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The dominant route of transmission of SARS-CoV-2 is respiratory (48). Growing evidence indicates that infectious virus can be found in aerosols and in exhaled breath samples (5, 6, 49), and it is likely that under certain circumstances, including during aerosol-generating procedures, while singing, or in indoor environments with poor ventilation, the virus may be transmitted at a distance through aerosols.
Of note, the period of infectiousness is far shorter than the duration of detectable RNA shedding. For mild to moderate cases, infectious virus can be isolated from samples only up until about day 8 of symptoms. Multiple studies have found virtually no viable virus in patients with mild or moderate disease after 10 days of symptoms despite frequent ongoing RNA shedding (24, 126, 127). Higher viral loads are associated with increased likelihood of isolation of infectious virus (24, 127). In a study that included patients from 0 to 21 days after symptom onset, viable virus was isolated in 26 of 90 samples but no viral growth was found when the cycle threshold was greater than 24 or the patient had had more than 8 days of symptoms (128). A study of a major outbreak at a nursing facility inWashington found viable virus 6 days before symptom onset through 9 days after symptom onset (129).
It may be possible to isolate infectious virus longer in hospitalized patients who have severe disease or are critically ill. A group from the Netherlands evaluated 129 hospitalized patients, including 89 who required intensive care, and collected samples from the upper and lower respiratory tracts (71). Isolation of infectious virus occurred a median of 8 days after symptom onset. The probability of isolation of infectious virus was less than 5% after 15.2 days and decreased with time after symptom onset, lower viral loads, and higher neutralizing antibody titers; the latest isolation of infectious virus was 20 days after symptom onset.
STI screening among MSM has been reported to be suboptimal. In a cross-sectional sample of MSM in the United States, approximately one third reported not having had an STI test during the previous 3 years, and MSM with multiple sex partners reported less frequent screening (221). MSM living with HIV infection and engaged in care also experience suboptimal rates of STI testing (222,223). Limited data exist regarding the optimal frequency of screening for gonorrhea, chlamydia, and syphilis among MSM, with the majority of evidence derived from mathematical modeling. Models from Australia have demonstrated that increasing syphilis screening frequency from two times a year to four times a year resulted in a relative decrease of 84% from peak prevalence (224). In a compartmental model applied to different populations in Canada, quarterly syphilis screening averted more than twice the number of syphilis cases, compared with semiannual screening (225). Furthermore, MSM screening coverage needed for eliminating syphilis among a population is substantially reduced from 62% with annual screening to 23% with quarterly screening (226,227). In an MSM transmission model that explored the impact of HIV PrEP use on STI prevalence, quarterly chlamydia and gonorrhea screening was associated with an 83% reduction in incidence (205). The only empiric data available that examined the impact of screening frequency come from an observational cohort of MSM using HIV PrEP in which quarterly screening identified more bacterial STIs, and semiannual screening would have resulted in delayed treatment of 35% of total identified STI infections (206). In addition, quarterly screening was reported to have prevented STI exposure in a median of three sex partners per STI infection (206). On the basis of available evidence, quarterly screening for gonorrhea, chlamydia, and syphilis for certain sexually active MSM can improve case finding, which can reduce the duration of infection at the population level, reduce ongoing transmission and, ultim