Systematic Review With Meta-analysis

SARS-CoV-2 Stool Testing and the Potential for Faecal-oral Transmission

Amarylle S. van Doorn; Berrie Meijer; Chris M. A. Frampton; Murray L. Barclay; Nanne K. H. de Boer


Aliment Pharmacol Ther. 2020;52(8):1276-1288. 

In This Article


Literature Search

This systematic literature search was performed following the PRISMA guidelines and conducted using the Embase database, Google scholar, The MEDLINE database through PubMed and The Cochrane Library from the outbreak in December 2019 until the 17 June 2020. The search strategy can be found in Online Supplement 1.

All articles were imported to Mendeley (version 1.17.6), and duplicates were removed. Extensive cross-checking of reference lists of the included articles and other reviews was performed. As a result of the rapidly evolving research field concerning COVID −19, we also included journal pre-proof articles.

Study Selection

All articles were screened based on title and abstract. Studies were included when the following inclusion criteria were met:

  1. Study population: Human COVID-19 patients (both adult and paediatric patients) tested for COVID-19 in gastrointestinal specimens (eg stool samples or anal swabs);

  2. Study design: case reports/case series, cohort studies, case-control studies and randomised controlled trials.

We excluded articles written before December 2019, when the article or abstract/outcomes were not available in English, Dutch or German and when the results or quality of data were ambiguous. Papers written in Chinese, of which the abstract contained sufficient data to provide answers to our research questions, were included for analysis and data extraction. We excluded articles in which follow-up data were insufficient (ie when results of stool testing were not mentioned). Review articles were not included, however, reference lists were scrutinised for additional articles.

Data Extraction

We collected the following data from the eligible original articles: study design, geographic location, study period, number of patients, age, types of tested specimens, number of tested specimens, methods of the performed tests, duration and prevalence of positive test results in different specimens, disease severity, gastrointestinal symptoms, endoscopic results, specific evidence supporting faecal-oral transmission and remarkable patient/population characteristics.

Data were subsequently analysed with descriptive statistics. Relevant data were tabulated with a subdivision by study population size. All studies with population of at least 10 patients were included in the meta-analysis.

Statistical Analysis

A weighted pooled estimate of the proportion testing positive from the stool samples was calculated using the Freeman-Tukey arcsine square root transformation under a random effects model. This analysis was undertaken using MedCalc® v19.4.0. The heterogeneity in the estimates between studies was statistically tested using Cochran's Q statistic and summarised as I2.