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      Fecal transmission in COVID‐19: A potential shedding route

      , MD 1 , 2 , , MD , 3

      Journal of Medical Virology

      John Wiley and Sons Inc.

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          To the Editor, We read with interest recent article by Zhang et al 1 on the diagnosis of Coronavirus disease 2019 (COVID‐19) by fecal specimen test. Following the recent outbreak of pneumonia with unknown pathogen in Hubei province in China, a severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) isolated from human airway epithelial cells and the disease was named COVID‐19. 2 It is a public health emergency of international concern and rapidly spearing all over the world. 3 Fever and cough are the most common clinical manifestations and gastrointestinal (GI) symptoms including nausea or vomiting and diarrhea are less common. 4 Moreover, ground‐glass opacity and lymphocytopenia are the most common radiologic and laboratory findings, respectively. 4 Angiotensin converting enzyme II (ACE2) may act as the potential intermediate hosts transmitting SARS‐CoV‐2 to humans. 5 Reverse transcriptase‐polymerase chain reaction (RT‐PCR) is a routine method for the diagnosis of COVID‐19 in oropharyngeal swabs. 6 Intestinal tissue involvement was reported in patients with SARS‐CoV and Middle East respiratory syndrome Coronavirus (MERS‐CoV) infection. 7 Because of the novelty of SARS‐CoV‐2, the features of this pathogen are still unclear. In the MERS‐CoV outbreak in 2012, 14.6% of patients had positive fecal specimens. 8 Wu et al verified the presence of SARS‐CoV‐2 RNA in 55% of fecal specimens in patients with positive oropharyngeal swab test. 9 Recent evidence showed that SARS‐CoV‐2 present in fecal specimens from patients with COVID‐19 and hands, food, and water contamination may occur by fecal content and may cause a critical infection by invading the oral cavity and respiratory tract. 1 , 10 , 11 According to a bioinformatics study by Zhang et al ACE2 was not only highly expressed in the lung alveolar type 2 cells, esophagus upper and stratified epithelial cells but also in absorptive enterocytes from ileum and colon. On the other hand, the GI system is a potential shedding route for COVID‐19. 12 In the study in China on 14 laboratory‐confirmed COVID‐19 patients, the molecular diagnosis of COVID‐19 in fecal specimens was equally accurate with oropharyngeal swab. Likewise, patients with a positive fecal test did not experience GI symptoms and had nothing to do with the severity of lung infection. 1 The clinical significance of evaluation RT‐PCR test in fecal specimens also emphasized in most recent studies because in more than 20% of patients with COVID‐19 the fecal swab test remains positive even after negative results in oropharyngeal swab test. 13 More positives result in anal swab specimens than oral swab in a later stage of infection, suggesting shedding and thereby transmitted through oral‐fecal route. 14 In conclusion, the present method for the diagnosis of viral RNA of SARS‐CoV‐2 in oral swabs is not perfect because live SARS‐CoV‐2 may exist in fecal while oropharyngeal specimen is negative. The major concern in this condition is person to person transmission when the patient considers as a cured person with negative nucleic acid test. On the other hand, negative oropharyngeal swab may not an indication for discharge and possible shift from more oropharyngeal positive results during the early period to more anal positive results during the later period should be considered in this patients. Furthermore, anal swab specimen will reduce health care providers' infections by COVID‐19. Finally, protection from fecal shedding route should be considered as important medical advice for reducing SARS‐CoV‐2 infection, notably in treated patients who met discharge criteria with negative oropharyngeal swab test. Further studies need to consider negative fecal viral RNA test as a criterion for patients discharge, undoubtedly, protect against fecal shedding is necessary during hospitalization and after patients discharge. CONFLICT OF INTERESTS The authors declare that there are no conflict of interests.

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          Most cited references 13

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          Clinical Characteristics of Coronavirus Disease 2019 in China

          Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)
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            A Novel Coronavirus from Patients with Pneumonia in China, 2019

            Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
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              Is Open Access

              A pneumonia outbreak associated with a new coronavirus of probable bat origin

              Since the outbreak of severe acute respiratory syndrome (SARS) 18 years ago, a large number of SARS-related coronaviruses (SARSr-CoVs) have been discovered in their natural reservoir host, bats 1–4 . Previous studies have shown that some bat SARSr-CoVs have the potential to infect humans 5–7 . Here we report the identification and characterization of a new coronavirus (2019-nCoV), which caused an epidemic of acute respiratory syndrome in humans in Wuhan, China. The epidemic, which started on 12 December 2019, had caused 2,794 laboratory-confirmed infections including 80 deaths by 26 January 2020. Full-length genome sequences were obtained from five patients at an early stage of the outbreak. The sequences are almost identical and share 79.6% sequence identity to SARS-CoV. Furthermore, we show that 2019-nCoV is 96% identical at the whole-genome level to a bat coronavirus. Pairwise protein sequence analysis of seven conserved non-structural proteins domains show that this virus belongs to the species of SARSr-CoV. In addition, 2019-nCoV virus isolated from the bronchoalveolar lavage fluid of a critically ill patient could be neutralized by sera from several patients. Notably, we confirmed that 2019-nCoV uses the same cell entry receptor—angiotensin converting enzyme II (ACE2)—as SARS-CoV.

                Author and article information

                Role: Assistant
                J Med Virol
                J. Med. Virol
                Journal of Medical Virology
                John Wiley and Sons Inc. (Hoboken )
                06 April 2020
                [ 1 ] Immunology Research Center Tabriz University of Medical Sciences Tabriz Iran
                [ 2 ] Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA) Universal Scientific Education and Research Network (USERN) Tehran Iran
                [ 3 ] Liver and Gastrointestinal Diseases Research Center Tabriz University of Medical Sciences Tabriz Iran
                Author notes
                [* ] Correspondence Leila Alizadeh, MD, Assistant Professor of Hepatology and Gastroenterology, Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Golgasht St, Tabriz 5166614756, Iran.

                Email: alizadele@

                © 2020 Wiley Periodicals, Inc.

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                Page count
                Figures: 0, Tables: 0, Pages: 2, Words: 1041
                Letter to the Editor
                Letter to the Editor
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                Microbiology & Virology


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