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.

Influence of pulmonary ventilation rate and breathing cycle period on the risk of cross-infection.

This study examined the characteristics of the exhaled airflow pattern and breathing cycle period of human subjects and evaluated the influence of pulmonary ventilation rate and breathing cycle period on the risk of cross-infection. Measurements with five human subjects and a breathing thermal manikin were performed, and the peak exhaled airflow velocity from the mouth and the breathing cycle period were measured. Experiments on cross-infection between two breathing thermal manikins were then conducted in a full-scale test room, in which the pulmonary ventilation rate and breathing cycle period were varied systematically. Both peak flow velocity and breathing cycle length varied considerably between different subjects. The breathing cycle period in a standing posture was 18.9% lower than in a sitting posture. The influence of pulmonary ventilation rate and breathing cycle period extended up to a separation distance of 1.0 m between the two manikins. Increasing the pulmonary ventilation rate of the exposed person greatly increased the risk of cross-infection. Decreasing the breathing cycle period from the widely used "6 second" value led to a considerable increase in the risk of cross-infection. Standing posture resulted in a higher risk of cross-infection than sitting posture.

Airborne transmission between room occupants during short-term events: Measurement and evaluation.

This study experimentally examines and compares the dynamics and short-term events of airborne cross-infection in a full-scale room ventilated by stratum, mixing and displacement air distributions. Two breathing thermal manikins were employed to simulate a standing infected person and a standing exposed person. Four influential factors were examined, including separation distance between manikins, air change per hour, positioning of the two manikinsand air distribution. Tracer gas technique was used to simulate the exhaled droplet nuclei from the infected person and fast tracer gas concentration meters (FCM41) were used to monitor the concentrations. Real-time and average exposure indices were proposed to evaluate the dynamics of airborne exposure. The time-averaged exposure index depends on the duration of exposure time and can be considerably different during short-term events and under steady-state conditions. The exposure risk during short-term events may not always decrease with increasing separation distance. It changes over time and may not always increase with time. These findings imply that the control measures formulated on the basis of steady-state conditions are not necessarily appropriate for short-term events.

The influence of heated or cooled seats on the acceptable ambient temperature range.

In 11 climate chamber experiments at air temperatures ranging from 15 to 45 degrees C, a total of 24 subjects, dressed in appropriate clothing for entering a vehicle at these temperatures, were each exposed to four different seat temperatures, ranging from cool to warm. In one simulated summer series, subjects were preconditioned to be too hot, while in other series they were preconditioned to be thermally neutral. They reported their thermal sensations, overall thermal acceptability and comfort on visual analogue scales at regular intervals. Instantaneous heat flow to the seat was measured continuously. At each ambient room temperature, the percentage dissatisfied was found to be a second-order polynomial function of local heat flow. Zero heat flow was preferred at an air temperature of 22 degrees C and the heat flow that minimized the percentage dissatisfied was found to be a single linear function of air temperature in all conditions. The analysis indicates that providing optimal seat temperature would extend the conventional 80% acceptable range of air temperature for drivers and passengers in vehicle cabins by 9.3 degrees C downwards and by 6.4 degrees C upwards.