The Risk of SARS-CoV-2 Transmission in Community Indoor Settings: A Systematic Review and Meta-analysis

Abstract

BACKGROUND: Quantifying the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in indoor settings is crucial for developing effective non-vaccine prevention strategies and policies. However, summary evidence on the transmission risks in settings other than households, schools, elderly care, and health care facilities is limited. We conducted a systematic review to estimate the secondary attack rates (SARs) of SARS-CoV-2 and the factors modifying transmission risk in community indoor settings. METHODS: We searched Medline, Scopus, Web of Science, WHO COVID-19 Research Database, MedrXiv, and BiorXiv from 1 January 2020 to 20 February 2023. We included articles with original data for estimating SARS-CoV-2 SARs. We estimated the overall and setting-specific SARs using the inverse variance method for random-effects meta-analyses. RESULTS: We included 34 studies with data on 577 index cases, 898 secondary cases, and 9173 contacts. The pooled SAR for community indoor settings was 20.4% (95% confidence interval [CI], 12.0%-32.5%). The setting-specific SARs were highest for singing events (SAR, 44.9%; 95% CI, 14.5%-79.7%), indoor meetings and entertainment venues (SAR, 31.9%; 95% CI, 10.4%-65.3%), and fitness centers (SAR, 28.9%; 95% CI, 9.9%-60.1%). We found no difference in SARs by index case, viral, and setting-specific characteristics. CONCLUSIONS: The risk of SARS-CoV-2 transmission was highest in indoor settings where singing and exercising occurred. Effective mitigation measures such as assessing and improving ventilation should be considered to reduce the risk of transmission in high-risk settings. Future studies should systematically assess and report the host, viral, and setting-specific characteristics that may modify the transmission risks of SARS-CoV-2 and other respiratory viruses in indoor environments.