Aerosols, Droplets, and Airborne

Spread: Everything you could

possibly want to know

by Justin Morgenstern |Published April 6, 2020 -Updated December 2, 2020 |68 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.

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 DROPLETS SMALL (1-2 UM)

ACTIVITY
PRODUCED AEROSOLS?

Normal breathing (5
A few Some
min)
 NUMBER OF DROPLETS SMALL (1-2 UM)
ACTIVITY
PRODUCED AEROSOLS?

Single strong nasal

Few to a few hundred Some
exhalation

Counting out loud Few dozen to few hundred. Some sources

Mostly
(talking) say a few thousand (Xie 2007)

Cough Few hundred to many thousand Mostly

Sneeze Few hundred thousand to a few million Mostly

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?”:

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)

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.