C O V I D / E B M R E V I E W S / F R O N T PA G E

Aerosols, Droplets, and Airborne Spread:

Everything you could possibly want to
know

by Justin Morgenstern | Published April 6, 2020 - Updated December 2, 2020 | 66 comments

December 1,2020: This post was based on the best available

evidence at the beginning of the pandemic (March-April 2020). The
information contained is still very relevant, but there is also now an
updated/companion review specifically looking at the transmission
of COVID-19 (and concluding aerosols play a very important role in
it’s transmission), that can be found here.

The rapid emergence of COVID-19 has created tremendous uncertainty in

medicine. We don’t know where this pandemic is headed. We don’t know
the ideal management strategy. Every day brings conflicting information.
Emergency medicine is a field that embraces (or at least tolerates)
uncertainty, but knowledge is an important pillar of our sense of control in
medicine, and COVID-19 is doing a good job highlighting massive gaps in
our knowledge. One of those gaps is the precise mechanisms through
which infectious diseases spread and how best to protect ourselves. We
hear terms like “aerosol generating” and “droplets”, but their precise
meaning can be unclear, and so it is hard to know how to adjust our
practice. In this post, I will review everything I have been able to learn
about aerosols and droplets, how they spread, and how they should impact
our practice.

I will start with a major caveat: despite reading hundreds of papers on this
topic, I still have a lot of uncertainty. I think that uncertainty is born from
uncertainty in the literature. There was debate and conflicting
information with every new paper I found. However, it is also important
to recognize that I am an emergency physician attempting to distill in a
few weeks topics that people have dedicated entire careers to. If you think
I missed something, or want to add to the discussion, please do so below.

I also want to acknowledge that these are incredibly trying times. We are
all anxious, and that anxiety is made worse by the conflicting information
that we are receiving. There is a risk that by adding even more potentially
conflicting information I might add to that anxiety. I think science is
fundamentally important. I think this information is important. How we
act on this information is equally important. Remember that nothing here
is definitive. In already trying times, we don’t want to create conflict with
our colleagues. Try to use any information available to work
collaboratively, focusing not on the negatives of uncertainty and
disagreement, but on the positives of growth and a common goal of safety
for all healthcare workers and our patients. For the most part, I am
reassured by what I read, and will continue to work hard to use this
information to keep my entire team safe.

There is an accompanying post that specifically looks at aerosol generating

procedures that you can find here.
What exactly is an aerosol?
I have to say, I didn’t expect this to be such a complicated question to
answer. There is actually a pretty heated academic debate, centering
around desiccation rates and the formulas for turbulent flow, such that it
seems that no one really agrees on an exact definition. You will see some
pretty definitive definitions in some sources, but that definition will
invariably be refuted in the next paper you encounter. In general, aerosols
are liquid or solid particles suspended in air. (Tellier 2009; Judson 2019)
They can be visible, like fog, but are most often invisible, like dust or
pollen.

They are often divided into small droplets (and many, but not all, people
reserve the term “aerosol” to refer only to these small droplets) and large
droplets. Large droplets drop to the ground before they evaporate, causing
local contamination. Disease transmission through these large droplets is
what we often refer to as “droplet/contact spread”, where disease
transmission occurs because you touch a surface contaminated by these
droplets, or get caught within the spray zone when the patient is coughing.
Aerosols are so small that buoyant forces overcome gravity, allowing them
to say suspended in the air for long periods, or they evaporate before they
hit the floor, leaving the solid particulate (“droplet nuclei”) free to float
very long distances, causing what we often refer to as “airborne”
transmission. (Nicas 2005; Judson 2019)

Respiratory aerosols are created when air passes over a layer of fluid.
(Fiegel 2006; Morawska 2006) There are a large number of factors that can
alter this process. The viscosity of the fluid layer is an important
determinant of aerosol generation, and could be a very important practical
consideration in medicine. Increases in surfactant increase overall droplet
formation, and produce smaller droplets (which will travel farther).
(Fiegel 2006) This could be an important consideration, as some people are
discussing the use of surfactant to manage COVID-19 lung disease.
Conversely, nebulized saline has been shown to decrease the number of
bio-aerosols produced, and has been suggested as a possible (but
unproven) infection control strategy. (Fiegel 2006)

In the world of aerosols, there seems to be two main points of contention.

The first is the size cutoff between large and small droplets. Various
sources will put the cutoff at 2 µm, 5 µm, 10 µm, 20 µm, or even 100 µm.
(Judson 2019; Morawska 2006; Fiegel 2006; Xie 2007; Chen 2010; Nicas 2005;
Tellier 2009) This is a key distinction, because it is the difference between
airborne and droplet precautions. Many papers make definitive
statements based on one of the cutoffs that would be incorrect if a
different cutoff was used. (For example, Morawska 2006 states that
droplets smaller than 100 µm, which is almost all droplets, will evaporate
before hitting the floor, meaning that they can transmit disease through
the airborne route, while other documents will use 5 µm as the cutoff.)
There is probably a grey area in which droplets can behave either way,
depending on how quickly they evaporate compared to how quickly they
fall to the ground based on the atmospheric conditions of the room. 

The second main point of contention is exactly how clean the distinction
between airborne and droplet transmission is. Some sources treat this as
black and white, but others point out that large droplets evaporate and
become smaller, and most activities create a very large variety of sizes, so
it is more like a spectrum than a dichotomous distinction. A lot of
epidemiologic studies will make strong claims that a disease is only spread
by close contact, but we have to remember, those studies cannot possibly
distinguish between short distance aerosol transmission (I caught it while
breathing a few feet away from you) and contact transmission (I touched
the door handle and then rubbed my eye.) Too often, if you were close
together, studies will just assume it was contact instead of aerosol spread,
biasing the literature in that direction.

What are aerosol generating procedures?

An aerosol generating procedure is a medical procedure that creates
aerosols in addition to those that the patient creates regularly from
breathing, coughing, sneezing, and talking. (Judson 2019) In other words, it
is important to remember that patients will create their own aerosols even
when we are not performing these procedures. Aerosol generating
procedures can produce both large and small droplets. Each procedure
will be unique, so they really need to be considered independently. (Judson
2019) Importantly, aerosol generating procedures can cause transmission
through pathways that microbes don’t usually use (a virus normally
spread through contact or droplets can become airborne). Procedures can
either generate aerosols directly or by inducing the patient to cough or
sneeze, a distinction that may be important when trying to mitigate risk.
(Judson 2019)

Although respiratory infections are the primary source of aerosols, they

are created in other ways as well.  Surgery can aerosolize pathogens found
in the blood or tissues. (For example, HIV was found in aerosols created by
surgical power tools.) (Judson 2019) Aerosols can also be produced by
seemingly mundane things, such as fast running tap water and flushing
toilets. (Morawska 2006)

Because the individual risks (and benefits) of each procedure is likely

unique, I will consider them each independently. For the sake of space, I
have done so in a second post that accompanies this one.

Aerosols and normal activities

Throughout our preparations for COVID-19, we have all been incredibly
focused on aerosol generating procedures, but it is important to
understand that aerosols are also produced through normal human
activities, including simply breathing. (Tellier 2009; Asadi 2019) Essentially
any air passing through the respiratory tract will create droplets. The
clinical significance will depend on the number of droplets produced, their
size, the concentration of infectious agents, the frequency with which the
activity is performed, and the PPE used by staff. (Morawska 2006) For
example, although a single cough produces far more droplets (of all sizes)
than a single breath, breathing occurs much more frequently, and so may
be responsible for more droplet production overall. (Morawska 2006;
Fiegel 2006) It is also important to understand that although the majority
of the droplets produced by a cough may be small enough to stay airborne,
their small size means that collectively they add up to only a tiny fraction
of the volume produced (perhaps less than 0.1%), and therefore only a tiny
fraction of the total virus spread. (Nicas 2005) However, despite carrying
smaller numbers of microorganisms, there is evidence that smaller
droplets don’t need to contain as many microorganisms as larger droplets
to cause a clinical infection (by several orders of magnitude). (Nicas 2005;
Tellier 2009) Furthermore, we must remember that not every droplet will
contain virus, and even if it does, it may not be enough to effectively
transmit disease.

Table adapted from Morawska 2006, with similar numbers reported in the
Fiegel 2006 review:

NUMBER OF
SMALL (1-2 UM)
ACTIVITY DROPLETS
AEROSOLS?
PRODUCED

Normal breathing (5
A few Some
min)

Single strong nasal Few to a few

Some
exhalation hundred

Few dozen to few

Counting out loud hundred. Some
Mostly
(talking) sources say a few
thousand (Xie 2007)
 NUMBER OF
SMALL (1-2 UM)
ACTIVITY DROPLETS
AEROSOLS?
PRODUCED

Few hundred to
Cough Mostly
many thousand

Few hundred
Sneeze thousand to a few Mostly
million

If you want a more specific breakdown, you can look at table 2 from Nicas
2005, but these numbers are estimates, and you will see different numbers
even in this same paper:
Older studies concluded that humans primarily produce large droplets,
but they were significantly limited because their instruments were
insensitive to smaller sizes. (Morawska 2006) Recent research has
indicated that as many as 80-90% of the particles generated by human
exhalation are smaller than 1 µm in size. (Papineni 1997) Although the
exact size of droplets produced is still debated, most sources agree that
speaking, coughing, and sneezing produce droplets that are sufficiently
small to remain airborne. (Fiegel 2006; Chen 2010)

Interestingly, the total amount of bioaerosols produced varies

tremendously among individuals, with some people creating very few, and
others acting as “super producers”. (Fiegel 2006) I wonder whether this
explains why we have observed super-spreaders of SARS and COVID-19, as
“it appears that a minor percentage of the population will be responsible
for disseminating the majority of exhaled bioaerosol”. (Fiegel 2006)

Super producers: Figure 2 from Fiegel 2006

Vomiting, in which humans can shed up to a million virus particles per

milliliter of vomit, can also produce aerosols. (Morawska 2006) A vomiting
SARs patient was associated with nosocomial spread in a hospital in Hong
Kong, although it isn’t clear by what route (contact, droplet, or airborne)
the transmission occurred. (Morawska 2006) Similarly, there can be as
many as a hundred million virus particles in every gram of feces, and flush
toilets are known to result in aerosolization. As is discussed below, this
form of aerosolization is thought to have spread SARS in the Amoy Garden
apartment complex in Hong Kong. (Morawska 2006)

However, whether these aerosols are capable of transmitting disease still

depends heavily on the number produced, the concentration of the
infectious agent, the virulence of the microbe, environmental factors (the
virus needs to be able to survive, whether in the air or on a surface, until it
enters a host), and the health and immunity of the host. (Morawska 2006)
Although it is clear that aerosols are commonly produced, it is also clear
that the vast majority of disease transmission occurs among people who
are in very close contact and therefore exposed to the largest of the
droplets. 

The fact that humans constantly produce aerosols is really important

when assessing studies of aerosol generating procedures. The result
sections of these papers will often only present a change in aerosols from
baseline, and frequently our procedures won’t produce more droplets.
However, if you look closely, we are already producing a ton of aerosols,
and even if the procedures don’t produce more, their ability to spread
those aerosols further is a big concern. (Simmonds 2010; Rule 2018)

Figure 1 from Simmonds 2010. Although noninvasive ventilation and oxygen mask did
not increase the number of aerosols being produced, the baseline rate is incredibly high.

Update: In one of the more entertaining and yet still scientific tweetorials
of all time, Dr. Andy Tagg asks the question, “Is farting an aerosol-
generating procedure?”:

Andrew Tagg
@andrewjtagg
 Is farting an aerosol-generating procedure?

A tweetorial…

9:03 AM · Apr 6, 2020

315 179 people are Tweeting about this

What happens to the aerosol after it is

expelled?
The only constant I could find in this data was a general lamentation of the
lack of experimental data. (Nicas 2005; Xie 2007; Tellier 2009; Judson 2019)
Most of the numbers we use clinically are based on mathematical models
making large numbers of (potentially faulty) assumptions. Where droplets
end up is regulated by a huge number of factors. The primary factor is
probably the size of the droplet. A 1000 µm droplet will fall 1 meter in 0.3
seconds. A 100 µm droplet will take 3 second to fall 1 meter. A 10 µm
droplet will take 300 seconds, and a 1 µm droplet will take 30,000 seconds.
(Morawska 2006) How long a droplet remains in the air is clearly a huge
factor in how far it is able to travel, and how likely healthcare workers are
to be exposed.

As I said, exact size cutoffs are controversial, but Chen (2010) suggests that
the distribution of all droplets between 0.1 and 200 µm will primarily be
influenced by ventilation patterns and the initial velocity of the droplet,
rather than gravity. In other words, these droplets do not just drop to the
ground within 1-2 meters of the patient, as many infection control
practices assume. However, the distribution of droplets is also influenced
by a very large number of factors, including relative humidity,
temperature, ventilation pattern and rate, initial velocity, shape of the
human body, and droplet nuclei size and composition. (Xie 2007;
Chen2010) Most of these factors are dynamic (droplet size changes as it
evaporates and temperature changes as you move away from a febrile
patient), making simplified calculations difficult. At smaller sizes,
Brownian motion, electrical forces, thermal gradients, and turbulent
diffusion have much bigger impacts. (Morawska 2006) Overall, it is
complicated, there are lots of formulas, and reading these papers generally
left me with a headache.

Many calculations regarding droplet distribution have significant

assumptions embedded. For example, initial studies that estimated droplet
dispersion made the assumption that the droplets were introduced into the
air without any velocity, which is a bad assumption when coughing and
sneezing can create tremendous initial particle velocities. (Morawska
2006) As general estimates, particles produced by normal breathing have a
velocity of approximately 1 m/sec, talking 5m/sec, coughing 10 m/sec, and
sneezing 20-50 m/sec. (Xie 2007) Thus, even though large particles are
often assumed to land close to the patient, that assumption is frequently
incorrect. (Bourouiba 2020) Think about walking by the sea on a windy
day. Large droplets that usually only travel a very short distance can easily
reach you a long way from the shore. (Judson 2019)

There are some mathematical models and experimental data that support
the 2 meter rule for normal breathing and talking, but most suggest that
coughing and sneezing spread droplets far further. (Xie 2007; Hui 2014;
Bourouiba 2020) However, this rule only applies to large droplets. Smaller
droplets remain trapped in the air and therefore can travel much greater
distances. Unfortunately, most of these models ignore the impact of the
patient covering their mouth and nose when they sneeze. Hopefully all of
these patients are wearing masks while sneezing in the hospital, which
will clearly change the distribution of droplets, and makes the 7-8 meter
number less likely to be true. (Bourouiba 2020)

So how far do these droplets travel? I think this science makes it clear that
there is no simple answer. Small droplets will remain in the air for very
long periods of time (become airborne), but the exact cutoff is unknown,
and can change significantly based on factors like temperature and
humidity. With normal breathing, large droplets mostly fall to the ground
within a 2 meter radius, but they can evaporate and become small
droplets. (Nicas 2005) Coughing and sneezing can propel these large
droplets much further – at least 6 meters or 18 feet. (Bourouiba 2020)

Perhaps the most important thing to remember is that this distribution is

probabilistic. (Morawska 2006) There is nothing that guarantees a droplet
will stop before a certain distance. When we make statements like,
droplets over size X will fall to the floor within distance Y, what we really
mean is that most droplets will. Luckily, for most diseases, knowing where
most of the droplets end up is probably good enough.

Aerosol trajectories: Fig 7 from Chen 2010

As a quick aside, some sources will state that very small particles are not
dangerous, because although you might breath them in, they remain in the
air and are not retained in the alveoli. However, it appears this is not true,
with 50% of particles smaller than 1 µm being retained in the respiratory
tract. (Morawska 2006)

In uenza: droplet or airborne?

We need to think about the practical implications of all this basic science.
Nobody is all that worried about influenza right now, but it is important to
know a little bit about the transmission of influenza, because almost all of
our PPE recommendations are based on extrapolations from this more
common disease. Although the science is not definitive, it appears that
influenza is transmitted by both large and small droplets (ie, transmission
occurs through both droplet and airborne routes). (Judson 2019) However,
although airborne transmission is possible, large droplet or contact
transmission is probably responsible for the vast majority of disease
transmission. 

Although some experts seem to doubt that influenza can be spread

through small droplets or airborne droplet nuclei, (Brankston 2007) there
are multiple lines of evidence that support this hypothesis. Studies in
ferrets showed that influenza spread even when the animals were
separated by “S” and “U” shaped ducts that would not allow for the
passage of larger droplets, indicating “that infection was conveyed either
by droplet-nuclei or very fine dust particles.” (Andrewes 1941) Likewise, in
studies of mice, lower ventilation rates led to higher transmission rates,
leading the authors to conclude spread must be by airborne droplet nuclei.
(Shulman 1962) There are numerous other animal studies demonstrating
the spread of influenza uphill (against gravity) over distances longer than
droplets are supposed to travel, strongly supporting the conclusion of
airborne spread. (Tellier 2009)

Influenza RNA has been detected in aerosol particles from infected

patients while just breathing comfortably. (Fabian 2008) Influenza has
been found in aerosols in random samples of air around an emergency
department during flu season. (Blachere 2009) In one study that tested the
air in an emergency department during flu season, influenza was
identified in 43% of the samples taken. The total amount of virus found on
samplers worn by healthcare providers was about twice that in the air,
suggesting that the risk is still highest from close contact with patients, but
that airborne spread is clearly possible. (Rule 2018) In another study, total
viral load in air samples was higher outside patients’ rooms than right
next to the patients. (Cummings 2014) On the other hand, Bischoff (2013)
did find higher viral loads closer to the patient, but virus was still detected
6 feet or 2 meters away. It has also been proven that humans can develop
influenza after breathing air artificially contaminated by the virus.
(Francis 1944) (And I just have to point out that Jonas Salk is one of the
authors on this paper!) The question is how often this occurs in a real
world setting. 

The TCID50, or the concentration of virus particles at which 50% of cells

become infected, has been estimated to be as low as 3 for some strains of
influenza A. (Thompson 2013) Assuming a respiratory rate of 10 L/min,
during a 10 minute visit to a patient room a healthcare worker will breath
100 L of air. At baseline, one study found 7,690 viral particles per L of air
in an influenza patient’s room. Therefore, in a 10 minute visit, the health
care provider would have inhaled 769,000 viral particles, which is clearly
above the TCID50. (Thompson 2013) Even studies that find lower viral
counts in the air (approx 300 in Rule 2018) will still be well above this
threshold. 

There is indirect evidence that airborne transmission occurs, as good

ventilation and UV irradiation limits influenza transmission. (McLean
1961; Shulman 1962; Drink 1996; Fiegel 2006; Tellier 2009) There are also
multiple influenza outbreaks where airborne spread is hypothesized as
the best explanation, however it is impossible to know retrospectively.
(Moser 1979; Klontz 1989; Davis 2009) There is the interesting case report
of an outbreak on a plane in Alaska in 1977. Because of a mechanical
failure, there was a 4.5 hour delay with the ventilation turned off. 1 person
was sick at the time of the flight, but over the next 3 days 38 others (72% of
the people on the plane) developed influenza A. The size of the plane
seems to make airborne transmission much more likely than large
droplets, which we are told should not spread beyond 1-2 meters. That
being said, if the index patient was the first person to use the washroom,
the outbreak could easily be explained by droplet spread. (Moser 1979)

I think the data is pretty clear that influenza can spread through airborne
aerosols, and I find that fact reassuring in the era of COVID-19. We
generally treat influenza in “droplet precautions”, and transmission to
healthcare workers is generally low. (Although the analogy fails because
vaccination and prior exposure to influenza provide a level of immunity
that does not exist with COVID-19). Even when a virus can be spread
through airborne transmission, you are still much more likely to become
ill as the result of close contact. If COVID-19 is transmitted similarly to
influenza, we can be somewhat reassured by our current practices.

Some faulty epidemiologic reasoning

Many people dismiss airborne spread for any disease that doesn’t behave
like measles or tuberculosis. They suggest that airborne must equate to
long distance transmission. They suggest that a low R0 and the lack of
large scale outbreaks proves that airborne spread is impossible. I think
that is a mistake.

I think the animal studies above make it pretty clear that influenza can
spread by the airborne route. This would provide direct evidence against
those epidemiologic arguments. Influenza has a low R0. It occasionally
causes large scale outbreaks (some of which have been blamed on
airborne transmission), but those outbreaks are rare. It is hard to know
exactly how people get sick, but we don’t routinely see influenza spread of
long distances. Thus, the epidemiologic argument that “the R0 of this
disease is too low for it to be airborne” doesn’t hold water. Any infection
that behaves like influenza could easily be spread through aerosols.
Aerosols are tiny and their concentration drops off exponentially as you
get farther from the source (especially with good ventilation). Of course we
don’t frequently see transmission over large distances or large scale
outbreaks. The chances of encountering viable virus across the room are
just too lw.

However, that line of reasoning completely discounts close range aerosol

spread. Aerosols will be most concentrated within a few meters of the
patient. At that distance, aerosol spread is almost indistinguishable from
droplet spread. In fact, it is generally completely ignored, because many
people just assume that short range spread is due to droplets. However,
short range aerosol spread would have significant implications for our PPE
choices.

This short range aerosol spread is exactly what we are talking about when
we discuss aerosol generating procedures. It isn’t the nurse 3 rooms down
that gets sick (usually). It is the people in the room that are exposed to
aerosols. However, as we discussed above, normal human activities like
talking and coughing produce just as many aerosols as most of our aerosol
generating procedures. Therefore, it is important to consider short range
aerosol spread in order to appropriate protect ourselves.

Coronaviruses: droplets or airborne?

I don’t think we can say definitively, but it is highly likely that COVID-19
can be spread through airborne aerosols. Both SARS and MERS were
thought to spread primarily by large droplets, but there were also
outbreaks that were best explained by airborne spread of the disease (and
others in which aerosols were thought possible, even if they weren’t highly
likely). (Wong 2004; Li 2004; Morawska 2006; Xie 2007; Judson 2019) SARS
was contracted by a nurse that never entered a patient’s room, which
could be explained by airborne transmission, but could also have been
through fomites. (Scales 2003) In a retrospective analysis out of Singapore,
insufficient ventilation on hospital wards was one of 5 major factors that
increased the risk of transmission of SARS. (Chen 2009) Although the
evidence isn’t definitive, the pattern of nosocomial spread followed
hospital ventilation patterns, rather than the random distribution you
would expect if the infection was spread via surfaces.

An outbreak of SARS that affected more than 300 people across 150
apartments in the Amoy Garden apartment complex in Hong Kong is
thought to have resulted from airborne spread of aerosols through the
sewer system. Rather than the random distribution that you might expect
from contact or droplets spread through common areas, residents on
higher floors were more likely to be infected, “consistent with a plume of
contaminated warm air”. (Morawska 2006)

It is also pretty clear that these viruses have been spread as the result of
aerosol generating procedures. There was a strong association between
multiple aerosol generating procedures and transmission of SARS to
healthcare workers. (Tran 2012)

For COVID-19, the virus has been found in the air more than 6 feet away
from the patient, in ventilation systems, and even in the air in hallways
outside patients’ rooms, indicating the potential for airborne spread.
(Santarpia 2020 preprint data; Ong 2020, Liu 2020) Guo (2020) found virus
RNA in the air up to 4 meters from the patient. However, the presence of
RNA doesn’t mean that there is viable virus, nor that it was present in
large enough numbers to cause clinical infection. That being said, if COVID
is aerosolized in large volumes, it is likely that the virus remains viable for
at least 3-5 hours, and maybe much longer. (Van Doremalen 2020; Fears
2020)

There is definitely debate on this point. Some organizations have stated

very strongly that SARS-CoV-2 is not spread by the airborne route.
However, others say the opposite. For example, the CDC guidance for
coronaviruses has always been to treat them as airborne, although that is
based more on the precautionary principle than hard science (see here
and here). Furthermore, the National Academies of Sciences, Engineering,
and Medicine states that “while the current SARS-CoV-2 specific research is
limited, the results of available studies are consistent with aerosolization
of virus from normal breathing.” (Fineberg 2020)

At this point, I think the only safe conclusion is that airborne transmission
is possible. However, that doesn’t make it likely. Because of their larger
size, large droplets contain as much as 99.9% of viral particles exhaled.
Although aerosols may carry small amounts of virus, they become very
diffuse the further you are from the patient and are effectively managed
by modern ventilation systems. I don’t think we should be making black
and white statements. We need to consider the potential for aerosol
spread, and how that might impact our PPE practices, while
simultaneously recognizing that droplets and close contact with patients
represent a far greater risk.

Update: It is becoming increasingly clear that there is significant pre-

symptomatic spread of COVID-19. When discussing this issue on the Saint
Emlyn’s podcast, professor of medical virology Pam Vallely made the
interesting point that presymptomatic spread is further evidence of
aerosol spread, as large droplets aren’t formed in any volume until you are
symptomatic.

A few infection control notes

Managing aerosols
One of the most important aspects of managing bioaerosols is good
ventilation. (Fiegel 2006) In ideal circumstances, 65% of all airborne
droplets can be removed with each air exchange, although because air
doesn’t mix perfectly, the number is probably in the 20-60% range in real
life. (Fiegel 2006) In medicine, we are used to thinking in half lives. Each
air exchange might take away half of the aerosols in a room, and
therefore, if you can determine the air exchange rate for your facility, you
can estimate the half life of aerosols, and use that to make PPE and clinical
decisions. 
You can also disinfect air using a number of different systems, such as
HEPA filters and UV light. (Fiegel 2006) I wonder if anyone is using
portable HEPA air purifiers in hallways to limit airborne spread of COVID?
And of course, the most important mechanism for managing aerosols is
almost certainly PPE, with a properly fit N95 mask being the medical
standard, which I will discuss further below. (Fiegel 2006) 

Is there evidence for the “2 meter rule”?

There is a widely spread infection control concept that as long as you are 2
meters away from the patient, you are safe from droplets. This claim is
usually made without citation, and there is plenty of data to say that it is
wrong, at least as a definitive cut off. The idea that all large droplets will
fall to the floor within 2 meters seems to have been initially proposed by
Wells, based on a very simplistic calculation, with assumptions that have
since been questioned, and limited empirical data. (Xie 2007)
Unfortunately, as is reviewed above, most of the existing data seems to
refute that hypothesis. For example, one recent study had 5 volunteers
cough after gargling with food colouring, and there was visible
macroscopic contamination beyond 2 meters with 4 of 5 participants. (Loh
2020) Simple pictures of sneezes show a droplet cloud out to 8 meters.
(Bourouiba 2020) In another study, in the absence of any aerosol
generating procedures, influenza viral loads were actually higher further
away from the patient, and they were highest outside the patient’s room.
(Cummings 2014)
We should not rely on the 2 meter rule to keep us perfectly safe. That being
said, because droplets spread through 3 dimensional space, the
concentration of droplets decreases exponentially as you get further from
the patient, and there is data that the majority of droplets created from
normal breathing fall within 1 meter, although coughing and sneezing
increase that distribution significantly. 

Overall, the further you are from the patient the safer you are. You are
more likely to become contaminated at 50 cm than you are at 1 meter.
Your risk is lower again at 2 meters, but it doesn’t drop to zero. You are
even safer 4 or 8 meters away from the patient (or even better, behind a
closed door). 

Practically speaking, this means that you should take off your PPE as far
from the patient as possible. In an ideal world, you would always take
your PPE off behind a screen or door to completely limit droplet
contamination. However, although increasing the distance will decrease
your risk from droplets, it actually increases the risk of contact spread.
Clearly, you don’t want to bring dirty PPE into clean hallways. The risk of
spread through contact with fomites is almost certainly higher than the
risk from droplets once you are further than 2 meters away from the
patient, which is why the 2 meter rule often works practically, even though
it is not scientifically accurate.

What this means clinically will depend a great deal on the layout of your
own space. If there is an empty anteroom to doff in, that makes the most
sense. If you can doff behind a curtain, that would be great. Otherwise,
realize that your risk is very small beyond that 2 meter mark as long as the
patient is wearing a mask, not actively coughing or sneezing, and there is
not an ongoing aerosol generating procedure. 

Update: A new systematic review examined this topic, and 8 of the 10

studies included demonstrated droplet spread beyond 2 meters. The
authors state, “although the studies employed very different
methodologies and should be interpreted cautiously, they still confirm that
the spatial separation limit of 1 m (≈3 ft) prescribed for droplet
precautions, and associated recommendations for staff at ports of entry
[10], are not based on current scientific evidence.” (Bahl 2020)

Comparing N95 and surgical masks

We actually use masks for 2 different purposes and it results in a common
misunderstanding among the lay public. We can use masks to keep
droplets out of the respiratory tract (to keep ourselves safe), but we can
also use masks to keep droplets in (to keep others safe). The surgical mask
is significantly less effective than the N95 at keeping particles out, but it is
very good at keeping particles in. (It’s primary purpose is to protect
patients from the surgeon during surgery). With coughing and sneezing
patients in the hospital, one of the most important infection control
strategies is placing surgical masks on the patients to limit the number of
droplets then make it to the environment. (This is also one of the reasons
that “aerosol generating procedures” are higher risk – because we
generally need to remove that primary layer of protection.) Similarly,
when hospitals are asking employees to wear surgical masks at all times
right now, it is not a strategy designed primarily to protect employees, but
to limit unintentional spread from asymptomatic or minimally
symptomatic individuals. 

There are a few studies that compare N95 and surgical masks in
healthcare workers. (Loeb 2009; MacIntyre 2013; Smith 2016; Radonovich
2019) All were looking at influenza, so will only extrapolate to COVID-19 if
the mechanism of spread is the same, which might not be a good
assumption. Similarly, all studies will be impacted by the rate of
compliance with the mask (as well as things like hand hygiene). In general,
compliance is lower with the less comfortable N95 masks, so the studies
may be biased to show no difference, even if there is a difference with
perfect mask use. Studies done in an outpatient setting may not
extrapolate well to critical care. Finally, although the studies contain what
look like large numbers of people, the power of the studies comes from the
event rate (or the number of people who get sick despite wearing a mask),
which is much lower, and so the confidence intervals are very large. A
systematic review and meta-analysis on this topic found no statistical
differences, but the point estimates are all on the side of N95s being better,
and the confidence intervals are huge. (Long 2020) Therefore, I don’t think
it is fair to conclude that the two masks are equivalent, but just that we
don’t know. It is hard to know what to do with that information. In an
ideal world, I think using N95s as the standard until surgical masks were
proven to be non-inferior makes the most sense, but that only works if we
have an adequate supply of N95s to use for all COVID-19 encounters.

Summary
This is a lot of information, and unfortunately it does not allow for any
black and white conclusions. There is pretty wide consensus that the
science surrounding aerosol transmission of disease is severely lacking.
(Morawska 2006; Chen 2010; Judson 2019) There are more questions than
there are answers. We should avoid making definitive statements, and
instead discuss the uncertainties and the trade-offs between alternating
risks. Overall, given the lack of solid evidence, it is generally
recommended that we rely on the “precautionary principle”. (Judson 2019)
In other words, we should not be looking for evidence that a practice is
harmful before avoiding it, but should instead be looking for evidence that
a practice is safe before adopting it. 

Based on this data, it doesn’t make sense to dichotomize into just airborne
aerosols and localized droplets. It is clearly far more complicated than
that, with larger droplets becoming smaller as they evaporate, and plenty
of evidence that virus can be found further from patients than our current
models predict. This literature also makes it clear that almost every
activity, including normal breathing, can create aerosols. However, the
risk from those aerosols is far lower than the risk of droplets and close
contact with the patient. 

Perhaps most importantly, we need to move beyond black and white

statements and think in terms of probabilities. This data disproves
definitive rules, such as “you are perfectly safe when 2 meters away from
the patient”. Instead, it tells us that the chance of infection is much higher
when close to the patient and much lower as we get further away. 

We need to distinguish between possible and likely. Airborne transmission

of influenza and COVID-19 is clearly possible, and probably does occur
occasionally, but we also have to acknowledge that it is very rare. How can
we know that it is rare? If airborne transmission was highly likely, we
would see much bigger outbreaks. There have been thousands of COVID
patients managed in normal hospital rooms, or behind curtains, and not
every person in that department gets sick. Similarly, there have been many
sick COVID patients on planes, and although there is some transmission,
most people are fine. I think that message is key. Airborne spread is
possible, but if there was a COVID patient coughing without a mask on the
other side of the department, it is still very unlikely you will actually catch
the disease, even if you aren’t wearing PPE. You are much more likely to
catch it from droplets or close contact, which is why infection control
practices are so focused on those activities. 
If you are a numbers person, people have done some calculations. There
are a lot of assumptions, but the best estimates are that if you spend 15
minutes in a room with a coughing patient, your chance of catching
influenza from large droplets and self inoculation (contact) is about the
same (and not very high). Transmission through airborne aerosols is about
100 to 1000 times less likely than the other two routes (Telllier 2009)

That is reassuring. However, it is a mistake to take that line of reasoning

too far.  Just because droplet spread is more likely, doesn’t mean that
airborne spread should be ignored. It is wrong to categorically say that
COVID does not spread through an airborne route. 

The focus should be on droplet and contact spread. At the same time, we
should not ignore the airborne route. The above science review gives hints
at activities that could increase airborne transmission: sicker patients with
higher viral loads, more coughing and sneezing, higher respiratory rates,
longer times spent with the patient, and of course aerosol generating
procedures. In these cases, the risk of airborne transmission increases, and
we should consider adding airborne precautions to our standard of
contact and droplet PPE. 

Unfortunately, at this point I am not sure we understand the concept of

“super spreaders” well enough. It is clear they exist. I think the above
review explains their existence: some people produce far more aerosols
than others, and if those same patients have high viral loads, you have an
infection control problem. The issue is we don’t know how to identify
these patients, nor do we know how to appropriately account for them in
our current infection control practices. In my mind, their existence is
probably the best argument for universal mask use during an outbreak.

I have said many times that the goal of every hospital during COVID-19
should be to ensure that ZERO healthcare workers become infected in the
course of their normal duties, while still providing exemplary care to all of
our patients. However, that goal may not be perfectly attainable. There are
always tradeoffs between risks. Removing your PPE further from the
patient may limit your exposure to droplets, but increases potential
exposure to fomites as we carry dirty PPE further from the source. The
small risk of airborne transmission might suggest increased use of N95
masks, but if we use our equipment in low risk scenarios it might not be
available for us in higher risk encounters. You might suggest wearing an
N95 at all times, but we have already seen providers suffering from skin
breakdown and other complications.

There are no easy answers. If N95s were plentiful, I think if you make
sense to wear them for all encounters with suspected COVID patients.
However, that is not the world we live in, and although airborne spread is
technically possible, it is incredibly unlikely. I am happy to wear a surgical
mask when assessing the average patient with respiratory complaints. I
think that will keep me close to 100% protected. But as the patient gets
sicker and the risk of aerosols increases (either through procedures or
natural activities like coughing), I will switch to an N95.

Other FOAMed and Reporting

I recorded a podcast that covers this material with Dr. David Hao on the
Depth of Anesthesia podcast.

Don’t Forget the Bubbles: AEROSOL GENERATING PROCEDURES

Epidemic podcast: A False Dichotomy: Airborne versus Droplet

COVID-19: Why We Should All Wear Masks — There Is New Scientific

Rationale

COVID 10: Is COVID-19 an airborne disease? Will we all …

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

How diseases and epidemics move through a breath of…

Watch later Share

A TedMed talk by Lydia Bourouiba on airborne transmission

Is the coronavirus airborne? Experts can’t agree

Perspective: Universal Masking in Hospitals in the Covid-19 Era

You can watch aerosol being created by talking in this Japanese news
program:

Covid-19 spread by micro droplets

Watch later Share
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Cite this article as: Justin Morgenstern, "Aerosols, Droplets, and

Airborne Spread: Everything you could possibly want to know",
First10EM blog, April 6, 2020. Available at:
https://first10em.com/aerosols-droplets-and-airborne-spread/.

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AUTHOR

Justin Morgenstern
Emergency doctor working in the community. FOAM enthusiast. Evidence
based medicine junkie. “One special advantage of the skeptical attitude of
mind is that a man is never vexed to find that after all he has been in the
wrong.” - William Osler
331 POSTS

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66 thoughts on “Aerosols, Droplets, and Airborne

Spread: Everything you could possibly want to
know”
38 comments

28 pingbacks

mdjkf
H 22, 2020, 6:31 am
April
i
Thanks for your paper. what is the source of your statement:
“Because of their larger size, large droplets contain as much as
99.9% of viral particles exhaled.” please? I note
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591312/pdf/ppat.10
03205.pdf which finds more influenza virus in exhaled fine droplets
than large and this paper
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3331822/pdf/12890_2
011_Article_304.pdf which in a cough finds very small droplets
predominate. It is a baffling area for sure!

Thanks
John Ferguson

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Justin Morgenstern Post author

April 22, 2020, 3:07 pm
It is a is a simple volume issue. Definitely virus in the smaller
particles, but the large ones are a much bigger total volume.
From the post: “It is also important to understand that although
the majority of the droplets produced by a cough may be small
enough to stay airborne, their small size means that collectively
they add up to only a tiny fraction of the volume produced
(perhaps less than 0.1%), and therefore only a tiny fraction of the
total virus spread. (Nicas 2005)”

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sudhir sane
May 5, 2020, 8:04 am
Very nice article, learned a lot. Only one point .. the quoted study
as concentration of influenza virus was higher outside the room
has an explanation in it. They say that some other source of the
influenza virus couldn’t be excluded.

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 Justin Morgenstern Post author
May 5, 2020, 8:29 am
I am not sure that “couldn’t exclude” is that same has having an
explanation. It certainly adds some uncertainty, but that is true
of all science.
Whatever the source, it is clear that influenza can be found in
airborne aerosols, and the animal studies make it clear that it
can be transmitted through the airborne route as well. In my
mind the question is not as much can this happen, but more how
often does this happen, and it seems like droplet spread still
outweighs airborne spread in most practical settings.

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Teresa HLADISH
April 27, 2020, 11:05 am
Thank you. A very clear unbiased opinion – based on the available
literature, from someone in the trenches. I learned a lot.

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Renee Pompei
April 28, 2020, 2:49 pm
I’m an orthodontist. The dental community is very concerned and
confused about the various recommendations for protecting our
patients, our staffs, and ourselves during this pandemic. We are
concerned about asymptomatic transmission in aerosols produced
during dental procedures. Many of our offices will have been closed
for 2 months+ when we resume work and if we haven’t contracted
COVID-19 yet and then do, we will have to shut down for another 2-3
weeks in the best case scenario of consequences. Based on your
research would you have any specific insights or takeaways that
apply to dental offices? How about large volume, open bay practices
like orthodontic offices? Would medical grade HEPA filters make a
significant difference in transmission? Any other best practices
you’d recommend in this setting? Thanks so much for such an
informative and unbiased article.
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Justin Morgenstern Post author

April 28, 2020, 7:54 pm
I wish I had specific answers to your questions. I have received
many similar questions from dentists, and the most honest answer
I can provide is I don’t know.
Unfortunately, working in the mouth is likely high risk for disease
transmission, but it is also really important work. I tried to include
everything I came across in this write up so hopefully people can
apply the science to their own practices, but the science is far from
perfect. The risk will probably depend a lot on the specifics of
procedures being done (drilling, spraying water into the mouth,
and suctioning all probably have a high risk of transmission). I
honestly don’t know enough about oral surgery or dentistry to say
specifically, but my guess is it probably requires full airborne type
PPE for many/most procedures, and full cleaning procedures
between patients.
Good luck and stay safe

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Chris Coulson
April 29, 2020, 6:32 am
The stand out best article I have read on this critical topic.
Outstanding work

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Paul Rosen
May 9, 2020, 11:43 pm
Hi Justin,

Thank you for the time you put into researching and assembling
Thank you for the time you put into researching and assembling
this.

Intuitively it doesn’t seem like normal breathing should produce

much in the way of droplets since it involves a pretty low-velocity
airflow through a fairly unrestricted passage. Since the air we
exhale is warm and humid, I wonder if a lot of the very small
droplets observed to result from breathing might actually be
condensate that forms after the air leaves the body and cools. It
seems like this difference would matter since if the water in the
droplets was in gas phase until it left the body, the droplets could not
contain any virus particles. Do you know if the research addressed
this possibility?

Thanks again for the great article,

Paul

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Justin Morgenstern Post author

May 10, 2020, 9:55 am
That is a fantastic question, and I didn’t see it addressed anywhere
in the literature. Most of what I read said that a single normal
breath makes very few aerosols (although the add up over time as
we are always breathing), which might not fit well with your
theory. Air flow is one component or aerosol generation, but
surface tension is another. We specifically produce surfactant to
lower surface tension, which will allow aerosols to form easier.
even without significant air flows. But I honestly don’t know. (We
can probably pretty definitively say that simple breathing is not
making large quantities of infectious aerosols, because otherwise
everyone would be sick by now – I have looked after many many
COVID patients with just a surgical mask, and haven’t caught it yet,
as far as I know.)

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diogenesnj
May 10, 2020, 4:15 pm
Thanks for a very useful article. It seems to explain easier
transmission in winter as well: indoor relative humidity is much
lower (big difference between outdoor and indoor temperature), so
droplets of any size evaporate faster, so more droplets shrink to dry,
light particles and survive in air.

Which doesn’t make me happy, because we’re reprising March at the

moment in NJ. Below freezing where I am 2 nights ago.

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Lesa
May 14, 2020, 3:34 pm
Thank you for doing so much research and putting this information
out to us laypeople in a way that is easier for us to understand than
all the scientific papers out there. I have been trying to develop
homemade masks that are both effective and comfortable to wear,
and have been trying to figure out what size the droplets coming out
of our mouths and noses might be. Some people suggest 2 layers of
quilting cotton, but is that really enough to protect other people
from the wearer? And what about protecting the wearer from
someone who might not be wearing a mask, or is wearing a
respirator with a valve in it, so their breath is coming out of that
mask unfiltered? Am I correct in thinking that a mask that protects
the wearer would need to be able to filter out smaller particles than
a mask that protects everyone else from the wearer, because the
droplets will evaporate through the air?

Also, what about Brownian motion and static electricity?

What are your thoughts on this study that was published on April
24? https://pubs.acs.org/doi/10.1021/acsnano.0c03252 News articles
about it are saying that 1 layer of 600TPI cotton and 2 layers of the
polyester/spandex chiffon they tested are almost as effective as an
N95 mask if it fits well with no gaps, but trying to interpret the study
myself is making me go cross-eyed. I think that’s what it actually
says, but I know reporters often have a tendency to misunderstand
scientific literature, and other reporters will just copy what the first
reporters say. Also, if this is true, and if we were to put the sheer
l h id f h k ld i b ild i h
layers on the outside of the mask, would moisture build up in the
cotton get the sheer fabric moist, eliminate the static, and render
those sheer fabrics ineffective? And one last thing, since mixing
negatively-charged materials with positively-charged materials is
supposed to create static, wouldn’t it be more effective to use one
layer of polyester/spandex chiffon with one layer of something like
silk along with the layer of cotton, since they have opposite charges,
instead of 2 layers of chiffon?

On a side note, the uppercase styling in a heading in one of your

charts is making “Small (1-2 µm)” look like it says “SMALL (1-2 MM)”.
If you have access to the HTML, you can add before the µm and after
it.

Thanks again, for all you do! Be well, and stay safe!
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Lesa
May 14, 2020, 3:45 pm
The system ate my HTML tags. I was trying to say, the uppercase
styling in a heading in one of your charts is making “Small (1-2
µm)” look like it says “SMALL (1-2 MM)”. If you have access to the
HTML, you can add (span style=”text-transform:none;”) before the
µm and (/span) after it, but change the parentheses to less-than
and greater-than symbols.

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bebe
May 16, 2020, 5:50 pm
Great summary.

How about
https://www.pnas.org/content/early/2020/05/12/2006874117

The airborne lifetime of small speech droplets and their potential

importance in SARS-CoV-2 transmission
Valentyn Stadnytskyi Christina E Bax Adriaan Bax and Philip
 Valentyn Stadnytskyi, Christina E. Bax, Adriaan Bax, and Philip
Anfinrud
PNAS first published May 13, 2020
https://doi.org/10.1073/pnas.2006874117

Edited by Axel T. Brunger, Stanford University, Stanford, CA, and

approved May 4, 2020 (received for review April 10, 2020)

Abstract

Speech droplets generated by asymptomatic carriers of severe

acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are
increasingly considered to be a likely mode of disease
transmission. Highly sensitive laser light scattering observations
have revealed that loud speech can emit thousands of oral fluid
droplets per second. In a closed, stagnant air environment, they
disappear from the window of view with time constants in the
range of 8 to 14 min, which corresponds to droplet nuclei of ca. 4
μm diameter, or 12- to 21-μm droplets prior to dehydration. These
observations confirm that there is a substantial probability that
normal speaking causes airborne virus transmission in confined
environments.

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Gerhard Scheuch, PhD

May 17, 2020, 8:06 am
Very good review. From an Aerosolphysicist and involveld in the
field of Aerosolmedicine since 1980 just a few remarks:
1.) Pollen are not invisible and are as big as 20 – 200 µm.
2.) You are correct that there is no real cutoff particle size in the
Aerosol Definition. Aerosol is a suspension of fine solid particles or
liquid droplets in air or another gas. When Aerosol particles fall out
of the gas in a few seconds, it is no longer an Aerosol particle. But
not only the size, but also the shape, the densitiy and some other
factors are responsible for beeing airborne.
3.) There is another important mechanism how aerosol particles are
generated by breathing: They are produced in the deep lungs by
reopening of collapsed small airways. This mechanism is described
by several aerosolphysicists (Edwards, 2004; Gebhart, 1988; Bake,
2016 and 2019; Johnson, 2009; Schwarz, 2009 and 2013…..).
Unfortunately it is not very often mentioned This mechanism
Unfortunately, it is not very often mentioned. This mechanism
produce ub to several hundred thousand particles per breath. And
in that way is much more effcient than cough, sneeze, speaking….
4.) Taking all that into account it is very likely that the transmission
via Aerosol is the major mechanism in the spread of COVID 19.

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Justin Morgenstern Post author

May 17, 2020, 10:18 am

Thank you for you comment.

I agree, physically speaking, it would seem like aerosols play a
huge role. However, based in the spread of disease, I would have a
hard time labelling it “the major mechanism”. In hospitals, we
don’t use protection against aerosols, even with patients with
known COVID. We just use droplet/contact precautions. If aerosols
were the major mechanism, I would think the Canadian health
workforce would all have been sick by now. That being said, as we
see more and more outbreaks among healthcare workers, we are
going to have to strongly revaluate the role of aerosols and the PPE
we use.

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Gerhard Scheuch
May 17, 2020, 11:04 am
👍

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jeff cardarella
May 30, 2020, 8:04 am
Having an expertise in both dust & static electricity control & salon
 industry air quality, I find the suddenly ubiquitous
implementation of plexiglass sneeze guards worrisome. These
plexiglass shields are providing a false sense of security in
preventing inhalation exposure to dust and microorganisms,
including COVID19. And, their use may be unwittingly
contributing to an unrecognized increased exposure source.

Plexiglass is an extremely non conductive material and has a high

propensity to create and hold high static charges, especially after
cleaning due to the friction created by simply wiping the surface
during the cleaning process. The higher the static charge, the
greater the likelihood of attracting airborne dust from greater
distances. Airborne droplets are able to attach themselves to dust
particles, which affect coronavirus by serving like vehicles to
transport droplets further than they would be able to travel
otherwise, and potentially entering the breathing zone of people
in close proximity. If these plexiglass guards/shields are now here
to stay and are going to be seen everywhere we go, it’s best to
understand how to prevent static electricity build up on their
surfaces. Feel free to contact me, should you have an interest in
learning how to maintain dust & static free surfaces, helping to
prevent airborne virus inhalation exposure.

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David Haddock
August 12, 2020, 10:03 am
I was just searching the internet, because I am supposing that a
static charge imparted to plastic shields, would attract droplets,
that being a good quality. Rather than floating around the shield
and around the room, they would rest on the surface and begin
to degrade.

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Laura Shoots
May 24, 2020, 10:56 am
Thanks for this amazing work!
Did you come across anything about exhaled cigarette smoke and
whether it could be aerosolizing? I was trying to click around and
found this article but had no idea how to interpret it in comparison
to a normal exhalation https://aaqr.org/articles/aaqr-12-02-oa-
0041.pdf

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Cyril
June 18, 2020, 3:30 pm
Hello!
I had to attend an interview today and did not have a face mask due
to the nature of the interview. When I arrived at the building there
were a couple of people but I was told the place had been very busy
prior to my arrival. When I went to the interview room there was a
plexiglass screen separating me from the two people interviewing
me.

My main concern is weather i could be contaminated by a person

who had been there before I arrived? I’m quite sure the interview
room had been empty a minimum 30 minutes prior to my arrival,
but I’m concerned that smaller aerosols could have remained in the
rather stale air of such a small room. What is the likelihood of
becoming sick from this?

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Justin Morgenstern Post author

June 19, 2020, 1:02 pm
I think if you read through the science above, you will find that
although the risk is not zero, it is very very low and probably not
worth worrying about, aside from the general precaution of not
touching your face and being sure to wash your hands

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 Cyril
June 19, 2020, 1:07 pm
Thank you for your fast reply!

I read most of what you wrote, and found it especially

interesting to see the paths of the smallest nuclei. But I think I
was just seeking some reassurance.

Fantastic blog!

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Justin Morgenstern Post author

June 19, 2020, 1:09 pm
Absolutely – we are all feeling that way these days. I wish I could
talk in absolutes, but everything we know is about grey areas.
The more experience we get with COVID, though, the more it
seems like the small droplet nuclei only have a small role in
transmission. I would still be more concerned about the stuff
everyone is talking about – masks, distancing, and hand
washing.

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Chuck Hammock
June 22, 2020, 4:28 pm
Thanks for your article! One comment and one question.

Question: Do you think the seasonal nature of higher influenza (and

maybe SAR-CoV-2 or other viruses/bacteria) levels in the winter
might be related to the (typically) lower indoor relative humidity
levels during that season? My thinking is that lower
dewpoints/vapor pressures/relative humidity increases the
evaporation rate on the surface of the airborne droplet. That in turn
reduces the mean aerodynamic diameter of the droplets
(evaporation occurs at a faster rate in the dry air than it would in
more humid “summer” air). This global reduction in the droplet’s
aerodynamic diameter creates a triple threat of: a. Deeper
penetration into the lungs of each droplet. b. Longer suspension
time in the air thereby increasing the probability the droplets
become/stay airborne and c., (perhaps of less consequence), The
concentration of virus has increased (the semi-spherical droplet has
shrank but virus count stayed the same) thereby depositing more
organisms per square micron at each landing site. Your
comments/thoughts are appreciated!

Comment: HVAC design for critical spaces like O/R Theaters or Clean
Room has general involved the near laminar flow of cooler/denser
filtered air flowing vertically downward over the
patient/occupants/hardware and then towards the floor where the
“return” grilles are location and the air (and hopefully much of its
contaminants) exits the room. It is typically then it is filtered, diluted
with outside (“fresh”) air, sometimes treated with UVC or bipolar-
ionization, heated/cooled/dehumidified and or humidified and
returned to the space. Adopting this HVAC “architecture” to
additional applications would be expensive but I suspect very
helpful in mitigating airborne transmission.

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Justin Morgenstern Post author

June 26, 2020, 10:59 am
My understanding is that the increased transmission in the winter
is simply from prolonged time spent in contained spaces with sick
people, but there may be a lot more to it than that. I haven’t seen
anything directly written about humidity, but these other factors
seem to make sense.

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Essam
June 27, 2020, 2:51 am
Thank you for your summaries and discussion.

I have added my comments already however don’t see it Anyway

I have added my comments already , however, don t see it . Anyway.
I have been preparing systematic review to find if covid-19 can
transmit during oral and maxillofacial aerosols generating
procedures.

So do you think dental generating procedures can spread the viruses

in dental offices? And respirators are mandatory?

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Justin Morgenstern Post author

July 6, 2020, 7:38 pm
Sorry about that – I have been so busy, I fell way behind on the
comments.
Honestly, I have not looked into dental procedures specifically.
Drilling seems to produce aerosols, so I would assume these
procedures would be very high risk, but I don’t have any data
myself. Best of luck.

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Sunil Kanhere
July 11, 2020, 11:38 am
Thanks for such painstaking effort.

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Paul
July 12, 2020, 8:32 pm
Thanks for all of this valuable information. I have a query. Is it
plausible that cloth masks turn exhaled breath into finer clouds of
aerosol? If the mask captures droplets but allows small particles to
pass wouldn’t exhaling through a mask be a means of generating
more aerosol from exhaled breath? Might it therefore do more harm
than exhaling without wearing a mask?

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Justin Morgenstern Post author

July 12, 2020, 8:45 pm
Thanks for the question
1) I think this has been specifically looked at, and wearing a mask
decreases the number of measurable aerosols.
2) Droplets are much much more important than aerosols in
spreading most diseases, including COVID, so even if it was true, it
would be irrelevant, and masks would still decrease overall
transmission.

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Paul
July 12, 2020, 9:01 pm
Thanks. The news has been full of headlines about aerosol
transmission of Corona virus recently. I would love to see a
study on the question of whether exhaling through a cloth mask
creates more aerosol than exhaling without wearing a mask.
Physical distancing alone could deal with droplet transmission.

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Paul Morgan
August 11, 2020, 5:08 pm
I’ve been proved right about this for some types of face coverings.
https://advances.sciencemag.org/content/early/2020/08/07/sciadv.a
bd3083.full

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David Michael Tichane
July 17, 2020, 7:11 pm
Ideas for experimentation– water molecules are slightly electrically
polar. So maybe a mask with an electrostatic charge — a watch
battery might be enough– would trap aerosols as well as droplets.
Another idea– would a good sized dehumidifier in the vicinity of
patients help– perhaps in conjunction with humidifiers strategically
placed to maintain overall humidity balance.

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TRM
July 21, 2020, 5:34 pm
“Perhaps most importantly, we need to move beyond black and
white statements and think in terms of probabilities.” – LOL. The
“quantum” approach.

Just wanted to say thanks for a great article. Very well written and
easy to read but not at the expense of thoroughness!

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Hugo J Bohorquez, PhD

August 2, 2020, 6:13 pm
As time pass by, the airborne route becomes more relevant than
originally considered. The disproportionate amount of health
workers with the disease – and deaths – means that even the best
trained people wearing PPE are not safe in highly infected areas. We
should focus on the airborne route even where everyone wears
masks.

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 Tara
November 17, 2020, 6:55 pm
You mentioned UV light. We have a UV-C light that we can place in
the room for added disinfection (not the far UV). Many staff
members want the magic box put into the patient room after
discharge to zap all the virus in the air. I don’t disagree but I don’t
have any evidence and do not want to give a false sense of security.
How much time or what dose of light, 5 minutes; 10 minutes?

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Justin Morgenstern Post author

November 17, 2020, 7:45 pm
At this point, I have not had the opportunity to look into the
specifics of UV light. It is mentioned hear as a line of evidence of
aerosol spread, and those specific are beyond the scope of this
review. However, it is a topic that I think I will be writing about
more in the near future.

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