Droplet vs Airborne: Different and Important

Sometimes professionals use words in very specific ways that aren’t obvious. Just the other day I realized that is what happened with those two words. My Facebook friends have seen me very carefully point out articles like these, which suggest than COVID-19 is airborne, rather than droplet. I did this carefully because before yesterday, the WHO and CDC staunchly denied any such thing and today the WHO merely confirms that there is “emerging evidence.” Today I want to explain why it’s different, and a really big deal, in fairly simple terms.

I work in a hospital, as an Infection Preventionist. Just as the name suggests, I help keep people from getting sicker in the hospital. We used to be called “Infection Control Nurses,” and it’s a tradition that literally goes all the way back to Florence Nightingale. Hospitals use different kinds of precautions — safety measures — to prevent the spread of disease. These measures are based on how the disease itself can move from person to person.

Standard precautions are what we do to protect everybody at all times. This includes keeping your hands clean, using disposable gloves, and changing those gloves between patients. Hand washing is still the most important thing you can do to keep from getting or transmitting any disease. It’s so important the CDC has an entire section on it.

When we know a person has certain infections that could spread, we use Contact precautions. This is for fairly heavy organisms that can survive for a while on surfaces, and that we can inadvertently transport to a new victim on our hands or clothing. One such organism you may have heard of is MRSA, Methicillin Resistant Staphlycoccus Aureus. We also use Contact for more mundane bugs like head lice. For Contact, we make sure to use gloves, treatment gowns to cover our clothing, and we are extra sure to wash our hands after taking our gear off.

Now for the meat of this discussion. Droplet precautions are for organisms that can move in droplets we create when we talk, cough, or sneeze. These droplets can go maybe 6 feet or so (that’s where the 6 feet apart for social distancing comes from) before they go SPLUT! onto a surface. Droplet precautions always includes Contact precautions. That surface can be somebody else’s face, which is why the protective gear for Droplet precautions includes a facemask and ideally eye protection, in addition to gloves and gown. The most common organism for which we use Droplet is the Flu. Remember, up until yesterday, the WHO insisted this was all we needed to protect ourselves from COVID-19. And as of this moment — subject to change without notice — the CDC still does.

By contrast, Airborne precautions are for organisms that can float in the air a long ways and a long time. Much farther than 6 feet. And to do this, they are very small and very lightweight. Examples include Measles, Tuberculosis, and Ebola. These bugs are small enough to get through and around normal surgical masks. These patients should be cared for in a special “negative pressure” hospital room — the HVAC system is designed to create lower air pressure than in surrounding areas while still having fresh air move in and out, so germs aren’t likely to go into the rest of the hospital. To care for these patients, you need special masks, such as N95 or a powered respirator, and they need to fit correctly to prevent germs getting around the edges. That’s over any above gloves, gown, shoe covers, hair covers, and eye/face protection.

As you can see, there’s actually a huge difference between droplet and airborne transmission. And although many experts have privately held that COVID-19 is airborne, its a huge step for the WHO to admit that. I hope the CDC joins them shortly.

A few words about masks

Masks in public has become the new normal. So let’s talk about this for a few minutes.

Masks are a whole lot like condoms: they do work; they only work if you use them, and use them correctly; they don’t work with holes cut in them; and they are not foolproof — you and the people around you are safer if you’re all doing something to prevent the spread of disease.

Nor are masks a substitute for things like quarantining the sick, isolating those who are known to have unprotected exposure, washing your hands, or social distancing. Hand hygiene is still the number one thing you can do to keep from getting almost any disease — it will even stop you from accidentally making somebody else sick. That last point is really important, because people can spread COVID-19 two days before they feel sick, and worse yet they can spread it and never feel sick at all.

Again, just like condoms, masks are only one tool to prevent the spread of disease.

We haven’t got a cure or a vaccine for this thing yet. Prevention is literally all we’ve got to prevent more people from getting sick and possibly dying.

Now for those of you who like actual research results: here’s the Mayo Clinic; Journal of the American Medical Association (JAMA); some research from Hong Kong; and The Lancet. For those of you who are total data nerds, here’s some more fine studies.

Wear the damn mask, people. There’s nothing “unconstitutional” about it. Your “rights” end when you interfere with the rights of others, such as when your selfishness accidentally spreads disease.

A Tale of Two Diseases

Today I would like to make some comparisons between COVID-19 and Influenza. For simplicity, we will look at data from the Southern Nevada Health District, which serves Las Vegas and surrounding communities.

This page will give you SNHD’s flu reports. Flu season is generally considered to run from October to March or April here. Let’s call it 6 months. Please note that when they refer to the week number, they mean for the year. So the first week of January is week 1. It is true that we never know exactly how many cases of the flu there are (the CDC estimates tens of millions of cases and tens of thousands of deaths nationwide). That’s because a lot of people recover at home without tests or hospital visits. However, if you look at the latest report, you’ll see that 47 people died of the flu this flu season. This number is pretty close to accurate; someone is either dead or they are not.

Now let’s move over to SNHD’s COVID-19 reporting. Just a reminder, COVID-19 is short for Coronavirus Disease 2019, it’s not the 19th anything. More about the basics here, but back to SNHD. We reported our first case March 5th, then our first death on the 16th. As of April 29th, we have 3979 confirmed cases. This needs to be treated as a minimum, because there simply hasn’t been enough testing. A lot of people are walking around with mild symptoms or none at all, blissfully unaware that they are spreading disease. Again, despite the lack of testing, there’s another number that is less prone to distortion.

The fact I want to point out is that as of April 29, Southern Nevada has had 202 deaths from COVID-19. In 6 weeks, 202 COVID-19 deaths, compared to 47 influenza deaths due to influenza in 6 months. Same population. Same location. Same risk factors. That’s four times as many deaths in about a quarter of the time.

In a nutshell, that is why we need to take this thing seriously.

I have become aware of voices on the Internet saying we shouldn’t waste time on a vaccine, but go for a cure. I would like to remind those folks that we never did get a cure for measles, polio, or rabies, just a vaccine. Even tuberculosis had a vaccine decades before we had a cure.

Stay safe out there. Wash your hands. Don’t stand too close to other people. Wear your mask in public. And remember that the economy is meaningless if you’re dead.

Ripple Effect

As I write, over 16 million people have filed for first time unemployment benefits in the last 3 weeks. There will be many ripples from the COVID-19 pandemic, and this is a good place to start.

First, I’d like to point out that at best this is a minimum number, and may in fact be a wild underestimate of the people who have lost their job in the last 3 weeks. Many state systems were slammed by not just 2 or 3 times normal volume, but 20 or 30 times normal volume. Turns out that many of these systems work using an ancient operating system called COBOL. For perspective, my late father used COBOL in the 60s and 70s. As if that’s not bad enough: “Still more people likely won’t qualify for unemployment benefits: parents who have to stay home with school-age kids, people quarantined because they’re at high risk for COVID-19 and new graduates who can’t even look for work.” That number probably doesn’t include most “gig economy” workers either.

Another direct ripple: those 16M+ people now don’t have health insurance. In a pandemic. I talked about this briefly very recently. COBRA is still a joke. If this isn’t a wake up call that we need true universal health insurance — not a patchwork of employer based benefits, not the “mandatory insurance” that Romneycare and Obamacare got us, but true “your citizenship is your insurance” universal health insurance — I don’t know what is. A lot of people are going to get a bill for tens of thousands of dollars just to keep from dying. And unlike diseases that can be traced to lifestyle, you can’t easily blame the victim. Keep that bill in mind, we’ll get back to it later.

A public health ripple: those unemployed people without insurance aren’t going to the doctor. They aren’t getting help for their small medical problem, so it’s becoming a bigger, more expensive medical problem. And if the problem turns out to be a communicable disease, they’re making other people sick. So yeah, the uninsured are a problem to your health.

Another ripple: people without jobs are having a hard time paying their rent or mortgage. Some of the renters who can’t pay in turn mean landlords can’t afford the mortgage. Sure, many areas have placed a moratorium on eviction and foreclosure, but that’s not a permanent solution. The forbearance plans in place still mean someday everything owed must be paid. Not meaning to sound insensitive, but how far do we kick the can down the road?

This ripple exposes another truth: over half of Americans had under a thousand dollars in savings just a few months ago. That hasn’t gotten better. With surging unemployment, it’s about to get worse.

Another ripple strikes the economy. About 70% of our economy is based on consumer spending. Consumers without jobs and without savings don’t spend a lot of money. Expect a drop in GDP.

And here’s where our ripples crash into the rocks. Eventually — not today, maybe not this quarter. Eventually, those rents and mortgages must be paid, or foreclosures and evictions will happen. Eventually the past due bills will grow including the medical debt, and bankruptcies will happen. Eventually we will have to confront the ways our health care system is not working. Eventually we will have to look at whether we can sustain an economy on services. Eventually we will have to come out of our shelters and see what is actually left of our economy.

Good luck, and keep your hands clean.