Current Insights Into Respiratory Virus Transmission and Potential Implications for Infection Control Programs : A Narrative Review

Ann Intern Med. 2021 Dec;174(12):1710-1718. doi: 10.7326/M21-2780. Epub 2021 Nov 9.


Policies to prevent respiratory virus transmission in health care settings have traditionally divided organisms into Droplet versus Airborne categories. Droplet organisms (for example, influenza) are said to be transmitted via large respiratory secretions that rapidly fall to the ground within 1 to 2 meters and are adequately blocked by surgical masks. Airborne pathogens (for example, measles), by contrast, are transmitted by aerosols that are small enough and light enough to carry beyond 2 meters and to penetrate the gaps between masks and faces; health care workers are advised to wear N95 respirators and to place these patients in negative-pressure rooms. Respirators and negative-pressure rooms are also recommended when caring for patients with influenza or SARS-CoV-2 who are undergoing "aerosol-generating procedures," such as intubation. An increasing body of evidence, however, questions this framework. People routinely emit respiratory particles in a range of sizes, but most are aerosols, and most procedures do not generate meaningfully more aerosols than ordinary breathing, and far fewer than coughing, exercise, or labored breathing. Most transmission nonetheless occurs at close range because virus-laden aerosols are most concentrated at the source; they then diffuse and dilute with distance, making long-distance transmission rare in well-ventilated spaces. The primary risk factors for nosocomial transmission are community incidence rates, viral load, symptoms, proximity, duration of exposure, and poor ventilation. Failure to appreciate these factors may lead to underappreciation of some risks (for example, overestimation of the protection provided by medical masks, insufficient attention to ventilation) or misallocation of limited resources (for example, reserving N95 respirators and negative-pressure rooms only for aerosol-generating procedures or requiring negative-pressure rooms for all patients with SARS-CoV-2 infection regardless of stage of illness). Enhanced understanding of the factors governing respiratory pathogen transmission may inform the development of more effective policies to prevent nosocomial transmission of respiratory pathogens.

Publication types

  • Review

MeSH terms

  • Aerosols
  • COVID-19 / prevention & control
  • COVID-19 / transmission
  • COVID-19 / virology
  • Cross Infection / prevention & control
  • Cross Infection / virology
  • Health Policy
  • Humans
  • Infection Control / methods*
  • Infectious Disease Transmission, Patient-to-Professional / prevention & control
  • Influenza, Human / prevention & control
  • Influenza, Human / transmission
  • Influenza, Human / virology
  • Masks
  • Personnel, Hospital
  • Respiratory Tract Infections / transmission*
  • Respiratory Tract Infections / virology*
  • SARS-CoV-2
  • United States / epidemiology
  • Ventilation


  • Aerosols