The timing of COVID-19 transmission

The timing of SARS-CoV-2 transmission is a critical factor to understand the epidemic trajectory and the impact of isolation, contact tracing and other non-pharmaceutical interventions on the spread of COVID-19 epidemics. We examined the distribution of transmission events with respect to exposure and onset of symptoms. We show that for symptomatic individuals, the timing of transmission of SARS-CoV-2 is more strongly linked to the onset of clinical symptoms of COVID-19 than to the time since infection. We found that it was approximately centered and symmetric around the onset of symptoms, with three quarters of events occurring in the window from 2-3 days before to 2-3 days after. However, we caution against overinterpretation of the right tail of the distribution, due to its dependence on behavioural factors and interventions. We also found that the pre-symptomatic infectious period extended further back in time for individuals with longer incubation periods. This strongly suggests that information about when a case was infected should be collected where possible, in order to assess how far into the past their contacts should be traced. Overall, the fraction of transmission from strictly pre-symptomatic infections was high (41%; 95%CI 31-50%), which limits the efficacy of symptom-based interventions, and the large fraction of transmissions (35%; 95%CI 26-45%) that occur on the same day or the day after onset of symptoms underlines the critical importance of individuals distancing themselves from others as soon as they notice any symptoms, even if they are mild. Rapid or at-home testing and contextual risk information would greatly facilitate efficient early isolation.

Ongoing outbreak of COVID-19 in Iran: challenges and signs of concern

Many countries with an early outbreak of SARS-CoV-2 struggled to gauge the size and start date of the epidemic mainly due to limited testing capacities and a large proportion of undetected asymptomatic and mild infections. Iran was among the first countries with a major outbreak outside China. Using all genomic sequences collected from patients with a travel link to Iran, we estimate that the epidemic started on 21/01/2020 (95% HPD: 05/12/2019 - 14/02/2020) with a doubling time of 3 days (95% HPD: 1.68 - 16.27). We also show, using air travel data from confirmed exported cases, that from late February to early March the number of active cases across the country were more than a hundred times higher than the reported cases at the time. A detailed province-level analysis of all-cause mortality shows 20,718 (CI 95%: 18,859 - 22,576) excess deaths during winter and spring 2020 compared to previous years, almost twice the number of reported COVID-19-related deaths at the time. Correcting for under-reporting of prevalence and deaths, we use an SEIR model to reconstruct the outbreak dynamics in Iran. Our model forecasted the second epidemic peak and suggests that by 14/07/2020 a total of 9M (CI 95%: 118K - 44M) have recovered from the disease across the country. These findings have profound implications for assessing the stage of the epidemic in Iran and shed light on the dynamics of SARS-CoV-2 transmissions in Iran and central Asia despite significant levels of under-reporting. One Sentence SummaryWe use epidemiological and genetic data to investigate the origins of the SARS-CoV-2 outbreak in Iran and assess the degree of under-reporting in prevalence and deaths.

Evaluating COVID-19 Public Health Messaging in Italy: Self-Reported Compliance and Growing Mental Health Concerns

PurposeThe COVID-19 death-rate in Italy continues to climb, surpassing that in every other country. We implement one of the first nationally representative surveys about this unprecedented public health crisis and use it to evaluate the Italian government public health efforts and citizen responses. Findings(1) Public health messaging is being heard. Except for slightly lower compliance among young adults, all subgroups we studied understand how to keep themselves and others safe from the SARS-Cov-2 virus. Remarkably, even those who do not trust the government, or think the government has been untruthful about the crisis believe the messaging and claim to be acting in accordance. (2) The quarantine is beginning to have serious negative effects on the populations mental health. Policy RecommendationsCommunications should move from explaining to citizens that they should stay at home to what they can do there. We need interventions that make staying following public health protocols more desirable, such as virtual social interactions, online social reading activities, classes, exercise routines, etc. -- all designed to reduce the boredom of long term social isolation and to increase the attractiveness of following public health recommendations. Interventions like these will grow in importance as the crisis wears on around the world, and staying inside wears on people.