Key Words:Respiratory droplet indoor air coughing droplet dispersion infection control environmental ventilation Background: Since the 2003 severe acute respiratory syndrome epidemic, scientific exploration of infection control is no longer restricted to microbiologists or medical scientists. Many studies have reported on the release, transport, and exposure of expiratory droplets because of respiratory activities. This review focuses on the airborne spread of infectious agents from mucus to mucus in the indoor environment and their spread as governed by airflows in the respiratory system, around people, and in buildings at different transport stages. Methods: We critically review the literature on the release of respiratory droplets, their transport and dispersion in the indoor environment, and the ultimate exposure of a susceptible host, as influenced by airflows. Results: These droplets or droplet nuclei are transported by expired airflows, which are sometimes affected by the human body plume and use of a face mask, as well as room airflow. Room airflow is affected by human activities such as walking and door opening, and some droplets are eventually captured by a susceptible individual because of his or her inspired flows; such exposure can eventually lead to longrange spread of airborne pathogens. Direct exposure to the expired fine droplets or droplet nuclei results in short-range airborne transmission. Deposition of droplets and direct personal exposure to expired large droplets can lead to the fomite route and the droplet-borne route, respectively. Conclusions: We have shown the opportunities for infection control at different stages of the spread. We propose that the short-range airborne route may be important in close contact, and its control may be achieved by face masks for the source patients and use of personalized ventilation. Our discussion of the effect of thermal stratification and expiratory delivery of droplets leads to the suggestion that displacement ventilation may not be applicable to hospital rooms where respiratory infection is a concern.

Although airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been recognized, the condition of ventilation for its occurrence is still being debated. We analyzed a coronavirus disease 2019 (COVID-19) outbreak involving three families in a restaurant in Guangzhou, China, assessed the possibility of airborne transmission, and characterized the associated environmental conditions. We collected epidemiological data, obtained a full video recording and seating records from the restaurant, and measured the dispersion of a warm tracer gas as a surrogate for exhaled droplets from the index case. Computer simulations were performed to simulate the spread of fine exhaled droplets. We compared the in-room location of subsequently infected cases and spread of the simulated virus-laden aerosol tracer. The ventilation rate was measured using the tracer gas concentration decay method. This outbreak involved ten infected persons in three families (A, B, C). All ten persons ate lunch at three neighboring tables at the same restaurant on January 24, 2020. None of the restaurant staff or the 68 patrons at the other 15 tables became infected. During this occasion, the measured ventilation rate was 0.9 L/s per person. No close contact or fomite contact was identified, aside from back-to-back sitting in some cases. Analysis of the airflow dynamics indicates that the infection distribution is consistent with a spread pattern representative of long-range transmission of exhaled virus-laden aerosols. Airborne transmission of the SARS-CoV-2 virus is possible in crowded space with a ventilation rate of 1 L/s per person.

The occurrence of close proximity infection for many respiratory diseases is often cited as evidence of large droplet and/or close contact transmission. We explored interpersonal exposure of exhaled droplets and droplet nuclei of two standing thermal manikins as affected by distance, humidity, ventilation, and breathing mode. Under the specific set of conditions studied, we found a substantial increase in airborne exposure to droplet nuclei exhaled by the source manikin when a susceptible manikin is within about 1.5 m of the source manikin, referred to as the proximity effect. The threshold distance of about 1.5 m distinguishes the two basic transmission processes of droplets and droplet nuclei, that is, short-range modes and the long-range airborne route. The short-range modes include both the conventional large droplet route and the newly defined short-range airborne transmission. We thus reveal that transmission occurring in close proximity to the source patient includes both droplet-borne (large droplet) and short-range airborne routes, in addition to the direct deposition of large droplets on other body surfaces. The mechanisms of the droplet-borne and short-range airborne routes are different; their effective control methods also differ. Neither the current droplet precautions nor dilution ventilation prevents short-range airborne transmission, so new control methods are needed.