Scientists to WHO: Virus is airborne

Agency unconvinced of spread through tiny particles lingering in air

The coronavirus is finding new victims worldwide, in bars and restaurants, offices, markets and casinos, giving rise to frightening clusters of infection that increasingly confirm what many scientists have been saying for months: The virus lingers in the air indoors, infecting those nearby.

If airborne transmission is a significant factor in the pandemic, especially in crowded spaces with poor ventilation, the consequences for containment will be significant. Masks may be needed indoors, even in socially distant settings. Health care workers may need N95 masks that filter out even the smallest respiratory droplets as they care for coronavirus patients.

Ventilation systems in schools, nursing homes, residences and businesses may need to minimize recirculating air and add powerful new filters. Ultraviolet lights may be needed to kill viral particles floating in tiny droplets indoors.

The World Health Organization has long held that the coronavirus is spread primarily by large respiratory droplets that, once expelled by infected people in coughs and sneezes, fall quickly to the floor.

But in an open letter to the WHO, 239 scientists in 32 countries have outlined the evidence showing that smaller particles can infect people and are calling for the agency to revise its recommendations.

Even in its latest update on the coronavirus, released June 29, the WHO said airborne transmission of the virus is possible only after medical procedures that produce aerosols, or droplets smaller than 5 microns. (A micron is equal to 1 millionth of a meter.)

Proper ventilation and N95 masks are of concern only in those circumstances, according to the WHO. Instead, its infection control guidance, before and during this pandemic, has heavily promoted the importance of handwashing as a primary prevention strategy, even though there is limited evidence for transmission of the virus from surfaces. (The Centers for Disease Control and Prevention now says surfaces are likely to play only a minor role.)

Dr. Benedetta Allegranzi, the WHO’s technical lead on infection control, said the evidence for the virus spreading by air was unconvincing.

“Especially in the last couple of months, we have been stating several times that we consider airborne transmission as possible but certainly not supported by sol

id or even clear evidence,” she said. “There is a strong debate on this.”

But interviews with nearly 20 scientists — including a dozen WHO consultants and several members of the committee that crafted the guidance — and internal emails paint a picture of an organization that, despite good intentions, is out of step with science.

Whether carried aloft by large droplets that zoom through the air after a sneeze, or by much smaller exhaled droplets that may glide the length of a room, these experts said, the coronavirus is borne through air and can infect people when inhaled.

Most of these experts sympathized with the WHO’s growing portfolio and shrinking budget, and noted the tricky political relationships it has to manage, especially with the United States and China.

But the infection prevention and control committee in particular, experts said, is bound by a rigid and overly medicalized view of scientific evidence, is slow and riskaverse in updating its guidance and allows a few conservative voices to shout down dissent.

“They’ll die defending their view,” said one longstanding WHO consultant, who did not wish to be identified because of her continuing work for the organization. Even its staunchest supporters said the committee should diversify its expertise and relax its criteria for proof, especially in a fast-moving outbreak.

Advice unchanged

In early April, a group of 36 experts on air quality and aerosols urged the WHO to consider the growing evidence on airborne transmission of the coronavirus. The agency responded promptly, calling Lidia Morawska, the group’s leader and a longtime WHO consultant, to arrange a meeting.

But the discussion was dominated by a few experts who were staunch supporters of handwashing and felt it must be emphasized over aerosols, according to some participants, and the committee’s advice remained unchanged.

Morawska and others pointed to several incidents that indicate airborne transmission of the virus, particularly in poorly ventilated and crowded indoor spaces. They said the WHO was making an artificial distinction between tiny aerosols and larger droplets, even though infected people produce both.

“We’ve known since 1946 that coughing and talking generate aerosols,” said Linsey Marr, an expert in airborne transmission of viruses at Virginia Tech.

The WHO also is relying on a dated definition of airborne transmission, Marr said. The agency believes an airborne pathogen, such as the measles virus, has to be highly infectious and to travel long distances.

People generally “think and talk about airborne transmission profoundly stupidly,” said Bill Hanage, an epidemiologist at the

Harvard T.H. Chan School of Public Health.

“We have this notion that airborne transmission means droplets hanging in the air capable of infecting you many hours later, drifting down streets, through letter boxes and finding their way into homes everywhere,” Hanage said.

Experts all agree that the coronavirus does not behave that way. Marr and others said the coronavirus seemed to be most infectious when people were in prolonged contact at close range, especially indoors, and even more so in superspreader events — exactly what scientists would expect from aerosol transmission.

Precautionary principle

Many experts said the WHO should embrace what some called a “precautionary principle” and others called “needs and values” — the idea that even without definitive evidence, the agency should assume the worst of the virus, apply common sense and recommend the best protection possible.

“There is no incontrovertible proof that SARSCoV-2 travels or is transmitted significantly by aerosols, but there is absolutely no evidence that it’s not,” said Dr. Trish Greenhalgh, a primary care doctor at the University of Oxford in Britain.

The agency also must consider the needs of all its member nations, including those with limited resources, and make sure its recommendations are tempered by “availability, feasibility, compliance, resource implications,” she said.

Aerosols may play some limited role in spreading the virus, said Dr. Paul Hunter, a member of the infection prevention committee and professor of medicine at the University of East Anglia in Britain.

But if the WHO were to push for rigorous control measures in the absence of proof, hospitals in low- and middle-income countries may be forced to divert scarce resources from other crucial programs.

In interviews, other scientists criticized this view as paternalistic. “‘We’re not going to say what we really think, because we think you can’t deal with it?’ I don’t think that’s right,” said Don Milton, an aerosol expert at the University of Maryland.

Even cloth masks, if worn by everyone, can significantly reduce transmission, and the WHO should say so clearly, he added.