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The
new england journal
of
medicine
n engl j med 382;10 nejm.org March 5, 2020
Cor responde nce
Transmission of 2019-nCoV Infection
from an Asymptomatic Contact in Germany
To the Editor: The novel coronavirus (2019-
nCoV) from Wuhan is currently causing concern
in the medical community as the virus is spread-
ing around the world.
1
Since identification of the
virus in late December 2019, the number of cases
from China that have been imported into other
countries is on the rise, and the epidemiologic
picture is changing on a daily basis. We are re-
porting a case of 2019-nCoV infection acquired
outside Asia in which transmission appears to
have occurred during the incubation period in
the index patient.
A 33-year-old otherwise healthy German busi-
nessman (Patient 1) became ill with a sore throat,
chills, and myalgias on January 24, 2020. The
following day, a fever of 39.1°C (102.4°F) devel-
oped, along with a productive cough. By the
evening of the next day, he started feeling better
and went back to work on January 27.
Before the onset of symptoms, he had attended
meetings with a Chinese business partner at his
company near Munich on January 20 and 21.
The business partner, a Shanghai resident, had
visited Germany between Januar y 19 and 22.
During her stay, she had been well with no signs
or symptoms of infection but had become ill on
her flight back to China, where she tested posi-
tive for 2019-nCoV on January 26 (index patient
in Fig. 1) (see Supplementary Appendix, available
at NEJM.org, for details on the timeline of symp-
tom development leading to hospitalization).
On January 27, she informed the company
about her illness. Contact tracing was started,
and the above-mentioned colleague was sent to
the Division of Infectious Diseases and Tropical
Medicine in Munich for further assessment. At
presentation, he was afebrile and well. He re-
ported no previous or chronic illnesses and had
no history of foreign travel within 14 days before
the onset of symptoms. Two nasopharyngeal
swabs and one sputum sample were obtained
and were found to be positive for 2019-nCoV on
quantitative reverse-transcriptase–polymerase-
chain-reaction (qRT-PCR) assay.
2
Follow-up qRT-
PCR assay revealed a high viral load of 10
8
copies
per milliliter in his sputum during the following
days, with the last available result on January 29.
On January 28, three additional employees at
the company tested positive for 2019-nCoV (Pa-
tients 2 through 4 in Fig. 1). Of these patients,
only Patient 2 had contact with the index patient;
the other t wo patients had contact only with
Patient 1. In accordance with the health au-
thorities, all the patients with conf irmed 2019-
nCoV infection were admitted to a Munich infec-
tious diseases unit for clinical monitoring and
isolation. So far, none of the four conf irmed
patients show signs of severe clinical illness.
This case of 2019-nCoV infection was diag-
nosed in Germany and transmitted outside Asia.
However, it is notable that the infection appears
to have been transmitted during the incubation
period of the index patient, in whom the illness
was brief and nonspecific.
3
The fact that asymptomatic persons are po-
tential sources of 2019-nCoV infection may war-
this week's letters
970 Transmission of 2019-nCoV Infection from an
Asymptomatic Contact in Germany
972 Dapagliflozin in Patients with Heart Failure and
Reduced Ejection Fraction
974 A Smartwatch to Identify Atrial Fibrillation
976 Focused Cardiac Ultrasonography for Left
Ventricular Systolic Function
The New England Journal of Medicine
Downloaded from nejm.org on April 11, 2020. For personal use only. No other uses without permission.
Copyright © 2020 Massachusetts Medical Society. All rights reserved.
Cor re spondence
n engl j med 382;10 nejm.org March 5, 2020
rant a reassessment of transmission dynamics of
the current outbreak. In this context, the detec-
tion of 2019-nCoV and a high sputum viral load
in a convalescent patient (Patient 1) arouse con-
cern about prolonged shedding of 2019-nCoV
after recovery. Yet, the viability of 2019-nCoV
detected on qRT-PCR in this patient remains to
be proved by means of viral culture.
Despite these concerns, all four patients who
were seen in Munich have had mild cases and
were hospitalized primarily for public health
purposes. Since hospital capacities are limited
— in particular, given the concurrent peak of
the influenza season in the northern hemi-
sphere — research is needed to determine
whether such patients can be treated with ap-
propriate guidance and oversight outside the
hospital.
Camilla Rothe, M.D.
Mirjam Schunk, M.D.
Peter Sothmann, M.D.
Gisela Bretzel, M.D.
Guenter Froeschl, M.D.
Claudia Wallrauch, M.D.
Thorbjörn Zimmer, M.D.
Verena Thiel, M.D.
Christian Janke, M.D.
University Hospital LMU Munich
Munich, Germany
rothe@lrz.uni-muenchen.de
Wolfgang Guggemos, M.D.
Michael Seilmaier, M.D.
Klinikum Mü nchen-Schwabing
Munich, Germany
Christian Drosten, M.D.
Charité Universitätsmedizin Berlin
Berlin, Germany
Patrick Vollmar, M.D.
Katrin Zwirglmaier, Ph.D.
Sabine Zange, M.D.
Roman Wölfel, M.D.
Bundeswehr Institute of Microbiology
Munich, Germany
Michael Hoelscher, M.D., Ph.D.
University Hospital LMU Munich
Munich, Germany
Disclosure forms provided by the authors are avail able wit h
the fu ll text of th is letter at NEJM.org.
This letter was published on Januar y 30, 2020, and updated on
February 6, 2020, at NEJM.org.
1 . Zhu N, Zhang D, Wang W, et al. A novel coronavi rus f rom
patient s with pneumonia in China, 2019. N Engl J Med 2020; 382:
727-33.
2 . Corman V, Bleicker T, Brün ink S, et al. Diag nostic detec-
tion of Wuha n coronavirus 2019 by rea l-time RT-PCR. Geneva:
World Health Organizat ion, January 13, 2020 (https://w ww
. who . int/ docs/ default - source/ coronaviruse/ wuhan - vi rus - assay
- v1991527e5122341d99287a1b17c111902 . pdf).
3 . Callaway E, Cyranosk i D. China coronavirus: si x questions
scientists are asking. Nature 2020; 577: 605-7.
DOI: 10.1056/NEJMc2001468
Figure 1. Timeline of Exposure to Index Patient with Asymptomatic 2019-CoV Infection in Germany.
Jan.
29
Jan.
28
Jan.
27
Jan.
26
Jan.
25
Jan.
24
Jan.
23
Jan.
22
Jan.
21
Jan.
20
Jan.
19
Date
Patient 1 Attended business
meetings
Symptoms
Positive PCR
Patient 2 Attended business
meetings
Symptoms
Positive PCR
Index Patient
Attended business
meetings
SymptomsVisit to Germany
Flight to
China
Positive PCR
Patient 3 Symptoms
Positive PCR
C C
Symptoms
Patient 4
Positive PCR
CCCC
Contact with Patient 1
C
The New England Journal of Medicine
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Copyright © 2020 Massachusetts Medical Society. All rights reserved.
... This patient had no symptoms but ground-glass lung opacities were detected in radiography [14]. Also, in a report from Germany, transmission of COVID-19 after probable direct contact with asymptomatic subjects was mentioned [15]. In previous reports about SARS and MERS, asymptomatic patients reached 7.5 % and 25% respectively [16,17]. ...
... In previous reports about SARS and MERS, asymptomatic patients reached 7.5 % and 25% respectively [16,17]. Weak immune response or other routes of transmission may possibly influence asymptomatic presentation of COVID-19 [15,18]. Whether the fecal-oral route plays a role in this respect calls for further investigation. ...
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Diagnostic detection of Wuhan coronavirus 2019 by real-time RT-PCR. Geneva: World Health Organization
  • V Corman
  • T Bleicker
  • S Brünink
Corman V, Bleicker T, Brünink S, et al. Diagnostic detection of Wuhan coronavirus 2019 by real-time RT-PCR. Geneva: World Health Organization, January 13, 2020 (https://www . who. int/ docs/ default -source/ coronaviruse/ wuhan -virus -assay -v1991527e5122341d99287a1b17c111902. pdf).
China coronavirus: Six questions scientists are asking
  • Callaway E.
  • Cyranoski D.