Persistent viral shedding of SARS‐CoV‐2 in faeces – a rapid review

  1. S. Gupta
  2. J. Parker
  3. S. Smits
  4. J. Underwood
  5. S. Dolwani

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Abstract

Aim

In addition to respiratory symptoms, COVID‐19 can present with gastrointestinal complaints suggesting possible faeco‐oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS‐CoV‐2 in patients with COVID‐19.

Methods

A systematic literature review identified studies describing COVID‐19 patients tested for faecal virus. Search terms for MEDLINE included ‘clinical’, ‘faeces’, ‘gastrointestinal secretions’, ‘stool’, ‘COVID‐19’, ‘SARS‐CoV‐2’ and ‘2019‐nCoV’. Additional searches were done in the American Journal of Gastroenterology , Gastroenterology , Gut , Lancet Gastroenterology and Hepatology , the World Health Organization Database, the Centre for Evidence‐Based Medicine, New England Journal of Medicine , social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco‐oral transmission of the virus.

Results

Twenty‐six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID‐19 is transmitted via faecally shed virus.

Conclusion

There is a high rate of positive polymerase chain reaction tests with persistence of SARS‐CoV‐2 in faecal samples of patients with COVID‐19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco‐oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

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  1. ScreenIT

    SciScore for 10.1101/2020.04.17.20069526: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.
    Cell Line AuthenticationAuthentication: Study identification: Articles were sorted alphabetically by author name and divided between two reviewers (SG and JP).

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Medline was searched to find articles published until 3 April 2020.
    Medline
    suggested: (MEDLINE, RRID:SCR_002185)
    COVID-19 preprints published until 10 April 2020 on medRxiv and bioRxiv and an independent search on social media (Twitter) by the authors (SS, SD) supplemented more articles.
    bioRxiv
    suggested: (bioRxiv, RRID:SCR_003933)
    The same process was used for full text articles and this data was managed through EndNote.
    EndNote
    suggested: (EndNote, RRID:SCR_014001)
    Data extraction: The final data extraction was also carried by the two reviewers (JP and SG) and managed through Microsoft Excel files.
    Microsoft Excel
    suggested: (Microsoft Excel, RRID:SCR_016137)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: Despite finding a high incidence of positive faecal samples for SARS-CoV-2 in the included studies, our review cannot confirm the true population prevalence of positive faecal samples or the rate of false negatives. This is due to the significant variability in study design which is an inherent problem with COVID-19 research at present. This heterogeneity was not formally assessed due to it being a rapid review but can be clearly identified on inspection of the study designs and outcomes. The variability in patient numbers and characteristics, sample timing, sample nature (faecal samples vs. anal or faecal swabs) and follow up testing should be considered when interpreting the reliability of the results. If other studies confirm viable virus in stool, then methods of culture also need to be described and standardised for comparison and replication in other populations. The majority of the included studies are small, heterogenous, retrospective and often did not assess viral shedding in the faeces as their primary aim. At present however this is the only evidence available. There were two foreign language articles excluded due to lack of translation resources. The pre-prints are not peer reviewed and therefore should be trusted with caution. Conclusion: The duration of viral shedding in the faeces is mostly reported from 1 to 33 days after a negative nasopharyngeal swab but can continue for up to 47 days after onset of symptoms in patients with COVID-19. These pos...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1111/codi.15138
  3. Version published to 10.1101/2020.04.17.20069526 on medRxiv