Characteristics associated with household transmission of SARS-CoV-2 in Ontario, Canada

Abstract BACKGROUND Within-household transmission of SARS-CoV-2 infection has been identified as one of the main sources of spread of COVID-19 after lockdown restrictions and self-isolation guidelines are implemented. Secondary attack rates among household contacts are estimated to be five to ten times higher than among non-household contacts, but it is unclear which individuals are more prone to transmit infection within their households. METHODS Using address matching, a cohort was assembled of all laboratory-confirmed cases of COVID-19 residing in private households in Ontario, Canada. Descriptive analyses were performed to compare characteristics of cases in households that experienced secondary transmission versus those that did not. Logistic regression models were fit to determine index case characteristics and neighbourhood characteristics associated with transmission. FINDINGS Between January and July, 2020, there were 26,152 cases of COVID-19 residing in 21,226 households. Longer testing delays (≥5 days versus 0 days OR=3·02, 95% CI: 2·53 - 3·60) and male sex (OR=1·28, 95% CI: 1·18 - 1·38) were associated with greater odds of household secondary transmission, while being a healthcare worker (OR=0·56, 95% CI: 0·50 - 0·62) was associated with lower odds of transmission. Neighbourhoods with larger average economic family size and a higher proportion of households with multiple persons per room were also associated with greater odds of transmission. INTERPRETATION It is important for individuals to get tested for SARS-CoV-2 infection as soon as symptoms appear, and to isolate away from household contacts; this is particularly important in neighbourhoods with large family sizes and/or crowded households. FUNDING This study was supported by Public Health Ontario. Research in Context EVIDENCE BEFORE THIS STUDY We searched PubMed and Google Scholar up to September 3, 2020 to identify individual-level cohort studies or meta-analyses on household transmission of COVID-19. We used the search terms (“COVID” OR “SARS-CoV-2”) AND (“household” [Title]), and also reviewed the reference lists of any studies found during the search to identify additional studies. We considered studies that reported secondary attack rates and/or other measures of association (i.e., relative risk, odds ratio, or hazard ratio) for household transmission. We did not consider any modelling studies, studies that focused specifically on children, or small case studies that included less than three households. The search returned 53 studies, of which 51 were included in three meta-analyses. Pooled household secondary attack rates from the three meta-analyses were 19%, 27%, and 30%; secondary attack rates in households were estimated to be five to ten times as high as in non-household settings. Most studies were conducted in Asia and identified households from contact tracing, with individual studies reporting on fewer than 6000 households. Most studies did not consider households with no secondary transmission, and focused on a limited set of secondary case characteristics. ADDED VALUE OF THIS STUDY We applied an address matching algorithm, which identified 21,226 private households of laboratory-confirmed cases of COVID-19 in Ontario, Canada. Ontario has the advantage of a universal healthcare system and population-wide data for the entire province. To our knowledge, this study contains the largest number of private households with at least one confirmed case of COVID-19. We compared a variety of individual- and neighbourhood-level characteristics of households with and without secondary transmission. We also applied logistic regression models to determine index case characteristics associated with transmission, which gave important insights into factors that may help reduce secondary transmission in households. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE Findings from this study and existing evidence suggest that testing delays and household crowding play important roles in whether household secondary transmission occurs. Odds of household transmission may be reduced by cases seeking testing as soon as symptoms appear, and self-isolating outside the home or in a room alone if possible. These strategies may be considered by public health officials to reduce household transmission and mitigate local spread of COVID-19. Future research should further investigate the role of children and youth in household transmission.

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