of peace such as ours in America up to the present have also
been. The call is coming now to us in pleasant cities and nice little
villages all over the United States, and the time is here when we too
are summoned from the even tenor of our ways because the high
white flashing moment of service is come. Eleanor Warrender was
called quite suddenly from a stately career as an English
gentlewoman. She kept house for her brother, Sir George
Warrender, afterward in the war Admiral Warrender. It was a lovely
old country house, High Grove, at Pinnar, in Middlesex County, of
which she was the chatelaine. There had been a delightful week-end
party there for which she was the hostess. She stood on a porch
embowered in roses to bid her guests good-bye on an afternoon in
August. And she had no more idea than perhaps you have who have
touched lightly the hand of friends who have gone out from your
dinner table to-night, that the farewell was final. But two days later in
a Red Cross uniform she was on her way to her place by the
bedside of the war wounded. There has been no more entertaining
since, and one cannot say when Eleanor Warrender shall ever again
see English roses in bloom.

THE DEMAND DEVELOPS THE CAPACITY

The Viscountess Elizabeth D’Azy had been with her young son
passing a summer holiday at a watering-place in France.
 She had just sent the boy back to boarding-school and herself had
returned to her apartment in Paris overlooking the Esplanade des
Invalides. At the moment she had no more intention of becoming a
war heroine than of becoming a haloed plaster saint set in a niche in
the Madeleine. Yet before she had ordered her trunks to be
unpacked, the nation’s call for Red Cross women had reached her.
“It was so sudden,” she has told me, “and I was so dazed, I
couldn’t even remember where I had put my Red Cross insignia. At
last my maid found it in my jewel case beneath my diamond
necklace. I hadn’t even seen it since I had received it at the end of
my Red Cross first-aid course of lectures.” The maid packed a
suitcase of most necessary clothing. Carrying this suitcase, the
Viscountess Elizabeth Benoit D’Azy, daughter of the Marquis de
Vogue of the old French aristocracy, in August, 1914, walked with
high head and firm tread out of a life of luxury and ease into the
place of toil and privation and self-sacrifice at the Vosges front where
her country had need of her.
That was, I think, the last time a maid has done anything for her
for whom up to that day in August there had been servants to
answer her least request. Ever since then the Viscountess D’Azy has
been doing things with her own hands for the soldiers of France. It
was in the second year of the war that a gentleman of France,
General Joffre, bent to kiss her small hand, now toil-hardened and
not so white as it used to be. There is a military group in front of a
hospital that she commands and they stand directly before a great
jagged hole in the wall torn there by a German bomb, which, as it
fell, missed her by a few metres. The General is giving her the
“accolade,” and on the front of her white uniform he has pinned the
Croix de Guerre of France for distinguished service. Last year, on
behalf of her grateful country, the Minister of War conferred on her
another decoration, the Médaille de Vermeil des Epidémies. I do not
know what others may have been added since to these with which
the front of her white blouse sagged last spring in Paris.
But the woman thus cited for military honours had before this
Armageddon as little expectation of playing any such rôle as have
you to-day who are, say, the social leader of the four hundred in Los
Angeles or the president of a foreign missionary society in Bangor,
Maine. Her one preparation was that two months’ course of Red
Cross lectures. Many women of the leisure class were taking it in
1910.
“I think I will, too,” she had said to her husband. “Some elemental
knowledge of the scientific facts of nursing I really ought to have
when the children are ill.” There were five children, four little
daughters and a son. And the Viscount thought of them and
reluctantly gave his consent.
“Very well, Elizabeth,” he had said. “I think I am willing that you
should hear the lectures. But on this I shall insist, my dear: I cannot
permit you to take the practical bedside demonstration work. I don’t
wish to think of my wife doing that kind of menial service even for
instruction purposes, and I simply could not have you so exposed to
all sorts of infection.”
Like that it happened when Elizabeth, the Viscountess D’Azy,
arrived at the battle front to which she was first called at Gérardmer;
she had had no practical nursing experience. Oh, she got it right
away. She had quite some within twenty-four hours. But up to now,
this flashing white moment of life which she faced so suddenly, she
had not so much as filled a hot-water bag for any one. And she had
never seen a man die.
At this military barracks where she took off her hat to don the
flowing white headdress with the red cross in the centre of the
forehead, one hundred and fifty men, some of them delirious with
agony, some of them just moaning with pain, all of them wounded
and waiting most necessary attention, lay on the straw on the floor
ranged against the wall.
There weren’t even cots. And there was only herself with one
other woman to assist her in doing all that must be done for these
one hundred and fifty helpless men.
The first that she remembers, a surgeon was calling out orders to
her like a pistol exploding at her head. She got him a basin of water
and some absorbent cotton and she managed to find the ether. Oh,
his shining instruments were flashing horribly in the light from the
window. He was going to cut off a man’s leg. “But, Doctor,” she
exclaimed, “I never had that in my Red Cross training. I don’t know
how.” She went so white that he looked at her and he hesitated. “Go
out in the garden outside,” he commanded, “and walk in the air.” He
looked at his watch. “I’ll give you just three minutes. Come back then
and we’ll do this job.”
They did this job, the Viscountess D’Azy holding the patient’s leg
while they did it. “After that,” she has told me, “I was never nervous. I
was never afraid. There wasn’t anything I couldn’t do.”
And there wasn’t anything she didn’t do. There were always the
one hundred and fifty men to be cared for: as fast as a cot was
vacated for the grave, it was filled again from the battle-line. For six
weeks the Viscountess was on her feet for seventeen hours out of
every twenty-four, carrying water, preparing food, dressing wounds,
closing the eyes of dying men. It took from eight in the morning until
five in the afternoon just to do the dressings alone. Twelve men on
an average died every night and they wrapped them in white sheets
for the burial, the Viscountess D’Azy did, daughter of one of the
proudest houses of France.
One day the message came that the Germans, sweeping through
the nearby village of St. Dié, had denuded the hospital there of all
supplies. Would the Viscountess with her influence, the commandant
begged, carry a report of their need to Paris. She went to Paris and
brought back a truck-load of supplies. She and the driver were three
days on the return journey. German shells were again falling on the
road to St. Dié as they approached. The chauffeur stopped in terror.
“Go on!” commanded the Viscountess. “Go on!” As the car shot
forward by her order, a bomb dropped behind them, tearing up in a
cloud of dust the exact spot in the road where the car had halted.
Word reached military headquarters of Elizabeth D’Azy’s skill in
nursing, of her unflinching coolness in the face of all danger. It was
decided that the war department had need of her at Dunkirk. The
town was under heavy bombardment, receiving between three
hundred and four hundred bombs daily. At the barracks hospital,
arranged at the railway station, there were cots for two hundred
wounded. Sometimes a thousand men were laid out on the floors.
One night there were three thousand. And there was only the
Viscountess, who was the commandant, one trained nurse, and
some voluntary untrained assistants. For a protection against the
Zeppelins it was necessary that there should be only the dimmest
candle light even for the performing of operations. As rapidly as
possible patients were evacuated to base hospitals. The
commandant one night was tenderly supervising the lifting into an
American ambulance of an officer whose wounds she had just
bandaged. She leaned over the wheel to admonish “Drive slowly or
he cannot live.” And as she touched the driver’s arm there was an
exclamation of mutual surprise. The driver was A. Piatt Andrews,
under secretary of the treasury in President Taft’s administration.
And the last time he had seen the Viscountess D’Azy he had taken
her in to dinner at the White House in Washington when her
husband was an attaché there of the French Embassy. How long
ago was all the gaiety of diplomatic social life at Washington! A siren
sounded shrilly now the cry of danger and death in an approaching
taube raid. And the greeting ended hastily, the hospital commandant
and the ambulance driver hurrying in the darkness to their respective
posts of duty.
The Viscountess has been in charge of a number of hospitals,
having been transferred from place to place at the front. When I saw
her, she was temporarily in command for a few weeks at the hospital
which had been opened at Claridge’s Hotel in Les Champs Elysées
in Paris. She didn’t care about her medals or her own magnificent
record. It wasn’t even the achievements of her husband, the
Viscount D’Azy, in command of the naval battleship Jauré-guiberry ,
of which she spoke most often. The Viscountess D’Azy’s one theme
is her boy. Before the war he was her little son. Now he is a tall and
handsome officer in uniform, at the age of nineteen, Sub-lieutenant
Charles Benoit D’Azy.
He wanted to enlist when she did. But she insisted that he remain
at school until he had finished his examinations in the spring of 1915.
He got into action in time for the great push on the Somme. Here at
the hospital in Les Champs Elysées the Viscountess shows me his
photograph, snapshots that she has taken with her kodak. Last night
she walked unattended and alone three miles through the streets of
Paris at midnight after seeing him off at the Gare de l’Est. He had
started again for the front after his furlough at home. Her one request
to the war department is to be detailed to hospital duty where she
may be near her boy’s regiment. Her pride in the boy is beautiful.
When she speaks his name that look of experience is gone for the
moment, and in the eyes of Elizabeth D’Azy there is only the soft
luminous mother-love, even as it may be reflected in your eyes that
have never yet seen bloodshed.
 LADY RALPH PAGET OF ENGLAND
Descendant of American forefathers. She is a war heroine
worshipped by the entire Serbian nation for her consecrated
devotion to their people.
“Up to the time of the war,” the Viscountess said in her pretty
broken English as she looked reminiscently out on the broad avenue
of Paris, “I was doing nothing but going to fêtes all day and dancing
most of the nights. But I think there is no reason why a woman who
has danced well should not be able to do her duty as well as she did
her pleasure. N’est ce pas?” And from the records of the European
war offices, I think so, too.

THE WOMAN WHOM A NATION ADORES

Among the English war heroines is Lady Ralph Paget, whose
name has gone round the world for her splendid service in Serbia. In
that defenceless little land, exposed so cruelly to the ravages of this
terrible war, she commanded with as efficient executive skill as any
of the generals who have been leading armies, one of the best-
managed hospitals that have faced the enemy’s fire.
Leila Paget had lived all her life in the environment where ladies
have their breakfast in bed and some one does their hair and hands
them even so much as a pocket handkerchief. “Leila going to
command a hospital?” questioned some of her friends, “Leila who
has always been so dependent on her mother?”
She is the daughter, you see, of the Lady Arthur Paget, the
beautiful Mary Paran Stevens of New York, who, ever since her
marriage into the British aristocracy, has been one of the leaders in
the Buckingham Palace set. Leila Paget was, of course, brought up
as is the most carefully shielded and protected English girl in high
life. She grew up in a stately mansion in Belgrave Square. She was
introduced to society in the crowded drawing-room there which has
been the scene of her brilliant mother’s so many social triumphs. But
she had no ambition to be a social butterfly. She was a débutante
who did not care for a cotillion. You see, it was not yet her hour. She
was a tall, rather delicate girl who continued to be known as the
beautiful Lady Paget’s “quiet” daughter. A few seasons passed and
she married her cousin, the British diplomat, Sir Ralph Paget, many
years her senior.
She had never known responsibility at all when one day she sat
down in the great red drawing-room in Belgrave Square to make out
a list of the staff personnel and the supplies that would be required
for running a war hospital in Serbia. Her heart at once turned to this
land in its time of trouble because she had for three years lived in
Serbia when Sir Ralph was the British Minister there. They had but
recently returned to England on his appointment as under secretary
of foreign affairs. And now she had determined to go to the relief of
Serbia with a hospital unit. I suppose British society has never been
more surprised and excited about any of the women who have done
things in this war than they were about Leila Paget. This day in the
great red drawing-room Leila Paget found her metier. She is the
daughter of a soldier, General Sir Arthur Paget, and what has
developed as her amazing organising and administrative ability is an
inheritance from a line of American ancestors through her beautiful
mother. But from her reserved, retiring manner none of her friends
had suspected that she was of the stuff of which heroines are made.
Now, as she laid her plans for war relief, she did it with an
expeditious directness and a mastery of detail with which some
Yankee forefather in Boston might have managed his business
affairs. With a comprehensive glance she seemed to see the
equipment that would be needed. Here in the red drawing-room she
sat, with long foolscap sheets before her on the antique carved
writing desk. She listed the requirements, item by item, a staff of so
many surgeons, so many physicians, so many nurses. Then she
estimated the supplies, so many surgeon’s knives, so many bottles
of quinine, everything from bandages and sheets down to the last
box of pins. And she planned to a pound the quantity of rice and
tapioca. Her hospital ultimately did have jam and tea when all the
others were scouring Serbia in a frantic search to supplement
diminishing supplies. Without any excitement, with an utter absence
of hysteria as a woman ordering gowns for a gay season in Mayfair,
Leila Paget gave her instructions and assembled her equipment. It
was, you see, her hour.
She arrived at Uskub in October, 1914, with the first English
hospital on the scene to stem the tide of the frightful conditions that
prevailed toward the end of 1914. After the retreat of the Austrians,
Serbia had been left a charnel house of the dead and dying. Every
large building of any kind—schools, inns, stables—was filled with the
wounded, among whom now raged also typhus, typhoid, and
smallpox. There were few doctors and no nurses, only orderlies who
were Austrian prisoners. At one huge barracks fifteen hundred cases
lay on the cots and under them; at another three thousand fever
patients overflowed the building and lay on the ground outside in
their uniforms, absolutely unattended. Facing conditions like these,
Lady Paget opened her hospital in a former school building. And
here in the war zone she instituted for herself such a régime as
probably was never before arranged for an Englishwoman of title.
She arose at four o’clock in the morning, and when she slipped
from her cot, no one handed her a silk kimono. The regulation “germ
proof” uniform worn by women relief workers in Serbia consisted of a
white cotton combination affair, the legs of which tucked tight into
high Serbian boots. Over this went an overall tunic with a collar tight
about the neck and bands tight about the wrists. There was a tight-
fitting cap to go over the hair. And beneath this uniform, about neck
and arms, you wore bandages soaked in vaseline and petroleum. It
was the protection against the attacking vermin that swarmed
everywhere as thick as common flies. Wounded men from the
trenches arrived infested with lice, and typhus is spread by lice. Lady
Paget stood heroically at her post by their bedsides, with her own
hands attending to their needs. What there was to be done in the
way of every personal service, she did not shrink from. And she
unpacked bales of goods. And she scrubbed floors. And she
assisted with the rites for the dying. There had to be a lighted candle
in a dying Serbian soldier’s hand, and often her own hand closed
firmly about the hand too weak to hold the candle alone. Her
wonderful nerve never failed, but there came a time when her frail
physical strength gave out. She still held on, working for two days
with a high fever temperature before she finally succumbed, herself
the victim of typhus. Her husband was telegraphed for. She was
unconscious when he arrived and it was three or four days before he
could be permitted to see her. Her life hung in the balance for weeks.
But finally recovery began and it was planned for her to return to
England for convalescence. She and Sir Ralph were attended to the
railroad station by the military governor of Macedonia, the
archbishop of the Serbian Church, and a guard of honour of Serbian
officers. The Serbian people in their devotion lined the street and
threw flowers beneath her feet and kissed the hem of her dress. At
the station the Crown Prince presented her with the highest