The Household Secondary Attack Rate of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Rapid Review

Clin Infect Dis. 2021 Jul 30;73(Suppl 2):S138-S145. doi: 10.1093/cid/ciaa1558.


Background: Although much of the public health effort to combat coronavirus disease 2019 (COVID-19) has focused on disease control strategies in public settings, transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within households remains an important problem. The nature and determinants of household transmission are poorly understood.

Methods: To address this gap, we gathered and analyzed data from 22 published and prepublished studies from 10 countries (20 291 household contacts) that were available through 2 September 2020. Our goal was to combine estimates of the SARS-CoV-2 household secondary attack rate (SAR) and to explore variation in estimates of the household SAR.

Results: The overall pooled random-effects estimate of the household SAR was 17.1% (95% confidence interval [CI], 13.7-21.2%). In study-level, random-effects meta-regressions stratified by testing frequency (1 test, 2 tests, >2 tests), SAR estimates were 9.2% (95% CI, 6.7-12.3%), 17.5% (95% CI, 13.9-21.8%), and 21.3% (95% CI, 13.8-31.3%), respectively. Household SARs tended to be higher among older adult contacts and among contacts of symptomatic cases.

Conclusions: These findings suggest that SARs reported using a single follow-up test may be underestimated, and that testing household contacts of COVID-19 cases on multiple occasions may increase the yield for identifying secondary cases.

Keywords: SARS-CoV-2; household transmission; secondary attack; testing frequency.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Aged
  • COVID-19*
  • Family Characteristics
  • Humans
  • Incidence
  • Motivation
  • SARS-CoV-2*