PERSPECTIVES

Cite as: K. A. Prather et al., Science

10.1126/science.abc6197 (2020).

Reducing transmission of SARS-CoV-2

Kimberly A. Prather1, Chia C. Wang,2,3 Robert T. Schooley4
1Scripps Institution ofOceanography, University of California San Diego, La Jolla, CA 92037, USA. 2Department of Chemistry, National Sun Yat-sen University, Kaohsiung,
Taiwan 804, Republic of China. 3Aerosol Science Research Center, National Sun Yat-Sen University, Kaohsiung, Taiwan 804, Republic of China. 4Department of Medicine,
Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, La Jolla, CA 92093, USA. Email: kprather@ucsd.edu

Masks and testing are necessary to combat asymptomatic spread in aerosols and droplets

Respiratory infections occur through the transmission of the patient has transmitted the virus without knowing.
virus-containing droplets (>5 to 10 μm) and aerosols (≤5 Identifying infected individuals to curb SARS-CoV-2
μm) exhaled from infected individuals during breathing, transmission is more challenging compared to SARS and
speaking, coughing, and sneezing. Traditional respiratory other respiratory viruses because infected individuals can be
disease control measures are designed to reduce transmis- highly contagious for several days, peaking on or before

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sion by droplets produced in the sneezes and coughs of in- symptoms occur (2, 7). These “silent shedders” could be crit-
fected individuals. However, a large proportion of the ical drivers of the enhanced spread of SARS-CoV-2. In Wu-
spread of coronavirus disease 2019 (COVID-19) appears to han, China, it has been estimated that undiagnosed cases of
be occurring through airborne transmission of aerosols pro- COVID-19 infection, who were presumably asymptomatic,
duced by asymptomatic individuals during breathing and were responsible for up to 79% of viral infections (3). There-
speaking (1–3). Aerosols can accumulate, remain infectious fore, regular, widespread testing is essential to identify and
in indoor air for hours, and be easily inhaled deep into the isolate infected asymptomatic individuals.
lungs. For society to resume, measures designed to reduce Airborne transmission was determined to play a role
aerosol transmission must be implemented, including uni- during the SARS outbreak in 2003 (1, 4). However, many
versal masking and regular, widespread testing to identify countries have not yet acknowledged airborne transmission
and isolate infected asymptomatic individuals. as a possible pathway for SARS-CoV-2 (1). Recent studies
Humans produce respiratory droplets ranging from 0.1 have shown that in addition to droplets, SARS-CoV-2 may
to 1000 μm. A competition between droplet size, inertia, also be transmitted through aerosols. A study in hospitals in
gravity, and evaporation determines how far emitted drop- Wuhan, China, found SARS-CoV-2 in aerosols further than 6
lets and aerosols will travel in air (4, 5). Respiratory droplets ft from patients with higher concentrations detected in
will undergo gravitational settling faster than they evapo- more crowded areas (8). Estimates using an average sputum
rate, contaminating surfaces and leading to contact trans- viral load for SARS-CoV-2 indicate that 1 min of loud speak-
mission. Smaller aerosols (≤5 μm) will evaporate faster than ing could generate >1000 virion-containing aerosols (9).
they can settle, are buoyant, and thus can be affected by air Assuming viral titers for infected super-emitters (with 100-
currents, which can transport them over longer distances. fold higher viral load than average) yields an increase to
Thus, there are two major respiratory virus transmission more than 100,000 virions in emitted droplets per minute of
pathways: contact (direct or indirect between people and speaking.
with contaminated surfaces) and airborne inhalation. The World Health Organization (WHO) recommenda-
In addition to contributing to the extent of dispersal and tions for social distancing of 6 ft and hand washing to re-
mode of transmission, respiratory droplet size has been duce the spread of SARS-CoV-2 are based on studies of
shown to affect the severity of disease. For example, influen- respiratory droplets carried out in the 1930s. These studies
za virus is more commonly contained in aerosols with sizes showed that large, ~100 μm droplets produced in coughs
below 1 μm (submicron), which lead to more severe infec- and sneezes quickly underwent gravitational settling (1).
tion (4). In the case of severe acute respiratory syndrome However, when these studies were conducted, the technolo-
coronavirus 2 (SARS-CoV-2), it is possible that submicron gy did not exist for detecting submicron aerosols. As a com-
virus-containing aerosols are being transferred deep into parison, calculations predict that in still air, a 100-μm
the alveolar region of the lungs, where immune responses droplet will settle to the ground from 8 ft in 4.6 s whereas a
seem to be temporarily bypassed. SARS-CoV-2 has been 1-μm aerosol particle will take 12.4 hours (4). Measurements
shown to replicate three times faster than SARS-CoV-1 and now show that intense coughs and sneezes that propel larg-
thus can rapidly spread to the pharynx from which it can be er droplets more than 20 ft can also create thousands of
shed before the innate immune response becomes activated aerosols that can travel even further (1). Increasing evidence
and produces symptoms (6). By the time symptoms occur, for SARS-CoV-2 suggests the 6 ft WHO recommendation is

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likely not enough under many indoor conditions where aer- tinuously undermine the effectiveness of even the most vig-
osols can remain airborne for hours, accumulate over time, orous testing, tracing, and social distancing programs. After
and follow air flows over distances further than 6 ft (5, 10). evidence revealed that airborne transmission by asympto-
In outdoor environments, numerous factors will deter- matic individuals might be a key driver in the global spread
mine the concentrations and distance traveled, and whether of COVID-19, the WHO recommended universal use of face
respiratory viruses remain infectious in aerosols. Breezes masks. Masks provide a critical barrier, reducing the num-
and winds often occur and can transport infectious droplets ber of infectious viruses in exhaled breath, especially of
and aerosols long distances. Asymptomatic individuals who asymptomatic people and those with mild symptoms (12)
are speaking while exercising can release infectious aerosols (see the figure). Surgical mask material reduces the likeli-
that can be picked up by air streams (10). Viral concentra- hood and severity of COVID-19 by substantially reducing
tions will be more rapidly diluted outdoors, but few studies airborne viral concentrations (13). Masks also protect unin-
have been carried out on outdoor transmission of SARS- fected individuals from SARS-CoV-2 aerosols (12, 13). Thus,
CoV-2. Additionally, SARS-CoV-2 can be inactivated by ul- it is particularly important to wear masks in locations with
traviolet radiation in sunlight, and it is likely sensitive to conditions that can accumulate high concentrations of vi-
ambient temperature and relative humidity, as well as the ruses, such as health care settings, airplanes, restaurants,

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presence of atmospheric aerosols that occur in highly pol- and other crowded places with reduced ventilation. The
luted areas. Viruses can attach to other particles such as aerosol filtering efficiency of different materials, thickness-
dust and pollution, which can modify the aerodynamic es, and layers used in properly fitted homemade masks was
characteristics and increase dispersion. Moreover, people recently found to be similar to that of the medical masks
living in areas with higher concentrations of air pollution that were tested (14). Thus, the option of universal masking
have been shown to have higher severity of COVID-19 (11). is no longer held back by shortages.
Because respiratory viruses can remain airborne for pro- From epidemiological data, countries that have been
longed periods before being inhaled by a potential host, most effective in reducing the spread of COVID-19 have im-
studies are needed to characterize the factors leading to loss plemented universal masking, including Taiwan, Hong
of infectivity over time in a variety of outdoor environments Kong, Singapore, and South Korea. In the battle against
over a range of conditions COVID-19, Taiwan (population 24 million, first COVID-19
Given how little is known about the production and air- case 21 January 2020) did not implement a lockdown during
borne behavior of infectious respiratory droplets, it is diffi- the pandemic, yet maintained a low incidence of 441 cases
cult to define a safe distance for social distancing. Assuming and 7 deaths (as of 21 May 2020). By contrast, the state of
SARS-CoV-2 virions are contained in submicron aerosols, as New York (population ~20 million, first COVID case 1
is the case for influenza virus, a good comparison is exhaled March 2020), had a higher number of cases (353,000) and
cigarette smoke, which also contains submicron particles deaths (24,000). By quickly activating its epidemic response
and will likely follow comparable flows and dilution pat- plan that was established after the SARS outbreak, the Tai-
terns. The distance from a smoker at which one smells ciga- wanese government enacted a set of proactive measures that
rette smoke indicates the distance in those surroundings at successfully prevented the spread of SARS-CoV-2, including
which one could inhale infectious aerosols. In an enclosed setting up a central epidemic command center in January,
room with asymptomatic individuals, infectious aerosol using technologies to detect and track infected patients and
concentrations can increase over time. Overall, the probabil- their close contacts, and perhaps most importantly, request-
ity of becoming infected indoors will depend on the total ing people to wear masks in public places. The government
amount of SARS-CoV-2 inhaled. Ultimately, the amount of also ensured the availability of medical masks by banning
ventilation, number of people, how long one visits an indoor mask manufacturers from exporting them, implementing a
facility, and activities that affect air flow will all modulate system to ensure that every citizen could acquire masks at
viral transmission pathways and exposure (10). For these reasonable prices, and increasing the production of masks.
reasons, it is important to wear properly fitted masks in- In other countries, there have been widespread shortages of
doors even when 6 ft apart. Airborne transmission could masks, resulting in most residents not having access to any
account, in part, for the high secondary transmission rates form of medical mask (15). This striking difference in the
to medical staff, as well as major outbreaks in nursing facili- availability and widespread adoption of wearing masks like-
ties. The minimum dose of SARS-CoV-2 that leads to infec- ly influenced the low number of COVID-19 cases.
tion is unknown, but airborne transmission through Aerosol transmission of viruses must be acknowledged
aerosols has been documented for other respiratory viruses as a key factor leading to the spread of infectious respiratory
including measles, SARS, and chickenpox (4). diseases. Evidence suggests that SARS-CoV-2 is silently
Airborne spread from undiagnosed infections will con- spreading in aerosols exhaled by highly contagious infected

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individuals with no symptoms. Owing to their smaller size,
aerosols may lead to higher severity of COVID-19 because
virus-containing aerosols penetrate more deeply into the
lungs (10). It is essential that control measures be intro-
duced to reduce aerosol transmission. A multidisciplinary
approach is needed to address a wide range of factors that
lead to the production and airborne transmission of respira-
tory viruses, including the minimum virus titer required to
cause COVID-19; viral load emitted as a function of droplet
size before, during, and after infection; viability of the virus
indoors and outdoors; mechanisms of transmission; air-
borne concentrations; and spatial patterns. More studies of
the filtering efficiency of different types of masks are also
needed. COVID-19 has inspired research that is already lead-
ing to a better understanding of the importance of airborne

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transmission of respiratory disease.
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ACKNOWLEDGMENTS
The authors thank S. Strathdee, D. Petras, and L. Marr for helpful discussions. K.A.P.
is supported by the NSF Center for Aerosol Impacts on Chemistry of the
Environment (CHE1801971). R.T.S. is supported by the National Institute of
Allergy and Infectious Diseases (R01 AI131424). C.C.W. is supported by the
Ministry of Science and Technology (MOST 108-2113-M-110-003) and the Higher
Education Sprout Project of the Ministry of Education, Taiwan, ROC.

Published online 27 May 2020

10.1126/science.abc6197

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Reducing transmission of SARS-CoV-2
Kimberly A. Prather, Chia C. Wang and Robert T. Schooley

published online May 27, 2020

ARTICLE TOOLS http://science.sciencemag.org/content/early/2020/05/27/science.abc6197

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REFERENCES This article cites 15 articles, 1 of which you can access for free
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