Long distance airborne transmission of SARS-CoV-2: rapid systematic review
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Abstract
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. Systematic review registration: PROSPERO CRD42021236762.
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For new healthcare interventions, systematic reviews and randomised controlled trials may be unavailable, as no RCTs were available for covid-19 early in the pandemic but emerged later.
“Importantly, systematic reviews and randomised controlled trials may not be available for new healthcare interventions-for example, no randomised controlled trials were available on covid-19 during the early era of the pandemic but emerged as the pandemic evolved.36”
From Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness (2024) · cites this paper as [36]
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- Authors
- Duval, D., Palmer, J. C., Tudge, I., Pearce-Smith, N., O’Connell, E., Bennett, A., & Clark, R.
- Affiliations
- University of Bristol (GB)
- UK Health Security Agency (GB)
- COVID-19 Rapid Evidence Service, UK Health Security Agency, London, UK
- COVID-19 Advice and Guidance, UK Health Security Agency, London, UK
- Corresponding author
- Duval, Daphne
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2022-06-29
- Volume
- 377
- Pages
- e068743
- ISSN
- 1756-1833 (ISSN-L)
- PMC
- PMC9240778
- OpenAlex
- W4283720276
- Cited by
- 120
- References
- 71
- Citations by year
- 2026: 6 · 2025: 22 · 2024: 41 · 2023: 37 · 2022: 14
- FWCI
- 4.93
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- BMJ (publishedVersion, cc-by-nc)
- medRxiv (acceptedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Explore Bristol Research (submittedVersion, cc-by-nc)
- Bristol Research (University of Bristol) (submittedVersion, cc-by-nc)
- Funders
- British Heart Foundation (AA/18/7/34219)
- University of Bristol (MC_UU_00011/6)
- Medical Research Council (MC_UU_00011/6, COVID-19, MC_UU_00011)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Infection Control and Ventilation
- Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
- Physical Sciences › Environmental Science › Global and Planetary Change › COVID-19 impact on air quality
- Keywords
- SARS-CoV-2, airborne transmission, long-distance transmission, aerosols, airflow direction, asymptomatic transmission, pre-symptomatic transmission, transmission risk factors, outbreak investigation, COVID-19 pandemic, restaurants, workplace, choir, singing, loud speech, ventilation, indoor air quality, public health recommendations
- MeSH terms
- COVID-19, SARS-CoV-2, Aerosols, Disease Outbreaks, Humans
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