#15,188
The more we learn about SARS-CoV-2 - the virus that causes COVID-19 - the more we realize that many of the old assumptions about influenza pandemics, and pandemic mitigation, may not apply when dealing with a novel coronavirus.
SARS-CoV-2 appears to be two or three times more contagious than influenza, but it isn't clear how much of that is due to an overwhelming lack of community immunity to a novel virus, and how much might be due to the mechanics of viral transmission.The early assumption that SARS-COV-2 transmits primarily by large droplets and via fomites has been challenged by recent studies that suggest aerosolization may play a significant role in spreading the virus (see COVID-19: The Airborne Division) and the following studies.
Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 - NEJM
Is the coronavirus airborne? Experts can’t agree - Nature
Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020) - Nat. Academy Sci.This makes a huge practical difference, because the PPEs required for `contact and droplet precautions' (gloves, gown, surgical mask & eye protection) are less rigorous than for an aerosolized virus.
But aerosolation also affects the duration, and the distance, over which a virus can travel. This means that air conditioning, or unfiltered ventilation, might spread the virus and that fomites, some distance from the source, could become contaminated.Although believed spread primarily by large droplets, following the 2015 MERS outbreak in South Korea researchers found extensive and persistent environmental contamination by the MERS virus in, and even adjacent to, isolation rooms, highlighting the need for strict environmental infection control (see IDWeek: Persistence Of MERS-CoV On Hospital Environmental Surfaces).
Another study from 2015 focused on the environmental persistence of human coronavirus (hCoV) 229E - which along with NL63, OC43 & HKU1 - are probably responsible for 15%-30% of the `common colds’ around the world (see mBio: Persistence Of Human Coronavirus 229E on Environmental Surfaces).
(Excerpt)
We report here that pathogenic human coronavirus 229E remained infectious in a human lung cell culture model following at least 5 days of persistence on a range of common nonbiocidal surface materials, including polytetrafluoroethylene (Teflon; PTFE), polyvinyl chloride (PVC), ceramic tiles, glass, silicone rubber, and stainless steel.Admittedly, SARS-CoV-2 is neither MERS-CoV, SARS, or hCoV 229E (if you've seen one coronavirus - you've seen one coronavirus). But these previous studies do foreshadow some of what we are learning today about our pandemic virus.
In a study, published yesterday in the CDC's EID Journal, researchers looked at the spread of SARS-CoV-2 in and around a Wuhan Hospital infectious disease ward, and found the virus ranged farther afield than expected, including to adjacent non-patient areas.
It should be noted that RT-PCR testing, used to identify SARS-CoV-2 contaminated surfaces, doesn't tell us about the viability of the virus at the time of collection. However we've seen other studies suggesting the virus can remain infectious for hours or even days under the right conditions.Some of this viral spread appears to be due to fomite contact/transfer by medical staff; on the soles of their shoes, by touching doorknobs and computers with contaminated hands, etc. But air sampling also found evidence of aerosolized virus particles, and the authors suggest SARS-CoV-2 could spread as far as 4 meters (twice the currently recognized distance) through the air.
I've posted the bulk of the study (reformatted for readability) below, but you'll want to follow the link to read it in its entirety.
Volume 26, Number 7—July 2020
Dispatch
Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020
Zhen-Dong Guo1, Zhong-Yi Wang1, Shou-Feng Zhang1, Xiao Li, Lin Li, Chao Li, Yan Cui, Rui-Bin Fu, Yun-Zhu Dong, Xiang-Yang Chi, Meng-Yao Zhang, Kun Liu, Cheng Cao, Bin Liu, Ke Zhang, Yu-Wei Gao, Bing Lu
Abstract
To determine distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards in Wuhan, China, we tested air and surface samples. Contamination was greater in intensive care units than general wards. Virus was widely distributed on floors, computer mice, trash cans, and sickbed handrails and was detected in air ≈4 m from patients.
As of March 30, 2020, approximately 750,000 cases of coronavirus disease (COVID-19) had been reported globally since December 2019 (1), severely burdening the healthcare system (2). The extremely fast transmission capability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has aroused concern about its various transmission routes.The main transmission routes for SARS-CoV-2 are respiratory droplets and close contact (3).
Knowing the extent of environmental contamination of SARS-CoV-2 in COVID-19 wards is critical for improving safety practices for medical staff and answering questions about SARS-CoV-2 transmission among the public. However, whether SARS-CoV-2 can be transmitted by aerosols remains controversial, and the exposure risk for close contacts has not been systematically evaluated.
Researchers have detected SARS-CoV-2 on surfaces of objects in a symptomatic patient’s room and toilet area (4). However, that study was performed in a small sample from regions with few confirmed cases, which might not reflect real conditions in outbreak regions where hospitals are operating at full capacity. In this study, we tested surface and air samples from an intensive care unit (ICU) and a general COVID-19 ward (GW) at Huoshenshan Hospital in Wuhan, China (Figure 1).
The Study
From February 19 through March 2, 2020, we collected swab samples from potentially contaminated objects in the ICU and GW as described previously (5). The ICU housed 15 patients with severe disease and the GW housed 24 patients with milder disease. We also sampled indoor air and the air outlets to detect aerosol exposure.
Air samples were collected by using a SASS 2300 Wetted Wall Cyclone Sampler (Research International, Inc., https://www.resrchintl.comExternal Link) at 300 L/min for of 30 min. We used sterile premoistened swabs to sample the floors, computer mice, trash cans, sickbed handrails, patient masks, personal protective equipment, and air outlets. We tested air and surface samples for the open reading frame (ORF) 1ab and nucleoprotein (N) genes of SARS-CoV-2 by quantitative real-time PCR. (Appendix).
Almost all positive results were concentrated in the contaminated areas (ICU 54/57, 94.7%; GW 9/9, 100%); the rate of positivity was much higher for the ICU (54/124, 43.5%) than for the GW (9/114, 7.9%) (Tables 1, 2). The rate of positivity was relatively high for floor swab samples (ICU 7/10, 70%; GW 2/13, 15.4%), perhaps because of gravity and air flow causing most virus droplets to float to the ground.
In addition, as medical staff walk around the ward, the virus can be tracked all over the floor, as indicated by the 100% rate of positivity from the floor in the pharmacy, where there were no patients. Furthermore, half of the samples from the soles of the ICU medical staff shoes tested positive. Therefore, the soles of medical staff shoes might function as carriers. The 3 weak positive results from the floor of dressing room 4 might also arise from these carriers. We highly recommend that persons disinfect shoe soles before walking out of wards containing COVID-19 patients.
The rate of positivity was also relatively high for the surface of the objects that were frequently touched by medical staff or patients (Tables 1, 2). The highest rates were for computer mice (ICU 6/8, 75%; GW 1/5, 20%), followed by trash cans (ICU 3/5, 60%; GW 0/8), sickbed handrails (ICU 6/14, 42.9%; GW 0/12), and doorknobs (GW 1/12, 8.3%). Sporadic positive results were obtained from sleeve cuffs and gloves of medical staff. These results suggest that medical staff should perform hand hygiene practices immediately after patient contact.
Because patient masks contained exhaled droplets and oral secretions, the rate of positivity for those masks was also high (data not shown). We recommend adequately disinfecting masks before discarding them.
We further assessed the risk for aerosol transmission of SARS-CoV-2. First, we collected air in the isolation ward of the ICU (12 air supplies and 16 air discharges per hour) and GW (8 air supplies and 12 air discharges per hour) and obtained positive test results for 35% (14 samples positive/40 samples tested) of ICU samples and 12.5% (2/16) of GW samples. Air outlet swab samples also yielded positive test results, with positive rates of 66.7% (8/12) for ICUs and 8.3% (1/12) for GWs. These results confirm that SARS-CoV-2 aerosol exposure poses risks.
Furthermore, we found that rates of positivity differed by air sampling site, which reflects the distribution of virus-laden aerosols in the wards (Figure 2, panel A). Sampling sites were located near the air outlets (site 1), in patients’ rooms (site 2), and (site 3). SARS-CoV-2 aerosol was detected at all 3 sampling sites; rates of positivity were 35.7% (5/14) near air outlets, 44.4% (8/18) in patients’ rooms, and 12.5% (1/8) in the doctors’ office area. These findings indicate that virus-laden aerosols were mainly concentrated near and downstream from the patients.
However, exposure risk was also present in the upstream area; on the basis of the positive detection result from site 3, the maximum transmission distance of SARS-CoV-2 aerosol might be 4 m. According to the aerosol monitoring results, we divided ICU workplaces into high-risk and low-risk areas (Figure 2, panel B). The high-risk area was the patient care and treatment area, where rate of positivity was 40.6% (13/32). The low-risk area was the doctors’ office area, where rate of positivity was 12.5% (1/8).
In the GW, site 1 was located near the patients (Figure 2, panel C). Site 2 was located ≈2.5 m upstream of the air flow relative to the heads of patients. We also sampled the indoor air of the patient corridor. Only air samples from site 1 tested positive (18.2%, 2/11). The workplaces in the GW were also divided into 2 areas: a high-risk area inside the patient wards (rate of positivity 12.5, 2/16) and a low-risk area outside the wards (rate of positivity 0) (Figure 2, panel D).
Conclusions
This study led to 3 conclusions.
- First, SARS-CoV-2 was widely distributed in the air and on object surfaces in both the ICU and GW, implying a potentially high infection risk for medical staff and other close contacts.
- Second, the environmental contamination was greater in the ICU than in the GW; thus, stricter protective measures should be taken by medical staff working in the ICU.
- Third, the SARS-CoV-2 aerosol distribution characteristics in the GW indicate that the transmission distance of SARS-CoV-2 might be 4 m.
As of March 30, no staff members at Huoshenshan Hospital had been infected with SARS-CoV-2, indicating that appropriate precautions could effectively prevent infection. In addition, our findings suggest that home isolation of persons with suspected COVID-19 might not be a good control strategy. Family members usually do not have personal protective equipment and lack professional training, which easily leads to familial cluster infections (6).
During the outbreak, the government of China strove to the fullest extent possible to isolate all patients with suspected COVID-19 by actions such as constructing mobile cabin hospitals in Wuhan (7), which ensured that all patients with suspected disease were cared for by professional medical staff and that virus transmission was effectively cut off. As of the end of March, the SARS-COV-2 epidemic in China had been well controlled.
Our study has 2 limitations. First, the results of the nucleic acid test do not indicate the amount of viable virus. Second, for the unknown minimal infectious dose, the aerosol transmission distance cannot be strictly determined.
Overall, we found that the air and object surfaces in COVID-19 wards were widely contaminated by SARS-CoV-2. These findings can be used to improve safety practices.
Drs. Guo, Z.Y. Wang, and S.F. Zhang are researchers at the Academy of Military Medical Sciences, Academy of Military Sciences in Beijing, China. Their research interests are the detection, monitoring, and risk assessment of aerosolized pathogens.
