key: cord-0718187-az9e2byy authors: Liu, Shih‐Feng; Kuo, Nai‐Ying; Kuo, Ho‐Chang title: Three Taiwan's domestic family cluster infections of coronavirus disease 2019 date: 2020-05-10 journal: J Med Virol DOI: 10.1002/jmv.25949 sha: bb4b07ea340ec1ef42d3f127e7a3c7461bb29c3b doc_id: 718187 cord_uid: az9e2byy Since the first case of coronavirus disease 2019 (COVID‐19) was identified in Taiwan 2020.01.21. Several family cluster infections were found later. This study aimed to report family cluster infections and observe subsequent development. We collected domestic family cluster infections among COVID‐19 confirmed cases from 21 January 2020 to 16 March 2020. There were three domestic family clusters infections in this period. The first cluster was cases 19 to 23. The infectious source was a Taiwanese passenger from Zhejiang. The second cluster was cases 24 to 26 and the third cluster was cases 27 to 32. The infectious sources of the latter clusters are currently uncertain. All contacts of three clusters have been isolated and no new confirmed cases have been identified to date. Some measures which have reduced the spread of these three clusters included: First, high suspicion of COVID‐19 for unexplained pneumonia is very important for early detection. Second, immediate epidemic investigation is taken especially COVID‐19 is infectious during the incubation period. Third, when the second and third clusters could not find infectious sources, CECC's press conference let the public know immediately the epidemic situation, so that people could raise their awareness and seek medical treatment or quarantine. In December 2019, since coronavirus disease 2019 (COVID- 19) was confirmed that the pathogen was severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), 1-4 many countries around the world have been infected in recent months. 5 The WHO announced that the COVID-19 epidemic was listed as an international public health emergency. 6 Taiwan is adjacent to mainland China and there are many cultural and economic exchanges and tourism between the two sides of Taiwan straits. [7] [8] [9] Taiwan is at great risk from being infected by SARS-CoV2. 7 Since the first case of COVID-19 was identified in Taiwan 2020.01. 21 Nai-Ying Kuo is co-first author. Having new cases in Taiwan, or major changes in the international epidemic situation, the CECC will hold a press conference to tell people about Taiwan case epidemic information and corresponding strategies. Therefore, all people, medical institutions, and health unit personnel can understand the epidemic and work together to cope with COVID-19. This study aims to report the domestic family cluster infection of COVID-19 in Taiwan, to explore the public health strategy of Taiwan's government and to observe the development of subsequent epidemics. We collected cases of family cluster infection among COVID-19 confirmed cases from 21 January 2020 to 16 Case definitions for confirmed cases meet laboratory diagnosis criteria, regardless of clinical signs and symptoms. 13 The laboratory diagnosis criteria show one or more of the following: (a) Pathogen (SARS-CoV-2) isolated and identified from a clinical specimen (nasopharyngeal swab, throat swab, expectorated sputum, or lower respiratory tract aspirates) and (b) Positive molecular biological testing for viral (SARS-CoV-2) RNA from a clinical specimen (nasopharyngeal swab, throat swab, expectorated sputum, or lower respiratory tract aspirates). 14 This is a retrospective study. Patient information was obtained from the content of CECC's press conference and the Taiwan CDC website. 12 The authors who do not know the patient's additional personal information will not involve privacy and personal security. In the face of the sudden outbreak of COVID-19, we do not know where the patients are, nor can we obtain the patient's informed consent. Given that the rights of patients are not infringed and the medical knowledge thus obtained can help more patients, I believe scholars will have the same consensus. We collected cases of domestic family cluster infection among COVID-19 confirmed cases from 21 January 2020 to 16 March 2020. The first domestic family cluster is cases 19 to 23 (Figures 1 and 2 The second domestic family cluster is cases 24 to 26 ( Figure 3 ). Although the friend's test was negative, he was not excluded from being an Index patient. Case 28 and 31 is asymptomatic and lives with case 27.30. They were infected by case 27 or case 30 who was during the incubation period or after the onset of symptoms. However, CECC is still logged as the index patient was not found in this cluster. SARS cases are infectious only during their symptomatic period and are noninfectious during the incubation period. 18 Evidence has demonstrated that human-to-human transmission of 2019 novel coronaviruses has occurred among close contacts, [19] [20] [21] even during the incubation period. 22 Therefore, the determination of close contacts should also include those who are exposed to case-patients during their incubation. The incubation period of COVID-19 is considered to be within 14 days after exposure, and most cases occur about 4 to 5 days after exposure. 19, 21, 23 However, the interval at which individuals with COVID-19 are infected is uncertain. It seems that SARS-CoV-2 can spread before symptoms appear and throughout the disease. 24 The severity of COVID-19 symptoms ranges from very mild to severe. 23, [26] [27] [28] [29] [30] [31] [32] [33] The patients, who are older or have underlying diseases, may be at higher risk of serious illness. The most common symptoms are fever and cough. 23, [26] [27] [28] [29] [30] In addition, there are gastrointestinal symptoms, sore throat, runny nose, etc. The symptoms may vary depending on the progress of the disease and individual differences. Owing to some patients with COVID-19 has early symptoms that are not obvious and without fever, some of them are mild or asymptomatic 31, 32 (for example, case 31, asymptomatic at confirmation), they often visit the local clinic due to mild respiratory infection. The local clinic has also become an important role in this epidemic prevention. Case 19 has no history of travel and no obvious contact history at initial history taking. Fortunately, the local clinician was alert and referred to a large hospital. He was admitted to a negative pressure isolation ward and thus prevented virus spreading. The measures taken by the Taiwan CECC have reduced the spread of these three family cluster infections of CARS-CoV-2 without causing community infections. We have some suggestions like the following: First, early detection of COVID-19 in patients with unexplained pneumonia with negative influenza test can prevent infection spread. The starters of these three family clusters were not easy to detect exposure history at first, high suspicion of COVID-19 for atypical pneumonia is very important. Second, the strict contact history tracking and immediate epidemic investigation of the confirmed cases, especially COVID-19 is infectious during the incubation period or asymptomatic period. Recognition of infections, time inference, and quarantine scope require new considerations. Third, a series of press conferences will let the public know immediately the changes in the epidemic situation in Taiwan and the world, and immediately educate the public on how to prevent the epidemic 34 including mask policies, 35 hand hygiene, and maintain appropriate social distance. Especially when the second and third family group infections could not find the source of the infection, the whereabouts of the diagnosed person will be announced, so that the public can raise their awareness and seek medical treatment or quarantine to prevent community infections. The data source of this study is the information released by the press conference of the Taiwan CECC. The authenticity of the information cannot be doubted, and there is no violation of personal privacy. There are still some limitations, such as deficiency in more detail of individual patient's medical history, laboratory data, or radiographic characterization. Because this study focuses on the development of the epidemic, the individual's clinical details did not affect the purpose of this study. In conclusion, the measures taken by the Taiwan CECC have reduced the spread of these three family cluster infections of CARS-CoV-2 without causing community infections. The authors thank Taiwan CECC for all the efforts due to COVID-19, also a series of the press conferences for their content, so we can complete this article. The authors declare that there are no conflict of interests. 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