New details have emerged surrounding the contested report of asymptomatic transmission of the novel coronavirus in Germany.
Responding to criticism that they had omitted key facts about the index patient -- a Shanghai resident who had traveled to Germany for business -- researchers spoke with the woman in question and relayed a timeline of how her illness developed, including the days before it became clear she was ill.
In a to their letter in the New England Journal of Medicine (NEJM), Camilla Rothe, MD, of University Hospital LMU Munich, and colleagues reported that the Shanghai woman landed in Munich on the morning of Sunday Jan. 19, feeling well but having noticed a passenger some rows behind her coughing on the flight.
Throughout the next day she had various meetings and felt no symptoms of illness, but that night awoke around midnight feeling "a little bit warm, but not in a febrile way," Rothe and colleagues said the woman told them. She took an over-the-counter Chinese drug containing acetaminophen as a preventive measure due to an intense schedule of meetings the following day.
These details, that she had felt warm and taken fever-reducing medication while in Germany, were called out in Tuesday's Science report questioning whether she was truly asymptomatic during her time there. This, however, turned out to be the one time during her stay in Germany that she reported feeling warm or taking any sort of medication, according to Rothe's group.
The NEJM otherwise made no changes in the group's published report, the described the Shanghai woman as an "asymptomatic contact."
On Tuesday Jan. 21, the woman recalled feeling tired around 3 p.m. and assumed this was due to the fact that it would have been her bedtime in China. She also reported minor muscle and bone pain in her chest when touching certain areas.
The patient described feeling cold on the morning of her last day in Germany, Wednesday Jan. 22, while wearing light business attire, but she resolved this by putting on a shawl. She had meetings all day and flew home that night, arriving Thursday afternoon in Shanghai, tired but otherwise feeling fine.
"I can certainly see how they would want to characterize this as a transmission in an asymptomatic phase," Fred N. Pelzman, MD, an internal medicine specialist at Weill Cornell Internal Medicine Associates in New York City, told 番茄社区. "None of what she did or felt seemed like a viral prodrome."
It was back in China on the evening of Jan. 23 that the woman started feeling ill. "This is the first moment I recognized getting sick," she told the researchers, and later reported a temperature of 100.4°F and localized chest pain. On Saturday Jan. 25, she went to a doctor and was hospitalized.
Five of her German colleagues ultimately tested positive for the novel coronavirus.
"None of us would have thought anything of this if she hadn't then subsequently come down with coronavirus and infected other people," said Pelzman, who is also a weekly blogger at 番茄社区. "There's a thin line, then there's the obvious line."
He noted that persons under investigation for the novel coronavirus in the U.S., per CDC recommendations, are those with significant symptoms and a travel history to Wuhan or those who have been exposed to someone known to be sick with the virus.