A Case Study Evaluating the Risk of Infection from Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) in a Hospital Setting Through Bioaerosols

Development and evaluation of an intensive short course: the Quantitative Microbial Risk Assessment Interdisciplinary Instructional Institute (QMRA III)

Quantitative microbial risk assessment (QMRA) is a growing interdisciplinary field addressing exposures to microbial pathogens and infectious disease processes. Risk science is inherently interdisciplinary, but few of the contributing disciplinary programs offer courses and training specifically in QMRA. To develop multidisciplinary training in QMRA, an annual 10-day long intensive workshop was conducted from 2015 to 2019-the Quantitative Microbial Risk Assessment Interdisciplinary Instructional Institute (QMRA III). National leaders in the fields of public health, engineering, microbiology, epidemiology, communications, public policy, and QMRA served as instructors and mentors over the course of the program. To provide cross-training, multidisciplinary teams of 5-6 trainees were created from the approximately 30 trainees each year. A formal assessment of the program was performed based on observations and surveys containing Likert-type scales and open-ended prompts. In addition, a longitudinal alumni survey was also disseminated to facilitate the future redevelopment of QMRA institutes and determine the impact of the program. Across all years, trainees experienced statistically significant increases (P < 0.05) in their perceptions of their QMRA abilities (e.g., use of specific computer programs) and knowledge of QMRA constructs (e.g., risk management). In addition, 12 publications, three conference presentations, and two research grants were derived from the QMRA III institute projects or tangential research. The success of QMRA III indicates that a short course format can effectively address many multidisciplinary training needs. Key features of QMRA III, including the inter-disciplinary training approach, hands-on exercises, real-world institute projects, and interaction through a mentoring process, were vital for training multidisciplinary teams housing multiple forms of expertise. Future QMRA institutes are being redeveloped to leverage hybrid learning formats that can further the multidisciplinary training and mentoring objectives.

A COVID-19 cluster analysis in an office: Assessing the long-range aerosol and fomite transmissions with infection control measures

Simulated exposure to severe acute respiratory syndrome coronavirus 2 in the environment was demonstrated based on the actual coronavirus disease 2019 cluster occurrence in an office, with a projected risk considering the likely transmission pathways via aerosols and fomites. A total of 35/85 occupants were infected, with the attack rate in the first stage as 0.30. It was inferred that the aerosol transmission at long-range produced the cluster at virus concentration in the saliva of the infected cases on the basis of the simulation, more than 108 PFU mL-1. Additionally, all wearing masks effectiveness was estimated to be 61%-81% and 88%-95% reduction in risk for long-range aerosol transmission in the normal and fit state of the masks, respectively, and a 99.8% or above decline in risk of fomite transmission. The ventilation effectiveness for long-range aerosol transmission was also calculated to be 12%-29% and 36%-66% reductions with increases from one air change per hour (ACH) to two ACH and six ACH, respectively. Furthermore, the virus concentration reduction in the saliva to 1/3 corresponded to the risk reduction for long-range aerosol transmission by 60%-64% and 40%-51% with and without masks, respectively.

Research gaps and priorities for quantitative microbial risk assessment (QMRA)

The coronavirus disease 2019 pandemic highlighted the need for more rapid and routine application of modeling approaches such as quantitative microbial risk assessment (QMRA) for protecting public health. QMRA is a transdisciplinary science dedicated to understanding, predicting, and mitigating infectious disease risks. To better equip QMRA researchers to inform policy and public health management, an Advances in Research for QMRA workshop was held to synthesize a path forward for QMRA research. We summarize insights from 41 QMRA researchers and experts to clarify the role of QMRA in risk analysis by (1) identifying key research needs, (2) highlighting emerging applications of QMRA; and (3) describing data needs and key scientific efforts to improve the science of QMRA. Key identified research priorities included using molecular tools in QMRA, advancing dose-response methodology, addressing needed exposure assessments, harmonizing environmental monitoring for QMRA, unifying a divide between disease transmission and QMRA models, calibrating and/or validating QMRA models, modeling co-exposures and mixtures, and standardizing practices for incorporating variability and uncertainty throughout the source-to-outcome continuum. Cross-cutting needs identified were to: develop a community of research and practice, integrate QMRA with other scientific approaches, increase QMRA translation and impacts, build communication strategies, and encourage sustainable funding mechanisms. Ultimately, a vision for advancing the science of QMRA is outlined for informing national to global health assessments, controls, and policies.

Applications of Quantitative Microbial Risk Assessment to Respiratory Pathogens and Implications for Uptake in Policy: A State-of-the-Science Review

BACKGROUND

Respiratory tract infections are major contributors to the global disease burden. Quantitative microbial risk assessment (QMRA) holds potential as a rapidly deployable framework to understand respiratory pathogen transmission and inform policy on infection control.

OBJECTIVES

The goal of this paper was to evaluate, motivate, and inform further development of the use of QMRA as a rapid tool to understand the transmission of respiratory pathogens and improve the evidence base for infection control policies.

METHODS

We conducted a literature review to identify peer-reviewed studies of complete QMRA frameworks on aerosol inhalation or contact transmission of respiratory pathogens. From each of the identified studies, we extracted and summarized information on the applied exposure model approaches, dose-response models, and parameter values, including risk characterization. Finally, we reviewed linkages between model outcomes and policy.

RESULTS

We identified 93 studies conducted in 16 different countries with complete QMRA frameworks for diverse respiratory pathogens, including SARS-CoV-2, Legionella spp., Staphylococcus aureus, influenza, and Bacillus anthracis. Six distinct exposure models were identified across diverse and complex transmission pathways. In 57 studies, exposure model frameworks were informed by their ability to model the efficacy of potential interventions. Among interventions, masking, ventilation, social distancing, and other environmental source controls were commonly assessed. Pathogen concentration, aerosol concentration, and partitioning coefficient were influential exposure parameters as identified by sensitivity analysis. Most (84%, n = 78 ) studies presented policy-relevant content including a) determining disease burden to call for policy intervention, b) determining risk-based threshold values for regulations, c) informing intervention and control strategies, and d) making recommendations and suggestions for QMRA application in policy.

CONCLUSIONS

We identified needs to further the development of QMRA frameworks for respiratory pathogens that prioritize appropriate aerosol exposure modeling approaches, consider trade-offs between model validity and complexity, and incorporate research that strengthens confidence in QMRA results. https://doi.org/10.1289/EHP12695.

Concern about the risk of aerosol contamination from ultrasonic scaler: a systematic review and meta-analysis

BACKGROUND

Many instruments used in dentistry are rotary, such as handpieces, water syringes, and ultrasonic scalers that produce aerosols. The spray created by these instruments can carry, in addition to water, droplets of saliva, blood, and microorganisms, which can pose a risk of infections for healthcare professionals and patients. Due to the COVID-19 pandemic, this gained attention.

OBJECTIVE

The aim was to carry out a systematic review of the evidence of the scope of the aerosol produced by ultrasonic scaler in environmental contamination and the influence of the use of intraoral suction reduction devices.

DESIGN

Scientific literature was searched until June 19, 2021 in 6 databases: Pubmed, EMBASE, Web of science, Scopus, Virtual Health Library and Cochrane Library, without restrictions on language or publication date. Studies that evaluated the range of the aerosol produced by ultrasonic scaler during scaling/prophylaxis and the control of environmental contamination generated by it with the use of low (LVE) and high (HVE) volume evacuation systems were included.

RESULTS

Of the 1893 potentially relevant articles, 5 of which were randomized controlled trials (RCTs). The meta-analysis of 3 RCTs showed that, even at different distances from the patient's oral cavity, there was a significant increase in airborne bacteria in the dental environment with the use of ultrasonic scaler. In contrast, when meta-analysis compared the use of HVE with LVE, there was no significant difference (P = 0.40/CI -0.71[-2.37, 0.95]) for aerosol produced in the environment.

CONCLUSIONS

There is an increase in the concentration of bioaerosol in the dental environment during the use of ultrasonic scaler in scaling/prophylaxis, reaching up to 2 m away from the patient's mouth and the use of LVE, HVE or a combination of different devices, can be effective in reducing air contamination in the dental environment, with no important difference between different types of suction devices.

Utilizing sinapic acid as an inhibitory antiviral agent against MERS-CoV PLpro

Concerns about the social and economic collapse, high mortality rates, and stress on the healthcare system are developing due to the coronavirus onslaught in the form of various species and their variants. In the recent past, infections brought on by coronaviruses severe acute respiratory syndrome coronaviruses (SARS-CoV and SARS-CoV-2) as well as middle east respiratory syndrome coronavirus (MERS-CoV) have been reported. There is a severe lack of medications to treat various coronavirus types including MERS-CoV which is hazard to public health due to its ability for pandemic spread by human-to-human transmission. Here, we utilized sinapic acid (SA) against papain-like protease (PLpro), a crucial enzyme involved in MERS-CoV replication, because phytomedicine derived from nature has less well-known negative effects. The thermal shift assay (TSA) was used in the current study to determine whether the drug interact with the recombinant MERS-CoV PLpro. Also, inhibition assay was conducted as the hydrolysis of fluorogenic peptide from the Z-RLRGG-AMC-peptide bond in the presence of SA to determine the level of inhibition of the MERS-CoV PLpro. To study the structural binding efficiency Autodock Vina was used to dock SA to the MERS-CoV PLpro and results were analyzed using PyMOL and Maestro Schrödinger programs. Our results show a convincing interaction between SA and the MERS protease, as SA reduced MERS-CoV PLpro in a dose-dependent way IC50 values of 68.58 μM (of SA). The TSA showed SA raised temperature of melting to 54.61 °C near IC50 and at approximately 2X IC50 concentration (111.5 μM) the Tm for SA + MERS-CoV PLpro was 59.72 °C. SA was docked to MERS-CoV PLpro to identify the binding site. SA bound to the blocking loop (BL2) region of MERS-CoV PLpro interacts with F268, E272, V275, and P249 residues of MERS-CoV PLpro. The effectiveness of protease inhibitors against MERS-CoV has been established and SA is already known for broad range biological activity including antiviral properties; it can be a suitable candidate for anti-MERS-CoV treatment.

Evaluating the threshold limit value of acceptable exposure concentration for exposure to bioaerosols in a wastewater treatment plant: Reverse-quantitative microbial risk assessment and sensitivity analysis

Agitation operations produce numerous pathogenic bioaerosols in WWTPs¹. QMRA² can determine risks of persons exposed to these bioaerosols. However, QMRA framework cannot help stakeholders in immediately deciding whether a risk is intolerable. Thus, evaluating threshold of acceptable exposure concentration is an urgent issue but is still rarely addressed in WWTPs. This study analyzed TLV³ benchmarks of E. coli and S. aureus bioaerosols emitted from a WWTP by reverse-QMRA. Furthermore, variance of input parameters was clarified by sensitivity analysis. Results showed that, under conservative and optimistic estimates, TLV of technicians was 1.52-2.06 and 1.26-1.68 times as large as those of workers, respectively; wearing mask drive TLV up to 1-2 orders of magnitude; TLV of M⁴ was at most 1.33 and 1.31 times as large as that of RD⁵, respectively. For sensitivity analysis, removal fraction by equipping PPE enlarge TLV for effortlessly obtaining an acceptable assessment result; exposure time was dominant when without PPE excepting the scenario of technicians exposed to E. coli bioaerosol. This study helps establish threshold guidelines for bioaerosols in WWTPs and contribute innovative perspectives for stakeholders.

Effectiveness of Using Face Masks and Personal Protective Equipment to Reducing the Spread of COVID-19: A Systematic Review and Meta-Analysis of Case-Control Studies

Recently published researches show that 59% of all transmission came from asymptomatic transmission and at the time of diagnosis health-care workers (HCWs) tend to present without respiratory symptoms. These evidences have raised questions on whether an essential policy for use of personal protective equipment (PPE) is the best approach in HCW and other people or not. Therefore, this study conducted to investigate the effectiveness of using face masks and PPE in reducing the spread of COVID-19 in health-care and non-health-care settings. This systematic review and meta-analysis study was prepared according to the preferred reporting items for systematic review and meta-analysis statement and guided by meta-analysis of observational studies recommendations. Searches in databases were conducted from December 2019 to July 2021. Random-effects meta-analysis was performed to investigate the effect of using face masks and PPE on spread of COVID-19. Heterogeneity among studies was assessed using Cochran's Q test and the I ² metrics. In total, 9920 individuals from 14 studies were included in this study. In all settings, application of PPE or any type of masks was associated with reduction in risk of COVID-19 (odds ratio [OR] = 0.44; 95% confidence interval [CI]: [0.29, 0.65]; I ² = 85.21%). In the HCW subgroup, the protective effect had a combined OR of 0.33 (95% CI: (0.15,0.73), I ² = 82.61%). Six studies were found protective effects of wearing mask in non-HCWs (OR = 0.58, 95% CI: (0.31, 1.06), I ² = 85.63%). Results suggest that there is association between face mask/PPE use and reduction of COVID-19.

SARS-CoV-2 detection in hospital indoor environments, NW Iran

This study aimed to investigate the potential contamination of SARS-CoV-2 in indoor settled dust and surfaces of Amir Al-Muminin hospital in Maragheh, Iran. Samples were taken from surfaces and settled dust using a passive approach and particulate matter (PM) using an active approach from different hospital wards. SARS-CoV-2 was detected in 15% of settled dust samples (N = 4/26) and 10% of surface samples (3/30). SARS-CoV-2 has been detected in 13.8% and 9.1% of the dust samples collected at a distance of fewer than 1 m and more than 3 m from the patient bed, respectively. SARS-CoV-2 was found in 11% of surface samples from low-touch surfaces and 8% from high touch surfaces. The relationship between PM_2.5, PM₁₀, humidity, temperature, and positive samples of SARS-CoV-2 was investigated. A positive correlation was observed between relative humidity, PM_2.5, and positive SARS-CoV-2 samples. Principal component analysis (PCA) suggested positive correlation between positive SARS-CoV-2 samples, relative humidity, and PM_2.5. Risk assessment results indicated that the annual mean infection risk of SARS-CoV-2 for hospital staff with illness and death was 2.6 × 10^-2 and 7.7 × 10^-4 per person per year. Current findings will help reduce the permanence of viral particles in the COVID 19 tragedy and future similar pandemics e.g., novel influenza viruses.

A Review of the Presence of SARS-CoV-2 in Wastewater: Transmission Risks in Mexico

The appearance of SARS-CoV-2 represented a new health threat to humanity and affected millions of people; the transmission of this virus occurs through different routes, and one of them recently under debate in the international community is its possible incorporation and spread by sewage. Therefore, the present work's research objectives are to review the presence of SARS-CoV-2 in wastewater throughout the world and to analyze the coverage of wastewater treatment in Mexico to determine if there is a correlation between the positive cases of COVID-19 and the percentages of treated wastewater in Mexico as well as to investigate the evidence of possible transmission by aerosol sand untreated wastewater. Methodologically, a quick search of scientific literature was performed to identify evidence the presence of SARS-CoV-2 RNA (ribonucleic acid) in wastewater in four international databases. The statistical information of the positive cases of COVID-19 was obtained from data from the Health Secretary of the Mexican Government and the Johns Hopkins Coronavirus Resource Center. The information from the wastewater treatment plants in Mexico was obtained from official information of the National Water Commission of Mexico. The results showed sufficient evidence that SARS-CoV-2 remains alive in municipal wastewater in Mexico. Our analysis indicates that there is a low but significant correlation between the percentage of treated water and positive cases of coronavirus r = -0.385, with IC (95%) = (-0.647, -0.042) and p = 0.030; this result should be taken with caution because wastewater is not a transmission mechanism, but this finding is useful to highlight the need to increase the percentage of treated wastewater and to do it efficiently. In conclusions, the virus is present in untreated wastewater, and the early detection of SAR-CoV-2 could serve as a bioindicator method of the presence of the virus. This could be of great help to establish surveillance measures by zones to take preventive actions, which to date have not been considered by the Mexican health authorities. Unfortunately, wastewater treatment systems in Mexico are very fragile, and coverage is limited to urban areas and non-existent in rural areas. Furthermore, although the probability of contagion is relatively low, it can be a risk for wastewater treatment plant workers and people who are close to them.

Airborne infection risk assessment of COVID-19 in an inpatient department through on-site occupant behavior surveys

Airborne transmission is a possible infection route of the coronavirus disease 2019 (COVID-19). This investigation focuses on the airborne infection risk of COVID-19 in a nursing unit in an inpatient building in Shenzhen, China. On-site measurements and questionnaire surveys were conducted to obtain the air change rates and occupant trajectories, respectively. The aerosol transport and dose–response models were applied to evaluate the infection risk. The average outdoor air change rate measured in the wards was 1.1 h⁻¹, which is below the minimum limit of 2.0 h⁻¹ required by ASHRAE 170–2021. Considering the surveyed occupant behavior during one week, the patients and their attendants spent an average of 19.4 h/d and 15.1 h/d, respectively, in the wards, whereas the nurses primarily worked in the nurse station (3.0 h/d) and wards (2.4 h/d). The doctors primarily worked in their offices (2.6 h/d) and wards (1.1 h/d). Assuming one undetected COVID-19 infector emitting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nursing unit, we calculated the accumulated viral dose and infection probabilities of the occupants. After one week, the cumulative infection risks of the patients and attendants were almost equal (0.002), and were higher than those of the nurses (0.0013) and doctors (0.0004). Proper protection measures, such as reducing the number of attendants, increasing the air change rate, and wearing masks, were found to reduce the infection risk. It should be noted that the reported results are based on several assumptions, such as the speculated virological properties of SARS-CoV-2 and the particular trajectories of occupants. Moreover, only second generations of transmission were taken into consideration, whereas in reality, the week-long exposure may cause third generation of transmission or worse.

COVID-19 and laryngological surgery

In 2019, the emergence of the novel SARS-CoV-2 virus in Wuhan, China transformed society and caused major changes in medical care. Efforts to implement protocols to keep providers and their staffs safe during care of all patients ensued. Within the field of laryngology, the risk of aerosol generation and viral spread was among the highest in medicine. It is important to understand the impact of COVID-19 on presurgical and surgical laryngoscopic care as well as the evolution of knowledge that led to our current practices and protocols.

Decontamination of SARS-CoV-2 from cold-chain food packaging provides no marginal benefit in risk reduction to food workers

Countries continue to debate the need for decontamination of cold-chain food packaging to reduce possible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) fomite transmission among frontline workers. While laboratory-based studies demonstrate persistence of SARS-CoV-2 on surfaces, the likelihood of fomite-mediated transmission under real-life conditions is uncertain. Using a quantitative microbial risk assessment model of a frozen food packaging facility, we simulated 1) SARS-CoV-2 fomite-mediated infection risks following worker exposure to contaminated plastic packaging; and 2) reductions in these risks from masking, handwashing, and vaccination. In a frozen food facility without interventions, SARS-CoV-2 infection risk to a susceptible worker from contact with contaminated packaging was 1.5 × 10-3 per 1h-period (5th - 95th percentile: 9.2 × 10-6, 1.2 × 10-2). Standard food industry infection control interventions, handwashing and masking, reduced risk (99.4%) to 8.5 × 10-6 risk per 1h-period (5th - 95th percentile: 2.8 × 10-8, 6.6 × 10-5). Vaccination of the susceptible worker (two doses Pfizer/Moderna, vaccine effectiveness: 86-99%) with handwashing and masking reduced risk to 5.2 × 10-7 risk per 1h-period (5th - 95th percentile: 1.8 × 10-9, 5.4 × 10-6). Simulating increased transmissibility of current and future variants (Delta, Omicron), (2-, 10-fold viral shedding) among a fully vaccinated workforce, handwashing and masking continued to mitigate risk (1.4 × 10-6 - 8.8 × 10-6 risk per 1h-period). Additional decontamination of frozen food plastic packaging reduced infection risks to 1.2 × 10-8 risk per 1h-period (5th - 95th percentile: 1.9 × 10-11, 9.5 × 10-8). Given that standard infection control interventions reduced risks well below 1 × 10-4 (World Health Organization water quality risk thresholds), additional packaging decontamination suggest no marginal benefit in risk reduction. Consequences of this decontamination may include increased chemical exposures to workers, food quality and hazard risks to consumers, and unnecessary added costs to governments and the global food industry.

Controlling risk of SARS-CoV-2 infection in essential workers of enclosed food manufacturing facilities

The SARS-CoV-2 global pandemic poses significant health risks to workers who are essential to maintaining the food supply chain. Using a quantitative risk assessment model, this study characterized the impact of risk reduction strategies for controlling SARS-CoV-2 transmission (droplet, aerosol, fomite-mediated) among front-line workers in a representative indoor fresh fruit and vegetable manufacturing facility. We simulated: 1) individual and cumulative SARS-CoV-2 infection risks from close contact (droplet and aerosols at 1-3 m), aerosol, and fomite-mediated exposures to a susceptible worker following exposure to an infected worker during an 8 h-shift; and 2) the relative reduction in SARS-CoV-2 infection risk attributed to infection control interventions (physical distancing, mask use, ventilation, surface disinfection, hand hygiene, vaccination). Without mitigation measures, the SARS-CoV-2 infection risk was largest for close contact (droplet and aerosol) at 1 m (0.96, 5th - 95th percentile: 0.67-1.0). In comparison, risk associated with fomite (0.26, 5th - 95th percentile: 0.10-0.56) or aerosol exposure alone (0.05, 5th - 95th percentile: 0.01-0.13) at 1 m distance was substantially lower (73-95%). At 1 m, droplet transmission predominated over aerosol and fomite-mediated transmission, however, this changed by 3 m, with aerosols comprising the majority of the exposure dose. Increasing physical distancing reduced risk by 84% (1-2 m) and 91% (1-3 m). Universal mask use reduced infection risk by 52-88%, depending on mask type. Increasing ventilation (from 0.1 to 2-8 air changes/hour) resulted in risk reductions of 14-54% (1 m) and 55-85% (2 m). Combining these strategies, together with handwashing and surface disinfection, resulted in <1% infection risk. Partial or full vaccination of the susceptible worker resulted in risk reductions of 73-92% (1 m risk range: 0.08-0.26). However, vaccination paired with other interventions (ACH 2, mask use, or distancing) was necessary to achieve infection risks <1%. Current industry SARS-CoV-2 risk reduction strategies, particularly when bundled, provide significant protection to essential food workers.

Contact transmission of SARS-CoV-2 on fomite surfaces: surface survival and risk reduction

There is an unprecedented concern regarding the viral strain SARS-CoV-2 and especially its respiratory disease more commonly known as COVID-19. SARS-CoV-2 virus has the ability to survive on different surfaces for extended periods, ranging from days up to months. The new infectious properties of SARS-CoV-2 vary depending on the properties of fomite surfaces. In this review, we summarize the risk factors involved in the indirect transmission pathways of SARS-CoV-2 strains on fomite surfaces. The main mode of indirect transmission is the contamination of porous and non-porous inanimate surfaces such as textile surfaces that include clothes and most importantly personal protective equipment like personal protective equipment kits, masks, etc. In the second part of the review, we highlight materials and processes that can actively reduce the SARS-CoV-2 surface contamination pattern and the associated transmission routes. The review also focuses on some general methodologies for designing advanced and effective antiviral surfaces by physical and chemical modifications, viral inhibitors, etc.

Effects of face masks and ventilation on the risk of SARS-CoV-2 respiratory transmission in public toilets: a quantitative microbial risk assessment

Public toilets may increase the risk of COVID-19 infection via airborne transmission; however, related research is limited. We aimed to estimate SARS-CoV-2 infection risk through respiratory transmission using a quantitative microbial risk assessment framework by retrieving SARS-CoV-2 concentrations from the swab tests of 251 Thai patients. Three virus-generating scenarios were investigated: an infector breathing, breathing with a cough, and breathing with a sneeze. The infection risk (95th percentile) was as high as 10^-1 with breathing and increased to 1 with a cough or a sneeze. No significant gender differences for toilet users (receptors) were noted. The highest risk scenario, namely breathing with a sneeze, was further evaluated for risk mitigation measures. Mitigation to a lower risk under 10^-3 succeeded only when the infector and the receptor both wore N95 respirators or surgical masks. Ventilation of up to 20 air changes per hour (ACH) did not decrease the risk. However, an extended waiting time of 10 min between an infector and a receptor resulted in approximately 1.0-log₁₀ further risk reduction when both wore masks with the WHO-recommended 12 ACH. The volume of expelled droplets, virus concentrations, and receptor dwell time were identified as the main contributors to transmission risk.

Front lines of the COVID-19 pandemic: what is the effectiveness of using personal protective equipment in health service environments?-a systematic review

PURPOSE

This systematic review aimed to evaluate the effectiveness of the use of personal protective equipment (PPE) in closed environments, similar to waiting or exam rooms of healthcare facilities, in the face of exposure to a bioaerosol.

METHODS

Combinations of words were selected for six electronic databases and for the gray literature. To consider the eligibility of the studies to be included/excluded, the acronym "PECOS" was used: humans and/or experimental models that simulate aerosol (Population); aerosol exposure and the use of masks/respirators (exposition/intervention); controlled or not controlled (comparison); effectiveness of PPE and the receiver exposure (outcomes); and randomized clinical studies or not, observational or laboratory simulation studies (Studies design).

RESULTS

A total of 4820 references were retrieved by the search strategy. Thirty-five articles were selected for complete reading, of which 13 articles were included for qualitative synthesis. A surgical mask or N95 respirator reduced the risk of transmission, even over short distances. The use of masks, even those with less filtering power, when used by all individuals in the same environment is more effective in reducing risk than the use of respirators with high filtering power for only some of the individuals present.

CONCLUSION

The use of mask in closed environments is effective in reducing the risk of transmission and contagion of a contaminated bioaerosol, with greater effectiveness when these devices are used by the source and receiver, regardless of the equipment's filtering power. (PROSPERO 2020 CRD 42020183759).

Bioaerosolization and pathogen transmission in wastewater treatment plants: Microbial composition, emission rate, factors affecting and control measures

Environmental consequences during wastewater management are vital and getting increased attention to interrupt any possible disease transmission pathways. Evidence of bioaerosolization of pathogen from wastewater to atmosphere during wastewater treatment have been highlighted previously. Understanding aerosol-based transmission in wastewater treatment plant (WWTP) is important because of the hazard it presents to the workers involved or to the population around and appears to be very significant during pandemic occurrences. This work aims to evaluate the possibility of pathogenic content of wastewater getting aerosolized during treatment by synthesizing the evidence on the potential aerosol generating treatment phases of WWTP, bioaerosol microbial composition, emission load and the factors affecting the bioaerosol formation. We also present some potential control strategies to take up in WWTP which may be useful to avoid such occurrences. Implementation of Aeration based strategies (use of diffused, submerged aeration, reduction in aeration rate), Improved ventilation based strategies (effective ventilation with adequate supply of clean air, minimizing air recirculation, supplementation with infection control measures such as filtration, irradiation), Improved protection based strategy (periodic monitoring of disinfection efficiency, pathogenic load of wastewater, improved operation policy) and other strategies (provision of buffer zone, wind shielding, water spraying on aerosol, screened surface of treatment units) could be very much relevant and significant in case of disease outbreak through aerosol formation in wastewater environment. Recent progress in sensor-based data collection, analysis, cloud-based storage, and early warning techniques in WWTP may help to reduce the risk of infectious transmission, especially during a pandemic situation.

The impact of heating, ventilation, and air conditioning design features on the transmission of viruses, including the 2019 novel coronavirus: A systematic review of ventilation and coronavirus

Aerosol transmission has been a pathway for the spread of many viruses. Similarly, emerging evidence has determined aerosol transmission for Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) and the resulting COVID-19 pandemic to be significant. As such, data regarding the effect of Heating, Ventilation, and Air Conditioning (HVAC) features to control and mitigate virus transmission is essential. A systematic review was conducted to identify and comprehensively synthesize research examining the effectiveness of ventilation for mitigating transmission of coronaviruses. A comprehensive search was conducted in Ovid MEDLINE, Compendex, Web of Science Core to January 2021. Study selection, data extraction, and risk of bias assessments were performed by two authors. Evidence tables were developed and results were described narratively. Results from 32 relevant studies showed that: increased ventilation rate was associated with decreased transmission, transmission probability/risk, infection probability/risk, droplet persistence, virus concentration, and increased virus removal and virus particle removal efficiency; increased ventilation rate decreased risk at longer exposure times; some ventilation was better than no ventilation; airflow patterns affected transmission; ventilation feature (e.g., supply/exhaust, fans) placement influenced particle distribution. Few studies provided specific quantitative ventilation parameters suggesting a significant gap in current research. Adapting HVAC ventilation systems to mitigate virus transmission is not a one-solution-fits-all approach. Changing ventilation rate or using mixing ventilation is not always the only way to mitigate and control viruses. Practitioners need to consider occupancy, ventilation feature (supply/exhaust and fans) placement, and exposure time in conjunction with both ventilation rates and airflow patterns. Some recommendations based on quantitative data were made for specific scenarios (e.g., using air change rate of 9 h-1 for a hospital ward). Other recommendations included using or increasing ventilation, introducing fresh air, using maximum supply rates, avoiding poorly ventilated spaces, assessing fan placement and potentially increasing ventilation locations, and employing ventilation testing and air balancing checks. Trial registration: PROSPERO 2020 CRD42020193968.

Evaluating the Preparedness of Indian States against COVID-19 Pandemic Risk: A Fuzzy Multi-criteria Decision-Making Approach

The preparedness of Indian states and union territories (UTs) against the COVID-19 pandemic has been evaluated. Ten parameters related to demographic, socioeconomic, and healthcare aspects have been considered and the performances of 27 states and three UTs have been evaluated applying the Fuzzy Analytic Hierarchy Process. Opinions of medical experts have been considered to ascertain the relative importance of decision criteria as well as subcriteria. The scores of various states and UTs in each of the decision subcriteria have been calculated by using the secondary data collected from authentic sources. It is found that Kerala and Bihar are the best prepared and worst prepared states, respectively, to combat COVID-19 pandemic. Karnataka, Goa, and Tamil Nadu have very good preparedness whereas Chhattisgarh, Jharkhand, and Bihar have very poor preparedness. Maharashtra, the most affected state in India, has average preparedness. As around 650 million people are vulnerable due to the poor and very poor preparedness of their states, the country needs to make region specific mitigation strategies to combat the COVID-19 pandemic and the preparedness map will be helpful in that direction.

SARS-CoV-2 ferritin nanoparticle vaccines elicit broad SARS coronavirus immunogenicity

The need for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) next-generation vaccines has been highlighted by the rise of variants of concern (VoCs) and the long-term threat of emerging coronaviruses. Here, we design and characterize four categories of engineered nanoparticle immunogens that recapitulate the structural and antigenic properties of the prefusion SARS-CoV-2 spike (S), S1, and receptor-binding domain (RBD). These immunogens induce robust S binding, ACE2 inhibition, and authentic and pseudovirus neutralizing antibodies against SARS-CoV-2. A spike-ferritin nanoparticle (SpFN) vaccine elicits neutralizing titers (ID50 > 10,000) following a single immunization, whereas RBD-ferritin nanoparticle (RFN) immunogens elicit similar responses after two immunizations and also show durable and potent neutralization against circulating VoCs. Passive transfer of immunoglobulin G (IgG) purified from SpFN- or RFN-immunized mice protects K18-hACE2 transgenic mice from a lethal SARS-CoV-2 challenge. Furthermore, S-domain nanoparticle immunization elicits ACE2-blocking activity and ID50 neutralizing antibody titers >2,000 against SARS-CoV-1, highlighting the broad response elicited by these immunogens.

Expert elicitation on the relative importance of possible SARS-CoV-2 transmission routes and the effectiveness of mitigations

OBJECTIVES

To help people make decisions about the most effective mitigation measures against SARS-CoV-2 transmission in different scenarios, the likelihoods of transmission by different routes need to be quantified to some degree (however uncertain). These likelihoods need to be communicated in an appropriate way to illustrate the relative importance of different routes in different scenarios, the likely effectiveness of different mitigation measures along those routes, and the level of uncertainty in those estimates. In this study, a pragmatic expert elicitation was undertaken to supply the underlying quantitative values to produce such a communication tool.

PARTICIPANTS

Twenty-seven individual experts from five countries and many scientific disciplines provided estimates.

OUTCOME MEASURES

Estimates of transmission parameters, assessments of the quality of the evidence, references to relevant literature, rationales for their estimates and sources of uncertainty.

RESULTS AND CONCLUSION

The participants' responses showed that there is still considerable disagreement among experts about the relative importance of different transmission pathways and the effectiveness of different mitigation measures due to a lack of empirical evidence. Despite these disagreements, when pooled, the majority views on each parameter formed an internally consistent set of estimates (for example, that transmission was more likely indoors than outdoors, and at closer range), which formed the basis of a visualisation to help individuals and organisations understand the factors that influence transmission and the potential benefits of different mitigation measures.

A critical review of heating, ventilation, and air conditioning (HVAC) systems within the context of a global SARS-CoV-2 epidemic

The Coronavirus disease (COVID-19) has spread over the world, resulting in more than 225 million patients, and 4.7 million deaths in September 2021. It also caused panic and terror, halted numerous activities, and resulted in the world economy deteriorates. It altered human behavior and compelled people to alter their lifestyles to avoid infection. Air conditioning systems are one of the most important sectors that must be considered because of the pandemic SARS-CoV-2 all over the world. Air is used as a heat transfer medium in heating, ventilation, and air conditioning (HVAC) systems. The air contains a variety of pollutants, viruses, and bacteria, all of which have an impact on and destroy human life. Significantly in summer, people spend more time in air conditioners which results in lower levels of vitamin D and melatonin which may affect the functioning of their immune system and are susceptible to receiving SARS-CoV-2 from other individuals. As an important component of air conditioning and ventilation systems, the air filter plays a significant role. As a result, researchers must work harder to improve its design to prevent the ultra-small particles loaded with COVID-19. This paper contributes to the design of existing HVAC systems in terms of their suitability and impact on the spread of the hybrid SARS-CoV-2 epidemic, as well as efforts to obtain a highly efficient air filter to remove super-sized particles for protection against epidemic infection. In addition, important guideline recommendations have been extracted to limit the spread of the SARS-CoV-2 throughout the world and to get the highest quality indoor air in air-conditioned places.

Breathing, speaking, coughing or sneezing: What drives transmission of SARS-CoV-2?

The SARS-CoV-2 virus is highly contagious, as demonstrated by numerous well-documented superspreading events. The infection commonly starts in the upper respiratory tract (URT) but can migrate to the lower respiratory tract (LRT) and other organs, often with severe consequences. Whereas LRT infection can lead to shedding of virus via breath and cough droplets, URT infection enables shedding via abundant speech droplets. Their viral load can be high in carriers with mild or no symptoms, an observation linked to the abundance of SARS-CoV-2-susceptible cells in the oral cavity epithelium. Expelled droplets rapidly lose water through evaporation, with the smaller ones transforming into long-lived aerosol. Although the largest speech droplets can carry more virions, they are few in number, fall to the ground rapidly and therefore play a relatively minor role in transmission. Of more concern is small speech aerosol, which can descend deep into the LRT and cause severe disease. However, since their total volume is small, the amount of virus they carry is low. Nevertheless, in closed environments with inadequate ventilation, they can accumulate, which elevates the risk of direct LRT infection. Of most concern is the large fraction of speech aerosol that is intermediate-sized because it remains suspended in air for minutes and can be transported over considerable distances by convective air currents. The abundance of this speech-generated aerosol, combined with its high viral load in pre- and asymptomatic individuals, strongly implicates airborne transmission of SARS-CoV-2 through speech as the primary contributor to its rapid spread.

A Global Overview of SARS-CoV-2 in Wastewater: Detection, Treatment, and Prevention

A novel coronavirus (SARS-CoV-2) causing corona virus disease 2019 (COVID-19) has attracted global attention due to its highly infectious and pathogenic properties. Most of current studies focus on aerosols released from infected individuals, but the presence of SARS-CoV-2 in wastewater also should be examined. In this review, we used bibliometrics to statistically evaluate the importance of water-related issues in the context of COVID-19. The results show that the levels and transmission possibilities of SARS-CoV-2 in wastewater are the main concerns, followed by potential secondary pollution by the intensive use of disinfectants, sludge disposal, and the personal safety of workers. The presence of SARS-CoV-2 in wastewater requires more attention during the COVID-19 pandemic. Thus, the most effective techniques, i.e., wastewater-based epidemiology and quantitative microbial risk assessment, for virus surveillance in wastewater are systematically analyzed. We further explicitly review and analyze the successful operation of a sewage treatment plant in Huoshenshan Hospital in China as an example and reference for other sewage treatment systems to properly ensure discharge safety and tackle the COVID-19 pandemic. This review offers deeper insight into the prevention and control of SARS-CoV-2 and similar viruses in the post-COVID-19 era from a wastewater perspective.

Two-dimensional mathematical framework for evaporation dynamics of respiratory droplets

In majority of pandemics in human history, respiratory bio-aerosol is the most common route of transmission of diseases. These tiny droplets ejected through mouth and nose from an infected person during exhalation process like coughing, sneezing, speaking, and breathing consist of pathogens and a complex mixture of volatile and nonvolatile substances. A cloud of droplets ejected in such an event gets transmitted in the air, causing a series of coupled thermo-physical processes. Contemplating an individual airborne droplet in the cloud, boundary layers and wakes develop due to relative motion between the droplet and the ambient air. The complex phenomenon of the droplet's dynamics, such as shear-driven internal circulation of the liquid phase and Stefan flow due to vaporization or condensation, comes into effect. In this study, we present a mathematical description of the coupled subprocesses, including droplet aerodynamics, heat, and mass transfer, which were identified and subsequently solved. The presented two-dimensional model gives a complete analysis encompassing the gas phase coupled with the liquid phase responsible for the airborne droplet kinetics in the ambient environment. The transient inhomogeneity of temperature and concentration distribution in the liquid phase caused due to the convective and diffusive transports are captured in the 2D model. The evaporation time and distance traveled by droplets prior to nuclei or aerosol formation are computed for major geographical locations around the globe for nominal-windy conditions. The model presented can be used for determining the evaporation timescale of any viral or bacterial laden respiratory droplets across any geographical location.

Critical Capability Needs for Reduction of Transmission of SARS-CoV-2 Indoors

Coordination of efforts to assess the challenges and pain points felt by industries from around the globe working to reduce COVID-19 transmission in the indoor environment as well as innovative solutions applied to meet these challenges is mandatory. Indoor infectious viral disease transmission (such as coronavirus, norovirus, influenza) is a complex problem that needs better integration of our current knowledge and intervention strategies. Critical to providing a reduction in transmission is to map the four core technical areas of environmental microbiology, transmission science, building science, and social science. To that end a three-stage science and innovation Summit was held to gather information on current standards, policies and procedures applied to reduce transmission in built spaces, as well as the technical challenges, science needs, and research priorities. The Summit elucidated steps than can be taken to reduce transmission of SARS-CoV-2 indoors and calls for significant investments in research to enhance our knowledge of viral pathogen persistence and transport in the built environment, risk assessment and mitigation strategy such as processes and procedures to reduce the risk of exposure and infection through building systems operations, biosurveillance capacity, communication form leadership, and stakeholder engagement for optimal response. These findings reflect the effective application of existing knowledge and standards, emerging science, and lessons-learned from current efforts to confront SARS-CoV-2.

Aerosol deposition and airflow dynamics in healthy and asthmatic human airways during inhalation

Inhalation of aerosols such as pharmaceutical aerosols or virus aerosol uptake is of great concern to the human population. To elucidate the underlying aerosol dynamics, the deposition fractions (DFs) of aerosols in healthy and asthmatic human airways of generations 13-15 are predicted. The Navier-stokes equations governing the gaseous phase and the discrete phase model for particles' motion are solved using numerical methods. The main forces responsible for deposition are inertial impaction forces and complex secondary flow velocities. The curvatures and sinusoidal folds in the asthmatic geometry lead to the formation of complex secondary flows and hence higher DFs. The intensities of complex secondary flows are strongest at the generations affected by asthma. The DF in the healthy airways is 0%, and it ranges from 1.69% to 52.93% in the asthmatic ones. From this study, the effects of the pharmaceutical aerosol particle diameters in the treatment of asthma patients can be established, which is conducive to inhibiting the inflammation of asthma airways. Furthermore, with the recent development of COVID-19 which causes pneumonia, the predicted physics and effective simulation methods of bioaerosols delivery to asthma patients are vital to prevent the exacerbation of the chronic ailment and the epidemic.

Indoor Air Quality Strategies for Air-Conditioning and Ventilation Systems with the Spread of the Global Coronavirus (COVID-19) Epidemic: Improvements and Recommendations

The coronavirus has come to the world and spread with great wide among the countries of the world and has resulted in numerous infections that exceeded 167,181,023 million patients and are close to 3.5 deaths by September 2021. It also brought with it panic and fear, halted many activities, and led to the decline of the global economy. It changed human behavior and forced people to change their lifestyles to avoid infection. One of the most sectors that must be taken into consideration through pandemic coronavirus (COVID-19) around the globe is the air conditioning systems. The HVAC systems depend on the air as a heat transfer medium. The air contains a group of pollutants, viruses, and bacteria, and it affects and destroys human life. The air filter plays a major role as an important component in the air conditioning systems. Thus, it requires more effort by researchers to improve its design to prevent the ultra-size of particles loaded with coronavirus (COVID-19). This paper provides insight into the design of existing combined air-conditioners on their suitability and their impact on the spread of the hybrid coronavirus epidemic and review efforts to obtain a highly efficient air filter to get rid of super-sized particles for protection against epidemic infection. In addition, important guideline recommendations have been made to limit the spread of the COVID-19 virus and to obtain indoor air quality in air-conditioned places.

Dose-response Relation Deduced for Coronaviruses From Coronavirus Disease 2019, Severe Acute Respiratory Syndrome, and Middle East Respiratory Syndrome: Meta-analysis Results and its Application for Infection Risk Assessment of Aerosol Transmission

BACKGROUND

A comprehensive understanding of the transmission routes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is of great importance to effectively control the spread of coronavirus disease 2019 (COVID-19). However, the fundamental dose-response relation is missing for evaluation of the infection risk.

METHODS

We developed a simple framework to integrate the a priori dose-response relation for SARS-CoV-2 based on mice experiments, the recent data on infection risk from a meta-analysis, and respiratory virus shedding in exhaled breath to shed light on the dose-response relation for humans. The aerosol transmission infection risk was evaluated based on the dose-response model for a typical indoor environment.

RESULTS

The developed dose-response relation is an exponential function with a constant k in the range of about 6.4 × 104 to 9.8 × 105 virus copies, which means that the infection risk caused by 1 virus copy in viral shedding is on the order of 10-6 to 10-5. The median infection risk via aerosol transmission with 1-hour exposure (10-6 to 10-4) was significantly lower than the risk caused by close contact (10-1) in a room with an area of 10 to 400 m2 with 1 infected individual in it and with a typical ventilation rate of 1 air change per hour.

CONCLUSIONS

The infection risk caused by aerosol transmission was significantly lower than the risk caused by close contact. It is still necessary to be cautious for the potential aerosol transmission risk in small rooms with prolonged exposure duration.

Numerical Modeling of Face Shield Protection against a Sneeze

The protection provided by wearing masks has been a guideline worldwide to prevent the risk of COVID-19 infection. The current work presents an investigation that analyzes the effectiveness of face shields as personal protective equipment. To that end, a multiphase computational fluid dynamic study based on Eulerian–Lagrangian techniques was defined to simulate the spread of the droplets produced by a sneeze. Different scenarios were evaluated where the relative humidity, ambient temperature, evaporation, mass transfer, break up, and turbulent dispersion were taken into account. The saliva that the human body generates was modeled as a saline solution of 8.8 g per 100 mL. In addition, the influence of the wind speed was studied with a soft breeze of 7 km/h and a moderate wind of 14 km/h. The results indicate that the face shield does not provide accurate protection, because only the person who is sneezed on is protected. Moreover, with a wind of 14 km/h, none of the droplets exhaled into the environment hit the face shield, instead, they were deposited onto the neck and face of the wearer. In the presence of an airflow, the droplets exhaled into the environment exceeded the safe distance marked by the WHO. Relative humidity and ambient temperature play an important role in the lifetime of the droplets.

COVID-19 crisis and minimally invasive surgery: a narrative review on intraoperative aerosol viral transmission and their impact on guidelines and clinical practice in Austria

PURPOSE OF REVIEW

The purpose of this review is to evaluate the risk of intraoperative aerosol viral transmission and the impact of updated COVID-19 guidelines on minimally invasive surgery (MIS) in Austria.

RECENT FINDINGS

The current literature does not support the risk of intraoperative viral transmission nor does it suggest a harm of minimally invasive procedures in the context of the COVID-19 pandemic. However, medical societies mostly adopted a precautionary approach with a focus on protective measures. Austrian surgeons considered MIS safe during the pandemic and Austria managed to keep the initial outbreak in control. Yet, MIS programs were still affected due to the postponements of elective procedures and switches to other methods by some surgeons.

SUMMARY

The postponement and cancellation of MIS caused complexities in health-care delivery in Austria, whilst the evidence to substantiate this precautionary approach is missing. It must be noted, both the guidelines and our review are limited by the scarcity of evidence. In further consequence, regional factors should be considered while taking precautions. Specific studies on the severe acute respiratory syndrome coronavirus type 2 transmission risk during MIS are urgently needed.

Does airborne pollen influence COVID-19 outbreak?

The fast spread of SARS-CoV-2 presented a worldwide challenge to public health, economy, and educational system, affecting wellbeing of human society. With high transmission rates, there are increasing evidences of COVID-19 spread via bioaerosols from an infected person. The current review was conducted to examine airborne pollen impact on COVID-19 transmission and to identify the major gaps for post-pandemic research. The study used all key terms to identify revenant literature and observation were collated for the current research. Based on existing literature, there is a potential association between pollen bioaerosols and COVID-19. There are few studies focusing the impact of airborne pollen on SARS-CoV-2, which could be useful to advance future research. Allergic rhinitis and asthma patients were found to have pre-modified immune activation, which could help to provide protection against COVID-19. However, does airborne pollen acts as a potent carrier for SARS-CoV-2 transport, dispersal and its proliferation still require multidisciplinary research. Further, a clear conclusion cannot be drawn due to limited evidence and hence more research is needed to show how pollen bioaerosols could affect virus survivals. The small but growing literature review focuses on searching for every possible answer to provide additional security layers to overcome near future corona-like infectious diseases.

Modeling of aerosol transmission of airborne pathogens in ICU rooms of COVID-19 patients with acute respiratory failure

The COVID-19 pandemic has generated many concerns about cross-contamination risks, particularly in hospital settings and Intensive Care Units (ICU). Virus-laden aerosols produced by infected patients can propagate throughout ventilated rooms and put medical personnel entering them at risk. Experimental results found with a schlieren optical method have shown that the air flows generated by a cough and normal breathing were modified by the oxygenation technique used, especially when using High Flow Nasal Canulae, increasing the shedding of potentially infectious airborne particles. This study also uses a 3D Computational Fluid Dynamics model based on a Lattice Boltzmann Method to simulate the air flows as well as the movement of numerous airborne particles produced by a patient's cough within an ICU room under negative pressure. The effects of different mitigation scenarii on the amount of aerosols potentially containing SARS-CoV-2 that are extracted through the ventilation system are investigated. Numerical results indicate that adequate bed orientation and additional air treatment unit positioning can increase by 40% the number of particles extracted and decrease by 25% the amount of particles deposited on surfaces 45s after shedding. This approach could help lay the grounds for a more comprehensive way to tackle contamination risks in hospitals, as the model can be seen as a proof of concept and be adapted to any room configuration.

Controlling risk of SARS-CoV-2 infection in essential workers of enclosed food manufacturing facilities

The SARS-CoV-2 global pandemic poses significant health risks to workers who are essential to maintaining the food supply chain. Using a quantitative risk assessment model, this study characterized the impact of risk reduction strategies for controlling SARS-CoV-2 transmission (droplet, aerosol, fomite-mediated) among front-line workers in a representative enclosed food manufacturing facility. We simulated: 1) individual and cumulative SARS-CoV-2 infection risks from close contact (droplet and aerosols at 1-3m), aerosol, and fomite-mediated exposures to a susceptible worker following exposure to an infected worker during an 8h-shift; and 2) the relative reduction in SARS-CoV-2 infection risk attributed to infection control interventions (physical distancing, mask use, ventilation, surface disinfection, hand hygiene). Without mitigation measures, the SARS-CoV-2 infection risk was largest for close contact (droplet and aerosol) at 1m (0.96, 95%CI: 0.67-1.0). In comparison, risk associated with fomite (0.26, 95%CI: 0.10-0.56) or aerosol exposure alone (0.05, 95%CI: 0.01-0.13) at 1m distance was substantially lower (73-95%). At 1m, droplet transmission predominated over aerosol and fomite-mediated transmission, however, this changed by 3m, with aerosols comprising the majority of the exposure dose. Increasing physical distancing reduced risk by 84% (1 to 2m) and 91% (1 to 3m). Universal mask use reduced infection risk by 52-88%, depending on mask type. Increasing ventilation (from 0.1 to 2-8 air changes/hour) resulted in risk reductions of 14-54% (1m) and 55-85% (2m). Combining these strategies, together with handwashing and surface disinfection, resulted in <1% infection risk. Current industry SARS-CoV-2 risk reduction strategies, particularly when bundled, provide significant protection to essential food workers.

SIGNIFICANCE STATEMENT

Using mathematical modeling, we find that workers in enclosed food manufacturing facilities are at higher risk of SARS-CoV-2 infection from close contact transmission (exposure to large droplets and small aerosol particles) than fomite transmission. Thus, strategies protecting workers should prioritize close contact transmission pathways, such as physical distancing, universal mask use, and room air changes, with surface disinfection (reducing fomite transmission) and handwashing of secondary importance. Our work supports current international (EU-OSHA), domestic (FDA, OSHA), and food industry-standard guidance for managing COVID-19 transmission in essential workers in the food manufacturing sector. Although our model was designed for an indoor food manufacturing setting, it can be readily adapted to other indoor environments and infectious respiratory pathogens.

Global Systemic Risk and Resilience for Novel Coronavirus and COVID-19

This Special Issue is dedicated to issues and challenges related to pandemic risk and resilience, with a focus on policy and operations of global systems in the COVID-19 pandemic. The cascading effects of emerging and reemerging infectious diseases to the global economy are a critical interest. Measures to confront the ongoing pandemic are an urgent need. Data analysis at regional and global scales is helping to prioritize response and resilience across locations of high risks. The risk sciences are available for addressing human health and infection risks; the evaluation of risk management strategies and tradeoffs; risk perception as it relates to information processing and receiving risk communication; and tracking system resilience as it relates to various imposed measures.

Aerosol-generating behaviours in speech pathology clinical practice: A systematic literature review

OBJECTIVE

To evaluate the evidence of aerosol generation across tasks involved in voice and speech assessment and intervention, to inform better management and to reduce transmission risk of such diseases as COVID-19 in healthcare settings and the wider community.

DESIGN

Systematic literature review.

DATA SOURCES AND ELIGIBILITY

Medline, Embase, Scopus, Web of Science, CINAHL, PubMed Central and grey literature through ProQuest, The Centre for Evidence-Based Medicine, COVID-Evidence and speech pathology national bodies were searched up until August 13th, 2020 for articles examining the aerosol-generating activities in clinical voice and speech assessment and intervention within speech pathology.

RESULTS

Of the 8288 results found, 39 studies were included for data extraction and analysis. Included articles were classified into one of three categories: research studies, review articles or clinical guidelines. Data extraction followed appropriate protocols depending on the classification of each article (e.g. PRISMA for review articles). Articles were assessed for risk of bias and certainty of evidence using the GRADE system. Six behaviours were identified as aerosol generating. These were classified into three categories: vegetative acts (coughing, breathing), verbal communication activities of daily living (speaking, loud voicing), and performance-based tasks (singing, sustained phonation). Certainty of evidence ranged from very low to moderate with variation in research design and variables.

CONCLUSIONS

This body of literature helped to both identify and categorise the aerosol-generating behaviours involved in speech pathology clinical practice and confirm the low level of evidence throughout the speech pathology literature pertaining to aerosol generation. As many aerosol-generating behaviours are common human behaviours, these findings can be applied across healthcare and community settings.

SYSTEMATIC REVIEW REGISTRATION

Registration number CRD42020186902 with PROSPERO International Prospective Register for Systematic Reviews.

Infection Risk Assessment of COVID-19 through Aerosol Transmission: a Case Study of South China Seafood Market

The Corona Virus Disease 2019 (COVID-19) is rapidly spreading throughout the world. Aerosol is a potential transmission route. We conducted the quantitative microbial risk assessment (QMRA) to evaluate the aerosol transmission risk by using the South China Seafood Market as an example. The key processes were integrated, including viral shedding, dispersion, deposition in air, biologic decay, lung deposition, and the infection risk based on the dose-response model. The available hospital bed for COVID-19 treatment per capita (1.17 × 10-3) in Wuhan was adopted as a reference for manageable risk. The median risk of a customer to acquire SARS-CoV-2 infection via the aerosol route after 1 h of exposure in the market with one infected shopkeeper was about 2.23 × 10-5 (95% confidence interval: 1.90 × 10-6 to 2.34 × 10-4). The upper bound could increase and become close to the manageable risk with multiple infected shopkeepers. More detailed risk assessment should be conducted in poorly ventilated markets with multiple infected cases. The uncertainties were mainly due to the limited information on the dose-response relation and the viral shedding which need further studies. The risk rapidly decreased outside the market due to the dilution by ambient air and became below 10-6 at 5 m away from the exit.

Quantitative Microbial Risk Assessment for Airborne Transmission of SARS-CoV-2 via Breathing, Speaking, Singing, Coughing, and Sneezing

BACKGROUND

Evidence for indoor airborne transmission of SARS-CoV-2 is accumulating.

OBJECTIVES

We assessed of the risk of illness due to airborne SARS-CoV-2 particles from breathing, speaking, singing, coughing, and sneezing in indoor environments.

METHODS

A risk assessment model, AirCoV2, for exposure to SARS-CoV-2 particles in aerosol droplets was developed. Previously published data on droplets expelled by breathing, speaking, singing, coughing, and sneezing by an infected person were used as inputs. Scenarios encompassed virus concentration, exposure time, and ventilation. Newly collected data of virus RNA copies in mucus from patients are presented.

RESULTS

The expelled volume of aerosols was highest for a sneeze, followed by a cough, singing, speaking, and breathing. After 20 min of exposure, at 107 RNA copies/mL in mucus, all mean illness risks were largely estimated to be below 0.001, except for the "high" sneeze scenario. At virus concentrations above 108 RNA copies/mL, and after 2 h of exposure, in the high and "low" sneeze scenarios, the high cough scenario and the singing scenario, risks exceeded 0.01 and may become very high, whereas the low coughing scenario, the high and low speaking scenarios and the breathing scenario remained below 0.1. After 2 h of exposure, singing became the second highest risk scenario. One air exchange per hour reduced risk of illness by about a factor of 2. Six air exchanges per hour reduced risks of illness by a factor of 8-13 for the sneeze and cough scenarios and by a factor of 4-9 for the other scenarios.

DISCUSSION

The large variation in the volume of expelled aerosols is discussed. The model calculations indicated that SARS-CoV-2 transmission via aerosols outside of the 1.5-m social distancing norm can occur. Virus concentrations in aerosols and/or the amount of expelled aerosol droplets need to be high for substantial transmission via this route. AirCoV2 is made available as interactive computational tool. https://doi.org/10.1289/EHP7886.

Quantitative Microbial Risk Assessment for Airborne Transmission of SARS-CoV-2 via Breathing, Speaking, Singing, Coughing, and Sneezing

BACKGROUND

Evidence for indoor airborne transmission of SARS-CoV-2 is accumulating.

OBJECTIVES

We assessed of the risk of illness due to airborne SARS-CoV-2 particles from breathing, speaking, singing, coughing, and sneezing in indoor environments.

METHODS

A risk assessment model, AirCoV2, for exposure to SARS-CoV-2 particles in aerosol droplets was developed. Previously published data on droplets expelled by breathing, speaking, singing, coughing, and sneezing by an infected person were used as inputs. Scenarios encompassed virus concentration, exposure time, and ventilation. Newly collected data of virus RNA copies in mucus from patients are presented.

RESULTS

The expelled volume of aerosols was highest for a sneeze, followed by a cough, singing, speaking, and breathing. After 20 min of exposure, at 107 RNA copies/mL in mucus, all mean illness risks were largely estimated to be below 0.001, except for the "high" sneeze scenario. At virus concentrations above 108 RNA copies/mL, and after 2 h of exposure, in the high and "low" sneeze scenarios, the high cough scenario and the singing scenario, risks exceeded 0.01 and may become very high, whereas the low coughing scenario, the high and low speaking scenarios and the breathing scenario remained below 0.1. After 2 h of exposure, singing became the second highest risk scenario. One air exchange per hour reduced risk of illness by about a factor of 2. Six air exchanges per hour reduced risks of illness by a factor of 8-13 for the sneeze and cough scenarios and by a factor of 4-9 for the other scenarios.

DISCUSSION

The large variation in the volume of expelled aerosols is discussed. The model calculations indicated that SARS-CoV-2 transmission via aerosols outside of the 1.5-m social distancing norm can occur. Virus concentrations in aerosols and/or the amount of expelled aerosol droplets need to be high for substantial transmission via this route. AirCoV2 is made available as interactive computational tool. https://doi.org/10.1289/EHP7886.

A review of the COVID-19 pandemic and its interaction with environmental media

Viruses are biologically active parasites that only exist inside a host they are submicroscopic level. The novel coronavirus disease, or COVID-19, is generally caused by the SARS-CoV-2 virus and is comparable to severe acute respiratory syndrome (SARS). As a result of globalization, natural alterations or changes in the SARS-CoV-2 have created significant risks to human health over time. These viruses can live and survive in different ways in the atmosphere unless they reach another host body. At this stage, we will discuss the details of the transmission and detection of this deadly SARS-CoV-2 virus via certain environmental media, such as the atmosphere, water, air, sewage water, soil, temperature, relative humidity, and bioaerosol, to better understand the diffusion, survival, infection potential and diagnosis of COVID-19.

Community Transmission of SARS-CoV-2 by Surfaces: Risks and Risk Reduction Strategies

SARS-CoV-2, the virus responsible for the COVID-19 pandemic, is perceived to be primarily transmitted via person-to-person contact through droplets produced while talking, coughing, and sneezing. Transmission may also occur through other routes, including contaminated surfaces; nevertheless, the role that surfaces have on the spread of the disease remains contested. Here, we use the Quantitative Microbial Risk Assessment framework to examine the risks of community transmission of SARS-CoV-2 through surfaces and to evaluate the effectiveness of hand and surface disinfection as potential interventions. Using conservative assumptions on input parameters of the model (e.g., dose-response relationship, ratio of genome copies to infective virus), the average of the median risks for single hand-to-surface contact followed by hand-to-face contact range from 1.6 × 10-4 to 5.6 × 10-9 for modeled prevalence rates of 0.2%-5%. For observed prevalence rates (0.2%, 1%), this corresponds to a low risk of infection (<10-6). Hand disinfection substantially reduces risks of transmission independently of the disease's prevalence and contact frequency. In contrast, the effectiveness of surface disinfection is highly dependent on the prevalence and the frequency of contacts. The work supports the current perception that contaminated surfaces are not a primary mode of transmission of SARS-CoV-2 and affirms the benefits of making hand disinfectants widely available.

COVID-19 and Dentistry in 72 Questions: An Overview of the Literature

The outbreak of Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has significantly affected the dental care sector. Dental professionals are at high risk of being infected, and therefore transmitting SARS-CoV-2, due to the nature of their profession, with close proximity to the patient's oropharyngeal and nasal regions and the use of aerosol-generating procedures. The aim of this article is to provide an update on different issues regarding SARS-CoV-2 and COVID-19 that may be relevant for dentists. Members of the French National College of Oral Biology Lecturers ("Collège National des EnseignantS en Biologie Orale"; CNESBO-COVID19 Task Force) answered seventy-two questions related to various topics, including epidemiology, virology, immunology, diagnosis and testing, SARS-CoV-2 transmission and oral cavity, COVID-19 clinical presentation, current treatment options, vaccine strategies, as well as infection prevention and control in dental practice. The questions were selected based on their relevance for dental practitioners. Authors independently extracted and gathered scientific data related to COVID-19, SARS-CoV-2 and the specific topics using scientific databases. With this review, the dental practitioners will have a general overview of the COVID-19 pandemic and its impact on their practice.

Transmission routes, preventive measures and control strategies of SARS-CoV-2 in the food factory

SARS-CoV-2 virus represents a health threat in food factories. This infectious virus is transmitted by direct contact and indirectly via airborne route, whereas contamination through inanimate objects/surfaces/equipment is uncertain. To limit the potential spread of the pathogen in the food industry, close working between individuals should be avoided and both personal and respiratory hygiene activities should be enforced. Despite the high infectivity, SARS-CoV-2, being an enveloped virus with a fragile lipid envelop, is sensitive to biocidal products and sanitizers commonly used in the food factory. In the context of the building design, interventions that promote healthy air quality should be adopted, especially in food areas with high-occupancy rates for prolonged times, to help minimize the potential exposure to airborne SARS-CoV-2. Air ventilation and filtration provided by heating, ventilation and air conditioning systems, are effective and easy-to-organize tools to reduce the risk of transmission through the air. In addition to conventional sanitation protocols, aerosolization of hydrogen peroxide, UV-C irradiation or in-situ ozone generation are complementary techniques for an effective virucidal treatment of the air.

Diagnostic Salivary Tests for SARS-CoV-2

The diagnosis of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection relies on the detection of viral RNA by real-time reverse transcription polymerase chain reaction (rRT-PCR) performed with respiratory specimens, especially nasopharyngeal swabs. However, this procedure requires specialized medical personnel, centralized laboratory facilities, and time to provide results (from several hours up to 1 d). In addition, there is a non-negligible risk of viral transmission for the operator who performs the procedure. For these reasons, several studies have suggested the use of other body fluids, including saliva, for the detection of SARS-CoV-2. The use of saliva as a diagnostic specimen has numerous advantages: it is easily self-collected by the patient with almost no discomfort, it does not require specialized health care personnel for its management, and it reduces the risks for the operator. In the past few months, several scientific papers, media, and companies have announced the development of new salivary tests to detect SARS-CoV-2 infection. Posterior oropharyngeal saliva should be distinguished from oral saliva, since the former is a part of respiratory secretions, while the latter is produced by the salivary glands, which are outside the respiratory tract. Saliva can be analyzed through standard (rRT-PCR) or rapid molecular biology tests (direct rRT-PCR without extraction), although, in a hospital setting, these procedures may be performed only in addition to nasopharyngeal swabs to minimize the incidence of false-negative results. Conversely, the promising role of saliva in the diagnosis of SARS-CoV-2 infection is highlighted by the emergence of point-of-care technologies and, most important, point-of-need devices. Indeed, these devices can be directly used in workplaces, airports, schools, cinemas, and shopping centers. An example is the recently described Rapid Salivary Test, an antigen test based on the lateral flow assay, which detects the presence of the virus by identifying the spike protein in the saliva within a few minutes.

Assessing the risk of COVID-19 from multiple pathways of exposure to SARS-CoV-2: Modeling in health-care settings and effectiveness of nonpharmaceutical interventions

We assessed the risk of COVID-19 infection in a healthcare worker (HCW) from multiple pathways of exposure to SARS-CoV-2 in a health-care setting of short distance of 0.6 m between the HCW and a patient while caring, and evaluated the effectiveness of a face mask and a face shield using a model that combined previous infection-risk models. The multiple pathways of exposure included hand contact via contaminated surfaces and an HCW's fingers with droplets, droplet spray, and inhalation of inspirable and respirable particles. We assumed a scenario of medium contact time (MCT) and long contact time (LCT) over 1 day of care by an HCW. SARS-CoV-2 in the particles emitted by coughing, breathing, and vocalization (only in the LCT scenario) by the patient were considered. The contribution of the risk of infection of an HCW by SARS-CoV-2 from each pathway to the sum of the risks from all pathways depended on virus concentration in the saliva of the patient. At a virus concentration in the saliva of 101-105 PFU mL-1 concentration in the MCT scenario and 101-104 PFU mL-1 concentration in the LCT scenario, droplet spraying was the major pathway (60%-86%) of infection, followed by hand contact via contaminated surfaces (9%-32%). At a high virus concentration in the saliva (106-108 PFU mL-1 in the MCT scenario and 105-108 PFU mL-1 in the LCT scenario), hand contact via contaminated surfaces was the main contributor (41%-83%) to infection. The contribution of inhalation of inspirable particles was 4%-10% in all assumed cases. The contribution of inhalation of respirable particles increased as the virus concentration in the saliva increased, and reached 5%-27% at the high saliva concentration (107 and 108 PFU mL-1) in the assumed scenarios using higher dose-response function parameter (0.246) and comparable to other pathways, although these were worst and rare cases. Regarding the effectiveness of nonpharmaceutical interventions, the relative risk (RR) of an overall risk for an HCW with an intervention vs. an HCW without intervention was 0.36-0.37, 0.02-0.03, and <4.0 × 10-4 for a face mask, a face shield, and a face mask plus shield, respectively, in the likely median virus concentration in the saliva (102-104 PFU mL-1), suggesting that personal protective equipment decreased the infection risk by 63%->99.9%. In addition, the RR for a face mask worn by the patient, and a face mask worn by the patient plus increase of air change rate from 2 h-1 to 6 h-1 was <1.0 × 10-4 and <5.0 × 10-5, respectively in the same virus concentration in the saliva. Therefore, by modeling multiple pathways of exposure, the contribution of the infection risk from each pathway and the effectiveness of nonpharmaceutical interventions for COVID-19 were indicated quantitatively, and the importance of the use of a face mask and shield was confirmed.

Enriched Aerosol-to-Hydrosol Transfer for Rapid and Continuous Monitoring of Bioaerosols

Bioaerosols, including infectious diseases such as COVID-19, are a continuous threat to global public safety. Despite their importance, the development of a practical, real-time means of monitoring bioaerosols has remained elusive. Here, we present a novel, simple, and highly efficient means of obtaining enriched bioaerosol samples. Aerosols are collected into a thin and stable liquid film by the unique interaction of a superhydrophilic surface and a continuous two-phase centrifugal flow. We demonstrate that this method can provide a concentration enhancement ratio of ∼2.4 × 10⁶ with a collection efficiency of ∼99.9% and an aerosol-into-liquid transfer rate of ∼95.9% at 500 nm particle size (smaller than a single bacterium). This transfer is effective in both laboratory and external ambient environments. The system has a low limit of detection of <50 CFU/m³_air using a straightforward bioluminescence-based technique and shows significant potential for air monitoring in occupational and public-health applications.

Airborne transmission of COVID-19 and the role of face mask to prevent it: a systematic review and meta-analysis

BACKGROUND AND AIMS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), belonging to the Coronaviridae family, is agent of 2019 novel coronavirus disease (COVID-19). COVID-19 emerged in Wuhan, Hubei province of China, in early December 2019 and is now considered a pandemic. This study aimed to investigate the airborne transmission of COVID-19 and the role of face mask to prevent it.

METHODS

A systematic search for English-language literature was done via PUBMED/Medline and Google Scholar up to October 2020. There was two search strategy; for airborne transmission and the role of face mask for prevention of SARS-CoV-2 infection. Based on a fixed and random effects model, the RR and 95% CI were used to evaluate the combined risk. This meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guidelines.

RESULTS

After eligibility assessment, four articles with a total of 7688 participants were included in this meta-analysis. The result of this meta-analysis has shown significant reduction in infection with face mask use; the pooled RR (95%CI) was 0.12 [0.06, 0.27] (P < 0.001).

CONCLUSION

In conclusion, this meta-analysis suggests that there is association between face mask use and reduction of COVID-19. However, COVID-19 spreads primarily with contact routes and respiratory droplets, but its transmissibility has many mysteries yet and there is controversy about airborne transmission of COVID-19.

Cough-independent production of viable Mycobacterium tuberculosis in bioaerosol

BACKGROUND

Symptoms of infectious respiratory illnesses are often assumed to drive transmission. However, production and release of Mycobacterium tuberculosis (Mtb) bioaerosols is poorly understood. We report quantitation of Mtb exhaled during specific respiratory manoeuvres.

METHODS

Direct capture of nascent bioaerosol particles and indirect collection of aged particles was performed in 10 healthy subjects. Indirect and direct capture of exhaled viable Mtb bacilli was compared in 38 PTB patients and directly captured viable Mtb during cough and bronchiole-burst manoeuvres in 27 of the PTB patients.

RESULTS

Direct sampling of healthy subjects captured larger bioaerosol volumes with higher proportions of 2-5 μm particles than indirect sampling. Indirect sampling identified viable Mtb in 92.1% (35 of 38) of PTB patients during 60-min relaxed breathing, median bacillary count 7.5 (IQR: 3.25-19). Direct sampling for 10-min identified Mtb in 97.4% (37 of 38) of PTB patients with higher bacilli counts (p < 0.001), median 24.5 (IQR:11.25-37.5). A short 5-min sampling regimen of 10 coughs or 10 bronchiole-burst manoeuvres yielded a median of 11 (IQR: 4-17) and 11 (IQR: 7-17.5) Mtb bacilli, respectively (p = 0.53).

CONCLUSIONS

Peripheral lung bioaerosol released through deep exhalations alone contained viable Mtb suggesting non-cough transmission is possible in PTB.

Thermodynamic equilibrium dose-response models for MERS-CoV infection reveal a potential protective role of human lung mucus but not for SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Middle East respiratory syndrome coronavirus (MERS-CoV) infect the human respiratory tract. A prototype thermodynamic equilibrium model is presented here for the probability of the virions getting through the mucus barrier and infecting epithelial cells based on the binding affinity (Kmucin) of the virions to mucin molecules in the mucus and parameters for binding and infection of the epithelial cell. Both MERS-CoV and SARS-CoV-2 bind strongly to their cellular receptors, DDP4 and ACE2, respectively, and infect very efficiently both bronchus and lung ex vivo cell cultures which are not protected by a mucus barrier. According to the model, mucin binding could reduce the infectivity for MERS-CoV compared to SARS-CoV-2 by at least 100-fold depending on the magnitude of Kmucin. Specifically Kmucin values up to 106 M-1 have little protective effect and thus the mucus barrier would not remove SARS-CoV-2 which does not bind to sialic acids (SA) and hence would have a very low Kmucin. Depending on the viability of individual virions, the ID50 for SARS-CoV-2 is estimated to be ~500 virions (viral RNA genomic copies) representing 1 to 2 pfu. In contrast MERS-CoV binds both SA and human mucin and a Kmucin of 5 × 109 M-1 as reported for lectins would mop up 99.83% of the virus according to the model with the ID50 for MERS-CoV estimated to be ~295,000 virions (viral RNA genomic copies) representing 819 pfu. This could in part explain why MERS-CoV is poorly transmitted from human to human compared to SARS-CoV-2. Some coronaviruses use an esterase to escape the mucin, although MERS-CoV does not. Instead, it is shown here that "clustering" of virions into single aerosol particles as recently reported for rotavirus in extracellular vesicles could provide a co-operative mechanism whereby MERS-CoV could theoretically overcome the mucin barrier locally and a small proportion of 10 μm diameter aerosol particles could contain ~70 virions based on reported maximum levels in saliva. Although recent evidence suggests SARS-CoV-2 initiates infection in the nasal epithelium, the thermodynamic equilibrium models presented here could complement published approaches for modelling the physical entry of pathogens to the lung based on the fate and transport of the pathogen particles (as for anthrax spores) to develop a dose-response model for aerosol exposure to respiratory viruses. This would enable the infectivity through aerosols to be defined based on molecular parameters as well as physical parameters. The role of the spike proteins of MERS-CoV and SARS-CoV-2 binding to SA and heparan sulphate, respectively, may be to aid non-specific attachment to the host cell. It is proposed that a high Kmucin is the cost for subsequent binding of MERS-CoV to SAs on the cell surface to partially overcome the unfavourable entropy of immobilisation as the virus adopts the correct orientation for spike protein interactions with its protein cellular receptor DPP4.