COVID-19 Symptoms at Presentation and Association with Positivity Among Outpatients Tested for SARS-CoV-2

Background: Symptoms associated with SARS-CoV-2 infection remain incompletely understood, especially among ambulatory, non-hospitalized individuals. Objective: Identify symptom and patient factors associated with detection of SARS-CoV-2 in outpatients. Design: Retrospective cohort analysis. Setting: An outpatient testing program in North Carolina. Patients: 20,177 individuals presenting between March 16 and September 3, 2020 for nasopharyngeal SARS-CoV-2 RNA RT-PCR testing. Measurements: Self-reported symptoms, demographic characteristics, and exposure and travel histories. Results: Among 20,177 tested individuals, the proportion positive was 9.4% (95% CI, 9.0-9.8) and was higher for men, younger individuals, and racial/ethnic minorities (all P<0.05); the positivity proportion was higher for Hispanics (26.9; 95% CI. 24.9-29.0) compared to Blacks (8.6%; 95% CI, 7.6-9.7) or Whites (5.8%; 95% CI, 5.4-6.3). Individuals reporting contact with a COVID-19 case had the highest positivity proportion (22.8%; 95% CI, 21.5-24.1). Among the subset of 8,522 symptomatic adults who presented for testing after May 1, when complete symptom assessments were performed, SARS-CoV-2 RNA PCR was detected in 1,116 (13.1%). Of the reported symptoms, loss of taste or smell was most strongly associated with SARS-CoV-2 RNA detection with an adjusted risk ratio of 3.88 (95% CI, 3.46-4.35). The presence of chills, fever, cough, aches, headache, fatigue and nasal congestion also significantly increased the risk of detecting SARS-CoV-2 RNA, while diarrhea or nausea/vomiting, although not uncommon, were significantly more common in those with a negative test result. Symptom combinations were frequent with 67.9% experiencing ≥4 symptoms, including 19.8% with ≥8 symptoms; report of greater than three symptoms increased the risk of SARS-CoV-2 RNA detection. Limitation: The study was conducted at a single large testing facility. Conclusion: In a large outpatient population in the Southeastern US, several symptoms, most notably loss of taste or smell, and greater symptom burden were associated with detection of SARS-CoV-2 RNA. Persons of color and those with who were a contact of a COVID-19 case were also more likely to test positive. These findings suggest that, given limited SARS-CoV-2 testing capacity, symptom presentation and host characteristics can be used to guide testing prioritization. Funding: Research support was provided by the National Institute of Allergy and Infectious Diseases-sponsored AIDS Clinical Trials Group (ACTG) (UM1 AI-068636), the UNC Chapel Hill AIDS Clinical Trials Unit (UM1 AI069423), the UNC Center for AIDS Research (P30 AI50410), and the NA-ACCORD COVID-19 Supplement (U01 AI069918); and the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (UL1 TR002489). This research support funded investigator effort. Declaration of Interests: There are no relevant conflicts of interest reported by the authors. Ethics Approval Statement: The study protocol was approved and granted a waiver of consent by the UNC School of Medicine Institutional Review Board.