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.

Targeted reduction of airborne viral transmission risk in long-term residential aged care.

COVID-19 has demonstrated the devastating consequences of the rapid spread of an airborne virus in residential aged care. We report the use of CO2-based ventilation assessment to empirically identify potential 'super-spreader' zones within an aged care facility, and determine the efficacy of rapidly implemented, inexpensive, risk reduction measures.

Increasing ventilation reduces SARS-CoV-2 airborne transmission in schools: A retrospective cohort study in Italy's Marche region.

Introduction: While increasing the ventilation rate is an important measure to remove inhalable virus-laden respiratory particles and lower the risk of infection, direct validation in schools with population-based studies is far from definitive. Methods: We investigated the strength of association between ventilation and SARS-CoV-2 transmission reported among the students of Italy's Marche region in more than 10,000 classrooms, of which 316 were equipped with mechanical ventilation. We used ordinary and logistic regression models to explore the relative risk associated with the exposure of students in classrooms. Results and discussion: For classrooms equipped with mechanical ventilation systems, the relative risk of infection of students decreased at least by 74% compared with a classroom with only natural ventilation, reaching values of at least 80% for ventilation rates >10 L s-1 student-1. From the regression analysis we obtained a relative risk reduction in the range 12%15% for each additional unit of ventilation rate per person. The results also allowed to validate a recently developed predictive theoretical approach able to estimate the SARS-CoV-2 risk of infection of susceptible individuals via the airborne transmission route. We need mechanical ventilation systems to protect students in classrooms from airborne transmission; the protection is greater if ventilation rates higher than the rate needed to ensure indoor air quality (>10 L s-1 student-1) are adopted. The excellent agreement between the results from the retrospective cohort study and the outcome of the predictive theoretical approach makes it possible to assess the risk of airborne transmission for any indoor environment.

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.

Risk of SARS-CoV-2 in a car cabin assessed through 3D CFD simulations.

In this study, the risk of infection from SARS-CoV-2 Delta variant of passengers sharing a car cabin with an infected subject for a 30-min journey is estimated through an integrated approach combining a recently developed predictive emission-to-risk approach and a validated CFD numerical model numerically solved using the open-source OpenFOAM software. Different scenarios were investigated to evaluate the effect of the infected subject position within the car cabin, the airflow rate of the HVAC system, the HVAC ventilation mode, and the expiratory activity (breathing vs. speaking). The numerical simulations here performed reveal that the risk of infection is strongly influenced by several key parameters: As an example, under the same ventilation mode and emitting scenario, the risk of infection ranges from zero to roughly 50% as a function of the HVAC flow rate. The results obtained also demonstrate that (i) simplified zero-dimensional approaches limit proper evaluation of the risk in such confined spaces, conversely, (ii) CFD approaches are needed to investigate the complex fluid dynamics in similar indoor environments, and, thus, (iii) the risk of infection in indoor environments characterized by fixed seats can be in principle controlled by properly designing the flow patterns of the environment.

Increased close proximity airborne transmission of the SARS-CoV-2 Delta variant.

The Delta variant of SARS-CoV-2 causes higher viral loads in infected hosts, increasing the risk of close proximity airborne transmission through breathing, speaking and coughing. We performed a Monte Carlo simulation using a social contact network and exponential dose-response model to quantify the close proximity reproduction number of both wild-type SARS-CoV-2 and the Delta variant. We estimate more than twice as many Delta variant cases will reproduce infection in their close proximity contacts (64%) versus the wild-type SARS-CoV-2 (29%). Occupational health guidelines must consider close proximity airborne transmission and recommend improved personal respiratory protection for high-risk workers.

Prevention of SARS-CoV-2 (COVID-19) transmission in residential aged care using ultraviolet light (PETRA): a two-arm crossover randomised controlled trial protocol.

BACKGROUND: SARS-CoV-2 poses a considerable threat to those living in residential aged care facilities (RACF). RACF COVID-19 outbreaks have been characterised by the rapid spread of infection and high rates of severe disease and associated mortality. Despite a growing body of evidence supporting airborne transmission of SARS-CoV-2, current infection control measures in RACF including hand hygiene, social distancing, and sterilisation of surfaces, focus on contact and droplet transmission. Germicidal ultraviolet (GUV) light has been used widely to prevent airborne pathogen transmission. Our aim is to investigate the efficacy of GUV technology in reducing the risk of SARS-CoV-2 infection in RACF. METHODS: A multicentre, two-arm double-crossover, randomised controlled trial will be conducted to determine the efficacy of GUV devices to reduce respiratory viral transmission in RACF, as an adjunct to existing infection control measures. The study will be conducted in partnership with three aged care providers in metropolitan and regional South Australia. RACF will be separated into paired within-site zones, then randomised to intervention order (GUV or control). The initial 6-week period will be followed by a 2-week washout before crossover to the second 6-week period. After accounting for estimated within-zone and within-facility correlations of infection, and baseline infection rates (10 per 100 person-days), a sample size of n = 8 zones (n = 40 residents/zone) will provide 89% power to detect a 50% reduction in symptomatic infection rate. The primary outcome will be the incidence rate ratio of combined symptomatic respiratory infections for intervention versus control. Secondary outcomes include incidence rates of hospitalisation for complications associated with respiratory infection; respiratory virus detection in facility air and fomite samples; rates of laboratory confirmed respiratory illnesses and genomic characteristics. DISCUSSION: Measures that can be deployed rapidly into RACF, that avoid the requirement for changes in resident and staff behaviour, and that are effective in reducing the risk of airborne SARS-CoV-2 transmission, would provide considerable benefit in safeguarding a highly vulnerable population. In addition, such measures might substantially reduce rates of other respiratory viruses, which contribute considerably to resident morbidity and mortality. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000567820 (registered on 14th May, 2021).

The nexus between in-car aerosol concentrations, ventilation and the risk of respiratory infection.

We examined the trade-offs between in-car aerosol concentrations, ventilation and respiratory infection transmission under three ventilation settings: windows open (WO); windows closed with air-conditioning on ambient air mode (WC-AA); and windows closed with air-conditioning on recirculation (WC-RC). Forty-five runs, covering a total of 324 km distance on a 7.2-km looped route, were carried out three times a day (morning, afternoon, evening) to monitor aerosols (PM2.5; particulate matter < 2.5 µm and PNC; particle number concentration), CO2 and environmental conditions (temperature and relative humidity). Ideally, higher ventilation rates would give lower in-car pollutant concentrations due to dilution from outdoor air. However, in-car aerosol concentrations increased with ventilation (WO > WC-AA > WC-RC) due to the ingress of polluted outdoor air on urban routes. A clear trade-off, therefore, exists for the in-car air quality (icAQ) versus ventilation; for example, WC-RC showed the least aerosol concentrations (i.e. four-times lower compared with WO), but corresponded to elevated CO2 levels (i.e. five-times higher compared with WO) in 20 mins. We considered COVID-19 as an example of respiratory infection transmission. The probability of its transmission from an infected occupant in a five-seater car was estimated during different quanta generation rates (2-60.5 quanta hr-1) using the Wells-Riley model. In WO, the probability with 50%-efficient and without facemasks under normal speaking (9.4 quanta hr-1) varied only by upto 0.5%. It increased by 2-fold in WC-AA (<1.1%) and 10-fold in WC-RC (<5.2%) during a 20 mins trip. Therefore, a wise selection of ventilation settings is needed to balance in-car exposure in urban areas affected by outdoor air pollution and that by COVID-19 transmission. We also successfully developed and assessed the feasibility of using sensor units in static and dynamic environments to monitor icAQ and potentially infer COVID-19 transmission. Further research is required to develop automatic-alarm systems to help reduce both pollutant exposure and infection from respiratory COVID-19 transmission.

Respiratory infection risk-based ventilation design method.

A new design method is proposed to calculate outdoor air ventilation rates to control respiratory infection risk in indoor spaces. We propose to use this method in future ventilation standards to complement existing ventilation criteria based on the perceived air quality and pollutant removal. The proposed method makes it possible to calculate the required ventilation rate at a given probability of infection and quanta emission rate. Present work used quanta emission rates for SARS-CoV-2 and consequently the method can be applied for other respiratory viruses with available quanta data. The method was applied to case studies representing typical rooms in public buildings. To reduce the probability of infection, the total airflow rate per infectious person revealed to be the most important parameter to reduce the infection risk. Category I ventilation rate prescribed in the EN 16798-1 standard satisfied many but not all type of spaces examined. The required ventilation rates started from about 80 L/s per room. Large variations between the results for the selected case studies made it impossible to provide a simple rule for estimating the required ventilation rates. Consequently, we conclude that to design rooms with a low infection risk the newly developed ventilation design method must be used.

Breath-, air- and surface-borne SARS-CoV-2 in hospitals.

The COVID-19 pandemic has brought an unprecedented crisis to the global health sector. When discharging COVID-19 patients in accordance with throat or nasal swab protocols using RT-PCR, the potential risk of reintroducing the infection source to humans and the environment must be resolved. Here, 14 patients including 10 COVID-19 subjects were recruited; exhaled breath condensate (EBC), air samples and surface swabs were collected and analyzed for SARS-CoV-2 using reverse transcription-polymerase chain reaction (RT-PCR) in four hospitals with applied natural ventilation and disinfection practices in Wuhan. Here we discovered that 22.2% of COVID-19 patients (n = 9), who were ready for hospital discharge based on current guidelines, had SARS-CoV-2 in their exhaled breath (~105 RNA copies/m3). Although fewer surface swabs (3.1%, n = 318) tested positive, medical equipment such as face shield frequently contacted/used by healthcare workers and the work shift floor were contaminated by SARS-CoV-2 (3-8 viruses/cm2). Three of the air samples (n = 44) including those collected using a robot-assisted sampler were detected positive by a digital PCR with a concentration level of 9-219 viruses/m3. RT-PCR diagnosis using throat swab specimens had a failure rate of more than 22% in safely discharging COVID-19 patients who were otherwise still exhaling the SARS-CoV-2 by a rate of estimated ~1400 RNA copies per minute into the air. Direct surface contact might not represent a major transmission route, and lower positive rate of air sample (6.8%) was likely due to natural ventilation (1.6-3.3 m/s) and regular disinfection practices. While there is a critical need for strengthening hospital discharge standards in preventing re-emergence of COVID-19 spread, use of breath sample as a supplement specimen could further guard the hospital discharge to ensure the safety of the public and minimize the pandemic re-emergence risk.

Predicting the effect of confinement on the COVID-19 spread using machine learning enriched with satellite air pollution observations.

The real-time monitoring of reductions of economic activity by containment measures and its effect on the transmission of the coronavirus (COVID-19) is a critical unanswered question. We inferred 5,642 weekly activity anomalies from the meteorology-adjusted differences in spaceborne tropospheric NO2 column concentrations after the 2020 COVID-19 outbreak relative to the baseline from 2016 to 2019. Two satellite observations reveal reincreasing economic activity associated with lifting control measures that comes together with accelerating COVID-19 cases before the winter of 2020/2021. Application of the near-real-time satellite NO2 observations produces a much better prediction of the deceleration of COVID-19 cases than applying the Oxford Government Response Tracker, the Public Health and Social Measures, or human mobility data as alternative predictors. A convergent cross-mapping suggests that economic activity reduction inferred from NO2 is a driver of case deceleration in most of the territories. This effect, however, is not linear, while further activity reductions were associated with weaker deceleration. Over the winter of 2020/2021, nearly 1 million daily COVID-19 cases could have been avoided by optimizing the timing and strength of activity reduction relative to a scenario based on the real distribution. Our study shows how satellite observations can provide surrogate data for activity reduction during the COVID-19 pandemic and monitor the effectiveness of containment to the pandemic before vaccines become widely available.

The airborne contagiousness of respiratory viruses: A comparative analysis and implications for mitigation

The infectious emission rate is a fundamental input parameter for airborne transmission risk assessment, but data are limited due to reliance on estimates from chance superspreading events. This study assesses the strength of a predictive estimation approach developed by the authors for SARS-CoV-2 and uses novel estimates to compare the contagiousness of respiratory pathogens. We applied the approach to SARS-CoV-1, SARS-CoV-2, MERS, measles virus, adenovirus, rhinovirus, coxsackievirus, seasonal influenza virus and Mycobacterium tuberculosis (TB) and compared quanta emission rate (ERq) estimates to literature values. We calculated infection risk in a prototypical classroom and barracks to assess the relative ability of ventilation to mitigate airborne transmission. Our median standing and speaking ERq estimate for SARS-CoV-2 (2.7 quanta h–1) is similar to active, untreated TB (3.1 quanta h–1), higher than seasonal influenza (0.17 quanta h–1), and lower than measles virus (15 quanta h–1). We calculated event reproduction numbers above 1 for SARS-CoV-2, measles virus, and untreated TB in both the classroom and barracks for an activity level of standing and speaking at low, medium and high ventilation rates of 2.3, 6.6 and 14 liters per second per person (L s–1 p–1), respectively. Our predictive ERq estimates are consistent with the range of values reported over decades of research. In congregate settings, current ventilation standards are unlikely to control the spread of viruses with upper quartile ERq values above 10 quanta h–1, such as SARS-CoV-2, indicating the need for additional control measures.

Large-Scale Spraying of Roads with Water Contributes to, Rather Than Prevents, Air Pollution.

Spraying roads with water on a large scale in Chinese cities is one of the supplementary precaution or mitigation actions implemented to control severe air pollution events or heavy haze-fog events in which the mechanisms causing them are not yet fully understood. These air pollution events were usually characterized by higher air humidity. Therefore, there may be a link between this action and air pollution. In the present study, the impact of water spraying on the PM2.5 concentration and humidity in air was assessed by measuring chemical composition of the water, undertaking a simulated water spraying experiment, measuring residues and analyzing relevant data. We discovered that spraying large quantities of tap or river water on the roads leads to increased PM2.5 concentration and humidity, and that daily continuous spraying produces a cumulative effect on air pollution. Spraying the same amount of water produces greater increases in humidity and PM2.5 concentration during cool autumn and winter than during hot summer. Our results demonstrate that spraying roads with water increases, rather than decreases, the concentration of PM2.5 and thus is a new source of anthropogenic aerosol and air pollution. The higher vapor content and resultant humidity most likely create unfavorable meteorological conditions for the dispersion of air pollution in autumn and winter with low temperature.

Coronavirus Disease 2019 Patients in Earlier Stages Exhaled Millions of Severe Acute Respiratory Syndrome Coronavirus 2 Per Hour.

Coronavirus disease 2019 (COVID-19) patients exhaled millions of severe acute respiratory syndrome coronavirus 2 RNA copies per hour, which plays an important role in COVID-19 transmission. Exhaled breath had a higher positive rate (26.9%, n = 52) than surface (5.4%, n = 242) and air (3.8%, n = 26) samples.

Tracing surface and airborne SARS-CoV-2 RNA inside public buses and subway trains.

Given the widespread concern but general lack of information over the possibility of SARS-CoV-2 infection in public transport, key issues such as passenger personal hygiene, efficient air circulation systems, and the effective disinfection of frequently touched surfaces need to be evaluated to educate the public and diminish the risk of viral transmission as we learn to live with the ongoing pandemic. In this context we report on a study involving the collection of 99 samples taken from inside Barcelona buses and subway trains in May to July 2020. From this sample group 82 (58 surface swabs, 9 air conditioning (a/c) filters, 3 a/c dust, 12 ambient air) were selected to be analysed by RT-PCR for traces of the SARS-CoV-2 virus. Thirty of these selected samples showed evidence for one or more of 3 target RNA gene regions specific for this virus (IP2, IP4, E). Most (24) of these 30 samples showed positivity for only 1 of the 3 RNA targets, 4 samples yielded 2 targets, and 2 samples provided evidence for all 3 targets. RNA remnants were more common in surface swabs from support bars (23 out of 58) than in ambient air inside the vehicles (3 out of 12), with relatively higher concentrations of viral RNA fragments in buses rather than in trains. Whereas subway train a/c filters examined were all virus-free, 4 of the 9 bus a/c filter/dust samples yielded evidence for viral RNA. After nocturnal maintenance and cleaning most buses initially yielding positive results subsequently showed elimination of the RT-PCR signal, although signs of viral RNA remained in 4 of 13 initially positive samples. The presence of such remnant viral traces however does not demonstrate infectivity, which in the present study is considered unlikely given the fragmentary nature of the gene targets detected. Nevertheless, best practice demands that close attention to ventilation systems and regular vehicle disinfection in public transport worldwide need to be rigorously applied to be effective at eliminating traces of the virus throughout the vehicle, especially at times when COVID-19 cases are peaking. Additionally, infectivity tests should be implemented to evaluate the efficiency of disinfection procedures to complement the information resulting from RT-PCR analysis. Modelling the probability of infection whilst travelling in buses under different scenarios indicates that forced ventilation greatly reduces the risk.