I thought I would say something more about airborne
viruses. They have been a hobby of mine for some time. The first time I heard
about how easily the current coronavirus was spreading I thought “this is an
airborne virus”. But then there were the usual protests. Some scientists came out and said that coronavirus requires “droplet” precautions rather
than “airborne” precautions. The common definition is that droplets are large
enough settle out quickly. They may touch you directly if you are close enough
but a lot of what droplets do is settle on surfaces. That leads to surface
contamination and spread of the virus.
Airborne viruses can travel longer distances within smaller droplets. An
even more unique characteristic is that airborne viruses are released with normal expiration. No coughing, sneezing, or shouting is necessary. Just normal
breathing can release airborne respiratory viruses into the air in the smallest droplet fraction.
An easy way to conceptualize airborne viral
spread is to look at the distribution of particles occurring with every breath.
They can range in size from 200 µm on the large end to less than 5 µm on the
lower end. Experiments can be done to show how aerosols of these particle sizes
spread through a room. Naturalistic experiments can also look at how these are
all spread through hospitals, airplanes, and other natural settings. By looking
at those patterns and the distance involved as well as any other paths that
could lead to transmission – a determination can be made about whether or not a
viruses “airborne” or not.
The second issue is whether or not live
infectious virus is spread by these droplets. In many cases that has been
limitation in the experiments. Direct evidence of viral spread at a distance
requires culture of the virus or a bioassay that shows the samples have a
cytopathic (killing) effect on live cells. Indirect evidence is typically by PCR where
the available nucleic acid is amplified and assayed. In researching this topic, I found early
literature that documented numerous respiratory viruses in ventilation systems
of buildings. That research was possible because nobody knew how to capture and
culture the virus samples until that time. The other technical issue is air
sampling. Certain air sampling devices do not allow for adequate virus
detection. There is a technical report recently that showed of a total of four
commonly used air sampling devices only one allowed virus to be identified or
cultured. These technical constraints have led to a lot of confusion about
whether a particular virus is airborne or not.
A practical definition of an airborne virus is
one that is exhaled during normal breathing can travel a distance in small
droplets (less than 5 µm) and create infection by landing on mucosal surfaces,
facial services, or the lining of the nasopharynx, oropharynx, or lungs. In that case you don’t have to be in the
presence of anyone coughing or sneezing. You don’t have to touch any
contaminated surfaces. You don’t have to touch your face. You just have to
breathe contaminated air. It is entirely possible that you can walk through a
cloud of airborne virus and not be aware of how it got there. A common example
is walking down the hallway after a crowd of people have walked through some of
them carrying the virus. Once you know about airborne viruses it gives you an
entirely different perspective on social distancing. Airborne particles can easily transverse the
longest dimension of typical rooms. The distance of 6 feet suggested in typical social distancing guidelines is not nearly far enough.
In a previous post I highlighted an experiment by
Donald K. Milton where he designed a machine to sample flu viruses in a natural
setting. Research subjects breathed normally and their expired air was sampled
for influenza virus. Influenza virus was recovered from 89% of the
nasopharyngeal swabs and 39% of the fine aerosol sample defined as droplets
less than or equal to 5 µm and greater than 0.05 µm. There was no coughing or
sneezing during the collection.. That is proof that influenza virus is airborne.
A recent experiment carried out at the
University of Nebraska Medical Center (3) in their bio containment and quarantine
units showed that in addition to abundant surface contamination by SARS-CoV-2 the
virus was also present in hallway air samples, in areas where only aerosol
deposits could reach, and personal air samplers carried by staff. The virus was detected by PCR analysis as
well as culture in some cases. The authors concluded that this was definite
evidence of an airborne virus and that facilities treating patients with SARS-CoV-2
should use airborne precautions. This paper is currently undergoing peer review
and is on a preprint server.
The technical aspects of aerosol fractionation
and dispersion is a subject best addressed in the engineering literature. The
best paper I could find on the subject (4) had a goal of studying the dispersion
characteristics of exhaled droplets in a ventilated room. The engineering goals
are to find out what physical parameters affect the dispersion rate and
hopefully lead to better indoor environments. The experimental paradigm looked
at a room that was 5 x 4 x 3 m (L x W x H) and ventilated by a downward
airflow from the ceiling. Aerosols were injected into this room and the
following distance and trajectory along with trajectory time was calculated for
the fractional droplets. As expected droplets with larger diameters (110-115
µm) fell at a faster rate and traveled a much shorter distance than the smaller diameter fraction. Droplet
dispersion was studied under a number of physical conditions including
different airflow, different temperatures, different relative humidity, and the
original exhaled initial velocity.
The 0.1, 1.0, and 10 µm droplets covered
horizontal distance of 5 m or the entire length of the room. Droplets in the
range of 50 to 200 µm cover distances ranging from 0.5 to 4 m. This study has numerous excellent graphs
about varying conditions and how droplets in different fractions are dispersed.
The reader is referred to the original reference to review all those
conditions. The bottom line for me was it is clear that airborne droplets in
the 0.1 to 10 µm range are commonly seen in exhaled air and easily covered
distance in this experiment of 5 m or (for Americans) 16.4 feet. That is well
beyond social distancing recommendations it explains why this virus continues
to spread. Within the past week I have seen clips of New Yorkers in congested
subway cars. Any asymptomatic SARS-CoV-2
carriers in those cars are expelling virus into the air just by tidal volume
breathing. Coughing and sneezing is not
required. It would be very good if you covered your cough or sneeze but when
your mouth is not covered and you are a symptomatic or asymptomatic carrier you are exhaling viral particles.
The relevance of this virus being airborne
cannot be underestimated. It is a substantial part of the reason behind social distancing and
stay-at-home orders. It is the reason for the new recommendation to wear masks
in public and the various explanations being given for those masks. The
absolute best approach is to not have any close social contact until this
pandemic is over. I am very concerned about my colleagues and fellow healthcare
workers who have inadequate personal protective equipment (PPE). The
expectation is that they will continue to take care of the very ill patients
with COVID-19. Every effort must be made to make sure they have adequate
protection.
In my particular specialty, all psychiatrists should have
access to electronic interviewing at this point. As I pointed out in my earlier
posts, I am used to talking people for 30 to 60 minutes at time. Some of those
evaluations are 90 minutes in duration. During that time the patient may be
coughing or sneezing but for the most part they are breathing and engaged in
normal interview conversation. My office is smaller than the room described in
the droplet dispersion experiment. By the end of one interview, the smallest
fraction of exhaled droplets is dispersed throughout the room. Any viral
particles in that fraction can lead to infection.
All health care workers in these environments need immediate protection by the implementation of airborne precautions. I am hopeful that as more people become aware of the airborne route of transmission that it will lead to more caution on the part of the public and the social distancing and staying at home and away from this kind of transmission will make more sense. In the future we need to design indoor environments that can minimize this type of transmission. There is too little innovation in the role of the physical environment in airborne transmission of infectious illness.
I hope the added cost will be looked at in terms of the total cost of illnesses caused by respiratory viruses every year with the recognition that they can still cause devastating pandemics.
George Dawson, MD, DFAPA
References:
1: Lei H, Li Y, Xiao S, Lin CH, Norris SL, Wei D, Hu Z, Ji S. Routes of transmission of influenza A H1N1, SARS CoV, and norovirus in air cabin: Comparative analyses. Indoor Air. 2018 May;28(3):394-403. doi: 10.1111/ina.12445. Epub 2018 Jan 6. PubMed PMID: 29244221.
2: Yu IT, Li Y, Wong TW, Tam W, Chan AT, Lee JH, Leung DY, Ho T. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med. 2004 Apr 22;350(17):1731-9. PubMed PMID: 15102999.
3: Santarpia et al. (2020) Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. Retrieved from https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2.
4: Chen C, Zhao B. Some questions on dispersion of human exhaled droplets in ventilation room: answers from numerical investigation. Indoor Air. 2010 Apr;20(2):95-111. doi: 10.1111/j.1600-0668.2009.00626.x. Epub 2009 Sep 24. PubMed PMID: 20002792.
3: Santarpia et al. (2020) Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center. Retrieved from https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2.
4: Chen C, Zhao B. Some questions on dispersion of human exhaled droplets in ventilation room: answers from numerical investigation. Indoor Air. 2010 Apr;20(2):95-111. doi: 10.1111/j.1600-0668.2009.00626.x. Epub 2009 Sep 24. PubMed PMID: 20002792.
5: Li, Y., Huang, X., Yu, I.T.S., Wong, T.W. and Qian, H. (2005), Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong. Indoor Air, 15: 83-95. doi:10.1111/j.1600-0668.2004.00317.x
6: Carl Heneghan, Jon Brassey, Tom Jefferson. SARS-CoV-2 viral load and the severity of COVID-19. March 26, 2020. Link
7: National Research Council 2020. Rapid Expert Consultation on the Possibility of
Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020).
Washington, DC: The National Academies Press. https://doi.org/10.17226/25769.
"While the current SARS-CoV-2 specific research is limited, the results of available studies are consistent with aerosolization of virus from normal breathing."
"While the current SARS-CoV-2 specific research is limited, the results of available studies are consistent with aerosolization of virus from normal breathing."
8: Pan M, Bonny TS, Loeb J, Jiang X, Lednicky JA, Eiguren-Fernandez A, Hering S, Fan ZH, Wu CY. Collection of Viable Aerosolized Influenza Virus and Other Respiratory Viruses in a Student Health Care Center through Water-Based Condensation Growth. mSphere. 2017 Oct 11;2(5). pii: e00251-17. doi: 10.1128/mSphere.00251-17. eCollection 2017 Sep-Oct. PubMed PMID: 29034325.
9: Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.200764
Graphics Credit:
Graphic is from Shutterstock per their standard agreement.
Thank you for the article. I found the following article that seems related to your discussion.
ReplyDeletehttps://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data
The topics seem to overlap and I wonder what your thoughts were? As a former biologist with PPE experience I find the "airborne" possibility terrifying but feel "masks for all" recommendation do little to alleviate.
from the artlce: "...and small aerosols (0.08 and 0.22 µm) N95 FFR filter efficiency was greater than 95%. Medical masks exhibited 55% efficiency, general masks 38% and handkerchiefs 2% (one layer) to 13% (four layers)."
For some reason I can't get to the U of MN link but I am familiar with this problem from the following study.
DeleteBae S, Kim M, Kim JY, et al. Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients. Ann Intern Med. 2020; [Epub ahead of print 6 April 2020]. doi: https://doi.org/10.7326/M20-1342
Exhaled velocity may be one parameter that might be relevant with the mask, but the numbers here suggest that the masks are not likely to block virus ejected by coughing. Per the authors:
"In conclusion, both surgical and cotton masks seem to be ineffective in preventing the dissemination of SARS–CoV-2 from the coughs of patients with COVID-19 to the environment and external mask surface."
It would be interesting to see if there were limitations on exhaled virus in the absence of coughing or sneezing but that would require more elaborate testing. In this case N95 testing would also have been interesting.
In general, the idea that homemade masks or even surgical masks are preventive seems to be borne out of the shortage of N95 masks and the recent evidence that the virus is airborne and the droplet precautions are not necessarily enough.
Asymmetric risk again. By the time you get a metaanalysis it's too late so precautionary principle applies. The cost of not wearing a mask is greater than the benefits of not wearing it when you're not sure.
DeleteAbsence of clear evidence is not evidence of absence.
In an emergency you don't have time for a double blind study or metaanalysis. We're not going to get that for HCQ or masks within a time frame that matters so you have to go with phenomenology and anecdotal reports on groups of patients.
Deletehttps://twitter.com/Jonn__Mc/status/1244957684820070402
That's enough to wear a mask for me. Again, risk asymmetry, inconvenience of a mask is far less impactful than probable benefit. The American Thoracic Society endorsed HCQ and 2/3 of doctors say they would use it. Raoult's work is good but not perfect but perfect should never be the enemy of good.
Before the seatbelt studies came out it made sense to wear a seatbelt. People never used to wear helmets skiing now almost everyone does. I don't think that's because of double blind studies.
I'd much rather have a medic for a group of army rangers with me in an emergency than a medical academician.
True story: about ten years ago I was on a surfing trip in Mexico with a friend. He was bitten by fire ants and went into anaphylactic shock, chest was not moving. I had no emergency kit. I was going to do a cric with a pen and knife but I remembered that I had a nasal steroid Flonase in my shaving kit. I pretty much emptied it into his throat and he started breathing again. Heuristics and thinking on the fly saved his life, evidence based medicine and relying on stuides would have gotten him killed.
Ludic fallacy: believing that which works in the lab is translatable to what works in the field. The brilliance of the Fat Man character in House of God was understanding that.
I'm hoping that one benefit of all this is reduction in general flu and antibiotic resistant bacteria morbidity and mortality. The culture and medical culture have been way too lax about it. I'd like to see the end of the handshake, vaccines as a condition of travel, and greater attention in general to the spread of viruses and bacteria and viruses through surfaces. I still wonder why copper tape is not used more often in hospitals.
ReplyDeleteSome interesting things may happen culturally as the appeal of large gatherings wanes. Sports are definitely going to be affected as will large venue concerts. I think music will change from Madonna/Taylor Swift/BTS pop spectacle song and dance shows to more intimate forms like small combo jazz and solo performer blues and folk.