Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020

Wycliffe E. Wei, MPH; Zongbin Li, MBBS; Calvin J. Chiew, MPH; Sarah E. Yong, MMed; Matthias P. Toh, MMed; Vernon J. Lee, PhD


Morbidity and Mortality Weekly Report. 2020;69(14):411-415. 

In This Article

Abstract and Introduction


Presymptomatic transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), might pose challenges for disease control. The first case of COVID-19 in Singapore was detected on January 23, 2020, and by March 16, a total of 243 cases had been confirmed, including 157 locally acquired cases. Clinical and epidemiologic findings of all COVID-19 cases in Singapore through March 16 were reviewed to determine whether presymptomatic transmission might have occurred. Presymptomatic transmission was defined as the transmission of SARS-CoV-2 from an infected person (source patient) to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19. Seven COVID-19 epidemiologic clusters in which presymptomatic transmission likely occurred were identified, and 10 such cases within these clusters accounted for 6.4% of the 157 locally acquired cases. In the four clusters for which the date of exposure could be determined, presymptomatic transmission occurred 1–3 days before symptom onset in the presymptomatic source patient. To account for the possibility of presymptomatic transmission, officials developing contact tracing protocols should strongly consider including a period before symptom onset. Evidence of presymptomatic transmission of SARS-CoV-2 underscores the critical role social distancing, including avoidance of congregate settings, plays in controlling the COVID-19 pandemic.

Early detection and isolation of symptomatic COVID-19 patients and tracing of close contacts is an important disease containment strategy; however, the existence of presymptomatic or asymptomatic transmission would present difficult challenges to contact tracing. Such transmission modes have not been definitively documented for COVID-19, although cases of presymptomatic and asymptomatic transmissions have been reported in China.[1,2] and possibly occurred in a nursing facility in King County, Washington.[3] Examination of serial intervals (i.e., the number of days between symptom onsets in a primary case and a secondary case) in China suggested that 12.6% of transmission was presymptomatic.[2] COVID-19 cases in Singapore were reviewed to determine whether presymptomatic transmission occurred among COVID-19 clusters.

The surveillance and case detection methods employed in Singapore have been described.[4] Briefly, all medical practitioners were required by law to notify Singapore's Ministry of Health of suspected and confirmed cases of COVID-19. The definition of a suspected case was based on the presence of respiratory symptoms and an exposure history. Suspected cases were tested, and a confirmed case was defined as a positive test for SARS-CoV-2, using laboratory-based polymerase chain reaction or serologic assays.[5] All cases in this report were confirmed by polymerase chain reaction only. Asymptomatic persons were not routinely tested, but such testing was performed for persons in groups considered to be at especially high risk for infection, such as evacuees on flights from Wuhan, China,[6] or families that experienced high attack rates.

Patients with confirmed COVID-19 were interviewed to obtain information about their clinical symptoms and activity history during the 2 weeks preceding symptom onset to ascertain possible sources of infection. Contact tracing examined the time from symptom onset until the time the patient was successfully isolated to identify contacts who had interactions with the patient. All contacts were monitored daily for their health status, and those who developed symptoms were tested as part of active case finding.

Clinical and epidemiologic data for all 243 reported COVID-19 cases in Singapore during January 23–March 16 were reviewed. Clinical histories were examined to identify symptoms before, during, and after the first positive SARS-CoV-2 test.

Records of cases that were epidemiologically linked (clusters) were reviewed to identify instances of likely presymptomatic transmission. Such clusters had clear contact between a source patient and a patient infected by the source (a secondary patient), had no other likely explanations for infection, and had the source patient's date of symptom onset occurring after the date of exposure to the secondary patient who was subsequently infected. Symptoms considered in the review included respiratory, gastrointestinal (e.g., diarrhea), and constitutional symptoms. In addition, the source patient's exposure had to be strongly attributed epidemiologically to transmission from another source. This reduced the likelihood that an unknown source was involved in the cases in the cluster.