COVID-19 and false dichotomies: time to change the black-or-white messaging

about health, economy, SARS-CoV-2 transmission, and masks

Running title: COVID-19 and false dichotomies

Kevin Escandón, MD MSc1, Angela L. Rasmussen, PhD2, Isaac I. Bogoch, MD3, Eleanor
J. Murray, ScD4, Karina Escandón, BA5

1 School of Medicine, Universidad del Valle, Cali, Colombia

ORCID 0000-0002-7173-7486
2
Center for Infection and Immunity, Columbia Mailman School of Public Health, New York
City, USA
ORCID 0000-0001-9462-3169
3 Division of Infectious Diseases, University of Toronto, Toronto General Hospital,
Toronto, Canada
ORCID 0000-0003-1590-6748
4 Department of Epidemiology, Boston University School of Public Health, Boston, USA
ORCID 0000-0003-0043-4901
5 Department of Anthropology, Universidad Nacional de Colombia, Bogotá, Colombia
ORCID 0000-0003-2692-2495

Corresponding author

Kevin Escandón, MD MSc

School of Medicine, Universidad del Valle, Cali, Colombia

[email protected]

Keywords: COVID-19; SARS-CoV-2; Public health; Lockdown; Droplet; Aerosol; Masks;

Dichotomy.
Abstract
Amid the coronavirus disease 2019 (COVID-19) pandemic, a myriad of logical fallacies
and cognitive biases have interfered with the understanding of the nuances and
communication of evidence-based guidance. In particular, multiple false dilemmas have
run rampant across social media with the pitfalls of black-or-white messaging and
reductionist frameworks. In this article, we thoughtfully review the evidence around five
COVID-19-related false dichotomies: 1) health and lives vs economy and livelihoods, 2)
indefinite lockdown vs unlimited reopening, 3) symptomatic vs asymptomatic severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) droplet vs aerosol
transmission of SARS-CoV-2, and 5) masks for all vs no masking. While we acknowledge
that there is not one unequivocal answer, we make a call for comprehensive messaging
and science-informed tailored policies that reckon with gray shades, uncertainties, and
social contexts.
Scientists and policymakers are operating on “Pandemic Standard Time”—struggling not
only to advance science and policy but also to counter the “infodemic” of misinformation
around coronavirus disease 2019 (COVID-19). In the previous months, a myriad of logical
fallacies and cognitive biases have interfered with the understanding of the nuances and
communication of evidence-based guidance [1]. In particular, a series of false dilemmas
have run rampant across social media with the pitfalls of black-or-white messaging.
Opponents for either side of these hot debates cherry-pick science to fit narratives that
align with their preconceptions. In this article, we deconstruct five COVID-19-related false
dichotomies (Figure) by reviewing the evidence thoughtfully and thoroughly.

Figure. False dichotomies around coronavirus disease 2019 (COVID-19)

Health and lives vs economy and livelihoods

A troubling dichotomy during the COVID-19 pandemic has been the idea that public health
and economy are two independent and opposing forces. That is, strategies deployed to
protect the public’s health necessarily hurt a nation’s economic health. This dilemma has
also been extended to include civil health (i.e., the right to protest against public health
measures such as lockdown, and public health threats such as racism and police brutality)
under the umbrella of the economy.

There is no such dichotomy of public health vs the economy; in reality, they are intimately
intertwined. The pandemic is both a public health and economic crisis [2]. The idea that
the economy could function uninterrupted when a substantial proportion of the workers
are stricken with an illness that can take weeks or months for recovery is idealistic at best.
Sound public health strategies that reduce the spread of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) protect the economy as well.

We should not ignore the physical and mental health effects and the tremendous
economic impact of COVID-19 or the related countermeasures, however [3]. Public health
professionals, economists, and bioethicists together must assess trade-offs and develop
proactive solutions to protect the multifaceted wellbeing of society. For example,
governments can consider universal basic income and payment freezes on rents and
loans for all individuals, and paid leaves for infected and exposed workers. Further
strategies aimed at ensuring food supply chains, keeping essential outpatient healthcare
services at usual throughput, decreasing unemployment, adapting businesses, and
minimizing bankruptcies are also needed.

Indefinite lockdown vs unlimited reopening

Early in the pandemic, delays in the availability of testing and contact tracing prohibited
reliance on isolation of infectious individuals and quarantine of their close contacts to curb
SARS-CoV-2 transmission. Governments were thus forced to require that all individuals
avoided non-essential contact by implementing stay-at-home orders, business and school
closings, and travel restrictions. These stringent forms of physical distancing, while
socially and economically devastating, were stop-gap tools to limit SARS-CoV-2 spread
in the first months of the pandemic while testing infrastructure, contact tracing workforce,
personal protective equipment availability, and hospital capacity were increased [4].

Currently, several countries and regions are reopening their economies to a greater or
lesser extent. Opening prematurely without robust countermeasures in place can send
societies back into lockdown, as illustrated by several US states that recently observed
surges in COVID-19 cases following unfettered reopening. Rather than posing an all-or-
nothing dilemma between staying closed indefinitely and returning to pre-COVID-19
normality, economies can be restarted in a “new normal” scenario. A stepwise, cautious
lifting of lockdowns and easing of other restrictions are only possible with non-
pharmaceutical interventions including broadened testing, rigorous contact tracing,
isolation of infected individuals, and quarantine of exposed individuals [4,5]. Given the
looming risk of COVID-19 resurgence, plans to avoid overwhelming healthcare systems
are also needed.

Since risk elimination is not feasible amid this pandemic, the right step is advocating a
sustainable strategy such as harm reduction [6]. This requires education campaigns on
SARS-CoV-2 transmission and assessment of the personal exposure risk associated with
routine activities, in tandem with physical distancing, masks, respiratory etiquette, hand
hygiene, environmental cleaning and disinfection, and ventilation improvement. Casting
shame and stigma on people violating preventive measures is likely to negatively reinforce
risky behaviors rather than reducing them, and should be avoided. Lower-risk outdoor
activities, staggered shifts, telework, and redesign of living and working places to avoid
crowding and optimize ventilation are recommended to address quarantine fatigue and
alleviate economic harm while safeguarding public health.
Symptomatic vs asymptomatic SARS-CoV-2 infection

Seven months into the pandemic, confusion remains regarding asymptomatic SARS-CoV-
2 infection—either the proportion of those infected or the role of asymptomatic
transmission. The issue of defining asymptomatic cases has been challenging. It is
generally agreed that “asymptomatic” individuals have no symptoms throughout their
entire course of infection, “paucisymptomatic” or “oligosymptomatic” individuals have few
or mild symptoms, and “presymptomatic” individuals demonstrate no symptoms during
the first days of infection but develop symptoms afterward. Yet these terms continue to be
misused to this day. Further complicating matters is the broad clinical presentation of
SARS-CoV-2 infection with symptoms such as fever, cough, shortness of breath, fatigue,
myalgia, chills, rhinorrhea, sore throat, headache, anosmia, diarrhea, and dysgeusia [7].

The proportion of “asymptomatic” SARS-CoV-2-infected individuals has been variably

reported from 4% to 96% [8,9]; nevertheless, most of these cross-sectional point-
prevalence studies do not account for the development of symptoms at a later date and
overestimate the proportion of asymptomatic individuals. Also, mild symptoms may not be
ascertained by screening questionnaires or recollected by patients. For example, it was
established that 43% of participants in countrywide screening in Iceland were
asymptomatic [10], but how many of these patients were really presymptomatic or
paucisymptomatic? Other studies, such as a study from Vo’, Italy, have reported a high
prevalence of asymptomatic infection (43%) but narrowly defined symptoms as the
presence of fever and/or cough [11]. A preprint of a systematic review and meta-analysis
estimated that only 15% (95% confidence interval 10%–22%) of SARS-CoV-2-infected
people remain asymptomatic [12].

If we take greater care to standardize definitions of symptoms, we can avoid the pitfalls of
misclassification and understand the true role of the spectrum of COVID-19 presentation
in driving the pandemic.
Droplet vs aerosol transmission of SARS-CoV-2

COVID-19 has reawakened the long-standing debate about the dichotomous

classification framework of respiratory droplets vs aerosols [13]. Droplets and aerosols
are erroneously seen as categorical transmission modes instead of a continuum
influenced by several aerodynamic factors such as particle size, emission composition,
turbulence, and environmental conditions [14]. Large, heavier droplets (conventionally
defined as >5 μm) generally settle rapidly on the ground, remain airborne for short periods,
and are generally transmitted over short distances, although airflow can propel them
farther across a room. Small-particle aerosols and droplet nuclei (<5 μm) evaporate and
disperse faster than they fall, remain suspended in the air, and generally travel longer
distances. Unfortunately, confusion around the term “airborne” stems from the subtle
difference between the regular meaning of the word (carried in the air) and scientific
conventions referring to either aerosols or their velocity of propagation into the
environment.

Transmission risk of respiratory pathogens varies with the inoculum size, distance,
duration, type of activity, environmental setting, and host factors [15]. While it is
acknowledged that coughing, sneezing, speaking, and breathing can generate both
droplets and aerosols [14], there is ample evidence arguing for SARS-CoV-2 infection
occurring primarily—not exclusively—through larger droplets reaching the nose, mouth,
or eyes. Contaminated fomites (contact transmission) and aerosols seem to play a minor
role. First, based on epidemiological studies, sustained person-to-person contact in
crowded or unventilated spaces is a major driver for SARS-CoV-2 infection [16,17].
Second, the basic reproduction number (R0, 2–3)[18] and household secondary attack
rates (generally 10%–20%)[19] for SARS-CoV-2 are compatible with predominant droplet
transmission rather than aerosol transmission [13]. Third, hospital reports of cases and
outbreaks amid this pandemic have indicated that droplet and contact precautions work if
instituted timely and consistently, especially in the absence of aerosol-generating
procedures (AGPs) [20–23]. Medical masks have shown to reduce infectious titers of
other enveloped droplet-borne respiratory viruses [24], suggesting that any small particles
not filtered out are less likely to contain infectious virus. Meta-analyses of studies
comparing medical masks to filtering facepiece respirators (FFRs) have reported no
substantial difference in preventing respiratory viral infections (including seasonal
coronaviruses and influenza) in healthcare workers [25–28]. These data suggest that
infectious aerosols do not occur predominantly during non-AGP healthcare, although
evidence is heterogeneous and hindered by mask compliance.

Indeed, no debate exists as to whether infectious aerosols can be generated from a

person infected with a respiratory pathogen. It is accepted that at least AGPs contribute
to the spread of SARS-CoV-2 via aerosols [29], and experimental animal models[30,31]
and outbreak investigations[32–38] suggest that short-range aerosol transmission may
occur in situations of prolonged exposure in indoor unventilated spaces. Also, fomite
transmission cannot be categorically excluded. Recently, the World Health Organization
(WHO) has updated its guidance[39] to acknowledge that, while airborne transmission of
SARS-CoV-2 has not been demonstrated outside AGPs and its extent remains unknown,
concurrent short-range aerosol transmission cannot be ruled out in favorable
circumstances.

Notwithstanding evidence supporting droplets as the major transmission mode of SARS-

CoV-2, narratives claiming that long-range aerosol-based transmission is a significant
danger have emerged [40–42]. These are based on outbreak studies of restaurants
[32,33], call centers [34], choirs [35], sports facilities [36], conference rooms [37], malls
[38], and bus transportation [37]; studies showing that experimentally-generated SARS-
CoV-2 aerosols remain infectious for up to 3–16 hours [43,44]; evidence of viral RNA in
air samples or ventilation systems of hospitals [45–52]; evidence of viral RNA in outdoor
particulate matter [53], and droplet dispersal modeling and experimental studies [41,54–
56]. The epidemiological investigations were not able to exclude droplet inhalation as the
primary mode of transmission [32–38]. Although some air sampling studies have detected
SARS-CoV-2 RNA, there is no evidence that infectious virus persists in the air for long
[45–48,50–53]. In these studies and others that have failed to detect SARS-CoV-2 RNA,
inconsistent findings could be related to the sampling methodology, environmental
conditions, and infection prevention and control (IPC) measures. Detection of viral RNA
by reverse transcriptase-polymerase chain reaction does not equate to viral
infectiousness or viability [57]. Studies under controlled laboratory conditions showing
infectivity of aerosolized SARS-CoV-2 do not reflect normal host processes and real-world
environmental conditions related to viral transmission [43,44]. Furthermore, small particle
transmission across long distances is especially subject to changes in ambient
temperature, relative humidity, airflow, chemicals, and solar ultraviolet radiation leading to
dilution or inactivation [58]. While some respiratory particles can travel long distances or
linger in the air for some time, transmission risk hinges greatly on how much infectious
virus those particles contain. The lack of epidemiological and virological evidence
supporting predominant long-range aerosol transmission of SARS-CoV-2 suggests that
infectious titers in small particles are insufficient to frequently cause infection.

There are unknown virological and biophysical features of SARS-CoV-2 that are germane
to elucidating transmission modes, including the minimum infectious dose and airborne
virus concentrations and virus viability in indoor and outdoor natural settings in function of
particle emission, size distribution, transformation, dispersion, deposition, time, and
environmental parameters. Currently available epidemiological data provide more reliable
evidence of how SARS-CoV-2 spreads than laboratory-based, theoretical, and in silico
studies, especially if these do not investigate SARS-CoV-2 infectiousness or are
conducted in poorly simulated environments. Infectious disease transmission has
important implications in developing effective preventive protocols and allocating
resources. Overclaimed science can lead to harmful policies. For now, claiming aerosols
as the dominant or exclusive transmission mode of SARS-CoV-2 is reckless since it would
move forward unnecessary IPC measures in hospital and community settings. Much more
high-quality research is needed to demonstrate otherwise. Unfortunately, by amplifying
findings from studies with considerable methodological limitations [59,60]. some mask
advocates are even endorsing mass use of FFRs in all healthcare areas and high-risk
community scenarios. Conflicting messages regarding transmission routes may result in
public unwillingness to adhere to risk reduction practices. For example, if the public
erroneously believes that transmission occurs overwhelmingly from virus-laden aerosols
over an extended distance and time, they may reject guidance to wear cloth masks given
their limited aerosol filtering ability, or may feel that distancing precautions are worthless.
Thus, while SARS-CoV-2 transmission cannot be separated into the dichotomy of droplets
vs aerosols, taking an adversarial position against health authorities like WHO and
“aerosol fearmongering” are decidedly unhelpful. Aerosol scientists should work with—not
against—health authorities.

Masks for all vs no masking

Masking has provoked a culture war amid the COVID-19 pandemic. On the one hand,
some “pro-mask” academics and self-promoters have adamantly hyped masks with
simplistic slogans such as “The science is simple and clear, masks are common sense,
something is better than nothing”, inaccurate analogies with parachutes, and ecological
fallacies and analyses without confounding control [23,40,42]. With an incendiary rhetoric,
they have overstated the potential benefits and have downplayed the potential unintended
consequences. On the other hand, there are two “anti-mask” groups—one that staunchly
upholds evidence-based medicine tenets and thus awaits “definitive” randomized clinical
trials, and other who has protested vociferously against masks based on unwarranted
claims (e.g., infringement on individual liberties, increased risk of hypercapnia, clinical
worsening of infected individuals). Unsurprisingly, deep-seated conspiracism and
scientific illiteracy have stoked the anti-mask sentiment of the latter group.

Setting up a binary choice between masks for all and no masking is misleading. Rather
than a panacea or a hoax, masks are likely an effective prevention bundle component to
fight the COVID-19 pandemic. Masks—especially medical masks and FFRs—have shown
to prevent respiratory viral infections in healthcare [26,60–62]. As for community
scenarios, there exists evidence for medical masks used by well and sick people in
households, university residences, schools, and the Hajj pilgrimage, but there is limited
research on cloth masks for source control [61,63,64]. The vast majority of healthcare and
community studies have focused on medical masks and FFRs, and have assessed clinical
and influenza-related outcomes. Direct evidence of mask use related to coronaviruses
infections is sparse [65]. Data on the filtration efficacy of cloth masks have demonstrated
variable degrees of protection depending on the textiles’ properties, number of layers, and
facial fit [63,66]. Mechanistic evidence has been published on the efficacy of medical
masks in reducing influenza virus and common cold coronaviruses respiratory emissions
from symptomatic individuals [24]. Some COVID-19 observational studies have
suggested a benefit from community masking [67,68]. In addition to a growing—though
indirect and somewhat contested—evidence base on the effectiveness of community
masking in preventing viral respiratory infections [28,59,60,62,69–72], a critical concern
underpinning masking during the COVID-19 pandemic has been the risk of unwitting
transmission from presymptomatic and asymptomatic individuals, as substantiated by
contact investigations, modeling studies, and virological studies [12,73]. All these nuances
explain the recommendation changes from public health agencies in past months as we
moved from containment to mitigation phase [74].

Today, several countries and regions with community-based transmission of SARS-CoV-

2 recommend or mandate cloth masks and face coverings to mitigate its impact . However,
from a public health standpoint, concerns exist about some policies and messages about
them. The potential benefits of masks should be considered, but potential downsides
should not be utterly disregarded (i.e., shortage of medical masks and FFRs for healthcare
workers, cross-contamination due to inappropriate mask wearing, complacency toward
other preventive measures, social impact, environmental impact, psychological and
physiological effects) [72,74–76]. Addressing these challenges may allow maximizing the
potential benefits of masking. Inappropriate mask wearing is a lingering concern that
points out failures in policy implementation, health education, community engagement,
and research. Studies assessing factors associated with public masking amid this
pandemic may contribute to understanding potential barriers and designing strategies to
increase mask compliance and acceptability [77]. Another concern of universal masking
is that of being compulsory. Mask mandates—targeting specific settings and situations—
should come when their implications have been carefully analyzed. Generalized
implementation of mandates may deepen social inequalities and erode public trust,
especially in regions with zero or low COVID-19 transmission. Educational interventions
should be preferred over coercive and punitive approaches (e.g., excessive fines,
imprisonment, violence, stigmatization). Governments enforcing mass masking should
ensure the availability of masks and consider distributing them to citizens for free. Public
service providers could be mandated to have a stock of masks for users, and private
businesses could provide masks to customers out of enlightened self-interest. Also, the
impact on vulnerable populations needs to be addressed (e.g., hearing-impaired people
that rely on lip reading; racial groups being asked to tip their masks, harassed for
concealing their face, or disproportionately penalized for not wearing masks; rural and
poor populations without access to online educational tools) [75,78].

Efficacy and effectiveness are not synonymous. Uncertainties still exist around the uptake
of masking as a universal measure. There are COVID-19 research opportunities to obtain
direct and actionable evidence. Research gaps include the effectiveness of specific cloth
mask designs in high-risk community scenarios, extended use and reuse of cloth masks,
the impact of different approaches to mask adoption, downsides of masking, attitudes and
behaviors toward masking, and comparative effectiveness of cloth masks and face shields
in the community [72,75,79]. It is monumentally frustrating that academics supporting
masks but asking for accurate messaging and further evidence are misrepresented as
anti-mask and accused of ill intent by some universal masking advocates. This pandemic
undoubtedly demands effective communication of benefits, risks, and uncertainties as well
as data-driven, context-sensitive policymaking that accounts for the cases for and against
interventions [1,75].

Aligned with the latest WHO guidance on masks [74], we advocate a “smart” or risk-based
community masking approach in lieu of a universal masking approach. A few exemptions
for masking are reasonable [80]. The term “universal” applies to persons, places, and
time, with no exceptions. The quandary of yes/no to masking should be replaced with a
debate about whom, where, when, and how. Some individuals are truly unable or
contraindicated to wear a mask (e.g., people with some breathing difficulties, children
under 2 years), masking of preschoolers may be challenging, and some people may prefer
face shields—which likely afford advantages over face masks in terms of eye protection,
no hand-to-face contact, breathability, full-face visibility, scalable production, reuse, and
disinfection [72,79,81]. Likewise, not all settings and activities confer the same risk of
infection [16,17]. To enhance uptake of masking, policies should be directed to risky
contexts such as public gatherings, transportation, unventilated places, and confined
settings among others. People engaging in negligible-risk activities (e.g., exercising in an
uncrowded park while ensuring physical distancing, driving alone) should be exempt from
mask wearing.

Final remarks

The black-or-white fallacy is pervasive and attractive—it offers an escape from

uncertainty. Science, policy, and risk of infection lie on a spectrum of gray shades; they
are not binary—or should not be regarded as such. For the sake of public health amid the
COVID-19 pandemic, we make a call to change the black-or-white messaging.
Comprehensive messaging and science-informed policies that reckon with uncertainties
and social contexts are long overdue. Naturally, the views set out here will evolve as
newer findings on SARS-CoV-2 and COVID-19 emerge.

Conflict of Interest Disclosure: The authors declare no conflicts of interest.

Funding: None.

Authors’ contributions: Conceptualization: KeE. Substantial contributions to the content

and critical revision: KeE, ALR, IIB, EJM, KaE. All authors take responsibility for the
integrity and accuracy of the data.

Acknowledgments: Our thanks go to Angélica L. Cruz, BA (Icesi University, Cali,

Colombia) who designed the infographic.
References

[1] Zagury-Orly I, Schwartzstein RM. Covid-19 — A Reminder to Reason. N Engl J

Med 2020:NEJMp2009405. doi:10.1056/NEJMp2009405.
[2] McKee M, Stuckler D. If the world fails to protect the economy, COVID-19 will
damage health not just now but also in the future. Nat Med 2020;26:640–2.
doi:10.1038/s41591-020-0863-y.
[3] Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the
wider health effects of covid-19 pandemic response. BMJ 2020;369:m1557.
doi:10.1136/bmj.m1557.
[4] Imai N, Gaythorpe KAM, Abbott S, Bhatia S, van Elsland S, Prem K, et al.
Adoption and impact of non-pharmaceutical interventions for COVID-19.
Wellcome Open Res 2020;5:59. doi:10.12688/wellcomeopenres.15808.1.
[5] Rubin R. Building an “Army of Disease Detectives” to Trace COVID-19 Contacts.
JAMA 2020:19–22. doi:10.1001/jama.2020.8880.
[6] Kutscher E, Greene RE. A Harm-Reduction Approach to Coronavirus Disease
2019 (COVID-19)—Safer Socializing. JAMA Heal Forum 2020;1:e200656.
doi:10.1001/jamahealthforum.2020.0656.
[7] Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-
19): Symptoms of coronavirus 2020. https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html (accessed June 22, 2020).
[8] Oran DP, Topol EJ. Prevalence of Asymptomatic SARS-CoV-2 Infection. Ann
Intern Med 2020:M20-3012. doi:10.7326/M20-3012.
[9] McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG, et al.
Epidemiology of Covid-19 in a Long-Term Care Facility in King County,
Washington. N Engl J Med 2020;382:2005–11. doi:10.1056/NEJMoa2005412.
[10] Gudbjartsson DF, Helgason A, Jonsson H, Magnusson OT, Melsted P, Norddahl
GL, et al. Spread of SARS-CoV-2 in the Icelandic Population. N Engl J Med
2020:1–14. doi:10.1056/nejmoa2006100.
[11] Lavezzo E, Franchin E, Ciavarella C, Cuomo-Dannenburg G, Barzon L, Del
Vecchio C, et al. Suppression of COVID-19 outbreak in the municipality of Vo’,
 Italy. Prepr MedRxiv 2020. doi:10.1101/2020.04.17.20053157.
[12] Buitrago-Garcia DC, Egli-Gany D, Counotte MJ, Hossmann S, Imeri H, Salanti G,
et al. The role of asymptomatic SARS-CoV-2 infections: rapid living systematic
review and meta-analysis. Prepr MedRxiv 2020.
doi:10.1101/2020.04.25.20079103.
[13] Klompas M, Baker MA, Rhee C. Airborne Transmission of SARS-CoV-2. JAMA
2020;172:766–7. doi:10.1001/jama.2020.12458.
[14] Bourouiba L. Turbulent Gas Clouds and Respiratory Pathogen Emissions. JAMA
2020;323:1837–8. doi:10.1001/jama.2020.4756.
[15] Kutter JS, Spronken MI, Fraaij PL, Fouchier RA, Herfst S. Transmission routes of
respiratory viruses among humans. Curr Opin Virol 2018;28:142–51.
doi:10.1016/j.coviro.2018.01.001.
[16] Leclerc QJ, Fuller NM, Knight LE, Funk S, Knight GM. What settings have been
linked to SARS-CoV-2 transmission clusters? Prepr Wellcome Open Res
2020;5:83. doi:10.12688/wellcomeopenres.15889.2.
[17] Qian H, Miao T, LIU L, Zheng X, Luo D, Li Y. Indoor transmission of SARS-CoV-2.
Prepr MedRxiv 2020. doi:10.1101/2020.04.04.20053058.
[18] Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of COVID-
19 is higher compared to SARS coronavirus. J Travel Med 2020;27:1–4.
doi:10.1093/jtm/taaa021.
[19] Koh WC, Naing L, Rosledzana MA, Alikhan MF, Chaw L, Griffith M, et al. What do
we know about SARS-CoV-2 transmission? A systematic review and meta-
analysis of the secondary attack rate, serial interval, and asymptomatic infection.
Prepr MedRxiv 2020. doi:10.1101/2020.05.21.20108746.
[20] Lessells R, Moosa Y, de Oliveira T. Report into a nosocomial outbreak of
coronavirus disease 2019 (COVID-19) at Netcare St. Augustine’s Hospital. 2020.
[21] Durante-Mangoni E, Andini R, Bertolino L, Mele F, Bernardo M, Grimaldi M, et al.
Low rate of severe acute respiratory syndrome coronavirus 2 spread among
health-care personnel using ordinary personal protection equipment in a medium-
incidence setting. Clin Microbiol Infect 2020:1198–9.
doi:10.1016/j.cmi.2020.04.042.
[22] Wong SCY, Kwong R.-S, Wu TC, Chan JWM, Chu MY, Lee SY, et al. Risk of
nosocomial transmission of coronavirus disease 2019: an experience in a general
ward setting in Hong Kong. J Hosp Infect 2020;105:119–27.
doi:10.1016/j.jhin.2020.03.036.
[23] Wang X, Ferro EG, Zhou G, Hashimoto D, Bhatt DL. Association Between
Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among
Health Care Workers. JAMA 2020;129:802–4. doi:10.1001/jama.2020.12897.
[24] Leung NHL, Chu DKW, Shiu EYC, Chan K-H, McDevitt JJ, Hau BJP, et al.
Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med
2020;26:676–80. doi:10.1038/s41591-020-0843-2.
[25] Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M. Medical masks vs N95
respirators for preventing COVID‐19 in healthcare workers: A systematic review
and meta‐analysis of randomized trials. Influenza Other Respi Viruses
2020;14:365–73. doi:10.1111/irv.12745.
[26] Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of Masks and Respirators
Against Respiratory Infections in Healthcare Workers: A Systematic Review and
Meta-Analysis. Clin Infect Dis 2017;65:1934–42. doi:10.1093/cid/cix681.
[27] Long Y, Hu T, Liu L, Chen R, Guo Q, Yang L, et al. Effectiveness of N95
respirators versus surgical masks against influenza: A systematic review and
meta‐analysis. J Evid Based Med 2020;13:93–101. doi:10.1111/jebm.12381.
[28] Jefferson T. Physical interventions to interrupt or reduce the spread of respiratory
viruses. Part 1- Face masks, eye protection and person distancing: systematic
review and meta-analysis. Prepr MedRxiv 2020.
doi:10.1101/2020.03.30.20047217.
[29] Schünemann HJ, Khabsa J, Solo K, Khamis AM, Brignardello-Petersen R, El-
Harakeh A, et al. Ventilation Techniques and Risk for Transmission of Coronavirus
Disease, Including COVID-19. Ann Intern Med 2020:M20-2306. doi:10.7326/M20-
2306.
[30] Richard M, Kok A, de Meulder D, Bestebroer TM, Lamers MM, Okba NMA, et al.
SARS-CoV-2 is transmitted via contact and via the air between ferrets. Nat
Commun 2020;11:3496. doi:10.1038/s41467-020-17367-2.
[31] Kim Y-I, Kim S-G, Kim S-M, Kim E-H, Park S-J, Yu K-M, et al. Infection and Rapid
Transmission of SARS-CoV-2 in Ferrets. Cell Host Microbe 2020;27:704-709.e2.
doi:10.1016/j.chom.2020.03.023.
[32] Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 Outbreak Associated with Air
Conditioning in Restaurant, Guangzhou, China, 2020. Emerg Infect Dis
2020;26:3–6. doi:10.3201/eid2607.200764.
[33] Li Y, Qian H, Hang J, Chen X, Hong L, Liang P, et al. Evidence for probable
aerosol transmission of SARS-CoV-2 in a poorly ventilated restaurant. Prepr
MedRxiv 2020:2020.04.16.20067728. doi:10.1101/2020.04.16.20067728.
[34] Park SY, Kim Y-M, Yi S, Lee S, Na B-J, Kim CB, et al. Coronavirus Disease
Outbreak in Call Center, South Korea. Emerg Infect Dis 2020;26.
doi:10.3201/eid2608.201274.
[35] Hamner L, Dubbel P, Capron I, Ross A, Jordan A, Lee J, et al. High SARS-CoV-2
Attack Rate Following Exposure at a Choir Practice — Skagit County,
Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:606–10.
doi:10.15585/mmwr.mm6919e6.
[36] Jang S, Han SH, Rhee J-Y. Cluster of Coronavirus Disease Associated with
Fitness Dance Classes, South Korea. Emerg Infect Dis 2020;26:26–8.
doi:10.3201/eid2608.200633.
[37] Shen Y, Li C. Airborne transmission of COVID-19: epidemiologic evidence from
two outbreak investigations. Prepr Res 2020. doi:10.13140/RG.2.2.36685.38881.
[38] Cai J, Sun W, Huang J, Gamber M, Wu J, He G. Indirect Virus Transmission in
Cluster of COVID-19 Cases, Wenzhou, China, 2020. Emerg Infect Dis
2020;26:1343–5. doi:10.3201/eid2606.200412.
[39] World Health Organization. Transmission of SARS-CoV-2: implications for
infection prevention precautions: scientific brief, 09 July 2020. 2020.
[40] Zhang R, Li Y, Zhang AL, Wang Y, Molina MJ. Identifying airborne transmission
as the dominant route for the spread of COVID-19. Proc Natl Acad Sci
2020:202009637. doi:10.1073/pnas.2009637117.
[41] Bahl P, Doolan C, de Silva C, Chughtai AA, Bourouiba L, MacIntyre CR. Airborne
or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019? J
 Infect Dis 2020. doi:10.1093/infdis/jiaa189.
[42] Prather KA, Wang CC, Schooley RT. Reducing transmission of SARS-CoV-2.
Science (80- ) 2020;6197:eabc6197. doi:10.1126/science.abc6197.
[43] van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson
BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-
CoV-1. N Engl J Med 2020;382:1564–7. doi:10.1056/NEJMc2004973.
[44] Fears AC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al.
Persistence of Severe Acute Respiratory Syndrome Coronavirus 2 in Aerosol
Suspensions. Emerg Infect Dis 2020;26. doi:10.3201/eid2609.201806.
[45] Santarpia JL, Rivera DN, Herrera VL, Morwitzer MJ, Creager HM, Santarpia GW,
et al. Aerosol and surface transmission potential of SARS-CoV-2. Prepr MedRxiv
2020. doi:10.1101/2020.03.23.20039446.
[46] Guo Z-D, Wang Z-Y, Zhang S-F, Li X, Li L, Li C, et al. Aerosol and Surface
Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital
Wards, Wuhan, China, 2020. Emerg Infect Dis 2020;26:1583–91.
doi:10.3201/eid2607.200885.
[47] Chia PY, Coleman KK, Tan YK, Ong SWX, Gum M, Lau SK, et al. Detection of air
and surface contamination by SARS-CoV-2 in hospital rooms of infected patients.
Nat Commun 2020;11:2800. doi:10.1038/s41467-020-16670-2.
[48] Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NK, et al. Aerodynamic analysis of
SARS-CoV-2 in two Wuhan hospitals. Nature 2020;582:557–60.
doi:10.1038/s41586-020-2271-3.
[49] Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT, Wong MSY, et al. Air, Surface
Environmental, and Personal Protective Equipment Contamination by Severe
Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic
Patient. JAMA 2020;323:1610. doi:10.1001/jama.2020.3227.
[50] Zhou J, Otter JA, Price JR, Cimpeanu C, Garcia DM, Kinross J, et al. Investigating
SARS-CoV-2 surface and air contamination in an acute healthcare setting during
the peak of the COVID-19 pandemic in London. Clin Infect Dis 2020:1–41.
doi:10.1093/cid/ciaa905.
[51] Ma J, Qi X, Chen H, Li X, Zhan Z, Wang H, et al. Exhaled breath is a significant
 source of SARS-CoV-2 emission. Prepr MedRxiv 2020.
doi:10.1101/2020.05.31.20115154.
[52] Jiang Y, Wang H, Chen Y, He J, Chen L, Liu Y, et al. Clinical Data on Hospital
Environmental Hygiene Monitoring and Medical Staffs Protection during the
Coronavirus Disease 2019 Outbreak. Prepr MedRxiv 2020.
doi:10.1101/2020.02.25.20028043.
[53] Setti L, Passarini F, De Gennaro G, Barbieri P, Perrone MG, Borelli M, et al.
SARS-Cov-2RNA found on particulate matter of Bergamo in Northern Italy: First
evidence. Environ Res 2020;188:109754. doi:10.1016/j.envres.2020.109754.
[54] Anfinrud P, Stadnytskyi V, Bax CE, Bax A. Visualizing Speech-Generated Oral
Fluid Droplets with Laser Light Scattering. N Engl J Med 2020;382:2061–3.
doi:10.1056/NEJMc2007800.
[55] Stadnytskyi V, Bax CE, Bax A, Anfinrud P. The airborne lifetime of small speech
droplets and their potential importance in SARS-CoV-2 transmission. Proc Natl
Acad Sci 2020;117:11875–7. doi:10.1073/pnas.2006874117.
[56] Somsen GA, van Rijn C, Kooij S, Bem RA, Bonn D. Small droplet aerosols in
poorly ventilated spaces and SARS-CoV-2 transmission. Lancet Respir Med
2020;8:658–9. doi:10.1016/S2213-2600(20)30245-9.
[57] Bullard J, Dust K, Funk D, Strong JE, Alexander D, Garnett L, et al. Predicting
infectious SARS-CoV-2 from diagnostic samples. Clin Infect Dis 2020;0954162:1–
4. doi:10.1093/cid/ciaa638.
[58] Jayaweera M, Perera H, Gunawardana B, Manatunge J. Transmission of COVID-
19 virus by droplets and aerosols: A critical review on the unresolved dichotomy.
Environ Res 2020;188:109819. doi:10.1016/j.envres.2020.109819.
[59] Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, et al. Physical
distancing, face masks, and eye protection to prevent person-to-person
transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-
analysis. Lancet 2020;395:1973–87. doi:10.1016/S0140-6736(20)31142-9.
[60] MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of face
masks and respirators against coronaviruses and other respiratory transmissible
viruses for the community, healthcare workers and sick patients. Int J Nurs Stud
 2020;108:103629. doi:10.1016/j.ijnurstu.2020.103629.
[61] MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in
healthcare and community settings. BMJ 2015;350:h694–h694.
doi:10.1136/bmj.h694.
[62] Chou R, Dana T, Jungbauer R, Weeks C, McDonagh MS. Masks for Prevention of
Respiratory Virus Infections, Including SARS-CoV-2, in Health Care and
Community Settings. Ann Intern Med 2020:M20-3213. doi:10.7326/M20-3213.
[63] Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of
infection control – evidence and policy gaps. Int J Infect Control 2013;9:1–12.
doi:10.3396/IJIC.v9i3.020.13.
[64] Barasheed O, Alfelali M, Mushta S, Bokhary H, Alshehri J, Attar AA, et al. Uptake
and effectiveness of facemask against respiratory infections at mass gatherings: a
systematic review. Int J Infect Dis 2016;47:105–11. doi:10.1016/j.ijid.2016.03.023.
[65] MacIntyre CR, Chughtai AA, Seale H, Dwyer DE, Quanyi W. Human coronavirus
data from four clinical trials of masks and respirators. Int J Infect Dis 2020;96:631–
3. doi:10.1016/j.ijid.2020.05.092.
[66] Taminato M, Mizusaki-Imoto A, Saconato H, Franco ESB, Puga ME, Duarte ML, et
al. Homemade cloth face masks as a barrier against respiratory droplets -
systematic review. Acta Paul Enferm 2020;33:1–11. doi:10.37689/acta-
ape/2020AR0103.
[67] Hendrix MJ, Walde C, Findley K, Trotman R. Absence of Apparent Transmission
of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal
Face Covering Policy — Springfield, Missouri, May 2020. MMWR Morb Mortal
Wkly Rep 2020;69:930–2. doi:10.15585/mmwr.mm6928e2.
[68] Wang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W, et al. Reduction of secondary
transmission of SARS-CoV-2 in households by face mask use, disinfection and
social distancing: a cohort study in Beijing, China. BMJ Glob Heal
2020;5:e002794. doi:10.1136/bmjgh-2020-002794.
[69] Liang M, Gao L, Cheng C, Zhou Q, Uy JP, Heiner K, et al. Efficacy of face mask in
preventing respiratory virus transmission: A systematic review and meta-analysis.
Travel Med Infect Dis 2020:101751. doi:10.1016/j.tmaid.2020.101751.
[70] Brainard J, Jones N, Lake I, Hooper L, Hunter PR. Facemasks and similar barriers
to prevent respiratory illness such as COVID-19: A rapid systematic review. Prepr
- MedRxiv 2020. doi:10.1101/2020.04.01.20049528v1.
[71] Xiao J, Shiu EYC, Gao H, Wong JY, Fong MW, Ryu S, et al. Nonpharmaceutical
Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective
and Environmental Measures. Emerg Infect Dis 2020;26:967–75.
doi:10.3201/eid2605.190994.
[72] Bahkit M, N K, Clark J, Mar C Del. Downsides of face masks and possible
mitigation strategies: a systematic review and meta-analysis. Prepr MedRxiv
2020:1–22. doi:10.1101/2020.06.16.20133207.
[73] Walsh KA, Jordan K, Clyne B, Rohde D, Drummond L, Byrne P, et al. SARS-CoV-
2 Detection, Viral Load and Infectivity over the Course of an Infection. J Infect
2020. doi:10.1016/j.jinf.2020.06.067.
[74] World Health Organization. Advice on the use of masks in the context of COVID-
19: interim guidance (5 June 2020) 2020:1–16. https://www.who.int/publications-
detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-
healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak
(accessed June 15, 2020).
[75] Martin GP, Hanna E, McCartney M, Dingwall R. Science, society and policy in the
face of uncertainty: reflections on the debate around face coverings for the public
during COVID-19. Crit Public Health 2020.
[76] Allison AL, Ambrose-Dempster E, Aparsi TD, Bawn M. The environmental dangers
of employing single-use face masks as part of a COVID-19 exit strategy. Prepr
UCLPRESS 2020. doi:10.14324/111.444/000031.v1.
[77] Fisher KA, Barile JP, Guerin RJ, Vanden Esschert KL, Jeffers A, Tian LH, et al.
Factors Associated with Cloth Face Covering Use Among Adults During the
COVID-19 Pandemic — United States, April and May 2020. MMWR Morb Mortal
Wkly Rep 2020;69:933–7. doi:10.15585/mmwr.mm6928e3.
[78] McFarling UL. ‘Which death do they choose?’: Many Black men fear wearing a
mask more than the coronavirus. Stat 2020.
https://www.statnews.com/2020/06/03/which-deamany-black-men-fear-wearing-
 mask-more-than-coronavirus/.
[79] Perencevich EN, Diekema DJ, Edmond MB. Moving Personal Protective
Equipment Into the Community. JAMA 2020;323:2252.
doi:10.1001/jama.2020.7477.
[80] Dorfman D, Raz M. Mask Exemptions During the COVID 19 Pandemic — A New
Frontier for Clinicians. JAMA Heal Forum 2020;1:e200810.
doi:10.1001/jamahealthforum.2020.0810.
[81] Esposito S, Principi N. To mask or not to mask children to overcome COVID-19.
Eur J Pediatr 2020;27:9–12. doi:10.1007/s00431-020-03674-9.