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SARS-CoV-2 shedding and seroconversion among passengers quarantined after disembarking a cruise ship: a case series.
Lancet Infect Dis. 2020 09; 20(9):1051-1060.LI

Abstract

BACKGROUND

A cruise ship is a closed-off environment that simulates the basic functioning of a city in terms of living conditions and interpersonal interactions. Thus, the Diamond Princess cruise ship, which was quarantined because of an onboard outbreak of COVID-19 in February, 2020, provides an opportunity to define the shedding pattern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and patient antibody responses before and after the onset of symptoms.

METHODS

We recruited adult (≥18 years) passengers from Hong Kong who had been on board the Diamond Princess cruise ship docked in Yokohama, Japan in February, 2020. All participants had been found to be negative for SARS-CoV-2 by RT-PCR 4 days before disembarking and were transferred to further quarantine in a public estate in Hong Kong, where they were recruited. Participants were prospectively screened by quantitative RT-PCR (RT-qPCR) of nasopharyngeal and throat swabs, and serum IgG and IgM against internal nucleoprotein and the surface spike receptor-binding protein (RBD) of SARS-CoV-2 at baseline (upon entering quarantine) and on days 4, 8, and 12 of quarantine.

FINDINGS

On Feb 22, 2020, 215 adults were recruited, of whom nine (4%; 95% CI 2-8) were positive for SARS-CoV-2 by RT-qPCR or serology and were hospitalised. Of these nine patients, nasopharyngeal swab RT-qPCR was positive in eight patients (89%; 57-99) at baseline. All nine patients were positive for anti-RBD IgG by day 8. Eight (89%; 57-99) were simultaneously positive for nasopharyngeal swab RT-PCR and anti-RBD IgG. One patient who was positive for anti-RBD IgG and had a negative viral load had multifocal peripheral ground-glass changes on high-resolution CT that were typical of COVID-19. Five patients (56%; 27-81) with ground-glass changes on high-resolution CT were found to have higher anti-nucleoprotein-IgG OD values on day 8 and 12 and anti-RBD IgG OD value on day 12 than patients without ground-glass changes. Six (67%; 35-88) patients remained asymptomatic throughout the 14-day quarantine period.

INTERPRETATION

Patients with COVID-19 can develop asymptomatic lung infection with viral shedding and those with evidence of pneumonia on imaging tend to have an increased antibody response. Positive IgG or IgM confirmed infection of COVID-19 in both symptomatic and asymptomatic patients. A combination of RT-PCR and serology should be implemented for case finding and contact tracing to facilitate early diagnosis, prompt isolation, and treatment.

FUNDING

Shaw Foundation Hong Kong; Sanming-Project of Medicine (Shenzhen); High Level-Hospital Program (Guangdong Health Commission).

Authors+Show Affiliations

Infectious Disease Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China; Infection Control Team, Queen Mary Hospital, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Infectious Disease Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China; Infection Control Team, Queen Mary Hospital, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China.Infectious Disease Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.Infectious Disease Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Radiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.Department of Radiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China.Infectious Disease Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China. Electronic address: kyyuen@hku.hk.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

32539986

Citation

Hung, Ivan Fan-Ngai, et al. "SARS-CoV-2 Shedding and Seroconversion Among Passengers Quarantined After Disembarking a Cruise Ship: a Case Series." The Lancet. Infectious Diseases, vol. 20, no. 9, 2020, pp. 1051-1060.
Hung IF, Cheng VC, Li X, et al. SARS-CoV-2 shedding and seroconversion among passengers quarantined after disembarking a cruise ship: a case series. Lancet Infect Dis. 2020;20(9):1051-1060.
Hung, I. F., Cheng, V. C., Li, X., Tam, A. R., Hung, D. L., Chiu, K. H., Yip, C. C., Cai, J. P., Ho, D. T., Wong, S. C., Leung, S. S., Chu, M. Y., Tang, M. O., Chen, J. H., Poon, R. W., Fung, A. Y., Zhang, R. R., Yan, E. Y., Chen, L. L., ... Yuen, K. Y. (2020). SARS-CoV-2 shedding and seroconversion among passengers quarantined after disembarking a cruise ship: a case series. The Lancet. Infectious Diseases, 20(9), 1051-1060. https://doi.org/10.1016/S1473-3099(20)30364-9
Hung IF, et al. SARS-CoV-2 Shedding and Seroconversion Among Passengers Quarantined After Disembarking a Cruise Ship: a Case Series. Lancet Infect Dis. 2020;20(9):1051-1060. PubMed PMID: 32539986.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - SARS-CoV-2 shedding and seroconversion among passengers quarantined after disembarking a cruise ship: a case series. AU - Hung,Ivan Fan-Ngai, AU - Cheng,Vincent Chi-Chung, AU - Li,Xin, AU - Tam,Anthony Raymond, AU - Hung,Derek Ling-Lung, AU - Chiu,Kelvin Hei-Yeung, AU - Yip,Cyril Chik-Yan, AU - Cai,Jian-Piao, AU - Ho,Deborah Tip-Yin, AU - Wong,Shuk-Ching, AU - Leung,Sally Sau-Man, AU - Chu,Man-Yee, AU - Tang,Milky Oi-Yan, AU - Chen,Jonathan Hon-Kwan, AU - Poon,Rosana Wing-Shan, AU - Fung,Agnes Yim-Fong, AU - Zhang,Ricky Ruiqi, AU - Yan,Erica Yuen-Wing, AU - Chen,Lin-Lei, AU - Choi,Charlotte Yee-Ki, AU - Leung,Kit-Hang, AU - Chung,Tom Wai-Hin, AU - Lam,Sonia Hiu-Yin, AU - Lam,Tina Poy-Wing, AU - Chan,Jasper Fuk-Woo, AU - Chan,Kwok-Hung, AU - Wu,Tak-Chiu, AU - Ho,Pak-Leung, AU - Chan,Johnny Wai-Man, AU - Lau,Chak-Sing, AU - To,Kelvin Kai-Wang, AU - Yuen,Kwok-Yung, Y1 - 2020/06/12/ PY - 2020/03/20/received PY - 2020/04/09/revised PY - 2020/04/17/accepted PY - 2020/6/17/pubmed PY - 2020/9/8/medline PY - 2020/6/17/entrez SP - 1051 EP - 1060 JF - The Lancet. Infectious diseases JO - Lancet Infect Dis VL - 20 IS - 9 N2 - BACKGROUND: A cruise ship is a closed-off environment that simulates the basic functioning of a city in terms of living conditions and interpersonal interactions. Thus, the Diamond Princess cruise ship, which was quarantined because of an onboard outbreak of COVID-19 in February, 2020, provides an opportunity to define the shedding pattern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and patient antibody responses before and after the onset of symptoms. METHODS: We recruited adult (≥18 years) passengers from Hong Kong who had been on board the Diamond Princess cruise ship docked in Yokohama, Japan in February, 2020. All participants had been found to be negative for SARS-CoV-2 by RT-PCR 4 days before disembarking and were transferred to further quarantine in a public estate in Hong Kong, where they were recruited. Participants were prospectively screened by quantitative RT-PCR (RT-qPCR) of nasopharyngeal and throat swabs, and serum IgG and IgM against internal nucleoprotein and the surface spike receptor-binding protein (RBD) of SARS-CoV-2 at baseline (upon entering quarantine) and on days 4, 8, and 12 of quarantine. FINDINGS: On Feb 22, 2020, 215 adults were recruited, of whom nine (4%; 95% CI 2-8) were positive for SARS-CoV-2 by RT-qPCR or serology and were hospitalised. Of these nine patients, nasopharyngeal swab RT-qPCR was positive in eight patients (89%; 57-99) at baseline. All nine patients were positive for anti-RBD IgG by day 8. Eight (89%; 57-99) were simultaneously positive for nasopharyngeal swab RT-PCR and anti-RBD IgG. One patient who was positive for anti-RBD IgG and had a negative viral load had multifocal peripheral ground-glass changes on high-resolution CT that were typical of COVID-19. Five patients (56%; 27-81) with ground-glass changes on high-resolution CT were found to have higher anti-nucleoprotein-IgG OD values on day 8 and 12 and anti-RBD IgG OD value on day 12 than patients without ground-glass changes. Six (67%; 35-88) patients remained asymptomatic throughout the 14-day quarantine period. INTERPRETATION: Patients with COVID-19 can develop asymptomatic lung infection with viral shedding and those with evidence of pneumonia on imaging tend to have an increased antibody response. Positive IgG or IgM confirmed infection of COVID-19 in both symptomatic and asymptomatic patients. A combination of RT-PCR and serology should be implemented for case finding and contact tracing to facilitate early diagnosis, prompt isolation, and treatment. FUNDING: Shaw Foundation Hong Kong; Sanming-Project of Medicine (Shenzhen); High Level-Hospital Program (Guangdong Health Commission). SN - 1474-4457 UR - https://www.unboundmedicine.com/medline/citation/32539986/SARS_CoV_2_shedding_and_seroconversion_among_passengers_quarantined_after_disembarking_a_cruise_ship:_a_case_series_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1473-3099(20)30364-9 DB - PRIME DP - Unbound Medicine ER -