Coronavirus Disease 2019 and Airborne Transmission: Science Rejected, Lives Lost. Can Society Do Better?

This is an account that should be heard of an important struggle: the struggle of a large group of experts who came together at the beginning of the COVID-19 pandemic to warn the world about the risk of airborne transmission and the consequences of ignoring it. We alerted the World Health Organization about the potential significance of the airborne transmission of SARS-CoV-2 and the urgent need to control it, but our concerns were dismissed. Here we describe how this happened and the consequences. We hope that by reporting this story we can raise awareness of the importance of interdisciplinary collaboration and the need to be open to new evidence, and to prevent it from happening again. Acknowledgement of an issue, and the emergence of new evidence related to it, is the first necessary step towards finding effective mitigation solutions.

Ventilation and thermal conditions in secondary schools in the Netherlands: Effects of COVID-19 pandemic control and prevention measures.

During the COVID-19 pandemic, the importance of ventilation was widely stressed and new protocols of ventilation were implemented in school buildings worldwide. In the Netherlands, schools were recommended to keep the windows and doors open, and after a national lockdown more stringent measures such as reduction of occupancy were introduced. In this study, the actual effects of such measures on ventilation and thermal conditions were investigated in 31 classrooms of 11 Dutch secondary schools, by monitoring the indoor and outdoor CO2 concentration and air temperature, both before and after the lockdown. Ventilation rates were calculated using the steady-state method. Pre-lockdown, with an average occupancy of 17 students, in 42% of the classrooms the CO2 concentration exceeded the upper limit of the Dutch national guidelines (800 ppm above outdoors), while 13% had a ventilation rate per person (VRp) lower than the minimum requirement (6 l/s/p). Post-lockdown, the indoor CO2 concentration decreased significantly while for ventilation rates significant increase was only found in VRp, mainly caused by the decrease in occupancy (average 10 students). The total ventilation rate per classrooms, mainly induced by opening windows and doors, did not change significantly. Meanwhile, according to the Dutch national guidelines, thermal conditions in the classrooms were not satisfying, both pre- and post-lockdown. While opening windows and doors cannot achieve the required indoor environmental quality at all times, reducing occupancy might not be feasible for immediate implementation. Hence, more controllable and flexible ways for improving indoor air quality and thermal comfort in classrooms are needed.

What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic?

The question of whether SARS-CoV-2 is mainly transmitted by droplets or aerosols has been highly controversial. We sought to explain this controversy through a historical analysis of transmission research in other diseases. For most of human history, the dominant paradigm was that many diseases were carried by the air, often over long distances and in a phantasmagorical way. This miasmatic paradigm was challenged in the mid to late 19th century with the rise of germ theory, and as diseases such as cholera, puerperal fever, and malaria were found to actually transmit in other ways. Motivated by his views on the importance of contact/droplet infection, and the resistance he encountered from the remaining influence of miasma theory, prominent public health official Charles Chapin in 1910 helped initiate a successful paradigm shift, deeming airborne transmission most unlikely. This new paradigm became dominant. However, the lack of understanding of aerosols led to systematic errors in the interpretation of research evidence on transmission pathways. For the next five decades, airborne transmission was considered of negligible or minor importance for all major respiratory diseases, until a demonstration of airborne transmission of tuberculosis (which had been mistakenly thought to be transmitted by droplets) in 1962. The contact/droplet paradigm remained dominant, and only a few diseases were widely accepted as airborne before COVID-19: those that were clearly transmitted to people not in the same room. The acceleration of interdisciplinary research inspired by the COVID-19 pandemic has shown that airborne transmission is a major mode of transmission for this disease, and is likely to be significant for many respiratory infectious diseases.

Exploring the possibility of using CO2 as a proxy for exhaled particles to predict the risk of indoor exposure to pathogens

Airborne transmission has been confirmed as one of three principal ways of SARS-CoV-2 transmission. To reduce the transmission of SARS-CoV-2 indoors, understanding the distribution of respiratory droplets (or aerosols) present in human breath seems therefore important. To study whether the CO2 concentration can be used as a proxy for the number of exhaled particles present in an occupied space, the distribution of particles with different diameters (0.3, 0.5, 1.0, 2.5, 5.0 and 10 ?m) and CO2 concentrations were monitored in a classroom setting with six healthy subjects. Additionally, numbers of particles with the same sizes were measured in the breath of the same six healthy subjects separately. Results showed that (1) on the contrary to CO2, the main source of indoor particles came from outdoor air, and not from occupants;(2) the impacts of ventilation regimes on indoor particle numbers were different to the impacts on CO2 concentrations;and (3) almost no significant relationship between the number of indoor particles and CO2 concentration was observed. Based on these results, this study could therefore not conclude that the CO2 concentration in a classroom can be used as a proxy for the number of exhaled particles by the occupants.

Profiling office workers based on their self-reported preferences of indoor environmental quality and psychosocial comfort at their workplace during COVID-19.

Due to the COVID-19 pandemic, a large number of office workers were required to conduct their work from home. Little is known about the indoor environmental quality (IEQ) preferences and psychosocial comfort preferences of staff working from home. Therefore this study aimed to cluster office workers working at home based on their self-reported preferences for IEQ and psychosocial comfort at their most used workspace and to identify these preferences and needs of workers during the COVID-19 pandemic. A questionnaire was administered to employees of ten offices in the Netherlands, and the 502 respondents were clustered with two models by using TwoStep cluster analysis. The first model was based on variables related to IEQ preferences, while the second was to psychosocial comfort preferences. The analysis revealed four IEQ clusters and six psychosocial comfort clusters. Comparison of these results with other similar studies proposed that the prevalence of anxiety, depression, migraine, and rhinitis, increased for this population during the work-from-home period of the pandemic. Further results suggest that both IEQ and psychosocial comfort preferences are situation- and gender-dependent.

Ventilation regimes of school classrooms against airborne transmission of infectious respiratory droplets: A review

Airborne transmission of small respiratory droplets (i.e., aerosols) is one of the dominant transmission routes of pathogens of several contagious respiratory diseases, which mainly takes place between occupants when sharing indoor spaces. The important role of ventilation in airborne infection control has been extensively discussed in previous studies, yet little attention was paid to the situation in school classrooms, where children spend long hours every day. A literature study was conducted to identify the existing ventilation strategies of school classrooms, to assess their adequacy of minimizing infectious aerosols, and to seek further improvement. It is concluded that school classrooms are usually equipped with natural ventilation or mixing mechanical ventilation, which are not fully capable to deal with both long-range and short-range airborne transmissions. In general, the required ventilation designs, including both ventilation rates and air distribution patterns, are still unclear. Current standards and guidelines of ventilation in school classrooms mainly focus on perceived air quality, while the available ventilation in many schools already fail to meet those criteria, leading to poor indoor air quality (IAQ). New ways of ventilation are needed in school classrooms, where the design should be shifted from comfort-based to health-based. Personalized ventilation systems have shown the potential in protecting occupants from aerosols generated within short-range contact and improving local IAQ, which can be used to compensate the existing ventilation regimes. However, more studies are still needed before such new ventilation methods can be applied to children in school classrooms.

Preferences for Indoor Environmental and Social Comfort of Outpatient Staff during the COVID-19 Pandemic, an Explanatory Study.

While the pressure on hospital workers keeps growing, they are generally more dissatisfied with their comfort than other occupants in hospitals or offices. To better understand the comfort of outpatient workers in hospitals, clusters for preferences and perceptions of the indoor environmental quality (IEQ) and social comfort were identified in a previous study before the outbreak of the coronavirus disease 2019 (COVID-19) pandemic. This qualitative study explains the outpatient workers' main preferences for comfort during the COVID-19 pandemic. Semi-structured interviews and photo-elicitation were used. Contextual changes due to the COVID-19 pandemic were included. The questions in the interviews were based on the characteristics of the profiles, corresponding with the clusters. The data were analyzed with content analysis according to the steps defined by Gioia. Seventeen outpatient workers who had been part of the previous study participated. For some outpatient workers differentiation of preferences was illogical due to interrelations and equal importance of the comfort aspects. The main changes in perceptions of comfort due to the pandemic were worries about the indoor air quality and impoverished interaction. Because the occupants' preferences for comfort can change over time, it was suggested that further development of occupant profiles needs to accommodate changes.

The effect of a mobile HEPA filter system on 'infectious' aerosols, sound and air velocity in the SenseLab.

High efficiency air filtration has been suggested to reduce airborne transmission of 'infectious' aerosols. In this study the 'air cleaning' effect as well as the effect on sound and air velocity (draught risk) of a mobile High-Efficiency Particulate Air (HEPA) filter system was tested for different settings and positions in the Experience room of the SenseLab. From both the noise assessments by a panel of subjects and sound monitoring it was concluded that the mobile HEPA filter system causes an unacceptable background sound level in the tested classroom setting (Experience room). With respect to the air velocity measurements and draught rating calculations, it was concluded that both depend on the position and the setting of the HEPA filter system as well as on the position and height of the measurements. For the removal of aerosols simulated by air-filled soap bubbles in front of the subject, the mobile HEPA filter system performed better as compared to the 'No ventilation' regime, for all settings and both positions, and for some settings, even better than all the tested mixing ventilation regimes. The use of a mobile HEPA filter system seems a good additional measure when only natural ventilation options are available. Future research should focus on rooms of different sizes or shapes, as this may also play a role in the filter's performance, noise and draught effects.

How can airborne transmission of COVID-19 indoors be minimised?

During the rapid rise in COVID-19 illnesses and deaths globally, and notwithstanding recommended precautions, questions are voiced about routes of transmission for this pandemic disease. Inhaling small airborne droplets is probable as a third route of infection, in addition to more widely recognized transmission via larger respiratory droplets and direct contact with infected people or contaminated surfaces. While uncertainties remain regarding the relative contributions of the different transmission pathways, we argue that existing evidence is sufficiently strong to warrant engineering controls targeting airborne transmission as part of an overall strategy to limit infection risk indoors. Appropriate building engineering controls include sufficient and effective ventilation, possibly enhanced by particle filtration and air disinfection, avoiding air recirculation and avoiding overcrowding. Often, such measures can be easily implemented and without much cost, but if only they are recognised as significant in contributing to infection control goals. We believe that the use of engineering controls in public buildings, including hospitals, shops, offices, schools, kindergartens, libraries, restaurants, cruise ships, elevators, conference rooms or public transport, in parallel with effective application of other controls (including isolation and quarantine, social distancing and hand hygiene), would be an additional important measure globally to reduce the likelihood of transmission and thereby protect healthcare workers, patients and the general public.