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November 2020 

In this issue: Open the Windows! An exclusive interview with Prof. Susan Roaf, Architectural Engineer, on airborne transmission of COVID-19. Why resistance is like the tobacco industry, and Germany ought to lead in the EU!

A Discussion with Prof. Susan Roaf, Emeritus professor of Architectural Engineering at Heriot Watt University, Edinburgh
AMR Think-Do-Tank, Geneva’s THE BRIEF AMR & COVID 19, Garance Upham, Editor in Chief, and Arno Germond, PhD, Riken Labs, Japan, Editor.
 

AMR & COVID19 THE BRIEF: Back early July, we were thunderstruck by the remarkable letter "It Is Time to Address Airborne Transmission of Coronavirus Disease 2019 (COVID-19)", signed by yourself with over 200 scientists from around the world --a FLASH in our July newsletter -- and soon noticed that it was relayed by some leaders in AMR (antimicrobial resistance) like Dr Michael Osterholm, head of the CIDRAP of now a member of President Elect Joe Biden new COVID-19 task-force.
 What's the story?

Susan Roaf: As I like to tell it, the story is as follows. It was only on the 6th of July 2020 that 239 scientists from around the world led by Lidia Morawska and Donald K. Milton signed this letter "Time to Address Airborne..." sent to the Journal of Clinical Infectious Diseases and in it they asked the question: Why is it that the WHO is not recognizing the airborne spread of COVID-19? Within 3 days, by the 9th of July, the WHO began to change their tune, they admitted that aerosol spread is happening with this coronavirus.
What's been a huge learning experience about COVID 19 in that it's so widespread, so huge numbers of people have been infected, and there are huge opportunities to learn how.

THE BRIEF: I read the WHO response and perhaps I'm naive, not being an engineer in this domain, but while individuals like Dr Allegranzi recognized the issue, the WHO is still very conservative and remained to this day (and the US CDC has become more straightforward this fall) still saying mostly short distance one-to-one transmission. Big aerosol, smaller particles can travel further, and then smaller aerosols might travel wider, but it’s a far cry from admitting airborne.

Susan Roaf: The initial reaction back then in July, was that the route of transfer was largely by fomite, or touch transmission, and then through droplets with traditional pictures of droplets being sneezed out or coughed up...1.5 to 2 meters from the person.
But we have a lot more evidence now and what we know is that actually, the main route of transmission is via aerosols, airborne.
Studies in hospital wards do not show not much evidence on the role of phones or door handles as source of transmission, for example. We know now that the virus can travel 4 to 8 meters or more from an infected person, and can then, on its way transform from droplets to aerosol form and as particles be born further following the buoyancy of the air.

The 4 W: Wash hands / Wear a mask / Watch your distance ...open the Windows!

THE BRIEF: Until today the WHO, and nearly all national campaigns recommend the '3W', shouldn't we say: '4W' and add ‘Windows’ : Wash Hands, Wear a Mask, Watch Your Distance, Open the Windows? Recently Dr Maria Neira, WHO ADG, did a science video show for the WHO on ventilation, so there is progress, albeit slow.

Susan Roaf: That's a good slogan: adding the fourth "W"! We need to angle what could be seen as a radical message so it's sympathetic to the heating and ventilating engineers, and adopted by them. There is a huge industry which regulates heating, cooling and ventilation within buildings. It is an industry largely dominated by hugely influential bodies (ASHREA in the USA and CIBSE in the UK). 

They write or oversee the writing of the indoor air quality regulations, comfort and heating and cooling standards related not only to the work of HVAC (Heating, Ventilating and AC) engineers who put AC or ventilation systems in buildings via ducts, but also the design of buildings by architects who figure little in the drafting of the standards. HVAC engineers are typically paid according to how much of that equipment they can get into a building.  The building regulations push for ever more HVAC equipment in buildings.

So what was shown in the 1990s and early 2000 with the tobacco industry, is that there is a problem with ‘affiliation bias’ in the development of related regulations.  In  passive smoking debates in the 90s, all the regulatory solutions were directed  to moving air faster through rooms to take away the passive smoking risks for people, yet that was obviously no solution as the smoke still passed around people on its way out the building.

The HVAC industry has grave problems in dealing with COVID.  The solutions they pose include using highly efficient filters, or UV disinfection units in the air stream within the duct systems. There's a problem with that!

Because it's fine to have filtered air coming into a space but the cross-infection is happening between people within that space. Speeding up air movement inside a room may well increase the distance travelled by particles and the number of people infected by them.  For instance, in Beijing there was the first 'canary in the coal mine' case, where you had one infected person in a restaurant infecting a number of people downstream of the airflow from his table. So no use putting in the filters BEFORE you enter the room, or in this case even increasing the amount of fresh air coming into the room because the infection happened between people in the space.  What may have helped is to have directed the air from each table to dump directly to the outside via open windows, but the space there had none. The direction of the air flows in rooms is critical but difficult to adjust in most HVAC systems.

From tobacco smoke to COVID-19

THE BRIEF: The link with the tobacco industry is telling. As a child (Garance) I used to travel a lot between Geneva and Boston, in the fifties and sixties and there was a lot of smoking on board, terrible intake of smoke from the air. Yet today the airlines pretend the air flow is ‘only’ circulating per row and the risks would be zero, they pretend to have had 44 identified cases out of 1.4 bill travelers (Jama’s article provoked a lot of disparaging and informative comments). Yet here in Geneva, we heard of a cluster of 23 people just on one flight, mostly in business class (not closely packed at all as in Economy class), with a WHO staff on board.
This is very worrisome as millions of unsuspecting Americans will be boarding for Thanksgiving. The Airlines are in denial and it will cost lives. I have read most US national newspapers available on line: they talk of the dangers of family meetings, but never of the potential clusters from the flights Americans will take to go to these family get togethers.

Susan ROAF: The same goes for all HVAC systems that recirculate air rather than using 100% fresh air – which includes some 99% of all systems. I went for work to Antarctica in February and I was in a rather posh hotel in Punta Arena en route, and I thought I could smell the smoke from every cigarette smoked, and every discarded sock in the hotel.

There will be much re-thinking going on in the HVAC industry over COVID, because if filters don't work because of viral transfer occurs within spaces,  and increasing air speed over people may or may not prevent infection, and this is exacerbated on planes where if you have one infected person on board, it is difficult for many of the other passengers to avoid being in the downwind air stream of the infected passenger.

This is what happens many increasingly think about cross infection within the meat or food packing production lines. They are pushing the cold air flow down cross the production line cooling the meat or foodstuffs and the workers, and that is why you are getting these mass clusters. Pushing the air faster is irrelevant, and possibly even leads to more infections, and certainly not the best answer. We are having to rethink the fundamentals of how we heat and cool buildings and their contents and occupants.

The second theory is actually, what you have to do is to reduce the load by diluting it, moving air more slowly, and mixing it within the space's air say in a big ward or something to reduce the viral load presented to any individual within the space. But again that's a problem because it can end up a warm, slowly moving, viral soup around, which must be potentially dangerous, particularly if the viral load is high to start with.

THE BRIEF: So in your informed opinion the best thing to do is to OPEN THE WINDOWS, often, to have natural ventilation. This has been started as a campaign by the UK NHS two days ago. In France or Switzerland, we haven't caught up.
Yet it's been shown in nursing homes and hospital wards, that slowly recycled air leads to a lot of clusters, while wards with open windows had none.


Susan ROAF: There's a lot of panic out there in the HVAC world, and if you look at the Japanese, the have first class scientists in the field, fantastic labs, and they are not so influenced with the industry, working collaboratively with the architects and engineers publishing joint advice, which includes, strange to make of us, to have all the ACs on and the windows open as well!
And the national Japanese standard now insist that in homes, you have to have air distribution systems in all new homes, and many have ACs on, but also windows open, because they realized that, you have got to dump the viral load outside.

The Japanese way: AC and Open Windows!

THE BRIEF: "The Japanese use a lot of AC because the insulation is really bad and houses are designed this way. In standard apartments the temperature is similar outside and inside, there is no central heating system.  Apartments also have big windows and no windows stores, so it's hard to keep it warm in winter, or cool in summer. But AC systems can be put in each room, by design. Because spring and autumn are so short here, the AC are on most of the time, both in shops and homes. "
 
Susan ROAF: You can get rid of the load with a mechanical extract system too. But importantly you need to test, identify and isolate infected people, of course … but you do have to understand that the directionality of the flow is key!
That is a problem with a lot of AC and heating systems, because they have a vent that directs air out into rooms, in one direction only!

Using local heat radiant sources in winter and turning off centralized airborne systems would be important to avoid exposing people, while opening the windows regularly. But it's been a huge learning curve and it's extremely steep, pointing to the fact that we have to really look at our building regulations, to make sure they would actually encourage pandemic proof design now, and for the future, so it means you need at least to have the option to open windows, - and that also means dealing with air pollution outdoors, and shallower, natural ventilation friendly, floor plans.

We have to think big now on how we can create survivable cities. Because these types of huge environmental challenges, means there will come times when cities can actually fail. COVID-19 can lead to a major reassessment of how we need to plan seriously and radically for a more viable future.

THE BRIEF: Germany is leading the EU today, and they were instrumental in bringing health into the G20 in the past few years, through health advisors of Chancellor Merkel (who, alone among EU heads of State has advised citizens to open the windows often). Now in your writings you emphasize the beauty of Berlin as a naturally ventilated city.
What Germany could/ should do today to bring this issue of preventing airborne dissemination of COVID-19 into the EU? Because Germany is putting itself forward as a leader in health and defender of a strong WHO and it could stop the denial and get real action going.

Susan ROAF: Let me be frank. In a world in which the building regulations and design standards are being written by an industry which is paid on depending on how much technology they put in a building, then there is inevitable bias in the way decisions are made. This COVID-19 crisis has highlighted this.
 
Again to overcome the influence of the tobacco industry lobby, it needed to be demonstrated that correct regulations were crucial important for the health of the whole population, that eventually led to common sense solutions.  Only then, they could move on and actually ban indoor smoking.

So we need this kind of large-scale decisions made here in the face of COVID-19, because the HVAC industry and the regulations writing industry for indoor air regulations are rather like what it was for tobacco. Most of the research on indoor air quality is currently funded by the air conditioning industry, a lot of it is undertaken by people who are paid for by the AC industry, in laboratories that are built by the AC industry.  Regulations are often based on studies done in small laboratory rooms, undertaken with a few laboratory subjects in artificial conditions.
Regulations are often based on fairly weak, and often outdated, science that bears little relevancy to real people in real buildings.

So when experts like the WHO talk of so many meters per second to two decimal points, this is irrelevant for most people in most buildings, and effectively attempting to blind people with science. These efforts may seem trivial, but they shape the way our buildings and cities are developed today.  If the regulations tell you that you can only have indoor temperatures between 20 and 26 degrees centigrade to keep employees, this is not only simply not true, but it means that to meet the regulations you have to install full AC, and the cost of that means you may value engineer out the slightly more expensive windows that actually open. Job done.
And if you are told you should only have CO2 levels under 1000 parts per million in a room or it will affect your health the regulations then insist you have to install whole building ventilation systems to keep CO2 levels down. This 1000pm is based on an 1858 study by Pettenkofer old papers on what level of CO2 are acceptable. This is simply not true, and in your bedroom every night you probably have well above that level. This dreamed up standard does mean you have to install more equipment though.  So we have to really go back to common sense thinking. The Germans, culturally...like fresh air and Angela Merkel understood early on how important it was to open windows and asked everyone in buildings to do so regularly to reduce viral loads indoors. Like Switzerland which being a cooler country, hasn't been overrun by the AC industry and their lobbyists in the development of their regulation systems.

Berlin is a naturally ventilated city by design! A great example in the EU, can Germany show the way?

I hope Germany will take the lead in having building regulations written by a wider range of people, than simply HVAC engineers drafting them. This also relates to decisions made by international organization like the WHO. Get doctors, epidemiologists, architects, psychologists and genuinely independent researchers into the room when regulations are drawn up, not developers and industries who stand to make a lot of money from steering the direction of those regulations. We do urgently need a fundamental rethink on designing buildings prepared for pandemics.

THE BRIEF: Let us talk of the US: Dr Michael Osterholm of CIDRAP (at the University of Minnesota) got nominated on the Joe Biden Task Force, and that is interesting because CIDRAP, which is a leading unit on AMR, had immediately endorsed the July letter which you had signed along with 238 scientists from around the world, "It is Time to Think of Airborne..."
The new US administration has to do better than President Trump, who, as you said, knew early on it was spreading in the air (from Bob Woodward’s book).
And in Europe too, we know and need to do better!
As the English say: Open the Windows!


 REFERENCES: 
THE BRIEF on AMR & COVID-19
This newsletter is published by the think tank, AMR Think-Do-Tank, Geneva International
Disclaimer: The named authors and editors alone are responsible for the views expressed in this publication.
Contact: editor@amr-covid19.info
The Editorial Board: 

- Garance F. Upham, Editor in Chief, ENG / FR editions (editor@amr-covid19.info)*
- Arno Germond, PhD, Researcher, Editor,  AMR Think-Do-Tank, Geneva International
- Mostafa El Yamany, Editor, (Egypt and the Netherlands), pharmacist and Ph.D. Candidate on AMR 
- Nora Mahfouf, PhD, Assistant French Edition, (Algeria & Dubai, U.A.E.) 
- Aye Mandibo, PhD, MD, Assistant, clinical issues review (West Africa)
- Jean-Jacques Monot, (France) Computer Engineer, database, and edition

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*editor in chief AMR-Control, 2015-2020
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