Long distance airborne transmission of SARS-CoV-2: rapid systematic review

Daphne Duval, Jennifer C Palmer, Isobel Tudge, Nicola Pearce-Smith, Emer O’connell, Allan Bennett, Rachel Clark

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Objectives: To evaluate the potential for long distance airborne transmission of SARS-CoV-2 in indoor community settings and to investigate factors that might influence transmission. Design: Rapid systematic review and narrative synthesis. Data sources: Medline, Embase, medRxiv, Arxiv, and WHO COVID-19 Research Database for studies published from 27 July 2020 to 19 January 2022; existing relevant rapid systematic review for studies published from 1 January 2020 to 27 July 2020; and citation analysis in Web of Science and Cocites. Eligibility criteria for study selection: Observational studies reporting on transmission events in indoor community (non-healthcare) settings in which long distance airborne transmission of SARS-CoV-2 was the most likely route. Studies such as those of household transmission where the main transmission route was likely to be close contact or fomite transmission were excluded. Data extraction and synthesis: Data extraction was done by one reviewer and independently checked by a second reviewer. Primary outcomes were SARS-CoV-2 infections through long distance airborne transmission (>2 m) and any modifying factors. Methodological quality of included studies was rated using the quality criteria checklist, and certainty of primary outcomes was determined using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Narrative synthesis was themed by setting. Results: 22 reports relating to 18 studies were identified (methodological quality was high in three, medium in five, and low in 10); all the studies were outbreak investigations. Long distance airborne transmission was likely to have occurred for some or all transmission events in 16 studies and was unclear in two studies (GRADE: very low certainty). In the 16 studies, one or more factors plausibly increased the likelihood of long distance airborne transmission, particularly insufficient air replacement (very low certainty), directional air flow (very low certainty), and activities associated with increased emission of aerosols, such as singing or speaking loudly (very low certainty). In 13 studies, the primary cases were reported as being asymptomatic, presymptomatic, or around symptom onset at the time of transmission. Although some of the included studies were well conducted outbreak investigations, they remain at risk of bias owing to study design and do not always provide the level of detail needed to fully assess transmission routes. Conclusion: This rapid systematic review found evidence suggesting that long distance airborne transmission of SARS-CoV-2 might occur in indoor settings such as restaurants, workplaces, and venues for choirs, and identified factors such as insufficient air replacement that probably contributed to transmission. These results strengthen the need for mitigation measures in indoor settings, particularly the use of adequate ventilation.

Original languageEnglish
Article numbere068743
Pages (from-to)e068743
JournalBritish Medical Journal
Publication statusPublished - 29 Jun 2022

Bibliographical note

Funding Information: JCP is supported by a British Heart Foundation accelerator award (AA/18/7/34219) and works in a unit that is supported by the University of Bristol and UK Medical Research Council (MC_UU_00011/6) and was also supported by a secondment to the COVID-19 Rapid Evidence Service.

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; AB reports grant funding from UK Research and Innovation (UKRI) and from PROTECT (National Core Study on Transmission and the Environment); no other relationships or activities that could appear to have influenced the submitted work.

Open Access: This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Publisher Copyright: Copyright © 2022, BMJ Publishing Group Ltd.

Citation: Duval D, Palmer J C, Tudge I, Pearce-Smith N, O'Connell E, Bennett A et al. Long distance airborne transmission of SARS-CoV-2: rapid systematic review BMJ 2022; 377 :e068743


Publisher Copyright:
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.


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