RESEARCH LETTERS

shopping space, and floor 7 contains shopping and the virus. However, according to screening protocols
office space. We created an illustration showing the implemented by the Wenzhou Center for Disease
floors where the eventual COVID-19 case-patients Control and Prevention, we traced all close contacts
worked or shopped, along with dates of symptom and included all patients with positive PCR results,
onset, potential incubation periods, symptom du- including the asymptomatic carrier (patient A), in
rations, confirmed times of positive diagnosis, and this study. Our findings appear to indicate that low
times of discharge (Figure 1, panel A). intensity transmission occurred without prolonged
Except for those who had been on floor 7, all other close contact in this mall; that is, the virus spread by
case-patients denied direct close contact with other case- indirect transmission.
patients. The possibility of customers being infected
from other sources cannot be excluded. However, most The work was supported by Major Project of Wenzhou
customers reported early symptom onset in a concen- Municipal Science and Technology Bureau (ZY202004).
trated time frame (Figure 1, panel B). We found no con-
vincing evidence of definitive transmission pathways in About the Author
this building. Patients A–G (Figure 1, panel A) worked Dr. Cai is deputy chief physician and deputy director of
in the same room on floor 7. Other case-patients who the comprehensive internal medicine department. Her
had been on other floors denied any direct contact with major research interest focuses on infectious diseases and
confirmed patients from floor 7, but they shared com- gastrointestinal diseases.
mon building facilities (e.g., restrooms, elevators). Also,
staff from floor 7 visited shops on other floors daily.
References
Until now, no evidence has shown that SARS- 1. National Microbiology Data Center. Novel Coronavirus
CoV-2 can survive outside the body for long. How- National Science and Technology Resource Service System
ever, Middle East respiratory syndrome coronavirus [cited 2020 Jan 30]. http://nmdc.cn/nCoV
demonstrates high robustness and a strong capability 2. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed
asymptomatic carrier transmission of COVID-19. JAMA.
to survive outside the body and can remain infectious 2020 Feb 21 [Epub ahead of print]. https://doi.org/10.1001/
for up to 60 minutes after aerosolization (4). Hence, jama.2020.2565
the rapid spread of SARS-CoV-2 in our study could 3. Rothe C, Schunk M, Sothmann P, Bretzel G, Froeschl G,
have resulted from spread via fomites (e.g., elevator Wallrauch C, et al. Transmission of 2019-nCoV Infection
from an asymptomatic contact in Germany. N Engl J Med.
buttons or restroom taps) or virus aerosolization in a 2020;382:970–1. https://doi.org/10.1056/NEJMc2001468
confined public space (e.g., restrooms or elevators). 4. Pyankov OV, Bodnev SA, Pyankova OG, Agranovski IE.
All case-patients other than those on floor 7 were Survival of aerosolized coronavirus in the ambient air.
female, including a restroom cleaner, so common Journal of Aerosol Science. 2018;115:158–63.
5. Meiping G. Coronavirus detected on doorknob in S.
restroom use could have been the infection source. China’s Guangzhou. 2020 [cited 2020 Feb 3].
For case-patients who were customers in the shop- https://news.cgtn.com/news/2020-02-03/Coronavirus-
ping mall but did not report using the restroom, the detected-on-doorknob-in-S-China-s-Guangzhou-
source of infection could have been the elevators. The NMua1LcOWY/index.html
Guangzhou Center for Disease Control and Preven-
tion detected the nucleic acid of SARS-CoV-2 on a Address for correspondence: Guiqing He, Department of
doorknob at a patient’s house (5), but Wenzhou Cen- Infectious Diseases, Infectious Diseases Laboratory, Wenzhou
ter for Disease Control and Prevention test results for Sixth People’s Hospital, Wenzhou Central Hospital Medical
an environmental sample from the surface of a mall Group, Wenzhou, 325000 China; email: [email protected];
elevator wall and button were negative. Jing Wu, Department of Infectious Diseases, #5-504, Huashan
We cannot exclude the possibility of unknown in- Hospital, Fudan Universit, 12 Wulumuqizhong Rd, Jing’an
fected persons (e.g., asymptomatic carriers) spreading District Shanghai 200040, China; email: [email protected]

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 6, June 2020 1345
RESEARCH LETTERS

COVID-19 in 2 Persons panel A). She and her roommate shared a bathroom
with 2 others who had similar symptoms earlier.
with Mild Upper Respiratory Case-patient 1 reported her symptoms but contin-
Symptoms on a Cruise Ship, ued to work because she was afebrile. On day 3,
Japan she had throat soreness, stayed in her room, and
was tested for SARS-CoV-2 by reverse transcription
PCR (RT-PCR). On days 4–5, her symptoms dimin-
Takeshi Arashiro, Keiichi Furukawa, Akira Nakamura ished. On day 6, she was told she tested positive and
Author affiliation: Asahi General Hospital, Chiba, Japan was transferred to Asahi General Hospital (Chiba,
Japan). At admission, she had a slight sore throat
DOI: https://doi.org/10.3201/eid2606.200452 and cough. Her temperature was 36.5°C; blood pres-
sure, 113/85 mm Hg; pulse, 92 bpm; respiration, 16
We describe 2 cases of coronavirus disease in patients
breaths/min; and oxygen saturation, 95% on ambi-
with mild upper respiratory symptoms. Both patients
worked on a cruise ship quarantined off the coast of Japan.
ent air. She had no underlying medical conditions
One patient had persistent, low-grade upper respiratory and was taking no routine medication. On exami-
tract symptoms without fever. The other patient had rapid nation, her throat was bright red without exudates,
symptom cessation but persistent viral RNA detection. lung auscultation was clear, and chest radiographs
and blood tests were not clinically significant (Ap-

S
pendix Figure 1, panel A, Table 1, http://wwwnc.
ince December 2019, an outbreak of coronavirus
cdc.gov/EID/article/26/6/20-0452-App1.pdf). We
disease (COVID-19) caused by severe acute respi-
did not suspect pneumonia and did not perform
ratory syndrome coronavirus 2 (SARS-CoV-2) has
computed tomography. On day 8, she reported
been spreading globally (1). On January 25, 2020, a
slight rhinorrhea. On day 9, RT-PCR again was posi-
passenger disembarked a cruise ship in Hong Kong
tive for SARS-CoV-2. Her symptoms continued to
and on February 1 tested positive for SARS-CoV-2 (2).
diminish, and by day 10 she had discontinued all
The ship docked in Yokohama, Japan, on February
medications. RT-PCR results were positive on days
3 for quarantine and isolation. On February 7, pas-
13 and 15, negative on day 19, positive again on day
sengers and crew were provided thermometers and
20, and negative again on days 22 and 23, meeting
asked to check their temperature several times daily.
the criteria for discharge, 2 consecutive negative as-
Crew members were instructed to continue duties, re-
says. She never had fever, shortness of breath, or
port fever or respiratory symptoms, and follow quar-
sputum, and daily lung auscultation was clear, sug-
antine instructions.
gesting absence of pneumonia.
By February 28, a total of 705 COVID-19 cases
Case 2 occurred in a 27-year-old man from
were confirmed among 4,061 passengers and crew
South Asia who worked as a kitchen cleaner on the
tested; 392 cases were asymptomatic, 36 persons were
ship. On day 1 of his illness, February 8, he had a
admitted to intensive care units, and 6 patients died
fever (38.6°C), sore throat, and cough. His room-
(2). All case-patients from the ship were transferred to
mate had similar symptoms that started 2 days
designated medical institutions in Japan (3).
before. Case-patient 2 reported his symptoms but
Preliminary reports describe COVID-19 mani-
continued to work. On day 2, he was tested for
festing as pneumonia (4–6), but most cases are
SARS-CoV-2 but continued to work. On day 3, his
milder and could have more transmission potential
fever persisted, so he stayed in his room. By day
because patients might not seek medical attention
4, his symptoms resolved. On day 5, he was told
(7). Because of the lower threshold for testing per-
he tested positive for SARS-CoV-2 and was trans-
sons on board, the cruise ship created an opportu-
ferred to Asahi General Hospital. At admission, he
nity to observe mild COVID-19 cases and monitor
had no respiratory or other symptoms. He had no
patient symptoms. We describe 2 COVID-19 cases
underlying medical conditions and was taking no
in persons with mild upper respiratory symptoms.
routine medication. His temperature was 36.0°C;
The patients provided written, informed consent to
blood pressure, 132/85 mm Hg; pulse, 87 bpm; res-
share their clinical details.
pirations, 16 breaths/min; and oxygen saturation,
Case 1 occurred in a 35-year-old woman from
95% on ambient air. On examination, his throat was
South Asia who worked as a restaurant server on
bright red without exudates (Appendix Figure 2),
the ship. On day 1 of her illness, February 7, she ex-
lung auscultation was clear, and chest radiographs
perienced throat dryness and a slight cough (Figure,
and blood tests were not clinically significant

1346 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 6, June 2020
 RESEARCH LETTERS

Figure. Clinical courses of 2 case-patients with coronavirus disease (COVID-19) admitted from a cruise ship docked in Japan,
2020. A) Case-patient 1, a 25-year-old woman who worked on the ship as a restaurant server. B) Case-patient 2, a 27-year-old
man who worked on the ship as a kitchen cleaner. Acetaminophen was administered on an as-needed basis >2×/day after taking
body temperature, so measured body temperature is not affected. Nasopharyngeal swabs were used after February 21, 2020,
because a study by Zou et al. (10) suggested higher sensitivity of nasopharyngeal swab specimens over oropharyngeal swab
specimens. AC, acetaminophen; Adm., admission; AM, amoxicillin; B, bakumondoto, a multiherb kampo medicine for dry cough;
C, codeine-containing cough syrup; F, fexofenadine; naso, nasopharyngeal swab; oro, oropharyngeal swab; RT-PCR, reverse
transcription PCR.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 6, June 2020 1347
RESEARCH LETTERS

(Appendix Figure 1, panel B, Table 2). He remained by air and instructed to self-isolate at home for an addi-
asymptomatic, but on day 8, RT-PCR results were tional 14 days.
positive; results remained positive on days 12, 14,
18, and 21. His throat redness did not improve, but
he did not report throat soreness or discomfort. He About the Author
never experienced shortness of breath or sputum, Dr. Arashiro is a junior resident at Asahi General Hospital
and daily lung auscultations were clear. in Chiba, Japan, and a collaborating researcher with the
We describe 2 mild cases of COVID-19 without Infectious Diseases Surveillance Center in the National
discernable pneumonia, which could represent the Institute of Infectious Diseases, Tokyo, Japan. His research
clinical course in young, healthy persons. Worldwide, interests include infectious disease epidemiology and
cases are appearing without apparent epidemiologic global health.
links (8). As the virus spreads, more mild COVID-19
cases are likely, and clinicians should be aware of References
clinical manifestations in the absence of severe symp- 1. World Health Organization. Coronavirus disease (COVID-19)
toms. Case-patient 2’s symptoms rapidly decreased, outbreak, 2020 [cited 2020 Feb 26]. https://www.who.int/
emergencies/diseases/novel-coronavirus-2019
but detectable viral RNA persisted for >2 weeks. As 2. Ministry of Health, Labour and Welfare, Japan. Regarding
of February 27, patients in Japan must have 2 consec- COVID-19 cases on a cruise ship, 2020 Feb 26 [in Japanese]
utive negative RT-PCR results before they can be dis- [cited 2020 Feb 26]. https://www.mhlw.go.jp/stf/houdou/
charged (9). Viral RNA detection does not necessarily houdou_list_202002.html
3. Ministry of Health, Labour and Welfare, Japan. Cabinet
indicate infectivity, so we urgently need guidance for order to designate novel coronavirus infection 2019 as
detection and management of mild COVID-19 to pre- designated infectious disease, 2020 Jan 28 [in Japanese]
pare for a possible pandemic and avoid overwhelm- [cited 2020 Feb 26]. https://www.mhlw.go.jp/
ing healthcare systems. content/10900000/000589747.pdf
4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical
features of patients infected with 2019 novel coronavirus in
Acknowledgments Wuhan, China. Lancet. 2020;395:497–506. https://doi.org/
We thank the staff of the Kaiso Public Health Center and 10.1016/S0140-6736(20)30183-5
5. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al.
Chiba Prefectural Public Health Institute for public health
Epidemiological and clinical characteristics of 99 cases of
support and testing, Ashley Stucky for thoughtful review 2019 novel coronavirus pneumonia in Wuhan, China: a
of the manuscript, and Yuzo Arima and Takahiro Asami descriptive study. Lancet. 2020;395:507–13. https://doi.org/
for intellectual discussion. We also thank the quarantine 10.1016/S0140-6736(20)30211-7
6. Chang D, Lin M, Wei L, Xie L, Zhu G, Dela Cruz CS, et al.
officers, cruise ship company, and healthcare personnel
Epidemiologic and clinical characteristics of novel
involved in the COVID-19 outbreak globally for their coronavirus infections involving 13 patients outside
selfless dedication. Wuhan, China. JAMA. 2020 Feb 7 [Epub ahead of print].
https://doi.org/10.1001/jama.2020.1623
7. Munster VJ, Koopmans M, van Doremalen N, van Riel D,
Addendum de Wit E. A novel coronavirus emerging in China—key
questions for impact assessment. N Engl J Med.
As of April 6, a total of 712 coronavirus disease cases had
2020;382:692–4. https://doi.org/10.1056/NEJMp2000929
been confirmed among 3,711 passengers and crew of the 8. World Health Organization. Emergency ministerial meeting
cruise ship (19.2%) (https://www.mhlw.go.jp/stf/hou- on COVID-19 organized by the African Union and the
dou/houdou_list_202004.html). At the time of testing, Africa Centres for Disease Control and Prevention, 2020 Feb
22 [cited 2020 Feb 26]. https://www.who.int/dg/speeches/
410 (57.6%) were asymptomatic; of those, 79 (11.1%) had
detail/emergency-ministerial-meeting-on-covid-19-
symptoms develop within the 14-day self-monitoring peri- organized-by-the-african-union-and-the-africa-centres-for-
od, leaving 331 persons who tested positive and remained disease-control-and-prevention
asymptomatic after the self-monitoring period (46.5% of 9. Ministry of Health, Labour and Welfare, Japan. Discharge
criteria for COVID-19 patients, 2020 Feb 18 [in Japanese]
all cases). Forty (5.6%) patients were admitted to intensive
[cited 2020 Feb 26]. https://www.mhlw.go.jp/con-
care units (ICUs); 12 patients died (1.7%), including 1 per- tent/10900000/000597947.pdf
son reported by the government of Australia to have died 10. Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al.
after transferring home. Of the cases we reported, case- SARS-CoV-2 viral load in upper respiratory specimens of
infected patients. N Engl J Med. 2020 Feb 19 [Epub ahead of
patient 2 remained asymptomatic; RT-PCR results were
print]. https://doi.org/10.1056/NEJMc2001737
negative on day 24, positive again on day 25, and negative
again on days 27 and 28, meeting the criteria for discharge. Address for correspondence: Takeshi Arashiro, Asahi General
His throat redness had improved by discharge. By March Hospital, I 1326, Asahi City, Chiba 289-2511, Japan; email:
27, both patients had been sent back to their home country [email protected]

1348 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 6, June 2020