MGH FLARE - May 31 - How is #SARS-CoV-2 transmitted?
Illustration of different transmission routes (Wei and Li 2016).
The “aerobiologic pathway” for the transmission of communicable respiratory diseases proposed by Roy and Milton (Roy and Milton 2004).
The rapid spread of COVID-19 across the globe has prompted researchers and public health officials to revisit the age-old question: Is this virus spreading via the airborne route? A letter published in the NEJM reported the three-hour long viability of SARS-CoV-2 in aerosols that were experimentally generated with a nebulizer, though with marked exponential decay in virus titer (van Doremalen et al. 2020). A recent non-peer reviewed preprint from the University of Nebraska found that air sampled in patient rooms and hallways contained SARS-CoV-2 viral RNA; however, further testing did not identify any viable, infectious virus in these samples (Santarpia et al. 2020). Additionally, findings from the Korean CDC have shown that patients who have recovered are not infectious despite some continuing to have positive RT-PCRs (KCDC). These findings reinforce two important notions: 1) that viral RNA is not equivalent to infectious virus, and correspondingly, 2) that the presence of SARS-CoV-2 RNA in air samples does not necessarily imply that this pathogen can be effectively transmitted via the airborne route.
Data thus far analyzing outbreaks and exposures during the care of patients with COVID-19 continue to support droplet and contact routes as the predominant modes of transmission for SARS-CoV-2, mirroring what was observed during the SARS epidemic (CDC: Cluster of Severe Acute Respiratory Syndrome Cases among Protected Health-Care Workers—Toronto, Canada, 2003). For example, an exposure investigation from Hong Kong did not identify any secondary cases among a group of 71 staff and 49 patients in contact with a confirmed COVID-19 patient who was initially admitted under standard precautions and spent thirty-five hours unmasked in an open cubicle (Wong et al. 2020). Investigators credited the lack of nosocomial transmission to the institution’s universal mask policy, aggressive hand hygiene, and environmental cleaning practices (Siegel et al. 2007). A case report from Singapore had similar findings: among 35 healthcare workers wearing surgical masks while in close contact with a COVID-19 positive patient during an aerosol-generating procedure, none tested positive for SARS-CoV-2 two weeks after exposure (Ng et al. 2020). A recently published MMWR report investigated high rates of secondary transmission of COVID-19 among attendees of a choir practice in Washington (Hamner et al. 2020). This superspreading event was heavily featured in media outlets nationwide, raising concerns of airborne spread of COVID-19. Nevertheless, although investigators did raise the possibility of aerosol emission via speech and singing, they concluded that the close and prolonged contact of attendees was highly conducive to disease spread via droplets and fomites.