Household Water Insecurity Will Complicate the Ongoing COVID-19 Response: Evidence from 29 Sites in 23 Low- and Middle-Income Countries

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Abstract

In March 2020, the World Health Organization (WHO) issued a set of public guidelines for Coronavirus Disease 2019 (COVID-19) prevention measures that highlighted handwashing, physical distancing, and household cleaning. These health behaviors are severely compromised in parts of the world that lack secure water supplies, particularly in low- and middle-income countries (LMICs). We used empirical data gathered in 2017-2018 from 8,297 households in 29 sites across 23 LMICs to address the potential implications of water insecurity for COVID-19 prevention and response. These data demonstrate how household water insecurity presents many pathways for limiting personal and environmental hygiene and impeding physical distancing, exacerbating existing social and health vulnerabilities that can lead to more severe COVID-19 outcomes. In the four weeks prior to the survey, 45.9% of households in our sample either were unable to wash their hands or reported borrowing water from others, which may undermine hygiene and physical distancing. Further, 70.9% of households experienced one or more water-related problems that potentially undermine COVID-19 control strategies or disease treatment, including insufficient water for bathing, laundering, or taking medication; drinking unsafe water; going to sleep thirsty; or having little-to-no drinking water. These findings help identify where water provision is most relevant to managing COVID-19 spread and outcomes.

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Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Neeltje van Doremalen, Trenton Bushmaker, Dylan H Morris … (2021)

To the Editor: A novel human coronavirus that is now named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (formerly called HCoV-19) emerged in Wuhan, China, in late 2019 and is now causing a pandemic. 1 We analyzed the aerosol and surface stability of SARS-CoV-2 and compared it with SARS-CoV-1, the most closely related human coronavirus. 2 We evaluated the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces and estimated their decay rates using a Bayesian regression model (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org). SARS-CoV-2 nCoV-WA1-2020 (MN985325.1) and SARS-CoV-1 Tor2 (AY274119.3) were the strains used. Aerosols (<5 μm) containing SARS-CoV-2 (105.25 50% tissue-culture infectious dose [TCID50] per milliliter) or SARS-CoV-1 (106.75-7.00 TCID50 per milliliter) were generated with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment. The inoculum resulted in cycle-threshold values between 20 and 22, similar to those observed in samples obtained from the upper and lower respiratory tract in humans. Our data consisted of 10 experimental conditions involving two viruses (SARS-CoV-2 and SARS-CoV-1) in five environmental conditions (aerosols, plastic, stainless steel, copper, and cardboard). All experimental measurements are reported as means across three replicates. SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours), with a reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air. This reduction was similar to that observed with SARS-CoV-1, from 104.3 to 103.5 TCID50 per milliliter (Figure 1A). SARS-CoV-2 was more stable on plastic and stainless steel than on copper and cardboard, and viable virus was detected up to 72 hours after application to these surfaces (Figure 1A), although the virus titer was greatly reduced (from 103.7 to 100.6 TCID50 per milliliter of medium after 72 hours on plastic and from 103.7 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). The stability kinetics of SARS-CoV-1 were similar (from 103.4 to 100.7 TCID50 per milliliter after 72 hours on plastic and from 103.6 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). On copper, no viable SARS-CoV-2 was measured after 4 hours and no viable SARS-CoV-1 was measured after 8 hours. On cardboard, no viable SARS-CoV-2 was measured after 24 hours and no viable SARS-CoV-1 was measured after 8 hours (Figure 1A). Both viruses had an exponential decay in virus titer across all experimental conditions, as indicated by a linear decrease in the log10TCID50 per liter of air or milliliter of medium over time (Figure 1B). The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours and 95% credible intervals of 0.64 to 2.64 for SARS-CoV-2 and 0.78 to 2.43 for SARS-CoV-1 (Figure 1C, and Table S1 in the Supplementary Appendix). The half-lives of the two viruses were also similar on copper. On cardboard, the half-life of SARS-CoV-2 was longer than that of SARS-CoV-1. The longest viability of both viruses was on stainless steel and plastic; the estimated median half-life of SARS-CoV-2 was approximately 5.6 hours on stainless steel and 6.8 hours on plastic (Figure 1C). Estimated differences in the half-lives of the two viruses were small except for those on cardboard (Figure 1C). Individual replicate data were noticeably “noisier” (i.e., there was more variation in the experiment, resulting in a larger standard error) for cardboard than for other surfaces (Fig. S1 through S5), so we advise caution in interpreting this result. We found that the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 under the experimental circumstances tested. This indicates that differences in the epidemiologic characteristics of these viruses probably arise from other factors, including high viral loads in the upper respiratory tract and the potential for persons infected with SARS-CoV-2 to shed and transmit the virus while asymptomatic. 3,4 Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events, 5 and they provide information for pandemic mitigation efforts.

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The effect of human mobility and control measures on the COVID-19 epidemic in China

Moritz Kraemer, Chia-Hung Yang, Bernardo Gutiérrez … (2020)

The ongoing COVID-19 outbreak expanded rapidly throughout China. Major behavioral, clinical, and state interventions have been undertaken to mitigate the epidemic and prevent the persistence of the virus in human populations in China and worldwide. It remains unclear how these unprecedented interventions, including travel restrictions, affected COVID-19 spread in China. We use real-time mobility data from Wuhan and detailed case data including travel history to elucidate the role of case importation on transmission in cities across China and ascertain the impact of control measures. Early on, the spatial distribution of COVID-19 cases in China was explained well by human mobility data. Following the implementation of control measures, this correlation dropped and growth rates became negative in most locations, although shifts in the demographics of reported cases were still indicative of local chains of transmission outside Wuhan. This study shows that the drastic control measures implemented in China substantially mitigated the spread of COVID-19.

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Prolonged presence of SARS-CoV-2 viral RNA in faecal samples

Yongjian Wu, Cheng Guo, Lantian Tang … (2020)

We present severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time RT-PCR results of all respiratory and faecal samples from patients with coronavirus disease 2019 (COVID-19) at the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China, throughout the course of their illness and obligated quarantine period. Real-time RT-PCR was used to detect COVID-19 following the recommended protocol (appendix p 1). Patients with suspected SARS-CoV-2 were confirmed after two sequential positive respiratory tract sample results. Respiratory and faecal samples were collected every 1–2 days (depending on the availability of faecal samples) until two sequential negative results were obtained. We reviewed patients' demographic information, underlying diseases, clinical indices, and treatments from their official medical records. The study was approved by the Medical Ethical Committee of The Fifth Affiliated Hospital of Sun Yat-sen University (approval number K162-1) and informed consent was obtained from participants. Notably, patients who met discharge criteria were allowed to stay in hospital for extended observation and health care. Between Jan 16 and March 15, 2020, we enrolled 98 patients. Both respiratory and faecal samples were collected from 74 (76%) patients. Faecal samples from 33 (45%) of 74 patients were negative for SARS CoV-2 RNA, while their respiratory swabs remained positive for a mean of 15·4 days (SD 6·7) from first symptom onset. Of the 41 (55%) of 74 patients with faecal samples that were positive for SARS-CoV-2 RNA, respiratory samples remained positive for SARS-CoV-2 RNA for a mean of 16·7 days (SD 6·7) and faecal samples remained positive for a mean of 27·9 days (10·7) after first symptom onset (ie, for a mean of 11·2 days [9·2] longer than for respiratory samples). The full disease course of the 41 patients with faecal samples that were positive for SARS-CoV-2 RNA is shown in the figure . Notably, patient 1 had positive faecal samples for 33 days continuously after the respiratory samples became negative, and patient 4 tested positive for SARS-CoV-2 RNA in their faecal sample for 47 days after first symptom onset (appendix pp 4–5). Figure Timeline of results from throat swabs and faecal samples through the course of disease for 41 patients with SARS-CoV-2 RNA positive faecal samples, January to March, 2020 A summary of clinical symptoms and medical treatments is shown in the appendix (pp 2–3, 6–8). The presence of gastrointestinal symptoms was not associated with faecal sample viral RNA positivity (p=0·45); disease severity was not associated with extended duration of faecal sample viral RNA positivity (p=0·60); however, antiviral treatment was positively associated with the presence of viral RNA in faecal samples (p=0·025; appendix pp 2–3). These associations should be interpreted with caution because of the possibility of confounding. Additionally, the Ct values of all three targeted genes (RdRp, N, E) in the first faecal sample that was positive for viral RNA were negatively associated with the duration of faecal viral RNA positivity (RdRp gene r= –0·34; N gene r= –0·02; and E gene r= –0·16), whereas the correlation of the Ct values with duration of faecal sample positivity was only significant for RdRp (p=0·033; N gene p=0·91; E gene p=0·33). Our data suggest the possibility of extended duration of viral shedding in faeces, for nearly 5 weeks after the patients' respiratory samples tested negative for SARS-CoV-2 RNA. Although knowledge about the viability of SARS-CoV-2 is limited, 1 the virus could remain viable in the environment for days, which could lead to faecal–oral transmission, as seen with severe acute respiratory virus CoV and Middle East respiratory syndrome CoV. 2 Therefore, routine stool sample testing with real-time RT-PCR is highly recommended after the clearance of viral RNA in a patient's respiratory samples. Strict precautions to prevent transmission should be taken for patients who are in hospital or self-quarantined if their faecal samples test positive. As with any new infectious disease, case definition evolves rapidly as knowledge of the disease accrues. Our data suggest that faecal sample positivity for SARS-CoV-2 RNA normally lags behind that of respiratory tract samples; therefore, we do not suggest the addition of testing of faecal samples to the existing diagnostic procedures for COVID-19. However, the decision on when to discontinue precautions to prevent transmission in patients who have recovered from COVID-19 is crucial for management of medical resources. We would suggest the addition of faecal testing for SARS-CoV-2. 3 Presently, the decision to discharge a patient is made if they show no relevant symptoms and at least two sequential negative results by real-time RT-PCR of sputum or respiratory tract samples collected more than 24 h apart. Here, we observed that for over half of patients, their faecal samples remained positive for SARS-CoV-2 RNA for a mean of 11·2 days after respiratory tract samples became negative for SARS-CoV-2 RNA, implying that the virus is actively replicating in the patient's gastrointestinal tract and that faecal–oral transmission could occur after viral clearance in the respiratory tract. Determining whether a virus is viable using nucleic acid detection is difficult; further research using fresh stool samples at later timepoints in patients with extended duration of faecal sample positivity is required to define transmission potential. Additionally, we found patients normally had no or very mild symptoms after respiratory tract sample results became negative (data not shown); however, asymptomatic transmission has been reported. 4 No cases of transmission via the faecal–oral route have yet been reported for SARS-CoV-2, which might suggest that infection via this route is unlikely in quarantine facilities, in hospital, or while under self-isolation. However, potential faecal–oral transmission might pose an increased risk in contained living premises such as hostels, dormitories, trains, buses, and cruise ships. Respiratory transmission is still the primary route for SARS-CoV-2 and evidence is not yet sufficient to develop practical measures for the group of patients with negative respiratory tract sample results but positive faecal samples. Further research into the viability and infectivity of SARS-CoV-2 in faeces is required.

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Author and article information

Journal

Journal ID (nlm-ta): Int J Hyg Environ Health

Journal ID (iso-abbrev): Int J Hyg Environ Health

Title: International Journal of Hygiene and Environmental Health

Publisher: Elsevier GmbH.

ISSN (Print): 1438-4639

ISSN (Electronic): 1618-131X

Publication date PMC-release: 19 February 2021

Publication date (Electronic): 19 February 2021

Electronic Location Identifier: 113715

Affiliations

[12 ]University of Notre Dame, South Bend, IN, USA

[13 ]Quaid-e-Azam University Islamabad, Pakistan

[14 ]Johns Hopkins University-Byramjee Jeejeebhoy Medical College Clinical Trials Unit, Pune, India

[15 ]African Population and Health Research Center, Nairobi, Kenya

[16 ]College of Medicine of the University of Lagos, Lagos, Nigeria

[17 ]Michigan State University, East Lansing, MI, USA

[18 ]Texas A&M University, College Station, TX, USA

[19 ]University of Florida, Gainesville, FL, USA

[20 ]University of the West of England, Bristol, UK

[21 ]Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA

[22 ]Shahid Beheshti University of Medical Sciences, Tehran, Iran

[23 ]Pontificia Universidad Javeriana, Bogotá, Colombia

[24 ]American University of Beirut, Beirut, Lebanon

[25 ]Arizona State University, Tempe, AZ, USA

[26 ]Yale University, New Haven, CT, USA

[27 ]Anode Governance Lab, Bengaluru, India

[28 ]Oregon State University, Corvallis, OR, USA

[29 ]Weill Cornell Medicine, New York, NY, USA

[30 ]Northwestern University, Evanston, IL, USA

[31 ]McGill University, Ste-Anne-de-Bellevue, Quebec, Canada

[32 ]Universidad Autónoma del Beni José Ballivián, Bolivia

[33 ]Autonomous University of Coahuila, Coahuila, Mexico

[34 ]International Centre for Diarrhoeal Disease Research Bangladesh, Mohakhali, Dhaka, 1212, Bangladesh

[35 ]Hospital Agustin O’Horan, Mérida, Yucatan, Mexico

[36 ]University of Miami, Coral Gables, FL, USA

[37 ]University of Amsterdam, Amsterdam, The Netherlands

[38 ]Oregon Health & Science University, Portland, OR, USA

[39 ]Delaware State University, Dover, DE, USA

[1 ]University of Miami, Coral Gables, FL, USA

[2 ]University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

[3 ]Arizona State University, Tempe, AZ, USA

[4 ]Emory University, Atlanta, GA, USA

[5 ]University of British Columbia, Vancouver, BC, Canada

[6 ]Texas A&M University, College Station, TX, USA

[7 ]Michigan State University, East Lansing, MI, USA

[8 ]Pennsylvania State University, University Park, PA, USA

[9 ]University of the West of England, Bristol, UK

[10 ]University of North Carolina at Greensboro, Greensboro, NC, USA

[11 ]Northwestern University, Evanston, IL, USA

Author notes

[∗ ]Corresponding author: 1300 Campo Sano Ave, Coral Gables, FL, 33146, USA;

Article

Publisher Item ID: S1438-4639(21)00030-4 Publisher ID: 113715

DOI: 10.1016/j.ijheh.2021.113715

PMC ID: 7894133

PubMed ID: 33735823

SO-VID: 086150dd-2b61-489a-9ca6-e7d57336c2ec

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

History

Date received : 3 November 2020

Date revision received : 25 January 2021

Date accepted : 11 February 2021

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Household Water Insecurity Will Complicate the Ongoing COVID-19 Response: Evidence from 29 Sites in 23 Low- and Middle-Income Countries

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Novel Coronavirus Disease COVID-19

Most cited references 56

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

The effect of human mobility and control measures on the COVID-19 epidemic in China

Prolonged presence of SARS-CoV-2 viral RNA in faecal samples

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