We identified seasonal human coronaviruses, influenza viruses and rhinoviruses in exhaled breath and coughs of children and adults with acute respiratory illness. Surgical face masks significantly reduced detection of influenza virus RNA in respiratory droplets and coronavirus RNA in aerosols, with a trend toward reduced detection of coronavirus RNA in respiratory droplets. Our results indicate that surgical face masks could prevent transmission of human coronaviruses and influenza viruses from symptomatic individuals.Respiratory virus infections cause a broad and overlapping spectrum of symptoms collectively referred to as acute respiratory virus illnesses (ARIs) or more commonly the 'common cold' . Although mostly mild, these ARIs can sometimes cause severe disease and death 1 . These viruses spread between humans through direct or indirect contact, respiratory droplets (including larger droplets that fall rapidly near the source as well as coarse aerosols with aerodynamic diameter >5 µm) and fine-particle aerosols (droplets and droplet nuclei with aerodynamic diameter ≤5 µm) 2,3 . Although hand hygiene and use of face masks, primarily targeting contact and respiratory droplet transmission, have been suggested as important mitigation strategies against influenza virus transmission 4 , little is known about the relative importance of these modes in the transmission of other common respiratory viruses 2,3,5 . Uncertainties similarly apply to the modes of transmission of 7 ).Some health authorities recommend that masks be worn by ill individuals to prevent onward transmission (source control) 4,8 . Surgical face masks were originally introduced to protect patients from wound infection and contamination from surgeons (the wearer) during surgical procedures, and were later adopted to protect healthcare workers against acquiring infection from their patients. However, most of the existing evidence on the filtering efficacy of face masks and respirators comes from in vitro experiments with nonbiological particles 9,10 , which may not be generalizable to infectious respiratory virus droplets. There is little information on the efficacy of face masks in filtering respiratory viruses and reducing viral release from an individual with respiratory infections 8 , and most research has focused on influenza 11,12 .Here we aimed to explore the importance of respiratory droplet and aerosol routes of transmission with a particular focus on coronaviruses, influenza viruses and rhinoviruses, by quantifying the amount of respiratory virus in exhaled breath of participants with medically attended ARIs and determining the potential efficacy of surgical face masks to prevent respiratory virus transmission.

A new expiratory droplet investigation system (EDIS) was used to conduct the most comprehensive program of study to date, of the dilution corrected droplet size distributions produced during different respiratory activities. Distinct physiological processes were responsible for specific size distribution modes. The majority of particles for all activities were produced in one or more modes, with diameters below 0.8 m at average concentrations up to 0.75 cm −3 . These particles occurred at varying concentrations, during all respiratory activities, including normal breathing. A second mode at 1.8 m was produced during all activities, but at lower concentrations of up to 0.14 cm −3 . Speech produced additional particles in modes near 3.5 and 5 m. These two modes became most pronounced during sustained vocalization, producing average concentrations of 0.04 and 0.16 cm −3 , respectively, suggesting that the aerosolization of secretions lubricating the vocal chords is a major source of droplets in terms of number. For the entire size range examined of 0.3-20 m, average particle number concentrations produced during exhalation ranged from 0.1 cm −3 for breathing to 1.1 cm −3 for sustained vocalization. Non-equilibrium droplet evaporation was not detectable for particles between 0.5 and 20 m, implying that evaporation to the equilibrium droplet size occurred within 0.8 s.

Our study reveals that for respiratory exhalation flows, the sizes of the largest droplets that would totally evaporate before falling 2 m away are between 60 and 100 microm, and these expelled large droplets are carried more than 6 m away by exhaled air at a velocity of 50 m/s (sneezing), more than 2 m away at a velocity of 10 m/s (coughing) and less than 1 m away at a velocity of 1 m/s (breathing). These findings are useful for developing effective engineering control methods for infectious diseases, and also for exploring the basic transmission mechanisms of the infectious diseases. There is a need to examine the air distribution systems in hospital wards for controlling both airborne and droplet-borne transmitted diseases.

Airborne spread of the virus appears to explain this large community outbreak of SARS, and future efforts at prevention and control must take into consideration the potential for airborne spread of this virus.

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Size distributions of expiratory droplets expelled during coughing and speaking and the velocities of the expiration air jets of healthy volunteers were measured. Droplet size was measured using the interferometric Mie imaging (IMI) technique while the particle image velocimetry (PIV) technique was used for measuring air velocity. These techniques allowed measurements in close proximity to the mouth and avoided air sampling losses. The average expiration air velocity was 11.7 m/s for coughing and 3.9 m/s for speaking. Under the experimental setting, evaporation and condensation effects had negligible impact on the measured droplet size. The geometric mean diameter of droplets from coughing was 13.5 m and it was 16.0 m for speaking (counting 1-100). The estimated total number of droplets expelled ranged from 947 to 2085 per cough and 112-6720 for speaking. The estimated droplet concentrations for coughing ranged from 2.4 to 5.2 cm −3 per cough and 0.004-0.223 cm −3 for speaking.

Although short-range large-droplet transmission is possible for most respiratory infectious agents, deciding on whether the same agent is also airborne has a potentially huge impact on the types (and costs) of infection control interventions that are required.The concept and definition of aerosols is also discussed, as is the concept of large droplet transmission, and airborne transmission which is meant by most authors to be synonymous with aerosol transmission, although some use the term to mean either large droplet or aerosol transmission.However, these terms are often used confusingly when discussing specific infection control interventions for individual pathogens that are accepted to be mostly transmitted by the airborne (aerosol) route (e.g. tuberculosis, measles and chickenpox). It is therefore important to clarify such terminology, where a particular intervention, like the type of personal protective equipment (PPE) to be used, is deemed adequate to intervene for this potential mode of transmission, i.e. at an N95 rather than surgical mask level requirement.With this in mind, this review considers the commonly used term of ‘aerosol transmission’ in the context of some infectious agents that are well-recognized to be transmissible via the airborne route. It also discusses other agents, like influenza virus, where the potential for airborne transmission is much more dependent on various host, viral and environmental factors, and where its potential for aerosol transmission may be underestimated.

There are few studies describing the presence of respiratory viruses in respiratory droplets and aerosols in the exhaled breath of infected persons, and the efficacy of facemasks as a source control to prevent respiratory virus transmission. Here, we recruited children and adults with acute respiratory illness and collected respiratory droplets and aerosols, with and without surgical facemasks. We identified human coronaviruses, influenza virus and rhinovirus from both respiratory droplets and aerosols. Surgical face masks reduced detection of coronavirus RNA in both respiratory droplets and aerosols, but only respiratory droplets and not aerosols for influenza virus RNA. Our results provide mechanistic evidence that surgical facemasks could prevent transmission of human coronavirus and influenza virus infections if worn by symptomatic individuals.Authors Donald K Milton and Benjamin J Cowling are joint senior authors.