Two Chinese students studying overseas returned to China on March 19 (patient A) and March 20 (patient B), 2020 (Table 1). On the day of their arrival in China, neither had fever or clinical symptoms, and they were transferred to a hotel for a 14-day quarantine. They had normal body temperatures (patient A, 36.3°C; patient B, 36.5°C) and no symptoms when they checked into the hotel. During the quarantine period, local medical staff were to monitor their body temperature and symptoms each morning and afternoon. On the morning of the second day of quarantine, they had no fever (patient A, 36.2°C; patient B, 36.7°C) or symptoms. At the same time their temperatures were taken, throat swab samples were collected; both tested positive for SARS-CoV-2 RNA by real-time reverse transcription PCR (rRT-PCR). The students were transferred to a local hospital for treatment. At admission, they remained presymptomatic, but nasopharyngeal swab, sputum, and fecal samples were positive for SARS-CoV-2 RNA with high viral loads (Table 1). In patient A, fever (37.5°C) and cough developed on day 2 of hospitalization, but his chest computed tomography images showed no significant abnormality during hospitalization. In patient B, fever (37.9°C) and cough developed on day 6 of hospitalization, and her computed tomography images showed ground-glass opacities.

Approximately 3 hours after the 2 patients were identified as positive for SARS-CoV-2 RNA, we sampled the environmental surfaces of the 2 rooms in the centralized quarantine hotel in which they had stayed. Because of the SARS-CoV-2 outbreak in China, the hotel had been closed during January 24–March 18, 2020. Therefore, only these 2 persons had stayed in the rooms. We used a sterile polyester-tipped applicator, premoistened in viral transport medium, to sample the surfaces of the door handle, light switch, faucet handle, thermometer, television remote, pillow cover, duvet cover, sheet, towel, bathroom door handle, and toilet seat and flushing button. We also collected control swab samples from 1 unoccupied room. We collected each sample by swabbing each individual surface. We tested the samples with an rRT-PCR test kit (DAAN GENE Ltd, http://www.daangene.com) targeting the open reading frame 1ab (ORF1ab) and N genes of SARS-CoV-2. We interpreted cycle threshold (C_t) <40 as positive for SARS-CoV-2 RNA and C_t >40 as negative.

We collected a total of 22 samples from the 2 rooms of the quarantine hotel (Table 2). Eight (36%) samples were positive for SARS-CoV-2 RNA. C_t values ranged from 28.75 to 37.59 (median 35.64). Six (55%) of 11 samples collected from the room of patient A were positive for SARS-CoV-2 RNA. Surface samples collected from the sheet, duvet cover, pillow cover, and towel tested positive for SARS-CoV-2 RNA, and surface samples collected from the pillow cover and sheet had a high viral load; C_t for ORF1ab gene from the pillow cover was 28.97 and from the sheet, 30.58. Moreover, the C_t values of these 2 samples correlated with those of patient A’s nasopharyngeal (24.73) and fecal (33.12) swab samples at hospital admission. One surface sample from the faucet in patient B’s room was positive for SARS-CoV-2 RNA; the C_t was 28.75 for the ORF1ab gene. Again, we detected SARS-CoV-2 RNA from the surface samples of the pillow cover; C_t was 34.57. All control swab samples were negative for SARS-CoV-2 RNA.

Our study demonstrates extensive environmental contamination of SARS-CoV-2 RNA in a relatively short time (<24 hours) in occupied rooms of 2 persons who were presymptomatic. We also detected SARS-CoV-2 RNA in the surface swab samples of the pillow cover, duvet cover, and sheet.

Evidence for SARS-CoV-2 transmission by indirect contact was identified in a cluster of infections at a shopping mall in China (10). However, no clear evidence of infection caused by contact with the contaminated environment was found. SARS-CoV-2 RNA has been detected on environmental surfaces in isolation rooms where the symptomatic or paucisymptomatic patients stayed for several days (3–5). In our study, we demonstrate high viral load shedding in presymptomatic patients, which is consistent with previous studies (8,9), providing further evidence for the presymptomatic transmission of the virus (5,11–15). In addition, presymptomatic patients with high viral load shedding can easily contaminate the environment in a short period.

Our results also indicate a higher viral load detected after prolonged contact with sheets and pillow covers than with intermittent contact with the door handle and light switch. The detection of SARS-CoV-2 RNA in the surface samples of the sheet, duvet cover, and pillow cover highlights the importance of proper handling procedures when changing or laundering used linens of SARS-CoV-2 patients. Thus, to minimize the possibility of dispersing virus through the air, we recommend that used linens not be shaken upon removal and that laundered items be thoroughly cleaned and dried to prevent additional spread.

The absence of viral isolation in our investigation was an obstacle to demonstrating the infectivity of the virus, but SARS-CoV-2 has been reported to remain viable on surfaces of plastic and stainless steel for up to 4–7 days (6,7) and 1 day for treated cloth (7). In summary, our study demonstrates that presymptomatic patients have high viral load shedding and can easily contaminate environments. Our data also reaffirm the potential role of surface contamination in the transmission of SARS-CoV-2 and the importance of strict surface hygiene practices, including regarding linens of SARS-CoV-2 patients.