Airborne transmission of severe acute respiratory syndrome coronavirus‐2 to healthcare workers: a narrative review

Abstract

Healthcare workers are at risk of infection during the severe acute respiratory syndrome coronavirus-2 pandemic. International guidance suggests direct droplet transmission is likely and airborne transmission occurs only with aerosol-generating procedures. Recommendations determining infection control measures to ensure healthcare worker safety follow these presumptions. Three mechanisms have been described for the production of smaller sized respiratory particles ('aerosols') that, if inhaled, can deposit in the distal airways. These include: laryngeal activity such as talking and coughing; high velocity gas flow; and cyclical opening and closure of terminal airways. Sneezing and coughing are effective aerosol generators, but all forms of expiration produce particles across a range of sizes. The 5-lm diameter threshold used to differentiate droplet from airborne is an over-simplification of multiple complex, poorly understood biological and physical variables. The evidence defining aerosol-generating procedures comes largely from low-quality case and cohort studies where the exact mode of transmission is unknown as aerosol production was never quantified. We propose that transmission is associated with time in proximity to severe acute respiratory syndrome coronavirus-1 patients with respiratory symptoms, rather than the procedures per se. There is no proven relation between any aerosolgenerating procedure with airborne viral content with the exception of bronchoscopy and suctioning. The mechanism for severe acute respiratory syndrome coronavirus-2 transmission is unknown but the evidence suggestive of airborne spread is growing. We speculate that infected patients who cough, have high work of breathing, increased closing capacity and altered respiratory tract lining fluid will be significant producers of pathogenic aerosols. We suggest several aerosol-generating procedures may in fact result in less pathogen aerosolisation than a dyspnoeic and coughing patient. Healthcare workers should appraise the current evidence regarding transmission and apply this to the local infection prevalence. Measures to mitigate airborne transmission should be employed at times of risk. However, the mechanisms and risk factors for transmission are largely unconfirmed. Whilst awaiting robust evidence, a precautionary approach should be considered to assure healthcare worker safety.

The COVID‐19 information pandemic: how have we managed the surge?

“…Knowledge and debate surrounding personal protective equipment (PPE) has been one of the most prominent COVID-19 discussion points, due to the high risk of contagion via droplet spread [18,19], contributing further to has been some excellent information collated about maintenance of well-being during this crisis [21]. A study from China looking at the impact of social media on mental well-being during the COVID-19 outbreak found there to be a high prevalence of mental health problems associated with frequent social media use [22].…”

Pre-hospital care & interfacility transport of 385 COVID-19 emergency patients: An air ambulance perspective.

“…Many medical interventions increase the risk of virus transmission (5,(9)(10)(11). Examples are non-invasive ventilation (NIV), airway management, CPR, or even recording an electrocardiogram (ECG) (11)(12)(13).…”

“…The healthcare providers and transferred patients are at high risk of infection if the ambulances and aircrafts are insu ciently disinfected before the next mission (5). Therefore, a strong hygiene concept, proper personal protective equipment (PPE), standard operating procedures (SOPs), and occasional access to special equipment are of utmost importance when managing patients with suspected or con rmed COVID-19 infection.…”

Critical care demand and intensive care supply for patients in Japan with COVID-19 at the time of the state of emergency declaration in April 2020: a descriptive analysis.

“…We extracted the number of ICU beds (n = 7109) and board-certi ed intensivists (n = 1957) from the JSICM website. This website has also reported the estimated number of mechanical ventilators for adults (n = 30091) and ECMO machines (n = 2208) in Japan ( [23][24][25][26] and its presence in aerosol has been con rmed at RNA level [27,28]. Many infectious control guidelines recommend that healthcare workers be protected through the use of personal protective equipment [29][30][31].…”