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Last Updated July 15, 2020

An introduction to SARS-CoV-2
The emergence of a novel coronavirus in late 2019, now identified as SARS-CoV-2, has resulted in a
global pandemic with an unprecedented public health response. This brief review of the properties of
SARS-CoV-2 and how it is transmitted outlines some of the evidence that currently forms the basis of
our evolving public health response to COVID-19. The evolving evidence on the dominant routes of
transmission, and potential importance of pre-symptomatic and asymptomatic transmission indicate
that preventing the spread of the SARS-CoV-2 virus requires a suite of precautionary measures. As
new evidence and new interpretations evolve, this document will be updated.
What is COVID-19?
Coronavirus disease (COVID-19) is an illness caused by the severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), a recently discovered novel coronavirus. Coronaviruses are genetically
distinct from viruses that cause influenza. They are enveloped, single-stranded RNA viruses whose
surface is covered by a halo of protein spikes, or “corona.” Other coronaviruses that have caused
significant and lethal outbreaks in the past 20 years include SARS-CoV-1 and MERS-CoV that caused
SARS and Middle East respiratory syndrome (MERS), respectively. Like the SARS-CoV-2 virus, these
viruses are thought to originate in bats, but may have had an intermediate mammalian host prior to
transfer to humans.

SARS-CoV-2 genetics
Phylogenetic (evolutionary) analysis has helped to establish that SARS-CoV-2 emerged in the human
population in November 2019. Since then, continued observation of the genome has identified small
mutations that can be used to track the evolution of the virus. The rate of mutation observed for SARS-
CoV-2 is significantly lower than influenza, suggesting it is evolving more slowly in response to
selective pressure.1,2 Further observation is needed to understand how mutations affect the function
of the virus. At the beginning of the pandemic, one variant of the SARS-CoV-2 virus was the most
prevalent (D614). In February 2020, a new variant, G614, emerged in Europe and has since replaced
D614 as the most dominant form.3 Infection with the G614 variant potentially results in higher viral
loads, which has been suggested could influence transmissibility;3 however, this has yet to be fully
evaluated. It does not appear that the G614 variant result in greater disease severity.4 Continued study
of the genome and relating genomic variants to health and epidemiological data is important to
evaluating how the evolution of the virus may impact on the public health response, vaccine
development and the design of therapies.2,4

What are the symptoms?

COVID-19 can result in a broad range of symptoms that can vary from person to person. These can
include cough, fever, shortness of breath, tiredness, sore throat, body aches, chills, headache and in
some cases result in lethal pneumonia. Some people may also experience loss of smell or taste,
nausea, vomiting or diarrhea. Among children, abdominal symptoms and skin changes or rash may be
more commonly reported.5

The severity of disease can also vary from person to person. Not everyone with COVID-19 will display
symptoms, and many cases will only experience mild symptoms.6 About 15% of those experiencing
symptoms will require hospitalization, of which about one-third may require admission to intensive
care.6The elderly, the obese, smokers, and immunosuppressed persons and those with pre-existing
conditions including diabetes, hypertension, heart disease or cancer are at the greatest risk of
requiring hospitalization or dying from COVID-19.7–9
Last Updated July 15, 2020

The case fatality rate for COVID-19 differs around the world and across Canada and relates in part to
case identification and to local epidemiology.10,11 The case fatality rate for Canada as of July 12, 2020
was reported as 8.2%, with the highest case fatality rates recorded in Quebec (10%), Ontario (7.5%),
B.C. (6.2%) and Nova Scotia (5.9%) and no deaths recorded in P.E.I. or the Territories.11 COVID-19 is
less prevalent in children as compared to adults, making up only about 1-10% of cases, and children
infected with SARS-CoV-2 experience less severe symptoms.12–16 Children under one year of age and
with underlying conditions may experience more severe illness than other children, but case mortality
rate for children is much lower than for adults.12 Some children with suspected or confirmed COVID-
19 have been reported to experience symptoms similar to Kawasaki disease, although this is rare and
typically non-life-threatening.17–20

Rate of Transmission
The basic reproduction number for a contagious disease, or the R0 value, estimated at the beginning
of an outbreak, indicates the number of secondary cases that can be infected by a primary case in a
population with no underlying immunity, vaccine or preventive measures. Where R0 is greater than 1,
the number of infected persons is likely to increase. Over time, the effective reproductive number (Rt)
changes as more people are infected and public health measures are implemented to contain the
spread. The goal of public health interventions is to bring the Rt below 1, which would indicate that
the outbreak is reducing and will eventually die out.21 Monitoring the change in Rt can help to evaluate
the effectiveness of public health measures.

For SARS-CoV-2 the preliminary World Health Organization estimate of R0 was 1.4-2.522 with
subsequent research estimating the mean R0 at 3.28.23 This suggests that every primary case at the
beginning of the outbreak could potentially infect about three others. The Rt is an average and can
vary depending on the location and patterns of local transmission over time.24 Estimates of Rt can not
easily account for secondary cases that are asymptomatic unless these cases have been detected in
the population through widespread testing.25 The Rt for Canada near the beginning of the pandemic
in March 2020 was estimated to be > 2. Following widespread public health measures to prevent
transmission, the Rt dropped to < 1 from about the end of April to late June 2020.26 Since then, the Rt
has shown a slight upward trend, reflecting localized outbreaks in some regions of the country. The Rt
varies between and within provinces and territories. For example, modelling for the province of
Ontario towards the end of June 2020 estimated the median Rt for the province to be 1.0. The Rt was
found to vary within Ontario from 0.8 in Toronto to 2.1 in the Northern region.27 This difference is
partially explained by the large difference in the total number of cases in Toronto (12802) compared
to the Northern region (330).

How is the virus transmitted?

SARS-CoV-2 is primarily transmitted via prolonged close contact with an infected person, likely due to
their respiratory secretions passed in the air, which can include a range of droplet sizes, and potentially
due to transmission via surfaces (fomites). The vast majority of COVID-19 outbreaks have taken place
indoors and are most often associated with close contacts in the home environment, or other indoor
spaces where there is a high density of people and an extended period of contact.28–31
Large respiratory droplets
The primary mode of human-to-human transmission of SARS-CoV-2 is considered to be via direct
contact with an infected person and their respiratory droplets generated during coughing, sneezing,
and other respiratory actions that produce large droplets (e.g., > 5 µm diameter) .19 Exposure potential
is greatest in close proximity of an infected person. Large respiratory droplets can be contained by
actions such as mask wearing, respiratory etiquette (covering one’s mouth and nose when coughing
or sneezing) and via physical distancing measures that help to ensure there is sufficient distance for
Last Updated July 15, 2020

respiratory droplets emitted from an infected person to drop to the ground before reaching others.
Large droplets are thought to travel less than 1 m before dropping to the ground, leading to the 2 m
physical distancing practice that has been adopted for limiting the spread in the general public.32–35
Current evidence has shown that measures to protect against the spread of respiratory droplets,
namely physical distancing and mask wearing, have led to a reduction in cases.36

Small respiratory droplets/respiratory aerosols

Increasingly, transmission via smaller droplets or respiratory aerosols (< 5 µm diameter) produced by
speaking, singing, shouting, or heavy breathing is considered to be an important route of transmission,
with some experts calling for greater awareness of airborne precautions for some activities and in
some settings.37–43 Small respiratory droplets can remain in the air longer than large droplets and
could present both a risk of exposure in close contact with an infected individual, and potentially over
longer distances in enclosed spaces.42,44 Some preliminary evidence under experimental conditions
suggests that SARS-CoV-2 may remain viable when airborne over short distances for several
hours.45,46 Transmission via respiratory aerosols could be occurring in settings where these particles
accumulate in poorly ventilated indoor environments where there is a high density of people and
extended duration of contact.31,47 Control measures for this type of transmission may rely heavily on
reducing crowding, reducing the duration of interactions in indoor spaces, and ensuring good
ventilation.48,49
The relative importance of transmission via droplets and airborne aerosols requires further
investigation and may have implications for public health recommendations for indoor versus outdoor
environments.45,50–54

Contact with surfaces

Contact with contaminated surfaces (fomites) followed by touching of the eyes, mouth or nose is a
another possible mode of SARS-CoV-2 transmission, although is not considered to be the main
transmission route.32 Fomites can become contaminated by deposition of droplets, aerosols, sputum
or feces, either directly or by cross-contamination by touching an object with contaminated hands.

The risk of transmission through contact can depend on the concentration of viable virus, its viability
on a specific surface over time (see below for persistence on different surfaces) and the quantity of
virus a person is exposed to by touching of the eyes, mouth or nose. Surfaces that are frequently
touched by many people, such as door handles or faucets may be more important in fomite
transmission compared to objects or surfaces that are only touched incidentally and less frequently.
Hand hygiene and routine cleaning and disinfection of surfaces reduces the likelihood of contact
transmission.55

There have been few studies that have assessed the presence of viable virus on surfaces. One
observations study of surfaces in clinical and public areas of a hospital treating COVID-19 patients
found SARS-CoV-2 RNA on over half of the surfaces tested, especially computer keyboards, chairs and
alcohol gel dispensers.56 While no culturable virus was detected in the study, evidence of surface
contamination supports recommendations for hand and surface hygiene. Washing with soap for 20
seconds followed by rinsing can help to emulsify the lipid layer of the virus, rendering it inviable and
diffuse virus particles, making spread less likely.24,57 Using hand sanitizers to inactivate the virus is an
alternative to handwashing.58 Chemical disinfectants can be used to inactivate the virus on surfaces.
Both Health Canada59 and the US EPA60 have issued a list of disinfectants that are approved for use on
hard surfaces against SARS-CoV-2. The Public Health Agency of Canada (PHAC) has also developed
guidance on cleaning and disinfection of public spaces for SARS-CoV-2.61
Last Updated July 15, 2020

Transmission via feces

There is some evidence that the SARS-CoV-2 virus is shed via feces,62 and the virus has been detected
in the toilets of COVID-19 patients.50–52 Several studies have identified the presence of SARS-CoV-2
RNA in feces but only a few have identified infectious virus.63 There is little evidence to suggest that
the fecal-oral pathway (e.g., passing in fecal particles from one person to the mouth, or fecal
contamination of food) is significant in the current pandemic.

When is the virus transmitted?

The mean incubation period (time between exposure to the virus and the appearance of symptoms)
has been estimated to be around five days,64,65 with modelling indicating a range of about two to 11
days (2.5th and 97.5th percentiles).66,67 An infected person can transmit the virus to others both before
they show any symptoms (pre-symptomatic) and when they are symptomatic. The efficiency of viral
transmission during exposure can be affected by the number of infectious viral particles inhaled and
the duration of exposure for a secondary case.68 Infection may occur as a result of a short but intense
dose of infectious virus, or following prolonged exposure to a smaller dose. Current evidence suggests
that most transmission occurs during the symptomatic phase, but research is still needed to
understand the relative importance of pre-symptomatic and asymptomatic transmission.69

Pre-symptomatic and asymptomatic transmission

The occurrence of pre-symptomatic transmission (during the incubation phase of an infected person)
and asymptomatic transmission (transmission via an infected person who never displays symptoms)
has been recorded throughout the pandemic in various locations around the world.28,70–74 The precise
incidence of pre-symptomatic and asymptomatic transmission and overall importance to the spread
of the virus is still unknown. A review of studies by Heneghan et al. (2020) found that between 5% and
80% of people infected with SARS-CoV-2 may be asymptomatic, but the rate of transmission to others
requires further study.75

Pre-symptomatic and asymptomatic cases have been found to shed virus.76,77It is not clear what level
of infectious virus is shed during the pre-symptomatic phase, or via asymptomatic spreaders, given
that a primary route of transmission (large respiratory droplets) is limited by the absence of coughing
and sneezing.71 Other routes of transmission, such as via smaller respiratory droplets released during
breathing, speaking, laughing or singing, may be more important for pre-symptomatic or
asymptomatic transmission.78 He et al. (2020)79 estimated that infected persons could be transmitting
the virus 0.6-2.5 days before the onset of symptoms, although for asymptomatic spread, the period
of transmission is still being investigated. Current evidence suggests that asymptomatic transmission
is more likely to occur following prolonged close contact, such as in family settings where there may
be exposure during shared meals, talking, and contact with shared common objects and
surfaces.28,69,72,80

Symptomatic transmission
Once a person becomes symptomatic, they could be transmitting the virus to others for days to several
weeks after symptom onset.67 Research is ongoing to help explain the relationship between viral dose
(e.g., the level of exposure to the virus via respiratory droplets, or contact with fomites), the viral load
(the quantity of viral particles per unit of bodily fluid in the infected person) and severity of disease.81
The viral dose required to cause infection by various routes remains unknown.82 Most cases of COVID-
19 are diagnosed using reverse transcription PCR (RT-PCR), which identifies whether viral RNA is
present or not, and can provide some indication of the level of viral load.83 While this type of test
cannot determine if viral particles are infectious, the more viral RNA in the body may be an indication
that more virus can potentially be released by coughs, sneezes, breathing or talking.
Last Updated July 15, 2020

The level of viral RNA has been measured to be highest soon after symptom onset in the early stages
of the disease, when level of transmission may also be highest, and decreases about one week
following the peak.84,85 The virus replicates predominantly in the tissues of the upper respiratory
tract.86 The pattern of viral shedding for SARS-CoV-2 has been found to be more similar to influenza
as compared to SARS-CoV-1.69,77 Patients with a higher viral load appear to experience more severe
symptoms and shed more virus over a longer timeframe than mild cases.87 Positive results for viral
RNA do not always indicate that infectious virus is being shed but Woelfel et al. (2020)86 found that
viable virus could be isolated at the peak of viral shedding, about four days after symptom onset.
Studies of viral load indicate that the amount of viable virus decreases over a much shorter period as
compared to viral RNA, which can persist much longer but is not infectious.67

Sensitivity of SARS-CoV-2 to environmental factors

Research is ongoing to understand the persistence of SARS-CoV-2 on different surfaces and under
various environmental conditions.

Temperature: Experiments have found that high temperatures are more effective for deactivating the
SARS-CoV-2 virus, and the virus is more persistent at colder temperatures. Experiments using viral
suspension found minimal reduction over 14 days at 4°C, but detected no viable particles after four
days at 22°C, within one day at 37° C, less than 30 minutes at 56°C and less than five minutes at 70°C.88–
90
A study of persistence of SARS-CoV-2 in milk also found that pasteurization temperatures of 56°C
and 63°C for 30 minutes resulted in no viable virus; however no reduction was detected after 48 hours
stored at 4°C, and only a minimal reduction after 48 hours stored at -30°C.91

Humidity: Humidity can influence both persistence on surfaces and infectivity of the virus, by affecting
spread of the virus and susceptibility of respiratory systems to viral infection.92 There is preliminary
evidence that persistence of the virus may decrease with increases in temperature and humidity and
the virus may remain infectious under dry conditions.89,92,93 Further research is needed to better
characterise how humidity influences persistence and infectivity of SARS-CoV-2 in indoor and outdoor
environments.

Light/Ultraviolet (UV) radiation: UV irradiation has been shown to reduce viral loads for respiratory
viruses, including SARS-CoV-1 in clinical and other controlled settings,94,95 Germicidal effects can occur
between 200-320 nm, which covers the range of UV produced by natural sunlight (UV-B, 280-320 nm)
and UV produced by lamps for specific applications (UV-C, below 280 nm) Solar UV-B has been shown
to provide a disinfectant effect under a high UV-index over a sustained period.96 Disinfection using UV-
C is more efficient than UV-B, and UV-C has been shown to be effective for inactivation of double-
stranded, enveloped RNA viruses.97–100 UV irradiation has also been proposed as a decontamination
method for personal protective equipment (PPE) contaminated by SARS-CoV-2.101–103 Initial results
suggest that UV treatment may be more effective on smooth surfaces such as steel as compared to
fabrics or porous materials.104 The use of UV-C for disinfection carries some risk, as UV-C can be
harmful to human skin and eyes. Further study is needed to determine the optimum dose needed for
inactivation of SARS-CoV-2, and how UV-C could be safely applied in public settings.

Persistence on surfaces
A limited number of studies have specifically examined the persistence of SARS-CoV-2 on common
surfaces.46,88,105–107 Previous study of coronaviruses (MERS, SARS-CoV-1 and other human coronavirus
variants) found that they are detectable on wood, glass, metal and plastic for between four and nine
days.106 One of the first studies on SARS-CoV-2 by van Doremalen et al. (2020) found that the virus
was most persistent on stainless steel and plastic surfaces and least persistent on cardboard and
copper.46 Chin et al. (2020)88 also found that SARS-CoV-2 was more persistent on smooth, hard
surfaces (stainless steel and plastic) than porous materials (wood, cloth, paper and tissue). Liu et al
Last Updated July 15, 2020

(2020) also found that the virus was least persistent on cloth and paper but on most other surfaces,
infectious virus was detectable after seven days. Studies of persistence on metals such as copper and
aluminum have found the shortest level of persistence under experimental conditions.88,107 It is
important to note that the studies mentioned have been conducted under different experimental
conditions, including temperature, relative humidity, and with variations in the concentrations and
volumes of infectious titer that were used. The findings of these studies are presented Table 1 below,
however additional research is needed to better understand how experimental conditions relate to
real-world situations.

Table 1: Persistence of SARS-CoV-2 on various surfaces under experimental conditions*

SURFACE Persistence of SARS-CoV-2 under experimental conditions

Paper/ Cardboard: up to 24 hours46

Cardboard Paper and tissue: up to three hours88
Paper: rapid loss of infectivity after one hour; no infectious virus after five days 108
Stainless steel Up to three days (72 hours) although viability significantly reduced at 48 hours46
Up to four days (96 hours)88
> 7 days108
Copper Up to four hours46
Aluminum Up to four hours107
Plastics Up to three days (72 hours)46
Up to four days (96 hours)88
> 92 hours (less than 1 log10 drop on polystyrene after 92 hours)107
> 7 days108
Wood Up to two days88
> 7 days108
Glass Up to four days88
> 44 hours (3.5 log10 drop after 44 hours)107
> 7 days108
Ceramics > 7 days108
Cloth Up to two days88
Cotton: rapid loss of infectivity after one hour; no infectious virus after four days108
Latex gloves > 7 days108
Surgical mask > 7 days108
*Reference Experimental Relative Concentration of Volume of
temperature humidity infectious titer infectious titer
46
van Doremalen et al. 21-23 °C 40 % 105 TCID50 per ml 50 µl
88
Chin et al. 22 °C 65 % 107.8 TCID50 per ml 5 µl
107
Pastorino et al. 19-21 °C 45-55 % 106 TCID50 per ml 50 µl
108
Liu et al. 25-27 °C 35 % 106 TCID50 per ml 50 µl

Additional COVID-19 related resources to support environmental health can be found on our
Environmental Health Resources for the COVID-19 Pandemic topic page.

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