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Trish Greenhalgh
Professor Trish Greenhalgh, University of Oxford, is one of 40 scientists who have issued the call in the journal Science.

A group of the world’s leading experts in the transmission of airborne pathogens are calling for a tightened regulatory system to control air quality in buildings - as a way of reducing the spread of COVID-19 and other illnesses.

Writing in the journal Science, the 40 scientists say that “a paradigm shift is needed on the scale that occurred when Chadwick’s Sanitary Report in 1842 led the British government to encourage cities to organise clean water supplies and centralised sewage systems. 

“In the 21st century we need to establish the foundations to ensure that the air in our buildings is clean with a significantly reduced pathogen count, contributing to the building occupants’ health, just as we expect for the water coming out of our taps.”  

The scientists who have contributed to the analysis include Trish Greenhalgh, Professor of Primary Care Health Sciences at Oxford University.

Professor Greenhalgh said: “It’s no exaggeration to call this a paradigm shift. Up to now, most of the efforts to prevent transmission of COVID-19 and other airborne respiratory diseases such as tuberculosis has focused on influencing individual behaviour such as mask-wearing, cough hygiene and handwashing. These measures are still important, but they will be relatively ineffective in the indoor environment until we ensure that the air that we inhale contains far fewer particles that have been exhaled by others in the room. 

“We need to re-think the practice, currently common in many countries, of keeping windows closed and recycling stale air in air-conditioning. Windows should be opened, and draughty rooms welcomed; if air is recycled it must be filtered and disinfected; and monitoring air quality—for example using CO2 monitors—should become commonplace. In short, we need to re-think—and re-regulate—what counts as a ‘healthy’ building.”

Recognising the risk of aerosol pathogen spread 

Historically, public health regulations have concentrated on sanitation, drinking water and food safety, whereas the risk from airborne pathogens whether it is flu or COVID-19 is “... addressed fairly weakly, if at all, in terms of regulations, standards, and building design and operation, pertaining to the air we breathe”, say the scientists. 

But research during the COVID-19 pandemic has underlined the role that aerosols play in spreading disease. When a person who has a respiratory infection speaks, coughs or sneezes, tiny infective particles are emitted from their nose and mouth. Indoors, those tiny particles are carried in the air and infect other people. 

The paper says: “... community outbreaks for COVID-19 infection in particular most frequently occur at larger distances through inhalation of airborne virus-laden particles in indoor spaces shared with infected individuals.   

“Such airborne transmission is potentially the dominant mode of transmission of numerous respiratory infections. We also have strong evidence on disease transmission, for example in restaurants, ships, and schools, suggesting that the way we design, operate, and maintain buildings influences transmission.” 

That risk of people becoming cross infected inside a building can be reduced through ventilation coupled with air disinfection and air filtration systems. However, the scientists note: “... almost no engineering-based measures to limit community respiratory infection transmission had been employed in public buildings - excluding health care facilities - or transport infrastructure anywhere in the world.”  

Tighter controls 

There are ventilation guidelines and standards which architects and builders must follow but the focus is on reducing odours and carbon dioxide levels and in maintaining thermal comfort. None provide recommendations on how to control the spread of pathogens.  

The scientists are calling for World Health Organisation indoor air-quality guidelines, which cover pollutants such as carbon monoxide and other chemicals, to be extended to include airborne pathogens.  The experts say individual governments need to introduce and enforce domestic regulations. 

“None of this means that every indoor space should become a biosafety facility. It means that a building should be designed and operated according to its purpose and the activities conducted there, so that airborne infection risk is maintained below an acceptable level," the scientists write in the paper. 

That would mean different standards for a gym where people may be breathing heavily as opposed to people relaxing in a cinema. 

The lead author of the paper, Lidia Morawska, Distinguished Professor in the School of Earth and Atmospheric Sciences at Queensland University of Technology in Australia, said: “For decades, the focus of architects and building engineers was on thermal comfort, odour control, perceived air quality, initial investment cost, energy use, and other performance issues, while infection control was neglected.”  


The scientists challenge the argument that costs of air quality control in buildings would be prohibitively expensive. They say the monthly cost of covid-19 is conservatively estimated at $1 trillion. Installing ventilation and air-quality systems designed to remove airborne pathogens would add about one percent to the construction costs of a typical building. 

Improving air quality in buildings would bring benefits beyond reducing sickness levels due to respiratory infections. It is likely to reduce allergens and the number of people who experience ‘sick building syndrome’. 

Read more:

A paradigm shift to combat indoor respiratory infection
L Morawska et al, Science, 14 May 2021. DOI: 10.1126/science.abg2025


A paradigm shift to combat indoor respiratory infection

  1. Lidia Morawska
  2. Joseph Allen
  3. William Bahnfleth
  4. Philomena M. Bluyssen
  5. Atze Boerstra
  6. Giorgio Buonanno
  7. Junji Cao
  8. Stephanie J. Dancer
  9. Andres Floto
  10. Francesco Franchimon
  11. Trisha Greenhalgh
  12. Charles Haworth
  13. Jaap Hogeling
  14. Christina Isaxon
  15. Jose L. Jimenez
  16. Jarek Kurnitski
  17. Yuguo Li
  18. Marcel Loomans
  19. Guy Marks
  20. Linsey C. Marr
  21. Livio Mazzarella
  22. Arsen Krikor Melikov
  23. Shelly Miller
  24. Donald K. Milton
  25. William Nazaroff
  26. Peter V. Nielsen
  27. Catherine Noakes
  28. Jordan Peccia
  29. Kim Prather
  30. Xavier Querol
  31. Chandra Sekhar
  32. Olli Seppänen
  33. Shin-ichi Tanabe
  34. Julian W. Tang
  35. Raymond Tellier
  36. Kwok Wai Tham
  37. Pawel Wargocki
  38. Aneta Wierzbicka
  39. Maosheng Yao

 See all authors and affiliations

Science  14 May 2021:
Vol. 372, Issue 6543, pp. 689-691
DOI: 10.1126/science.abg2025


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