Sewage as a Possible Transmission Vehicle During a Coronavirus Disease 2019 Outbreak in a Densely populated Community: Guangzhou, China, April 2020

SARS-CoV-2 has been identified in the fecal matter of COVID-19 patients. However, sewage transmission has never been shown. In April 2020, a COVID-19 outbreak occurred in a densely populated community in Guangzhou, China. We investigated this outbreak to identify the mode of transmission.

A home quarantined order was issued in the community. We collected throat swab samples from the residents and environmental samples from the surfaces inside and around the houses, and conducted RT-PCR testing and genome sequencing. We defined a case as a resident in this community with a positive RT-PCR test, with or without symptoms. We conducted a retrospective cohort study of all residents living in the same buildings as the cases to identify exposure risk factors.

We found eight cases (four couples) in this community of 2888 residents (attack rate=2.8/1000), with onset during April 5–21, 2020. During their incubation periods, Cases 1-2 frequented market T with an ongoing outbreak. Cases 3-8 never visited market T during incubation period, lived in separate buildings from, and never interacted with, Cases 1-2. Retrospective cohort study showed that working as cleaners or waste picker (RR=13, 95% CI_exact: 2.3-180), not changing to clean shoes after returning home (RR=7.4, 95% CI_exact: 1.8-34), collating and cleaning dirty shoes after returning home (RR=6.3, 95% CI_exact: 1.4-30) were significant exposure risk factors. Of 63 samples collected from street-sewage puddles and sewage-pipe surfaces, 19% tested positive for SARS-CoV-2. Of 50 environmental samples taken from cases’ apartments, 24% tested positive.

Viral genome sequencing showed that the viruses identified from the squat toilet and shoe-bottom dirt inside the apartment of Cases 1-2 were homologous with those from Cases 3-8 and those identified from sewage samples. The sewage pipe leading from the apartment of Cases 1-2 to the drainage had a large hole above ground. Rainfalls after the onset of Cases 1-2 flooded the streets.

Our investigation has for the first time pointed to the possibility that SARS-CoV-2 might spread by sewage. This finding highlighted the importance of sewage management, especially in densely-populated places with poor hygiene and sanitation measures, such as urban slums and other low-income communities in developing countries. ...