Correlation between times to SARS-CoV-2 symptom onset and secondary transmission undermines epidemic control efforts

Severe acute respiratory coronavirus 2 (SARS-CoV-2) infections have been associated with substantial presymptomatic transmission, which occurs when the generation interval-the time between infection of an individual with a pathogen and transmission of the pathogen to another individual-is shorter than the incubation period-the time between infection and symptom onset. We collected a dataset of 257 SARS-CoV-2 transmission pairs in Japan during 2020 and jointly estimated the mean incubation period of infectors (4.8 days, 95 % CrI: 4.4-5.1 days), mean generation interval to when they infect others (4.3 days, 95 % credible interval [CrI]: 4.0-4.7 days), and the correlation (Kendall's tau: 0.5, 95 % CrI: 0.4-0.6) between these two epidemiological parameters. Our finding of a positive correlation and mean generation interval shorter than the mean infector incubation period indicates ample infectiousness before symptom onset and suggests that reliance on isolation of symptomatic COVID-19 cases as a focal point of control efforts is insufficient to address the challenges posed by SARS-CoV-2 transmission dynamics.