Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

The coronavirus disease 2019 (COVID-19) pandemic has caused untold disruption throughout the world. Understanding the mechanisms for transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is key to preventing further spread, but there is confusion over the meaning of 'airborne' whenever transmission is discussed. Scientific ambivalence originates from evidence published many years ago which has generated mythological beliefs that obscure current thinking. This article collates and explores some of the most commonly held dogmas on airborne transmission in order to stimulate revision of the science in the light of current evidence. Six 'myths' are presented, explained and ultimately refuted on the basis of recently published papers and expert opinion from previous work related to similar viruses. There is little doubt that SARS-CoV-2 is transmitted via a range of airborne particle sizes subject to all the usual ventilation parameters and human behaviour. Experts from specialties encompassing aerosol studies, ventilation, engineering, physics, virology and clinical medicine have joined together to produce this review to consolidate the evidence for airborne transmission mechanisms, and offer justification for modern strategies for prevention and control of COVID-19 in health care and the community.

Sensory evaluation and chemical analysis of exhaled and dermally emitted bioeffluents.

Conditions in which exhaled and dermally emitted bioeffluents could be sampled separately or together (whole-body emission) were created. Five lightly dressed males exhaled the air through a mask to another, identical chamber or without a mask to the chamber in which they were sitting; the outdoor air supply rate was the same in both chambers. The carbon dioxide concentration in the chamber with exhaled air was 2000 ppm. Chamber temperatures were 23°C or 28°C, and ozone was present or absent in the supply airflow. When dermally emitted bioeffluents were present, the perceived air quality (PAQ) was less acceptable, and the odor intensity was higher than when only exhaled bioeffluents were present. The presence or absence of exhaled bioeffluents in the unoccupied chamber made no significant difference to sensory assessments. At 28°C and with ozone present, the odor intensity increased and the PAQ was less acceptable in the chambers with whole-body bioeffluents. The concentrations of nonanal, decanal, geranylacetone, and 6-MHO were higher when dermally emitted bioeffluents were present; they increased further when ozone was present. The concentration of squalene then decreased and increased again at 28°C. Dermally emitted bioeffluents seem to play a major role in the sensory nuisance experienced when occupied volumes are inadequately ventilated.

Physiological responses during exposure to carbon dioxide and bioeffluents at levels typically occurring indoors.

Twenty-five subjects were exposed to different levels of carbon dioxide (CO2 ) and bioeffluents. The ventilation rate was set high enough to create a reference condition of 500 ppm CO2 with subjects present; additional CO2 was then added to supply air to reach levels of 1000 or 3000 ppm, or the ventilation rate was reduced to allow metabolically generated CO2 to reach the same two levels (bioeffluents increased as well). Heart rate, blood pressure, end-tidal CO2 (ETCO2 ), oxygen saturation of blood (SPO2 ), respiration rate, nasal peak flow, and forced expiration were monitored, and the levels of salivary α-amylase and cortisol were analyzed. The subjects performed a number of mental tasks during exposures and assessed their levels of comfort and the intensity of their acute health symptoms. During exposure to CO2 at 3000 ppm, when CO2 was added or ventilation was restricted, ETCO2 increased more and heart rate decreased less than the changes that occurred in the reference condition. Exposure to bioeffluents, when metabolically generated CO2 was at 3000 ppm, significantly increased diastolic blood pressure and salivary α-amylase level compared with pre-exposure levels, and reduced the performance of a cue-utilization test: These effects may suggest higher arousal/stress. A model is proposed describing how mental performance is affected by exposure to bioeffluents.

Effects of exposure to carbon dioxide and bioeffluents on perceived air quality, self-assessed acute health symptoms, and cognitive performance.

The purpose of this study was to examine the effects on humans of exposure to carbon dioxide (CO2 ) and bioeffluents. In three of the five exposures, the outdoor air supply rate was high enough to remove bioeffluents, resulting in a CO2 level of 500 ppm. Chemically pure CO2 was added to this reference condition to create exposure conditions with CO2 at 1000 or 3000 ppm. In two further conditions, the outdoor air supply rate was restricted so that the bioeffluent CO2 reached 1000 or 3000 ppm. The same 25 subjects were exposed for 255 min to each condition. Subjective ratings, physiological responses, and cognitive performance were measured. No statistically significant effects on perceived air quality, acute health symptoms, or cognitive performance were seen during exposures when CO2 was added. Exposures to bioeffluents with CO2 at 3000 ppm reduced perceived air quality; increased the intensity of reported headache, fatigue, sleepiness, and difficulty in thinking clearly; and reduced speed of addition, the response time in a redirection task, and the number of correct links made in the cue-utilization test. This suggests that moderate concentrations of bioeffluents, but not pure CO2 , will result in deleterious effects on occupants during typical indoor exposures.

The effects of bedroom air quality on sleep and next-day performance.

The effects of bedroom air quality on sleep and next-day performance were examined in two field-intervention experiments in single-occupancy student dormitory rooms. The occupants, half of them women, could adjust an electric heater to maintain thermal comfort but they experienced two bedroom ventilation conditions, each maintained for 1 week, in balanced order. In the initial pilot experiment (N = 14), bedroom ventilation was changed by opening a window (the resulting average CO2 level was 2585 or 660 ppm). In the second experiment (N = 16), an inaudible fan in the air intake vent was either disabled or operated whenever CO2 levels exceeded 900 ppm (the resulting average CO2 level was 2395 or 835 ppm). Bedroom air temperatures varied over a wide range but did not differ between ventilation conditions. Sleep was assessed from movement data recorded on wristwatch-type actigraphs and subjects reported their perceptions and their well-being each morning using online questionnaires. Two tests of next-day mental performance were applied. Objectively measured sleep quality and the perceived freshness of bedroom air improved significantly when the CO2 level was lower, as did next-day reported sleepiness and ability to concentrate and the subjects' performance of a test of logical thinking.

Use of visual CO2 feedback as a retrofit solution for improving classroom air quality.

Carbon dioxide (CO2 ) sensors that provide a visual indication were installed in classrooms during normal school operation. During 2-week periods, teachers and students were instructed to open the windows in response to the visual CO2 feedback in 1 week and open them, as they would normally do, without visual feedback, in the other week. In the heating season, two pairs of classrooms were monitored, one pair naturally and the other pair mechanically ventilated. In the cooling season, two pairs of naturally ventilated classrooms were monitored, one pair with split cooling in operation and the other pair with no cooling. Classrooms were matched by grade. Providing visual CO2 feedback reduced CO2 levels, as more windows were opened in this condition. This increased energy use for heating and reduced the cooling requirement in summertime. Split cooling reduced the frequency of window opening only when no visual CO2 feedback was present.

Quantitative relationships between occupant satisfaction and satisfaction aspects of indoor environmental quality and building design.

UNLABELLED: The article examines which subjectively evaluated indoor environmental parameters and building features mostly affect occupants' satisfaction in mainly US office buildings. The study analyzed data from a web-based survey administered to 52,980 occupants in 351 office buildings over 10 years by the Center for the Built Environment. The survey uses 7-point ordered scale questions pertaining to satisfaction with indoor environmental parameters, workspace, and building features. The average building occupant was satisfied with his/her workspace and building. Proportional odds ordinal logistic regression shows that satisfaction with all 15 parameters listed in the survey contributed significantly to overall workspace satisfaction. The most important parameters were satisfaction with amount of space (odds ratio OR 1.57, 95% CI: 1.55-1.59), noise level (OR 1.27, 95% CI: 1.25-1.29), and visual privacy (OR 1.26, 95% CI: 1.24-1.28). Satisfaction with amount of space was ranked to be most important for workspace satisfaction, regardless of age group (below 30, 31-50 or over 50 years old), gender, type of office (single or shared offices, or cubicles), distance of workspace from a window (within 4.6 m or further), or satisfaction level with workspace (satisfied or dissatisfied). Satisfaction with amount of space was not related to the gross amount of space available per person. PRACTICAL IMPLICATIONS: To maximize workspace satisfaction, designer should invest in aspects that increase satisfaction with amount of space and storage, noise level, and visual privacy. Office workers will be most satisfied with their workspace and building when located close to a window in a private office. This may affect job satisfaction, work performance, and personal and company productivity.

Effects of thermal discomfort in an office on perceived air quality, SBS symptoms, physiological responses, and human performance.

UNLABELLED: The effects of thermal discomfort on health and human performance were investigated in an office, in an attempt to elucidate the physiological mechanisms involved. Twelve subjects (six men and six women) performed neurobehavioral tests and tasks typical of office work while thermally neutral (at 22°C) and while warm (at 30°C). Multiple physiological measurements and subjective assessment were made. The results show that when the subjects felt warm, they assessed the air quality to be worse, reported increased intensity of many sick building syndrome symptoms, expressed more negative mood, and were less willing to exert effort. Task performance decreased when the subjects felt warm. Their heart rate, respiratory ventilation, and end-tidal partial pressure of carbon dioxide increased significantly, and their arterial oxygen saturation decreased. Tear film quality was found to be significantly reduced at the higher temperature when they felt warm. No effects were observed on salivary biomarkers (alpha-amylase and cortisol). The present results imply that the negative effects on health and performance that occur when people feel thermally warm at raised temperatures are caused by physiological mechanisms. PRACTICAL IMPLICATIONS: This study indicates to what extent elevated temperatures and thermal discomfort because of warmth result in negative effects on health and performance and shows that these could be caused by physiological responses to warmth, not by the distraction of subjective discomfort. This implies that they will occur independently of discomfort, i.e. even if subjects have become adaptively habituated to subjective discomfort. The findings make it possible to estimate the negative economic consequences of reducing energy use in buildings in cases where this results in elevated indoor temperatures. They show clearly that thermal discomfort because of raised temperatures should be avoided in workplaces.

Can a photocatalytic air purifier be used to improve the perceived air quality indoors?

UNLABELLED: The effect of a photocatalytic air purifier on perceived air quality (PAQ) was examined in rooms polluted by typical sources of indoor pollution. The rooms were ventilated at three different outdoor air supply rates. The air quality was assessed by a sensory panel when the purifier was in operation as well as when it was off. Operation of the purifier significantly improved PAQ in the rooms polluted by building materials (used carpet, old linoleum, and old chipboard), and a used ventilation filter as well as a mixture of building materials, used ventilation filter and cathode-ray tube computer monitors. The effect corresponded to approximately doubling the outdoor air supply rate. Operation of the purifier significantly worsened the PAQ in rooms with human bioeffluents, probably due to incomplete oxidation of alcohols which are one of the main pollutants emitted by humans. Present results show that the photocatalytic air purifier can supplement ventilation when the indoor air is polluted by building-related sources, but should not be used in spaces where human bioeffluents constitute the main source of pollution. PRACTICAL IMPLICATIONS: The present results suggest that a photocatalytic air purifier can supplement ventilation when the indoor air is polluted mainly by building-related sources, for example in unoccupied buildings outside working hours when ventilation is considerably reduced or turned off and pollutants build up and adsorb on indoor surfaces. The results also suggest that use of a photocatalytic air purifier should be avoided when humans are present and constitute main source of pollution.

Determination of material emission signatures by PTR-MS and their correlations with odor assessments by human subjects.

UNLABELLED: The objectives of this study were to determine volatile organic compound (VOC) emission signatures of nine typical building materials by using proton transfer reaction-mass spectrometry (PTR-MS) and to explore the correlation between the PTR-MS measurements and the measurements of acceptability by human subjects. VOC emissions from each material were measured in a 50-l small-scale chamber. Chamber air was sampled by PTR-MS to determine emission signatures. Sorbent tube sampling and TD-GC/MS analysis were also performed to identify the major VOCs emitted and to compare the resulting data with the PTR-MS emission signatures. The data on the acceptability of air quality assessed by human subjects were obtained from a previous experimental study in which the emissions from the same batch of materials were determined under the same area-specific ventilation rates as in the case of the measurements with PTR-MS. Results show that PTR-MS can be an effective tool for establishing VOC emission signatures of material types and that there were reasonable correlations between the PTR-MS measurements and the acceptability of air quality for the nine materials tested when the sum of selected major individual VOC odor indices was used to represent the emission level measured by PTR-MS. PRACTICAL IMPLICATIONS: The study shows that unique emission patterns may exist for different types of building materials. These patterns, or signatures, can be established by using PTR-MS, an online monitoring device. The sum of selected major individual VOC odor indices determined by PTR-MS correlates well with the acceptability of air quality assessed by human subjects, and hence provides a feasible approach to assessing perceived indoor air quality. This online assessment will open a new gate in understanding the role of VOC emissions from building materials on perceived air quality, forming a good foundation to develop real-time or near real-time methods for standard material emission testing and labeling, quality control of emissions from materials, and assessing the acceptability of air quality in buildings.

Sensory pollution sources in buildings.

UNLABELLED: Indoor air in non-industrial buildings is polluted by people, their activities, tobacco smoking, heating, ventilation and air-conditioning (HVAC) systems, building and furnishing materials, and electronic equipment. The sensory pollution loads on the air indoors quantified with an olf unit are summarized. They can be used to predict the impact of indoor pollution sources on the perceived air quality. Despite some limitations, they at present seem to be a suitable pragmatic tool for estimating the ventilation requirements for acceptable indoor air quality, based on perceived air quality. Control of pollution sources indoors and the avoidance of superfluous pollution sources is the most effective method to reduce sensory pollution loads in buildings. PRACTICAL IMPLICATIONS: Data on sensory pollution loads can be used to predict ventilation requirements for acceptable perceived indoor air quality.

Effects of pollution from personal computers on perceived air quality, SBS symptoms and productivity in offices.

UNLABELLED: In groups of six, 30 female subjects were exposed for 4.8 h in a low-polluting office to each of two conditions--the presence or absence of 3-month-old personal computers (PCs). These PCs were placed behind a screen so that they were not visible to the subjects. Throughout the exposure the outdoor air supply was maintained at 10 l/s per person. Under each of the two conditions the subjects performed simulated office work using old low-polluting PCs. They also evaluated the air quality and reported Sick Building Syndrome (SBS) symptoms. The PCs were found to be strong indoor pollution sources, even after they had been in service for 3 months. The sensory pollution load of each PC was 3.4 olf, more than three times the pollution of a standard person. The presence of PCs increased the percentage of people dissatisfied with the perceived air quality from 13 to 41% and increased by 9% the time required for text processing. Chemical analyses were performed to determine the pollutants emitted by the PCs. The most significant chemicals detected included phenol, toluene, 2-ethylhexanol, formaldehyde, and styrene. The identified compounds were, however, insufficient in concentration and kind to explain the observed adverse effects. This suggests that chemicals other than those detected, so-called 'stealth chemicals', may contribute to the negative effects. PRACTICAL IMPLICATIONS: PCs are an important, but hitherto overlooked, source of pollution indoors. They can decrease the perceived air quality, increase SBS symptoms and decrease office productivity. The ventilation rate in an office with a 3-month-old PC would need to be increased several times to achieve the same perceived air quality as in a low-polluting office with the PC absent. Pollution from PCs has an important negative impact on the air quality, not only in offices but also in many other spaces, including homes. PCs may have played a role in previously published studies on SBS and perceived air quality, where PCs were overlooked as a possible pollution source in the indoor environment. The fact that the chemicals identified in the office air and in the chamber experiments were insufficient to explain the adverse effects observed during human exposures illustrates the inadequacy of the analytical chemical methods commonly used in indoor air quality investigations. For certain chemicals the human senses are much more sensitive than the chemical methods routinely used in indoor air quality investigations. The adverse effects of PC-generated air pollutants could be reduced by modifications in the manufacturing process, increased ventilation, localized PC exhaust, or personalized ventilation systems.

Ventilation and health in non-industrial indoor environments: report from a European multidisciplinary scientific consensus meeting (EUROVEN).

Scientific literature on the effects of ventilation on health, comfort, and productivity in non-industrial indoor environments (offices, schools, homes, etc.) has been reviewed by a multidisciplinary group of European scientists, called EUROVEN, with expertise in medicine, epidemiology, toxicology, and engineering. The group reviewed 105 papers published in peer-reviewed scientific journals and judged 30 as conclusive, providing sufficient information on ventilation, health effects, data processing, and reporting, 14 as providing relevant background information on the issue, 43 as relevant but non-informative or inconclusive, and 18 as irrelevant for the issue discussed. Based on the data in papers judged conclusive, the group agreed that ventilation is strongly associated with comfort (perceived air quality) and health [Sick Building Syndrome (SBS) symptoms, inflammation, infections, asthma, allergy, short-term sick leave], and that an association between ventilation and productivity (performance of office work) is indicated. The group also concluded that increasing outdoor air supply rates in non-industrial environments improves perceived air quality; that outdoor air supply rates below 25 l/s per person increase the risk of SBS symptoms, increase short-term sick leave, and decrease productivity among occupants of office buildings; and that ventilation rates above 0.5 air changes per hour (h-1) in homes reduce infestation of house dust mites in Nordic countries. The group concluded additionally that the literature indicates that in buildings with air-conditioning systems there may be an increased risk of SBS symptoms compared with naturally or mechanically ventilated buildings, and that improper maintenance, design, and functioning of air-conditioning systems contributes to increased prevalence of SBS symptoms.

Subjective perceptions, symptom intensity and performance: a comparison of two independent studies, both changing similarly the pollution load in an office.

The present paper shows that introducing or removing the same pollution source in an office in two independent investigations, one in Denmark and one in Sweden, using similar experimental methodology, resulted in similar and repeatable effects on subjective assessments of perceived air quality, intensity of sick building syndrome symptoms and performance of office work. Removing the pollution source improved the perceived air quality, decreased the perceived dryness of air and the severity of headaches, and increased typing performance. These effects were observed separately in each experiment and were all significant (P < or = 0.05) after combining the data from both studies, indicating the advantages of pollution source strength control for health, comfort, and productivity.

Measurements of the effects of air quality on sensory perception.

Occupants in indoor non-industrial environments decide whether the indoor air quality is acceptable or not. This paper describes the method by which the assessments of acceptability of air quality can be used to measure short-term sensory effects on humans caused by indoor exposures. Advantages and disadvantages of the method are discussed in the light of a need for future research in order to fully understand how many variables (environmental, organismic, physiological and psychological) influence the ratings of acceptability of air quality and to learn how the results obtained in laboratory experiments can be used to predict responses in natural environments.

The effects of outdoor air supply rate in an office on perceived air quality, sick building syndrome (SBS) symptoms and productivity.

Perceived air quality, Sick Building Syndrome (SBS) symptoms and productivity were studied in a normally furnished office space (108 m3) ventilated with an outdoor airflow of 3, 10 or 30 L/s per person, corresponding to an air change rate of 0.6, 2 or 6 h-1. The temperature of 22 degrees C, the relative humidity of 40% and all other environmental parameters remained unchanged. Five groups of six female subjects were each exposed to the three ventilation rates, one group and one ventilation rate at a time. Each exposure lasted 4.6 h and took place in the afternoon. Subjects were unaware of the intervention and remained thermally neutral by adjusting their clothing. They assessed perceived air quality and SBS symptoms at intervals, and performed simulated normal office work. Increasing ventilation decreased the percentage of subjects dissatisfied with the air quality (P < 0.002) and the intensity of odour (P < 0.02), and increased the perceived freshness of air (P < 0.05). It also decreased the sensation of dryness of mouth and throat (P < 0.0006), eased difficulty in thinking clearly (P < 0.001) and made subjects feel generally better (P < 0.0001). The performance of four simulated office tasks improved monotonically with increasing ventilation rates, and the effect reached formal significance in the case of text-typing (P < 0.03). For each two-fold increase in ventilation rate, performance improved on average by 1.7%. This study shows the benefits for health, comfort and productivity of ventilation at rates well above the minimum levels prescribed in existing standards and guidelines. It confirms the results of a previous study in the same office when the indoor air quality was improved by decreasing the pollution load while the ventilation remained unchanged.

Perceived air quality, sick building syndrome (SBS) symptoms and productivity in an office with two different pollution loads.

Perceived air quality, Sick Building Syndrome (SBS) symptoms and productivity were studied in an existing office in which the air pollution level could be modified by introducing or removing a pollution source. This reversible intervention allowed the space to be classified as either non-low-polluting or low-polluting, as specified in the new European design criteria for the indoor environment CEN CR 1752 (1998). The pollution source was a 20-year-old used carpet which was introduced on a rack behind a screen so that it was invisible to the occupants. Five groups of six female subjects each were exposed to the conditions in the office twice, once with the pollution source present and once with the pollution source absent, each exposure being 265 min in the afternoon, one group at a time. They assessed the perceived air quality and SBS symptoms while performing simulated office work. The subject-rated acceptability of the perceived air quality in the office corresponded to 22% dissatisfied when the pollution source was present, and to 15% dissatisfied when the pollution source was absent. In the former condition there was a significantly increased prevalence of headaches (P = 0.04) and significantly lower levels of reported effort (p = 0.02) during the text typing and calculation tasks, both of which required a sustained level of concentration. In the text typing task, subjects worked significantly more slowly when the pollution source was present in the office (P = 0.003), typing 6.5% less text than when the pollution source was absent from the office Reducing the pollution load on indoor air proved to be an effective means of improving the comfort, health and productivity of building occupants.