Top 10: September 2

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By Christian Hoffmann &
Bernd S. Kamps


2 September


Kang M, Wi J, Yuan J, et al. Probable Evidence of Fecal Aerosol Transmission of SARS-CoV-2 in a High-Rise Building. Ann Intern Med 2020, published 1 September. Full-text:

Nanshan Zhong, Min Kang and colleagues report 9 infected patients in 3 families. While the first family had a history of travel to the coronavirus disease 2019 (COVID-19) epicenter Wuhan, the other 2 families had no travel history and a later onset of symptoms. The families lived in 3 vertically aligned flats connected by drainage pipes in the master bathrooms. The authors suggest that virus-containing fecal aerosols may have been produced in the associated vertical stack during toilet flushing after use by the index patients. This report reminds us of a SARS-1 outbreak in March 2003 among residents of Amoy Gardens, Hong Kong, with a total of 320 SARS cases in less than three weeks (see, page 65).

See also the comment by Michael Gormley [Gormley M. SARS-CoV-2: The Growing Case for Potential Transmission in a Building via Wastewater Plumbing Systems. Ann Intern Med 2020, published 1 September. Full-text:] concludes that that wastewater plumbing systems, particularly those in high-rise buildings, deserve closer investigation, both immediately in the context of SARS-CoV-2 and in the long term, because they may be a reservoir for other harmful pathogens.


Deng W, Bao L, Gao H, et al. Ocular conjunctival inoculation of SARS-CoV-2 can cause mild COVID-19 in rhesus macaques. Nat Commun 11, 4400 (2020). Full-text:

If you are exploring extra-respiratory routes of SARS-CoV-2 transmission, read the article by Chuan Qin, Wei Deng and colleagues. The authors inoculated five rhesus macaques with SARS-CoV-2 conjunctivally, intratracheally, and intragastrically. The conjunctivally infected animal had a higher viral load in the nasolacrimal system than the intratracheally infected animal but also showed mild interstitial pneumonia, suggesting distinct viral distributions.



Vermaa S, Dhanak M, Frankenfield J. Visualizing droplet dispersal for face shields and masks with exhalation valves featured. Physics of Fluids 32, 091701 (2020). Full-text;

Are you tempted to substitute your standard surgical masks for clear plastic face shields? Don’t, recommend Siddhartha Verma, Manhar Dhanak and John Frankenfield! Find out why widespread public use of plastic face shields could have an adverse effect on mitigation efforts.



Gudbjartsson DF, Norddahl GL, Melsted P, et al. Humoral Immune Response to SARS-CoV-2 in Iceland. N Engl J Med 2020, published 1 September. Full-text:

How long will people be protected from reinfection by SARS-CoV-2? Generally, many months, as may be expected from a coronavirus infection. In this study by Kari Stefansson, Daniel Gudbjartsson and colleagues, over 90% of 1,215 qPCR-positive persons tested positive with two pan-Ig SARS-CoV-2 antibody assays and remained seropositive 120 days after diagnosis, with no decrease of antibody levels. Another piece of good news: the infection fatality risk in Iceland was 0.3%. Less good news: only 0.9% of Icelanders were infected with SARS-CoV-2 indicating that the Icelandic population is vulnerable to a second wave of infection.

See also the editorial by Galit Alter and Robert Seder: Alter G, Seder R: The Power of Antibody-Based Surveillance. N Engl J Med 2020, published 1 September. Full-text: In particular, they stress the utility of antibody assays as highly cost-effective alternatives to PCR testing for population-level surveillance, which is critical to the safe reopening of cities and schools.


Varadé J, Magadán S, González-Fernández Á. Human immunology and immunotherapy: main achievements and challenges. Cell Mol Immunol 2020, published 2 September. Full-text:

The review for your next sleepless night – 18 pages and 332 references. The trio Jezabel Varadé, Susana Magadán and África González-Fernández will take you on a trip to the past and the future of immunotherapy.



Giamarellos-Bourboulis EJ, Tsilika M, Moorlag S. ACTIVATE: randomized clinical trial of BCG vaccination against infection in the elderly. Cell 2020, published 31 August. Full-text:

In this double-blind, randomized trial, 198 elderly patients received BCG or placebo vaccine at hospital discharge and were followed for 12 months. At interim analysis (78 patients allocated to placebo vaccination and 72 patients allocated to BCG vaccination), Evangelos Giamarellos-Bourboulis et al. found that BCG vaccination significantly increased the time to first infection (median 16 weeks compared to 11 weeks after placebo). The incidence of new infections was 42.3% after placebo vaccination and 25.0% after BCG vaccination; most of the protection was against respiratory tract infections of probable viral origin. Any effect on SARS-CoV-2 infection? The number of individuals participating in the trial was too low to allow for any conclusions. Larger trials will provide the answer.



Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 2020, published 1 September. Full-text:

In this ‘living review’ and meta-analysis of 77 studies, Shakila Thangaratinam, John Allotey and colleagues warn that pregnant women are less likely to manifest COVID-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for COVID-19. Unsurprisingly, risk factors for severe COVID-19 in pregnancy would include increasing maternal age, high body mass index, and pre-existing comorbidities.



Kishore N, Kiang MV, Engø-Monsen K, et al. Measuring mobility to monitor travel and physical distancing interventions: a common framework for mobile phone data analysis. Lancet Digital Health 2020, published 1 September. Full-text:

Google and Apple will soon be loading our mobile phones with coronavirus-tracking technology and use our mobility data to monitor physical distancing (see The Guardian). Will they respect the principles of privacy and data protection? Now Caroline Buckee, Nishant Kishore and colleagues describe a common syntax for how aggregated data are used in research and policy. The authors argue that data protection are vital in assessing more technical aspects of aggregation and should be an important central feature to guide partnerships with governments who make use of research products.



If you read Spanish, read Ansede M. Expertos de la OMS alertan de que una vacuna aprobada con prisas podría “empeorar” la pandemia. El País 2020, published 1 September. Full-text:

Los científicos critican “las presiones políticas y económicas” para autorizar inyecciones experimentales cuanto antes. Among other artices, Manuel Ansede discusses Krause P, Fleming TR, Longini I, Henao-Restrepo AM, Peto R; World Health Organization Solidarity Vaccines Trial Expert Group. COVID-19 vaccine trials should seek worthwhile efficacy. Lancet. 2020 Aug 27:S0140-6736(20)31821-3. PubMed: Full-text:



If you read French, read the following articles:

Vaudano M, Dagoern G, Sénécat A : Coronavirus : pourquoi tant de contaminations et si peu de morts ? Le Monde 2020, publié le 29 août. Lien :

Le nombre de cas confirmés de Covid-19 augmente régulièrement depuis le milieu de l’été, mais le bilan humain reste relativement stable. Rien ne permet, pour autant, de prévoir la fin de l’épidémie.


Dagorn G. Coronavirus : masque, densité, aération… évaluez le risque de transmission en un coup d’œil. Le Monde 2020, publié le 1 septembre. Lien :

Les risques de contamination varient grandement en fonction du type d’activité, du milieu et de la circulation de l’air. Voici comment vous y retrouver.