Clinical Infectious Diseases

Review Article

The Incubation Period Distribution of Coronavirus

Disease 2019: A Systematic Review and Meta-analysis
Hualei Xin,1 Jessica Y. Wong,1 Caitriona Murphy,1 Amy Yeung,1 Sheikh Taslim Ali,1,2 Peng Wu,1,2, and Benjamin J. Cowling1,2
1
World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
Special Administrative Region, China; and 2Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, New Territories, Hong Kong Special Administrative Region, China

Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021

Incubation period is an important parameter to inform quarantine period and to study transmission dynamics of infectious diseases.
We conducted a systematic review and meta-analysis on published estimates of the incubation period distribution of coronavirus
disease 2019, and showed that the pooled median of the point estimates of the mean, median and 95th percentile for incubation pe-
riod are 6.3 days (range, 1.8–11.9 days), 5.4 days (range, 2.0–17.9 days), and 13.1 days (range, 3.2–17.8 days), respectively. Estimates
of the mean and 95th percentile of the incubation period distribution were considerably shorter before the epidemic peak in China
compared to after the peak, and variation was also noticed for different choices of methodological approach in estimation. Our find-
ings implied that corrections may be needed before directly applying estimates of incubation period into control of or further studies
on emerging infectious diseases.
Keywords.  COVID-19; SARS-CoV-2; incubation period; systematic review; meta-analysis.

The incubation period of an infectious disease describes the
time delay between infection and onset of illness. Incubation
periods can vary from one individual to another for various
reasons including the difference in pathogen transmission
route, the dose of exposure to a pathogen, and the functionality
of the host immune system. Incubation periods are often char-
acterized by parametric probability distributions such as the
log-normal, Weibull, and gamma distributions. Coronavirus
disease 2019 (COVID-19) was first detected in China in
December 2019 and rapidly spread worldwide, causing a global
pandemic with >1.9 million deaths by 13 January 2021. The in-
cubation period distribution of COVID-19 has been a critical
epidemiological parameter in characterizing the transmission
dynamics, particularly the role of presymptomatic transmission
[1–4] and determination of the quarantine period for persons
who might have been exposed to infection [5, 6].
A number of studies have reported estimates of the incubation
period distribution, with quite considerable variability between
studies [7, 8]. However, a number of issues can complicate esti-
mation of the incubation period distribution and lead to partic-
ular biases. First, data on the time of infection or exposure are
typically interval-censored rather than exactly known [9, 10], and
the probability of infection over time within an exposure interval
may not follow a uniform distribution [4]. Furthermore, the
Received 15 January 2021; editorial decision 22 May 2021; published online 12 June 2021.
Correspondence: P.  Wu, School of Public Health, Li Ka Shing Faculty of Medicine, The
University of Hong Kong, 7 Sassoon Road, Pokfulam, Hong Kong (pengwu@hku.hk).
Clinical Infectious Diseases®  2021;XX(XX):0–0
© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society
of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
DOI: 10.1093/cid/ciab501
selection bias during the exponential phase of an epidemic [11],
determination of illness onset by the predetermined syndromic
definitions [12], transmission occurring in different settings [11],
and statistical methods and underlining assumptions [10] would
have influenced estimation of the incubation period.
Here, we reviewed published estimates of the incubation pe-
riod distribution with a particular interest in the methodology
applied and potential biases that might have affected the esti-
mated mean and the right-hand tail measure of the incubation
period distribution.
METHODS
This systematic review and meta-analysis followed the check-
list of the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines [13].
Search Strategy and Selection Criteria
Articles reporting estimates of the incubation period distri-
bution of COVID-19 were extracted from the database of
Medline (PubMed; US National Library of Medicine, Bethesda,
Maryland) with the publication date between 1 February 2020
and 25 September 2020. The following search strategy was used
to search in “All Fields” of PubMed:
1. “incubation period”
2. “coronavirus” OR “nCoV” OR “COVID” OR “COVID-19”
OR “2019-nCoV” OR “2019 novel coronavirus” OR “nCoV-
2019” OR “SARS-CoV-2” OR “Wuhan pneumonia”
3.
(“2020/02/01”[Date - Publication]: “2020/09/25”[Date
- Publication])
4. #1 AND #2 AND #3

Incubation Period Distribution of COVID-19  •  cid 2021:XX (XX XXXX) • 1

Full texts of the articles identified via the search strategy were
reviewed for eligibility. Articles in English and Chinese were
selected for assessment if the mean or median estimate of the
incubation period distribution was reported or if detailed indi-
vidual data were included in the article allowing us to calculate
the median of the incubation period distribution. We excluded
studies that reported estimates derived from systematic reviews,
studies that only reported the incubation period for a subgroup
of the population (eg, children, older adults, persons with severe
illness or having certain types of underlying conditions), and
studies that were published as letters or conference proceedings.
All articles identified were reviewed by 2 authors (H. X.  and
C. M.) independently, and the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) checklist
was used to evaluate quality of the studies [14] (Supplementary
Table 1).
Data Extraction
All data were extracted independently and entered in a stand-
ardized form by 2 authors. Information was extracted on the es-
timates of the mean, the median, and the 95th percentile, and the
corresponding 95% confidence interval (CI) of the incubation
period distribution of COVID-19. For studies reporting both
the mean and the median, we selected the one with an estimated
95% CI while the mean was selected if the 95% CI was available
for both or neither of the 2 measures. We used a normal ap-
proximation to derive the 95% CI for a reported mean incuba-
tion period without an estimated 95% CI when the interquartile
range and sample size were available [15]. For studies providing
individual data on the duration between infection and onset
instead of an estimate of the incubation period, a normal per-
centile method was used to estimate the median and the 95th
percentile. For studies without 95th percentile but reporting the
fitted distribution parameters, we calculated the 95th percentile
based on these parameters using fitdistrplus package in R. Other
information such as study language, study country, sample size,
start and end dates of the study period, parametric distribution,
or statistical model used in estimation of the incubation period
(log-normal, gamma, Weibull, normal) was also extracted for
each selected study. Some studies provided multiple estimates
of the incubation period based on different parametric distribu-
tions; we only selected the best-fitted distribution as indicated.
Statistical Analysis
The mid-date of the study period corresponding to each esti-
mate was calculated based on the start and end dates of the re-
ported study period. Several studies did not disclose their exact
start date. For studies that analyzed cases outside Hubei prov-
ince in China without reporting a start date of the study, the
start date was redefined as 20 January 2020 on which the first
confirmed case outside Hubei was identified [16]. For other
studies conducted in China, the start date was redefined as 31
2 • cid 2021:XX (XX XXXX) • Xin et al
December 2019 when the first case in China was reported. We
categorized estimates of the incubation period in China for
time periods before and after the epidemic peak on 27 January
2020 [17]. We also categorized the estimates based on the fitting
approaches of the probability distribution (log-normal, gamma,
Weibull, normal) used in the studies.
Mean and median incubation periods were described and
compared between the studies. Reported estimates of the mean
and the 95th percentile of the incubation period distribution of
COVID-19 for different subgroups (different study period and
statistical approach) were combined using a random-effects
Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
model, with the statistical heterogeneity assessed by the I2 sta-
tistic. Meta-regression analyses using a mixed-effects model
were conducted to quantify the association between study pe-
riod and statistical approach and the estimates of the mean and
the 95th percentile of incubation period [18]. In addition, we
retrieved open-source data on individual cases to reestimate
the incubation period for some of these studies to examine and
validate the results of our meta-analysis in particular. Finally,
we derived a prospective correction on the estimates of incuba-
tion period to address possible sampling bias during the early
exponential growth phase of the epidemic (see Supplementary
Materials for details). Analyses were conducted in R version
3.6.1 (R Foundation for Statistical Computing, Vienna, Austria)
with the metafor package.
RESULTS
By applying the selection criteria, we included 72 of 311 iden-
tified studies into our analysis, with 75 central tendency esti-
mates, including 34 means and 41 medians (Figure 1). Most
(58/72 [80.6%]) of the publications were in English, and 62
(86.1%) studies reported estimates of the incubation period
using the data collected from China. The reported sample sizes
ranged between 4 and 2907 with only 13 (18.1%) studies having
a sample size >200 cases (Supplementary Table 2).
The mid-dates of study period for the 34 estimates of the
mean incubation period were between 11 January 2020 and
13 April 2020. Of the 29 means reported from China, the mid-
dates of the study period of 9 studies (31.0%) were before the
peak of the first epidemic wave while the rest (20/29 [69.0%])
were after the epidemic peak. Various distributions were applied
to parameterize the incubation period, including log-normal (9
[26.5%]), gamma (6 [17.6%]), Weibull (7 [20.6%]), and normal
(12 [35.3%]) (Supplementary Table 2). Estimates of the mean
incubation period were found to be higher than estimates of the
median (Figure 2), as would be expected from a typically right-
skewed distribution. The pooled medians of the point estimates
of the mean and median incubation period were 6.3 days (range,
1.8–9.1 days) and 5.4 days (range, 2.0–17.6 days), respectively.
Typical delays between the study period and the time of
publication were a few weeks in early 2020, which increased

Figure 1.  Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram indicating the screening process to identify studies reporting estimates of
the incubation period for coronavirus disease 2019.
to a few months in later 2020 (Figure 3A). The estimates of
the mean incubation period appeared to be longer for studies
using data collected in a later period (Figure 2A). The pooled
estimate of mean incubation periods before the epidemic peak
in China was 5.2 days (9 studies; 95% CI, 4.8–5.7; I2 = 56.5%),
significantly lower than the pooled estimate for studies con-
ducted after the peak (18 studies; 7.2 days [95% CI, 6.6–7.8];
I2 = 89.5%) (Figure 3B, Figure 3C). We also identified an asso-
ciation between the choice of parametric distribution and the
estimated mean incubation period (Figure 4B). The shortest
estimate of the pooled mean incubation period was from
log-normal (9 studies; 5.9 days [95% CI, 5.1–6.7]; I2 = 81.0%),
followed by gamma distribution (6 studies; 6.5 days [95% CI,
4.9–8.1]; I2 = 94.4%), normal distribution (11 studies; 6.7 days
[95% CI, 6.0–7.3]; I2  =  89.8%), and Weibull distribution (6
studies; 7.0 days [95% CI, 5.8–8.2]; I2 = 93.3%). Similar vari-
ations were identified from an analysis of individual case data
collected from Singapore and Tianjin (Supplementary Figures
1 and 2).
We identified 34 estimates of the 95th percentile of the in-
cubation period distribution. The mid-dates of study period
for these studies were between 11 January 2020 and 5 March
2020, with 11 (32.4%) estimates calculated before the local epi-
demic peak. Distributions of log-normal (10 [29.4%]), gamma
(5 [14.7%]), Weibull (7 [20.6%]), and normal (12 [35.3%]) were
Incubation Period Distribution of COVID-19  •  cid 2021:XX (XX XXXX) • 3
Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
used to estimate the 95th percentile (Supplementary Table 2).
The pooled median of the point estimates of the 95th percen-
tile of the incubation period was 12.5  days (range, 3.2–18.3).
Similar to the mean incubation period, lower estimates of the
95th percentile were reported in the early phase of the epi-
demic compared to the later phase of the epidemic in China
(Figure 3D), with the pooled estimate of 95th percentile to be
11.0 days (5 studies; 95% CI, 9.9–12.0; I2 = 0.0%) before peak
and 14.6 days (7 studies; 95% CI, 13.7–15.5; I2 = 66.9%) after
peak. Figure 4D shows variations in the 95th percentile with
different distributional assumptions. Pooled estimates of the
95th percentile were 12.6  days (7 studies; 95% CI, 11.2–14.0;
I2  =  61.7%) and 14.1  days (5 studies; 95% CI, 12.3–15.8;
I2 = 87.8%) for estimates based on log-normal distribution and
Weibull distribution, respectively. Our analyses on individual
case data available for Singapore and Tianjin produced similar
observations (Supplementary Figure 2).
The meta-regression analyses were conducted based only
on the data collected from China, which allowed us to ex-
amine the potential variations in the reported incubation
periods before and after the epidemic peak. In total, 27 and
12 estimates of the mean and 95th percentile were included
into the analysis after excluding the estimates from other
territories (5 and 13 estimates for mean and 95th percen-
tile, respectively), without reporting the standard deviation,
 Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021

Figure 2.  Estimates of the incubation period for coronavirus disease 2019 from selected studies by type of measure. A, Forest plot of reported mean (dots) estimates of the
incubation period with 95% confidence intervals (CIs) (bars) ordered by mid-date of the study period. B, Forest plot of reported median (triangles) estimates of the incubation
period with 95% CIs (bars) ordered by mid-date of the study period. C, Boxplot of reported mean and median estimates of the incubation period. Citations in panels A and B
corresponds to the reference numbers in Supplementary Materials.

4 • cid 2021:XX (XX XXXX) • Xin et al

 Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
Figure 3.  Reported estimates of the mean and the 95th percentile of the incubation period for coronavirus disease 2019 (COVID-19) by study period. A, The study pe-
riod (bars) and publication date (dots) for studies included in the analysis, ordered by mid-date of the study period. Citations corresponds to the reference numbers in
Supplementary Materials. B, Estimates of the mean (circles) and the 95th percentile (triangles) by study mid-date from studies using the data collected from China. Gray bars
indicate daily numbers of confirmed COVID-19 cases in China reported to the World Health Organization. Red dotted line indicates the date of 27 January 2020 to classify
the time periods before and after the epidemic peak in China. C, Boxplot and reported individual estimates (dots and triangles) of the mean before and after the peak of an
epidemic based on the dichotomized mid-date of the study period. D, Boxplot and reported individual estimates (dots and triangles) of the 95th percentile before and after
the peak of an epidemic based on the dichotomized mid-date of the study period.

standard error, or 95% CI (1 and 8 estimates), and an ob-
vious outlier (1.8 days and 3.2 days for the mean and 95th
percentile). Table 1 shows that the estimates of the mean
and the 95th percentile after the epidemic peak were sig-
nificantly higher than estimates before the peak. Compared
to studies using log-normal distribution, no significant dif-
ferences in the estimates were identified for studies using
either gamma, Weibull, or normal distribution.
We examined the estimates from 4 studies with the mid-point
of the study period before the epidemic peak characterizing
the incubation period with gamma distributions to explore
possible sampling bias in early stage of pandemic. The pooled
mean incubation period from these 4 studies was 5.4  days
(95% CI, 4.4–6.5). If allowing for an exponential growth rate
to be 0.10 [5], the corrected mean incubation period would be
6.4 days (95% CI, 5.2–7.6) (Figure 5). A higher growth rate was

Incubation Period Distribution of COVID-19  •  cid 2021:XX (XX XXXX) • 5

 Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
Figure 4.  Reported estimates of the mean and the 95th percentile of the incubation period for coronavirus disease 2019 by type of distribution applied in data fitting. A,
Forest plot of reported mean incubation periods with 95% confidence intervals (CIs) (bars) estimated with log-normal, gamma, Weibull, or normal distribution, ordered first
by analysis method and then, within each analysis method, by the mid-date of the study period. B, Boxplot and reported individual estimates of the mean incubation period
by type of analytic approach. C, Forest plot of reported 95th percentiles of the incubation period with 95% CIs (bars) estimated with log-normal, gamma, Weibull, or normal
distribution (color coded), with the estimates ordered by the mid-date of the study period within each category of the analytic approaches. D, Boxplot and reported individual
estimates of the 95th percentiles of the incubation period by type of analytic approach. Citations in panels A and C corresponds to the reference numbers in Supplementary
Materials.

associated with a greater underestimation of the mean incu-
bation period in estimates without a correction (Figure 5 and
Supplementary Materials).
DISCUSSION
We reviewed 72 studies on the incubation period distribution
of COVID-19, 62 of which were based on data collected from
China. The pooled estimates from our analysis indicated that
the mean incubation period of COVID-19 was likely to fall
between 5.2 and 7.2  days, and the 95th percentile would be
between 11 and 14.6 days. Notably, we identified a bias towards
shorter estimates of the incubation period in the early stage of
the pandemic while case numbers were rising exponentially,
which was also indicated by the temporal patterns of the incu-
bation period estimated throughout the epidemic based on in-
dividual case data from Singapore and Tianjin (Supplementary
Figure 1).
Variation in estimates of the mean incubation period were
expected to result from bias in case ascertainment that people
with shorter incubation periods were more likely to be included
in the growing stage of the pandemic, which could be corrected

6 • cid 2021:XX (XX XXXX) • Xin et al

Table 1.  Results From a Meta-regression Analysis of Variables Potentially Associated With Estimation of the Mean and 95th Percentile of the Coronavirus
Disease 2019 Incubation Period

Mean of Incubation Period 95th Percentile of Incubation Period

(n = 27) (n = 12)

Variable No. of Estimates β (95% CI) No. of Estimates β (95% CI)

Study period
  Before peak 9 0 Referent 5 0 Referent
  After peak 18 1.95 (.92–2.98) 7 3.4 (1.62–5.17)
Approach
 Log-normal 7 0 Referent 7 0 Referent
 Gamma 5 .61 (–.80 to 2.02) … …

Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021

 Weibull 6 .82 (–.54 to 2.18) 5 .43 (–1.18 to 2.05)
 Normal 9 .15 (–1.21 to 1.52) … …

by observing exposure to infection and the development of
symptoms in a cohort of individuals over the epidemic [11]. In
addition, in the early stage of the pandemic, published studies
tended to include patients with well-characterized informa-
tion, such as seriousness of infection or exposure details, which
might lead to a underestimation of the incubation period [19].
Other factors could also contribute to the difference, including
publication bias, overrepresentation of milder cases, and dif-
ferent ways of establishing exposure windows. Few studies ac-
counted for such potential bias in estimation of the incubation
period. The earliest, perhaps biased, estimates of the incubation
period distribution have been, however, widely used in many
Figure 5.  Prospective correction for the incubation period estimates during the
early phase of the pandemic. For given estimates of incubation period as gamma
(mean [standard deviation]) in the different studies during the exponential phase of
the epidemic, the corrected pooled mean (blue line) and 95% confidence interval
(shaded area) are presented for different possible growth rates (r = 0.00–0.20). The
scenario r = 0 indicates no correction for growth rate and the respective suggested
corrections can be attained based on the exponential growth rates, r > 0.
subsequent analyses and to support health policies [20]. Our
proposed correction for sampling bias might be able to pro-
vide a more accurate estimate of the incubation period from
data collected in the early phase of an epidemic when infections
are increasing exponentially. Correcting for the growth rate
can account for the proportion of cases with longer incubation
periods who are relatively less likely to be included in early data
(Supplementary Materials and Figure 5). Shorter estimates of
the incubation period could also be related to exposure to a
high viral load or virus strains with higher virulence [16].
One of the applications of the incubation period distribution
is in determining the time period of quarantine for exposed in-
dividuals. Our study found that the pooled estimates of the 95th
percentile of the incubation period before and after the epi-
demic peak were 11.0 and 14.6 days, respectively. This indicated
that a quarantine period of 14 days could capture at least 95% of
infected individuals who would develop symptoms.
The distinction between the incubation period and the latent
period implies that the latent period of COVID-19 is gener-
ally expected to be shorter than the incubation period because
of the occurrence of presymptomatic transmission [3, 21, 22].
A number of estimates of the latent period have been published,
with the reported means ranging from 2.6 to 3.3 days [23, 24] or
from 1.88 to 7.4 days before symptom onset [3, 22]. The earlier
shedding of virus than symptom onset made it critical to test
exposed individuals during quarantine so that asymptomatic
cases could also be identified [25–28]. Laboratory testing before
exit from 2-week quarantine may identify some infected persons
with the incubation period >14 days. Johansson et al estimated
that the residual risk of transmission after a 10-day quarantine
would be as low as 0.3% for asymptomatic individuals with a
negative laboratory test result at the last day of quarantine [29].
Quilty et  al estimated that the transmission-potential averted
rates were similar between 14 days of quarantine without poly-
merase chain reaction test and 7 days of quarantine with a neg-
ative exit test [30]. On 2 December 2020, the US Centers for
Disease Control and Prevention updated the recommendation
on the quarantine period, allowing asymptomatic individuals

Incubation Period Distribution of COVID-19  •  cid 2021:XX (XX XXXX) • 7

to exit quarantine after 10 days, or after 7 days with a negative
virus test at exit [31].
Since incubation periods of most infectious diseases follow
a right-skewed distribution [32], application of the symmetric
normal distribution would tend to underestimate the right-hand
tail of the incubation period. Variations in the reported estimates
of incubation period were observed from studies using different
distributions whereas no significant difference was identified in
our meta-regression analysis. The estimates of the 95th percentile
of the incubation period might have been more heavily affected
by the tail probability of the underlining distributions assumed,
leading to larger estimates of the 95th percentile if a higher prob-
ability was assumed at the tail of the underlying distribution. This
was further validated by the estimated incubation periods by fit-
ting different distributions based on the same individual data from
Singapore and Tianjin (Supplementary Figure 1). Several other
studies similarly reported that the 95th percentile of the incuba-
tion period was longer with a log-normal distribution than with
a gamma or Weibull distribution [33–36]. Less-variable estimates
might have derived if the exact time of exposure could be obtained
[10]. Furthermore, the sample size would also affect the precision
of estimates of the 95th percentile of the incubation period [10].
Our study had a number of limitations. First, most arti-
cles included in our study used publicly available data. Some
studies in our review might have used overlapping data,
leading to double counting in the pooled estimates. Second,
as described above, self-reported information on symptom
onset could be subject to reporting biases as well as affected
by the case definitions and approaches to ascertainment.
Third, some factors that could correlate with the incubation
period such as age, disease severity, and interval censoring
of exposure or illness onset were not included in this study
because of data availability. Finally, we were not able to as-
sess the potential impact of contact tracing strategies on es-
timates of the incubation period, particularly when the time
period of contact tracing was changed, given the lack of rel-
evant information.
In conclusion, our study identified variations in the reported
estimates of the incubation period for COVID-19 and method-
ological factors associated with the estimates, including time of
study, type of estimate, and assumed distribution of the param-
eter. Shorter incubation periods were more likely to be identi-
fied at the early stage of an epidemic or by a certain statistical
approach, indicating the need for correction on the estimate be-
fore using it for determination of a valid quarantine period or
for studies on transmission dynamics of COVID-19.
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases on-
line. Consisting of data provided by the authors to benefit the reader,
the posted materials are not copyedited and are the sole responsibility
of the authors, so questions or comments should be addressed to the
corresponding author.
8 • cid 2021:XX (XX XXXX) • Xin et al
Notes
Author Contributions. H.  X., P.  W., and B.  J. C.  conceived the study.
H. X., J. Y. W., C. M., and A. Y. contributed to data collection. H. X. per-
formed the data analyses and wrote the first draft of the manuscript. All
authors interpreted the data, provided critical review and revision of the
text, and approved the final version of the manuscript.
Acknowledgments. The authors thank Julie Au for technical support.
Financial support. This work was supported by the Health and Medical
Research Fund, Food and Health Bureau, Government of the Hong Kong
Special Administrative Region (grant number COVID190118). B.  J. C.  is
supported by the AIR@innoHK program of the Innovation and Technology
Commission of the Hong Kong Special Administrative Region government.
Potential conflicts of interest. B.  J. C.  consults for Roche and Sanofi
Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
Pasteur. All other authors report no other potential conflicts of interest.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the con-
tent of the manuscript have been disclosed.
References
1. Nishiura H, Linton NM, Akhmetzhanov AR. Serial interval of novel coronavirus
(COVID-19) infections. Int J Infect Dis 2020; 93:284–6.
2. Du Z, Xu X, Wu Y, Wang L, Cowling BJ, Meyers LA. Serial interval of COVID-19
among publicly reported confirmed cases. Emerg Infect Dis 2020; 26:1341–3.
3. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissi-
bility of COVID-19. Nat Med 2020; 26:672–5.
4. Ren X, Li Y, Yang X, et al. Evidence for pre-symptomatic transmission of corona-
virus disease 2019 (COVID-19) in China. Influenza Other Respir Viruses 2021;
15:19–26.
5. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel
coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199–207.
6. Linton NM, Kobayashi T, Yang Y, et al. Incubation period and other epidemiolog-
ical characteristics of 2019 novel coronavirus infections with right truncation: a
statistical analysis of publicly available case data. J Clin Med 2020; 9:538.
7. Biggerstaff  M, Cowling  BJ, Cucunubá  ZM, et  al; WHO COVID-19 Modelling
Parameters Group. Early insights from statistical and mathematical modeling of
key epidemiologic parameters of COVID-19. Emerg Infect Dis 2020; 26:e1–e14.
8. Khalili  M, Karamouzian  M, Nasiri  N, Javadi  S, Mirzazadeh  A, Sharifi  H.
Epidemiological characteristics of COVID-19: a systematic review and meta-
analysis. Epidemiol Infect 2020; 148:e130.
9. Sartwell PE. The distribution of incubation periods of infectious disease. Am J
Hyg 1950; 51:310–8.
10. Cowling  BJ, Muller  MP, Wong  IO, et  al. Alternative methods of estimating an
incubation distribution: examples from severe acute respiratory syndrome.
Epidemiology 2007; 18:253–9.
11. Qin J, You C, Lin Q, Hu T, Yu S, Zhou XH. Estimation of incubation period dis-
tribution of COVID-19 using disease onset forward time: a novel cross-sectional
and forward follow-up study. Sci Adv 2020; 6:eabc1202.
12. Böhmer MM, Buchholz U, Corman VM, et al. Investigation of a COVID-19 out-
break in Germany resulting from a single travel-associated primary case: a case
series. Lancet Infect Dis 2020; 20:920–8.
13. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS
Med 2009; 6:e1000097.
14. Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019; 13:31–4.
15. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard devi-
ation from the sample size, median, range and/or interquartile range. BMC Med
Res Methodol 2014; 14:135.
16. Leung C. The difference in the incubation period of 2019 novel coronavirus
(SARS-CoV-2) infection between travelers to Hubei and nontravelers: the
need for a longer quarantine period. Infect Control Hosp Epidemiol 2020;
41:594–6.
17. Ali ST, Wang L, Lau EHY, et al. Serial interval of SARS-CoV-2 was shortened over
time by nonpharmaceutical interventions. Science 2020; 369:1106–9.
18. Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat
Softw 2010; 36:1–48.
19. McAloon C, Collins Á, Hunt K, et al. Incubation period of COVID-19: a rapid
systematic review and meta-analysis of observational research. BMJ Open 2020;
10:e039652.
20. Hellewell  J, Abbott  S, Gimma  A, et  al; Centre for the Mathematical Modelling
of Infectious Diseases COVID-19 Working Group. Feasibility of controlling
COVID-19 outbreaks by isolation of cases and contacts. Lancet Glob Health
2020; 8:e488–96.
21. Ferretti  L, Wymant  C, Kendall  M, et  al. Quantifying SARS-CoV-2 transmission
suggests epidemic control with digital contact tracing. Science 2020; 368:eabb6936.
22. Tindale LC, Stockdale JE, Coombe M, et al. Evidence for transmission of COVID-
19 prior to symptom onset. Elife 2020; 9:e57149.
23. Peirlinck M, Linka K, Sahli Costabal F, Kuhl E. Outbreak dynamics of COVID-19
in China and the United States. Biomech Model Mechanobiol 2020; 19:2179–93.
24. Zhao  S. Estimating the time interval between transmission generations when
negative values occur in the serial interval data: using COVID-19 as an example.
Math Biosci Eng 2020; 17:3512–9.
25. Ng  Y, Li  Z, Chua  YX, et  al. Evaluation of the effectiveness of surveillance and
containment measures for the first 100 patients with COVID-19 in Singapore—
January 2–February 29, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:307–11.
26. Li Z, Chen Q, Feng L, et al; China CDC COVID-19 Emergency Response Strategy
Team. Active case finding with case management: the key to tackling the COVID-
19 pandemic. Lancet 2020; 396:63–70.
27. Lin J, Huang W, Wen M, et al. Containing the spread of coronavirus disease 2019
(COVID-19): meteorological factors and control strategies. Sci Total Environ
2020; 744:140935.
28. Jin H, Liu J, Lu L, Cui M. COVID-19 emergencies in the globe: China’s experi-
ence in controlling COVID-19 and lessons learned. Int J Qual Health Care 2020;
744:mzaa143.
29. Johansson  MA, Wolford  H, Paul  P, et  al. Reducing travel-related SARS-CoV-2
transmission with layered mitigation measures: symptom monitoring, quaran-
tine, and testing. BMC Med 2021; 19:94.
Incubation Period Distribution of COVID-19  •  cid 2021:XX (XX XXXX) • 9
30. Quilty  BJ, Clifford  S, Flasche  S, Kucharski  AJ, Edmunds  WJ. Quarantine and
testing strategies in contact tracing for SARS-CoV-2: a modelling study. Lancet
Public Health 2021; 6:e175–83.
31. Centers for Disease Control and Prevention. Options to reduce quarantine for
contacts of persons with SARS-CoV-2 infection using symptom monitoring and
diagnostic testing. 2020. Available at: https://www.cdc.gov/coronavirus/2019-
ncov/more/scientific-brief-options-to-reduce-quarantine.html. Accessed 30
December 2020.
32. Lessler  J, Reich  NG, Brookmeyer  R, Perl  TM, Nelson  KE, Cummings  DA.
Incubation periods of acute respiratory viral infections: a systematic review.
Lancet Infect Dis 2009; 9:291–300.
33. Backer  JA, Klinkenberg  D, Wallinga  J. Incubation period of 2019 novel coro-
navirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28
January 2020. Euro Surveill 2020; 25:2000062.
34. Lai  CKC, Ng  RWY, Wong  MCS, et  al. Epidemiological characteristics of the
Downloaded from https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab501/6297425 by guest on 20 August 2021
first 100 cases of coronavirus disease 2019 (COVID-19) in Hong Kong Special
Administrative Region, China, a city with a stringent containment policy. Int J
Epidemiol 2020; 49:1096–105.
35. Dai J, Yang L, Zhao J. Probable longer incubation period for elderly COVID-19
cases: analysis of 180 contact tracing data in Hubei Province, China. Risk Manag
Healthc Policy 2020; 13:1111–7.
36. Patrikar  SR, Kotwal  A, Bhatti  VK, et  al. Incubation period and reproduction
number for novel coronavirus 2019 (COVID-19) infections in India. Asia Pac J
Public Health 2020; 32:458–60.