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Review
. 2020 Dec 20:749:141364.
doi: 10.1016/j.scitotenv.2020.141364. Epub 2020 Jul 31.

Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19

David L Jones  1 , Marcos Quintela Baluja  2 , David W Graham  2 , Alexander Corbishley  3 , James E McDonald  4 , Shelagh K Malham  5 , Luke S Hillary  4 , Thomas R Connor  6 , William H Gaze  7 , Ines B Moura  8 , Mark H Wilcox  9 , Kata Farkas  10
Affiliations
Review

Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19

David L Jones et al. Sci Total Environ. .

Abstract

The recent detection of SARS-CoV-2 RNA in feces has led to speculation that it can be transmitted via the fecal-oral/ocular route. This review aims to critically evaluate the incidence of gastrointestinal (GI) symptoms, the quantity and infectivity of SARS-CoV-2 in feces and urine, and whether these pose an infection risk in sanitary settings, sewage networks, wastewater treatment plants, and the wider environment (e.g. rivers, lakes and marine waters). A review of 48 independent studies revealed that severe GI dysfunction is only evident in a small number of COVID-19 cases, with 11 ± 2% exhibiting diarrhea and 12 ± 3% exhibiting vomiting and nausea. In addition to these cases, SARS-CoV-2 RNA can be detected in feces from some asymptomatic, mildly- and pre-symptomatic individuals. Fecal shedding of the virus peaks in the symptomatic period and can persist for several weeks, but with declining abundances in the post-symptomatic phase. SARS-CoV-2 RNA is occasionally detected in urine, but reports in fecal samples are more frequent. The abundance of the virus genetic material in both urine (ca. 102-105 gc/ml) and feces (ca. 102-107 gc/ml) is much lower than in nasopharyngeal fluids (ca. 105-1011 gc/ml). There is strong evidence of multiplication of SARS-CoV-2 in the gut and infectious virus has occasionally been recovered from both urine and stool samples. The level and infectious capability of SARS-CoV-2 in vomit remain unknown. In comparison to enteric viruses transmitted via the fecal-oral route (e.g. norovirus, adenovirus), the likelihood of SARS-CoV-2 being transmitted via feces or urine appears much lower due to the lower relative amounts of virus present in feces/urine. The biggest risk of transmission will occur in clinical and care home settings where secondary handling of people and urine/fecal matter occurs. In addition, while SARS-CoV-2 RNA genetic material can be detected by in wastewater, this signal is greatly reduced by conventional treatment. Our analysis also suggests the likelihood of infection due to contact with sewage-contaminated water (e.g. swimming, surfing, angling) or food (e.g. salads, shellfish) is extremely low or negligible based on very low predicted abundances and limited environmental survival of SARS-CoV-2. These conclusions are corroborated by the fact that tens of million cases of COVID-19 have occurred globally, but exposure to feces or wastewater has never been implicated as a transmission vector.

Keywords: Bathing waters; Fecal-oral route; Infection risk; Sanitation; Waterborne illness.

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Conflict of interest statement

Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Unlabelled Image
Graphical abstract
Fig. 1
Fig. 1
Summary of symptoms experienced in clinically reported SARS-CoV-2 infections. The data is the summary of 48 independent reports involving a total of 3706 patients. The yellow bars are those associated with gastrointestinal problems. In the box plots, the boundary of the box closest to zero indicates the 25th percentile, a black line within the box marks the median, and the boundary of the box farthest from zero indicates the 75th percentile. Whiskers above and below the box indicate the 10th and 90th percentiles. Points above and below the whiskers indicate outliers outside the 10th and 90th percentiles. The average size of the cohort studies was 79 ± 21 (n = 48). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 2
Fig. 2
Temporal dynamics of SARS-CoV-2 in the sputum, throat and stools. Data are from a cohort (n = 32) of COVID-19 patients in China. Adapted from Huang et al. (2020a) and Huang et al. (2020b).
Fig. 3
Fig. 3
Prevalence of human pathogenic viruses in nasopharyngeal and stool samples from individuals (n = 331). The points represent individual viruses including Human Coronavirus (HCoV), Influenza A, Influenza B, Human Rhinovirus (HRV), Respiratory syncytial virus (RSV), Human Adenovirus (HAdV), Human Bocavirus (HBoV) and Human Parainfluenzavirus (HPIV). Data calculated from Minodier et al. (2017).
Fig. 4
Fig. 4
Main routes by which SARS-CoV-2 leaves the body (left), and a summary of the mechanism of viral replication (right).
Fig. 5
Fig. 5
Summary of the main infection pathways by which SARS-CoV-2 can theoretically contaminate the environment and cause secondary infections. The numbers denote the major pathogen transport routes and exposure points: (1) contamination of toilets by infected individuals, aerosolization of feces/urine, faulty plumbing in buildings (2) pathogen transfer in the sewer network and potential exposure to sanitation workers in the sewer network, (3) discharge of untreated contaminated wastewater to rivers (sewer overflows), (4) release in bioaerosols from wastewater treatment plants and exposure of workers to potentially contaminated wastewater, (5) release of treated wastewater to rivers, (6) disposal of wastewater-derived biosolids to land, (7) transport in freshwater and exposure of individuals during recreational activities, (8) abstraction of river water for human consumption, (9) breaks in sewage pipes leading to groundwater contamination (10) hospital/medical centre release of wastewater, (11) contamination of groundwater from burial of infected bodies, (12) irrigation of crops with potentially contaminated water abstracted from rivers, (13) contamination of marine waters, dispersal in the coastal zone and potential contamination of fish/shellfish and people engaging in recreational activities.
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