What is the evidence to support

the 2-metre social distancing rule

to reduce COVID-19
transmission?
Zeshan Qureshi1, Nicholas Jones2, Robert Temple3, Jessica PJ
Larwood4, Trisha Greenhalgh,2 Lydia Bourouiba5
June 22, 2020
Centre for Evidence-based Medicine
 Dr Sudjoko Kuswadji (MSc(OM) NUS , PKK IDI, SpOk IDI)
• 1972 Fakultas Kedokteran Universitas Indonesia (Jakarta);
• 1974-1980 TNI AU Wamil (Halim, Kalijati, Timtim);
• 1980-1983 Tesoro Indonesia Migas (Tarakan);
• 1983-1996 Unocal Indonesia Migas (Balikpapan);
• 1987-1988 National University of Singapore COFM
• 1996-1999 Internasional Health Benefits Indonesia JPKM (Jakarta);
• 1999-2001 Sucofindo BUMN (Jakarta);
• 2001-2004 SOS International Kesehatan Kerja (Jakarta);
• 2005- sekarang trainer dan konsultan bebas (Jakarta);
 Penyebaran virus Covid 19

• Droplets, ketika berbicara dan bernapas, lewat butir

droplets yang besar dan berat jatuh ke bawah pada jarak 50
cm;
• Yang kecil dan ringan (aerosol) terbang di udara lewat
batuk mencapai jarak 1-2 meter;
• Yang ringan (aerosol) bisa terbang dengan
menggumpal-gumpal (turbulence) mencapai jarak 8-9
meter;
Bernapas, bicara, batuk dan bersin
https://www.youtube.com/watch?v=piCWFgwysu0&feature=youtu.be
 Kesan...
• Virus dalam tubuh manusia sukar dikendalikan: tanpa
gejala, diagnosis, patofisiologi, obat, vaksin dst;
• Virus di luar tubuh lebih mudah dikendalikan, bisa dihitung
viral loadnya, antiseptik dst.
• Konsentrasi penanganan lebih banyak menyangkut
manusia, dengan segala macam kesulitannya;
• Protokol kesehatan mestinya protokol kesehatan dan
lingkungan;
• Perlu disusun program pengendalian Covid 19 dalam
lingkungan;
Physical Distancing

x
 An over-simplistic picture of viral
transfer
• The 2-metre social distancing rule assumes that the dominant routes
of transmission of SARS-CoV-2 are via respiratory large droplets
falling on others or surfaces. A one-size-fits-all 2-metre social
distancing rule is not consistent with the underlying science of
exhalations and indoor air. Such rules are based on an over-simplistic
picture of viral transfer, which assume a clear dichotomy between
large droplets and small airborne droplets emitted in isolation without
accounting for the exhaled air.
• The reality involves a continuum of droplet sizes and an important
role of the exhaled air that carries them. Smaller airborne droplets
laden with SARS-CoV-2 may spread up to 8 metres concentrated in
exhaled air from infected individuals, even without background
ventilation or airflow. Whilst there is limited direct evidence that live
SARS-CoV-2 is significantly spread via this route, there is no direct
evidence that it is not spread this way.
 Even 2 metres may be too close

• The risk of SARS-CoV-2 transmission falls as physical

distance between people increases, so relaxing the
distancing rules, particularly for indoor settings, might
therefore risk an increase in infection rates.
• In some settings, even 2 metres may be too close. Safe
transmission mitigation measures depend on multiple
factors related to both the individual and the environment,
including viral load, duration of exposure, number of
individuals, indoor versus outdoor settings, level of
ventilation and whether face coverings are worn.
Observational and non-peer-reviewed

• The longstanding dichotomy of large droplet versus small

airborne droplet transmission is outdated and SARS-CoV-2
may be present and stable in a range of droplet sizes,
which will travel across a range of distances, including
some beyond 2 metres.
• The majority of existing evidence specific to SARS-CoV-2 is
observational and non-peer-reviewed, with significant
heterogeneity in terms of populations, study settings,
sample collection methods and primary outcome.
 Easing restrictions from 2 to 1 metre may
result in a significant increase in risk
• Determining the relative risk of SARS-CoV-2 at different
distances is therefore difficult from such studies.
• Evidence from community studies suggest prolonged
exposure in an enclosed space, with unknown information
about distancing, may be linked to clusters of cases,
particularly in the context of activities such as choirs,
sports events or fitness gyms.
• Increasing physical distance is associated with decreasing
risk, so easing restrictions from 2 to 1 metre may result in a
significant increase in risk if other measures are not taken.
 A complex transmission risk that is
multifactorial.
• Other factors such as duration of time spent with others in
an indoor space, e.g. at work in a confined office and the
indoor air conditions are as important to account for in the
estimation and mitigation of risk.
• Single thresholds for social distancing, such as the current
2-metre rule, over-simplify what is a complex transmission
risk that is multifactorial.
Social distancing is not a magic bullet
• Social distancing is not a magic bullet to eliminate risk.
• A graded approach to physical distancing that reflects the
individual setting, the indoor space and air condition, and other
protective factors may be the best approach to reduce risk.
• Other important factors to take account when considering safe
social distancing (which were beyond the scope of this review
to cover in depth) include host viral load, duration of exposure,
number of infected individuals, indoor versus outdoor settings,
air ventilation, wearing of PPE including facemasks,
effectiveness and type of cleaning measures, individual
susceptibility to infection, and activities that project airborne
particles over greater distances in exhaled gas clouds, such as
singing, coughing or heavy breathing.
 Combination with other strategies
• Social distancing should therefore be used in combination
with other strategies to reduce transmission risk, including
hand washing, regular surface cleaning, PPE and face
coverings where appropriate, strategies of air hygiene, and
isolation of affected individuals.
 Violent expiratory events:
on coughing and sneezing
Lydia Bourouiba1 , 2 , †, Eline Dehandschoewercker3 and John
W. M. Bush1
1 Department of Mathematics, Massachusetts Institute of Technology, Cambridge, MA 02130, USA
2 Department of Civil and Environmental Engineering, Massachusetts Institute of Technology, Cambridge, MA 02130, USA
3 PMMH - ESPCI, O207 10, rue Vauquelin, 75005 Paris, France
 Various possible transmission
• An illustration of various possible transmission routes of
respiratory infection between an infected and a susceptible
individual.
• Both close range (i.e. conversational) airborne
transmission and longer range (over several meters)
transmission routes are illustrated here.
• The orange head colour represents a source and the white
head colour a potential recipient (with the bottom right
panel indicating that both heads are potential recipients via
self-inoculation from contaminated surface fomite
sources).
 Various possible transmission
• Here 'Expiration' also includes normal breathing exhalation,
as well as coughing and/or sneezing airflows.
• Airborne droplets can then settle on surfaces (fomites)
from where they can be touched and carried on hands
leading to further self-inoculation routes of transmission
 VIOLENT RESPIRATORY EVENTS
• A human sneeze can eject droplets of fluid and potentially
infectious organisms.
• The image sequence captures, in increments of 20 msec, the
emission of a sneeze cloud produced by a healthy person.
• The sneeze was produced naturally, without the introduction of
additives, colorants, or contaminants for visualization.
• High-speed video (Video 1, normal speed; Video 2, slowed down
by a factor of 67), recorded at 1000 frames per second, shows a
turbulent cloud that consists of hot and moist exhaled air,
mucosalivary filaments and drops, and residues from droplet
evaporation (nuclei).
 VIOLENT RESPIRATORY EVENTS
• The ejection lasts up to 150 msec (top row) and then
transitions into a freely evolving turbulent puff cloud
(middle and bottom rows).
• The largest droplets rapidly settle within 1 to 2 m away
from the person.
• The smaller and evaporating droplets are trapped in the
turbulent puff cloud, remain suspended, and, over the
course of seconds to a few minutes, can travel the
dimensions of a room and land up to 6 to 8 m away.
 Evidence for probable aerosol
transmission of SARS-CoV-2 in a
poorly ventilated restaurant
Yuguo Li1*†, Ph.D.; Hua Qian2†, Ph.D.; Jian Hang3†, Ph.D.;
Xuguang Chen4, M.Sc.; Ling Hong3, Ph.D.; Peng Liang5,
M.Sc.; Jiansen Li4, M.Sc.; Shenglan Xiao1, Ph.D.; Jianjian
Wei6, Ph.D.; Li Liu7, Ph.D.; and Min Kang4†, M.Sc.
 Three families
• Three families (A, B, C), 10 members of which were subsequently
found to have been infected with SARS-CoV-2 at this time, or
previously, ate lunch at Restaurant X on Chinese New Year’s Eve
(January 24, 2020) at three neighboring tables.
• Subsequently, three members of family B and two members of family
C became infected with SARS-CoV-2, whereas none of the waiters or
68 patrons at the remaining 15 tables became infected.
• During this occasion, the ventilation rate was 0.75–1.04 L/s per
person.
• No close contact or fomite contact was observed, aside from
back-to-back sitting by some patrons.
• Our results show that the infection distribution is consistent with a
spread pattern representative of exhaled virus-laden aerosols.
Figure 1. Distribution of
SARS-CoV-2 infection cases at
tables in Restaurant X. The
probable air-flow zones are in dark
grey and light grey. Each table is
numbered as T#. Eighty-nine
patrons are shown at the 18 tables,
with one table being empty (T04).
Tables TA, TB, and TC are where
families A, B and C sat, some of
whose members became infected.
Patient A1 at TA is the suspected
index patient. Patients A2–A5,
B1–B3, and C1–C2 are the
individuals who became infected.
Other tables are numbered as
T4–T18. Each of the five
air-conditioning units condition a
particular zone. Patrons and waiters
entered the restaurant floor via the
elevator and stairwell, which are
connected by the fire door.
According to the video analysis, there was no significant close contact between the three families in the
elevator or restroom (Supplementary information A). Contact tracing identified 193 patrons in the
restaurant, 68 of whom were on the third floor at the same time as families A, B, and C, including 57
restaurant workers and 11 workers in the hotel where Family A had stayed. None of these people were
infected with the virus.
Figure 3. Simulated dispersion of
fine droplets exhaled from index
Patient A1 (magenta-blue), which
are initially confined within the
cloud envelope due to the zoned
air-conditioning arrangement.
The fine droplets eventually
disperse into the other zones via
air exchange and are eventually
removed via the restroom
exhaust fan. The ABC zone
clearly has a higher
concentration of fine droplets
than the non-ABC zone. Other
infected patients are shown in
red and other non-infected in
gold color. Only a single human
body is used to represent all
patrons
Relative Risks
 Coronavirus Disease
Outbreak in Call Center,
South Korea
Shin Young Park, Young-Man Kim, Seonju Yi, Sangeun Lee,
Baeg-Ju Na, Chang Bo Kim, Jung-il Kim, Hea Sook Kim, Young
Bok Kim, Yoojin Park, In Sil Huh, Hye Kyung Kim, Hyung Jun
Yoon, Hanaram Jang, Kyungnam Kim, Yeonhwa Chang, Inhye Kim,
Hyeyoung Lee, Jin Gwack, Seong Sun Kim, Miyoung Kim, Sanghui
Kweon, Young June Choe, Ok Park, Young Joon Park, Eun Kyeong
Jeong
 The role of asymptomatic COVID-19
case-patients
• The role of asymptomatic COVID-19 case-patients in spreading
the disease is of great concern.
• Among 97 confirmed COVID-19 case-patients in this study, 4
(4.1%) remained asymptomatic during the 14-days of
monitoring.
• This rate is lower than the 30.8% rate estimated in previous
modeling (4).
• A case-patient series from Beijing, China, indicated that
asymptomatic case-patients accounted for 5% (13/262) of
patients transferred to a designated COVID-19 hospital (5).
• Our data might represent the likely proportion of asymptomatic
COVID-19 infections in the community setting..
 The role of asymptomatic COVID-19
case-patients
• We also found that, among 17 household contacts of
asymptomatic casepatients, none had secondary
infections.
• Previous reports have postulated that SARS-CoV-2 in
asymptomatic (or presymptomatic) case-patients might
become transmissible to others (6);
• however, given the high degree of self-quarantine and
isolation measures that were instituted after March 8
among this cohort, our analyses might have not detected
the actual transmissibility in asymptomatic COVID-19
case-patients.
 The role of asymptomatic COVID-19
case-patients
• Robust mass testing of all suspected case-patients might
have prevented asymptomatic transmission because
asymptomatic persons were given information about their
possible infection and therefore might have self-isolated
from their household members.
High at the 11 th Floor
Nearly all the case-patients were on
one side of the building on 11th
floor.
Severe acute respiratory syndrome
coronavirus, the predecessor of
SARS-CoV-2, exhibited multiple
superspreading events in 2002 and
2003, in which a few persons
infected others, resulting in many
secondary cases.
Despite considerable interaction
between workers on different floors
of building X in the elevators and
lobby, spread of COVID-19 was
limited almost exclusively to the
11th floor, which indicates that the
duration of interaction (or contact)
was likely the main facilitator for
further spreading of SARS-CoV-2.
Symptomatic. A symptomatic,
presymptomatic
 KESIMPULAN
• Masker, Cuci tangan, Jaga jarak ternyata tidak menjamin
tidak terjadi penularan. Kualitas masker, kualitas cuci
tangan, dan kualitas jaga jarak perlu juga diperhatikan.
• Satu gedung di mana banyak penghuninya kok hanya
beberapa lantai saja yang terkena, sementara mereka
sering ketemu di lift dan lobby. Satu lantai hanya satu
sayap yang banyak terkena pada hal mereka satu AHU;
• Covid 19 memang penuh dengan misteri, sukar
dipecahkan, walaupun semua ahli terlibat. Mari kita
tingkatkan kualitas apa yang kita kerjakan.