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Last updated: July 1, 2020.

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Last updated: July 1, 2020.

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COVID 10: Is COVID-19 an airborne disease? Will we all need to wear face-masks against SARS-CoV-2?

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There seems to be a lot of confusion
in this whole aerosol versus dropletdiscussion, even in the medical community. So I thought I’d take a closer look. What actually is a droplet
and what is an aerosol?There are different definition, but
it’s most useful to differentiate themaccording to their behavior
in the environment. Droplets are both 20 micro
meters or microns in size. They’re usually produced during things
like coughs, sneezes, shouting, et cetera,and usually succumb to gravity, meaning
that they fall down after traveling in theair for one to two meters. Aerosols on the other hand, is made up
of fine particles under 10 microns indiameter, and they can travel from many
meters before they fall to the ground orsome other surface. So an aerosol is below 10 microns
and can travel far in the air. Droplets are larger than 20 microns. They usually succumb to
gravity and fall to the ground. And then there are the in between sized
particles of 10 to 20 microns that canhave somewhat of an intermediate behavior,
but are generally thought to fall to theground, like droplets. And there’s an even more granular
distinction between the different aerosolparticles. Those below five microns are so small that
they can travel all the way down into thealveolar space where
they can cause pneumonia. Whereas particles below 10 and above five
microns can only penetrate down below theglottis and are thought to land
somewhere in the tracheal branch. When droplets fall on surfaces, uninfected
individuals can pick them up and bytouching their face can get infected. That’s why hand washing is so crucial. To make matters more complicated when the
water component of droplets dries up inthe air, when the wind and temperature
conditions are right, the remaining bitsof floating virus are called droplet
nuclei, and these can then behave likeaerosols too. Also, when, wind conditions are right,
even droplets might travel much furtherthan two meters. When you go to the ocean on a windy day
and feel the sea spray on your face. You’ve just encountered droplets
that have become airborne. What does that mean for
COVID-19 or influenza?Well, it means that actual suspension
times of droplets will be far higher whenthere are significant crossflows, which is
often the case in healthcare environmentswith doors, opening beds and equipment
moving and people walking back and forthconstantly. So the general wisdom is that for stuff
that flies around in the air that we mustinhale, in order to get sick, we need
masks to protect ourselves and others. When we’re dealing with droplets that
are falling to the ground and on surfacescalled fomites, we need hand hygiene
and we need to keep a distance. So what about COVID-19
and the SARS-CoV-2 virus?Is it airborne and inhaled or
droplet based via fomites and hands?While the uncomfortable truth is that we
have evidence for both, which is also thecase for influenza, by the way. Let’s have a look at this paper from Wuhan
University — Aerodynamic Characteristicsand RNA Concentration of SARS-CoV-2
Aerosol in Wuhan hospitals During theCOVID-19 Outbreak. These authors looked at aerosols and
surface samples at the Renmin Hospital ofWuhan University, which was and is
designated for the treatment of severecases of COVID-19, and the Wuchang
Fangcang Field Hospital, one of the firsttemporary hospitals, which was renovated
from an indoor sports stadium toquarantine and treat mildly symptomatic
patients, and from outdoor public areas inWuhan during the coronavirus outbreak. They then measured the viral RNA
concentrations in these specimen. It’s important to know that these authors
did not look at whether these viralspecimen could infect cells in turn, they
only looked for the presence of viral RNA. And here’s what they found. In the patient area of Fangcang Hospital
airborne viral load was minimal and wasentirely absent in the intensive
care unit of Renmin Hospital. The negative pressure ventilation and
higher air exchange rate inside the ICU,CCU and ward room of Renmin Hospital
seem to have been effective in minimizingairborne SARS-CoV- 2. Fangcang Hospital hosted over 200 mildly
symptomatic patients in each zone duringthe peak of the COVID-19 outbreak. However, the SARS-CoV-2 aerosol
concentrations inside the patient hall arejudged to be very low with
ranges between one to nine. They also took the position samples from
two spots of the floor of the ICU roomsand there they found a
pretty high concentration. The deposited virus probably comes from
the respiratory droplets or virus-ladenaerosol transmission. They also found elevated airborne
SARS-CoV-2 concentrations inside thepatient mobile toilet
in Fangcang Hospital. This may come from either the patient’s
breath, or the aerosolization of patientsfeces or urine during use. We know that SARS-CoV-2 has been isolated
from patients, stools and bladders, andit’s very much in line with another
paper that we’re going to get to shortly. The authors call for extra care and
attention on the proper design use anddisinfection of the toilets in hospitals
and in communities to minimize thepotential for transmission. What was particularly concerning in this
paper is the high airborne concentrationof virus in staff rooms, especially in
changing rooms where staff removed theirprotective gear. The authors believe that one direct
source of the high SARS-CoV-2 aerosolconcentration in these changing rooms
may be the resuspension of virus-ladenaerosols from the surface of protective
apparel while they are being removed. These resuspended aerosols originally
may come from the direct, deposition ofrespiratory droplets or virus-laden
aerosols, onto the protective apparel,while medical staff are working
long-hours inside the patient area. Another possible source, of course, is
the resuspension of floor dust, aerosolcontaining virus that were transferred
from the patient area to the staff areavia the staff’s shoes. In public areas outside the hospital they
found that the majority of sample siteshad undetectable or very low
concentrations of SARS-CoV-2 aerosol. Except for one crowded gathering site
about one meter to the entrance of adepartment store with customers frequently
passing through, and the other site nextto the Renmin Hospital entrance where
the outpatients and passengers passed by. Similar findings were
reported by these authors. They performed ear and surface samples
of three COVID-19 patients in Singapore. Samples were taken in the patient’s
room, the anteroom, and the bathrooms. The samples of patients A and B were taken
after cleaning and were all negative. For patient C whose samples were collected
before routine cleaning, they foundpositive results with 13 out of 15 room
sites or 87% testing positive, and threeout of five toilet sites or 60%
testing positive for the virus. All air samples were
negative in this study. Now we have to consider that these were
all special isolation rooms with a specialkind of ventilation. The fact that air exhaust outlets tested
positive suggests that small virus-ladendroplets were displaced and landed there. But it’s important to remember that all of
these studies looked at viral RNA or viralparticles, but we don’t know if these
viral particles were still viable and ableto infect humans or cells in culture. So how long will viral particles survive?How long after they fall on a surface or
get suspended in the air will they stayviable and able to infect cells or humans?That’s what these authors looked at. They suspended the virus in air and on
various surfaces like copper, cardboard,steel, and plastic, and took
samples at various time points. They then look to see whether that
virus was still able to infect cells. So that’s way stronger than just
measuring RNA concentration. They found that SARS-CoV-2, was most
stable on plastic with viable virusdetectable up to 72 hours after
application, seen here in the right mostpane, followed by stainless steel
with 24 hours, cardboard and copper. Aerosolized virus remained viable for
the entire experiment, which lasted threehours. So in summary, when it comes to viral load
in the air, the data suggests that theconcentration of suspended virus in the
air increases from almost no virus inuncrowded public places ICUs and isolation
rooms, to a little more in crowdedoutdoors areas, even more in medical staff
rooms and patient toilets, to a lot instaff changing rooms where they
take off their protective apparel. In general, the concentration of virus in
the air inside hospitals seems to be low,but may be significantly elevated when
staff having spent long hours taking careof patients with aerosol and droplets
being deposited on their protective gear,when they then take off the protective
equipment deposited materials might becomeresuspended in the air. Medical staff might have a false sense
of security when they’re outside thepatient’s rooms, like in medical staff
rooms or changing rooms, but the datasuggests that these are the places where
they’re most likely to be infected. What the data also shows is that patient
toilets seem to be particularly prone tocontamination, and heightened cleaning
measures in these toilets seem to benecessary to prevent transmission. One last statement coming from this paper. These authors say that if they’re ongoing,
contradictory finding in multiple studiesas with influenza and potentially also
SARS-CoV-2, it may be more likely that thevarious transmission routes may
predominate in different settings, makingthe airborne route for that particular
pathogen, more of an opportunistic pathwayrather than the norm. This means that the airborne route is
probably mainly relevant for certainsituations. And I’d say that would be the hospitals
and hospital staff as well as crowded andbadly ventilated public spaces. Everyone else is probably more likely to
get the virus through touching surfaces,bad hand hygiene and touching their face.

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