Predictors of incident viral symptoms ascertained in the era of COVID-19

PLoS One. 2021 Jun 17;16(6):e0253120. doi: 10.1371/journal.pone.0253120. eCollection 2021.


Background: In the absence of universal testing, effective therapies, or vaccines, identifying risk factors for viral infection, particularly readily modifiable exposures and behaviors, is required to identify effective strategies against viral infection and transmission.

Methods: We conducted a world-wide mobile application-based prospective cohort study available to English speaking adults with a smartphone. We collected self-reported characteristics, exposures, and behaviors, as well as smartphone-based geolocation data. Our main outcome was incident symptoms of viral infection, defined as fevers and chills plus one other symptom previously shown to occur with SARS-CoV-2 infection, determined by daily surveys.

Findings: Among 14, 335 participants residing in all 50 US states and 93 different countries followed for a median 21 days (IQR 10-26 days), 424 (3%) developed incident viral symptoms. In pooled multivariable logistic regression models, female biological sex (odds ratio [OR] 1.75, 95% CI 1.39-2.20, p<0.001), anemia (OR 1.45, 95% CI 1.16-1.81, p = 0.001), hypertension (OR 1.35, 95% CI 1.08-1.68, p = 0.007), cigarette smoking in the last 30 days (OR 1.86, 95% CI 1.35-2.55, p<0.001), any viral symptoms among household members 6-12 days prior (OR 2.06, 95% CI 1.67-2.55, p<0.001), and the maximum number of individuals the participant interacted with within 6 feet in the past 6-12 days (OR 1.15, 95% CI 1.06-1.25, p<0.001) were each associated with a higher risk of developing viral symptoms. Conversely, a higher subjective social status (OR 0.87, 95% CI 0.83-0.93, p<0.001), at least weekly exercise (OR 0.57, 95% CI 0.47-0.70, p<0.001), and sanitizing one's phone (OR 0.79, 95% CI 0.63-0.99, p = 0.037) were each associated with a lower risk of developing viral symptoms.

Interpretation: While several immutable characteristics were associated with the risk of developing viral symptoms, multiple immediately modifiable exposures and habits that influence risk were also observed, potentially identifying readily accessible strategies to mitigate risk in the COVID-19 era.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • COVID-19 / epidemiology
  • COVID-19 / prevention & control*
  • COVID-19 / virology
  • Female
  • Fever / diagnosis*
  • Fever / epidemiology
  • Humans
  • Incidence
  • Logistic Models
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Pandemics
  • Prospective Studies
  • Risk Factors
  • SARS-CoV-2 / isolation & purification*
  • SARS-CoV-2 / physiology
  • Self Report / statistics & numerical data*
  • Smartphone
  • United States / epidemiology