What Were the Historical Reasons for the Resistance to Recognizing Airborne Transmission during the COVID-19 Pandemic?

Abstract

The question of whether SARS-CoV-2 is transmitted by droplets or aerosols has been very controversial. We sought to explain this controversy through a historical analysis of transmission research in other diseases. For most of human history, many diseases were thought to transmit through the air, often over long distances and in a phantasmagorical way, and often in error (e.g. malaria, cholera). Building on the germ theory of disease developed in the mid 19th century and on the demise of miasma theory, prominent public health official Charles Chapin in 1910 urged the public health community to focus on contact and droplet infection. However, he introduced a major error in the process: that ease of infection in close proximity is associated exclusively with large “sprayborne” droplets that fall to the ground quickly, and he deemed airborne transmission as very unlikely. This new paradigm became dominant, leading to systematic errors in the interpretation of research evidence on transmission. For the next five decades, no disease was accepted by the general medical and infection control communities as airborne, until tuberculosis (which had been misclassified as droplet) in 1962. Chapin’s paradigm remained dominant and only a few diseases were widely accepted as transmitted by aerosols before COVID-19: those that were clearly transmitted over long distances or time scales. Resistance to the idea of airborne spread of a respiratory infection is not new. In fact, it has occurred repeatedly over much of the last century and greatly hampered understanding of how diseases transmit.

Note:
Funding Information: M. Yao was supported by National Natural Science Foundation of China grants (21725701, 22040101) and Guangzhou Laboratory (EKPG21-02). T. Greenhalgh was supported by a Wellcome Senior Investigator grant (WT104830MA).

Declaration of Interests: The authors declare no competing interest.

Keywords: COVID-19, aerosols, droplets, transmission, history