Systematic review with meta‐analysis: SARS‐CoV‐2 stool testing and the potential for faecal‐oral transmission

van Doorn, Amarylle S.; Meijer, Berrie; Frampton, Chris M. A.; Barclay, Murray L.; de Boer, Nanne K. H.

BACKGROUND: Since the start of the COVID‐19 pandemic, there have been many scientific reports regarding gastrointestinal manifestations. Several reports indicate the possibility of viral shedding via faeces and the possibility of faecal‐oral transmission. AIMS: To critically assess the clinical relevance of testing stool samples and anal swabs and provide an overview of the potential faecal‐oral transmission of SARS‐CoV‐2. METHODS: A systematic literature search with MeSH terms was performed, scrutinising the Embase database, Google scholar, MEDLINE database through PubMed and The Cochrane Library, including articles from December 2019 until July 7 2020. Data were subsequently analysed with descriptive statistics. RESULTS: Ninety‐five studies were included in the qualitative analysis. 934/2149 (43%) patients tested positive for SARS‐CoV‐2 in stool samples or anal swabs, with positive test results up to 70 days after symptom onset. A meta‐analysis executed with studies of at least 10 patients revealed a pooled positive proportion of 51.8% (95% CI 43.8 ‐ 59.7%). Positive faecal samples of 282/443 patients (64%) remained positive for SARS‐CoV‐2 for a mean of 12.5 days, up to 33 days maximum, after respiratory samples became negative for SARS‐CoV‐2. Viable SARS‐CoV‐2 was found in 6/17 (35%) patients in whom this was specifically investigated. CONCLUSIONS: Viral shedding of SARS‐CoV‐2 in stool samples occurs in a substantial portion of patients, making faecal‐oral transmission plausible. Furthermore, detection in stool sample or anal swab can persist long after negative respiratory testing. Therefore, stool sample or anal swab testing should be (re)considered in relation to decisions for isolating or discharging a patient.