Surface contamination and fleeting encounters are less of a worry than close-up, person-to-person interactions for extended periods

It’s not common to contract Covid-19 from a contaminated surface, scientists say. And fleeting encounters with people outdoors are unlikely to spread the coronavirus.

Instead, the major culprit is close-up, person-to-person interactions for extended periods. Crowded events, poorly ventilated areas and places where people are talking loudly—or singing, in one famous case—maximize the risk.

These emerging findings are helping businesses and governments devise reopening strategies to protect public health while getting economies going again. That includes tactics like installing plexiglass barriers, requiring people to wear masks in stores and other venues, using good ventilation systems and keeping windows open when possible.

Two recent large studies showed that wide-scale lockdowns—stay-at-home orders, bans on large gatherings and business closures—prevented millions of infections and deaths around the world. Now, with more knowledge in hand, cities and states can deploy targeted interventions to keep the virus from taking off again, scientists and public-health experts said.

That means better protections for nursing-home residents and multigenerational families living in crowded conditions, they said. It also means stressing physical distancing and masks, and reducing the number of gatherings in enclosed spaces.

“We should not be thinking of a lockdown, but of ways to increase physical distance,” said Tom Frieden, chief executive of Resolve to Save Lives, a nonprofit public-health initiative. “This can include allowing outside activities, allowing walking or cycling to an office with people all physically distant, curbside pickup from stores, and other innovative methods that can facilitate resumption of economic activity without a rekindling of the outbreak.”

The group’s reopening recommendations include widespread testing, contact tracing and isolation of people who are infected or exposed.

The virus has to make its way into your respiratory tract and use the ACE-2 receptors there to enter cells and replicate.

Health agencies have so far identified respiratory-droplet contact as the major mode of Covid-19 transmission. These large fluid droplets can transfer virus from one person to another if they land on the eyes, nose or mouth. But they tend to fall to the ground or on other surfaces pretty quickly.

Some researchers say the new coronavirus can also be transmitted through aerosols, or minuscule droplets that float in the air longer than large droplets. These aerosols can be directly inhaled.

That’s what may have happened at a restaurant in Guangzhou, China, where an infected diner who was not yet ill transmitted the virus to five others sitting at adjacent tables. Ventilation in the space was poor, with exhaust fans turned off, according to one study looking at conditions in the restaurant.

Aerosolized virus from the patient’s breathing or speaking could have built up in the air over time and strong airflow from an air-conditioning unit on the wall may have helped recirculate the particles in the air, according to authors of the study, which hasn’t yet been peer-reviewed.

Sufficient ventilation in the places people visit and work is very important, said Yuguo Li, one of the authors and an engineering professor at the University of Hong Kong. Proper ventilation—such as forcing air toward the ceiling and pumping it outside, or bringing fresh air into a room—dilutes the amount of virus in a space, lowering the risk of infection.

Superspreaders
At a March 10 church choir practice in Washington state, 87% of attendees were infected, said Lea Hamner, an epidemiologist with the Skagit County public-health department and lead author of a study on an investigation that warned about the potential for “superspreader” events, in which one or a small number of people infect many others.

Members of the choir changed places four times during the 2½-hour practice, were tightly packed in a confined space and were mostly older and therefore more vulnerable to illness, she said. All told, 53 of 61 attendees at the practice were infected, including at least one person who had symptoms. Two died.

Several factors conspired, Ms. Hamner said. When singing, people can emit many large and small respiratory particles. Singers also breathe deeply, increasing the chance they will inhale infectious particles.

Similar transmission dynamics could be at play in other settings where heavy breathing and loud talking are common over extended periods, like gyms, musical or theater performances, conferences, weddings and birthday parties. Of 61 clusters of cases in Japan between Jan. 15 and April 4, many involved heavy breathing in close proximity, such as karaoke parties, cheering at clubs, talking in bars and exercising in gyms, according to a recent study in the journal Emerging Infectious Diseases.

The so-called attack rate—the percentage of people who were infected in a specific place or time—can be very high in crowded events, homes and other spaces where lots of people are in close, prolonged contact.

An estimated 10% of people with Covid-19 are responsible for about 80% of transmissions, according to a study published recently in Wellcome Open Research. Some people with the virus may have a higher viral load, or produce more droplets when they breathe or speak, or be in a confined space with many people and bad ventilation when they’re at their most infectious point in their illness, said Jamie Lloyd-Smith, a University of California, Los Angeles professor who studies the ecology of infectious diseases.

But overall, “the risk of a given infected person transmitting to people is pretty low,” said Scott Dowell, a deputy director overseeing the Bill & Melinda Gates Foundation’s Covid-19 response. “For every superspreading event you have a lot of times when nobody gets infected.”

The attack rate for Covid-19 in households ranges between 4.6% and 19.3%, according to several studies. It was higher for spouses, at 27.8%, than for other household members, at 17.3%, in one study in China.

Rosanna Diaz lives in a three-bedroom apartment in New York City with five other family members. The 37-year-old stay-at-home mother was hospitalized with a stroke on April 18 that her doctors attributed to Covid-19, and was still coughing when she went home two days later.

She pushed to get home quickly, she said, because her 4-year-old son has autism and needed her. She kept her distance from family members, covered her mouth when coughing and washed her hands frequently. No one else in the apartment has fallen ill, she said. “Nobody went near me when I was sick,” she said.

Being outside is generally safer, experts say, because viral particles dilute more quickly. But small and large droplets pose a risk even outdoors, when people are in close, prolonged contact, said Linsey Marr, a Virginia Tech environmental engineering professor who studies airborne transmission of viruses.

No one knows for sure how much virus it takes for someone to become infected, but recent studies offer some clues. In one small study published recently in the journal Nature, researchers were unable to culture live coronavirus if a patient’s throat swab or milliliter of sputum contained less than one million copies of viral RNA.

Air travel is full of opportunities for coronavirus transmission. Touchless check-in, plexiglass shields, temperature checks, back-to-front boarding and planes with empty middle seats are all now part of the flying experience, and the future may bring even more changes. Illustration: Alex Kuzoian
“Based on our experiment, I would assume that something above that number would be required for infectivity,” said Clemens Wendtner, one of the study’s lead authors and head of the department of infectious diseases and tropical medicine at München Klinik Schwabing, a teaching hospital at the Ludwig Maximilian University of Munich.

He and his colleagues found samples from contagious patients with virus levels up to 1,000 times that, which could help explain why the virus is so infectious in the right conditions: It may take much lower levels of virus than what’s found in a sick patient to infect someone else.

Changing policies
Based on this emerging picture of contagion, some policies are changing. The standard procedure for someone who tests positive is to quarantine at home. Some cities are providing free temporary housing and social services where people who are infected can stay on a voluntary basis, to avoid transmitting the virus to family members.

The CDC recently urged Americans to keep wearing masks and maintaining a distance from others as states reopen. “The more closely you interact with others, the longer the interaction lasts, the greater the number of people involved in the interaction, the higher the risk of Covid-19 spread,” said Jay Butler, the CDC’s Covid-19 response incident manager.

If the number of Covid-19 cases starts to rise dramatically as states reopen, “more extensive mitigation efforts such as what were implemented back in March may be needed again,” a decision that would be made locally, he said.

CDC guidelines for employers whose workers are returning include requiring masks, limiting use of public transit and elevators to reduce exposure, and prohibiting hugs, handshakes and fist-bumps. The agency also suggested replacing communal snacks, water coolers and coffee pots with prepacked, single-serve items, and erecting plastic partitions between desks closer than 6 feet apart.

Current CDC workplace guidelines don’t talk about distribution of aerosols, or small particles, in a room, said Lisa Brosseau, a respiratory-protection consultant for the University of Minnesota’s Center for Infectious Disease Research and Policy.

“Aerosol transmission is a scary thing,” she said. “That’s an exposure that’s hard to manage and it’s invisible.” Ensuring infected individuals stay home is important, she said, but that can be difficult due to testing constraints. So additional protocols to interrupt spread, like social distancing in workspaces and providing N95 respirators or other personal protective equipment, might be necessary as well, she said.

Some scientists say while aerosol transmission does occur, it doesn’t explain most infections. In addition, the virus doesn’t appear to spread widely through the air.

“If this were transmitted mainly like measles or tuberculosis, where infectious virus lingered in the airspace for a long time, or spread across large airspaces or through air-handling systems, I think you would be seeing a lot more people infected,” said the CDC’s Dr. Brooks.

Sampling the air in high-traffic areas regularly could help employers figure out who needs to get tested, said Donald Milton, professor of environmental and occupational health at the University of Maryland School of Public Health.

“Let’s say you detect the virus during lunchtime on Monday in a dining hall,” he said. “You could then reach out to people who were there during that time telling them that they need to get tested.”

Erin Bromage, a University of Massachusetts Dartmouth associate professor of biology, has been fielding questions from businesses, court systems and even therapists after a blog post he wrote titled “The Risks—Know Them—Avoid Them” went viral.

Courts are trying to figure out how to reconvene safely given that juries normally sit close together, with attorneys speaking to them up close, Dr. Bromage said. Therapists want to be able to hold in-person counseling sessions again. And businesses are trying to figure out what types of cleaning and disease-prevention methods in which to invest most heavily.

He advises that while wiping down surfaces and putting in hand-sanitizer stations in workplaces is good, the bigger risks are close-range face-to-face interactions, and having lots of people in an enclosed space for long periods. High-touch surfaces like doorknobs are a risk, but the virus degrades quickly so other surfaces like cardboard boxes are less worrisome, he said. “Surfaces and cleaning are important, but we shouldn’t be spending half of our budget on it when they may be having only a smaller effect,” he said.

Drugmaker Eli Lilly & Co. has a medical advisory panel that’s reading the latest literature on viral transmission, which it is using to develop recommendations for bringing back the company’s own workers safely.

To go into production facilities, some of which are in operation now, scientists must don multiple layers of personal protective equipment, including gloves, masks, goggles and coveralls. That’s not abnormal for drug-development settings, said Lilly Chief Scientific Officer Daniel Skovronsky. “The air is extensively filtered. There’s lots of protection,” he said.

The places he worries about are the break rooms, locker rooms and security checkpoints, where people interact. Those are spaces where the company has instituted social-distancing measures by staggering the times they are open and how many people can be there at once. Only a few cafeterias are open, and those that are have socially distanced seating. In bathrooms, only half the stalls are available to cut down on the number of people.

“We’ll never be more open than state guidelines,” Dr. Skovronsky said, but “we’re often finding ourselves being more restrictive because we’re following the numbers.” (www.wsj.com)

With the tragic demise of Bollywood actor Sushant Singh Rajput, Indian media unfortunately chose to focus on the suicide rather than the loss of a young life. In this piece, senior journalist Aarti Dhar stresses on the need for the media to abide by guidelines and report suicides with sensitivity, which might prevent others from taking the extreme step.

Hyderabad: Sunday afternoon came with rather unfortunate news. Actor Sushant Singh Rajput had passed away. His body was reportedly found hanging in his flat in a posh Mumbai locality. By the next day, post-mortem confirmed that it was a case of suicide.

The life of the 34-year-old actor with a promising future had been cut short. This fact will not change, but what needs to change is the way suicides are covered by media.

Within minutes, television channels switched to the 'big breaking' news of the day. The focus was on how Sushant Singh Rajput had committed suicide rather than the loss of a young life. Most television channels 'broke this news' for almost the entire day describing the way Sushant Singh had ended his life.

So much so, even telling the viewers the colour of the cloth with which the body was found hanging when the door of his bedroom was broken open. Telecasting live when the body was taken out from the house and almost insisting on a quote from the grieving family members back home at Patna. Worse was speculating on the reason behind his alleged suicide -- from professional failure to break up with girlfriend to financial crisis, until it was realised he had been suffering from depression and was on treatment.

As expected, the morning newspapers too, front-paged the story with the actor's picture and details of the act that had ended a precious life.

Not to be blamed, electronic media is about 'breaking the news first' and newspapers compete with each other on the minutest details, display and pictures!

The news deserves prominence, no doubt, but does suicide deserve to be highlighted? One would say it is difficult to differentiate the two as prima facie it does appear to be a case of suicide, but what one generally forgets is that repeated stories on suicide can 'prompt' many to take the extreme step.

More than 50 researches done across the world have found that news coverage can increase the likelihood of suicide in vulnerable individuals, depending on the amount, duration and prominence of coverage. By 'vulnerable individuals' we mean those people who are already thinking about suicide and can be influenced to copycat the act based on what they see or read on media. Sensationalising suicides of celebrities can 'inspire' such individuals to do the same because they feel it is 'ok' to do it and can even make them a celebrity instantly.

Research has also shown showing stories of suicide on media can increase the incidence of suicides by 2.5 times. Referred to as 'Copycat Suicides', it has been proven that suicide rates rise after the suicides of celebrities the most, and to a lesser extent political figures that receive publicity in the mass media, or sensationalised — to put it in simple terms.

On the other side, there is also increasing evidence for the positive roles media can play in suicide prevention. The 'Papageno Studies' is the effect that mass media can have by presenting non-suicide alternatives to crises. Media can make a very relevant contribution to suicide prevention by minimising sensationalist reporting, and maximising reporting on how to cope with suicidality and adverse circumstances.

There is no single reason behind suicides. But more often, they are the result of a mental disorder that can range from depression/stress to severe mental ailments. At times, it is also genetic or there is a history of suicides in the family. But suicides can be prevented if mental disorders are destigmatised, accepted as any other illness and mental healthcare is accessible to all. Sometimes just listening to a suicidal person can make him/her change the decision. People with mental disorders are not 'mad' as is often believed.

The World Health Organisation in 2008 came out with guidelines for media on suicide reporting. For some reason, these guidelines are not being followed by media in letter and spirit.

The WHO has listed 11 points for media to follow while reporting on suicide. The most important being not to sensationalise suicides and educate people on mental health issues to prevent suicide. By not sensationalising, one would mean to avoid using the word 'suicide' in the headline, instead saying an individual was dead would still catch eyeballs.

Not using the picture of the deceased, not identifying the place where the suicide took place and not describing the method used to end the life are some other crucial guidelines media is supposed to follow. Respecting the sentiments of the family at that critical moment by not insisting on their quotes of filming them and taking pictures without prior permission is also recommended. Instead, the WHO says mentioning helpline numbers and healthcare centres where mental healthcare facility is available could be of great use to people with suicidal tendencies. Being careful in choosing words is crucial. The contents of the suicide note need not be given out. Just saying a suicide note was found and is being looked into is good enough.

Not using phrases that normalise self-harm such as 'epidemic' of suicide or 'failed attempt' is recommended. It is equally important to educate the community about mental health issues, the guidelines say while saying that including warning signs, and helpline number is critical. Quoting people as saying or drawing inference that suicide had ended the problems of an individual could just be an idea for some vulnerable individual trying to brave problems in his/her life.

The Press Council of India in September 2019 also endorsed these guidelines and asked media to abstain from identifying a mentally ill person or using his/her picture or footage without prior permission.

But coverage of suicides in media in India is far from ideal while experiences from Austria, the first country worldwide to implement their own set of media recommendations back in 1987 as well as from other countries nowadays support that active collaboration with the media can help prevent suicides and improve the quality of reporting.

According to the National Crime Records Bureau report, the suicide rate in India in 2018 was 10.2 per 100,000 population. As many as 1.34 lakh people commit suicide in the country every year while another 1.60 lakh suicides are not even reported. Majority of the suicides are reported in the age group of 14-29 years — the most productive years of life!

The death of Sushant Singh Rajput is an opportunity for the media and other stakeholders to push for stricter implementation of the WHO guidelines to save lives. The life can be that of a media person also because they are no exception to this contagion.

More so at a time when Coronavirus has put lives under stress and India has already seen suicides due to job loss, withdrawal symptoms and even at quarantine centres because of stigma attached to the disease. (moneycontrol.com)