Symptomatic, Presymptomatic, and Asymptomatic Transmission of SARS-CoV-2 in a University Student Population, August-November 2020

Objectives: The impact and risk of SARS-CoV-2 transmission from asymptomatic and presymptomatic hosts remains an open question. This study measured the secondary attack rates (SARs) and relative risk (RR) of SARS-CoV-2 transmission from asymptomatic and presymptomatic index cases as compared with symptomatic index cases. Methods: We used COVID-19 test results, daily health check reports, and contact tracing data to measure SARs and corresponding RRs among close contacts of index cases in a cohort of 12 960 young adults at the University of Notre Dame in Indiana for 103 days, from August 10 to November 20, 2020. Further analysis included Fisher exact tests to determine the association between symptoms and COVID-19 infection and z tests to determine statistical differences between SARs. Results: Asymptomatic rates of transmission of SARS-CoV-2 were higher (SAR = 0.19; 95% CI, 0.14-0.24) than was estimated in prior studies, producing an RR of 0.75 (95% CI, 0.54-1.07) when compared with symptomatic transmission. In addition, the transmission rate associated with presymptomatic cases (SAR = 0.25; 95% CI, 0.21-0.30) was approximately the same as that for symptomatic cases (SAR = 0.25; 95% CI, 0.19-0.31). Furthermore, different symptoms were associated with different transmission rates. Conclusions: Asymptomatic and presymptomatic hosts of SARS-CoV-2 are a risk for community spread of COVID-19, especially with new variants emerging. Moreover, typical symptom checks may easily miss people who are asymptomatic or presymptomatic but still infectious. Our study results may be used as a guide to analyze the spread of SARS-CoV-2 variants and help inform appropriate public health measures as they relate to asymptomatic and presymptomatic cases.