Time from symptom onset to hospitalisation of coronavirus disease 2019 (COVID-19) cases: implications for the proportion of transmissions from infectors with few symptoms

Interventions targeting symptomatic hosts and their contacts were successful in bringing the 2003 SARS pandemic under control. In contrast, the COVID-19 pandemic has been harder to contain, partly because of its wide spectrum of symptoms in infectious hosts. Current evidence suggests that individuals can transmit the novel coronavirus while displaying few symptoms. Here, we show that the proportion of infections arising from hosts with few symptoms at the start of an outbreak can, in combination with the basic reproduction number, indicate whether or not interventions targeting symptomatic hosts are likely to be effective. However, as an outbreak continues, the proportion of infections arising from hosts with few symptoms changes in response to control measures. A high proportion of infections from hosts with few symptoms after the initial stages of an outbreak is only problematic if the rate of new infections remains high. Otherwise, it can simply indicate that symptomatic transmissions are being prevented successfully. This should be considered when interpreting estimates of the extent of transmission from hosts with few COVID-19 symptoms.